2022 RCEMS Protocol Book PDF

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#PPL  North Carolina College of Emergency Physicians Protocols Table of Contents Protocol Introduction PI (Black) PI-1. Introduction PI-2. Key to Protocol Utilization Universal Protocols UP (Light Green) UP-1. Universal Patient Care UP-2. Triage UP-3. Abdominal Pain / Vomiting and Diarrhea UP-4. Altered Mental Status UP-5. Back Pain UP-6. IV or IO Access UP-7. Dental UP-8. Emergencies Involving Indwelling Central Lines UP-9. Epistaxis UP-10. Fever / Infection Control UP-11. Pain Control UP-12. Police Custody UP-13. Seizure UP-14. Suspected Stroke UP-15. Suspected Sepsis UP-16. Syncope UP-17. Behavioral Health Crisis UP-18. Behavioral Agitation / Sedation Guide UP-19. Behavioral Excited Delirium Syndrome / Violent UP-20 Well Person Check Airway Respiratory Section AR (Light Blue) AR-1. Adult Airway AR-2. Adult, Failed Airway AR-3. Airway, Drug Assisted (Not Adopted) AR-4. COPD / Asthma AR-5. Pediatric Airway AR-6. Pediatric Failed Airway AR-7. Pediatric Respiratory Distress AR-8 Post-intubation / BIAD Management AR-9. Ventilator Emergencies AR-10. Tracheostomy Tube Emergencies Revised Table of Contents - Protocols 10/15/2021 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS  North Carolina College of Emergency Physicians Protocols Table of Contents Adult Cardiac Section AC (Dark Blue) AC-1. Asystole / Pulseless Electrical Activity AC-2. Bradycardia; Pulse Present AC-3. Cardiac Arrest; Adult AC-4. Chest Pain: Cardiac and STEMI AC-5. CHF / Pulmonary Edema AC-6. Adult Tachycardia Narrow Complex (≤ 0.11 sec) AC-7. Adult Monomorphic Tachycardia Wide Complex (≥ 0.12 sec) AC-8. Adult Polymorphic Tachycardia WIDE (≥ 0.12 sec) Torsades de pointes AC-9. Ventricular Fibrillation Pulseless Ventricular Tachycardia AC-10. Post Resuscitation AC-11. Team Focused CPR (Optional) AC-12. On-scene Resuscitation / Termination of CPR (Optional) AC-13. Target Temperature Management (Not Adopted) AC-14. LVAD Emergency AC-15. Total Mechanic Circulation AC-16. Wearable Cardioverter Defibrillator Vest Adult Medical Section AM (Olive Green) AM-1. Allergic Reaction / Anaphylaxis AM-2. Diabetic; Adult AM-3. Dialysis / Renal Failure AM-4. Hypertension AM-5. Hypotension / Shock AM-6. Stroke; Activase / t-PA Transfer (Not Adopted) Adult Obstetrical Section AO (Dark Purple) AO-1. Childbirth / Labor AO-2. Newly Born AO-3. Obstetrical Emergency Table of Contents - Protocols Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS  North Carolina College of Emergency Physicians Protocols Table of Contents Trauma and Burn Section TB (Red) TB-1. Blast Injury / Incident TB-2. Chemical and Electrical Burn TB-3. Crush Syndrome Trauma TB-4. Extremity Trauma TB-5. Head Trauma TB-6. Multiple Trauma TB-7. Radiation Incident TB-8. Spinal Motion Restriction TB-9. Thermal Burn TB-10. Traumatic Arrest (Optional) Pediatric Cardiac Section PC (Light Purple) PC-1. Pediatric Asystole / PEA PC-2. Pediatric Bradycardia PC-3. Pediatric CHF / Pulmonary Edema PC-4. Pediatric Pulseless Arrest PC-5. Pediatric Tachycardia Narrow Complex PC-6. Pediatric Tachycardia Wide Complex PC-7. Pediatric Ventricular Fibrillation / Pulseless VT PC-8. Pediatric Post Resuscitation Pediatric Medical Section PM (Grey Blue) PM-1. Pediatric Allergic Reaction PM-2. Pediatric Diabetic PM-3. Pediatric Hypotension / Shock Toxin-Environmental Section TE (Gold) TE-1. Bites and Envenomations TE-2. Carbon Monoxide / Cyanide TE-3. Drowning TE-4. Hyperthermia TE-5. Hypothermia / Frostbite TE-6. Marine Envenomation / Injury TE-7. Overdose / Toxic Ingestion TE-8. WMD – Nerve Agent Protocol TE-9. Medication Assisted Treatment (MAT) Table of Contents - Protocols Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS  North Carolina College of Emergency Physicians Protocols Table of Contents Special Circumstances Section SC (Black) SC-1. Suspected Viral Hemorrhagic Fever – Ebola SC-2. High Consequence Pathogens SC-3. Hospice or Palliative Care Patient (Optional) SC-4. Vaccination/Immunization SC-5. SARS CoV2 Monoclonal Antibody Infusion Special Operations Section SO (Gold) SO-1. Scene Rehabilitation: General (Optional) SO-2. Scene Rehabilitation: Responder (Optional) Table of Contents - Protocols Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS  Introduction The following medical treatment protocols are developed for North Carolina EMS agencies. The process has evolved since 2007 and continues with input from Medical Directors, EMS Administration, North Carolina Chapter of Emergency Physicians Protocol Committee, North Carolina Office of EMS, EMS field personnel and the public at large through on-line surveys, public meetings across North Carolina and direct communication with stakeholders. The 2017 update expands on the 2012 and 2009 version and continues to incorporate evidence-based guidelines, expert opinion and historically proven practices meant to ensure that citizens and visitors of North Carolina will continue to be provided the highest quality pre-hospital patient care available. The North Carolina Chapter of Emergency Physicians develops and provides final approval. The purpose of the protocol section is to provide treatment protocols outlining permissible and appropriate assessment , delivery of care, reassessment and procedures which may be rendered by pre-hospital providers. The protocols also outline which medical situations require direct voice communication with medical control. In general treatment protocols are specific orders which may and should be initiated prior to contact with Medical Control. Please note the medical protocols are divided into three (3) to four (4) sections. The upper section includes three (3) boxes (History, Signs and Symptoms and Differential) which serves as a guide to assist in obtaining pertinent patient information and exam findings as well as considering multiple potential causes of the patients complaint. It is not expected that every historical element or sign / symptom be recorded for every patient. It is expected that those elements pertinent to your patient encounter will be included in the patient evaluation. Protocol Introduction The algorithm section describes the essentials of patient care. Virtually every patient should receive the care outlined in this section, usually in the order described. However each medical emergency must be dealt with individually and appropriate care determined accordingly. Professional judgment is mandatory in determining treatment modalities within the parameters of these protocols. Circumstances will arise where treatment may move ahead in the algorithm, move outside to another protocol and then re-enter later. While protocols are written based on body systems and primary complaints the patient should be treated as a whole and therefore the protocols should be considered as a whole in providing care. Professional judgment hierarchy: The pre-hospital provider may determine that no specific treatment is needed; Or The pre-hospital provider may follow the appropriate treatment protocols and then consult Medical Control ; Or The pre-hospital provider may consult Medical Control before initiating any specific treatment. Some protocols will encompass two (2) pages. Protocols which exist in a single page format may have page 2 added by the local medical director. The PEARLS section will either be located at the bottom of page 1 (single page protocol) or page 2 (double page protocol). The PEARLS section provides points regarding the main protocol based on evidence to date, common medical knowledge and expert medical opinion. Information boxes highlighted in purple. These areas are editable at the local level. They will mainly involve specific medications and dosages utilized by the local EMS agency. Page 2 will have a large section highlighted in purple where the local Medical Director may edit as they see fit to provide expanded points and treatment not otherwise specified in the algorithm. If the box is not to be utilized – add “This Space Left Blank Intentionally.” Finally these medical treatment protocols are established to ensure safe , efficient and effective interventions to relieve pain and suffering and improve patient outcomes without inflicting harm. They also serve to ensure a structure of accountability for Medical Directors, EMS agencies, pre-hospital providers and facilities to provide continual performance improvement. A recent report of the Institute of Medicine calls for the development of standardized , evidence-based pre-hospital care protocols for the triage, treatment and transport of patients. These protocols establish expectations of pre-hospital care in North Carolina. PI 1  Introduction Authors: R. Darrell Nelson, MD Doug Swanson, MD Medical Director Davie and Stokes County Medical Director Mecklenburg County EMS Agency Assistant Medical Director Forsyth County Medical Director MedCenter Air CCT Assistant Professor Associate Professor Wake Forest University Carolinas Medical Center / UNC-Chapel Hill Department of Emergency Medicine Department of Emergency Medicine Co-Chairman NCCEP EMS Committee Co-Chairman NCCEP EMS Committee Chairman NCCEP Protocol Committee Roberto (Bobby) Portela, MD Eric Hawkins, MD Medical Director Pitt County EMS Medical Director Union County EMS Clinical Assistant Professor Carolinas Medical Center East Carolina University Department of Emergency Medicine Juan March, MD Professor and Chief, Division of EMS East Carolina University Department of Emergency Medicine Protocol Introduction Jason Stopyra, MD Jeff Williams, MD Medical Director Randolph County EMS Deputy Medical Director Wake County EMS Medical Director Surry County EMS Assistant Professor Assistant Professor UNC-Chapel Hill Wake Forest University Department of Emergency Medicine Department of Emergency Medicine Bryan Kitch, MD Seth C. Hawkins, MD Medical Director Hyde County Medical Director Burke County EMS Assistant Professor Assistant Professor East Carolina University Wake Forest University Department of Emergency Medicine Department of Emergency Medicine Matthew Harmody, MD Medical Director, FirstHealth EMS and CCT Medical Director, Moore Regional Hospital Medical Director Moore Regional Hospital-Hoke Campus EDs Mark Quale, MD Henderson McGinnis, MD Medical Director Alamance County EMS Medical Director Wilkes County EMS Clinical Affiliate Medical Director Wake Forest Baptist AirCare CCT Wake Forest University Associate Professor Department of Emergency Medicine Wake Forest University Department of Emergency Medicine Jose Cabanos, MD Jane Brice, MD Director Wake County EMS Professor and Chair Medical Director Wake County EMS UNC-Chapel Hill Adjunct Associate Professor Department of Emergency Medicine UNC-Chapel Hill Department of Emergency Medicine PI 1  Key to Protocol Utilization History Signs and Symptoms Differential  Important history items  Important Signs and Symptoms  A list of other disease or injury which should  Circumstances of event specific to each protocol be considered  SAMPLE  Time of onset  Duration Red Box Universal Patient Care Protocol Black Box Assumed all protocols utilize and will not Highlights Critical appear on individual protocols Hightlights Information Important Information May direct to another protocol Signals protocol within a protocol Indicates Information box Entry / Exit from / to Protocol Introduction to another protocol(s) Decision Point Darker outline to highlight Highlights medication after Contact Medical Control May be added by Local Medical Director Purple Shading of Information Box Indicates items changeable at local agency level, including medications / dosages on NCMB formulary Local Medical Director may add / change at his / her discretion Local medical director may add page 2 to any protocol where none exists for additional comments Algorithm Legend Emergency Medical Responder B Emergency Medical Technician A Advanced Emergency Medical Technician P Paramedic Notify Destination or Contact Medical Control Pearls  Important information specific to each protocol will appear here.  Will usually appear on page.  Important exam items listed here specific to protocol. PI 2  Universal Patient Care Bring all necessary equipment to patient Scene Demonstrate professionalism and courtesy Required VS: YES Mass assembly consider WMD Blood pressure Safe NO Palpated pulse rate Utilize appropriate PPE Respiratory rate Consider Airborne, Contact, or Droplet Isolation Pulse ox if available if indicated Call for help / additional If Indicated: resources Initial assessment Glucose Stage until scene safe BLS maneuvers 12 Lead ECG Initiate oxygen if indicated Temperature Adult Assessment Procedure Pain scale CO Monitoring Pediatric Assessment Procedure EtCO2 Monitoring Use Broselow-Luten tape Trauma Medical Medical or Trauma Patient Patient Evaluate MOI Mental Status Exam Universal Protocol Section Unresponsive Responsive Significant MOI No Significant MOI Primary and Primary and Primary and Obtain secondary Secondary Secondary trauma Chief Complaint assessment trauma assessment Primary and assessment Obtain history of Secondary Focused assessment present illness from assessment on specific injury available sources / Focused assessment scene survey on specific complaint Spinal Motion Restriction Procedure / Protocol TB 8 as indicated Obtain VS Obtain SAMPLE Repeat assessment while preparing for transport Exit to Age Appropriate Protocol(s) as indicated Continue on-going assessment Repeat initial VS Evaluate interventions / procedures Transfer Patient hand-off includes patient information, personal Patient does not property and summary of care and response to care fit specific protocol Notify Destination or Contact Medical Control Revised UP 1 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Universal Patient Care Scene Safety Evaluation: Identify potential hazards to rescuers, patient, and public. Identify number of patients and utilize SMART protocol if indicated. Observe patient position and surroundings. General: All patient care must be appropriate to your level of training / certification and documented in the PCR. After arriving on scene and Universal Protocol Section upon contacting the patient(s) 911 communications will be notified of patient contact to document time. The PCR narrative should be considered a story of the circumstances, events and care of the patient and should allow a reader to understand the complaint, the assessment, the treatment, why procedures were performed and why indicated procedures were not performed as well as ongoing assessments and response to treatment and interventions. Adult Patient: An adult is considered hypotensive when Systolic Blood Pressure is less than 90 mmHg. Diabetic patients and women may have atypical presentations of cardiac related problems such as MI. General weakness can be the symptom of a very serious underlying process. Beta blockers and other cardiac drugs may prevent a reflexive tachycardia in shock with low to normal pulse rates. Geriatric Patient: Hip fractures and dislocations have high mortality. Altered mental status is not always dementia. Always check Blood Sugar and assess signs of stroke, trauma, etc. with any alteration in a patient's baseline mental status. Minor or moderate injury in the typical adult may be very serious in the elderly. Special note on oxygen administration and utilization: Oxygen in pre-hospital patient care and probably over utilized. Oxygen is a drug with indications, contraindications as well as untoward side effects. Recent research demonstrates a link with increased mortality when oxygen is over-utilized (hyperoxia / hyperventilation) in cardiac arrest. Utilize oxygen when indicated and not because it is available. A reasonable target oxygen saturation in all treatment protocols is 94% regardless of delivery. Pearls Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status with GCS, and location of injury or complaint. Any patient contact which does not result in an EMS transport must have a completed disposition form. Vital signs should be obtained before, 10 minutes after, and at patient hand off with all pain medications. 2 complete vital sign acquisitions should occur at a minimum with a patient encounter. Patient Refusal Patient refusal is a high risk situation. Encourage patient to accept transport to medical facility. Encourage patient to allow an assessment, including vital signs. Documentation of the event is very important including a mental status assessment describing the patient’s capacity to refuse care. Guide to Assessing capacity: C:Patient should be able to communicate a clear choice: This should remain stable over time. Inability to communicate a choice or an inability to express the choice consistently demonstrates incapacity. R: Relevant information is understood: Patient should be able to display a factual understanding of the illness, the options and risks and benefits. A: Appreciation of the situation: Ability to communicate an understanding of the facts of the situation. They should be able to recognize the significance of the outcome potentially from their decision. M: Manipulation of information in a rational manner: Demonstrate a rational process to come to a decision. Should be able to describe the logic they are using to come to the decision, though you may not agree with decision. Pediatric Patient General Considerations: A pediatric patient is defined by fitting a Length-based Resuscitation Tape, Age ≤ 15, weight ≤ 49 kg. Patients off the Broselow-Luten tape should have weight based medications until age ≥ 16 or weight ≥ 50 kg. Special needs children may require continued use of Pediatric based protocols regardless of age and weight. Initial assessment should utilize the Pediatric Assessment Triangle which encompasses Appearance, Work of Breathing and Circulation to skin. The order of assessment may require alteration dependent on the developmental state of the pediatric patient. Generally the child or infant should not be separated from the caregiver unless absolutely necessary during assessment and treatment. Timing of transport should be based on patient's clinical condition and the transport policy. Never hesitate to contact medical control for patient who refuses transport. Blood Pressure is defined as a Systolic / Diastolic reading. A palpated Systolic reading may be necessary at times. SAMPLE: Signs / Symptoms; Allergies; Medications; PMH; Last oral intake; Events leading to illness / injury Revised UP 1 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Triage Secondary Triage Able to Walk YES Minor Evaluate Infants FIRST Repeating Triage Process NO Reposition Upper Airway Results in Spontaneous Breathing Breathing NO YES IMMEDIATE Follow Adult or Ped Arm YES NO Pediatric Adult Pulse NO DECEASED YES Universal Protocol Section 2 Rescue Breaths Breathing NO YES IMMEDIATE Respiratory Adult > 30 / minute IMMEDIATE Rate Ped < 15 or > 45 Adult < 30 / minute Ped > 15 or < 45 Cap Refill > 2 Sec (Adult) Perfusion IMMEDIATE No palpable Pulse (Pediatric) Obeys Commands Adult Mental YES DELAYED Status Appropriate to AVPU Pediatric NO IMMEDIATE Revised UP 2 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Triage Triage is used to bring control to a seemingly overwhelming situation. Incidents which produce multiple casualties are rare but do occur and planning is paramount. A multiple casualty incident is defined as any incident where more casualties are present than Universal Protocol Section initial response can reasonably handle. More response is needed for triage, treatment and transport than can arrive in a timely fashion. Responders are also tasked with assuring / maintaining the scene safety as well as dealing with injury and illness. First arriving responders can become overwhelmed with patients presenting with a wide variety of injury and illness as well an those with no injury or illness. This protocol incorporates pediatric patient multiple casualty triage tool. It provides an objective structure to help assure responders triage children with their heads and not their hearts which can lead to over triage and diversion of precious resources from other patients who may need them more. Under triage is addressed as well by recognizing key differences between adult and pediatric physiology. This should only be used with true multiple casualty incidents and disasters where resources for care are limited and should not be used for routine pre-hospital triage. Sorting / Triage: Sort patients based on objective criteria in how they present. The severity of injury and therefore treatment / transport priority is color coded. Triage tags contain these colors so treatment and transport crews easily can see which patients have been triaged and to which level. If your patient falls into the RED TAG category, stop, place RED TAG and move on to next patient. Attempt only to correct airway problems or treat uncontrolled bleeding before moving to next patient. Pearls.When approaching a multiple casualty incident where resources are limited: Triage decisions must be made rapidly with less time to gather information Emphasis shifts from ensuring the best possible outcome for an individual patient to ensuring the best possible outcome for the greatest number of patients. Scene Size Up: 1. Conduct a scene size up. Assure well being of responders. Determine or ensure scene safety before entering. If there are several patients with the same complaints consider HazMat, WMC or CO poisoning. 2. Take Triage system kit. 3. Determine number of patients. Communicate the number of patients and nature of the incident, establish command and establish a medical officer and triage officer if personnel available Triage is a continual process and should recur in each section as resources allow. Step 1: Global sorting: Call out to those involved in the incident to walk to a designated area and assess third. For those who cannot walk, have them wave / indicate a purposeful movement and assess them second. Those involved who are not moving or have an obvious life threat, assess first. Step 2: Individual assessments: Control major hemorrhage Open airway and if child, give 2 rescue breaths Perform Needle Chest Decompression Procedure if indicated. Administer injector antidotes if indicated Assess the first patient you encounter using the three objective criteria which can be remembered by RPM. R: Respiratory P: Perfusion M: Mental Status If your patient falls into the RED TAG category, stop, place RED TAG and move on to next patient. Attempt only to correct airway problems, treat uncontrolled bleeding, or administer an antidote before moving to next patient. Treatment: Once casualties are triaged focus on treatment can begin. You may need to move patients to treatment areas. RED TAGs are moved / treated first followed by YELLOW TAGs. BLACK TAGs should remain in place. You may also indicate deceased patients by pulling their shirt / clothing over their head. As more help arrives then the triage / treatment process may proceed simultaneously. Capillary refill can be altered by many factors including skin temperature. Age-appropriate heart rate may also be used in triage decisions. SMART triage tag system is utilized in NC. Revised UP 2 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Abdominal Pain Vomiting and Diarrhea History Signs and Symptoms Differential Age Pain CNS (increased pressure, headache, stroke, Time of last meal Character of pain (constant, CNS lesions, trauma or hemorrhage, vestibular) Last bowel movement/emesis intermittent, sharp, dull, etc.) Myocardial infarction Improvement or worsening Distention Drugs (NSAID's, antibiotics, narcotics, with food or activity Constipation chemotherapy) Duration of problem Diarrhea GI or Renal disorders Other sick contacts Anorexia Diabetic ketoacidosis Past medical history Radiation OB-Gyn disease (ovarian cyst, PID, Pregnancy) Past surgical history Associated symptoms: Infections (pneumonia, influenza) Medications Fever, headache, blurred vision, Electrolyte abnormalities Menstrual history (pregnancy) weakness, malaise, myalgias, cough, Food or toxin induced Travel history headache, dysuria, mental status Medication or Substance abuse Bloody emesis / diarrhea changes, rash Psychological Consider Blood Glucose Analysis Procedure B 12 Lead ECG Procedure A IV Procedure P Cardiac Montior Age Appropriate Diabetic Protocol AM 2 / PM 2 if indicated Pain Control Protocol UP 11 if indicated Universal Protocol Section Age Appropriate Cardiac IV / IO Procedure Protocol(s) Consider 2 Large Bore sites if indicated Normal Saline 500 mL Bolus Repeat as needed Serious Signs / Symptoms Titrate SPB ≥ 90 mmHg Hypotension, poor YES A Maximum 2 L perfusion, shock Peds: 20 mL/kg IV / IO Repeat as needed NO Titrate to Age Appropriate Normal Saline IV TKO SBP ≥ 70 + 2 x Age A Maximum 60 mL/kg Or Saline Lock Odansetron 4 mg Odansetron 4 mg IV / IO / ODT / IM IV / IO / ODT / IM P Peds: 0.2 mg/kg PO / ODT Peds: 0.2 mg/kg PO / ODT Peds Maximum 4 mg Peds Maximum 4 mg May repeat in 15 minutes P May repeat in 15 minutes Age Appropriate If no response Hypotension / Shock Promethazine Protocol AM 5 / PM 3 12.5 mg IV/ IO / IM if indicated May repeat x 1 as needed Monitor and Reassess Notify Destination or Contact Medical Control Revised UP 3 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Abdominal Pain Vomiting and Diarrhea Abdominal pain is a common complaint encountered by EMS. Abdominal pain may arise from many organ systems including cardiac, pulmonary, endocrine, genitourinary and renal systems. Often 40 – 60 % of abdominal complaints have no diagnosis after extensive testing once in the emergency department so a diagnosis is very difficult in the pre-hospital setting. Four patient populations which deserve special focus: Elderly Universal Protocol Section May signal significant morbidity and mortality in patients > 50 years of age. Disease significance may be out of proportion to exam findings and presentation. Vascular problems are seen more often. Consider cardiac etiology and obtain ECG if warranted. Immunocompromised HIV, Diabetes, Renal Failure, Transplant patients, Patients taking chronic steroids. Women of childbearing age Consider ectopic pregnancy until proven otherwise. Pediatric Blood Glucose Analysis as abdominal pain and N/V can be an initial sign of diabetes or DKA Stable versus unstable patient: Very important as the stable patient with undifferentiated abdominal pain may require only supportive care , anti-emetics and possibly pain medications. The unstable patient needs more directed therapy which is typically driven by presentation and vital signs. Pearls Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Age specific blood pressure 0 – 28 days > 60 mmHg, 1 month - 1 year > 70 mmHg, 1 - 10 years > 70 + (2 x age) mmHg and 11 years and older > 90 mmHg. Abdominal / back pain in women of childbearing age should be treated as pregnancy related until proven otherwise. The diagnosis of abdominal aneurysm should be considered with abdominal pain, with or without back and / or lower extremity pain or diminished pulses, especially in patients over 50 and / or patients with shock/ poor perfusion. Notify receiving facility early with suspected abdominal aneurysm. Consider cardiac etiology in patients > 50, diabetics and / or women especially with upper abdominal complaints. Repeat vital signs after each fluid bolus. Heart Rate: One of the first clinical signs of dehydration, almost always increased heart rate, tachycardia increases as dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal. Promethazine (Phenergan) may cause sedative effects in pediatric patients and ages ≥ 60 and the debilitated, etc.) When giving promethazine IV dilute with 10 mL of normal saline and administer slowly as it can also harm the veins. Beware of vomiting only in children. Pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures) all often present with vomiting. Document the mental status and vital signs prior to administration of Promethazine (Phenergan). Isolated vomiting may be caused by pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures). Vomiting and diarrhea are common symptoms, but can be the symptoms of uncommon and serious pathology such as stroke, carbon monoxide poisoning, acute MI, new onset diabetes, diabetic ketoacidosis (DKA), and organophosphate poisoning. Maintain a high index of suspicion. Revised UP 3 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Altered Mental Status History Signs and Symptoms Differential Known diabetic, medic alert Decreased mental status or lethargy Head trauma tag Change in baseline mental status CNS (stroke, tumor, seizure, infection) Drugs, drug paraphernalia Bizarre behavior Cardiac (MI, CHF) Report of illicit drug use or Hypoglycemia (cool, diaphoretic Hypothermia toxic ingestion skin) Infection (CNS and other) Past medical history Hyperglycemia (warm, dry skin; fruity Thyroid (hyper / hypo) Medications breath; Kussmaul respirations; signs Shock (septic, metabolic, traumatic) History of trauma of dehydration) Diabetes (hyper / hypoglycemia) Change in condition Irritability Toxicological or Ingestion Changes in feeding or sleep Acidosis / Alkalosis habits Environmental exposure Pulmonary (Hypoxia) Electrolyte abnormality Psychiatric disorder Age Appropriate Airway Protocol(s) AR 1, 2, 3, 5, 6 if indicated Blood Glucose Analysis Procedure B 12 Lead ECG Procedure A IV / IO Procedure Age Appropriate Diabetic Protocol(s) AM 2 / PM 2 if indicated Exit to Age Appropriate Signs of shock / Poor perfusion Universal Protocol Section YES Hypotension / Shock Protocol AM 5 / PM 3 Traumatic Injury Multiple Trauma Protocol TB 6 Head Injury Protocol TB 5 NO Exit to Signs of OD / Toxicology YES Overdose / Toxic Exposure Protocol TE 7 NO Exit to Signs of CVA Or Seizure YES Suspected Stroke Protocol UP 14 Seizure Protocol UP 13 NO Exit to Signs of Hypo / Hyperthermia YES Hypothermia Protocol TE 5 Hyperthermia Protocol TE 4 NO Exit to Arrhythmia / STEMI / CP YES Age Appopriate Appropriate Cardiac Protocol(s) NO Exit to Fever / Sepsis YES Fever Protocol UP 10 Suspected Sepsis Protocol UP 15 NO Notify Destination or Contact Medical Control Revised UP 4 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Altered Mental Status General: The patient with AMS poses one of the most significant challenges to you as a provider. A careful assessment of the patient, the scene and the circumstances should be undertaken. Assume the patient has a life threatening cause of their AMS until proven otherwise. The algorithm is written in a step wise fashion but circumstances may dictate moving within the protocol. The stepwise fashion should serve as a reminder of the importance of a methodical approach to the patient with AMS. An Universal Protocol Section example is the 12 lead ECG procedure and interpretation of the rhythm. As you work as a team one provider may be assessing the finger stick glucose while another provider interprets the ECG rhythm. Spinal Motion Restriction / Trauma: As noted only utilize spinal immobilization if the situation warrants. The patient with AMS may worsen in some instances when immobilized so only use when necessary. In AMS with trauma evident you should move immediately to the Adult Head Trauma Protocol in conjunction with the Altered Mental Status Protocol. Excited Delirium Syndrome: Excited Delirium is a hyper-stimulated state usually induced by either a psychiatric condition or drug use (usually stimulants such as cocaine or meth). The surge of catecholamine (the body’s natural equivalent of epinephrine and norepinephrine) can induce cardiac arrest and death. The treatment is Midazolam. Consider this diagnoses in a patient that is severely agitated. The longer the patient is restrained, the higher the risk of cardiac arrest. This is especially true if the patient has been restrained by police prior to your arrival on scene. The longer they fight, the higher the risk. Consider chemical restraint early. See UP17 Behavioral Health Crisis, UP18 Behavioral Agitation/ Sedation Guide, and UP19 Behavioral Excited Delirium Syndrome/Violent Protocols. Pearls Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. AMS may present as a sign of an environmental toxin or Haz -Mat exposure - protect personal safety. General: The patient with AMS poses one of the most significant challenges. A careful assessment of the patient, the scene and the circumstances should be undertaken. Assume the patient has a life threatening cause of their AMS until proven otherwise. Pay careful attention to the head exam for signs of bruising or other injury. Information found at the scene must be communicated to the receiving facility. Substance misuse: Patients ingesting substances can pose a great challenge. DO NOT assume recreational drug use and / or alcohol are the sole reasons for AMS. Misuse of alcohol may lead to hypoglycemia. More serious underlying medical and trauma conditions may be the cause. Behavioral health: The behavioral health patient may present a great challenge in forming a differential. DO NOT assume AMS is the result solely of an underlying psychiatric etiology. Often an underlying medial or trauma condition precipitates a deterioration of a patients underlying disease. Spinal Motion Restriction / Trauma: Only utilize spinal immobilization if the situation warrants. The patient with AMS may worsen with increased agitation when immobilized. It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or Glucagon Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure. Revised UP 4 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Back Pain History Signs and Symptoms Differential Age Pain (paraspinous, spinous Muscle spasm / strain Past medical history process) Herniated disc with nerve compression Past surgical history Swelling Sciatica Medications Pain with range of motion Spine fracture Onset of pain / injury Extremity weakness Kidney stone Previous back injury Extremity numbness Pyelonephritis Traumatic mechanism Shooting pain into an extremity Aneurysm Location of pain Bowel / bladder dysfunction Pneumonia Fever Spinal Epidural Abscess Improvement or worsening with Metastatic Cancer activity AAA Consider Cardiac Etiology B 12 Lead ECG Procedure if indicated Cardiac Monitor P if indicated Age Appropriate Cardiac Protocol(s) if indicated Spinal Motion Restriction Injury or Traumatic YES Procedure / Protocol TB 8 Mechanism If indicated NO Universal Protocol Section Shock YES Hemodynamic Instability Age Appropriate Airway Protocol(s) AR 1, 2, 3, 5, 6 NO if indicated Normal Saline Bolus 500 mL IV Titrate to SBP ≥ 90 2 L Maximum A Peds: 20 mL/kg IV / IO Titrate age appropriate SBP ≥ 70 + 2 x Age Maximum 60 mL/kg Age Appropriate Hypotension / Shock Protocol(s) AM 5 / PM 3 if indicated Multiple Trauma Protocol TB 6 if indicated Pain Control Protocol UP 11 if indicated Monitor and Reassess Notify Destination or Contact Medical Control Revised UP 5 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Back Pain Back pain is one of the most common complaints in medicine and effects more than 90 % of adults at some point in their life. Most often it is a benign process but in some circumstances can be life or limb threatening. Have a high suspicion of Abdominal Aortic Aneurysm (AAA) if the patient is > 50 years of age and presents with flank pain and no history of Kidney stones. First presentation of kidney stones in a patient greater than 50 y/o is rare. Ketorolac is drug of choice when treating kidney stones. Narcotic analgesia should only be given secondary to Ketorolac. Universal Protocol Section Associated symptoms: Fever, chills and night sweats. Symptoms outside the musculoskeletal system like urinary, gastrointestinal or pulmonary. Progressive neurological symptoms described below. Past medical history described below. Abnormal vital signs. Non-traumatic back pain: Most important signs/symptoms or bowel and bladder function, sexual function, weakness, numbness especially saddle anesthesia (numbness in the inner thighs, buttocks and perineum – what would sit in a horse saddle) as this increases suspicion of cauda equina syndrome. Traumatic back pain: Red flags for spinal fracture: Major trauma Minor trauma/strenuous lifting in older adults (> 50) or those with known osteoporosis or other bone diseases or diseases like renal failure which affects bone metabolism. Back pain in patients with known malignancy: Should always be evaluated by physician. Pearls Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Neuro, Lower extremity perfusion Back pain is one of the most common complaints in medicine and effects more than 90 % of adults at some point in their life. Back pain is also common in the pediatric population. Most often it is a benign process but in some circumstances can be life or limb threatening. Consider pregnancy or ectopic pregnancy with abdominal or back pain in women of childbearing age. Consider abdominal aortic aneurysm with abdominal pain especially in patients over 50 and/or patients with shock/ poor perfusion. Patients may have abdominal pain and / or lower extremity pain with diminished pulses,. Notify receiving facility early with suspected abdominal aneurysm. Consider cardiac etiology in patients > 50, diabetics and / or women especially with upper abdominal complaints. Red Flags which may signal more serious process associated with back pain: Age > 50 or < 18 Neurological deficit (leg weakness, urinary retention, or bowel incontinence) IV Drug use Fever History of cancer, either current or remote Night time pain in pediatric patients Cauda equina syndrome is where the terminal nerves of spinal cord are being compressed (Symptoms include):. Saddle anesthesia Recent onset of bladder and bowel dysfunction. (Urine retention and bowel incontinence) Severe or progressive neurological deficit in the lower extremity. Motor weakness of thigh muscles or foot drop Back pain associated with infection: Fever / chills. IV Drug user (consider spinal epidural abscess) Recent bacterial infection like pneumonia. Immune suppression such as HIV or patients on chronic steroids like prednisone. Meningitis. Spinal motion restriction in patients with underlying spinal deformity should be maintained in their functional position. Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area. Revised UP 5 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  IV or IO Access History Signs and Symptoms Differential Chronic medical conditions Fever Infection or sepsis requiring recurrent need for IV Bleeding Infection of catheter access for medication, Hypotension Clotted IV catheter hydration, or blood sampling. Redness, swelling, and/or pain at Air embolism Medical condition requiring IV catheter site Pneumothorax administration of IV medications Shortness of breath Overdose of home medication at home. Chest pain Shock End-stage renal disease IV catheter patency requiring hemodialysis. Chronic medical condition requiring IV nutrition. Exit to Age Appropriate NO Patient requires IV access Protocol(s) YES Universal Protocol Section Patient has current Serious Signs or Symptoms NO NO Central IV access Unstable condition YES YES Consider IO initially Dialysis Catheter PICC Line Port-a-cath VasCath or Permcath Central Line A Limit IV attempts to 3 If unsuccessful: Insert IO May utilize if DO NOT ACCESS May Access already accessed Cardiac arrest ONLY Parenteral Access: Existing Port-a-Cath Parenteral Existing Catheters Procedure PAS-7 Access Procedure Catheters Procedure PAS 13 if available Exit to DO NOT ACCESS Age Appropriate Unless trained Protocol(s) Pearls Frequent encounter of patients with IV access devices and confusion as to which device can be accessed and used by EMS providers. If unclear about device use, always ask “Is this device used for dialysis?” When accessing central catheter, always ensure sterility of catheter connection point by cleaning port with alcohol, or similar disinfectant, 2 – 3 times prior to access. Central line catheters placed for administration of chemotherapy, medications, electrolytes, antibiotics, and blood are available to EMS providers for access and administration of fluids, medications, antibiotics, and blood products. Central line catheters placed for hemodialysis are NOT available for access by EMS providers unless the patient is in cardiac arrest. Long term IV access is frequently needed for a variety of indications: Medication administration such as antibiotics, pain relief, or chemotherapy Administration of IV nutrition or feeding Revised Need for multiple IV line access or recurrent blood sampling 01/01/2017 Poor vasculature requiring repeated attempts at IV access End-stage renal disease requiring hemodialysis Common complications of central access devices: Infection Loss of patency due to clogging or clotting Damage to vasculature Pneumothorax Air embolism UP 6 Revised 10/15/2021 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 1  IV or IO Access Types of IV catheters: Port-a-Cath® : Surgically implanted device allowing easy access to venous system. The port and the catheter are all placed beneath the skin. Requires a special kit and a specific needle to access. Paramedic does NOT routinely access this device. Paramedic may utilize if already accessed with needle/extension. Paramedic may access if trained on procedure with access to proper equipment. Dialysis Catheter: Surgically implanted device used to access the vasculature for hemodialysis. Universal Protocol Section May be tunneled under the skin with access on outside of skin surface or may be non-tunneled with greater portion of catheter on outside of skin surface. Catheter has a RED port indicating use for dialysis: Most catheters have a RED port and a BLUE port. Some catheters have a RED port and a WHITE port. Dialysis catheters may be used for both short and long-term dialysis and should not accessed or used for delivery of fluids, medications, antibiotics, or blood products as it increases risk of infection, which then requires removal and subsequent loss of dialysis access. Paramedic and AEMT do NOT routinely access this device. Paramedic and AEMT MAY access during cardiac arrest only (Only if IV or IO access cannot be established.) PICC (Peripherally Inserted Central Catheters): Long catheter inserted into a vein in arm or leg (less common) with the tip of the catheter positioned into the central circulation. Used for long-term IV fluids, medication administration, blood administration or blood draws. May have 1 or 2 ports (possibly more, but less common.) Port ends usually white, blue, or purple. (May be red, less common and is not used for dialysis.) Paramedic and AEMT may access and utilize following clean technique. Central Lines: Catheter placed in large vein in the neck, under the clavicle, or in the groin. Used for long-term IV fluids, medication administration, blood administration or blood draws. May have 1 - 4 ports (possibly more, but less common.) Port ends usually white, blue, or purple. (May be red, less common and is not used for dialysis.) Paramedic and AEMT may access and utilize following clean technique. UP 6 Revised 10/15/2021 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2  Dental Problems History Signs and Symptoms Differential Age Bleeding Decay Past medical history Pain Infection Medications Fever Fracture Onset of pain / injury Swelling Avulsion Trauma with "knocked out" tooth Tooth missing or fractured Abscess Location of tooth Facial cellulitis Whole vs. partial tooth injury Impacted tooth (wisdom) TMJ syndrome Myocardial infarction Dental or Jaw Pain YES B 12 Lead ECG Procedure Suspicious for Cardiac P Cardiac Monitor Age Appropriate NO Cardiac Protocol(s) Control Bleeding with Direct Pressure Fashion gauze into a small square and Bleeding YES Universal Protocol Section place into socket with patient closing teeth to exert pressure NO Place tooth in Milk / Normal Saline / Commercial Preparation Dental Avulsion YES May rinse gross contamination Do not rub or scrub tooth NO Significant Pain YES Pain Protocol UP 11 Monitor and Reassess NO Exit to Age Appropriate Protocol(s) Notify Destination or Contact Medical Control Pearls Recommended Exam: Mental Status, HEENT, Neck, Chest, Lungs, Neuro Significant soft tissue swelling to the face or oral cavity can represent a cellulitis or abscess. Scene and transport times should be minimized in complete tooth avulsions. Reimplantation is possible within 4 hours if the tooth is properly cared for. Occasionally cardiac chest pain can radiate to the jaw. All pain associated with teeth should be associated with a tooth which is tender to tapping or touch (or sensitivity to cold or hot). Revised UP 7 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Emergencies Involving Indwelling Central Lines History Signs and Symptoms Differential Central Venous Catheter Type External catheter dislodgement Fever Tunneled Catheter Complete catheter dislodgement Hemorrhage (Broviac / Hickman) Damaged catheter Reactions from home nutrient or medication PICC (peripherally inserted Bleeding at catheter site Respiratory distress central catheter Internal bleeding Shock Implanted catheter Blood clot (Mediport / Hickman) Air embolus Occlusion of line Erythema, warmth or drainage Complete or partial dislodge about catheter site indicating Complete or partial disruption infection Exit to Circulation Problem YES Age Appropriate Protocol(s) NO Suspect Air Embolus Tachypnea, Dyspnea, YES Place on left side in head down position Chest Pain Stop infusion if ongoing A Clamp catheter NO Universal Protocol Section Age Appropriate Airway Protocol(s) AR 1, 2, 3, 5, 6 as indicated Hemorrhage at catheter YES Apply direct pressure around catheter site NO Clamp catheter proximal to disruption Damage to catheter YES A May use hemostat wrapped in gauze Stop infusion if ongoing NO Catheter completely or YES Apply direct pressure around catheter partially dislodged A Stop infusion if ongoing NO Continue infusion Ongoing infusion YES A Do not exceed 20 mL/kg NO Notify Destination or Contact Medical Control Pearls Always talk to family / caregivers as they have specific knowledge and skills. Use strict sterile technique when accessing / manipulating an indwelling catheter. Cardiac arrest: May access central catheter and utilize if functioning properly. Do not attempt to force catheter open if occlusion evident. Some infusions may be detrimental to stop. Ask family or caregiver if it is appropriate to stop or change infusion. Hyperalimentation infusions (IV nutrition): If stopped for any reason monitor for hypoglycemia. Revised UP 8 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Epistaxis History Signs and Symptoms Differential Age Bleeding from nasal passage Trauma Past medical history Pain Infection (viral URI or Sinusitis) Medications (HTN, anticoagulants, Nausea Allergic rhinitis aspirin, NSAIDs) Vomiting Lesions (polyps, ulcers) Previous episodes of epistaxis Hypertension Trauma Duration of bleeding Quantity of bleeding Significant or Multi- YES Direct Pressure System Trauma Appropriate Trauma Protocol(s) TB 5 / TB 6 / TB 8 NO Compress Nostrils with Direct Pressure Active Bleeding YES Head Tilt Forward Position of Comfort NO Have Patient Blow Nose Universal Protocol Section Suction Active Bleeding Leave Gauze in place if present Topical Hemostatic Agent Head Tilt Forward if available / indicated Position of Comfort Oxymetazoline 2 Sprays to Nostril Monitor and Reassess B Followed by Direct Pressure IV / IO Procedure A If indicated Age Appropriate Hypotension / Shock Protocol AM 5 / PM 3 Monitor and Reassess Notify Destination or Contact Medical Control Pearls Recommended Exam: Mental Status, HEENT, Heart, Lungs, Neuro Age specific hypotension: 0 – 28 days < 60 mmHg, 1 month – 1 year < 70 mmHg, 1 year – 10 years < 70 + ( 2 x age)mmHg, 11 years and greater < 90 mmHg. It is very difficult to quantify the amount of blood loss with epistaxis. Bleeding may also be occurring posteriorly. Evaluate for posterior blood loss by examining the posterior pharnyx. Anticoagulants include warfarin (Coumadin), Apixaban (Elequis), heparin, enoxaparin (Lovenox), dabigatran (Pradaxa), rivaroxaban (Xarelto), and many over the counter headache relief powders. Anti-platelet agents like aspirin, clopidogrel (Plavix), aspirin/dipyridamole (Aggrenox), and ticlopidine (Ticlid) can contribute to bleeding. Revised UP 9 10/15/2021 This protocol has been altered f rom the original NCCEP Protocol by the local EMS Medical Director  Fever / Infection Control History Signs and Symptoms Differential Age Warm Infections / Sepsis Duration of fever Flushed Cancer / Tumors / Lymphomas Severity of fever Sweaty Medication or drug reaction Past medical history Chills/Rigors Connective tissue disease Medications Associated Symptoms Arthritis Immunocompromised (transplant, (Helpful to localize source) Vasculitis HIV, diabetes, cancer) myalgias, cough, chest pain, Hyperthyroidism Environmental exposure headache, dysuria, abdominal pain, Heat Stroke Last acetaminophen or ibuprofen mental status changes, rash Meningitis Contact, Droplet, and Airborne Precautions Temperature Measurement Procedure if available IV / IO Protocol UP 6 Universal Protocol Section If indicated Temperature ≥ 100.4° F NO YES (38° C) Exit to Ibuprofen 10 mg / kg PO Age Appropriate (if age > 6 months) Protocol(s) Adult Ibuprofen 400 – 600 mg PO as indicated And / Or Acetaminophen 15 mg / kg PO Adult Acetaminophen 325 – 1000 mg PO Exit to Age Appropriate Protocol(s) as indicated Pearls Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in temperature. Droplet precautions: Include standard PPE plus a standard surgical mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected. A patient with a potentially infectious rash should be treated with droplet precautions. Airborne precautions: Include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g. MRSA), scabies, or zoster (shingles), or other illnesses spread by contact are suspected. All-hazards precautions: Include standard PPE plus airborne precautions plus contact precautions. This level of precaution is utilized during the initial phases of an outbreak when the etiology of the infection is unknown o r when the causative agent is found to be highly contagious (e.g. SARS). All patients should have drug allergies documented prior to administering pain medications. Allergies to NSAIDs (non-steroidal anti-inflammatory medications) are a contraindication to Ibuprofen. Do not give to patients who have renal disease or renal transplant. NSAIDs should not be used in the setting of environmental heat emergencies. Do not give aspirin to a child, age ≤ 15 years. UP 10 Agency Medical Director may require contact of medical control prior to EMT / EMR administering any medication. Revised 10/15/2021 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS  Pain Control History Signs and Symptoms Differential Age Severity (pain scale) Per the specific protocol Location Quality (sharp, dull, etc.) Musculoskeletal Duration Radiation Visceral (abdominal) Severity (1 - 10) Relation to movement, respiration Cardiac If child use Wong-Baker faces scale Increased with palpation of area Pleural / Respiratory Past medical history Neurogenic Medications Renal (colic) Drug allergies Specific Complaint Protocol Assess Pain Severity Combination of Pain Scale, MOI, circumstances, Injury or Illness severity Mild Moderate to Severe Ibuprofen 10 mg/kg PO IV / IO Protocol UP 6 (400 – 600 mg typical adult) Maximum 800 mg Ketorolac 15 mg IV / IO Or 30 mg IM Acetaminophen 15 mg/kg A Peds: 0.5 mg/kg IV / IO / IM Universal Protocol Section (325 – 1000 mg typical adult) Maximum 1000 mg Maximum 30 mg Or Cardiac Monitor Aspirin 324 to 650 mg PO (≥ 16 only) If no improvement Consider IV Protocol UP 6 Fentanyl 50 – 100 mcg IV / IO / IM if indicated Repeat every 5 minutes Maximum 3 mcg/kg Peds: 1 mcg/kg IV / IO / IM / IN May repeat 0.5 mcg/kg every 5 minutes Maximum 2 mcg/kg Or Morphine 4 mg IV / IO / IM P Repeat 2 mg every 5 minutes as needed Peds: 0.1 mg/kg IV / IO / IM May repeat every 5 minutes Maximum 10 mg Monitor and Reassess Every 10 minutes following sedative Notify Destination or Contact Medical Control UP 11 Revised 10/15/2021 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 1  Pain Control The relief of pain is a key aspect in emergency medicine care: 1. Pain is the most common complaint EMS encounters. 50 -75 % of all patients are experiencing pain. 2. An essential mission of EMS providers is the relief of pain. 3. We are often judged in how effective we are in relieving pain. 4. Often procedures we perform cause pain. 5. Unrelieved pain is associated with many untoward effects. a. Increased sympathetic response. b. Increase in peripheral vascular resistance. c. Increase in myocardial oxygen consumption. d. Increase in carbon dioxide production. e. Increase in clotting potentials. Universal Protocol Section f. Decrease in gastric motility. g. Decrease in immune function. 6. It is important to measure, document and treat pain. 7. Poorly treated acute pain can lead to a patient experiencing chronic pain as a response. Measurement of pain: 1. Use the verbal pain scale of 0 -10. Explain to the patient how the system works, zero is no pain and 10 is the worst pain you can imagine. An example may be hitting your hand with a sledge hammer. If the patient uses a number like 11 or 20 then the patient does not understand the scale and/or you have not explained the score clearly. 4.4The worst pain you can imagine is 10, 20 does not exist. 2. If a person cannot speak, but hears and understands or reads lips then you can draw the pain scale on paper from 0 -10 and ask the patient to point the their pain number. Unfortunately the only device we have to truly measure pain is the patient and this totally relies on their perception. While you can use demeanor, facial expression and other body language to help assess the degree of pain they are not reliable alone. Approach to pain management: 1. We have several classes of pain relievers. Initial attempts at pain relief can begin with ibuprofen or acetaminophen as long as the patient may take liquids/medications by mouth. Patients where surgery is anticipated should remain NPO. 2. Opioids: Morphine is well known an commonly used. It is well known to cause histamine release which can cause itching but more importantly hypotension. In patients where hypotension is a concern Fentanyl is a better choice. IV, IO route is preferred as it is better titrated. IM use has variable and unpredictable onset of action. 3. Abdominal pain/orthopedic injuries: In a patient who is not actively vomiting you may use PO medications even if you believe they may require surgery. 4. Patients should not be given narcotics without being transported. Confirm patients will be transported prior to administering narcotic pain medication. If the patient does not wish to be transported, Medical Control must be contacted for orders to administer narcotic analgesia. Additional Information: Ketorolac - Do not use in pregnant women or in women who are breast feeding. - Do not use in patients who have recently taken NSAID's orally. Pearls Recommended Exam: Mental Status, Area of Pain, Neuro Pain severity (0-10) is a vital sign to be recorded before and after PO, IV, IO or IM medication delivery and at patient hand off. Monitor BP closely as sedative and pain control agents may cause hypotension. Ketamine: Ketamine may be used in patients who are outside a Pediatric Medication/Skill Resuscitation System product. Ketamine may be used in patients who fit within a Pediatric Medication/Skill Resuscitation System product only with DIRECT ONLINE MEDICAL ORDER, by the system MEDICAL DIRECTOR or ASSISTANT MEDICAL DIRECTOR. Ketamine: appropriate indications for pain control: Patients who have developed opioid-tolerance. Sickle cell crisis patients with opioid-tolerance. Patients who have obstructive sleep apnea. May use in combination with opioids to limit total amount of opioid administration. Ketamine: caution when using for pain control: Slow infusion or IV push over 10 minutes is associated with less side effects. Do not administer by rapid IV push. Avoid in patients who have cardiac disease or uncontrolled hypertension. Avoid in patients with increased intraocular pressure such as glaucoma. Avoid use in combination with benzodiazepines due to decreased respiratory effort. Both arms of the treatment may be used in concert. For patients in Moderate pain for instance, you may use the combination of an oral medication and parenteral if no contraindications are present. Pediatrics: For children use Wong-Baker faces scale or the FLACC score (see Assessment Pain Procedure) Use Numeric (> 9 yrs), Wong-Baker faces (4-16yrs) or FLACC scale (0-7 yrs) as needed to assess pain Vital signs should be obtained before, 10 minutes after, and at patient hand off with all pain m