Protocols Flashcards
1
Q
Abdominal Discomfort GI/GU (non traumatic) - (S-120)
- BLS
A
Ensure patent airway
02 saturation prn
02 and/or ventilation prn
Transport suspected symptomatic aortic aneurysm to facility with surgical resources immediately available
2
Q
Abdominal Discomfort GI/GU (non traumatic) - (S-120)
- ALS (general)
A
- Monitor EKG
- IV/IO SO, adjust prn
- Treat pain as per Pain Management Protocol (S-141)
….. (extra credit):
- Suspected Volume Depletion:
500 ml fluid bolus IV/IO - SO
- Suspected AAA:
500 ml fluid bolus IV/IO - SO; for BP<80 to maintain BP of 80, MR (may repeat) 1x SO
- For nausea or vomiting:
Zofran 4mg IV/IM/ODT - SO; MR 1x q 10’ SO
3
Q
RUQ (right upper quadrant) of abdomen: what organs?
A
Small bowel Ascending colon Transverse colon Liver Gallbladder Head of pancreas
4
Q
RLQ (right lower quadrant) of abdomen: what organs?
A
Small bowel
Ascending colon
Appendix
R ureter
5
Q
LUQ (left upper quadrant) abdominal: what organs?
A
Small bowel Descending colon Transverse colon Stomach Spleen Body of Pancreas
6
Q
LLQ (left lower quadrant) abdominal: what organs?
A
Small bowel
Descending colon
L ureter
7
Q
Common causes of abdominal pain in RUQ
A
AMI, appendicitis, CHF, duodenal/gastric ulcer, gastritis, hepatitis, hepatomegaly, herpes zoster, pancreatitis, pericarditis, pneumonia, cholecystitis
8
Q
Common causes of abdominal pain in LUQ
A
AMI, aortic dissection, gastritis, herpes zoster, lower lobe pneumonia, pericarditis, splenic rupture, Ulcer, pancreatitis
9
Q
Common causes of abdominal pain in RLQ
A
Appendicitis, endometriosis, hernia, intestinal obst., kidney stones, ovarian cyst, PID, pyelonephritis, ruptured ectopic pregnancy, UTI
10
Q
Common causes of abdominal pain in LLQ
A
AAA, appendicitis, diverticulitis, endometriosis, intestinal obst., kidney stones, ovarian cyst, PID, pyelonephritis, ruptured ectopic pregnancy, UTI
11
Q
Common causes of abdominal pain: Epigastric
A
AMI, aortic aneurysm, appendicitis, esophageal disease, gastroenteritis, heartburn, ulcer
12
Q
Common causes of abdominal pain, Midline
A
Aortic aneurysm, bladder/UTI, early appendicitis, intestinal disease, uterine disease
13
Q
Common causes of abdominal pain, Diffuse
A
Appendicitis, diabetes, dissecting/ruptured aortic aneurysm, gastroenteritis, intestinal obstruction, ischemic bowel, pancreatitis, peritonitis, sickle cell crisis
14
Q
Common causes of abdominal pain, FLANK
A
Diverticulitis, kidney stones, pyelonephritis
15
Q
Common causes of abdominal pain, SHOULDER
A
Abdominal aortic aneurysm, ectopic pregnancy, splenic rupture
16
Q
Common causes of abdominal pain, BACK
A
AMI, aortic aneurysm, cholecystitis, diverticulitis
17
Q
Airway Obstruction (foreign body): S-121
BLS protocol
A
For a conscious patient:
- reassure, encourage to cough
- 02 prn
For inadequate air exchange:
- abdominal thrusts
- use chest thrusts for obese or pregnant patients
If patient becomes/found unconscious:
- begin CPR
Once obstruction is removed:
- high flow 02, ventilate prn
- 02 saturation prn
18
Q
Airway Obstruction (foreign body): S-121
ALS protocol
A
If patient becomes unconscious or has a decreasing LOC:
- direct laryngoscopes and Magill forceps SO - MR prn
- capnography SO prn
Once obstruction is removed:
- monitor/EKG
- IV/IO SO adjust prn
Note: if unable to secure airway, transport STAT
19
Q
Airway Obstruction (foreign body) - S-121: Respiratory Disease Chart
Asthma
A
Lung Sound: wheezing, diminished
S/S - other: Hx allergies/asthma. Taking bronchodilators. Episodic
20
Q
Airway Obstruction (foreign body): S-121 Respiratory Disease Chart
Bronchitis
A
Lung Sound: Wheezing; crackles
S/S-others: recent respiratory tract infection. Smoker. Productive cough
21
Q
Airway Obstruction (foreign body): S-121
Respiratory Disease Chart
CHF (pulmonary edema)
A
Lung Sound: crackles (rales); wheezing; dismissed
S/S-other: Hx CHF, MI, HTN. Taking diuretics. Gradual onset, orthopedic. JVD, pedal edema. R/O aspiration/infection
22
Q
Airway Obstruction (foreign body): Respiratory Disease Chart
COPD (emphysema)
A
Lung sounds: Wheezing/diminished
S/S-other: smoker, barrel chest, chronic cough. On home 02. Exertional
23
Q
Airway Obstruction (foreign body): Respiratory Disease Chart
Hyperventilation
A
Lung sounds: Clear
S/S-other: hand/face numbness, hand cramping. R/O cause: PE, shock, sepsis, OD etc.
24
Q
Airway Obstruction (foreign body): Respiratory Disease Chart
Obstruction:
A
Lung Sound: stridor - inspiratory
S/S-other: anxious, hoarse, cough, cyanosis, drooling, pain
25
Airway Obstruction (foreign body): Respiratory Disease Chart
Pneumonia
Lung Sounds: Scattered; Crackles; Rhonchi
S/S-other: fever. Taking antibiotics. C/P. Cough/sputum: brown, green, yellow
26
Airway Obstruction (foreign body): Respiratory Disease Chart
Pneumothorax
Lung Sounds: decreased/absent on affected side, or clear bilaterally.
S/S-other: spontaneous or traumatic. Sudden onset of pain typically pleuritic. Acute= hypotension, tracheal deviation
27
Airway Obstruction (foreign body): Respiratory Disease Chart
Pulmonary Embolism
Lung Sounds: Clear
S/S-other: tachypnea, tachycardia, pain, dyspnea on exertion (sudden onset). 02 sat low with oxygen and good ventilations
28
Allergic Reaction/Anaphylaxis: S-122
BLS
- ensure patent airway
- 02 saturation prn
- 02 and/or ventilation prn
- Remove stinger/injection mechanism
- May assist patient to self-medicate own prescribed epinephrine auto-injector or MDI 1X ONLY. Base hospital contact required prior to any repeat dose
- If available & trained:
Epinephrine auto-injector 0.3mg IM x1
29
Allergic Reaction/Anaphylaxis: S-122
ALS
- Monitor EKG
- IV/IO SO Adjust prn
- capnography SO prn
Hives (Urticaria):
- Benadryl 50mg IV/IM SO
ANAPHYLAXIS:
Anaphylaxis:
- Epinephrine 1:1,000 0.3mg IM per SO. MR x2 q5 min SO
...then
- 500ml fluid bolus IV/IO for systolic BP <90 SO
MR to maintain systolic BP ≥ 90. SO
- Benadryl 50mg IM/IV SO
- Albuterol 6ml .083% via nebulizer SO
MR SO for respiratory involvement
- Atrovent 2.5ml .02% via nebulizer added to the first dose of Albuterol SO for respiratory involvement
- Epinephrine 1:10,000 0.1mg IV/IO BHO. MR x2 q3-5 min BHO
- Dopamine 400mg/250ml @ 10-40 mcg/kg/min IV/IO drip.
Titrations systolic BP ≥ 90 BHO
Anaphylaxis criteria (may include any):
1. Unknown exposure: Skin and respiratory and/or cardiovascular
2. Likely allergen exposure - e.g. bee sting, peanut,: 2/4 systems involved (skin, GI, respiratory, cardiovascular)
3. Known allergen exposure
Angioedema:
- lip/tongue/face swelling; difficulty swallowing/throat tightness; hoarse voice
30
Abdominal Discomfort GI/GU (non traumatic): S-122
for suspected volume depletion?
500 ml fluid bolus IV/IO SO
31
Abdominal Discomfort GI/GU (non traumatic): S-120
For suspected AAA
500 ml fluid bolus SO for BP < 80 to maintain a BP of 80, MR x1 SO
32
Abdominal Discomfort GI/GU (non traumatic): S-20
For nausea or vomiting
Zofran 4mg IV/IM/ODT SO; MR x1 in 10” SO
33
Airway obstructio, BLS: S-121
for Conscious patient
- Reassure, encourage coughing
| - 02 prn
34
Airway obstruction, BLS: S-121
for inadequate air exchange?
- Abdominal thrusts
| - chest thrusts for obese or pregnant patients
35
Airway obstruction, BLS: S-121
after obstruction is removed?
- High flow 02, ventilate prn
| - 02 saturation prn
36
Airway obstruction - ALS, S-121
If patient becomes unconscious or has a decreasing LOC?
Direct laryngoscopy and direct Magill forceps SO... MR prn
37
Airway obstruction - ALS, S-121
after obstruction is removed?
- Monitor EKG
| - IV/IO SO adjust prn
38
Allergic Reaction/Anaphylaxis: BLS, S-122
how many times can we assist/give epinephrine?
What dose?
(1x - Base Hospital Contact required for any repeat dose
.3 mg IM)
* “May assist patient to self-medicate own prescribed epinephrine auto-injector or MDI, ONE TIME ONLY. Base Hospital contact required prior to any repeat dose
39
Allergic Reaction/Anaphylaxis, S-122: ALS
For Hives?
Benadryl 50 mg IV/IM SO
40
Allergic Reaction/Anaphylaxis, S-122: ALS
Initial dose of epinephrine?
Epinephrine 1:1,000 .3 mg IM ... MR x2 q 5 min SO
41
Allergic Reaction/Anaphylaxis, S-122: ALS
Fluids and reason
500 ml fluid bolus IV/IO SO for systolic BP < 90 SO
| ... MR to maintain systolic BP ≥ 90. SO
42
Allergic Reaction/Anaphylaxis, S-122: ALS
how much Albuterol?
Albuterol 6ml .083% via nebulizer SO.. MR SO for respiratory involvement
43
Allergic Reaction/Anaphylaxis, S-122: ALS
How much Atrovent
Atrovent 2.5ml .02% via nebulizer added to the first dose of Albuterol for respiratory involvement
44
Allergic Reaction/Anaphylaxis, S-122: ALS
Secondary dose of epinephrine?
Epinephrine 1:10,000 - .1m mg IV/IO BHO. MR x2 q3-5 min BHO
45
Allergic Reaction/Anaphylaxis, S-122: ALS
Dopamine?
Dopamine 400 mg/250ml @ 10-40 mcg/kg/min IV/IO drop
Titrate systolic BP ≥90 BHO
46
Allergic Reaction/Anaphylaxis, S-122: ALS
Anaphylaxis Criteria?
1. Unknown exposure: Skin AND Respiratory AND/OR Cardiovascular
2. Unknown Allergen Exposure: (e.g. bee sting; peanut) 2/4 systems involved (skin, GI, respiratory, cardiovascular)
3. Known Allergen Exposure
47
Allergic Reaction/Anaphylaxis, S-122: ALS
Angioedema:
Lip/tongue/face swelling; difficulty swallowing; throat tightness; hoarse voice
48
Altered Neurologic Function (non-traumatic), S-123:
BLS
Symptomatic suspected opioids OD (w/ respiratory rate <12):
*use caution in opioid dependent pain management patients
- Naloxone nasal spray - 4mg - preloaded single dose device
- administer full dose in one nostril
.... OR....
- Naloxone assemble - 2mg- syringe and atomizer
- administer 1mg (1ml) into each nostril
49
Altered Neurologic Function (non-traumatic), S-123:
BLS:
Hypoglycemia (suspected) or patient’s glucometer reads <60:
- if patient is conscious and able to swallow: give 3 glucose tabs or paste (15g total). Patient may eat or drink, if able.
- If patient is unconscious: NPO
50
Altered Neurologic Function (non-traumatic), S-123:
BLS:
CVS/Stroke:
See S-144, Stroke/Transient Ischemic Attack (TIA) for details
51
Altered Neurologic Function (non-traumatic), S-123:
BLS
Seizures:
- protect airway; protect from injury
| - treat associated injuries
52
Altered Neurologic Function (non-traumatic), S-123:
BLS
Behavioral Emergencies:
Behavioral Emergencies (S-422 and S-142)
53
Altered Neurological Function (non-traumatic), S-123:
ALS
General:
- monitor EKG
- Capnography SO prn
- IV/IO SO adjust prn
- monitor blood glucose prn SO
54
Altered Neurological Function (non-traumatic), S-123:
ALS
Symptomatic suspected opioids OD (with respiratory rate <12)
* use caution in opioid dependent pain management patients
- Naloxone .2mg IN/IM/IV, SO. MR SO; Titrate IV dose to effect, to drive respiratory rate
- If patient refuses transport, give additional Naloxone 2mg IM, SO
55
Altered Neurological Function (non-traumatic), S-123:
ALS
Hypoglycemia: symptomatic patient with altered LOC or unresponsive to oral glucose agents:
- D50 25Gm IV, SO if BS <60
- MR SO if patient remains symptomatic and BS is still <60
- IF NO IV and BS <60: Glucagon 1ml IM, SO
56
Altered Neurological Function (non-traumatic), S-123:
ALS:
Hyperglycemia:
Symptomatic patient with diabetic history:
- 500 ml fluid bolus IV/IO if BS ≥350 or reads high, SO x1
57
Altered Neurological Function (non-traumatic), S-123:
ALS
Seizures:
A: ongoing generalized seizures lasting ≥5 minutes (includes seizure time prior to arrival of prehospital provider), SO
B: Recurrent tonic-clinic seizures without lucid interval, SO
C: Eclamptic seizure of any duration, SO
- Versed IN/IM/IV/IO, SO to a max dose of 5mg (d/c if seizure stops) SO; MR x1 in 10 minutes SO; Max 10mg total.
58
BURNS (S-124): general BLS
- Move patient to safe environment
- Break contact with causative agent
- Ensure patent airway, 02 and/or ventilate prn
- 02 saturation prn
- Treat other life threatening injuries
- Carboxyhemoglobin monitor prn, if available
58
BURNS (S-124): BLS thermal burns:
- Do not allow patient to become hypothermic
Burns of <10% body surface area:
- Stop burning with non-chilled water or saline
Burns >10% body surface area:
- cover with DRY dressing and keep warm
58
BURNS (S-124): BLS - Toxic Inhalation (CO exposure, more, gas, etc)
- Move patient to safe environment
- 100% 02 via mask
For suspected CO poisoning for unconscious or pregnant patient:
- Consider transport to facility with hyperbaric chamber
58
BURNS (S-124): BLS- Chemical Burns
- Brush off dry chemicals
| - Flush with copious amounts of water
58
BURNS (S-124): BLS - Tar Burns:
- Cool with water, transport; do not remove tar
58
BURNS (S-124): ALS, general
- Monitor EKG
- IV/IO SO adjust prn
- Treat pain as per Pain Management Protocol (S-141)
58
BURNS (S-124): ALS
For patients with ≥20% partial thickness or ≥5% full thickness burns and ≥15 yrs old:
- 500 ml fluid bolus IV/IO then TKO, SO
58
BURNS (S-124): ALS
In the presence of respiratory distress with bronchospasm:
- Albuterol 6ml .083% via nebulizer, SO. MR SO
58
BURNS (S-124):
Base Hospital Contact and Transport (per S-415):
Will be made to UCSD Base Hospital for patients meeting burn center criteria
58
BURNS (S-124):
Burn Center Criteria:
Patients with burns involving:
- ≥20% BSA partial thickness or
- ≥5% BSA full thickness
- Suspected respiratory involvement or significant smoke inhalation in a confined space
- Injury of the face, hands, feet, or perineum, or circumferential
- Electrical injury due to high voltage; (greater than 120 volts)
58
BURNS (S-124):
“Rule of Nines”... adult
Head: 9
Left arm: 9
Right arm: 9
Front torso: 18
Back torso: 18
Left leg: 18
Right leg: 18
Groin: 1
59
BURNS (S-124)
“Rule of Nines” - child
Left Arm: 9
Right arm: 9
Head: 18
Front: 18
Left Leg: 14
Right Leg: 14
Groin: 1
60
BURNS (S-124):
“Rule of Palms”
The surface of the patient’s palm represents approx. 1% of body surface area and is also helpful in estimating BSA
61
Discomfort/Pain of Suspected Cardiac Origin (S-126):
BLS
- Ensure patent airway
- 02 saturation prn
- Only use supplemental 02 to maintain 02 saturation 94-98%
- 02 and/or ventilation prn
- Do not allow patient to walk
- If systolic BP ≥100, may assist patient to self-medicate own prescribed NTG SL (max 3 doses, including what patient already took)
- May assist with placement of 12 lead
- May assist patient to self-medicate own prescribed Aspirin (81mg to max dose of 325mg)
62
Discomfort/Pain of Suspected Cardiac Origin (S-126):
ALS - general
- Monitor EKG
- IV SO adjust prn
- Obtain 12 lead EKG. If STEMI, notify base immediately and transport to appropriate STEMI center *
- ASA 324 mg chewable PO SO
63
Discomfort/Pain of Suspected Cardiac Origin (S-126):
ALS - IF systolic BP ≥100:
- NTG .4mg SL, SO. MR q3-5” SO
- NTG ointment 1 inch, SO
- Treat pain per Pain Management Protocol (S-141)
64
Discomfort/Pain of Suspected Cardiac Origin (S-126):
ALS- IF systolic BP <100:
- NTG .4mg SL BHO. MR, BHPO
| - Treat pain per Pain Management Protocol (S-141)
65
Discomfort/Pain of Suspected Cardiac Origin (S-126):
ALS- Discomfort/Pain of suspected Cardiac Origin with Associated Shock:
- 250ml fluid bolus IV/IO without rales, SO.
MR to maintain systolic BP ≥90, SO
- IF BP refractory to second fluid bolus:
- Dopamine 400mg/250ml @10-40 mcg/kg/min IV droop.
Titrate to systolic BP ≥90 BHO
66
Discomfort/Pain of Suspected Cardiac Origin (S-126):
Note:
- If discomfort/pain is relieved prior to arrival, continue treatment with NTG ointment and ASA. ASA should be given regardless of prior daily dose(s).
- If any patient has taken an erectile dysfunction medication such as Viagra, Ciaglia, Levitra within 48 hours, NTG is contraindicated
- May encounter patients taking similar medication for pulmonary hypertension (Revatio, Flolan, Veletri). NTG is contraindicated in these patients as well.
67
Discomfort/Pain of Suspected Cardiac Origin (S-126):
* Report:
- 12 lead interpretation of STEMI
- Bundle Branch Block (LBBB, RBBB)
- Poor quality EKG artifact, paced rhythm, atrial fibrillation or atrial flutter for consideration of a false positive reading STEMI
- Repeat 12 lead EKG only if original EKG interpretation is NOT ***ACUTE MI SUSPECTED****, and patient’s condition worsens. Do not delay transport to repeat
- Document findings on the PPR and transmit EKG if available and leave EKG with patient
68
Dysrhythmias, (S-127): BLS
- 02 and/or ventilate prn
| - 02 sat prn
69
Dysrhythmias , (S-127): ALS
Unstable Bradycardia with Pulse:
(BP <90 AND chest pain, dyspnea or altered LOC):
Narrow Complex Bradycardia:
- Monitor EKG
- 250ml fluid bolus IV/IO without rales, SO to maintain BP ≥90,
MR SO
- Atropine .5mg IV/IO for pulse <60, SO. MR q3-5” to max 3mg. SO
- If rhythm refractory to a minimum of Atropine 1mg:
External cardiac pacemaker SO**
- If capture occurs and BP ≥100, consider medication for discomfort:
Treat per Pain Management Protocol (S-141)
- For discomfort related to pacing not relieved with analgesics and BP ≥100:
Versed 1-5mg IV/IO. SO
- Dopamine 400mg/250ml @10-40 mcg/kg/min IV/IO drip; titrate to BP ≥90 (after max Atropine or initiation of pacing). BHO
70
Dysrhythmias , (S-127): ALS
Unstable Bradycardia with Pulse:
(BP <90 AND chest pain, dyspnea or altered LOC):
Narrow Complex Bradycardia:
... If rhythm refractory to a minimum of Atropine 1mg:
- External cardiac pacemaker SO **
* * Note:
- Document rate setting, milliamperes, and capture
- External pacingon standing orders should begin with minimum rate set at 60/min. Energy output should be dialed up until capture occurs, usually between 50-100 mA. The mA should then be increased a small amount, usually about 10% for ongoing pacing.
71
Dysrhythmias , (S-127): ALS
Unstable Bradycardia with Pulse:
(BP <90 AND chest pain, dyspnea or altered LOC):
Narrow Complex Bradycardia:
... If capture occurs and BP ≥100, consider medication for discomfort:
- Treat per Pain Management Protocol (S-141)
72
Dysrhythmias , (S-127): ALS
Unstable Bradycardia with Pulse:
(BP <90 AND chest pain, dyspnea or altered LOC):
Narrow Complex Bradycardia:
... For discomfort related to pacing not relieved with analgesics and BP ≥100:
- Versed 1-5mg IV/IO, SO
73
Dysrhythmias , (S-127): ALS
Unstable Bradycardia with Pulse:
(BP <90 AND chest pain, dyspnea or altered LOC):
Wide Complex Bradycardia:
- Monitor EKG
- 250ml fluid bolus IV/IO without rales SO to maintain BP ≥90, MR SO
- External cardiac pacemaker SO **
If capture occurs and BP ≥100, consider medications for discomfort:
- Treat per Pain Management Protocol (S-141)
For discomfort related to pacing not relieved with analgesics and BP ≥100:
- Versed 1-5mg IV/IO, SO
- Dopamine 400mg/250ml @10-40 mcg/kg/min IV/IO drop; titrate to BP ≥90 (after initiation of pacing). BHO
- If external pacing unavailable:
- May give Atropine .5mg IV/IO for pulse <60 SO
MR q3-5min to max 3mg, SO
74
Dysrhythmias , (S-127): ALS
Supraventricular Tachycardia (SVT):
- Monitor EKG
- 250ml fluid bolus IV/IO without rales, SO to maintain BP ≥90,
MR SO
- VSM SO. MR SO
- Adenosine 6mg rapid IV/IO, followed with 20ml NS rapid IV/IO SO
- (Patient’s with history of bronchospasm or COPD: BHO)
- Adenosine 12mg rapid IV/IO followed with 20ml NS rapid IV/IO SO
If no sustained rhythm change, MR x1 in 1-2” SO
75
Dysrhythmias , (S-127): ALS
... If patient unstable OR rhythm refractory to treatment:
Conscious (BP <90 AND chest pain, dyspnea or altered LOC):
- Versed 1-5mg IV/IO prn pre-cardioversion BHO
- If age ≥60 consider lower dose with attention to age and
hydration status
- Synchronized cardioversion at manufacturer’s recommended energy
dose, BHO. MR, BHO
Unconscious:
- Synchronized cardioversion at manufacturer’s recommended energy dose SO. MR x3 SO. MR BHO
76
Dysrhythmias , (S-127): ALS
Ventricular Tachycardia (VT):
- Monitor EKG
- 250 ml fluid bolus IV/O without rales SO to maintain BP ≥90
MR, SO
- Lidocaine 1.5mg/kg IV/IO, SO. MR at .5mg/kg IV/IO q8-10 min to max
3mg/kg (including initial bolus) SO
.... OR.....
- Amiodarone 150mg in 100ml of NS over 10 min IV/IO, SO
MR x1 in 10 min BHO
77
Dysrhythmias , (S-127): ALS
..if patient unstable (BP<90 AND chest pain, dyspnea or altered LOC)
Conscious:
- Versed 1-5mg IV/IO prn pre-cardioversion, SO
- If age ≥60 consider lower dose with attention to age and
hydration status
- Synchronized cardioversion at manufacturer’s recommended
energy dose SO. MR x3 SO. MR BHO
Unconscious:
- Synchronized cardioversion at manufacturer’s recommended energy dose SO. MR x3 SO. MR BHO
78
Dysrhythmias , (S-127): ALS
Reported/witnessed ≥2 AICD:
- Monitor EKG
- 250ml fluid bolus IV/IO without rales SO to maintain BP ≥90, MR SO
If pulse <60:
- Lidocaine 1.5mg/kg IV/IO q8-10” to max 3mg/kg (including initial bolus) SO
....OR....
- Amiodarone 150mg in 100ml of NS over 10” IV/IO BHO
79
Dysrhythmias , (S-127): ALS
Note:
San Diego & Vicinity LVAD/TAH Coordinators:
- Sharp Memorial Hospital: 858-939-3863 (if no answer, leave message and phone number - OR - enter your phone number followed by # for a call back)
- Scripps La Jolla Hospital: 858-626-5823 or 858-554-9100.
- UCSD: business hours 858-657-5050 .. or after hours:
619-543-6737, ask for “on call” VAD Coordinator
Los Angeles Cedars Sinai Medical Center: 310-887-0599 (dial “0” for operator, state you are EMS and to patch to the VADD coordinator on call)
80
Dysrhythmias (S-127): BLS - CPR
| associated with VF/Pulseless VT
- CPR
- 10:1 compression ratio @ rate of 110/min continuous
Compressions with ventilations every 6 seconds
- Rotate compressor every 2 minutes
- Metronome @ rate of 110/min for manual CPR
- Team Leader role-CPR quality, monitor rhythm checks
- If arrest witnessed by medical personnel, perform CPR until
Ready to defibrillate
- If unwitnessed arrest, perform CPR for 2 min prior to rhythm check
- TAH patients DO NOT perform compressions unless instructed
otherwise by VAD or TAH coordinator or Base Hospital
- AED
- Assist ventilations with BVM
- Monitor 02 stat
81
DYSRHYTHMIAS, (S-127):
ALS
VF/PULELESS VT
- Monitor EKG
- Defibrillate when ready every 2 min while VF/VT persists
- Charge monitor prior to rhythm checks, do not interrupt CPR while charging defibrillation
- Capnography
- Rhythm check-minimize interruption of compressions less than 5 sec.
- IV/IO do not interrupt CPR
- Epinephrine 1:10,000 1mg IV/IO q3-5” SO
(After 1st shock if still refractory.....)
82
DYSRHYTHMIAS, (S-127):
ALS
VF/Pulseless VT:
After 1st shock if still refractory:
Amiodarone 300mg IV/IO, MR 150mg (mag of 450mg) SO
...OR...
Lidocaine 1.5mg/kg IV/IO, MR x1 in 3-5min (max 3mg/kg), SO
- Document EtCO2 during BVM, if zero do not intubate, continue to
ventilate with BVM
- Intubate/PAA, SO without interrupting compressions
- NG/OG prn, SO
If persistent or shock refractory VF/VT after 3 rounds of drugs, contact base hospital for direction.
83
DYSRHYTHMIAS, (S-127):
ALS
VF/Pulseless VT:
ROSC:
- Ventilate with goal of EtCO2 of 40
- Check blood pressure
- Obtain 12 lead
- Transport to closest STEMI Center regardless of 12 lead reading, SO
84
Dysrhythmias (S-127)
CPR/Pulseless Bulletpoints
- For drug administration and intubation, perform high quality CPR with goal of appropriate rate (110), depth (1/3 of anterior/posterior chest diameter), allow full recoil, and minimize interruptions.
- Do not interrupt compressions
- Compression ratio 10:1 continuous compressions with ventilations every 6 seconds
- EtCO2 <10 = poor survivability
- Use mechanical CPR device if available
- Do not over-ventilate
- Transport traumatic arrests to trauma centers
- Transfer monitor data to QA/QI department if able
- Consider reviewing call with crew post event
85
Dysrhythmias (S-127): BLS, CPR
Associated with PEA
- CPR
- 10:1 compression ratio at rate of 110/min continuous compressions with ventilations every 6 seconds
- CPR rotate compressor every 2 minutes
- Start metronome at rate of 110/min for manual CPR
- Team leader role-CPR quality, monitor, rhythm checks
- TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator, or Base Hospital
- AED
- Assist ventilation with BVM
- Monitor 02 stat
86
Dysrhythmias (S-127):
ALS
PEA, if patient DOES NOT meet TOR criteria:
- Monitor
- Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation
- Capnography
- Rhythm check-minimize interruption of compressions less than 5 sec
- IV/IO do not interrupt CPR
- Epinephrine 1:10,000 1mg IV/IO. MR q3-5” SO
- Document EtCO2 during BVM, if zero do not intubate, continue to ventilate with BVM
- Intubate/PAA SO, without interrupting compressions
- NG/OG prn, SO
- 250ml fluid bolus IV/IO
If persistent PEA after 3 rounds of Epinephrine, contact base hospital for direction
ROSC:
- Ventilate with goal of EtCO2 of 40
- Check blood pressure
- Obtain 12 lead
- Transport to closest STEMI Center regardless of 12 lead reading, SO
87
Dysrhythmias (S-127):
Bullet points related to PEA’s:
- For drug administration and intubation, perform high quality CPR with goal of appropriate rate (110), depth (1/3 of anterior/posterior chest diameter), allow full recoil, and minimize interruptions.
- Do not interrupt compressions
- Compression ratio 10:1 continuous compressions with ventilations every 6 seconds
- EtCO2 <10 = poor survivability
- Use mechanical CPR device if available
- Do not over-ventilate
- Consider reversible causes of PEA (Hyperkalemia, Hypokalemia, Hypovolemia, Hypoxia, Tamponade, Thrombosis)
- Transport traumatic arrests to trauma centers
- Transfer monitor data to QA/QI department if able
- Consider reviewing call with crew post event
88
Dysrhythmias (S-127):
BLS associated with Asystole:
- CPR
- 10:1 compression ratio at rate of 110/min continuous compressions with ventilations every 6 seconds
- CPR rotate compressor every 2 minutes
- Start metronome at rate of 110/min for manual CPR
- Team leader role-CPR quality, monitor, rhythm checks
- TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator, or Base Hospital
- AED
- Assist ventilation with BVM
- Monitor 02 stat
(Q*hint: same as PEA)
89
DYSRHYTHMIAS (S-127):
ALS:
Asystole:
- Monitor
- Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation
- Capnography
- Rhythm check-minimize interruption of compressions less than 5 sec
- IV/IO do not interrupt CPR
- Epinephrine 1:10,000 1mg IV/IO. MR q3-5” SO
- Document EtCO2 during BVM, if zero do not intubate, continue to ventilate with BVM
- Intubate/PAA SO, without interrupting compressions
- NG/OG prn, SO
ROSC:
- Ventilate with goal of EtCO2 of 40
- Check blood pressure
- Obtain 12 lead
- Transport to closest STEMI Center regardless of 12 lead reading, SO
...Termination of Resuscitation (TOR) Criteria. If all these criteria have been met.... (continued)
90
Dysrhythmias (S-127): ALS
Asystole: Termination of Resuscitation (TOR) Criteria. If all these criteria have been met:
1. Victim arrest was not witnessed by EMS
- AND-
2. No bystander witness of collapse
- AND-
3. No bystander CPR
- AND-
4. Never received a rescue shock
- AND-
5. Never had a return pulse
THEN
- If there is no improvement and patient is in asystole after continuous resuscitation of less than 20 min, base contact is necessary in order to terminate resuscitation BHPO
- If asystolic after 20 min resuscitative efforts with no improvement cease efforts, SO. Document the Time of Apparent Death and the name of the paramedic.
- If all of the above criteria for TOR are met, Base Hospital Contact not required even if ALS interventions performed
91
Dysrhythmias (S-127):
Bulletpoints related to Asystole:
- This protocol only applies to asystole arrests of presumed cardiac origin. Drowning, Hypothermia, Electrocution are excluded
- Asystolic patients of cardiac origin should not be transported
- For drug administration and intubation, perform high quality CPR with goal of appropriate rate (110), depth (1/3 of AP chest diameter), allow full recoil, and minimize interruptions
- Do not interrupt compressions
- Compression rate of 110 with ventilations q6 seconds
- EtCO2 <10 = poor survivability
- Use mechanical CPR device if available
- Do not over-ventilate
- Transport Traumatic arrests to Trauma centers
- Transfer monitor data to QA/QI department if able
- Consider reviewing call with crew post event
92
Envenomation Injuries (S-129) - BLS
- 02 and/or ventilate prn
* Jellyfish sting:
- Liberally rinse with salt water ≥ 30 seconds.
- Scrape to remove stinger(s)
- Heat as tolerated (not exceeding 110°
* Stingray or Sculpin injury:
- Heat as tolerated (not exceeding 110°
* Snakebites:
- Mark proximal extent of swelling and/or tenderness
- Keep involved extremity at heart level and immobile
- Remove pre-existing constrictive device
93
Envenomation Injuries (S-129) - ALS:
- IV/IO, SO adjust prn
| - Treat pain as per Pain Management Protocol (S-141)
94
Environmental Exposure (S-130):
BLS - general
- Ensure patent airway
- 02 saturation prn
- 02 and/or ventilate prn
- Remove excess/wet clothing
- Obtain baseline temperature
95
Environmental Exposure (S-130):
BLS - Heat Exhaustion:
- Cool gradually
- Fanning, sponging with tepid water
- Avoid shivering
- If conscious, give small amounts of fluid
96
Environmental Exposure (S-130):
BLS - Heat Stroke:
- Rapid cooling
- Spray with cool water, fan. Avoid shivering.
- Ice packs to carotid, I guitar, and auxiliary regions
97
Environmental Exposure (S-130):
BLS - Cold Exposure:
- Gentle warming
- Blankets, warm packs
- Dry dressings
- Avoid unnecessary movement or rubbing
- If alert, give warm liquids
- If severe, NPO
- Prolonged CPR may be indicated
98
Environmental Exposure (S-130):
BLS - Near Drowning:
Spinal motion restriction when indicated
99
Environmental Exposure (S-130):
ALS
- Monitor EKG
- IV/IO, SO adjust prn
Severe Hypothermia with Cardiac Arrest:
- Hold medications
- Continue CPR
- If defibrillation needed, limit to 1 shock maximum
Suspected Heat Exhaustion/Heat Stroke:
- 500 ml fluid bolus IV/IO, SO, without rales. MR x1, SO
Near Drowning:
- CPAP at 5-10cm H20, SO for respiratory distress
100
Hemodialysis Patient (S-131):
BLS
- Ensure patent airway
- 02 saturation prn
- Give 02
- Ventilate if necessary
101
Hemodialysis Patient (S-131):
ALS
- Monitor EKG
- Determine time of last dialysis
* For Immediate Definitive Therapy ONLY:
- IV access in arm that does not have graft/AV fistula SO. Adjust prn
- EJ/IO access prior to accessing graft.
*If UNABLE & no other medication delivery route available:
- Access Percutaneous Vas Catheter BHPO if present (aspirate 5mL PRIOR to infusion)
... OR ...
- Access graft/AV fistula BHPO
* Fluid overload with rales:
- Treat as per S-136 (CHF/Cardiac)
(... continued: Symptomatic patient with suspected Hyperkalemia (widened QRS complex or peaked T-waves))
102
Hemodialysis Patient (S-131):
ALS
... Symptomatic patient with suspected Hyperkalemia (widened QRS complex or peaked T-waves):
- obtain 12 lead EKG
If >72 hrs since last dialysis:
- Continuous Albuterol 6ml .083% via Nebulizer, SO
- CaCl2 500mg IV/IO per SO
- NaHCO3 1mEq/kg IV/IO x1 per SO
NOTE: Vas-Caty contains concentrated dose of Heparin which must be aspirated PRIOR to infusion
103
Hemodialysis Patient (S-131)
SDCPA Educational Notes:
Hyperkalemia patients may be asymptomatic or report the following:
Generalized fatigue; Paresthesias; Palpitations; Weakness; Paralysis; Hypotension
ECG findings generally correlate with the potassium level, but potentially life-threatening arrhythmia can occur without warning at almost any level of hyperkalemia
- Early changes: peaked T waves, shortened QT interval, and ST-segment depression. These changes are followed by bundle-branch blocks causing a widening of the QRS complex, increases in the PR interval, and decreased amplitude of the P wave.
- Late Changes: P wave neutrally disappears and the QRS morphology widens to resemble a sine wave. Ventricular fibrillation or asystole follows.
104
Hemodialysis Patient (S-131):
Temporary Access - “Vas Caty”:
Temporary access is created for patients who need urgent dialysis or those who are waiting for their new fistula to mature. The VAS-CATH is a Subclavian, Internal Jugular or femoral placed catheter which has direct access to the heart. Extra care should be taken with temporary access which tends to have problems like blocked catheter from clots or infection at the time. Typically there are 2 ports (Red & Blue) and either may be acceded in an emergency situation. The Vas Cath must be aspirated thoroughly prior to flushing to remove any high concentrations of heparin within the catheter.
105
Hemodialysis Patient (S-131):
Arterio - Venous Fistula:
An arteriovenous (AV) fistula is created by directly connecting a vein to an arterial wall allowing arterial blood to flow directly into the vein. This is the best vascular access for dialysis, having been shown to stay open the longest with less clotting and infections than synthetic grafts. The arterial pressure causes the win to increase in size and allows high blood flow rates and repeated needle sticks. The patient will need temporary access (Vas Cath) for 6-12 weeks.
106
Hemodialysis Patient (S-131):
AV Grafts:
An AV Graft is a bridge created between an artery and deep vein. Grafts are relatively easy to place and can be used earlier than fistula (2-4 weeks). Grafts are used in patients who lack suitable vessels for a fistula and may be either straight or looped. They provide a large surface for cannulation and may be of material such as Gortex, or can be obtained from the patient’s own vein e.g. the vein in the thigh.
107
Decompression Illness/Diving/Altitude Incidents (S-132):
BLS
- 100% 02 and/or ventilate prn
- 02 saturation prn
- Spinal stabilization when indicated
* Reference Policy S-415 for Disposition of Diving Victims
108
Decompression Illness/Diving/Altitude Incidents (S-132):
ALS
- Monitor EKG
- IV/IO, SO adjust prn
*Reference Policy S-415 for Disposition of Diving Victims
109
Decompression Illness/Diving/Altitude Incidents (S-132):
Diving Victims:
Any victim who has breathed courses of compressed air below the water’s surface and presents the following:
- Minor Presentation: minimal localized joint pain, mottling of the skin surface, localized swelling with pain; none of which are progressive
- Major Presentation: symptoms listed above that are severe and/or rapidly progressing, vertigo, altered LOC, progressive paresthesia, paralysis, severe SOB, blurred vision, crepitus, hematemesis, hemoptysis, pneumothorax, trunk pain, or girdle or band-like burning discomfort.
110
Decompression Illness/Diving/Altitude Incidents (S-132):
Disposition of Diving Victims:
Major Presentation:
- All patients with a “major” presentation should be transported to UCSD Hillcrest
- Trauma issues are secondary in the presence of a “Major” presentation
- If the airway is unmanageable, divert to the closest BEF
Minor Presentation:
- Major trauma candidate: catchment trauma center
- Non-military patients: routine
- Active Duty Military Personnel: transport to the Military Duty Recompression Chamber if possible. The Base Hospital will contact the Duty Recompression Chamber at 619-556-7130 to determine chamber location. Paramedics/Base Hospital shall transfer care to Diving Medical Officer (or designee) upon arrival to chamber. Hyperbaric treatment may begin in accordance with military medical protocols.
Naval Hyperbaric Chamber Location:
Naval Station 32nd St & Harbor Dr.
Note: If possible, obtain dive computer or records. Hyperbaric Chambers must be capable of Recompression to 165ft.
111
Obstetrical Emergencies (S-133):
BLS
Mother:
- Ensure patent airway
- 02 saturation prn
- 02 ventilate Pain
- If no time for transport and delivery is imminent (crowning and pushing), proceed with delivery
- If no delivery, transport on left side
112
Obstetrical Emergencies (S-133):
BLS
Routine Delivery:
- Massage fund us if placenta delivered. (Do not wait on scene)
- Clamp and cut cord between clamps following delivery (wait 60 seconds after delivery prior to clamping and cutting cord)
- Document name of person cutting cord, time cut, and address
- Place identification bands on mother and infant
113
Obstetrical Emergencies (S-133):
BLS
Post-Partum Hemorrhage:
- Massage fund us vigorously
| - Baby to breast
114
Obstetrical Emergencies (S-133):
BLS
Eclampsia (seizures):
- Protect airway, and protect from injury
STAT transport for third trimester bleeding to facility with OB services per Base Hospital direction
... Note: If trauma related refer to S-139 and T-460 for disposition
115
Obstetrical Emergencies (S-133):
ALS
Mother:
- Monitor EKG
- IV/IO, SO adjust prn
Direct to Labor/Delivery area per BHO if ≥20 weeks gestation.
Eclampsia (seizures):
- Versed IN/IM/IV/IO, SO to a max dose of 5 mg (d/c if seizure stops) SO
MR x1 in 10 min SO. Max 10mg total.
... Note: If trauma related refer to S-139 and T-460 for disposition
116
```
Poisoning/Overdose (S-134):
BLS:
- general
- Ingestion
- Skin
```
- Ensure patent airway
- 02 saturation prn
- 02 and/or ventilate prn
- Carboxyhemoglobin monitor prn, if available
INGESTION:
- Identify substance
SKIN:
- Remove clothes
- Brush off dry chemicals
- Flush with copious water
117
Poisoning/Overdose (S-134):
```
BLS
Toxic Inhalation (CO exposure, smoke, gas, etc):
```
- Move patient to safe environment
- 100% 02 via mask
- Consider transport to facility with hyperbaric chamber for suspected carbon monoxide poisoning for unconscious or pregnant patient
118
Poisoning/Overdose (S-134):
BLS
Symptomatic suspected opioid OD with respiratory rate <12: (use with caution in opioid dependent pain management patients)
- Naloxone nasal spray 4mg preloaded single dose device*
- Administer full dose in one nostril *
...OR...
- Naloxone assemble 2mg syringe & atomizer*
- Administer 1mg into each nostril *
119
Poisoning/Overdose (S-134):
BLS
Contamination with commercial grade (“low level”) radioactive material:
Patients with mild injuries may be decontaminated (removal of contaminated clothing, brushing off of material prior to treatment and transport. Decontamination proceedings SHALL NOT delay treatment and transport of patients with significant or life-threatening injuries. Treatment of significant injuries is always the priority
120
Poisoning/Overdose (S-134):
ALS
- general
- Ingestions:
- Monitor EKG
- IV/IO, SO adjust prn
- Capnography SO prn
INGESTIONS:
- Charcoal 50Gm PO ingestion with any of the following within 60min SO if not vomiting:
Acetaminophen, colchicine, Cetacea blockers, calcium channel blockers, salicylates, valproate, oral anticoagulants (including rodenticides), Paraguay, amanita mushrooms
- Assure patient has gag reflex and is cooperative
121
Poisoning/Overdose (S-134):
ALS
Symptomatic suspected opioids OD with respiratory rate <12 (use with caution in opioid dependent pain management patients)
- Naloxone 2mg IN/IM/IV, SO. MR SO. Titrate IV dose to effect
- If patient refuses transport, give additional Naloxone 2mg IM, SO.
122
Poisoning/Overdose (S-134):
ALS
Symptomatic Organophosphate poisoning:
-Atropine 2mg IV/IM/IO, SO.
| MR x2 q3-5min SO. MR q3-5min BHO
123
Poisoning/Overdose (S-134):
ALS
Extrapyramidal reactions
- Benadryl 50mg slow IV/IM, SO
124
Poisoning/Overdose (S-134):
ALS
Suspected Tricyclics OD with cardiac effects (e.g. hypotension, heart block, or widened QRS):
NaHCO3 1 mEq/kg IV/IO, SO
125
Poisoning/Overdose (S-134):
ALS
In suspected cyanamide poisoning:
If cyanide kit is available on site (e.g. industrial site) may administer if patient is exhibiting significant symptoms:
- Amyl nitrite inhalation (over 30sec) BHPO
- Sodium thiosulfate 25%, 12.5 grams IV, BHPO
...OR...
- Hydroxocobalamin (Cyanokit) 5g IV BHPO
126
Poisoning/Overdose (S-134):
Notes:
For scene safety, consider HAZMAT activation as needed.,
- In symptomatic opioid OD (excluding opioid dependent pain management patients), administer Naloxone IN/IM prior to IV
- EMT’s not trained in Naloxone IN administration may assist family or friend to medicate with patient’s prescribed Naloxone in symptomatic suspected opioid OD.
- Note: EMT’s are authorized to administer one dose of Naloxone. If a patient refuses transport or if additional doses are required, initiate 911
* Per Title 22, chapter 1.5, Section 100019, public safety personnel may administer IN Naloxone when authorized by the County of San Diego EMS Medical Director.
127
Poisoning/Overdose (S-134):
BLS
Hyperthermia for Suspected Stimulant, Intoxication:
- Initiate cooling measures
- Obtain baseline temperature, if possible
Excited Delirium: SDCPA education note:
A medical emergency characterized by panic, shouting, violence, and hyperactivity, followed by sudden cessation of struggle, respiratory arrest and sudden death. It is often associated with stimulant drug use (cocaine/meth/PCP). Hyperthermia may be an ominous sign in these patients. Patients often disrobe due to hyperthermia.
Note: for agitated patient IN/IM Versed is preferred route to decrease risk of injury to patient and personnel
Note: Use caution when considering Versed use with ETOH intoxication. Can result in apnea.
128
Pre-Existing Medical Interventions (S-135):
BLS
- (general)
- Previously established electrolyte and/or glucose containing peripheral IV lines:
- Proceed with transport when person responsible for operating the device (the individual or another person) is able to continue to provide this function during transport
- Bring back-up equipment/batteries as appropriate
* Previously established electrolyte and/or glucose containing peripheral IV lines:
- Maintain at preset rates
- Turn off when indicated
129
Pre-Existing Medical Interventions (S-135):
BLS
Previously applied dermal medication delivery systems:
- Remove chest transdermal medication patches when indicated (CPR, shock), SO
130
Pre-Existing Medical Interventions (S-135):
BLS
Previously established IV medication delivery systems and/or other predicting treatment modalities with preset rates:
- If the person responsible for operating the device is unable to continue to provide this function during transport, contact the BH for direction.
BH may ONLY direct BLS personnel to:
1. Leave device as found OR turn the device off;
THEN:
2. Transport patient OR wait for ALS arrival
131
Pre-Existing Medical Interventions (S-135):
BLS
Transports to another facility or to home:
- No wait period is required after medication administration.
- If there is a central line, the tip of which lies in the central circulation, the catheter MUST be capped with a device which occluded the end.
- IV solutions with added medications OR other ALS treatment/monitoring modalities require ALS personnel (or RN/MD) in attendance during transport.
132
Pre-Existing Medical Interventions (S-135):
ALS
* Maintain previously established electrolyte and/or glucose containing IV solutions:
- Adjust rate or d/c BHO
* Maintain previously applied topical medication delivery systems:
- Remove dermal medications when indicated (CPR, shock) SO
* Pre-existing external vascular access (considered to be IV TKO):
- To be used for definitive therapy ONLY
* Maintain previously established and labeled IV medication delivery systems with preset rates and/or other per existing treatment modalities:
- d/c BHO
* If no medication label or clear identification of infusing substance:
- d/c BHO
133
Pre-Existing Medical Interventions (S-135):
Notes
Note: Consider early base hospital contact
Note: San Diego & Vicinity MCS Coordinators:
- Sharp Memorial Hospital: 858-939-3863 (if no answer, leave message & phone number, OR enter your phone number followed by “#” for a call back)
- Scripps La Jolla Hospital: 858-626-5823 or 858-554-9100
- UCSD: business hours: 858-657-5050 or
After hours: 619-543-6737 - ask for “ON CALL” VAD Coordinator
- Los Angeles Cedars Sinai Medical Center: 310-887-0599 (dial “0” for operator, state you are EMS and to patch to the VAD coordinator on call)
134
Respiratory Distress (S-136):
BLS, (general)
- Ensure patent airway
- Reassure
- 02 Saturation prn
- 02 and/or ventilate prn
- May assist patient to self-medicate own prescribed MDI ONE TIME ONLY. Base hospital contact required prior to repeat dose
135
Respiratory Distress (S-136):
BLS
Hyperventilation:
- Coaching/reassurance
- Remove patient from causative environment
- Consider underlying medical problem
136
Respiratory Distress (S-136):
```
BLS
Toxic Inhalation (CO exposure, smoke gas, etc):
```
- Move patient to safe environment
- 100% 02 via mask
- Consider transport to facility with hyperbaric chamber for suspected CO poisoning for unconscious or pregnant patient
137
Respiratory Distress (S-136):
BLS
Respiratory Distress with croup-like cough:
- Aerosolized saline or water 5mL via oxygen powered nebulizer/mask. MR prn
138
Respiratory Distress (S-136):
ALS, “general”
- Monitor EKG
- Capnography monitoring SO prn
- IV/IO SO, adjust prn
- Intubate SO prn
- NG/OG prn per SO
139
Respiratory Distress (S-136):
ALS
Respiratory Distress Suspected CHF/cardiac origin:
```
- NTG SL:
If systolic BP ≥100 but <150:
- NTG .4mg SL, SO. MR q3-5” SO
If systolic BP ≥150:
- NTG .8mg SL SO. MR q3-5” SO
If systolic BP ≥100:
- NTG ointment 1 inch, SO
If systolic BP <100:
- NTG .4mg SL per BHO. MR BHPO
- CPAP at 5-10 cm H2O, SO
```
140
Respiratory Distress (S-136):
ALS
Respiratory Distress Suspected non-cardiac:
- Albuterol 6ml .083% via nebulizer SO. MR SO
- Atrovent 2.5ml .02% via nebulizer added to first dose of Albuterol
- CPAP at 5-10cm H2O, SO
141
Respiratory Distress (S-136):
ALS
If severe respiratory distress/failure or inadequate response to Albuterol/Atrovent, consider:
If history of asthma or suspected allergic reaction:
- Epinephrine .3mg 1:1,000 IM, SO.
MR x2 q5 min, SO
If no definite history of asthma:
- Epinephrine .3mg 1:1,000 IM, BHPO
MR x2 q5 min, BHPO
142
Respiratory Distress (S-136):
Note:
- If any patient has taken an erectile dysfunction medication such as Viagra, Cailin, and Levitra within 48 hours, NTG is contraindicated.
- May encounter patients taking similar medications for pulmonary hypertension, usually Sildenafil (trade name: Revatio, Flolan, Veletri). NTG is contraindicated in these patients as well.
- Use caution with CPAP in patients with COPD, i.e. start low and titrate pressure.
- Epinephrine IM: use caution if known cardiac history or history of hypertension or BP >150 or age >40
- Fireline Paramedics (FEMP) without access to oxygen may use MDI delivery for Albuterol in place of nebulizer.
143
Sexual Assault (S-137): BLS/ALS
- Ensure patent airway
- 02 and/or ventilate prn
- Advise patient not to bathe or change clothes
- Consult with law enforcement on scene for evidence collection
If patient requires a medical evaluation:
- Transport to the closest, most appropriate facility
- Law enforcement will authorize and arrange an evidentiary exam after the patient is stabilized
If only evidentiary exam is needed
- Should release to load enforcement for transport to a SART facility
144
Shock (S-138):
BLS
- 02 saturation prn
- 02 and/or ventilation prn
- Control obvious external bleeding
- Treat associated injuries
- NPO, anticipate vomiting
- Remove any transdermal patch
145
Shock (S-138):
ALS, “general”
- Monitor EKG
- IV/IO, SO
- Capnography SO, prn
146
Shock (S-138):
ALS
Shock (suspected cardiac etiology):
- 250ml fluid bolus IV/IO without rales SO
| MR x1 to maintain BP ≥ 90 SO
147
Shock (S-138):
ALS
If BP refractory to second fluid bolus:
- Dopamine 400mg/250ml @ 10-40 mcg/kg/min IV/IO drop.
| Titrate BP ≥90 BHO
148
Shock (S-138):
ALS
Shock: Hypovolemic (non-traumatic):
- 500ml Fluid bolus IV/IO, SO
| MR to maintain BP ≥ 90, SO
149
Shock (S-138):
ALS
Shock: Hypovolemic (suspected AAA)
- 500ml fluid bolus IV/IO SO
| MR to maintain BP ≥80 SO
150
Shock (S-138):
ALS
Shock (suspected Anaphylactic, Neurogenic):
500ml fluid bolus IV/IO, SO
| MR to maintain BP ≥90 SO
151
Shock (S-138):
ALS
If BP refractory to fluid boluses:
- Dopamine 400mg/250ml @10-40 mcg/kg/min, IV/IO drop.
| Titrate BP ≥90 BHO
152
Shock (S-138):
ALS
Shock: (Sepsis)
Treat as per Sepsis Protocol (S-143)
153
Shock (S-138):
NOTE: (from S-101 Glossary of Terms):
“Shock” is defined by the following: (age ≥15 years):
- Systolic BP <80 mmHg ... OR...
- Systolic BP <90 mmHg AND exhibiting any of the following signs of inadequate perfusion:
1. altered mental status (decreased LOC, confusion, agitation)
2. Tachycardia
3. Pallor
5. Diaphoresis
154
Trauma (S-139):
BLS - “general”
- ensure patent airway, protecting C-spine
- control obvious bleeding
- spinal stabilization prn. (Except in penetrating trauma without neurological deficits)
- 02 saturation prn
- 02 and/or ventilate prn
- keep warm
- hemostatic gauze
155
Trauma (S-139):
BLS
Abdominal Trauma
Cover eviscerated bowel with saline pads
156
Trauma (S-139):
BLS
Chest Trauma
- Cover open chest wound with three-sided occlusive dressing; release dressing if ?tension pneumothorax develops.
- Use of chest seal
157
Trauma (S-139):
BLS
Extremity Trauma:
- Splint neurologically stable fractures as they lie.
- Use traction splint as indicated.
- Grossly Angela Ted long bone fractures with neurovascular compromise may be reduced with GENTLE unidirectional traction for splinting per BHO
- Apply tourniquet in severely injured extremity when direct pressure or pressure dressing fails to control life-threatening hemorrhage.
- In Mass Casualty direct pressure not required prior to tourniquet application
158
Trauma (S-139):
BLS
Impaled Objects:
- Immobilize and leave impaled objects in place. Remove BHPO
- Exception: may remove impaled object in face/cheek or from neck if there is total airway obstruction.
159
Trauma (S-139):
```
BLS
Neurological Trauma (head and spine injuries):
```
- Ensure adequate oxygenation without hyperventilating patient. Goal: 6-8 ventilations/minute
160
Trauma (S-139):
BLS
Pregnancy ≥ 6 months
- Where spinal stabilization precaution is indicated, tilt on spine board 30°
161
Trauma (S-139):
BLS
Blunt Traumatic Arrest:
Consider pronouncement at scene, BHPO
162
Trauma (S-139):
ALS - “general”
- Monitor EKG
- IV/IO, SO
- If MTV IV/IO en route, SO
- 500ml fluid bolus IV/IO to maintain BP at 80
- Capnography SO, prn
- Treat pain as per Pain Management Protocol (S-141)
163
Trauma (S-139):
ALS
Crush injury with extended compression >2 hrs of extremity or torso:
Just Prior to Extremity Release:
- 500ml fluid bolus IV/IO, then TKO SO
- CaCl2 500mg IV/IO over 30 sec. BHO
- NaHCO3 1mEq/kg IV/IO, BHO
164
Trauma (S-139):
ALS
Grossly Angela Ted long bone fractures
Reduce with gentle unidirectional traction for splinting, SO
165
Trauma (S-139):
ALS
Severe Respiratory Distress with unilateral dismissed breath sounds and systolic BP <90
Needle thoracostomy, SO
166
Trauma (S-139):
ALS
Blunt Traumatic Arrest
Consider pronouncement at scene*
* note: Reference Policy S-402 Prehospital Determination of Death
167
Trauma (S-139):
ALS
Penetrating Traumatic Arrest
Rapid transport off scene
