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MEDICAL ADVISORY COMMITTEE AGENDA Tuesday May 14, 2013, 2 p.m.-4
p.m.
Conference Room – 1350 Arnold Drive
1. Introductions 5 min 2. Announcements 10 min 3. System Updates
10 min
a. STEMI/Stroke (Mia Fairbanks) b. Cardiac Arrest Data (CARES)
c. QI (Craig Stroup)
4. Spinal Immobilization Task Force 5 min 5. 2014 Treatment
Guidelines 30 min 6. Intraosseous Procedures Changes 10 min 7.
Vascular Access – External Jugular 10 min 8. Proposed Policy
Changes 15 min
a. Policy 13 – Trauma Triage – Call-in criteria b. Policy 9 –
Destination – Cardiac Arrest with ROSC
9. Chlorhexidine Skin Prep 5 min 10. Equipment List Changes 5
min
a. Adenosine b. Stopcocks c. Spinal immobilization devices d.
Other
11. Hospital Off-Load Issues 5 min 12. Other
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Proposed Treatment Guideline and Prehospital Care Manual Changes
for 2014 – May 6, 2013 A2 Chest Pain/ACS/STEMI Modify 12-lead ECG
item to reflect continuous monitoring via 12-lead
Change morphine to fentanyl IV A3 Cardiac Arrest Initial Care
Under Compressions rate – state 100-120 and use metronome A4 VF/VT
Revised CPR/Rhythm Check to remind on q2 rhythm checks. Comment re:
glucose check during arrest A5 PEA/Asystole Comment re: glucose
check during arrest A6 Symptomatic Bradycardia Change morphine to
fentanyl IV A10 Shock/Hypovolemia Under Sepsis screen, correct
heart rate/pulse greater than 90 (not 100) A12 Public Safety
Defibrillation Under compressions rate – state 100-120 G1
Anaphylaxis/Allergy Add comment that anaphylaxis may include
hypotension alone. Add comment that thigh is preferred site
for epinephrine IM due to most rapid absorption, G2 ALOC Remove
D50 G3 Behavioral Emergency Remove base order requirement for use
of Midazolam (no repeat dose) – limit IV dose to 3 mg
Need to look at documentation requirements also G4 Burns Change
morphine to fentanyl IV and IM G10 Pain Management (Non-Traumatic)
Change morphine to fentanyl IV and IM
Modify contraindications and cautions G11 Poisoning-Overdose For
HF exposure, Change morphine to fentanyl IV and IM
Add section on suspected carbon monoxide poisoning G13
Respiratory Distress Remove morphine for anxiety G16 Trauma –
General Change morphine to fentanyl IV and IM. Modify indications
and precautions G16 Trauma – Extremity Change morphine to fentanyl
G17 Vomiting and Severe Nausea Changed reference from morphine to
fentanyl. Removed co-administration comment (less likely).
Consider
12-lead ECG P2 Cardiac Arrest Initial Care Under Compressions
rate – state 100-120 and use metronome IFT1 IFT of STEMI patients
Change morphine to fentanyl IV Procedure 12-lead Acquisition Add
statement about continuous monitoring Procedure Spinal
Immobilization Change to spinal motion restriction – revision after
spinal immobilization task force (not done yet) Procedure Humeral
IO Add to key procedures, modify vascular access, modify procedure
manual (not yet done) Procedure Procedure – CO Monitoring (new) Add
in Key Procedures Chart and add procedure Drug Adult Drug Reference
Add fentanyl, remove morphine, remove D50, modify midazolam for
behavioral sedation Drug Pediatric Drug Reference Add fentanyl,
remove morphine Drug Color charts May Need to adjust for weight
ranges to reflect new Broselow ranges (not done yet)
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A2 ADULT
CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME / STEMI
OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock
ALS: Titrate to sPO2 of at least 94% CARDIAC MONITOR
ASPIRIN 325 mg po to be chewed by patient – DO NOT administer if
patient has allergies to aspirin or salicylates or has apparent
active gastrointestinal bleeding 12 – LEAD ECG Repeat ECGs are
encouraged. Monitor 12-lead continuously. IV TKO
If ECG Does Not Indicate Acute MI or STEMI
NITROGLYCERIN
0.4 mg sublingual or spray - May repeat every 5 minutes until
pain subsides, maximum 3 doses. Contact base hospital if further
dosages indicated. IV placement prior to NTG recommended for
patients who have not taken NTG previously. PRECAUTIONS: Do not
administer NTG if: • Blood pressure below 90 systolic; • Heart rate
below 50; • Patient has recently taken erectile dysfunction (ED)
drugs:
o Viagra, Levitra, Staxyn or Stendra within 24 hours o Cialis
within 36 hours
Consider FLUID BOLUS
500 ml NS if BP less than 90, lungs clear and unresponsive to
supine positioning with legs elevated. May repeat X 1.
Consider FENTANYL CITRATE
50-200 mcg IV titrated in 25-50 mcg increments (consider 25 mcg
increments in elderly patients). Consider earlier administration to
patients in severe distress from pain. Titrate to pain relief,
systolic BP greater than 90, and adequate respiratory effort.
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Acute MI / STEMI Noted by 12-Lead ECG
NITROGLYCERIN Do not administer Nitroglycerin if Acute MI /
STEMI noted on 12-lead ECG. Exception: Patients with suspected
pulmonary edema and STEMI should receive nitroglycerin if no other
contraindications (e.g. hypotension, bradycardia or use of erectile
dysfunction drugs)
STEMI ALERT Transmit ECG to STEMI Center and contact as soon as
possible to notify facility of transport. Enter patient identifiers
prior to transmission. EARLY TRANSPORT Minimize scene time
FLUID BOLUS • 500 ml NS for Inferior MI (elevation in leads II,
III, aVF) if lungs clear
(regardless of blood pressure) • 500 ml NS if BP less than 90,
lungs clear and unresponsive to positioning.
May repeat up to X 3.
Consider FENTANYL CITRATE
50-200 mcg IV in 50 mcg increments (consider 25 mcg increments
in elderly patients). Consider earlier administration to patients
in severe distress from pain. Titrate to pain relief, systolic BP
greater than 90, and adequate respiratory effort. Caution: If
Inferior MI suspected, use 25-50 mcg increments and observe
carefully for hypotension
Key Treatment Considerations • Classic symptoms: Substernal
pain, discomfort or tightness with radiation to jaw, left shoulder
or arm,
nausea, diaphoresis, dyspnea (shortness of breath), anxiety •
Diabetic, female or elderly patients more frequently present
atypically • Atypical symptoms can include syncope, weakness or
sudden onset fatigue • Many STEMI’s evolve during prehospital
period and are not noted on initial 12-lead ECG • ECG should be
obtained prior to treatment for bradycardia if condition permits •
Transmit all 12-lead ECGs - whether STEMI is detected or not
detected
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A3 ADULT CARDIAC ARREST – INITIAL CARE AND CPR
ESTABLISH TEAM LEADER
• First agency on scene assumes leadership role • Leadership
role can be transferred as additional personnel arrive
CONFIRM ARREST • Unresponsive, no breathing or agonal
respirations, no pulse
COMPRESSIONS
Begin Compressions: • Rate – 100-120 per minute. Use metronome.
• Depth - 2 inches in adults – allow full recoil of chest (lift
heel of hand) • Rotate compressors every 2 minutes if manual
compression used Minimize interruptions. If necessary to interrupt,
limit to 10 seconds or less. • Perform CPR during charging of
defibrillator • Resume CPR immediately after shock (do not stop for
pulse or rhythm check) Prepare mechanical compression device (if
available) • Apply with minimal interruption • Should be placed
following completion of at least one 2-minute manual CPR
cycle or at end of subsequent cycle
AED or MONITOR/ DEFIBRILLATOR
• Apply pads while compressions in progress • Determine rhythm
and shock, if indicated • Check rhythm every 2 minutes • Follow
specific treatment guideline based on rhythm
BASIC AIRWAY MANAGEMENT and VENTILATION
• Open airway and provide 2 breaths after every 30 compressions
• Avoid excessive ventilation – no more than 8 – 10 ventilations
per minute • Ventilations should be about 1 second each, enough to
cause visible chest rise • Use two-person BLS Airway management
(one holding mask and one
squeezing bag) • If available, use ResQPOD with two-person BLS
airway management
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IV / IO ACCESS • IO access is preferred unless no suitable site
is available • If IV used (no IO access), antecubital vein is
preferred • Hand veins and other smaller veins should not be used
in cardiac arrest
ADVANCED AIRWAY
• Placement of advanced airway is not a priority during the
first 5 minutes of resuscitation unless no ventilation is occurring
with basic maneuvers o Exception: If ResQPOD used, early use of
King Airway is appropriate
• Placement of King Airway or endotracheal tube should not
interrupt compressions for more than 10 seconds
• For endotracheal intubation, position and visualize airway
prior to cessation of CPR for tube passage. Immediately resume
compressions after tube passage.
• Confirm tube placement and provide on-going monitoring using
end-tidal carbon dioxide monitoring
TREATMENT ON SCENE
• Movement of a patient may interrupt CPR or prevent adequate
depth and rate of compressions, which may be detrimental to patient
outcome
• Provide resuscitative efforts on scene up to 30 minutes to
maximize chances of return of spontaneous circulation (ROSC)
• If resuscitation does not attain ROSC, consider cessation of
efforts per policy
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A4 ADULT
VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA
INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3)
DEFIBRILLATION 200 joules (low energy 120 joules) CPR For 2 minutes
or 5 cycles between rhythm check
VENTILATION/AIRWAY • BLS airway is preferred method during first
5 -6 minutes of CPR • If no ventilation occurring with basic
maneuvers, proceed to advanced airway
IO or IV TKO. Should not delay shock or interrupt CPR
DEFIBRILLATION 300 joules (low energy 150 joules) EPINEPHRINE
1:10,000 - 1 mg IV or IO every 3-5 minutes DEFIBRILLATION 360
joules (low energy 200 joules) AMIODARONE 300 mg IV or IO
DEFIBRILLATION 360 joules (low energy 200 joules) as indicated
after every CPR cycle
ADVANCED AIRWAY • Should not interfere with initial 5-6 minutes
of CPR – minimize interruptions • Do not interrupt compressions
more than 10 seconds to obtain airway
Consider repeat AMIODARONE If rhythm persists, 150 mg IV or IO,
3-5 minutes after initial dose
TRANSPORT If indicated. If return of spontaneous circulation
(ROSC), patient should be transported to a STEMI center. Patients
without ROSC should be transported to closest facility.
Consider SODIUM BICARBONATE 1 mEq/kg IV or IO for suspected
hyperkalemia or pre-existing acidosis
If Return of Spontaneous Circulation, see Post-Cardiac Arrest
Care (A11)
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Key Treatment Considerations • Uninterrupted CPR and timely
defibrillations are the keys to successful resuscitation. Their
performance
takes precedence over advanced airway management and
administration of medications. • To minimize CPR interruptions,
perform CPR during charging, and immediately resume CPR after
shock
administered (no pulse or rhythm check) • Rotate compressors
every 2 minutes
• Avoid excessive ventilation. Provide no more than 8-10
ventilations per minute. • Ventilations should be about one second
each, enough to cause visible chest rise • If advanced airway
placed, perform CPR continuously without pauses for ventilation
• If available, ResQPOD impedance threshold device may be used
with BLS airway or King / ET tube • If utilizing Endotracheal Tube,
minimize CPR interruptions by positioning airway and laryngoscope,
and
performing airway visualization prior to cessation of CPR for
tube passage. Immediately resume CPR after passage.
• Confirm placement of advanced airway (King Airway or ET tube)
with end-tidal carbon dioxide measurement. Continuous monitoring
with ETCO2 is mandatory – if values less than 10 mm Hg seen, assess
quality of compressions for adequate rate and depth. Rapid rise in
ETCO2 may be the earliest indicator of return of circulation.
• Prepare drugs before rhythm check and administer during CPR •
Follow each drug with 20 ml NS flush
• Fingerstick glucose determinations are unreliable during
cardiac arrest. Glucose checks should be reserved for patients with
return of spontaneous circulation.
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A5 ADULT PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE
INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3)
EPINEPHRINE 1:10,000 1 mg IV or IO every 3-5 minutes
Consider treatable causes – treat if applicable: Consider FLUID
BOLUS For hypovolemia: 500-1000 ml NS IV or IO
VENTILATION For hypoxia: Ensure adequate ventilation (8-10
breaths per minute)
Consider SODIUM BICARBONATE
For pre-existing acidosis (e.g. kidney failure), hyperkalemia,
or tricyclic antidepressant overdose are suspected: • 1 mEq/kg IV
or IO if indicated • Should not be used routinely in cardiac
arrest
Consider CALCIUM CHLORIDE
For hyperkalemia or calcium channel blocker overdose: • 500 mg
IV or IO – may repeat in 5-10 minutes • Should not be used
routinely in cardiac arrest
Consider WARMING MEASURES For hypothermia
Consider NEEDLE THORACOSTOMY For tension pneumothorax
If Return of Spontaneous Circulation, see Post-Cardiac Arrest
Care (A11)
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Consider TERMINATION OF RESUSCITATION
Patients who have all of the following criteria are highly
unlikely to survive: • Unwitnessed Arrest and • No bystander CPR
and • No shockable rhythm seen and no shocks delivered during
resuscitation and • No return of spontaneous circulation (ROSC)
during resuscitation Patients with asystole or PEA whose arrests
are witnessed and/or who have had bystander CPR administered have a
slightly higher likelihood of survival. If unresponsive to
interventions these patients should be considered for termination
of resuscitation.
TRANSPORT If indicated. If return of spontaneous circulation
(ROSC), patient should be transported to a STEMI center. Patients
without ROSC should be transported to closest facility.
Key Treatment Considerations • Atropine is no longer used in
cardiac arrest • Pre-existing acidosis or hyperkalemia should be
suspected in patients with renal failure or dialysis or if
suspected diabetic ketoacidosis • In clear-cut traumatic arrest
situations, epinephrine is not indicated in PEA or asystole. If any
doubt as
to cause of arrest, treat as a non-traumatic arrest (e.g. solo
motor vehicle accident at low speed in older patients).
• Fingerstick glucose determinations are unreliable during
cardiac arrest. Glucose checks should be reserved for patients with
return of spontaneous circulation.
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A6 - ADULT SYMPTOMATIC BRADYCARDIA - Heart rate less than 50
with signs or symptoms of poor perfusion (e.g., acute altered
mental status, hypotension, other signs of shock). Correction of
hypoxia should be addressed prior to other treatments.
OXYGEN BLS: High flow initially ALS: Titrate to sPO2 of at least
94% CARDIAC MONITOR
IV TKO. If not promptly available, proceed to external cardiac
pacing. Consider IO ACCESS if patient in extremis and unconscious
or not responsive to painful stimuli. Consider FLUID BOLUS 250-500
ml NS if clear lung sounds and no respiratory distress
12-LEAD ECG Consider pre- and post-treatment if condition
permits TRANSCUTANEOUS PACING
Set rate at 80 Start at 10 mA, and increase in 10 mA increments
until capture is achieved
Consider SEDATION
If pacing urgently needed, sedate after pacing initiated •
MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg
increments
(maximum dose 5 mg), and/or • FENTANYL CITRATE 25-100 mcg IV or
IO in 25-50 mcg increments for pain
relief if BP 90 systolic or greater
Consider ATROPINE
May be used as a temporary measure while awaiting transcutaneous
pacing but should not delay initiation onset of pacing • 0.5 mg IV
or IO if availability of pacing delayed or pacing ineffective •
Consider repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3
mg Use with caution in patients with suspected ongoing cardiac
ischemia Atropine should not be used in wide-QRS second- and
third-degree blocks
TRANSPORT
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A10 ADULT SHOCK / HYPOVOLEMIA
HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with
dry lungs, flat neck veins • May have poor skin turgor, history of
GI bleeding, vomiting or diarrhea, altered level of
consciousness • May be warm and flushed, febrile, may have
respiratory distress • Sepsis patients may or may not have an
associated fever CARDIOGENIC SHOCK • Signs/symptoms of shock,
history of CHF, chest pain, rales, shortness of breath, pedal edema
HYPOVOLEMIA WITHOUT SHOCK • No signs of shock, but history of poor
fluid intake or fluid loss (e.g. vomiting, diarrhea). May
have tachycardia, poor skin turgor. OXYGEN BLS/ALS: High flow.
Be prepared to support ventilations as needed.
Consider CPAP If suspected pulmonary edema / cardiogenic shock
ADDRESS HYPOTHERMIA Keep patient warm if suspected hypothermia
CARDIAC MONITOR Treat dysrhythmias per specific treatment
guideline
EARLY TRANSPORT CODE 3
IV or IO TKO only if suspected pulmonary edema
FLUID BOLUS • For hypovolemic or septic shock, 500 ml NS bolus.
May repeat once. • For hypovolemia (poor intake/fluid loss), 250 ml
NS bolus. May repeat X 1.
Do not administer bolus if pulmonary edema or cardiogenic shock
suspected
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Consider 12-LEAD ECG If cardiac etiology for shock suspected
SEPSIS SCREEN
Check temperature, use sepsis screening tool and advise hospital
of positive sepsis screen if indicated A positive sepsis screen in
adults occurs in the setting of suspected infection when 2 of 3
conditions are met: • Heart rate/pulse greater than 90; •
Respiratory rate greater than 20; • Temperature above 100.4 or
below 96
BLOOD GLUCOSE Check and treat if indicated
Related guidelines: Altered level of consciousness (G2),
Respiratory Depression or apnea (G12)
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A12 ADULT
PUBLIC SAFETY DEFIBRILLATION BLS / LAW ENFORCEMENT
SCENE SAFETY / BSI Use universal blood and body fluid
precautions at all times
CONFIRM Unconscious, pulseless patient with no breathing or no
normal breathing
COMPRESSIONS
• Begin compressions at a rate of at least 100-120 per minute •
Compress chest at least 2 inches and allow full recoil of chest
(lift heel of hand) • Change compressors every 2 minutes • Minimize
interruptions in compressions. If necessary to interrupt, limit to
10
seconds or less. • Stop compressions for analysis only – resume
compressions while AED is charging • Resume compressions
immediately after any shock • If available, place mechanical
compression device after first rhythm analysis or
after subsequent rhythm analysis (LUCAS or Auto-Pulse)
AUTOMATED EXTERNAL DEFIBRILLATOR (AED)
• Priority of second rescuer is to apply pads while compressions
are in progress • If less than 8 years of age, attach pediatric
electrodes, if available. If not, attach adult
electrodes with anterior-posterior placement (pads should not
touch). • (*) Allow AED to analyze heart rhythm
o If the rhythm is shockable Resume compressions until charging
of unit is complete Clear bystanders and crew (stop compressions)
Deliver shock Resume CPR for 2 minutes, beginning with chest
compressions – then return to (*)
o If the rhythm is NOT shockable (“No Shock Advised”) Resume CPR
for 2 minutes, beginning with chest compressions – then return to
(*)
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BASIC AIRWAY MANAGEMENT and VENTILATION
Open airway and provide 2 breaths after every 30 compressions •
AVOID EXCESSIVE VENTILATION – Provide no more than 8 –10
ventilations per minute • Ventilations should be about one second
each, enough to cause visible chest rise. Use
two-person BLS Airway management (one holding mask and one
squeezing bag – compressor can squeeze the bag)
If patient begins to breathe or becomes responsive: • Maintain
airway • Assist ventilations as necessary
CHECK BLOOD PRESSURE
If patient begins to breathe or becomes responsive: • Check
blood pressure if equipment available
DOCUMENTATION • Complete AED Use Report • Forward report to EMS
whenever an AED is used (whether shock administered or not)
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G1 GENERAL
ANAPHYLAXIS / ALLERGY • Systemic reactions (anaphylaxis) include
upper and lower respiratory tracts, gastrointestinal or
vascular system. Symptoms include dyspnea, stridor, change in
voice, wheezing, anxiety, tachycardia, tightness in chest,
vomiting, diarrhea, abdominal pain, dizziness or hypotension
• Serious systemic reactions may involve hypotension alone
without respiratory or skin findings • Skin and mucous membrane
reactions (swelling of face, lip, tongue, palate), may be seen in
either
uncomplicated allergic reactions or in anaphylaxis
OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock
ALS: Titrate to sPO2 of at least 94% EPI-PEN May assist with
administration of patient’s auto-injector
CARDIAC MONITOR If systemic reaction (anaphylaxis):
EPINEPHRINE 1:1000 IM
• Adult – 0.3-0.5 mg IM (use 0.3 mg in elderly, small patients
or mild symptoms) Pediatric – 0.01 mg/kg IM – maximum dose 0.3 mg
May repeat in 15 minutes if systemic symptoms persist Lateral thigh
site should be used for IM injection (fastest absorption)
ALBUTEROL Adult and pediatric - 5 mg/6 ml saline via nebulizer –
may repeat as needed
IV TKO Consider FLUID BOLUS
• Adult – wide-open NS if hypotensive. Recheck vitals after
every 250 ml Pediatric - 20 ml/kg NS bolus if hypotensive, may
repeat X 2
If skin or mucous membrane reactions (itching, hives or
facial/oral swelling), consider:
DIPHENHYDRAMINE • Adult - 50 mg slow IV or IM
Consider 25 mg dose if patient has taken po diphenhydramine
Pediatric – 1 mg/kg IV or IM – Maximum dose 50 mg
Consider 0.5 mg/kg dose if patient has taken po
diphenhydramine
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If serious progression of symptoms after treatment with IM
epinephrine: • Includes profound hypotension, absence of palpable
pulses, unconsciousness, cyanosis, severe
respiratory distress or respiratory arrest Consider IO If IV
access not immediately available
FLUID BOLUS • Adult - wide open NS. Recheck vitals after every
250 ml Pediatric - 20 ml/kg NS bolus, may repeat X 2
Consider EPINEPHRINE 1:10,000 IV
If patient not responsive to IM epinephrine treatment in 5-10
minutes:
• Adult - titrate in 0.1 mg doses slow IV or IO to a maximum
dose of 0.5 mg Use extreme caution with patients with cardiac
history, angina, hypertension
Pediatric - titrate in up to 0.1 mg doses slow IV or IO to a
maximum of 0.01 mg/kg
Key Treatment Considerations • Epinephrine IM administered early
is the cornerstone of treatment in anaphylaxis
o Epinephrine is well tolerated in pediatric patients and
healthy young adults o In patients with prior history of coronary
artery disease (angina, MI, stent placement), use of
epinephrine IM is still indicated if symptoms are moderate to
severe. If symptoms mild, careful observation is prudent. Consider
base contact if any questions
• Diphenhydramine and albuterol are secondary considerations in
anaphylaxis • Up to 20% of anaphylaxis patients may present without
any skin findings (e.g. hives) • Gastrointestinal symptoms may
predominate in some patients, especially with serious reactions to
food • In pediatric patients, hypotension is late sign of shock Use
length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
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G2 GENERAL ALTERED LEVEL OF CONSCIOUSNESS
Glasgow Coma Scale less than 15 – uncertain etiology. Consider
AEIOU/TIPPS
OXYGEN BLS: High flow initially. ALS: Titrate to sPO2 of at
least 94%. Be prepared to support ventilations as needed.
ORAL GLUCOSE Consider if known diabetic, conscious, able to sit
upright, able to self-administer • Adult - 30 g po Pediatric –
15-30 g po
CARDIAC MONITOR
BLOOD GLUCOSE Check level
EARLY TRANSPORT In patients with ALOC without low blood
sugar
IV TKO NS
DEXTROSE 10% If glucose 60 or less: • Adult – DEXTROSE 10% 100
ml IV Pediatric – DEXTROSE 10% 0.5 g/kg IV (5 ml/kg)
GLUCAGON
If unable to establish IV (at least 2 attempts or if unable to
find suitable site): • Adult – 1 mg IM Pediatric – 24 kg or more –
1 mg IM Pediatric – Less than 24 kg – 0.5 mg IM
BLOOD GLUCOSE Recheck if symptoms not resolved. If GLUCAGON has
been administered, change in glucose/mentation may require 15
minutes or more. DEXTROSE 10% Repeat additional DEXTROSE 10% 150 ml
IV if glucose remains 60 or less.
DEXTROSE 50% Administer DEXTROSE 50% 25 g IV if glucose remains
60 or less after full Dextrose 10% dose given (250 ml) Related
guideline: Respiratory Depression or Apnea (G12)
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Key Treatment Considerations • Naloxone should not be given as
treatment for altered level of consciousness in the absence of
respiratory depression (respiratory depression = rate of less
than 12 breaths per minute) • After treatment(s) for hypoglycemia,
recheck glucose before considering repeat treatment. Mental
status improvement may lag behind improved glucose levels
(especially in elderly patients or prolonged hypoglycemia). Further
treatment when glucose is 60 or above is not indicated.
• Oral glucose is the preferred treatment when patient is able
to take medication orally • Dextrose 10% is the preferred treatment
when patient is unable to take oral medication • Glucagon should
not be administered if patient able to take oral glucose and should
be administered
only if IV starts are unsuccessful or no suitable IV sites
found. It may not be effective in patients with starvation, poor
oral intake, alcoholism or alcohol intoxication.
• Glucagon may take 10-15 minutes or longer to increase glucose
level (peak effects in 45-60 minutes) Wait for 10-15 minutes for
recheck glucose before considering additional treatment
• For diabetics with insulin pumps, the amount of insulin
administered by the pump is very small and should not impede
treatment of hypoglycemia. Insulin pumps should not be discontinued
because of the development of hypoglycemia.
• The presence of the pump should be identified during patient
report at the hospital.
• Transport is highly recommended in patients with hypoglycemia
as a result of oral diabetic medications and patients over 65 years
of age (higher risk of recurrent hypoglycemia).
• Transport is also highly recommended for any hypoglycemic
patient who is not a diabetic (may occur with renal failure,
starvation, alcohol intoxication, sepsis, rare metabolic disorders,
aspirin overdoses and sulfa drugs or following bariatric
surgery).
• Consider transport earlier in patients with poor vascular
access who are not responding to glucagon or have reasons listed
above for possible impaired response to glucagon
Use length-based tape for pediatric weight determination. See
Pediatric Drug Chart for D10 dose.
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G3 GENERAL BEHAVIORAL EMERGENCY
• A behavioral emergency is defined as combative or irrational
behavior not caused by medical illnesses such as hypoxia, shock,
hypoglycemia, head trauma, drug withdrawal, intoxicated states or
other conditions
• Combative or irrational behavior may be caused by psychiatric
or other behavioral disorder
• History of event and past history are important in patient
evaluation
• Past history of psychiatric condition does not eliminate need
to assess for other illnesses
SCENE SAFETY • Many patients merit a weapons search by law
enforcement • Physical restraints may be needed if patient exhibits
behavior that presents a
danger to him/herself or others
ASSESS PATIENT • Assess for evidence of hypoxia, hypoglycemia,
trauma • Consider other medical causes for behavioral symptoms
VITAL SIGNS Obtain vital signs as possible
Consider OXYGEN BLS: Low flow unless ALOC / respiratory distress
/ shock ALS: Titrate to sPO2 of at least 94% CARDIAC MONITOR Place
as possible / safe
Consider BLOOD GLUCOSE Obtain as possible / safe
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Consider CHEMICAL RESTRAINT
BASE ORDER REQUIRED Despite verbal de-escalation and physical
restraint, if adult patient (15 years or older) remains extremely
combative and struggling against restraints, consider: • MIDAZOLAM
5 mg IM. Lower doses should be considered in elderly or small
patients (under 50 kg). • MIDAZOLAM 1-3 IV mg in 1 mg increments
if IV established and patent.
Contact base if further medication needed.
MONITOR PATIENT Monitor closely for respiratory compromise.
Assess and document mental status, vital signs, and extremity exams
(if restrained) at least every 15 minutes. Related guidelines:
Altered Level of Consciousness (G2), Trauma (G16)
Key Treatment Considerations • Calming measures may be effective
and may preclude need for restraint in some circumstances • Utilize
a single person to establish rapport. Separate patient from crowd
and seek quiet environment if
possible, but maintain contact with other personnel and ability
to exit rapidly. • Avoid violating patient’s personal space, making
direct eye contact or sudden movements. Frequent
reassurance and calm demeanor of personnel are important.
• Enlist assistance of law enforcement if restraint needed.
Never transport patient in prone position. • Assure adequate
resources available to manage patient’s needs. Restraint may
require up to five
persons to safely control patient. • Patients with past history
of violent behavior are more likely to exhibit recurrent violent
behavior • In pediatric patients, consider child’s developmental
level when providing care • Sedation with Midazolam intended for
adult patients only (age 15 and over) • Not all patients will
respond to Midazolam. Repeat dosage is not recommended - requires
base order.
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G4 GENERAL BURNS
• Damage to the skin caused by contact with caustic material,
electricity, or fire • Second or third degree burns involving 20%
of the body surface area, or those associated with
respiratory involvement are considered major burns SCENE
SAFETY
STOP BURNING PROCESS • Remove contact with agent, unless adhered
to skin • Brush off chemical powders • Flush with water to stop
burning process or to decontaminate
OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock
ALS: Titrate to sPO2 of at least 94%
BURN CARE Protect the burned area. Do not break blisters, cover
with clean dressings or sheets. Remove restrictive clothing/jewelry
if possible. Assess for associated injuries Assess for associated
injuries if other trauma suspected
Consider IV or IO TKO
Consider FENTANYL CITRATE IV
For pain relief in the absence of hypotension (systolic BP less
than 90), significant other trauma, altered level of consciousness:
• Adult – 50-200 mcg IV or IO, titrated in 25-50 mcg increments
(consider 25 mg increments in elderly patients). Pediatric – 1
mcg/kg IV – See Pediatric Drug Chart
Consider FENTANYL CITRATE Intranasal
If IV or IO access not available: • Adult – 100 mcg Intransal –
may repeat once in 15 minutes Pediatric – 1.5 mcg/kg Intranasal –
See Pediatric Drug Chart
Consider FENTANYL CITRATE IM
If IV or IO access not available and intranasal route not
advisable: • Adult – 50-100 mcg IM – may repeat once in 15 minutes
Pediatric – 1 mcg/kg IM – See Pediatric Drug Chart
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Key Treatment Considerations • Airway burns may lead to rapid
compromise of airway (soot around nares, mouth, visible burns
or
edematous mucosa in mouth are clues) • Transport to closest
receiving facility for advanced airway management if it cannot be
done on scene in
a timely manner. Do not wait for helicopter (air ambulance) if
airway patency is a concern and care can be provided more rapidly
at a receiving facility.
• Do not apply wet dressings, liquids or gels on burns. Cooling
may lead to hypothermia.
• Refer to Rule of Nines to determine burn surface area (in
Policy and Hospital Reference section)
Use length-based tape for pediatric weight determination. See
Pediatric Drug Chart for dose.
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G10 GENERAL PAIN MANAGEMENT (NON-TRAUMATIC)
• Patients of all ages expressing verbal or behavioral
indicators of pain shall have an appropriate assessment and
management of pain
• Fentanyl should be given in sufficient amount to manage pain
but not necessarily to eliminate it Consider OXYGEN
BLS: Low flow unless ALOC / respiratory distress / shock ALS:
Titrate to sPO2 of at least 94%
IV TKO
ASSESS PAIN • Assess and document the intensity of the pain
using the visual analog scale • Reassess and document the intensity
of the pain after any intervention that
could affect pain intensity
PAIN RELIEF MEASURES
• Psychological measures and BLS measures, including cold packs,
repositioning, splinting, elevation, and/or traction splints, are
important considerations for patients with pain
• If pain cannot be managed using above measures, consider
FENTANYL CITRATE, especially in patients reporting pain levels of 5
or greater
Consider FENTANYL CITRATE IV
See contraindications and cautions below: For pain relief: •
Adult – 50-200 mcg IV, titrated in 25-50 mcg increments to pain
relief
(consider 25 mg increments in elderly patients) Pediatric – 1
mcg/kg IV – See Pediatric Drug Chart
Consider FENTANYL CITRATE Intranasal
If no IV access: • Adult - 100 mcg Intranasal. May repeat once
in 15 minutes. Pediatric – 1.5 mcg/kg Intranasal – See Pediatric
Drug Chart
Consider FENTANYL CITRATE IM
If no IV access and intranasal route not advisable: • Adult -
50-100 mcg IM. May repeat once in 15 minutes. Pediatric 1 mcg/kg IM
– See Pediatric Drug Chart
-
Contraindications and Cautions for Fentanyl Citrate
Contraindications for Fentanyl Citrate:
• Closed head injury • Altered level of consciousness • Headache
• Respiratory failure or worsening
respiratory status • Childbirth or suspected active
labor
• Hypotension o Adults - Systolic BP less than 90 o Pediatric -
Hypotension or impaired perfusion
(e.g. capillary refill > 2 seconds) Infants 1mo-1yr systolic
BP < 60 mmHg Toddler 1-4 yrs systolic BP < 75 mmHg School age
5-13 yrs systolic BP < 85 mmHg Adolescent >13 yrs systolic BP
< 90 mmHg
Cautions for Fentanyl: • Use with caution in patients with
suspected drug or alcohol ingestion or with suspected hypovolemia •
Older patients may be more sensitive to fentanyl – consider 25 mcg
increments IV initially • Patients with Inferior MI (STEMI with ST
elevation in II, III, aVF) may develop hypotension with
morphine
o Give 1-2 mg increments IV and administer fluid bolus when
indicated Key Treatment Considerations
• Have Naloxone available to reverse respiratory depression
should it occur • Preferred route of administration for Fentanyl
Citrate is IV • Intranasal route is preferred if IV not available
and patient does not have suspected hypovolemia Use length-based
tape for pediatric weight determination. See Pediatric Drug Chart
for dose.
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G11 GENERAL POISONING - OVERDOSE
• If possible, determine substance, amount ingested, time of
ingestion. Bring in container or label. • Be careful not to
contaminate yourself and others
DECONTAMINATION Remove contaminated clothing, brush off powders,
wash off liquids Irrigate eyes if affected
OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock
ALS: Titrate to sPO2 of at least 94%. Be prepared to support
ventilation. CARDIAC MONITOR
Consider IV TKO if unstable patient or suspected serious
ingestion
Related guidelines: Respiratory Depression or Apnea (G12),
Altered Level of Consciousness (G2), Seizures (G14),
Shock/Hypovolemia (A10, P8)
TRICYCLIC ANTIDEPRESSANT OVERDOSE • Frequently associated with
respiratory depression, usually tachycardia. Widened QRS
complexes
and associated ventricular arrhythmias are generally signs of a
life-threatening ingestion.
SODIUM BICARBONATE For adults only: For life-threatening
hemodynamically significant dysrhythmias, 1 mEq/kg slow IV or
IO
-
ORGANOPHOSPHATE POISONING • Hypersalivation, sweating,
bronchospasm, abdominal cramping, diarrhea, muscle weakness,
small/pinpoint pupils, muscle twitching, and/or seizures may
occur
ATROPINE For adults only: 1-2 mg IV • Repeat every 3-5 minutes
as necessary until relief of symptoms • Large doses of Atropine may
be required
HYDROFLUORIC ACID EXPOSURE
CALCIUM CHLORIDE For adults only: For tetany or cardiac arrest,
500mg IV (5 ml of 10% solution)
Consider FENTANYL CITRATE IV
For adults only: In the absence of hypotension, significant
other trauma or altered level of consciousness: 50-200 mcg IV
titrated in 25-50 mcg increments to pain relief
Consider FENTANYL CITRATE IM
For adults only: If no IV access, 50-100 mcg IM. May repeat once
in 15 minutes.
Consider FENTANYL CITRATE Intranasal
For adults only: If no IV access, 100 mcg intranasal. May repeat
once in 15 minutes.
Key Treatment Considerations • Few overdoses have specific
antidotes. Supportive care is the mainstay of treatment.
Contact Base Hospital if any questions concerning treatment of
overdose in pediatric patients
• Contact Base Hospital for other suspected overdoses that may
have specific treatment (e.g. Calcium Channel Blocker overdose)
• Poison Control Center can offer information but cannot provide
medical direction to EMS
-
SUSPECTED CARBON MONOXIDE POISONING • Symptoms may be diverse
and often non-specific. Headache, dizziness, fatigue and
nausea are most common symptoms. • Neurologic symptoms may
include confusion, lethargy, drowsiness, agitation, coma,
syncope, seizure or bizarre neurologic symptoms. • Other
symptoms may include chest pain, palpitations, dyspnea, weakness,
or flu-like
symptoms. • Evaluate for CO poisoning in suspected smoke
inhalation • Suspect and evaluate in situations when multiple
patients have symptoms • Consider evaluation when other causes for
symptoms are not obvious OXYGEN BLS/ALS: High flow. Be prepared to
support ventilations as needed CARDIAC MONITOR
CO-OXIMETRY Measure using manufacturer’s recommendation. May be
unreliable if low perfusion, excessive patient motion, or excessive
ambient light. Consider CPAP If patient compliant and co-oximetry
readings are greater than X%. 12-lead ECG
TRANSPORT If patient pregnant or levels greater than X%, contact
base hospital for potential destination determination IV TKO
Related Guidelines: Chest Pain/Suspected ACS (A2), Seizure
(G14)
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G13 GENERAL RESPIRATORY DISTRESS
• Wheezing may be noted in asthma, COPD exacerbation, or
pulmonary edema • Rales may be present in pneumonia, pulmonary
edema, and many other conditions
INITIAL THERAPY OXYGEN BLS: Low flow unless ALOC / respiratory
distress / shock ALS: Titrate to sPO2 of at least 94% CARDIAC
MONITOR Consider CPAP If respiratory rate greater than 25,
accessory muscle use, pulse ox less than 94% Consider IV TKO. Do
not delay transport for vascular access if in extremis.
ASTHMA ALBUTEROL Adult and Pediatric – 5 mg in 6 ml NS via
nebulizer. Repeat as needed.
Consider EPINEPHRINE 1:1000 SC (subcutaneously)
For use in asthma only: Use only if respiratory status
deteriorating despite repeat treatment with Albuterol and transport
time more than 10 minutes Do not use in patients with history of
coronary artery disease or hypertension • Adult - 0.3 mg SC
Pediatric - 0.01 mg/kg SC - max dose 0.3 mg Never give Epinephrine
1:1000 intravenously!
EPINEPHRINE 1:1000 IM
If respiratory arrest from asthma or bronchospasm: • Adult - 0.3
mg IM Pediatric - 0.01 mg/kg IM - max dose 0.3 mg
COPD EXACERBATION ALBUTEROL 5 mg in 6 ml NS via nebulizer.
Repeat as needed.
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SUSPECTED PULMONARY EDEMA (ADULTS ONLY)
NITROGLYCERIN
0.4 mg sublingual if systolic BP between 90 and 149 0.8 mg
sublingual if systolic BP 150 or greater Repeat every 5 minutes
until symptoms improve Maximum dose 4.8 mg (12 - 0.4 mg doses)
Discontinue if hypotension develops Caution: Do not administer if
patient has taken erectile dysfunction medications Viagra, Levitra,
Staxyn or Stendra within prior 24 hours or Cialis within 36
hours
(morphine deleted) Related guidelines – Chest pain / Suspected
ACS (A2), Shock (A10)
Key Treatment Considerations • CPAP is not a ventilation device.
Patients with inadequate respiratory rate or inadequate depth
of
respiration will need assistance with BVM. • Patients with
potential respiratory failure should be transported emergently •
Patients requiring advanced airway management in these situations
are best handled in the hospital
setting and CPAP may be a valuable “bridge” in care to
potentially delay need for emergent intubation • IV access should
not delay transport • For patients with significant anxiety or
claustrophobia with CPAP, consider base contact for midazolam • For
suspected pulmonary edema, re-evaluate blood pressure between each
dose of nitroglycerin. If
blood pressure initially over 150, then between 150 and 90 after
treatment, lower dosage to 0.4 mg. • Patients with suspected
pulmonary edema and STEMI should receive nitroglycerin if no
other
contraindications (e.g. hypotension, bradycardia or use of
erectile dysfunction drugs) • Consider cardiac etiology for
diabetic patients with respiratory distress Use length-based tape
for pediatric weight determination. See Pediatric Drug Chart for
dose.
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G16 GENERAL TRAUMA - GENERAL
SPINAL IMMOBILIZATION As indicated
OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock
ALS: Titrate to sPO2 of at least 94% EARLY TRANSPORT Limit scene
time to less than 10 minutes when possible. Load and go if high
risk. WOUND / GENERAL CARE
Place splints, cold packs, dressings and pressure on bleeding
sites as needed Keep patient warm – minimize exposure after
assessment
Consider NEEDLE THORACOSTOMY Evaluate for and treat tension
pneumothorax if indicated
IV TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO
ACCESS.
Consider FLUID BOLUS
Fluid resuscitation appropriate in adults if: • Head injury and
hypotension (BP < 90 or unable to detect peripheral pulses) • No
head injury but markedly hypotensive and unable to converse due to
shock
Administer 250-500 ml NS, recheck vitals. Titrate to presence of
peripheral pulses.
In pediatric patients with signs of poor perfusion or shock:
Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X
2
BLOOD GLUCOSE Test if GCS less than 15. See Altered Level of
Consciousness (G2). CARDIAC MONITOR
-
INDICATIONS AND PRECAUTIONS FOR FENTANYL USE
Fentanyl may be used for relief of extremity pain in the absence
of head or torso trauma, hypotension (age-specific), poor perfusion
or ALOC. Use with caution in geriatric elderly patients or in
patients with drug or alcohol intoxication.
FENTANYL CITRATE IV
See precautions above • Adult – 50-200 mcg IV in 25-50 mcg
increments. Titrate to pain relief and
systolic BP greater than 100. Pediatric – 1 mcg/kg IV – See
Pediatric Drug Chart
FENTANYL CITRATE IM
See precautions above When IV access not available (non-critical
patients only): • Adult – 50-100 mcg IM – may repeat in 15 minutes
Pediatric – 1 mcg/kg IM – See Pediatric Drug Chart
FENTANYL CITRATE Intranasal
See precautions above When IV access not available (non-critical
patients only): • Adult – 100 mcg intranasal – may repeat once in
15 minutes • Pediatric – 1.5 mcg/kg intranasal– See Pediatric Drug
Chart
Related guidelines: Altered Level of Consciousness (G2),
Respiratory Depression or Apnea (G12) Key Treatment
Considerations
• ALS procedures in the field (IV or advanced airway) do not
improve outcome in critical trauma patients o IV starts should be
done en route on these patients o Advanced airway should only be
done if patient is unable to be ventilated via BLS maneuvers
• Repeated IV attempts in non-critical pediatric patients should
be avoided Use length-based tape for pediatric weight
determination. See Pediatric Drug Chart for dose.
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G16 GENERAL TRAUMA – HEAD INJURY
AIRWAY CONTROL
• Basic airway management is preferred unless unable to manage
with BLS maneuvers. Utilize jaw thrust technique to open
airway.
• Intubation in head injury patients is best addressed at the
hospital or with RSI (aeromedical capability)
• King Airway should be used only in arrest unless no other
method to ventilate
VENTILATION
• Avoid hyperventilation if BVM used or patient with advanced
airway. • Support respiratory rate to 10-12 per minute if slow. •
Monitor patient with pulse oximetry and end-tidal CO2. Ideal ETCO2
is 35 mm Hg
– may be unreliable if multiple system trauma or poor perfusion.
• In patients with a dilated pupil on one side or
decerebrate/decorticate posturing
indicating impending brainstem herniation, modest
hyperventilation (increase in rate of 2-4 per minute) is
appropriate (keep ETCO2 30 or above)
CONTROL HEMORRHAGE
Scalp hemorrhage can be life threatening. Treat with direct
pressure and pressure dressing.
TREAT HYPOTENSION
In adult patients, in the setting of hypotension (systolic BP 90
or less or absence of peripheral pulses), administer NS 250-500 ml.
Repeat if necessary.
In pediatric patients with signs of poor perfusion or shock:
Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X
2.
PATIENT POSITION
Elevate head of backboard 30 degrees unless contraindicated
Position patient on side if needed for vomiting / airway
protection
Consider ONDANSETRON
• Adults - for vomiting/nausea, 4 mg IV/IM. May repeat every 10
minutes to a total dose of 12 mg.
Pediatric – Limited to patients 4 years of age or older – 4 mg
IV/IM For patients 40 kg and greater only, may repeat every 10
minutes to a total dose of 12 mg
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G16 GENERAL TRAUMA - EXTREMITY
Consider TOURNIQUET
If vigorous hemorrhage not controlled with elevation and direct
pressure on wound. May be used in pediatric patients. May be
appropriate for hemorrhage control in multi-casualty
situations.
SUSPECTED DISLOCATION If dislocation suspected or noted, splint
in position found
AMPUTATIONS
• For partial amputations, splint in anatomic location and
elevate extremity • If complete amputation, place amputated part in
a dry container or bag and
place on ice. Seal or tie off bag and place in second container
or bag. DO NOT place amputated part directly on ice or in water.
Elevated extremity and dress with dry gauze.
PAIN RELIEF • Consider Fentanyl Citrate as directed in G16
Trauma - General Guideline CRUSH INJURY SYNDROME
• Caused by muscle crush injury and cell death. Most patients
have an extensive area of involvement such as a large muscle mass
in a lower extremity and/or pelvis.
• May develop after 1 hour in severe crush, but usually requires
at least 4 hours of compression • Hypovolemia and hyperkalemia may
occur, particularly in extended entrapments • Hyperkalemia should
be suspected if ECG monitor reveals peaked ‘T’ waves, absent ‘P’
waves or
widened QRS complexes FLUID BOLUS 20 ml/kg NS prior to release
of compression
IF ECG CHANGES SUGGEST HYPERKALEMIA:
ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer CALCIUM
CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after
administration of calcium chloride to avoid precipitation with
sodium bicarbonate.
SODIUM BICARBONATE - 1 mEq/kg IV. Additionally, consider 1
mEq/kg added to IV 1L NS - use second IV line as other medications
may not be compatible
-
G17 GENERAL VOMITING AND SEVERE NAUSEA
Vomiting or nausea may be due to viral illness (gastroenteritis)
or other medical conditions including acute coronary syndrome,
stroke, head injury, or toxic ingestion. It may be associated with
a number of painful abdominal conditions, and may also occur as a
result of treatment of pain with fentanyl.
Consider OXYGEN BLS: Low flow unless ALOC / respiratory distress
/ shock ALS: Titrate to sPO2 of at least 94%
POSITION PATIENT Position patient to avoid aspiration
NON-INVASIVE MEASURES Fresh air, oxygen, and removal of noxious
odors may lessen nausea
Consider 12-LEAD ECG Cardiac events are often accompanied by
gastrointestinal symptoms
Consider IV TKO
Consider FLUID BOLUS
Consider if patient has prolonged history of vomiting or poor
intake, if vital signs or exam suggest volume depletion (rapid
pulse, low blood pressure, dry mucous membranes, poor skin turgor,
or capillary refill greater than 2 seconds) • Adult – 250-500 ml.
Recheck vitals – may repeat X 1 Pediatric – 20 ml/kg. Recheck
vitals – may repeat X 1.
-
Consider ONDANSETRON
For severe nausea or persistent vomiting: • Adult – 4 mg IV, IM,
or po (oral disintegrating tablet - ODT). May repeat
every 10 minutes to a total of 12 mg. Pediatric – limited to
patients 4 years of age or older – 4 mg IV, IM, or
po (ODT). For patients 40 kg and greater only, may repeat every
10 minutes to a total of 12 mg
NOTE: Administer IV dosage over 1 minute. Ondansetron is
contraindicated if patient has a history of hypersensitivity to
other similar drugs (Dolasetron – (Anzemet), granisetron (Kytril),
or Palonosetron (Aloxi)
Related guidelines: Shock/Hypovolemia (A10), Pain Management
(Non-Traumatic) (G10)
Key Treatment Considerations Rapid administration of ondansetron
has been associated with increased incidence of side effects – most
notably syncope. Ondansetron must be administered intravenously
over 1 minute. Rare side effects of ondansetron include headache,
dizziness, tachycardia, sedation, hypotension, or syncope. Rarely
QT prolongation has been seen (with higher doses and rapid
administration). Ondansetron can be used in pregnancy and with
breast-feeding mothers
May be co-administered with MORPHINE SULFATE when used for pain
relief
Oral disintegrating tablets should be handled with care as
moisture may cause premature breakdown of tablets before
administration Oral disintegrating tablets can be placed on tongue
and do not need to be chewed. Medication will dissolve and be
swallowed with saliva. Use length-based tape for pediatric weight
determination. See Pediatric Drug Chart for dose.
-
P2 PEDIATRIC CARDIAC ARREST – INITIAL CARE AND CPR
ESTABLISH TEAM LEADER
• First agency on scene assumes leadership role • Leadership
role can be transferred as additional personnel arrive
CONFIRM ARREST • Unresponsive, no breathing or agonal
respirations, no pulse
COMPRESSIONS
• Begin compressions at a rate of at least 100-120 per minute.
Use metronome. • Compress chest approximately 1/3 of AP diameter of
chest:
o In children (age 1-8) - around 2 inches o In infants (under
age 1) – around 1 ½ inches
• Allow full chest recoil (lift heel of hand) • Change
compressors every 2 minutes • Minimize any interruptions in
compressions. If necessary to interrupt, limit to 10
seconds or less. • Do not stop compressions while defibrillator
is charging • Resume compressions immediately after any shock
AED or MONITOR/ DEFIBRILLATOR
• Apply pads while compressions in progress • Determine rhythm
and shock, if indicated • Follow specific treatment guideline based
on rhythm
BASIC AIRWAY MANAGEMENT and VENTILATION
• Open airway – For 2-person CPR: o Provide 2 breaths:30
compressions for children over age 8 o Provide 2 breaths:15
compressions for infants > 1 month & children to age 8
• Avoid Excessive Ventilation • Ventilations should last one
second each, enough to cause visible chest rise • Use 2-person BLS
Airway management (one holding mask and one squeezing
bag)
-
MEDICATIONS AND DEFIBRILLATION
• Use length-based tape to determine weight • If child is obese
and length-based tape used to determine weight, use next
highest color to determine appropriate equipment and drug
dosing
• See Pediatric Drug Chart for medication dose and
defibrillation energy levels
ADVANCED AIRWAY MANAGEMENT and END-TIDAL CO2 MONITORING
For patients 40 kg or greater only: • Placement of advanced
airway is not a priority during the first 5 minutes of
resuscitation unless no ventilation is occurring with basic
maneuvers. • Placement of endotracheal tube or King Airway should
not interrupt
compressions for a period of more than 10 seconds • For
endotracheal intubation, position and visualize airway prior to
cessation of
CPR for tube passage. • Confirm tube placement and provide
ongoing monitoring using end-tidal carbon
dioxide monitoring
BLOOD GLUCOSE Treat if indicated. Glucose may be rapidly
depleted in pediatric arrest.
PREVENT HYPOTHERMIA
Move to warm environment and avoid unnecessary exposure •
Pediatric arrest victims are at risk for hypothermia due to their
increased body
surface area, exposure and can be exacerbated by rapid
administration of IV/IO fluids
TRANSPORT Consider rapid transport to definitive care
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IFT 1 TRANSFER INTERFACILITY TRANSFER OF STEMI PATIENTS
Patients with ST-elevation Myocardial Infarction (STEMI) needing
interventional cardiac care require timely transfer. A scene time
of 10 minutes or less at the sending facility is ideal.
OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock
ALS: Titrate to sPO2 of at least 94% Monitor IV Maintain TKO or
other existing flow rate Prompt Transport Transfer for definitive
care is the priority in STEMI patients
Consider FENTANYL CITRATE IV
50-200 mcg IV in 25-50 mcg increments (consider 25 mcg
increments in elderly patients). Patients with STEMI often do not
get complete relief with medication. Caution: If Inferior MI
suspected, use 25-50 mcg increments and observe carefully for
hypotension
Key Treatment Considerations Treatment during interfacility
transfer varies from field approach to chest pain/ACS: •
Confirmatory ECG for STEMI has been done by hospital and does not
need repeat prior to transfer or en
route to accepting facility • Nitroglycerin treatment is not
required and generally ineffective in patients with confirmed STEMI
Aspirin or other anti-platelet treatment if indicated should be
administered by sending hospital prior to patient departure
Patients generally will be directed directly to catheterization
laboratory Outcome in STEMI patients directly related to timeliness
of intervention to relieve coronary artery blockage. Minimizing
time delay in transfer is essential.
-
12-LEAD MONITORING AND LEAD PLACEMENT
Limb Lead Placement: Place limb leads on distal extremities if
possible Confirm correct lead placement for each limb May be moved
to proximal if needed (if motion artifact)
Chest Lead Placement: To begin placement of chest leads, locate
sternal angle (2nd ribs are adjacent) then count down to 4th
interspace (below 4th rib)
V1 – 4th intercostal space at the right sternal border V2 – 4th
intercostal space at the left sternal border V4 – 5th intercostal
space at left midclavicular line Note: Place V4 lead first to aid
in correct placement of V3 V3 – Directly between V2 and V4 V5 –
Level of V4 at left anterior axillary line V6 – Level of V4 at left
mid-axillary line
IMPORTANT: Careful skin preparation prior to lead placement (rub
with gauze or abrasive, clean skin oils with alcohol) is critical
to obtaining a high-quality ECG
Once leads have been placed, 12-lead monitoring should continue
throughout call to assess for potential changes.
Sternal angle
-
KEY PROCEDURES Skill Indication / Comment Contraindication
12-Lead ECG
• Chest pain or suspected Acute Coronary
Syndrome (ACS) • Atypical ACS or anginal equivalents:
o Symptoms include shortness of breath, diaphoresis, syncope,
dizziness, weakness, and altered level of consciousness
o Elderly patients, females and diabetics are more likely to
present atypically
• Arrhythmias (both pre- and post-conversion) • Suspected
cardiogenic shock • Cardiac arrest after return of spontaneous
circulation
• Uncooperative patient • Any condition in which delay to
obtain ECG would compromise immediately needed care (e.g.
arrhythmia requiring immediate shock)
Autopulse (SRVFPD) • Cardiac Arrest in Adults
• Pediatric patients • Trauma patients • Patients too small or
large for
the compression band
Blood Glucose Testing
• Altered level of consciousness • Patients with signs and
symptoms of
hypoglycemia (may include diaphoresis, weakness, hunger,
shakiness, anxiety)
• Patients not meeting any indication
Co-Oximetry (Carbon Monoxide)
• Suspected carbon monoxide poisoning • May be unreliable with
poor perfusion, excessive
patient motion or excessive ambient light • None
-
PARAMEDIC SCOPE OF PRACTICE California Code of Regulations,
Title 22, Division 9, Chapter 4: 100145. Scope of Practice of
Paramedic. a) A paramedic may perform any activity identified in
the scope of practice of an EMT in Chapter 2 of the
Division, or any activity identified in the scope of practice of
an Advanced EMT in Chapter 3 of this Division.
b) A paramedic shall be affiliated with an approved paramedic
service provider in order to perform the scope of practice
specified in this Chapter.
c) A paramedic student or a licensed paramedic, as part of an
organized EMS system, while caring for patients in a hospital as
part of his/her training or continuing education under the direct
supervision of a physician, registered nurse, or physician
assistant, or while at the scene of a medical emergency or during
transport, or during interfacility transfer, or while working in a
small and rural hospital pursuant to section 1797.195 of the Health
and Safety Code, may perform the following procedures or administer
the following medications when such are approved by the medical
director of the local EMS agency and are included in the written
policies and procedures of the LEMSA. 1) Basic Scope of
Practice:
A) Utilize electrocardiographic devices and monitor
electrocardiograms, including 12-lead electrocardiograms.
B) Perform defibrillation, synchronized cardioversion, and
external cardiac pacing. C) Visualize the airway by use of the
laryngoscope and remove foreign body(ies) with forceps. D) Perform
pulmonary ventilation by use of lower airway multi-lumen adjuncts,
the esophageal
airway, perilaryngeal airways, stomal intubation, and adult oral
endotracheal intubation. E) Utilize mechanical ventilation devices
for continuous positive airway pressure (CPAP), bi-level
positive airway pressure (BPAP) and positive end expiratory
pressure (PEEP) in the spontaneously breathing patient.
F) Institute intravenous (IV) catheters, saline locks, needles,
or other cannulae (IV lines), in peripheral veins; and monitor and
administer medications through pre-existing vascular access.
G) Institute intraosseous (IO) needles or catheters H)
Administer intravenous glucose solutions or isotonic balanced salt
solutions, including Ringer's
lactate solution. I) Obtain venous blood samples.
-
J) Use laboratory devices, including point of care testing, for
pre-hospital screening use to measure lab values including, but not
limited to: glucose, capnometry, capnography, and carbon monoxide
when appropriate authorization is obtained from State and Federal
agencies, including from the Centers for Medicare and Medicaid
Services pursuant to the Clinical Laboratory Improvement Amendments
(CLIA).
K) Utilize Valsalva maneuver. L) Perform needle
cricothyroidotomy. (not currently used in Contra Costa County) M)
Perform needle thoracostomy N) .Perform nasogastric and orogastric
tube insertion and suction (not currently used in Contra
Costa County) O) Monitor thoracostomy tubes P) Monitor and
adjust IV solutions containing potassium, equal to or less than 40
mEq/L. Q) Administer approved medications by the following routes:
IV, IO, intramuscular, subcutaneous,
inhalation, transcutaneous, rectal, sublingual, endotracheal,
oral or topical. R) Administer, using prepackaged products when
available, the following medications:
(1) 10%, 25% and 50% dextrose; (2) activated charcoal; (not
currently used in Contra Costa County) (3) adenosine; (4)
aerosolized or nebulized beta-2 specific bronchodilators; (5)
amiodarone; (6) aspirin; (7) atropine sulfate; (8) pralidoxime
chloride; (9) calcium chloride; (10) diazepam; (not currently used
in Contra Costa County) (11) diphenhydramine hydrochloride; (12)
dopamine hydrochloride; (not currently used in Contra Costa County)
(13) epinephrine;
-
(14) fentanyl; (15) glucagon; (16) ipratropium bromide (not
currently used in Contra Costa County) (17) lorazepam (18)
midazolam (19) lidocaine hydrochloride; (20) magnesium sulfate;
(21) morphine sulfate; (22) naloxone hydrochloride; (23)
nitroglycerin preparations, except IV, unless permitted under
(c)(2)(A) of this section; (24) ondansetron (25) sodium
bicarbonate
-
PARAMEDIC SCOPE OF PRACTICE (continued) – LOCAL OPTIONAL SCOPE
Paramedic Regulations (continued) 2) Local Optional Scope of
Practice: A) Perform or monitor other procedure(s) or administer
any other medication(s) determined to be
appropriate for paramedic use, in the professional judgment of
the medical director of the local EMS agency, that have been
approved by the Director of the Emergency Medical Services
Authority when the paramedic has been trained and tested to
demonstrate competence in performing the additional procedures and
administering the additional medications.
CONTRA COSTA LOCAL OPTIONAL SCOPE
• Impedance Threshold Device (ResQPOD) • Pediatric Endotracheal
Intubation (limited to patients > 40 kg)
CONTRA COSTA LOCAL OPTIONAL SCOPE ITEMS ITEMS LIMITED TO
CRITICAL CARE TRANSPORT PARAMEDICS ONLY
• Blood/Blood Product Infusion • Glycoprotein IIb/IIIa Receptor
Inhibitor Infusion • Heparin Infusion • KCL Infusion
• Lidocaine Infusion • Midazolam Infusion • Morphine Sulfate
Infusion • Nitroglycerin Infusion • Sodium Bicarbonate Infusion •
Total Parenteral Nutrition (TPN) Infusion
-
ADULT DRUG REFERENCE
Drug Indication Adult Dosage Precautions / Comments
DEXTROSE 50% Hypoglycemia 25 g IV Use D10 initially – use D50 if
repeat dosage needed
DIPHENHYDRAMINE
Allergy – Hives / Itching
25-50 mg IV or IM
For allergy, consider lower dose if patient has already taken po
dose in past two hours for symptoms Dystonic Reaction
EPINEPHRINE 1:10,000
Cardiac Arrest 1 mg IV or IO every 3-5 minutes Alpha & beta
sympathomimetic. May cause serious dysrhythmias and exacerbate
angina. Anaphylactic Shock
0.1 mg increments IV or IO up to 0.5 mg IV total dose
Use only if IM treatment ineffective
EPINEPHRINE 1:1000
Allergy/ Anaphylactic Shock
0.3-0.5 mg IM Use lower dose in smaller, older patients
Never administer intravenously! Do not use in asthma patients
with a history of hypertension or coronary artery disease. May
cause serious dysrhythmias and exacerbate angina.
Asthma
0.3 mg subcutaneously 0.3 mg IM if respiratory arrest from
asthma or bronchospasm
-
ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions /
Comments
FENTANYL CITRATE
Pain Control
50-200 mcg IV (25-50 mcg increments) 100 mcg Intranasally 50-100
mcg IM
Can cause hypotension and respiratory depression. Recheck VS
between each dose. Hypotension more common in patients with low
cardiac output or volume depletion. Respiratory depression
reversible with naloxone. Additional IV doses (titration) can be
given every 5 minutes. IM and intranasal doses can be repeated once
in 15 minutes.
Sedation – Pacing 25-100 mcg IV in 25-50 mcg increments
GLUCAGON Hypoglycemia 1 mg IM Effect may be delayed 5–20 min
LIDOCAINE IO Anesthesia 40 mg IO Repeat dose 20 mg Administer
slowly over 1 minute Not needed in arrest situations
MIDAZOLAM
Seizure
Titrate 1-5 mg IV in 1-2 mg increments
0.1 mg/kg IM (max. dose 5 mg IM)
With IV dosing, begin with 1 mg dose. IV increments should not
exceed 2 mg.
Observe respiratory status
Use with caution in patients over age 60
Base order required for behavioral emergency indication
Sedation for pacing or cardioversion
Titrate 1-5 mg IV in 1-2 mg increments
Sedation – transfer of intubated patient
Titrate 2-5 mg IV in up to 2 mg increments
Behavioral Emergency
5 mg IM 1-3 mg IV in 1 mg increments if IV available
-
(Morphine deleted - pulmonary edema indication deleted)
ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions /
Comments
NALOXONE
Respiratory Depression or Apnea (Respiratory rate less than
12)
2 mg intranasally (IN) 1-2 mg IV or IM
For careful titration in chronic pain or terminal patients,
dilute 1:10 and give 0.1 mg increments
Intranasal administration preferred unless patient in shock or
has copious secretion/blood in nares. Shorter duration of action
than that of most narcotics. Abrupt withdrawal symptoms and
combative behavior may occur.
NITROGLYCERIN
Chest Pain – Suspected ACS
0.4 mg sl or spray up to 3 doses
Can cause hypotension and headache. Do not give if BP less than
90 systolic or heart rate below 50. Perform 12-lead ECG before
administration. Do not give if STEMI detected. Do not give if
Viagra, Levitra, Staxyn or Stendra taken within 24 hours or if
Cialis taken within 36 hours.
Pulmonary Edema
0.4 mg sl or spray if systolic BP 90-149
0.8 mg sl or spray if systolic BP 150 or over Max.dose 4.8
mg
ONDANSETRON Vomiting and Severe Nausea 4 mg IV, IM or po (ODT)
May repeat q 10 min X 2
Give IV over 1 minute – may cause syncope if administered too
rapidly
SODIUM BICARBONATE
Cardiac arrest 1 mEq/kg IV or IO
For crush injury, consider additional 1 mEq/kg added to 1L NS
using second IV line
Assure adequate ventilation. Can precipitate or inactivate other
drugs. In cardiac arrest, indicated for treatment of suspected
hyperkalemia (history of renal failure or diabetes).
Tricyclic Antidepressant OD
Crush injury
-
PEDIATRIC DRUG REFERENCE Drug Indication Pediatric Dosage
Precautions / Comments
DEXTROSE 10%
Hypoglycemia 0.5 g/kg IV (5 ml/kg) Maximum 250 ml Recheck
glucose after administration
DIPHENHYDRAMINE Allergy - Hives / Itching 1 mg/kg IV or IM
Maximum dose 50 mg
Consider lower dose (0.5 mg/kg) if patient has already taken po
dose in the past two hours for symptoms
EPINEPHRINE 1:10,000
Cardiac Arrest 0.01 mg/kg IV or IO every 3-5 minutes Max. dose 1
mg
In anaphylactic shock, IM epinephrine 1:1000 should be
administered first and epinephrine 1:10,000 IV should only be used
if IM is ineffective Anaphylactic
Shock
Titrate in up to 0.1 mg increments slow IV or IO to a max. of
0.01 mg/kg
EPINEPHRINE 1:1000
Allergy/ Anaphylactic Shock
0.01 mg/kg IM Max single dose 0.3 mg Never administer
intravenously!
If respiratory arrest from asthma or bronchospasm, administer IM
Asthma
0.01 mg/kg subcutaneously Maximum dose 0.3 mg
FENTANYL CITRATE Pain Control
See drug chart for exact dosage. 1 mcg/kg IV or IM 1.5 mcg/kg
Intranasal
Can cause hypotension and respiratory depression. Hypotension is
more common in patients with volume depletion. Nausea may
occur.
GLUCAGON Hypoglycemia Weight less than 24 kg: 0.5 mg IM Weight
24 kg or more: 1 mg IM
Effect may be delayed 5–20 minutes - if patient responds, give
po sugar
-
PEDIATRIC DRUG REFERENCE Drug Indication Pediatric Dosage
Precautions / Comments
LIDOCAINE IO Pain 0.5 mg/kg IO. Maximum dose 20 mg Give slowly
over one minute. Not needed in arrest situations
MIDAZOLAM
Seizure
Titrate in up to 1 mg increments IV up to 0.1 mg/kg Maximum
total IV dose 5 mg
0.1 mg/kg IM Maximum dose 5 mg IM
Observe respiratory status carefully
Sedation for Cardioversion
0.1 mg/kg IV or IO titrated in 1 mg increments Maximum dose 5
mg
Sedation and cardioversion only with base hospital order
MORPHINE Pain Control
See pain management drug chart for dosage. Use IV increments of
up to 2 mg 0.1 mg/kg IM
Can cause hypotension and respiratory depression. Hypotension is
more common in patients with volume depletion. Nausea is a frequent
side effect.
NALOXONE Respiratory Depression or Apnea
0.1 mg/kg IM or IV Maximum dose 2 mg
May repeat as needed
Use IM route initially unless shock present. Shorter duration of
action than that of most narcotics.
ONDANSETRON Vomiting and Severe Nausea 4 mg IV, IM, or po (ODT)
In patients 40 kg and over, may repeat q 10 min X 2
For use in patients 4 years and up. Administer IV over 1 minute.
Rapid administration may cause syncope.
-
Intraosseous Infusion (IO) in Adults
Indications • Cardiac arrest – IO is the preferred vascular
access method • IV access unsuccessful or after evaluation of
potential sites, it is determined that an IV attempt
would not be successful in the following conditions: o Shock or
evolving shock, regardless of cause o Impending arrest or unstable
dysrhythmia
Contraindications • Fracture of the targeted bone • IO within
the past 48 hours in the targeted bone • Infection at the insertion
site • Burns that disrupt actual bone integrity at insertion site •
Inability to locate landmarks or excessive tissue over the
insertion site • Previous orthopedic procedure near insertion site
(prosthetic limb or joint)
Equipment • Chlorhexidine prep solution • IV NS 1000 ml • 10-12
ml syringe filled with normal saline for flush • Gloves • Pressure
bag • EZ-IO power driver • EZ-IO needle catheters - 25mm (blue
hub), or 45 mm (yellow hub) • EZ-IO catheter stabilizer • Lidocaine
2% for injection • Wristband to identify patient as patient having
IO insertion Insertion Sites • Proximal humerus (preferred in
patients with perfusing rhythms) • Proximal tibia • Distal tibia
(can be utilized if humerus or proximal tibia unavailable) Note:
Paramedics should only utilize insertion sites for which they have
been formally trained to access Procedure 1) Locate insertion
site:
a) The proximal humerus site is the greater tubercle,
identifiable as a prominence on the humerus when the arm is rotated
inward and patient’s hand is on the abdomen;
b) The proximal tibial site on the flat medial aspect of the
tibia 2 finger-breadths below the lower edge of the patella and 1
fingerbreadth medial to the tibial tuberosity;
c) The distal tibial site is 2 finger-breadths above the most
prominent aspect of the medial malleolus (inside aspect of ankle)
in the midline of the shaft of the tibia.
2) Prep the insertion site with chlorhexidine and let air dry.
3) Select and load the appropriately sized needle onto the
driver:
a) For humeral access, the 45 mm (yellow) needle is used except
in very small adult patients;
-
b) For proximal or distal tibial access, the amount of soft
tissue should be gauged to determine if a 25 mm (blue) or 45 mm
(yellow) needle is appropriate.
4) Introduce the intraosseous as follows without pulling the
trigger of the power driver: a) For humeral site, the direction of
the needle should be a downward angle of 45 degrees (see
image); b) For tibial sites, the direction of the needle should
be at a 90 degree angle to the flat surfaces of
the tibia (see images). 5) Once the needle has touched the bone
surface, assess to see if the black line on the needle is
visible.
If it is not visible, either a larger needle is needed or (in
the case of use of 45 mm needle) the soft tissue is too thick to
allow use of the IO.
6) With firm pressure, insert needle using power driver. In most
cases, the hub should be flush or touching the skin. Verify that
needle is firmly seated in the bone (should not wobble).
7) Remove stylet and instill lidocaine if patient not in arrest:
a) For adult patients not in arrest, 40 mg (2 ml) of lidocaine 2%
should be infused slowly over 1-2
minutes and allow one additional minute before starting flush.
b) For patients in arrest, no lidocaine is necessary initially but
may be needed if patient regains
consciousness. 8) Flush with 10 ml saline. 9) Attach stabilizer
to skin. 10) Attach IV tubing to intraosseous hub, and begin
infusion using pressure bag on IV bag. 11) If painful, an
additional 20 mg (1 ml) of lidocaine 2% can be infused over 30
seconds, and after
another minute, infusion should be restarted. 12) Monitor site
for swelling or signs of infiltration and monitor pulses distal to
area of placement. 13) Place wristband included with IO set on
patient.
Possible Complications Local infiltration of fluid or drugs into
subcutaneous tissue due to improper needle placement Cessation of
infusion due to clotting in the needle or bevel of needle lodged
against posterior cortex Osteomyelitis or sepsis Fluid overload Fat
or bone emboli Fracture
-
Intraosseous Infusion (IO) in Pediatric Patients
Indications • Cardiac arrest – IO is the preferred vascular
access method • IV access unsuccessful or after evaluation of
potential sites, it is determined that an IV attempt
would not be successful in the following conditions: o Shock or
evolving shock, regardless of cause o Impending arrest or unstable
dysrhythmia
Contraindications • Fracture of the targeted bone • IO within
the past 48 hours in the targeted bone • Infection at the insertion
site • Burns that disrupt actual bone integrity at insertion site •
Inability to locate landmarks or excessive tissue over the
insertion site • Previous orthopedic procedure near insertion site
(prosthetic limb or joint)
Equipment • Chlorhexidine prep solution • IV NS 250-500 ml •
10-12 ml syringe filled with normal saline for flush (5 ml flush in
small children) • Gloves • EZ-IO power driver • EZ-IO needle
catheters - 10 mm (pink hub), 25mm (blue hub), or 45 mm (yellow
hub) • EZ-IO catheter stabilizer • Lidocaine 2% for injection •
3-way stopcock to facilitate fluid and medication administration •
30-50 ml syringe to facilitate fluid administration • Wristband to
identify patient as patient having IO insertion Insertion Sites
• Proximal tibia only Procedure 1) Locate the insertion site –
for pediatric patients the location of proximal tibial site is on
the flat
medial aspect of the tibia 2 finger-breadths below the lower
edge of the patella and 1 fingerbreadth medial to the tibial
tuberosity.
2) Prep the insertion site with chlorhexidine and let air dry.
3) Select and load the appropriately sized needle onto the
driver:
a) The 15 mm (pink hub) needle is appropriate in infants or in
small children with thin amounts of soft tissue in the proximal
tibial site;
b) The 25 mm (blue hub) needle is appropriate for larger
children or smaller children with thicker amounts of tissue in the
proximal tibial site.
4) Introduce the intraosseous needle at a 90 degree angle to the
flat surface of the tibia (see image) without pulling the trigger
of the power driver.
5) Once the needle has touched the bone surface, assess to see
if the black line on the needle is visible. If it is not visible, a
larger needle is needed .
-
6) With mild to firm pressure, insert needle using power driver.
For small children, once a “give” is sensed as the outer bony
cortex is penetrated, remove finger from power driver trigger to
stop insertion (do not withdraw driver when stopping).
7) Remove stylet and instill lidocaine if patient not in arrest:
a) For pediatric patients not in arrest, 0.5 mg/kg of lidocaine 2%
should be infused slowly over 1-2
minutes and allow one additional minute before starting flush.
See pediatric drug chart for weight-based dose.
b) For patients in arrest, no lidocaine is necessary initially
but may be needed if patient regains consciousness.
8) Flush with 10 ml saline (5 ml in smaller children and
infants). 9) Attach stabilizer to skin or anchor with tape. 10)
Attach IV tubing to intraosseous hub:
a) Begin infusion with stopcock and syringe to administer
appropriate fluid dose in smaller children b) Pressure bag may be
used in larger children (>50 kg).
11) Monitor site for swelling or signs of infiltration and
monitor pulses distal to area of placement 12) Place wristband
included with IO set on patient.
Possible Complications Local infiltration of fluid or drugs into
subcutaneous tissue due to improper needle placement Cessation of
infusion due to clotting in the needle or bevel of needle lodged
against posterior cortex Osteomyelitis or sepsis Fluid overload Fat
or bone emboli Fracture
1 - 2014 - Proposed Treatment Guideline and Prehospital Care
Manual Changes7 - 2014 Revision Draft A2A - Chest Pain CHEST
PAINA2SUSPECTED ACUTE CORONARY SYNDROME / STEMIOXYGENCARDIAC
MONITOR
ADULT
8 - 2014 Revision Draft A2B - Chest PainFLUID BOLUS
9 - 2014 Revision Draft A3A - CPR and Cardiac ArrestA3CARDIAC
ARREST – INITIAL CARE AND CPRADULT
10 - 2013 A3B - CPR and Cardiac Arrest11 - 2014 Revision Draft
A4A - VF adultVENTRICULAR FIBRILLATIONA4PULSELESS VENTRICULAR
TACHYCARDIAEPINEPHRINE
ADULT
12 - 2014 revision draft A4B - VF adultKey Treatment
Considerations
13 - 2013 A5A - PEA - Asystole - AdultA5PULSELESS ELECTRICAL
ACTIVITY / ASYSTOLEINITIAL CARE
ADULT
14 - 2014 Revision Draft A5B - PEA - Asystole - AdultKey
Treatment Considerations
15 - 2014 Revision Draft A6A - sympt brady - adultA6 - ADULT
23 - 2013 A10A - Shock - Hypovolemia - adultA10SHOCK /
HYPOVOLEMIAADULT
24 - 2014 Revision Draft 10B - Shock - Hypovolemia - adult27 -
2014 Revision Draft A12A Public Safety DefibrillationPUBLIC SAFETY
DEFIBRILLATIONA12BLS / LAW ENFORCEMENTCOMPRESSIONS
ADULT
28 - 2013 A12B Public Safety DefibrillationVENTILATION
31 - 2014 Draft Revision G1A - allergy and anaphylaxisG1
32 - 2013 G1B - allergy and anaphylaxis33 - 2014 Revision Draft
G2A - ALOCALTERED LEVEL OF CONSCIOUSNESS
34 - 2013 G2B - ALOCKey Treatment Considerations
35 - 2013 G3A - behavioral emergencyG3BEHAVIORAL
EMERGENCYConsiderBLOOD GLUCOSE
GENERAL
36 - 2014 Draft Revision G3B - behavioral emergencyBASE ORDER
REQUIRED
37 - 2014 Revision Draft G4A - burnsG4BURNSGENERAL
38 - 2013 G4B - BurnsKey Treatment Considerations
47 - 2014 Revision Draft G10A - pain managementG10
48 - 2014 Revision Draft G10B - pain managementContraindications
and Cautions for Fentanyl Citrate
49 - 2013 G11A - poisons - overdoseG11TRICYCLIC ANTIDEPRESSANT
OVERDOSE
50 - 2014 Revision Draft G11B - poisons -
overdoseORGANOPHOSPHATE POISONINGHYDROFLUORIC ACID EXPOSUREKey
Treatment Considerations
50 - 2014 Revision Draft G11C - poisons - overdose - carbon
monoxide - NEWSUSPECTED CARBON MONOXIDE POISONING Symptoms may be
diverse and often non-specific. Headache, dizziness, fatigue and
nausea are most common symptoms. Neurologic symptoms may include
confusion, lethargy, drowsiness, agitation, coma, syncope, seizure
or bizarre neurologic symptoms. Other symptoms may include chest
pain, palpitations, dyspnea, weakness, or flu-like symptoms.
Evaluate for CO poisoning in suspected smoke inhalation Suspect and
evaluate in situations when multiple patients have symptoms
Consider evaluation when other causes for symptoms are not
obvious
53 - 2013 G13A - respiratory distressG13RESPIRATORY
DISTRESSINITIAL THERAPYASTHMAALBUTEROL Adult and Pediatric – 5 mg
in 6 ml NS via nebulizer. Repeat as needed.Never give Epinephrine
1:1000 intravenously!COPD EXACERBATION
ALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed.
GENERAL
54 - 2014 Revision Draft G13B - respiratory distressSUSPECTED
PULMONARY EDEMA (ADULTS ONLY)Key Treatment Considerations
59 - 2013 G16A - traumaG16TRAUMA - GENERALGENERAL
60 - 2014 Revision Draft G16B - trauma61 - 2013 G16C -
traumaG16TRAUMA – HEAD INJURYGENERAL
62 - 2014 Revision Draft G16D - traumaG16TRAUMA -
EXTREMITYConsider TOURNIQUETIf vigorous hemorrhage not controlled
with elevation and direct pressure on wound.May be used in
pediatric patients. May be appropriate for hemorrhage control in
multi-casualty situations.SUSPECTEDDISLOCATIONIf dislocation
suspected or noted, splint in position foundAMPUTATIONS For partial
amputations, splint in anatomic location and elevate extremity If
complete amputation, place amputated part in a dry container or bag
and place on ice. Seal or tie off bag and place in second container
or bag. DO NOT place amputated part directly on ice or in water.
Elevated extremity and dress with dry gauze.PAIN RELIEF Consider
Fentanyl Citrate as directed in G16 Trauma - General GuidelineCRUSH
INJURY SYNDROME
GENERAL
63 - 2014 Revision Draft G17A - vomiting and nauseaG17Vomiting
or nausea may be due to viral illness (gastroenteritis) or other
medical conditions including acute coronary syndrome, stroke, head
injury, or toxic ingestion. It may be associated with a number of
painful abdominal conditions, and may also occur as a result of
treatment of pain with fentanyl.POSITION PATIENT
64 - 2014 Revision Draft G17B - Vomiting and nausea69 - 2014
Revision Draft P2A - CPR and Cardiac ArrestP2CARDIAC ARREST –
INITIAL CARE AND CPRPEDIATRIC
70 - 2013 P2B - Cardiac Arrest - CPR85 - 2014 Revision Draft IFT
1 - Transfer of STEMI PatientsIFT 1TRANSFERMonitor IVPrompt
TransportKey Treatment Considerations
106 - 2014 Revision Draft - EKG 1 - 12-lead placementSternal
angle
114 - 2014 Revision Draft - 2013 - KEY PROCEDURESKEY
PROCEDURES12-Lead ECGKEY PROCEDURES
Helmet RemovalImpedance Threshold Device (ITD) - ResQPOD
(SRVFPD)KEY PROCEDURESContraindication
KEY PROCEDURESContraindication
136 - 2014 Revision Draft Paramedic scope137 - 2014 Revision
Draft - LOCAL OPTIONAL Paramedic scope142 - 2014 Revision Draft -
adult drug referenceADULT DRUG
REFERENCEADENOSINEALBUTEROLAMIODARONEADULT DRUG REFERENCE
ASPIRINATROPINEADULT DRUG REFERENCEDIPHENHYDRAMINE
Never administer intravenously!ADULT DRUG REFERENCE
FENTANYL CITRATEGLUCAGONADULT DRUG REFERENCE
NALOXONENITROGLYCERIN
144 - 2014 Revision Draft - peds drug referencePEDIATRIC DRUG
REFERENCEADENOSINEALBUTEROLPEDIATRIC DRUG REFERENCEDEXTROSE
10%DIPHENHYDRAMINE
Never administer intravenously!PEDIATRIC DRUG REFERENCE
IO procedures.pdfAdult Intraosseous Infusion version 2Pediatric
Intraosseous Infusion version 2