Memorial Medical Center EMS System Critical Care Manual PDF

MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Memorial Medical Center EMS System Critical Care Manual Updated Edition August 2021  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Log of Additions and Revisi...

MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Memorial Medical Center EMS System Critical Care Manual Updated Edition August 2021  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Log of Additions and Revisions Date Page(s) Addition/ Revision Distribution Notes  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Table of Contents A. Administrative Expectations...................................................................................... Section 1 Statement of Purpose, Policy and Applicability........................................................... 1.A.1. Scope of Practice........................................................................................................... 1.B.1. Pediatric Transfer Requests........................................................................................... 1.C.1. Provider Responsibilities.............................................................................................. 1.D.1. Substance Abuse Policy................................................................................................ 1.E.1. Complex Patient Management..................................................................................... 1.F.1. B. General Assessment and Patient Care Procedures..................................................... Section 2 Patient Care Overview.................................................................................................. 2.A.1. Medical Control Authority............................................................................................ 2.B.1. Previously Initiated Medications................................................................................... 2.C.1. Pain Control Protocol................................................................................................... 2.D.1. Patient Sedation Protocol.............................................................................................. 2.E.1. Use of Advanced Access............................................................................................... 2.F.1. Blood Administration................................................................................................... 2.G.1. Temperature Monitoring.............................................................................................. 2.H.1. C. Patient Care Procedures-Respiratory.......................................................................... Section 3 Bronchospasm.............................................................................................................. 3.A.1. Capnography Monitoring.............................................................................................. 3.B.1. Advanced Airway/ Rapid Sequence Intubation............................................................ 3.C.1. Pneumothorax Management......................................................................................... 3.D.1. Quick Trach/ Emergency Crichothyrotomy.................................................................. 3.E.1. Mechanical Ventilation................................................................................................. 3.F.1. Non-Invasive Positive Pressure Ventilation................................................................. 3.G.1. D. Patient Care Procedures-Cardiac................................................................................ Section 4 12 Lead EKG................................................................................................................ 4.A.1. Hypertensive Emergency.............................................................................................. 4.B.1. Pulmonary Edema/ CHF............................................................................................... 4.C.1. ACS/ STEMI................................................................................................................ 4.D.1. Induced Hypothermia.................................................................................................... 4.E.1. Cardiac Arrest................................................................................................................ 4.F.1. Resuscitation of Pulseless Rhythms............................................................................. 4.G.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Unstable Bradycardia................................................................................................... 4.H.1. Narrow Complex Tachycardia....................................................................................... 4.I.1. Wide Complex Tachycardia........................................................................................... 4.J.1. Vassopressor/ Hypotensive Emergency....................................................................... 4.K.1. Transcutaneous Pacing.................................................................................................. 4.L.1. Synchronized Cardioversion........................................................................................ 4.M.1. Ventricular Assist Devices............................................................................................ 4.N.1 E. Patient Care Procedures-Medical............................................................................... Section 5 Nausea and Vomiting/Acute Bowel Obstruction......................................................... 5.A.1. GI Bleeding................................................................................................................... 5.B.1. Hypoglycemia............................................................................................................... 5.C.1. Hyperglycemia/ DKA................................................................................................... 5.D.1. Seizures......................................................................................................................... 5.E.1. Altered Mental Status.................................................................................................... 5.F.1. Stroke............................................................................................................................ 5.G.1. Toxin Exposure............................................................................................................ 5.H.1. Sepsis.............................................................................................................................. 5.I.1. Potassium Imbalance...................................................................................................... 5.J.1. Anaphylaxis.................................................................................................................. 5.K.1. Temperature Related Illnesses....................................................................................... 5.L.1. Pulmonary Embolism................................................................................................... 5.M.1. Aortic Aneurysm/ Aortic Dissection............................................................................ 5.N.1. F. Patient Care Procedures-Trauma................................................................................ Section 6 Trauma Care Overview................................................................................................ 6.A.1. Tranexamic Acid/ TXA................................................................................................. 6.B.1. Musculoskeletal Trauma............................................................................................... 6.C.1. Facial Trauma............................................................................................................... 6.D.1. Thoracic Abdominal Trauma........................................................................................ 6.E.1. Spinal Trauma/Cord Injury........................................................................................... 6.F.1. Traumatic Brain Injury................................................................................................. 6.G.1. Crush Injuries............................................................................................................... 6.H.1. Burn Trauma................................................................................................................... 6.I.1. Near Drowning............................................................................................................... 6.J.1. G. Appendix.................................................................................................................... Section 7  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL A. Administrative Expectations A. Section 1  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Statement of Purpose, Policy and Applicability In 2014, Memorial EMS took a great step forward to address the needs of our patients and our communities. To do this, we began the process of building a ground Critical Care Transport program in Central Illinois. This Critical Care Transport program is designed to meet the needs of hospitals whose critically ill and injured patients require treatment at a facility with greater capabilities. With the increased volume of these patient transfers occurring, a safe, consistent, and quality transport program was especially needed in the greater community of Critical Access Hospitals. To transport patients of this level of acuity was no simple lift in capabilities, but a focused mission developed by several providers of the Memorial EMS System. To meet this need, Memorial EMS Critical Care Transport now provides care at Tier I, Tier II and Tier III as outlined by the Illinois Department of Public Health. Tier I will continue to sit as a stand alone manual for all transport providers. Tier II and Tier III protocols are outlined in this manual. The Memorial EMS Prehospital Care Manuals serve as a resource for information, treatment guidelines, and points of attention for the Prehospital Care Provider. They are designed to begin with basic assessment and treatment and build up to more advanced care for specific illnesses or injuries. The Patient Care Manuals can continue to serve as a resource for the Critical Care Transport (CCT) provider in such situations as the initial assessment and/ or treatment needs to be completed or re-evaluated. The Memorial EMS Critical Care Manual expects that treatment will be assumed from a caregiver of a certain level and continues that care through the capacities of the CCT team. The enclosed treatment policies and protocols are intended for the care of a patient from one hospital facility to another hospital facility. Furthermore, the Memorial EMS Critical Care Manual is written specifically to address the needs of the adult patient (age 16 or greater). Patients under age sixteen may meet criteria for this program and are addressed in specifics within this manual. The Memorial EMS system will continue to strive for the highest quality care we can give our patients, the best education we can give our providers, and protocols which help us best care for those who call in a time of need. Quality improvement review are performed on patient care, Prehospital provider education, and system wide protocols regularly to ensure our policies, procedures, and providers remain the highest quality that we can provide. As healthcare continues to improve and evolve, we continue to raise the expectation of care for our providers, specifically at the Critical Care level. Providing care at such an advanced level is both a responsibility and a privilege. As we work to address the needs of this growing patient need, I ask that you become advocates, both for your patient and for the advancement of your profession. Sincerely, Matthew Johnston, MD Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.A.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Scope of Practice CCT Tier II and Tier III In order to better meet the needs of our patients, our transferring facilities and our Critical Care Transports providers, an additional level of care has been added to these protocols. With this addition, providers must be ever more attentive to the needs of the patient at the time of request so to ensure that the crew responding for the transport is capable and qualified to address all expected needs of the patient during the time of care and transport. In order to outline the capabilities of Tier II and Tier III, protocols were rewritten in 2018. Included in this rewrite is clarification as to what protocols meet the capabilities of Tier II and where Tier III is needed. Crews at the Tier II level need to critically assess the situation they are asked to respond to and their ability to meet that patient’s needs. Crews must have the ability to defer the request based on concerns about their ability to meet the needs of the patient. As providers review this manual, sub headings for Tier II and Tier III have been added. Additionally, a red line will be noticed at the point where the patients care exceeds the ability of the Tier II provider and requires a Tier III crew, or hospital staffed equivalent. Questions about the ability to take a transport request can continue to be assisted by the EMS Office and Medical Control at Memorial Medical Center. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.B.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Pediatric Transfer Requests Tier III The adult population equates to a greater than equal proportion of critically ill and injured patients who seek treatment in the healthcare system. The adult population, due to their longer time to develop medical conditions, greater range of activities and work environments, are significantly more likely to suffer from complex and compounding medical conditions. As such, adult medical and trauma patients will be the most common patient that the CCT team will be called upon to transport. In regards to pediatric patients, often the decreased frequency of such patients, leads to a need to transfer the pediatric patient. Such requests should be triaged for the most appropriate receiving facility as well as the most appropriate transport method. At this point pediatric transports will be categorized into two groups: ages 13-15 and under age 13. Transport requests for patients ages 13-15 can be conditionally accepted by the CCT team. Included in the information received at initial contact, must be patient history, interventions, current status, transport orders and distance of transport. The CCT team must then contact Medical Control for review and approval of the transport. The CCT team shall contact the requesting facility within ten minutes of the request to confirm or deny their ability to accept the request. Transport requests for patients under age 13 can be conditionally accepted by the CCT team based on the status of the patient. Included in the information received at initial contact, must be patient history, interventions, current status, transport orders and distance of transport. Patients under age 13 must be considered stable at discharge from the transfer facility. Interventions must be limited to monitoring of cardiac rhythm, previously initiated intravenous medications, and non-invasive respiratory support. The CCT team must then contact Medical Control for review and approval of the transport. The CCT team shall contact the requesting facility within ten minutes of the request to confirm or deny their ability to accept the request. Of note, many of these transfers may not seem to meet CCT level of care, but will require the full complement of CCT providers in order to meet the level of care expectations of the transferring facility. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.C.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Provider Responsibilities Listed below are the requirements for agencies to function at the Critical Care Level under the Memorial EMS System. This list is based on the System manuals and IDPH rules and regulations. The requirements are grouped in four categories (Operational Requirements, Notification Requirements, System Certification Requirements and Reporting Requirements.) Operational Requirements 1. A provider agency must comply with minimum staffing requirements for the Tier III Critical Transport Ambulance. Staffing patterns must be in accordance with the provider’s approved system plan and in compliance with Section 515.830(f). Staffing requirements for Tier II will be required to exceed the minimum outlined in Section 515.830(f). a. Tier III requires a Critical Care credentialed paramedic, a Registered Nurse meeting EMS System requirements and an EMT who assists on scene, but has responsibility for transportation to ensure the patient care team always includes the CCT paramedic and Registered Nurse. b. Tier II requires a Critical Care credentialed paramedic, an Expanded Scope (Tier I) paramedic and an EMT who assists on scene, but has responsibility for transportation to ensure the patient care team always includes the CCT paramedic and the Expanded Scope paramedic. 2. No agency shall employ or permit any member or employee to perform services for which he or she is not licensed, certified or otherwise authorized to perform (Section 515.170). 3. A provider agency must comply with the requirements for the Patient Care Report as outlined in the Patient Treatment Overview. 4. Agencies with must abide by all provisions of the Controlled Substance Policy including: maintaining a security log, maintaining a Controlled Substance Usage Form and reporting any discrepancies to the EMS Office. 5. Notify the EMS Office of any incident or unusual occurrence which could or did adversely affect the patient, co-worker or the System within 24 hours via incident report form. Agencies functioning at the Critical Care Transport level, must meet the Quality Assurance requirements set forth by the EMS System Office. Every report is to be reviewed at the agency level. Reports are to be forwarded to the EMS Office weekly for the first year and then may be allowed to report less frequently (at minimum quarterly.) Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.D.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Provider Responsibilities (continued) Notification Requirements An agency participating as an EMS provider in the Memorial EMS System must notify the Resource Hospital, (Memorial Medical Center), of the following: 1. Notify the System in any instance when the agency lacks the appropriately licensed and System-certified personnel to provide 24-hour coverage. Transporting agencies must apply for an ambulance staffing waiver if the agency is aware a staffing shortage is interfering with the ability to provide such coverage. 2. Notify the System of agency personnel changes and updates within 10 days. This includes addition of new personnel and resignations of existing personnel. Rosters must include: Name/level of provider, license number, expiration date, current address, phone number, date of birth, and all certification documents. 3. Notify the System anytime an agency is not able to respond to a call due to lack of staffing. The report should also include the name of the agency that was called for mutual aid and responded to the call. 4. Notify the System of any incident, via incident report within 24 hours, which could or did adversely affect the patient, co-worker or the System. 5. Notify the System of any changes in medical equipment or supplies. 6. Notify the System of any changes in vehicles. Vehicles must be inspected by the System and the appropriate paperwork must be completed prior to the vehicle being placed into service. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.D.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Provider Responsibilities (continued) Certification Requirements The ability to work in the field of Critical Care Transport is a privilege and responsibility that should not be taken lightly. Providers functioning at this level must meet and maintain specific requirements in order to function within a Critical Care Transport vehicle or vehicles. 1. A System applicant must hold a State of Illinois license for a minimum of two years. 2. A System applicant must have two years or more experience in the capacity in which they are applying for. 3. A Pre-Certification Application must be completed and submitted to the EMS Office. 4. The System applicant must also submit copies of the following:  IDPH license (Paramedic or PHRN) or IDPFR license (RN)  National Registry certification (if applicable)  ACLS  PHTLS, ITLS, TNCC, TNS or BTLS  PEPP, PALS or ENPC  CPR {AHA Healthcare Provider OR American Red Cross}  Letter of reference from current EMS Medical Director  Resume´ (education and employment history)  CCEMTP, CCP-C, FP-C (Paramedics or PHRN) o Additional certifications will be reviewed on a case by case basis  CCEMTP, CEN, CCRN, CFRN or CTRN (RN) 5. All providers functioning at the Critical Care Transport level must be approved to function by the EMS Medical Director, Critical Care Coordinator or EMS System Coordinator. 6. The System applicant must pass the Memorial EMS System CCT Protocol Exam with a score of 70% or higher. The applicant may retake the exam with the approval of the EMS Medical Director. A maximum of two (2) retakes are permitted. Updated competencies are required annually in compliance with Section 515.830. 7. Successfully complete any practical skills evaluations required by the EMS Medical Director. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.D.3.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Provider Responsibilities (continued) 8. Satisfactory completion of a 90-day probationary period is required once System- certification is granted. If the provider completes fewer than ten (10) transports in the 90-day probationary period, the time will be extended to 180-days. 9. The EMS Medical Director reserves the right to deny System provider status or to place internship & field skill evaluation requirements on any candidate requesting System certification at any level. Maintaining System Certification Critical Care EMT-Paramedic  Current AHA Healthcare Provider or ARC (EMT-P)/Prehospital RN (PHRN) Professional Rescuer or ARC Professional Rescuer CPR card  PHTLS, ITLS, TNCC, TNS or BTLS  ACLS  PEPP, PALS or ENPC  CCEMTP, FP-C, CCP-C, or other approved coursework  Active member of Memorial EMS System agency  Successfully complete annual System protocol testing and skills evaluation Registered Nurse (RN)  Current AHA Healthcare Provider or ARC Professional Rescuer or ARC Professional Rescuer CPR card  PHTLS, ITLS, TNCC, TNS or BTLS  ACLS  PEPP, PALS or ENPC  CCEMTP, CEN, CCRN, CFRN or CTRN  Active member of Memorial EMS System agency  Successfully complete annual System protocol testing and skills evaluation Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.D.4.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Provider Responsibilities (continued) Expanded Scope EMT-Paramedic  Current AHA Healthcare Provider or ARC (EMT-P)/Prehospital RN (PHRN) Professional Rescuer or ARC Professional Rescuer CPR card  PHTLS, ITLS, TNCC, TNS or BTLS  ACLS  PEPP, PALS or ENPC  Active member of Memorial EMS System agency  Successfully complete annual System protocol testing and skills evaluation at the Expanded Scope level  Minimum 2 years experience EMT (B, I or P)/Prehospital RN (PHRN)  Current AHA Healthcare Provider or ARC Professional Rescuer or ARC Professional Rescuer CPR card Maintaining of current certifications and tracking of expiration dates is ultimately the responsibility of the individual provider. Agency training officers will be assisting with monitoring these certifications and reporting to the EMS Office. However, these officers are not responsible for any certifications other than their own. Failure to maintain current certification in CPR, ACLS, ITLS/PHTLS/TNCC/ TNS/ BTLS, PEPP/PALS/ ENPC, and CCEMTP/ FP-C/ CCP-C (paramedic or PHRN) or CEN/CCRN/CFRN/CTRN (RN) or any other System certification may result in suspension of the individual in violation. Suspended individuals will remain on suspension until proof of current certification is presented to the EMS Office. Summary of Re-licensure Requirements Critical Care EMT-Paramedic (EMT-P)  The initial credentially requirements are Prehospital RN (PHRN) required to be maintained without lapse Registered Nurse (RN) during the period of service in the Critical Care Role, additionally  License/ certification requirements may vary based on licensing/ certifying body. At minimum, twelve (12) hours continuing education, seminars, and workshops addressing adult and pediatric critical care must be completed annually in order to be on track for renewal. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.D.5.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Provider Responsibilities (continued) Reporting Responsibilities and Maintenance  Comply with Memorial EMS System Quality Assurance Plan, including agency self-review, timely submission of incident reports, timely submission of patient care reports, maintain controlled substance security logs and usage tracking forms. Logs must be made available upon request of EMS Office personnel.  Maintain glucometer logs. Testing should be done a minimum of once per week, any time a new bottle of strips is put into service and any time the glucometer is dropped. Glucometer logs should be kept in the ambulance (or other vehicle) and must be made available upon request of EMS Office personnel.  All electronic equipment used for patient care must be maintained based on manufacturer’s recommendations. Equipment needs to be evaluated through regularly scheduled preventative maintenance by qualified technicians. Records of such must be held for the life of the equipment.  All agencies and agency personnel are to comply with all of the requirements outlined in HIPAA regulations with regard to protected health information. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.D.6.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Substance Abuse Policy The Memorial EMS System considers substance abuse (drug and/or alcohol dependency) to be a health problem and will assist any System provider who becomes dependent on drugs and/or alcohol. The System, and ultimately our patients, will suffer the adverse effects of having a CCT care provider whose work performance and attendance are below acceptable standards. Any employee whose substance abuse problems jeopardize the safety of patients, co-workers or bystanders shall be deemed “unfit to work”. Any CCT care provider involved in the Memorial EMS System who voluntarily requests assistance with a personal substance abuse problem will be referred to the EMS Medical Director for assessment and referral for treatment when necessary. Testing for Drugs & Alcohol The Memorial EMS System does not require employees to submit to blood and/or urine testing for drugs and/or alcohol as a routine part of their employment. However, individual agencies may require testing as part of the application process. Any CCT team member or associated healthcare provider may contact the EMS Medical Director (or designee) if he/she has reasonable cause to suspect that a co-worker is under the influence of drugs and/or alcohol while on duty. The EMS Medical Director may choose to require the System provider to submit to a blood/ breathe alcohol test and/or blood/urine toxicology screening. The cost of this testing procedure may be billed to the provider’s agency, or in the case of a student, the requesting agency. Disputes related to billing of drug testing should not delay the procedure(s). 1. If a System provider who is required to submit to testing for drugs and/or alcohol refuses to cooperate, he/she will be subject to disciplinary action for insubordination (up to and including termination from the System). 2. Anyone caught tampering with, or attempting to tamper with his/her test specimen (or the specimen of any other Prehospital care provider) will be subject to immediate termination from the System. 3. If any of the test results are positive, the EMS Medical Director will interview the provider. The EMS Medical Director will consult with the provider’s agency to determine if referral to an assistance program shall occur. 4. The CCT team member’s privilege of serving in the CCT capacity will be suspended for a minimum of 6 months for the first offense. Any subsequent positive test will result in immediate termination from the System. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.E.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Substance Abuse Policy (continued) Testing for Drugs & Alcohol (continued)  The progress of employees with substance abuse problems who have been referred to an assistance program will be closely monitored by their agency/employer and the EMS Medical Director. The provider must successfully complete the entire required rehabilitative program and maintain the preventative course of conduct prescribed by the assistance program. He/she must attend the appropriate after-care program(s) and provide verification of compliance with the program requirements, including additional drug testing as determined by the EMS Medical Director and the agency/employer. 5. If the test results are negative, a conference with the EMS Medical Director and the provider’s agency/employer will be held to determine what future action, if any, will be taken. The use, sale, purchase, transfer, theft or possession of an illegal drug is a violation of the law. Illegal drug means any drug which is (a) not legally obtainable or (b) legally obtainable but has not been legally obtained. The term illegal drug includes prescription drugs not legally obtained and prescription drugs legally obtained but not being used for prescribed purposes. Anyone in violation will be referred to law enforcement, licensing and/or credentialing agencies when appropriate. Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.E.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Complex Patient Management In order to appropriately meet the needs of that patients at each level of the Critical Care Transport program, the providers, especially at the Tier II level, must be very diligent in their assessment of the situation and the likely and potential deterioration of the patient’s condition when determining if transporting the patient is within their capabilities. While the scope of Tier II and Tier III are very similar, the complexity of the patient with more than one critical care intervention is when a Tier II crew must defer to a Tier III crew. A Tier II crew can transport any patient meeting Tier II criteria in these protocols as long as there is no more than one (1) intervention needed at the Tier II level. If there are two or more interventions needed at or above the Tier I (Expanded Scope) level or any Tier III criteria, then that patient requires a Tier III crew for transport. For example, if a patient has both a new chest tube and was just intubated then the patient has two critical care interventions. That specific patient would require a Tier III Crew. If there are any questions if a patient can be transported Tier II contact the EMS Medical Director, EMS System Manager or EMS Coordinator. The following medications are only allowed at the Tier III level. o Nitroprusside o Milrinone o Isoproterenol o Mannitol o Phenylephrine o Vasopressin (infusion) o Procainamide Controlled Copy- not for distribution beyond intended recipient. Intended recipients will be notified of updates after initial distribution. 1.F.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL B. General Assessment and Patient Care Procedures B. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution Section 2  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Patient Care Overview Tier II & Tier III The goal of Critical Care Transport under the Memorial EMS System is to provide safe, appropriate transportation for critically ill or injured patients who have been evaluated in a hospital facility and their condition deems transfer to a higher level of care is necessary for continued treatment. The following Critical Care Manual is to provide a guideline for standard of care when online Medical Control is not required. Medical Control is always available during the initial patient assessment and transport phases of care. Assessment The Critical Care Team will be comprised of either a Registered Nurse, EMT-Paramedic/Pre- Hospital Registered Nurse (each with additional training/ certifications) and an EMT of any level at the Tier III level or an EMT-Paramedic/Pre-Hospital Registered Nurse (each with additional training/ certifications), an Expanded Scope Paramedic with a minimum 2 years’ experience and an EMT of any level While the providing Critical Care treatment, the team should always work as a team and maintain a constant path of communication. In most scenarios the members of the team will handle specific responsibilities based on their licensure, experience and the needs of the patient. While a significant degree of overlap exists between the roles of the Registered Nurse and the EMT-Paramedic/PHRN, certain procedures will be required of only the Registered Nurse or only the EMT-Paramedic/PHRN. Treatment and Interventions 1. Standard Precautions and PPE will be utilized at all times during patient care. Enhanced PPE may be deemed necessary while caring for certain patient conditions or while performing certain patient interventions. 2. Prior to any intervention by the Critical Care Team a basic assessment of the patient must occur. This assessment must include a. Assessing the patency of the airway or airway adjunct. b. Assessing the effort of breathing including lung sounds, respiratory rate, SaO2 or ETCO2. c. Assessing circulation including pulse rate and quality, blood pressure and any interventions that affect circulation. d. Assessing the patient for any injuries or deficits. This includes a head to toe assessment of focused physical exam. 3. Report should be received from the transferring RN/LPN/MD/ Midlevel provider including any transfer orders, accepting physician and accepting facility. If preliminary room assignment is given, that should be verified during transport when an update on patient condition and ETA are given fifteen minutes prior to arrival at destination. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.A.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Patient Care Overview (continued) 4. Prior to or immediately after the patient is moved to the CCT stretcher the following interventions must be started or transitioned to the CCT equipment a. Supplemental Oxygen b. Cardiac monitor, blood pressure and oxygen saturation monitoring equipment. These should be documented every fifteen minutes or less and include respiratory rate. Monitoring strips and waveform capnograghy graph should be printed at the beginning and end of transport, at minimum. c. Non-Invasive Blood Pressure Monitoring (NIBP) is required on all patients unless Invasive Blood Pressure Monitoring (IBP) is utilized. d. ETCO2 is required for patients who have a I-Gel, endotracheal tube, or cricothyrotomy/ quick trach in place or who are receiving CPAP or BiPAP. Addional protocols will also require ETCO2. 5. Prior to and following every patient movement all advanced airway adjuncts must be assessed for correct tube placement by at least two methods and included in the PCR. Continuous waveform capnography is required for any patient with an endotracheal tube. 6. Intubated patients should be ventilated with a transport ventilator unless the patient condition does not allow toleration of the ventilator. 7. Patients at risk of vomiting and/or aspiration should be assessed for placement of a gastric tube. 8. IV access is mandatory unless specific condition protocol identifies otherwise. 9. Patency of each IV site should be verified prior to transport and prior to any medication administration. 10. Fluid/ Medication administration should be verified and maintained in accordance with patient condition. 11. Fluid/ Medication administration should be done through the use of a Baxter Sigma Smart Pump. All medications should be moved to the CCT equipment and total amount infused prior to move documented by transferring facility. a. The only exception would be fluid and/ or blood administration in the adult patient where rapid infusion is required. 12. Patients at risk for hemodynamic instability should have two large bore IV lines. 13. If IV lines are not possible, or the time to obtain is delaying critical interventions intraosseous access should be obtained. A maximum of two attempts are allowed. 14. Invasive lines should be assessed for accuracy and continuously monitored. 15. Patients should be assessed for comfort prior to and after every move. This includes a. Pain assessment and management per protocol. b. Positioning and warmth/coolness. c. Patients should be reassessed after every intervention so to recognize changes and trends in the patient condition. 16. If transporting patients under the age of 16 a. Contact with Medical Control is required. b. Weight must be verified by Broslow Tape for patients under 10 years of age. c. Temperature and blood glucose must be assessed. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.A.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Patient Care Overview (continued) 17. The CCT team is responsible for ensuring a. Patient family has had the opportunity to see the patient prior to transport. b. Information regarding transport destination has been provided to on-site family. c. Patient information and privacy is respected and maintained. d. All documentation for the transferring facility is taken with the patient. Ideally this would include digital copies of radiology procedures. e. Providing complete report to the receiving nurse/team. f. Completing of the Patient Care Report following every transport. g. A copy should be provided to the receiving facility. h. The PCR shall include copies of all strips printed during care of the patient. Strips should be labeled with name and date of birth clearly noted. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.A.3..  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Medical Control Authority Tier II & Tier III The transport of patients from facility to facility creates unique challenges for a transport provider. Traditional EMS providers function based on written protocols with the ability and situations where they are required to contact Medical Control. Any care that is given prior to their arrival is either basic first aid or by providers functioning under the same or similar Prehospital Care Protocols. When arriving at a hospital facility to transport to another hospital facility, the patient may be at any point within the treatment algorithm/protocol based on the transferring facility’s capabilities and other situations at the time of transfer. The CCT team should always function within their respective scopes of practice. The following Critical Care Manual should serve as a guide of care. Orders for Transport When arriving at the transferring facility, the CCT team should review all patient records and the results of any diagnostic tests. Additionally the CCT team should perform their own assessment of the patient. The facility transferring the patient should provide to the Memorial EMS CCT team the orders for treatment that is to occur during transport. This is to be continued through transport unless a change is detected in patient condition. These orders are to be written down and signed by the transferring physician. The orders should be reviewed for clarity prior to the CCT team assuming care of the patient. If at any time the Memorial EMS CCT team feels that the orders are inappropriate or outside their scope of practice they are to contact Medical Control at Memorial Medical Center Emergency Department immediately. The only situation that would supersede immediate contact with Medical Control would be the need for life saving intervention. Any deviation from written orders shall be reviewed by the agency QA officer as well as forwarded, in writing, to the Memorial EMS Critical Care Transport Coordinator within twenty-four (24) hours. Direct Medical Control There are specific procedures in this manual which require direct Medical Control. These procedures/ mediations have a notation identifying that Medical Control is required. Medical Control is to be contacted prior to the initiation of such procedures/ medications. Any time such a procedure is completed without prior Medical Control authorization the situation shall be reviewed by the agency QA officer as well as forwarded, in writing, to the Memorial EMS Critical Care Transport Coordinator within twenty-four (24) hours. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.B.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Medical Control Authority (continued) Potentially Unstable Transports It is the expectation that the transferring facility will do everything within their capacity to stabilize the patient prior to transport. If, in the opinion of the Memorial EMS CCT team, the patient could be further stabilized by interventions within their scope of practice, the delay versus the benefit must be weighed by the transferring physician, Memorial EMS CCT team, accepting physician and, if needed, Medical Control. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.B.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Previously Initiated Medications Tier II & Tier III It is the expectation that the transferring facility will do everything within their capacity to stabilize the patient prior to transport. However, the capabilities of a facility has some bearing on their ability to rapidly stabilize the patient. Unless contraindicated, treatment with previously initiated medications should be continued by the CCT team. If additional medications are warranted, the CCT team should consult their protocols, Medical Control, transferring physician and/ or receiving physician regarding those additional interventions. Assessment In addition to general patient assessment, all medications should be assessed by the CCT team to validate that 1. Medications being administered and reason for it’s particular use 2. Concentration of medication, 3. Rate of infusion and validate this is within limits of transport orders, 4. Total medication that has already been infused. Treatment and Interventions 1. All medication infusions will be administered by IV pump. The only allowable exception to this is IV fluids and blood products that are being given for rapid infusion. 2. The information from the transferring facility pump must be entered into the CCT pump. a. The infusion must be stopped. b. The infusion tubing should be completely removed from the patient. c. The infusion must be removed from the transferring facility pump. d. The infusion tubing should be removed and the Baxter Sigma Smart pump 10 gttp tubing applied. e. The Baxter Sigma Smart pump 10 gttp tubing should be primed and loaded into the CCT pump. f. The IV site should be flushed prior to the new line being connected. g. The CCT line should be attached to the patient. h. The CCT pump should be started. i. The RN at the transferring facility will validate that the information has been transferred from the original pump to the CCT pump. 3. Only medications listed on a Drug Compatibility Chart (to be stored in medication bag) are allowed to be hung as a primary and secondary infusion or through the same IV site. 4. The process in #2 should be followed for every medication infusion. 5. If any inconsistency or potential error in the labeling of a previously mixed medication, the CCT crew is to remix the medication and hang the new infusion. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.C.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Previously Initiated Medications (continued) 6. The Memorial EMS CCT protocols should be utilized to validate the ranges of previously established medications. 7. All Infusions should be secured; special attention needs to be paid to infusions in glass bottles to secure them during movements. 8. The CCT team should calculate to ensure that they have enough medication for the entire transport and patient transition time prior to departure from transferring facility. 9. Memorial EMS CCT can continue narcotic or sedation infusions if started by transferring facility if approved by protocol or direct Medical Control. If additional medication is needed and infusion completes, IVP medications should be utilized. Pearls  Every medication has the potential to cause allergic reactions.  Many medications are incompatible with other medications. Because of this potential, additional medications should be given through separate IV lines. If this cannot be accomplished, the infusion must be stopped, tubing flushed, injection given, and tubing flushed again. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.C.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Pain Control Protocol Tier II & Tier III Pain, and the lack of relief from the pain, is the most common complaint among patients. Pain control can reduce the patient’s anxiety and discomfort, making patient care easier. The patient’s severity of pain must be properly assessed in order to provide appropriate relief. Managing pain clinically in the inter facility setting will provide greater patient care. Special attention must be paid to this as the patient is being taken from the controlled environment of the transferring facility to the mobile environment involving multiple moves and transport. Assessment 1. Assess level of pain using the Pain Assessment Scale (0-10) or the Wong-Baker Faces Pain Rating Scale. 2. Place patient in a position of comfort if at all possible. 3. Reassure the patient. Treatment and Interventions 1. Consider ice or splinting. 2. Reassess level of pain using the approved pain scale. 3. Care should also focus on the pharmaceutical management of pain. 4. Pain medication can be given in situations where the patient still requires additional doses and the systolic BP > 90mmHg. 5. IVP medications can include a) Morphine Sulfate: 2-5mg IV every 5 minutes to reduce the patient’s anxiety and severity of pain. If unable to establish IV access, may administer Morphine 2-5mg IM every 15 minutes. b) Ondansetron (Zofran): 4mg IV over 2 minutes or IM for nausea and/or vomiting. May repeat in 15 minutes with additional 4 mg IV. c) If the patient is allergic to Morphine or if Morphine is not effective: d) Fentanyl: 50mcg IV over 2 minutes for pain. Fentanyl 50mcg IV may be repeated one time in 5 minutes to a total of 100mcg. If unable to establish IV access, may administer Fentanyl 50 mcg IM. May be repeated one time in 15 minutes to a total of 100mcg. e) Hydromorphone: 0.5mg-1mg IV. This may be repeated only once total. f) Ketamine: 30 mg IV (patients over age 15 only) after initial Opioid administration. May repeat in 15 minutes. 9. Narcan 2.0 mg IV/ IN should be available at all times. 10. Contact Medical Control if prolonged transport and have maxed out narcotic dose on protocol. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.D.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Pain Control Protocol (continued) Wong-Baker Faces Pain Rating Scale Pearls Monitor the patient for respiratory depression when administering narcotics. Blood pressure should be monitored closely – check 5 minutes after narcotic administration (and prior to administering repeat doses). Verify that the patient is not allergic to the pharmaceutical agent prior to administration. Patients with a head injury / ALOC or patients with unstable vital signs should not receive pain medications without direct order from Medical Control. In patients with known renal failure, the Fentanyl dose must be reduced to 25mcg. The dose may be repeated one time to a maximum dose of 50mcg. Lidocaine: 30mg IO (slowly) to reduce discomfort from infusion may be given IO to conscious patients experiencing discomfort from IO infusion. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.D.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Patient Sedation Protocol Tier II & Tier III Situations will exist where safe management and transportation of the patient will require sedation of the patient. This could be to prevent the patient from further injuring themselves during transport or to support the sedation needed for airway maintenance. Assessment 1. Assess for any causes of anxiety, confusion or other conditions that can be corrected. 2. Attempt verbal reassurance to calm patient. 3. Ensure that the patient can be safely transported by the CCT. a. If uncertain the CCT can safely transport the patient, seek restraint order for transport. Treatment and Interventions- Sedation 1. Midazolam: 2.5-5mg IV/IN/IM to reduce the patient’s anxiety. May repeat in 5 minutes if needed. If giving IV, give slowly over 2 minutes. Watch respiratory status and have bag valve mask ready. 2. Lorazepam: 1-4 mg IV. May repeat every 15 minutes. 3. Diazepam: 2-10 mg IV/IM. May repeat every 10 minutes. Treatment and Interventions- Sedation of the Intubated Patient 1. Propofol: Continue IV infusion established at transferring facility. Infusion can be increased by 5-10 mcg/kg/min every 5-10 minutes until desired sedation is achieved. Infusion rate parameters are 5-55mcg/kg/min. 2. Midazolam: 2.5-5mg IV/IN/IM to reduce the patient’s anxiety. May repeat in 5 minutes if needed. If giving IV, give slowly over 2 minutes. 3. If paralytic is needed in addition to sedation (On Call Critical Care Medical Control must be contacted before paralytic is used) a. Rocuronium: 1 mg/kg or 100 mg (one time push) Onset 1-2 minutes. Treatment and Interventions- Excited Delirium 1. Use extreme caution to provide for crew safety. 2. Have restraints ready. Ensure you have enough providers to complete restraint procedure. 3. Ketamine: 1mg/kg IVP or 2 mg/kg IM. May repeat X 1 if necessary. 4. Prepare to provide airway and ventilatory support. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.E.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Use of Advanced Access Tier II & Tier III Patient’s with certain ongoing medical problems may have an Implanted Subcutaneous Port (ISP). If the port is accessed via steril technique by the transferring facility and not signs or infection or infiltration exist, the CCT crew can continue to use the port. If any concerns the crew should more to obtaining intraosseos access utilizing pain medications as needed. Tier III In certain situations the CCT team may be called to transport a patient who the transferring physician has inserted a central line. The transferring facility may or may not have accessed the line for medication/ fluid administration prior to arrival of the CCT team. Accessing Central Venous Catheters 1. Special attention should be paid to maintaining aseptic technique. 2. Wear clean gloves. 3. Scrub the injection cap (e.g., needleless connector) with an appropriate antiseptic (e.g., chlorhexidine, povidone iodine, or 70% alcohol), and allow to dry (if povidone iodine is used, it should dry for at least 2 minutes). 4. Access the injection cap with the syringe or IV tubing (opening the clamp, if necessary). Flushing Technique 1. Single-use flushing systems (e.g., single-dose vials, prefilled syringes) should be used. 2. Access the catheter as outlined above, maintaining aseptic technique. 3. Use a syring with size 10 mL or greater. 4. Flush the catheter vigorously using pulsating technique and maintain pressure at the end of the flush to prevent reflux. 5. Positive pressure technique (may not apply to neutral-displacement or positive- displacement needleless connectors): a. Flush the catheter, continue to hold the plunger of the syringe while closing the clamp on the catheter and then disconnect the syringe. b. For catheters without a clamp, withdraw the syringe as the last 0.5-1 mL of fluid is flushed. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.F.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Blood Administration Tier II & Tier III Severely ill of injured patients will greatly benefit from the administration of blood products as soon as they can be administered. Ideally, this would be started at the outlying hospital and continued by the CCT team. In some situations the blood products may not be available prior to the CCT team arrival. In such instance, initiation by the CCT team would be of great benefit to the patient. Assessment Patients who are candidates for blood product administration include 1. Adults who are, or suspected to have acute blood loss. 2. Are still considered unstable after administration of 2 liters Normal Saline. 3. SBP less the 90mmHg or other clinical signs of shock (AMS, tachycardia, pallor, delayed capillary refill, etc.) 4. Who have had 2 boluses of 20mL/kg without stabilizing of condition. 5. Other clinical signs of shock (AMS, tachycardia, pallor, delayed capillary refill, etc.) Prior to administration, and every 15 minutes afterward, the patient should be assessed for 1. Complete set of vital signs, including temperature 2. Skin condition 3. Lung sounds 4. Previous transfusion history 5. Current fluid resuscitation status 6. IV site 7. Adults 18ga or larger (20ga if not infusing PRBCs) 8. IV site patency 9. IV site dedication as only being used for blood product administration 10. Include in the documentation any blood typing information obtained at the transferring facility. 11. If any blood products are being taken with patient, maintain products in cooler on ice for transport. Document time units were accessed from Blood Bank. If unused during transport, these should be turned in at receiving facility Blood Bank. Treatment and Interventions 1. Appropirate PPE should be worn by the CCT team member performing the intervention. Prior to any intervention, if patient condition allows, the procedure should be explained to the patient. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.G.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Blood Administration (continued) 2. Remove blood products from cooler. Verify temperature of 2-8 degrees Celcius. Once removed from 2-8 degree Celcius enviroment, products must be administered or discarded within four hours. 3. The following information must be confirmed by at least two health care providers a. Patient’s name (this could be a john or jane doe assignment) b. Patient’s blood type c. Type of blood products d. ABO type of blood products e. Unit number and expiration 4. The two health care providers who verified should sign all appropriate documentation. This should also include the time the infusion began. 5. Infusion rates vary 6. Begin at slower rate and closely monitor for signs of reaction. 7. Infusion can be sped up after no signs of reaction are seen 8. Blood products can be infused with the assistance of a pressure bag so long as the pressure in the bag does not exceed 300mmHg for adults. 9. If reaction is noted a. Immediately stop the transfusion b. Remove all tubing associated with the infusion from the patient c. Reassess patient. d. Treat any complaints of patient. e. Deliver all blood and delivery devices to receiving facility. 10. Blood products should be administered with a. 10 gttp Baxter Sigma Smart Pump tubing b. Leukocyte reduction filter c. Piggyback 1000 mL Normal Saline d. Rate based on transfer orders. e. Rate can be increased to wide open and pressure bag utilized if patient condition necessitates. 11. When infusion is complete, flush IV site with Normal Saline. 12. Document in the PCR a. Type of blood product b. Unit number c. Time transfusion was started and ended d. Total volume and rate infused e. Signs or lack of signs of reaction f. Complete vital signs at completion of transfusion Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.G.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Blood Administration (continued) 13. Consider a. Diphenhydramine: 25-50 mg IV/IM if signs of allergic reaction noted. b. Furosemide: 20 mg IV/IO after each unit for adult patients demostrating any signs of CHF. i. If patient with penetrating trauma < 3 hours since injury, and signs of hypovolemic shock see TXA Protocol. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.G.3.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Temperature Monitoring Tier II & Tier III Both medical and trauma patients can experience decreases and elevations in temperature that can be detrimental to patient care and patient outcome. Additionally, on some occasions, treatment includes controlling the patient’s temperature at a lower than normal value. Therefore, the ability to monitor patient temperature during transport becomes a necessary component of the CCT team’s assessment resources. Assessment Temperature monitoring should be considered on any patient. Temperature monitoring is required on 1. Patients suffering from hypo- or hyperthermia. 2. Patient where induced hypothermia has been instituted post cardiac arrest. 3. Any patient with a GCS < 8. Temperature monitoring can be accomplished with  Esophageal tubes  Skin probes  Urinary catheters Treatment and Interventions 1. To utilize Skin Probe a. Determine baseline temperature from transferring facility b. Connect temp cable to monitor and connect disposable skin temp probe to cable. c. Identify desired location. i. Central body core ii. Not over a bony prominence d. Clean site with alcohol skin prep e. Remove adhesive backing from probe f. Ensure probe adherance and monitoring. 2. Alternate method for monitoring skin temperature a. Utilize disposable forehead monitor b. Adjust to determine core temperature is not adjust by device 3. To utilize Esophagel Probe a. Patient must have endotracheal tube or I-Gel in place. b. Determine baseline temperature from transferring facility. c. Connect temp cable to monitor and connect disposable esophageal temp probe to cable. d. Pediatric size probe will be used on all patients unless copious amounts of vomitus have been experienced. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.H.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Temperature Monitoring (continued) e. Lubricate tip of probe with surgical lubricant. f. Insert the probe through mouth and advance to desired depth. g. Optimal placement is in the lower 25% of the esophagus. (Measuring to manubrium instead of Xiphoid Process.) h. Laryngoscope blade can be used to assist placement. 4. To utilize Urinary Catheter a. No changing of urinary catheter is allowed. b. If transferring facility has placed a urinary catheter compatible with CCT team monitoring equipment monitoring of temperature via urinary catheter is allowed. c. If urinary catheter has not been placed by transferring facility, a urinary catheter with temperature monitoring capibilities can be placed by the CCT team. i. Sterile technique must be strictly adhered to. d. Determine baseline temperature from transferring facility e. Connect temp cable to monitor and connect disposable urinary catheter temp probe to cable. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.H.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL C. Patient Care Procedures-Respiratory C. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution Section 3  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Bronchospasm Tier II & Tier III Asthma, emphysema and chronic obstruction pulmonary disease (COPD) are all medical conditions that significantly reduce the patient’s ability to properly exchange air. While each disease impacts a particular area of the respiratory system, treatment for these diseases tends to overlap. Asthma is a restrictive pulmonary disorder that is often exacerbated by irritants, secretions, airway edema or exertion. Key to the treatment of the asthma patient is the ability to dilate the narrowed airways to improve air exchange. Emphysema is a more chronic disease where damage has occurred to the alveoli structure, reducing their ability to adequately exchange air. Of importance in treatment is allowing for the full expiration of each breath to occur after each inspiration. COPD (also referred to as Chronic Bronchitis) is a disease that affects the bronchi. Increased secretions interfere with the air flow into the alveoli. As a result the alveoli receive less than optimal volume of air to exchange leading to hypoxia and hypercarbia. Assessment Assessment of all respiratory distress patients should include focus on  The events leading up to current status  Comparison to previous attacks  Associated symptoms  Compensation methods being utilized, and success of those methods  Questioning what has worked most successfully in the past for the patient  Has the patient ever improved through the use of CPAP or BiPAP?  Has the patient ever required intubation? Treatment and Interventions 1. Initiate patient care based on the Patient Care Overview. 2. Place patient in semi-Fowlers position or higher if patient can tolerate. 3. Administer 100% Oxygen via NRB. If unable to tolerate NRB, reduce to cannula. 4. Secure advanced airway as needed based on Advanced Airway/RSI Protocol. 5. Be alert to changes in patient condition that will require securing advanced airway. a. If advanced airway is needed PEEP 5-15 cmH2O. 6. If SBP>90 mmHg initiate CPAP or BiPAP based on Non-Invasive Positive Pressure Ventilation Protocol. 7. Pain management per Pain Control Protocol. 8. Albuterol: 2.5 mg in 3 mL via nebulizer. May repeat as necessary. Can be given as in- line neb. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3.A.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Bronchospasm (continued) 9. Ipratropium: 0.5 mg in 2.5 mL via nebulizer. Can be given as Duo-Neb. May repeat to a maxmimum of 4 doses. 10. Consider the use of steriods a. Prednisone: 60 mg PO. b. Methylprednisolone Sodium Succinate: 125 mg IV. c. Dexamethasone: 10 mg IV 11. Racemic Epinepherine 2.25%: Max single dose 0.5 mL. May repeat every 20 minutes. 12. Magensium Sulfate: 2g IV over 20 minutes for severe asthma exacerbation. 13. Epinephrine 1:1,000: 0.3 mg IM. Medical Control needed for patients over 50 years of age or with known cardiovascular disease. 14. Terbutaline: 0.25 mg SQ/IM. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3.A.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Capnography Monitoring Tier II & Tier III Capnography is one of several tools/ techniques that can be used to verify endotracheal tube or I- Gel airway placement as well as validate the patient’s respiratory status. During transport, capnography is a more reliable and easily assessable tool for verification of airway patency and effects of respiratory support. All patients with advanced airways under the care of Memorial EMS CCT will be monitored based on their quantitative (waveform) capnography. Assessment Prior to connection of CCT capnography equipment, attention should be given to the trends of the patient prior to CCT team arrival. If capnography has already been utilized, a good wave form pattern should be established by the transferring facility. This can be used as a comparison after the patient has been transferred to the CCT monitor and ventilator. Treatment and Interventions 1. Assemble all equipment prior to utilization. If utilizing capnography as a part of rapid sequence intubation, all equipment should be prepped prior to administration of paralytics and/or sedation. a. If required by unit model, zero the unit. 2. Apply ETCO2 adapter. a. If utilizing for monitoring of conscious patient, nasal cannula can be applied. b. If utilizing with ETT, placement location in circuit should be based on manufacturer recommendations. 3. Resume ventilations (continue spontaneous ventilations). 4. Observe monitor for numeric value and waveform. a. Obtain documentation strip prior to and after each patient move. b. If absent or low numeric value and/or absent or inappropriate waveform i. Immediately verify placement of advanced airway via  Colormetric device  Direct laryngoscopy ii. Assess circulation for possible cause of low/ absent/ inappropriate readings c. If low/ absent/ inappropriate readings occur prior to departure of transferring facility i. Return patient to original equipment to work to verify tube placement and reason for error. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3.B.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Capnography Monitoring (continued) 5. Unless directed otherwise by specific treatment protocol, seek to maintain ETCO2 range of 35-45 mmHg. Pearls If adjustment in ventilator rate (VR) is needed to improve ETCO2 Current ETCO2 x Current VR = Desired VR to achieve desired C02 Desired ETCO2 Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3.B.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Advanced Airway/ Rapid Sequence Intubation Tier II & Tier III The decision to provide an advanced airway in a patient who still has respiratory effort is not a decision to be made without consideration of all possible options and outcomes of actions. All necessary equipment should be readied before any action beyond BLS ventilation occurs. Additionally, an alternative airway adjunct must be at the patient’s bedside prior to initiation of the intervention. Assessment t Assessment of the potential advanced airway patient must include 1. Assessment of current airway, adjuncts, and respiratory status a. Look for and address possible causes of airway obstruction. b. For patient with some respiratory effort, rule out other methods to improve respirations. Consider i. Pharmacological agents that could quickly address cause of respiratory difficulty. ii. Positional adjustments that can improve patient’s respiratory effort. iii. Patient’s emotional state as a contributing factor to respiratory distress. 2. Compare current state to patient’s normal based on patient and family ability to provide history. 3. Consider patient’s ability and possible likelihood to deteriorate during transport. 4. If airway placement will be needed, strongly consider initiation prior to departure from transferring facility. Treatment and Interventions 1. Prior to initiation of any advanced airway intervention a. All needed equipment must to gathered and inspected. b. Back-up airway option must be identified by the CCT team. c. All medications must be checked by both the RN and EMT-P/ PHRN. 2. When CCT team is ready to proceed with airway procedure, medications are to be given. All medications should be identified and drawn up prior to any RSI intervention 3. Sedation to be given second. Only ONE should be given a. Etomidate: 20 mg IVP b. Midazolam: 5 mg IVP. May cause hypotension 3.C.1. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Advanced Airway/ Rapid Sequence Intubation (continued) 4. Paralytic to be given third. Only ONE should be given a. Rocuronium: 1mg/kg or 100 mg IVP (one time push) b. Succinylcholine: 100 mg IVP i. Consider contraindications for Succinylcholine 5. After paralytic is given the CCT team should be ready to provide ventilatory support. This should be provided by a CCT member other than the one preparing to place the advanced airway. 6. Await paralytic to take effect. 7. Make sure to sedate following intubation according to sedation of intubated patient protocol in 2.E.1 For Endotracheal Intubation 1. Implement basic airway measures. 2. Pre-oxygenate the patient with high concentration oxygen prior to intubation attempt. 3. Conduct a pre-intubation assessment using the Cormack-Lehane scale: GRADE 1 GRADE 2 GRADE 3 GRADE 4  If the pre-intubation assessment is GRADE 3 or GRADE 4, consider I-Gel as the first-line device.  An airway bougie may also be considered for a GRADE 2-4 airways 4. Select the proper tube size (based on patient size) and attach a 10mL syringe. Inflate the cuff to be sure it does not leak (the cuff must be deflated prior to insertion). 5. Insert stylet and bend to the approximate configuration of the pharynx. 6. Lubricate the ETT with a water-soluble lubricant. 7. Have suction, BVM, stethoscope, colorimetric end-tidal CO2 detector/capnography and commercial ETT holder readily available. 8. Suction the pharynx as needed. 9. Insert the laryngoscope blade into the mouth on the right side, moving the tongue to the left. Follow the natural contour of the pharynx, lifting the tongue (not prying) until you can see the glottic opening. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3.C.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Advanced Airway/ Rapid Sequence Intubation (continued) a. If you are using a straight blade (Miller), insert it until you can see the epiglottis. With the tip of the blade, lift up on the epiglottis so that you can visualize the vocal cords and glottic opening. If needed, have someone gently press down on the cricoid cartilage (Sellick Maneuver) and/or utilize the BURP procedure to aid in visualization of the vocal chords and to help compress the esophagus. b. If you are using a curved blade (Macintosh), insert the tip into the vallecula and lift up. This will lift the epiglottis and expose the vocal cords and glottic opening. If needed, have someone gently press down on the cricoid cartilage (Sellick Maneuver) so that you can see the cords well. 10. After visualizing the glottic opening, grasp the ETT with your right hand and advance the tube from the right corner of the mouth. Insert the tube into the glottic opening between the vocal cords, just far enough to pass the cuff of the tube past the opening. If spinal injury is considered a possibility 1. Any type of cervical spine manipulation may be dangerous during airway control of the suspected spinal injury patient. Maintain in-line stabilization while attempting airway control. Consider utilizing the I-Gel Airway in lieu of traditional intubation. 2. A minimum of two (2) trained rescuers is needed to assure special attention to spinal precautions. 3. One rescuer will apply manual in-line stabilization by placing the rescuers hands about the patient’s ears with the little fingers under the occipital skull and the thumbs on the face over the maxillary sinuses. 4. The rescuer performing airway placement should be at the head. Placement Verification 1. Verify proper position by ventilating the patient through the tube with a bag-valve device while listening to each side of the chest with a stethoscope to be sure air is entering both lungs. a. Check for inadvertent esophageal intubation by listening for air movement in the epigastric area during ventilations. 2. Utilize a colorimetric end-tidal CO2 (ETCO2) detector or waveform capnography as one confirmation method. 3. If breath sounds are heard on both sides of the chest, no epigastric sounds are heard, colorimetric ETCO2 detector/capnography indicate proper placement, inflate the cuff with 10mL of air and secure the tube with a commercial ETT holder. 4. If you have inserted the ETT too far, it will usually go into the right main stem bronchus. Therefore, if you hear breath sounds only on the right, you should pull the tube back ½ inch at a time until you hear bilateral breath sounds. Inflate the cuff with 10mL of air and secure the ETT with a commercial holder. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3.C.3.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Advanced Airway/ Rapid Sequence Intubation (continued) 5. If you hear no breath sounds, you are in the esophagus and must remove the ETT immediately. Repeat above steps. a. If no breaths sounds on second attempt ventilate patient and proceed to I-Gel Airway insertion or continue basic airway control measures. 6. Frequently reassess breath sounds to be sure that the ETT is still in place. 7. Ventilate the patient at a rate of 12 times per minute until ventilator settings can be established. 8. Treat based on Patient Sedation Protocol as needed to maintain sedation during transport. Use of the Endotracheal Tube Introducer (AKA “Bougie”) 1. The endotracheal tube introducer, AKA “Bougie” is a useful tool to help facilitate difficult intubation. Unlike a stylet, a bougie is inserted independent of the ET tube and is used as a guide, over which an ET Tube may be placed into the trachea. It is used where a difficult intubation is anticipated, or a poor view of the glottis opening has been confirmed on laryngoscopy (Cormack-Lehane II, IV). 2. Prepare the endotracheal tube introducer for use: Curve the bougie and ensure the distal tip is formed into a J (coudé) shape. 3. Utilize the laryngoscope as you would do during intubation to obtain the best possible view of the glottis opening. You should always be able to view the tip of the epiglottis and, ideally, the arytenoid cartilages. 4. Advance the bougie, continually observing its distal tip, with the concavity facing anteriorly. 5. Visualize the tip of the bougie passing posteriorly to the epiglottis and (where possible) anterior to the arytenoid cartilages. 6. Once the tip of the bougie has passed the epiglottis, continue to advance it in the mid-line so that it passes behind the epiglottis but in an anterior direction. 7. As the tip of the bougie enters the glottis opening you may feel “clicks” as it passes over the tracheal rings or the tip may stop against the wall of the airways. This suggests correct insertion, although this cannot be relied upon to indicate correct positioning. 8. Hold the bougie firmly in place and pass the endotracheal tube over the proximal end of the bougie. 9. As the proximal tip of the bougie is re-exposed, carefully grasp it, assuming control of the bougie. 10. The ET tube should then be carefully advanced along the bougie and hence through the glottic opening, taking care to avoid movement of the bougie. 11. Once the ET tube is fully in place hold it securely as you slowly withdraw the bougie. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3.C.4.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Advanced Airway/ Rapid Sequence Intubation (continued) i-Gel  The i-Gel is an airway device designed for emergency or difficult airway management in the apneic or unresponsive patient without a gag reflex.  It is the primary airway of choice for adult and pediatric cardiac arrest patients.  It is the back-up airway in cases of an unsuccessful intubation attempt. Contraindication s  Active gag reflex  Ingestion of a caustic substance (e.g. gasoline, drain cleaner, etc.)  Use caution in pregnant females  Morbid obesity  Tracheostomy (it will be ineffective)  Patient less than 30kg (BLS provider restriction only)  Known or suspected esophageal disease (e.g. esophageal varices) i-Gel Airway Insertion Procedure 1. Don appropriate PPE 2. Pre-Oxygenate the patient with 100% Oxygen. 3. Select the appropriate i-Gel size from the chart above. 4. Remove the device from the packaging and check for signs of damage. 5. Place water-soluble jelly in the middle of the cradle packaging. 6. Lubricate the back, sides, and tip of the i-Gel’s non-inflatable cuff. Ensure no lubricant is inside the cuff. 7. Grasp along the integral bite block and face the cuff towards the patients’ chin. 8. Insert the i-Gel into the mouth in the direction of the hard palate. 9. Glide the device down and back along the hard palate with continuous, gentle pressure until resistance is met. Controlled Copy – not for distribution beyond intended recipient; 3.C.5. Intended recipients will be notified of updates after initial distribution  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Advanced Airway/ Rapid Sequence Intubation (continued) i-Gel Airway Insertion Procedure (Cont.) 10. Tape the device Maxilla to Maxilla or use a commercial i-Gel 02 holder for gentle downward pressure. 11. Connect the i-Gel to the BVM. 12. Confirm i-Gel placement with ETCO2 detector or waveform capnography (preferred), auscultation of bilateral breath sounds, and visualizing equal chest rise/fall. 13. Continuously monitor the patient with pulse oximetry, capnography, and cardiac monitor. 14. (ALS only) Insert appropriately sized gastric tube if time permits. a. Use a 12Fr gastric tube for I-Gel sizes #2- #5 b. Use a 10Fr gastric tube for I-Gel size #1.5 Critical Thinking If unsuccessful in placing a Supraglottic Airway, remove the airway and a second attempt with the device following the same insertion procedures may be made. If this attempt is unsuccessful, immediately revert to Basic Airway Control Procedures. Sizes for the i-Gel are based on ideal body weight for the size of the patient. A proficient provider can insert an i-Gel in 5 seconds or less. Do NOT administer medications via any Supraglottic Airway Device. It is designed as an airway adjunct only and cannot be utilized as a medication route. Warning: In order to avoid the possibility of the device moving up out of position prior to being secured in place, it is essential that as soon as insertion has been successfully completed, the i-Gel is held in the correct position until being secured. Warning: Do not apply excessive force on the device during insertion. It is not necessary to insert fingers or thumbs into the patients’ mouth during the i-Gel insertion process. Supraglottic Airways do not prevent the aspiration of gastric contents. Controlled Copy – not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 3. C. 6  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Advanced Airway/ Rapid Sequence Intubation (continued) If changing from a defective Endotracheal Tube to new Endotracheal Tube 1. Prepare all needed equipment in advance. 2. Hyperoxygeniate patient prior to procedure. 3. Remove BVM or ventilator circuit from Endotracheal Tube. 4. Insert lubricated Bougie Tube into ventilation port of Endotracheal Tube (approximately 30 cm.) 5. Deflate bulb on Endotracheal Tube. 6. Remove Endot