Pennsylvania IALS Protocols 2023 PDF

Pennsylvania Statewide Intermediate Advanced Life Support Protocols Pennsylvania Department of Health Bureau of Emergency Medical Services 2023 v1.2 (717) 787-8740 December 29, 2023 Dear EMS P...

Pennsylvania Statewide Intermediate Advanced Life Support Protocols Pennsylvania Department of Health Bureau of Emergency Medical Services 2023 v1.2 (717) 787-8740 December 29, 2023 Dear EMS Provider: The Bureau of EMS, Department of Health, is pleased to provide these updated “Statewide IALS Protocols” to the EMS providers of Pennsylvania. This 2021 update contains many important changes, but some of the highlights include new protocols: 1101i IALS Release to BLS Pennsylvania has used Statewide IALS Protocols since July 1, 2015, and this edition is an update to the version that has been in effect since September 1, 2020. To assist IALS providers when reviewing the changes, new sections of the protocols that correspond to this 2020 version are identified with yellow highlighting, and sections that have been removed are struck through and highlighted. If an agency wishes to utilize this 2023 version of the statewide BLS protocols before the March 31 deadline, that agency may do so when its personnel have completed the statewide protocol updates for their level of training and its medical director approves early implementation. All personnel must have completed the training and begin functioning under the new protocols no later than the March 31 deadline. EMS providers are permitted to perform patient care, within their PA defined scope of practice, when following the appropriate protocol(s) or when following the order of a medical command physician. Each EMS provider is responsible for being knowledgeable regarding current state-approved protocols so that they may provide the safest, highest quality and most effective care to patients. To assist providers in becoming familiar with the changes to the protocols, a continuing education presentation is available to regions and agencies. This update is available for in- person presentations, or the course can be completed on TRAIN PA, the on-line Learning Management System (LMS). The 2023 IALS Protocol Update (BEMS course # 1000058615 ) will be considered a core requirement for all levels of EMS providers that register their certification during the current time period. It is essential that EMS agencies and regions that utilize IALS ambulances work with their county PSAPs and dispatch centers to ensure that the expansion of this level of care does not keep ALS agencies from being dispatched to appropriate calls. For example, an IALS agency with a provider functioning at the IALS level may be appropriate for a diabetic patient with altered mental status, but the additional interventions of an ALS agency should be dispatched to other patients with altered level of consciousness. EMS agencies providing IALS should work in conjunction with their PSAP and local ALS agencies to ensure the best care for their patients. When providing patient care under the EMS Act, EMS providers of all levels must follow applicable protocols. Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS providers to use their training and judgment regarding any protocol-driven care that would be harmful to a patient. When the provider believes that following a protocol is not in the best interest of the patient, the EMS provider should contact a medical command physician if possible. Cases where deviation from the protocol is justified are rare. The reason for any deviation should be documented. All deviations are subject to investigation to determine whether they were appropriate. In all cases, EMS providers are expected to deliver care within the scope of practice for their level of certification. The Department of Health’s Bureau of EMS website will always contain the most current version of the EMS protocols, the scope of practice for each level of provider, important EMS Information Bulletins, and many other helpful resources. This information can be accessed online at www.health.pa.gov. The Statewide IALS Protocols may be directly printed or downloaded into a mobile device for easy reference. In these protocols, terms have the meanings ascribed to them in the EMS System Act (Act) and corresponding Department regulations. The Act is available at the Pennsylvania General Assembly website found here1. The regulations are available on the Pennsylvania Code website found here2. The Department is committed to providing Pennsylvania’s EMS providers with the most up- to-date protocols, and to do this requires periodic updates. The protocols will be reviewed regularly, and EMS providers are encouraged to provide recommendations for improvement at any time. Comments should be directed to the Commonwealth EMS Medical Director, Pennsylvania Department of Health, Bureau of EMS, 1310 Elmerton Avenue, Harrisburg, PA 17110. Anthony Martin, Dan Bledsoe, MD, PHP, FAEMS Director Commonwealth EMS Medical Director Bureau of Emergency Medical Services Bureau of Emergency Medical Services Pennsylvania Department of Health Pennsylvania Department of Health 1 Pennsylvania EMS Act of 2009 https://www.legis.state.pa.us/cfdocs/legis/LI/consCheck.cfm?txtType=HTM&ttl=35&div=0&chpt=81 2 Pennsylvania EMS Rules and Regulations https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter1021/s1021.2.html&d=reduce Pennsylvania Department of Health IALS - Adult/Peds TABLE OF CONTENTS SECTION 1000i: Operations 1000i – General Protocol Principles........................................................................ 1000i-1 thru 1000i-5 1101i – IALS Release to BLS………………………………………………………….. 1101i-1 SECTION 2000i: Assessments & Procedures 2010i – Indications for ALS Use.............................................................................. 2010i-1 thru 2010i-2 2032i – Confirmation of Airway Placement................................................................................. 2032i-1 SECTION 3000i: Resuscitation 3031iA – General Cardiac Arrest – Adult........................................................... 3031iA-1 thru 3031iA-4 3031iP – General Cardiac Arrest – Pediatric..................................................... 3031iP-1 thru 3031iP-3 3032i – Cardiac Arrest - Traumatic......................................................................... 3032i-1 thru 3032i-3 3035i – Cardiac Arrest (Hypothermia)..................................................................... 3035i-1 thru 3035i-2 SECTION 4000i: Respiratory 4001i – Airway Management................................................................................... 4001i-1 thru 4001i-2 4011i – Allergic Reaction......................................................................................... 4011i-1 thru 4011i-3 4022i – Asthma/COPD/Bronchospasm................................................................... 4022i-1 thru 4022i-2 4023iP – Croup – Pediatric................................................................................ 4023iP-1 thru 4023iP-2 SECTION 5000i: Cardiac 5001i – Chest Pain / Suspected Acute Coronary Syndrome.................................. 5001i-1 thru 5001i-2 SECTION 6000i: Trauma & Environmental 6002i – Multisystem Trauma or Traumatic Shock................................................... 6002i-1 thru 6002i-3 6003i – Musculoskeletal Trauma............................................................................ 6003i-1 thru 6003i-3 6004i – Crush Syndrome......................................................................................... 6004i-1 thru 6004i-2 6071i – Burns................................................................................................................................. 6071i SECTION 7000i: Medical & Ob/Gyn 7002iA – Altered Level of Consciousness-Adult................................................ 7002iA-1 thru 7002iA-3 7002iP – Altered Level of Consciousness.......................................................... 7002iP-1 thru 7002iP-3 7003i – Non-Traumatic Pain Management............................................................. 7003i-1 thru 7003i-3 7005i – Shock / Sepsis............................................................................................ 7005i-1 thru 7005i-2 7006i – Stroke......................................................................................................... 7006i-1 thru 7006i-3 7010i – Nausea/Vomiting........................................................................................ 7010i-1 thru 7010i-2 7087i – Post-Partum Hemorrhage................................................................................................. 7087i SECTION 8000i: Behavioral & Poisoning SECTION 9000i: Special Considerations 9001i – Medical Command Contact........................................................................ 9001i-1 thru 9001i-3 APPENDICES: Appendix A: Required Medication List for IALS Vehicles..................................................................A-2 Appendix B: Medication Dosing Chart...............................................................................................A-3 Appendix C: Common Oral Medication Dosing Chart.......................................................................A-4 Appendix D: Pediatric Weight Conversion Chart...............................................................................A-5 Index................................................................................................................................................... I-1 Effective 03/31/2024 i of i THIS PAGE INTENTIONALLY LEFT BLANK Pennsylvania Department of Health Operations 1000i - IALS - Adult/Peds GENERAL PROTOCOL PRINCIPLES STATEWIDE IALS PROTOCOL A. Statewide Medication List 1. AEMTs may only use medications that are listed on the Approved and Required Medication List as published in the Pennsylvania Bulletin and posted on the Bureau of EMS website. 2. At a minimum, the IALS (Intermediate Advanced Life Support) vehicle must carry each medication that is required to provide the care that is listed in the Statewide AEMT protocols. This list will be used by regional council staff when conducting licensure inspections. In addition, the IALS vehicle may carry any additional medications that are listed within state AEMT drug list as optional. B. Medications/Procedural Skills 1. The protocols may list some medications and treatments that are optional and are not required of every IALS vehicle or of every AEMT provider. Any optional medications or treatments within the AEMT scope of practice or medication list may be carried on an IALS vehicle at the discretion of the EMS agency medical director. 2. AEMTs are able to obtain and transmit a 12-lead ECG for suspected acute coronary syndrome (ACS) when indicated by protocol. Although cardiac monitors on IALS vehicles may also be capable of continuous monitoring of an ECG rhythm strip, this is not in the scope of practice of an AEMT. Under no circumstances should an AEMT connect a patient to a continuous ECG rhythm monitoring, unless when directly supervised and assisting an EMS provider above the level of AEMT. The AEMT may leave a patient connected to the 12 lead ECG and should repeat and transmit the 12-lead ECG with any change in patient condition. This is not a substitute for a higher level provider to be observing the monitor. 3. General medication issues a. When possible, dosing for various medications has been standardized across all protocols. EMS providers must use their training and knowledge to assure that doses given are appropriate for the patient’s age and weight. Although doses may not exceed those listed in the protocol, it may be appropriate to decrease the doses of some medications based upon patient condition, patient vital signs or patient age. b. All references to medications, abbreviations, and doses have been standardized with attention to pharmacologic principles of medication error reduction. c. Agencies should assure that medications are stored in a manner that provides for maximal shelf life and appropriate security. Some medications may have limitations to the listed expiration date if the medication is not refrigerated. EMS agencies should follow Department guidance and good medication storage practices to assure that medications have not lost their potency. d. EMS providers are expected to know the contraindications for each medication and are expected to assess patients for allergies, when possible, to any medication that is given. EMS providers should not administer medications to a patient when that medication is contraindicated in that situation. 4. Normal saline solution (NSS) and balanced solutions. When intravenous fluids are indicated, NSS is used throughout these protocols. NSS has the advantage of being compatible with all EMS medications and being preferred for patients with traumatic head injury. Lactated Ringers1 and other balanced salt solutions may be carried as an option by an EMS agency if approved by the agency medical director and used within the protocols when NSS is indicated, but it is up to the agency medical director to educate providers when one fluid is indicated over another. This does not apply to hypertonic concentrations of these solutions or to solutions with replacement doses of electrolytes, or other solvents, that exceed physiologic concentrations. Effective 03/31/2024 1000i-1 of 3 Pennsylvania Department of Health Operations 1000i - IALS - Adult/Peds 5. The use of intravenous EPINEPHrine is restricted to use during cardiac arrest only and should not be given in any other situation by IV or IO routes. Carrying and administering EPINEPHrine, diphenhydrAMINE, or ondansetron by IV or IO routes are optional and require approval of the EMS agency medical director. 6. Drawing blood samples – Drawing blood in the prehospital setting may assist receiving facilities in providing better diagnoses or more rapid treatment of patients, but in some areas the receiving facilities will not accept blood drawn by prehospital providers. 7. Vascular Access: a. Intravenous access – AEMTs may initiate intravenous access when included in treatment protocols. Peripheral venous access will be established with a NSS intravenous infusion, unless the EMS agency medical director establishes indications for other fluids as defined in protocol 1000i section G.3.. The rate of the infusion should be determined by specific IV fluid volumes as stated in the appropriate protocol or a saline lock may be established if fluid volume is not indicated. b. Intraosseous access – AEMTs may insert an intraosseous needle for vascular access when indicated by a specific treatment protocol. 1) IO access may be obtained in the following extremity sites: a) Proximal tibia b) Distal femur c) Proximal humerus 2) Any acceptable method or device carried by an ALS agency that obtains IO access in an extremity site listed above is appropriate. The AEMT must have received education and be assessed as competent in the skill by the EMS agency medical director. EMS agency policy may indicate which technique or extremity sites listed above are acceptable for IO access. C. Pediatric issues 1. Unless otherwise stated, pediatric protocols will apply to patients ≤ 14 years of age. If the patient’s age is not known, then pediatric protocols will apply until there are physical signs that the patient has reached puberty/adolescence as indicated by armpit hair in boys and breast development in girls. 2. All IALS agencies and above, in consultation with agency medical director to assure compliance with state-wide protocol, must carry the most current version of a pediatric length- based drug dosing/equipment sizing tape to estimate patient weight and appropriate drug dosages. When possible, these devices should be used as the primary method for determining the weight/appropriate drug doses for children. Additionally, the following formula or table may be used: a. Formula: (Age in years x 3) + 7 = estimated weight in kgs. b. Table 1) 1 y/o =10 kg 2) 3 y/o =15 kg 3) 5 y/o =20 kg 4) 7 y/o =25 kg 5) 9 y/o =30 kg Effective 03/31/2024 1000i-2 of 3 Pennsylvania Department of Health Operations 1000i - IALS - Adult/Peds D. Equipment Issues 1. All medical devices must be used, maintained, and calibrated in accordance with the recommendations from the manufacturer. 2. All IALS vehicles must carry electronic glucose testing meters, and these agencies must have either a CLIA license or certificate of waiver. An IALS agency performing glucose testing with a meter cleared for home use by the FDA must hold a CLIA certificate of waiver. A CLIA certificate of waiver (CoW) is good for two years. Each agency is responsible for determining whether a CLIA license or waiver is required. E. Acetaminophen (if available) 15mg/kg up to 650mg may be given for fever if: 1, 2, and 3: 1. Patient is at least 3 months old. 2. Temperature > 38° C or 100.4° F (ambulances are required to have a non- tympanic, digital thermometer). 3. Patient has not had a dose of acetaminophen within the last 4 hours. Notes: 1. AEMTS will advise higher level providers when IV fluid other than NSS has been initiated. Effective 03/31/2024 1000i-3 of 3 Pennsylvania Department of Health Operations 1101i - IALS - Adult/Peds IALS RELEASE TO BLS STATEWIDE IALS PROTOCOL Criteria: 1. Patient assessed by IALS provider who determines that treatment above the BLS level is not needed or anticipated to be needed. Exclusion Criteria: A. Any patient who refuses IALS care (e.g. patient refuses IV) should be transported by the IALS unit, unless patient refuses transport by the IALS unit then contact medical command. Procedure: A. If a BLS crew arrives on-scene prior to the IALS provider arrival: 1. If multiple patients, perform triage. 2. BLS provider performs assessment of the patient in accordance with Statewide BLS Protocols and prepares for transport. B. When IALS and BLS agencies have arrived at a patient incident: 1. If BLS provide did initial patient assessment, BLS provider will give a verbal patient report to the IALS provider. 2. IALS provider will assess the patient and determine if care beyond BLS level is needed or may be anticipated to be needed.1 The IALS provider will complete a PCR documenting their assessment for every patient assessed except when triaging patients in a muti-casuality incident. 3. IALS provider may hand off patient to BLS provider if patient does not require IALS care. 4. If an IALS provider performs any IALS procedure (including ECG, but not general IALS care patient assessment or glucose check) they must contact Medical Command prior to hand off to BLS. C. When the IALS and BLS providers are on the crew of an IALS ambulance together: 1. The IALS provider must perform the initial assessment. After determining that IALS care is neither needed or anticipated to be needed, the IALS provider may hand off care to the BLS provider on the crew, but the IALS provider must review and is also responsible for the PCR completed by their BLS partner. 2. Should the patient condition unexpectedly change, the BLS partner should notify the IALS provider driving the vehicle, who should stop the vehicle at the next safe and practical point, return to the patient, receive a verbal report or interim care, and resume care of the patient. Notes: 1. When the number of patients exceeds the number of IALS providers, the IALS provider(s) must triage the patient that require a higher level of care, and may not have the resources to evaluate all patients directly. Performance Parameters: A. Review calls where the number of patients exceeds the number of IALS providers, the IALS provider(s) must triage the patient that require a higher level of care, and may not have the resources to evaluate all patients directly. Effective 03/31/2024 1101i-1 of 1 THIS PAGE INTENTIONALLY LEFT BLANK Pennsylvania Department of Health Assessments & Procedures 2010i - IALS - Adult/Peds INDICATIONS FOR ALS USE STATEWIDE IALS PROTOCOL Criteria: A. All patients. Exclusion Criteria: A. None. Procedure: A. All patients: 1 1. An IALS agency provider should consider requesting an ALS squad/ambulance when a patient’s needs exceed their capabilities. These conditions may include but are not limited to: a. Altered level of consciousness (except apparent hypoglycemia or opioid overdose that may be managed by IALS) b. Allergic reaction to medication or bites with difficulty breathing or swallowing, altered level of consciousness, or known previous reaction; hives within 5 minutes of exposure. c. Cardiac symptoms. d. Cardiac arrest. e. Diabetic problem (except altered level of consciousness from apparent hypoglycemia that may be managed by IALS) f. Multi-system trauma or severe single system trauma. g. OB/Gyn (2nd or 3rd trimester bleeding or miscarriage). h. Overdose/poisoning (associated with any other categories on this list), except altered level of consciousness from apparent opioid overdose, which may be managed by IALS i. Respiratory distress. j. Respiratory arrest. k. Seizures/convulsions. l. Entrapment with injuries (unless obviously minor injuries). m. Severe blood loss. n. Shock (Hypoperfusion). o. Stroke/CVA symptoms. p. Syncope (fainting). q. Unconsciousness. r. Severe pain anywhere. s. Excited delirium – fighting against restraints without being aware of actions t. A patient with vital signs outside of the normal range: 1) Patient does not follow commands (motor GCS 35 a minute or irregular. 5) Pediatric Patients: Vital signs outside of normal range per Statewide BLS Protocol Pediatric Vital Signs (Appendix G) 2. If transport by IALS ambulance to an appropriate receiving facility can be accomplished before ALS can initiate care, then the IALS agency should transport as soon as possible and should not request or should cancel ALS. For patients in cardiac arrest, protocols 3031iA and 3031iP should guide the appropriate time to initiate transport. Effective 09/01/2020 2010i-1 of 2 Pennsylvania Department of Health Assessments & Procedures 2010i - IALS - Adult/Peds 3. IALS ambulances should not delay patient care and transport while waiting for ALS agency. If ALS arrival at scene is not anticipated before initiation of transport, arrangements should be made to rendezvous with the ALS agency. 2 Notes: 1. AEMTs should initiate patient care and transport to the level of their ability following applicable BLS /AEMT protocol(s). 2. In the case of a long IALS transport time with a nearby ALS agency coming from the opposite direction, it may be appropriate to delay transport for a short period of time while awaiting the arrival of ALS if this delay will significantly decrease the time to ALS care for the patient. When IALS transport time to a receiving facility is relatively short, this delay is not appropriate. Performance Parameters: A. Review outcome and care of patients with above conditions who were treated / transported by IALS only. Note that ALS care is not mandatory for these conditions in all cases. Effective 09/01/2020 2010i-2 of 2 Pennsylvania Department of Health Assessments & Procedures 2032i - IALS - Adult/Peds CONFIRMATION OF AIRWAY PLACEMENT STATEWIDE IALS PROTOCOL Criteria: A. Patient who has a supraglottic (King/ iGel) airway device inserted by EMS provider. Exclusion Criteria: A. None System Requirements: A. Every IALS vehicle must carry and use an electronic wave-form ETCO2 detector device monitor1 for confirmation and continuous monitoring of alternative airway device placement. Procedure: A. Insert Alternative Airway Device B. Attach electronic ETCO2 monitor to BVM. C. Ventilate 2 while simultaneously: 1. Assuring “positive” CO2 wave with each ventilation. 2. Verifying absence of gastric sounds. D. Verify presence of bilateral breath sounds. E. Secure airway device. F. Continuously monitor waveform capnography. 3 G. Reassess bilateral breath sounds and absence of gastric sounds after each move or transfer of the patient. H. Document all of the above. Notes: 1. Colorimetric ETCO2 detectors may give false negative results when the patient has had prolonged time in cardiac arrest. EDD aspiration devices may give false negative results in patients with lung disease (e.g. COPD or status asthmaticus), morbid obesity, late stages of pregnancy, or cardiac arrest. IALS agencies may consider carrying colorimetric ETCO2 detectors or EDD aspiration devices as back-ups in case of electronic device failure, but must primarily use the wave-form ETCO2 detector as described in this procedure. 2. Immediately remove alternative supraglottic airway device if any step reveals evidence of lack of lung ventilation. If there is any doubt about adequate ventilation with an alternative airway device, remove the device and ventilate with BVM. 3. Quantitative ETCO2 readings may be beneficial in assessing the quality of CPR or as an indicator of the prognosis for successful resuscitation. Performance Parameters: A. Review all alternative airway device insertions for documentation of absence of gastric sound, presence of bilateral breath sounds, and appropriate use of a confirmation device. B. If systems have the capability of recording a capnograph tracing, review records of all intubated patients with advanced airway in place. to assure that capnograph was recorded. C. Document ETCO2 reading immediately after airway device placement, after each movement or transfer of patient and final transfer to ED stretcher. Effective 03/31/2024 2032i-1 of 1 THIS PAGE INTENTIONALLY LEFT BLANK Pennsylvania Department of Health Resuscitation 3031iA - IALS - Adult GENERAL CARDIAC ARREST – ADULT STATEWIDE IALS PROTOCOL Initial Patient Contact - See Protocol # 201 Patient pulseless, may have gasping/agonal breathing Cardiac arrest witnessed by EMS personnel OR Quality CPR in progress on EMS arrival NO 200 Uninterrupted YES DURING Chest Compressions1,2 UNINTERRUPTED COMPRESSIONS: IO/IV Access ASAP Analyze with AED EPINEPHrine (0.1 mg/mL) Shock (360 joules3,4) if indicated 1 mg IO/IV every 3 - 5 minutes If ROSC, (if available)5 200 Uninterrupted Assess Vital Chest Compressions1,2 Signs Airway Options6: Naso/oropharyngeal Analyze with AED Provide Shock (360 joules3,4) if indicated Oxygen and Airway Ventilate as Advanced Airway needed (King LT or iGel)7 (Goal= SpO2 200 Uninterrupted Chest Compressions1,2 95-99%) Ventilation Options6: Obtain and No Ventilation (during Analyze with AED Transmit 12- initial cycles of Shock (360 joules3,4) if indicated Lead ECG compressions if less than 3 providers) After Above 200 Uninterrupted Steps, 1 ventilation every 10 Chest Compressions1,2 Transport compressions (Monitor ASAP Perfusion with Analyze with AED Capnography) Shock (360 joules3,4) if indicated DO NOT INTERRUPT CPR TO Supplemental Oxygen PACKAGE AND TRANSPORT. CONSIDER Give Compressions while AWAITING ARRIVAL OF ALS AED is charging Continue cycles of 200 if ALS ETA < 20 mins.8,9,10 compressions followed by AED OR NO mechanical CPR analysis/shock1,3 device during initial 10 BVM: 1 ventilation/ 15 Contact Medical minutes1 compressions Command May use mechanical CPR for possible Checking glucose during device (optional) field termination CPR is not appropriate of CPR11,12 Effective 03/31/2024 3031iA-1 of 4 Pennsylvania Department of Health Resuscitation 3031iA - IALS - Adult GENERAL CARDIAC ARREST – ADULT STATEWIDE IALS PROTOCOL Criteria: A. Adult patient (>14 years old) with cardiac arrest (may have gasping or agonal breathing). Exclusion Criteria: A. If patient meets criteria for DOA (e.g. decapitation, decomposition, rigor mortis in warm environment, etc.…) then follow DOA protocol # 322. B. Cardiac arrest due to acute traumatic injury – see Cardiac Arrest - Traumatic Protocol #332. AED use is not indicated in traumatic cardiac arrest, but this protocol should be followed if there is the possibility of a medical condition causing cardiac arrest prior to a traumatic incident. C. Patient displaying an Out-of-Hospital Do Not Resuscitate (OOH-DNR) original order, bracelet, or necklace - see OOH-DNR Protocol #324. System Requirements: A. Ideally, providers in each EMS agency will use a “pit crew” approach when using this protocol to ensure the most effective and efficient cardiac arrest care. Training should include teamwork simulations integrating QRS, BLS, IALS, and ALS crew members who regularly work together. High-performance systems should practice teamwork using “pit crew” techniques with predefined roles and crew resource management principles. For example: 1. Rescuer 1 and 2 set up on opposite sides of patient’s chest and perform continuous chest compressions, alternating after every 100 compressions to avoid fatigue. 2. Use metronome or CPR feedback device to ensure that compression rate is 100-120/ minute. 3. Chest compressions are only interrupted during rhythm check (AED analysis or manual) and defibrillation shocks. Continue compressions when AED/ defibrillator is charging. 4. During the first four cycles of compressions/defibrillation (approximately 10 minutes) do not apply or use mechanical CPR device. 5. Use of a CPR checklist to ensure that all best practices are followed during CPR. B. For efficient “pit crew” style care, the EMS agency medical director should establish whether any ventilation is given during initial compression cycles. If BVM ventilation is used, compressions should not be interrupted when giving a ventilation every 10 compressions. C. The EMS agency, overseen by the agency medical director, must perform a QI review of care and outcome for every patient that receives CPR. 1. The QI should be coordinated with involved ALS agency and receiving hospital to include hospital admission, discharge, and condition information. This EMS agency QI can be accomplished by participation in the Cardiac Arrest Registry for Enhanced Survival (CARES) program through the ALS agency. 2. The QI should be coordinated with local PSAP/dispatch centers to review opportunities to assure optimal recognition of possible cardiac arrest cases and provision of dispatch-assisted CPR (including hands-only CPR when appropriate). Notes: 1. Excellent CPR is a priority: a. Push hard (at least 2 inches deep) and fast (100-120/min) and allow full recoil of chest during compressions. b. Change rescuer doing compressions every 1-2 minutes (100-200 compressions) to avoid fatigue Effective 03/31/2024 3031iA-2 of 4 Pennsylvania Department of Health Resuscitation 3031iA - IALS - Adult c. Restart CPR immediately after any defibrillation attempts. d. Keep pauses in CPR to a minimum. Immediately after AED recommends shock resume compressions until AED is fully charged, then immediately after shock, resume compressions without checking pulse or rhythm. Avoid pauses in CPR during airway management. e. CPR sequence is CAB (Compressions, Airway, Ventilation) for all ages, except the ABC sequence should be used in drowning. f. For pregnant patients, a rescuer should manually displace the uterus to the patient’s left during CPR. g. Mechanical CPR devices may be utilized, after consultation with the agency Medical Director, when there is low personnel or transport of the patient is expected. 2. Do not move or package patient for transport at this time. Chest compressions are much less effective during patient transportation/movement, and any possible interventions by medical command will be less effective without optimal CPR. 3. Shock at maximum output of defibrillator, up to maximum of 360 joules, for initial and subsequent defibrillation attempts. 4. Patient with severe hypothermia (if available, core temperature < 90° F or 32° C) see Hypothermic Protocol # 681. For hypothermic patients, no more than 1 shock should be delivered. Further action will be directed by medical command. Begin transport immediately after initial countershock. Transport to center with capability of cardiopulmonary bypass surgery if possible. 5. WARNING: The concentration of IV/IO EPINEPHrine (0.1 mg/mL) for cardiac arrest is different than the concentration used for IM use in anaphylaxis (1 mg/mL). Administration of EPINEPHrine in cardiac arrest is optional for an IALS agency, requires additional training, and must be approved by the EMS agency medical director. 6. The optimal airway management/ventilation during initial cycles of uninterrupted compressions has not been established. Agency medical director can set agency policy using the following approaches: a. Open airway with manual technique or naso/oropharyngeal airway – with or without passive oxygen b. Provide either no active ventilation (passive ventilation from compressions) or bag ventilate 8-10 breaths per minute (one ventilation every 10 compressions) without interrupting compressions (monitor perfusion with capnography if providing active ventilation) c. If BVM ventilation, consider 2-thumbs-up 2-person BVM technique 7. Confirm and document tube placement with absence of gastric sounds and presence of bilateral breath sounds AND continuous waveform ETCO2 detector. Follow Confirmation of Airway 8. Monitor CPR quality with waveform capnography – in cardiac arrest, level of ETCO2 capnography correlates with perfusion/cardiac output from CPR. The minimum ETCO2 reading is 10mmHg with an optimal goal of >20mmHg. A SUDDEN increase in ETCO2 by >10mmHg may indicate return of spontaneous circulation (ROSC) 9. If the AED continues to indicate that shocks are advised, it is best to focus on excellent chest compressions and use AED to reanalyze every 2 minutes until ALS arrives. Packaging or moving the patient at this point will decrease the effectiveness of CPR. After three AED messages of “no shock advised”, contact medical command. If unable to contact medical command, transport patient as soon as possible while continuing CPR. 10. During packaging and transport, minimize interruptions of CPR and reanalyze rhythm about every 10 minutes, and deliver additional shocks if advised. a. The vehicle and all patient movement should stop before reanalyzing the rhythm. Effective 03/31/2024 3031iA-3 of 4 Pennsylvania Department of Health Resuscitation 3031iA - IALS - Adult b. Providers must be familiar with the AED used by their agency. AEDs that automatically analyze every 2 minutes should be temporarily disabled during patient movement and transport, since the motion of transport may lead to inappropriate shocks. In many machines, this can be accomplished by disconnecting the electrodes from the machine. Avoid turning the AED off, since this may reset all of the data collection within the device. c. Transport without lights or siren to minimize chance of injury to EMS personnel providing CPR and patient care, unless unusual circumstances exist. 11. AHA Guidelines suggest that the following are reliable and valid criteria for BLS termination of resuscitation. Before moving the patient to the ambulance, consider contact with medical command for orders to terminate CPR in the field if ALL of the following apply: a. Arrest not witnessed by EMS personnel, AND b. No return of spontaneous circulation/ pulse (prior to transport), AND c. No AED shock was delivered (prior to transport). 12. If CPR has been initiated, the patient remains pulseless with no shock advised, and the patient has received four doses of Epinephrine, contact medical command to consider termination of resuscitation. To consider termination of resuscitation. Verify appropriate patient: a. No central pulse b. No respiratory efforts c. No shock advised d. ETCO2 < 10 during CPR correlates with irreversible death, but field termination may also be considered with ETCO2 levels > 10. i. If ETCO2 to 20 minutes without a response. Performance Parameters: A. EMS agency should document patient outcome and QI indicators for cardiac arrest, including ROSC during EMS care, ROSC on arrival to ED, admitted to hospital, discharged from hospital alive, and neurologic function on discharge. B. Review of number of cardiac arrest patients that received bystander CPR. [Benchmark may be set with the goal of increasing community CPR classes to improve this percentage.] C. System review of time from dispatch to arrival on scene of initial responder with access to AED. [Possible benchmark of response of 5 minutes or less to 90% of cardiac arrests.] D. Review for cases where patient was inappropriately moved before arrival of ALS. Moving patients with CPR before ROSC is associated with decreased survival. Effective 03/31/2024 3031iA-4 of 4 Pennsylvania Department of Health Resuscitation 3031iP - IALS - Ped GENERAL CARDIAC ARREST – PEDIATRIC STATEWIDE IALS PROTOCOL Initial Patient Contact - See Protocol # 201 Patient pulseless, may have gasping/agonal breathing Call for ALS if not already dispatched Infant < 1 year of Assess patient age age Child between 1-14 years old CPR 1,2,3 Cardiac arrest witnessed by EMS personnel 15:2 (Infant) OR Quality CPR in progress on EMS arrival TRANSPORT 9 NO YES 2 ASAP CPR 15:2 1,2 PAUSE FOR 10 cycles or 2 minutes VENTILATIONS, BUT MINIMIZE ALL OTHER INTERRUPTIONS IN Analyze with AED3,4 COMPRESSIONS Shock (360 joules,5,6,7) if indicated Give Compressions CPR 15:2 1,2 If ROSC: while AED is charging 10 cycles or 2 minutes Assess Vital 3,4 Signs ONLY IF ENOUGH Analyze with AED HELP FOR QUALITY Shock (360 joules,5,6,7) if indicated Provide Oxygen CPR: and Ventilate as IO/IV Access needed EPINEPHrine (0.1 CPR 15:2 1,2 (Goal= SpO2 95- mg/mL) 10 cycles or 2 minutes 99%, if available) See Pediatric Dose Chart, Place in Recovery every 3 - 5 minutes Analyze with AED3,4 Position (if available)8 Shock (360 joules,5,6,7) if indicated Transport ASAP CPR 15:2 1,2 Naso/oropharyngeal 10 cycles or 2 minutes Airway or Age-appropriate Analyze with AED3,4 DO NOT INTERRUPT CPR TO Supraglottic Airway, Shock (360 joules,5,6,7) if indicated PACKAGE AND King LT or iGel TRANSPORT. CONSIDER (if available)9 AWAITING ARRIVAL OF ALS if ALS ETA < 20 mins7,10,11 Monitor capnography OR Continue cycles CPR 15:2 Supplemental Oxygen followed by AED Contact Medical analysis/shock every 2 minutes Command Mechanical CPR for possible should not be used for field termination pediatric patients of CPR12 Effective 03/31/2024 3031iP-1 of 4 Pennsylvania Department of Health Resuscitation 3031iP - IALS - Ped GENERAL CARDIAC ARREST – PEDIATRIC STATEWIDE IALS PROTOCOL Criteria: A. Pediatric patient (≤14 years old) with cardiac arrest (may have gasping or agonal breathing). Exclusion Criteria: A. If patient meets criteria for DOA (e.g. decapitation, decomposition, rigor mortis in warm environment, etc…) then follow DOA protocol # 322. B. Cardiac arrest due to acute traumatic injury – see Cardiac Arrest - Traumatic Protocol #332. AED use is not indicated in traumatic cardiac arrest, but this protocol should be followed if there is the possibility of a medical condition causing cardiac arrest prior to a traumatic incident. C. Cardiac arrest in newborn – see Newborn / Neonatal Resuscitation Protocol # 333. D. Patient displaying an Out-of-Hospital Do Not Resuscitate (OOH-DNR) original order, bracelet, or necklace - see OOH-DNR Protocol #324. Possible Medical Command Orders: A. After 4 “no shock advised messages, if ETA to hospital or ETA of ALS are > 15 minutes, medical command may order termination of resuscitation efforts. Notes: 1. Ventilations should be given over 1 second. When giving chest compressions: a. Push hard (at least 1/3 AP chest diameter for children and infants) b. Push fast (100-120 compressions/min) c. Release hand pressure completely after each compression. d. To avoid tiring, rescuer doing chest compressions should be replaced at least every 5 cycles or 2 minutes. e. It is essential to minimize interruptions in chest compressions during CPR. f. CPR sequence is CAB (Compressions, Airway, Ventilation) for all ages, except the ABC sequence should be used in drowning. g. Compression to ventilation ratio is 30:2 for all single rescuers, but 15:2 for children and infants when 2 rescuers are available. 2. Ventilate the patient with appropriate oral/nasopharyngeal airway using high flow oxygen, as soon as possible, but Do Not delay CPR to connect oxygen. Ideal ventilation includes two-person technique. Routine cricoid pressure is not recommended during CPR. a. Before extraglottic/ alternative supraglottic airway, compression to ventilation ratio is: Child and Infant = 15:2. (NOTE: 1-rescuer CPR compression to ventilation ratio is 30:2 for all patients except newborns) b. After extraglottic/ advanced airway, avoid overzealous hyperventilation. After an advanced airway is in place, chest compressions should be given by one rescuer at a rate of 100-120 compressions/ minute without pauses while a second rescuer provides continuous ventilations at a rate of 8-10 breaths/ minute for all patient ages. c. If unable to ventilate, proceed to Obstructed Airway maneuvers. 3. Pediatric AED Use: If pediatric AED electrodes are immediately available, follow protocol flowchart for adult patients but use pediatric AED electrodes if patient is < 8 years old. If no pediatric AED electrodes are available, adult AED/electrodes should be used on patients < 8 year old, including infants. Check pulse only after the AED gives a “no shock indicated” message. After each shock is delivered, start CPR immediately without checking the pulse. 4. If no shock is indicated, check pulse, if pulseless repeat 5 cycles of CPR and then re-analyze (if applicable). After three sequential “no shock indicated” messages, repeat “analyze” period every 10 minutes. (Note: some AEDs automatically re-analyze for you.) 5. If available, pediatric AED pads used on patients < 8 years of age will provide appropriate lower shock energy dose. Effective 03/31/2024 3031iP-2 of 4 Pennsylvania Department of Health Resuscitation 3031iP - IALS - Ped 6. Patient with severe hypothermia (if available, core temperature < 90° F or 32° C) see Hypothermic Protocol # 681. For hypothermic patients, no more than 1 shock should be delivered. Further action will be directed by medical command. Begin transport immediately after initial countershock. Transport to center with capability of cardiopulmonary bypass surgery if possible. 7. If the AED continues to indicate that shocks are advised, it is best to focus on excellent chest compressions and use AED to reanalyze every 2 minutes until ALS arrives. Packaging or moving the patient at this point will decrease the effectiveness of CPR. After three AED messages of “no shock advised”, contact medical command. If unable to contact medical command, transport patient as soon as possible while continuing CPR. 8. WARNING: The concentration of IV/IO EPINEPHrine (0.1 mg/mL) for cardiac arrest is different than the concentration used for IM use in anaphylaxis (1 mg/mL). Administration of EPINEPHrine in cardiac arrest is optional for an IALS agency, requires additional training, and must be approved by the EMS agency medical director. 9. Confirm and document tube placement with absence of gastric sounds and presence of bilateral breath sounds AND continuous electronic waveform capnography ETCO2 detector. Follow Confirmation of Airway 10. During packaging and transport, minimize interruptions of CPR and reanalyze rhythm about every 10 minutes, and deliver additional shocks if advised. a. The vehicle and all patient movement should stop before reanalyzing the rhythm. b. Providers must be familiar with the AED used by their agency. AEDs that automatically analyze every 2 minutes should be temporarily disabled during patient movement and transport, since the motion of transport may lead to inappropriate shocks. In many machines, this can be accomplished by disconnecting the electrodes from the machine. Avoid turning the AED off, since this may reset all of the data collection within the device. c. Transport without lights or siren to minimize chance of injury to EMS personnel providing CPR and patient care, unless unusual circumstances exist. 11. Agency medical director may establish policy for immediate transport if local pediatric receiving center in close proximity has capabilities for extracorporeal membrane oxygenation (ECMO) and mutually agree on appropriate criteria for rapid transport for immediate ECMO. 12. AHA Guidelines suggest that the following are reliable and valid criteria for BLS termination of resuscitation. Before moving the patient to the ambulance, consider contact with medical command for orders to terminate CPR in the field if ALL of the following apply: a. Arrest not witnessed by EMS personnel, AND b. No return of spontaneous circulation/ pulse (prior to transport), AND c. No AED shock was delivered (prior to transport). Performance Parameters: A. EMS agency should document patient outcome and QI indicators for cardiac arrest, including ROSC during EMS care, ROSC on arrival to ED, admitted to hospital, discharged from hospital alive, and neurologic function on discharge. B. Review of number of cardiac arrest patients that received bystander CPR. [Benchmark may be set with the goal of increasing community CPR classes to improve this percentage.] C. System review of time from dispatch to arrival on scene of initial responder with access to AED. [Possible benchmark of response of 5 minutes or less to 90% of cardiac arrests.] D. Documentation of code summary from monitor /ECG rhythm strips. E. Documentation of confirmation of advanced airway placement including documentation of gastric sounds, breath sounds and use of confirmatory device (include waveform capnography tracings.) Effective 03/31/2024 3031iP-3 of 4 Pennsylvania Department of Health Resuscitation 3031iP - IALS - Ped Pediatric Dose Chart – EPINEPHrine, 0.1 mg/ 1 mL for Cardiac Arrest AGE (years) 20mmHg. A SUDDEN increase in ETCO2 by >10mmHg may indicate return of spontaneous circulation (ROSC) 5. Ventilate with BVM or alternative supraglottic airway. (King LT or iGel). 6. Confirm and document alternative airway placement with absence of gastric sounds and presence of bilateral breath sounds AND electronic waveform capnography confirmatory device (like wave- form ETCO2 detector). Follow Confirmation of Airway Placement Protocol #2032. 7. Transport immediately if patient can arrive at a trauma center (preferred destination) or the closest hospital in ≤ 15 minutes. a. If the patient can arrive at the closest trauma center within 15 minutes, the patient should be taken to the trauma center even if another hospital is closer. b. Notify the receiving facility ASAP to allow maximum time for preparation to receive the patient. Effective 03/31/2024 3032i-2 of 3 Pennsylvania Department of Health Resuscitation 3032i - IALS - Adult/Peds c. Air medical transport of patients in traumatic cardiac arrest is generally not indicated. 8. Contact medical command for possible field termination of resuscitation if the patient remains in cardiac arrest after initial resuscitation attempt and cannot arrive at the closest receiving facility within 15 minutes. 9. See Cervical Spine Immobilization Protocol # 261 10. Field termination of resuscitation must be ordered by Medical Command Physician, otherwise continue resuscitation attempts and initiate transport. Performance Parameters: A. Review all care given on scene for benefit of intervention versus potential delay to transport time. Especially procedures other than airway management and chest needle decompression in non- entrapped victims with short transport times. B. Review for transport to appropriate destination based upon protocol. C. Consider possible benchmark of on-scene time < 10 minutes for non-entrapped patients, although agencies may want to set goal of even less time on-scene Pediatric Dose Chart – EPINEPHrine for Cardiac Arrest AGE (years) 34 C° or > 92.3 F°) or who have been rewarmed to a temperature > 34 C°, follow appropriate Cardiac Arrest protocol. C. Patients with hypothermia (temperature < 34 C°) that are not in cardiac arrest. Follow Hypothermia Protocol #681. Notes: 1. Initiate transport to center capable of cardiac bypass rewarming (Level I trauma centers or other facilities known to have capability of emergency bypass rewarming) as soon as possible. Medical Command can be contacted for assistance in identifying appropriate facility and mode of transport. Consider air transport if ground transport time is > 30 minutes or if it will decrease transport time. Generally, air ambulances are not indicated for patients in cardiac arrest, but hypothermia is the exception to this. 2. Notify the receiving facility as soon as possible. Bypass rewarming requires the mobilization of specialized personnel and equipment. 3. Prevent heat loss by all means available: a. Move to warm environment (like inside ambulance with heaters on maximum) b. Remove wet clothing c. Wrap patient in warm dry blankets d. Apply heat packs to axilla, groin, and neck 4. In severe hypothermia, EMS providers should attempt to prevent additional heat loss, but transport should not be delayed by attempts to provide rewarming in the field. Pediatric Dose Chart – EPINEPHrine, for Cardiac Arrest AGE (years) 100 NO Initiate IV NSS Initiate IV NSS Obtain 12-Lead ECG 4,5,6 and Obtain 12-Lead ECG 4,5,6 and Transmit to receiving facility ASAP Transmit to receiving facility ASAP If not using Viagra-type drugs 7, Nitroglycerin 0.4 mg SL (Repeat up to 3 doses 6) Contact Medical Contact Medical Command 6 Command 6 If STEMI identified by ECG device and Medical Command can’t be contacted, transport to closest STEMI receiving center 5,6 capable of emergency primary percutaneous coronary angioplasty (PPCI) if within 45 minute transport time. intercept with ALS enroute, if possible. Effective 03/31/2024 5001i-1 of 2 Pennsylvania Department of Health Cardiac 5001i - IALS - Adult CHEST PAIN / SUSPECTED ACUTE CORONARY SYNDROME STATEWIDE IALS PROTOCOL Criteria: A. Adult patients with symptoms of possible cardiac ischemia. Diabetics, women, and elderly patients may have atypical symptoms without retrosternal chest pain. May include: 1. Retrosternal chest heaviness/pressure/pain 2. Radiation of pain to arm(s), neck, or jaw 3. Associated Shortness of Breath, nausea/vomiting, or sweating 4. Possibly worsened by exertion 5. Patient over 30 y/o or with known cardiac ischemic disease 6. Patient with history of recent cocaine/amphetamine/stimulant drug use Exclusion Criteria: A. Chest pain/symptoms, probably not cardiac origin: 1. May include: a. Pleuritic chest pain - worsens with deep breath or bending/turning b. Patient less than 30 y/o Possible MC Orders: A. Diversion to receiving facility capable of emergent primary percutaneous coronary intervention (PPCI). Notes: 1. Some potentially lethal mimics of Acute Coronary Syndrome (ACS) that must be considered as the patient is assessed and treated include: a. Aortic dissection d. Spontaneous pneumothorax b. Acute pericarditis e. Pulmonary embolism c. Acute myocarditis f. Pneumonia/Lung infection 2. Administer oxygen by appropriate method and monitor Pulse Oximetry. Place patient in position of comfort. Nasal cannula may be utilized if patient is unable to tolerate a facemask. 3. Preferred method is to chew 4 baby ASA (81 mg each). 4. 12-lead ECG is to be obtained as soon as possible after patient contact, but in no more than 10 minutes. 12-lead ECG should be transmitted to receiving/ command facility ASAP. If transmission failure, give copy of all 12-lead ECGs to ED physician ASAP on arrival to facility. 5. Contact medical command after transmitting 12-lead ECG to determine if it is consistent with STEMI since some patients may benefit from transport to a receiving facility capable of emergent primary percutaneous coronary intervention (PPCI). Medical Command may order transport to STEMI-receiving center (facilities that are either accredited as a Mission Lifeline STEMI (Heart Attack) Receiving Center by the American Heart Association or accredited as a Chest Pain Center with PCI by the Society of Cardiovascular Patient Care or identified by the EMS region to have PPCI capabilities). See protocol 170. 6. Early contact with Medical Command is encouraged for patients with chest pain who have continued pain despite 3 doses of NTG, shock, or evidence of STEMI on prehospital 12-lead ECG, since these patients may benefit by direct transport to a receiving facility capable of PPCI. 7. WARNING: Nitroglycerin may lead to fatal hypotension if given to patients using drugs for erectile dysfunction. a. DO NOT administer nitroglycerin (NTG) to a patient has taken sildenafil (Viagra/Revatio) or vardenafil (Levitra) within 24-48 hours. b. DO NOT administer NTG to a patient who has taken tadalafil (Cialis) within the last 48 hours. c. These medications may be used for conditions other than erectile dysfunction (e.g. Revation is used for pulmonary hypertension). Performance Parameters: A. All patients should either receive aspirin or the PCR should include documentation of why aspirin was contraindicated. B. Review for appropriate transmission of 12-lead ECG. Review for appropriate diversion to facility capable of PCI and/or for appropriate notification of receiving facility when STEMI is identified. C. 12-lead ECGs documented with graphs included in PCR. D. Possible benchmark for on scene time of ≤ 20 minutes. E. Vital signs documented after each use of vasoactive medication (e.g. nitroglycerin). Effective 03/31/2024 5001i-2 of 2 Pennsylvania Department of Health Trauma & Environmental 6002i - IALS - Adult/Peds MULTISYSTEM TRAUMA OR TRAUMATIC SHOCK STATEWIDE IALS PROTOCOL Initial Patient Contact – See Protocol #201 Stabilize C-spine during assessment Open airway using jaw thrust, if indicated. Consider Air Ambulance – per Trauma Triage Protocol #180 Consider Rapid Extrication 1 Manage Airway/Administer Oxygen/Ventilate, if needed 2,3,4,5 Control External Bleeding Restrict spinal motion, if indicated 6 The Following Treatments Should Injury Specific Treatments: Not Delay Transport: Initiate IV/IO NSS Immobilize Suspected Fractures − Initiate 2 large-bore IVs or single IO, − Traction splint preferred for isolated femur if possible fracture − If hypotensive, titrate NSS bolus as − Consider pelvic binder (if available) for described 7 suspected pelvis fracture with hypotension 8 Monitor Pulse Oximetry Occlude sucking chest wounds 9 Notify Trauma Center/receiving facility Cover eviscerations 10 of ETA/category ASAP BEGIN TRANSPORT TO TRAUMA CENTER ASAP, if possible (See Trauma Destination Protocol #180) CONTACT MEDICAL COMMAND If hypotension persists AND due to hypovolemic shock: Repeat IV/IO NSS fluid bolus 7 Effective 03/31/2024 6002i-1 of 3 Pennsylvania Department of Health Trauma & Environmental 6002i - IALS - Adult/Peds MULTISYSTEM TRAUMA OR TRAUMATIC SHOCK STATEWIDE IALS PROTOCOL Criteria: A. Patient that meets Category 1 or Category 2 trauma triage criteria related to traumatic injury. B. Patients with symptoms of spinal cord injury including extremity weakness, numbness or sensory loss. Exclusion Criteria: A. Cardiac Arrest related to trauma – Follow BLS Cardiac Arrest – Traumatic Protocol #332. B. Hypotension not related to trauma – See appropriate Shock or Cardiac protocol. C. Patient that meets Category 3 trauma triage criteria – See appropriate injury-specific protocol. Possible Medical Command Orders: A. Additional NSS for hypotension. B. Assistance with destination decisions (Trauma Center v. non-Trauma Center, Pediatric Trauma Center v. Adult Trauma Center, etc.) Notes: 1. Rapid extrication may be appropriate in any unsafe environment: danger of explosion (including potential secondary explosion at a terrorism incident); rapidly rising water; danger of structural collapse; hostile environments (e.g. riots); patient position prevents access to another patient that meets criteria for rapid extrication; shock; inability to establish an airway, adequately ventilate a patient, or control bleeding in entrapped position; or cardiac arrest. 2. Indications for ventilatory support include GCS < 8, inadequate respiratory effort, and airway not patent. 3. Consider BVM ventilation if needed. 4. Confirm and document advanced airway (King LT or iGel) placement with absence of gastric sounds and presence of bilateral breath sounds AND confirmation with electronic waveform capnography confirmatory device (like wave-form ETCO2 detector). Follow Confirmation of Airway Placement Protocol #2032. 5. If ventilation is needed, AVOID OVERZEALOUS HYPERVENTILATION. a. For all other trauma patients requiring ventilation, ventilate initially at the following rate, ideally with a timing device: patients with these signs of severe head injury (GCS motor score of 1-2 or unequal/unreactive pupils), hyperventilate at: 1) 10 bpm for adults 2) 20 bpm for children >2 and ≤14 y/o 3) 25 bpm for infant < 2 y/o b. Then monitor capnography and adjust ventilation rate to ETCO2 target of 40mmHg (range 35- 45mmHg) c. For all other trauma patients requiring ventilation, ventilate at: 1) 10 bpm for adults 2) 20 bpm for children ≤ 14 y/o 6. Follow BLS Spine Care Protocol #261. Effective 03/31/2024 6002i-2 of 3 Pennsylvania Department of Health Trauma & Environmental 6002i - IALS - Adult/Peds 7. IV/IO NSS fluid resuscitation should be guided by the following: a. Adults: Administer NSS at wide open rate only until desired blood pressure is attained: 1) When bleeding has not been controlled, titrate NSS to permit moderate hypotension (SBP between 70-90) unless severe head injury also present. 2) When bleeding has been controlled or if severe head injury, titrate NSS to achieve SBP >90. 3) Maximum NSS dose is 1000 mL before contacting Medical Command. b. Pediatrics (preadolescent or age ≤ 14 y/o: 1) When bleeding has not been controlled, titrate NSS to permit moderate hypotension (SBP between [50 + 2(age)] – [70 + 2(age)]), unless severe head injury also present. 2) When bleeding has been controlled or if severe head injury, titrate NSS to achieve SBP > 70 + 2(age). 3) Maximum NSS dose is 40 20 mL/kg 1000mL before contacting Medical Command. 8. Pelvic binder splinting devices (circumferential commercial devices that compress the pelvis) are appropriate splinting devices. 9. If sucking chest wound, cover wound with occlusive dressing sealed on 3 sides or commercial chest seal. Release dressing if worsened shortness of breath or signs of tension pneumothorax. 10. If intestinal evisceration, cover intestines with a sterile dressing moistened with sterile saline or water; cover the area with an occlusive material (aluminum foil or plastic wrap). Cover the area with a towel or blanket to keep it warm. Transport with knees slightly flexed if possible. a. DO NOT PUSH VISCERA BACK INTO ABDOMEN, unless prolonged extrication. In wilderness/delayed transport situations with prolonged evacuation time (at least several hours), examine the bowel for visible perforation or fecal odor. If no perforation is suspected, irrigate the eviscerated intestine with saline and gently try to replace in abdomen. Performance Parameters: A. Documentation of reason for any on scene time interval over 10 minutes. B. Percentage of calls, without entrapment, with on scene time interval < 10 minutes. Consider benchmark for on scene time for non-entrapped patients < 10 minutes and < 20 minutes for entrapped trauma patients and Category 2 trauma patients. C. Documentation of applicable trauma triage criteria. D. Appropriate destination per Trauma Patient Destination Protocol #180. E. Appropriate utilization of air medical transport per Trauma Patient Destination Protocol #180. Effective 03/31/2024 6002i-3 of 3 THIS PAGE INTENTIONALLY LEFT BLANK  Pennsylvania Department of Health Trauma & Environmental 6003i - IALS - Adult/Peds MUSCULOSKELETAL TRAUMA STATEWIDE IALS PROTOCOL Initial Patient Contact – See Protocol #201 Splint suspected fractures as appropriate: Traction splinting is preferred for isolated femur fractures 1 Straighten severely angulated fractures if distal extremity has signs of decreased perfusion. Assess pain on 1-10 scale Assess Neurovascular Status distal to injury Oral medication not contraindicated Nausea or contraindication to oral Place in position of comfort Peds medication or moderate/severe pain < 2 y/o Provide verbal reassurance Place in position of comfort If mild to moderate pain: Provide verbal reassurance Acetaminophen, 2 if available, 650 mg orally Initiate IV/IO NSS 4 Peds: See Pediatric Oral Medication Dose Chart OR If nausea, consider ondansetron, if available (see protocol 7010i) Ibuprofen, if available, 10mg/kg, max 600mg Peds ≥ 2 y/o, See Pediatric Oral Med. Dose Chart Administer Nitrous Oxide 5 (if available, see box below) OR Monitor Pulse Oximetry (if nitrous Aspirin 324-650 mg orally (adult > 14 y/o only) oxide given) WARNING: Do not administer these medications if patient had medication recently (within 4 hours for acetaminophen/aspirin, within 6 hours for NSAID). CONTACT MEDICAL COMMAND ANALGESIC MEDICATION OPTION Nitrous Oxide, if available, (50:50) by inhalation 6 Effective 03/31/2024 6003i-1 of 4  Pennsylvania Department of Health Trauma & Environmental 6003i - IALS - Adult/Peds Pediatric Oral Dose Chart for Mild Pain AGE 6 mos to < 2 2-3 4-5 6-8 9-10 11-12 13-14 (years) 12-17 18-23 24-35 36-47 48-59 60-71 72-95 Reported Weight >95 lbs lbs Lbs lbs lbs lbs lbs lbs (lbs) Reported Weight 5.5-7.5 8-11 11.5-16 16.5-21 22-27 27.5-32.5 33-43 > 43 kg (kg) kg kg kg kg kg kg kg Provide dose based upon AGE, unless you have specific information about patient weight. These are one-time INITIAL doses by the oral route. Do not give these oral medications if the patient has had the medication within the last 4-6 hours. Ensure proper syringe is available to deliver graduated dose required Infant Drops Ibuprofen (Motrin, 1.2 ml 2.0 ml 2.5 ml 3.75 ml 5 ml --- --- --- Advil) 50 mg/1.25 ml) Children’s Ibuprofen 100 mg / 5 ml 3 ml 5 ml 5 mL 7.5 mL 10 mL 12.5 mL 15 mL 20 mL Children’s Acetaminophen (Tylenol) 2.5 ml 3.75 ml 5 mL 7.5 mL 10 mL 12.5 mL 15 mL 20 mL 160 mg / 5ml Effective 03/31/2024 6003i-2 of 4 Pennsylvania Department of Health Trauma & Environmental 6003i - IALS - Adult/Peds MUSCULOSKELETAL TRAUMA STATEWIDE IALS PROTOCOL Criteria: A. Patient with isolated suspected extremity fractures. B. Patient with acute extremity pain after trauma C. Patient with acute back pain, excluding chronic back pain D. Patient with acute thoracic/ rib pain after trauma Exclusion Criteria: A. Multisystem trauma or traumatic/hypovolemic shock (Follow Multisystem Trauma or Traumatic Shock protocol #6002i) Possible Medical Command Orders: A. Analgesia/ pain medication 1. ketorolac for adults 15mg IV or 30mg IM. Notes: 1. Traction splinting should not be used for hip (proximal femoral neck) fractures. 2. Acetaminophen is contraindicated in patients with liver disease/failure. 3. NSAID (nonsteroidal anti-inflammatory drugs), including ibuprofen and ketorolac are contraindicated if: a. Oral NSAID (e.g. ibuprofen, naproxen, etc.) taken by patient in last 6 hours b. Bleeding or suspected bleeding (e.g. external/internal trauma, gastrointestinal, vascular). c. Known kidney disease/failure or kidney transplant d. NSAIDS can be given to any child older than 6 months. The maximum dose is 600mg. 4. IV/IO access is not required for administration of nitrous oxide. 5. Reassess and document 1-10 pain score 15-30 minutes after analgesic dose or at time of transfer of care. 6. Nitrous oxide should be self-administered. Patient should be coached to hold mask on his/her face, and the patient will drop mask if he/she becomes sedated. Over-sedation may occur if EMS provider holds mask to patient’s face. Nitrous oxide may be administered without IV access. Avoid nitrous oxide in: a. SBP 1 hour, administer additional NSS bolus of 20 mL /kg/hr (or administer fluids to maintain urine output of 300 mL/hr [Peds: 2 mL/kg/hr]) Examine urine/ measure output if prolonged entrapment Contact Medical Command if communications possible After extrication: IV NSS wide open to maintain SBP > 100 [Pediatrics SBP > 70 + 2 (age)] For children 1-10 years old and BP 20% TBSA, 6 Administer Nitrous Oxide (see box below), if indicated 7 TRANSPORT TO CLOSEST APPROPRIATE FACILITY/ TRAUMA CENTER 8 Contact Medical Command 9 If hypotension persists or if extensive BSA burn, repeat 20 mL /kg NSS fluid bolus 6 If pain continues, Administer Repeat dose(s) of Analgesic Medication (see box below) ANALGESIC MEDICATION OPTIONS Nitrous Oxide, if available(50:50) by inhalation 7 Effective 03/31/2024 6071i-1 of 3 Pennsylvania Department of Health Trauma & Environmental 6071i - IALS - Adult/Peds BURNS STATEWIDE IALS PROTOCOL Criteria: A. Patient with burns from: 1. Thermal injury 2. Chemical dermal injury. B. Patient with lightning or electrical injury. Possible MC Orders: A. Transport to a burn center or trauma center B. CPAP/BiPAP for respiratory difficulty Notes: 1. Consider scene safety. Be aware of possible chemical contamination and/or electrical sources. Stop the burning process. Remove clothing and constricting jewelry. 2. Determine presence of respiratory burns as indicated by carbonaceous sputum, cough, hoarseness, or stridor (late). All patients with exposure to smoke or fire in a confined space should receive high-flow oxygen and Pulse Oximetry monitoring. 3. Consider early intubation in patients with respiratory distress, hoarseness, carbonaceous sputum or stridor. If unsure, contact medical command early for assistance with this decision. 1. For chemical burn exposure, brush dry powders then begin flushing immediately with water or appropriate agent for chemical. Exceptions: for phosphorous and sodium, DO NOT flush with water, cover with cooking oil if available; for Phenol remove with alcohol and follow with large volume of water. If eye is burned, flush with large volume of NSS for 15-20 minutes. May administer tetracaine eye drops before flushing. Continue eye flushing during transport. 2. Indicators of severe burn injury include: a. Respiratory tract injury, inhalation injury. b. 2nd and 3rd degree burns that involve face, hands, feet, genitalia or perineal area or those that involve skin overlying major joints. c. 3rd degree burns of greater than 5% BSA. d. 2nd degree burns of greater than 15% BSA. e. Significant electrical burns, including lightning injury. f. Significant chemical burns. g. Burn injury in patients with pre-existing illnesses that could complicate management, prolong recovery, or affect mortality. Medical Command physician may direct transport to Burn Center in these cases. 3. DO NOT provide fluid bolus if respiratory symptoms are present. 4. Nitrous oxide should be self-administered. Patient should be coached to hold mask on his/her face, and the patient will drop mask if he/she becomes sedated. Oversedation may occur if EMS provider holds mask to patient’s face. 5. Transport to the closest appropriate medical facility, using the following order of preference: Effective 03/31/2024 6071i-2 of 3 Pennsylvania Department of Health Trauma & Environmental 6071i - IALS - Adult/Peds a. If unable to maintain airway or unable to ventilate or patient has symptoms of shortness of breath/cough or inhalation injury is suspected, transport to closest hospital. b. Transport to Trauma Center, if patient has associated trauma. Follow Trauma Destination Protocol #180. c. Transport to a burn center if: 1) The patient has burns to more than 15% BSA or burns to face or hands, and 2) The patient does not meet trauma triage criteria, and 3) The difference between estimated transport time to the closest receiving facility and the burn center is 20 minutes or less. d. If none of the above apply, transport to the closest hospital. 6. Medical Command Physician may direct transport to Burn Center. Performance Parameters: A. Review all burn calls for compliance with Trauma Destinations Protocol # 180 B. Review all burn calls for frequency of administration of or documentation of offering pain medication. Effective 03/31/2024 6071i-3 of 3 THIS PAGE LEFT INTENTIONALLY BLANK Pennsylvania Department of Health Medical & OB/GYN 7002iA - IALS - Adult ALTERED LEVEL OF CONSCIOUSNESS STATEWIDE IALS PROTOCOL Initial Patient Contact - See Protocol # 201 Administer Oxygen 1 Manage Airway/Ventilate, if needed Monitor Pulse Oximetry 2 Assess Glasgow Coma Scale Check glucose meter < 60 mg/dl NO YES Evidence of opiate overdose 3 AND Initiate IV NSS Respiratory depression 10% Dextrose 25 g IV (250 mL)9 OR NO YES Glucagon 1 mg, IM or IN (if available) Naloxone 0.1 mg/kg IV/IO/IM/IN4,5,6 (maximum dose 0.4 mg) May repeat 0.1 mg/kg (max. 2 mg) May repeat 0.1 mg/kg (max. 2 mg) NO Patient becomes alert 3 Respiratory rate and level of consciousness improves 7 NO YES YES TRANSPORT 8 TRANSPORT 8 Contact Medical Command Effective 03/31/2024 7002iA-1 of 3 Pennsylvania Department of Health Medical & OB/GYN 7002iA - IALS - Adult ALTERED LEVEL OF CONSCIOUSNESS - ADULT STATEWIDE IALS PROTOCOL Criteria: A. Patient with altered level of consciousness due to: 1. Unclear etiology after assessing patient 2. History consistent with hypoglycemia 3. Suspected drug ingestion /overdose 4. Seizure Exclusion Criteria: A. Altered level of consciousness due to: 1. Trauma - Follow appropriate trauma protocol (e.g. head injury or multi-system trauma protocol) 2. Shock - Follow Shock AEMT protocol # 7005i 3. Toxicologic a. Carbon monoxide - Follow Poisoning/Toxic Exposure Protocol #831. 4. Stroke - Follow Stroke AEMT Protocol #7006i (If glucose 95% and SBP >90. 5. Naloxone can be administered IM, IO, or intranasally if IV cannot be established. IN administration should be done via an atomizing device, giving half of dose in each nostril. If IM route is required, use 2 mg. 6. The goal of each naloxone dose is return of adequate spontaneous respirations – the goal is not consciousness or walking. Do not give additional doses if patient breathing spontaneously with adequate oxygen saturation. Larger individual doses of naloxone can precipitate opiate withdrawal with the potential for a violent or combative patient that is difficult to manage at the scene and once the patient is admitted to the hospital. Some opioids may require higher doses of naloxone. Principles related to naloxone use include: a. Assisting ventilation with BVM should occur prior to and during naloxone administration if needed. Effective 03/31/2024 7002iA-2 of 3 Pennsylvania Department of Health Medical & OB/GYN 7002iA - IALS - Adult b. If patient has history of chronic or daily use of opioids, contact medical command (if possible) for lower dosing to avoid withdrawal symptoms. Options for titrating naloxone dosing every 2-4 minutes until adequate spontaneous respirations: i. IV/IO: 0.4 mg, then up to 2 mg1.6 - 2 mg, then 2 mg (up to 4.4 mg total) ii. IM/IN: 2 mg, then 2 mg (4 mg total); may use 4 mg IN prefilled device iii. 2 mg dose by any route is acceptable for patient with both respiratory depression and poor perfusion (hypotension, weak/thread pulse), then additional 2 mg c. If inadequate spontaneous ventilation after a total of up to 4 mg naloxone by any route, efforts should be focused on adequate BVM ventilation and placement of advanced airway, if possible 7. Indicators of improved mental status include: a. Orientation to person, place and time b. Increased alertness c. Increased responsiveness to questions 8. For patients refusing transport, adhere to Refusal of Treatment /Transport Protocol #111. 9. There is an increased risk of tissue damage if 50% dextrose extravasates, and the time to regaining consciousness is similar when using either 10% or 50%, therefore administration of 10% dextrose is preferred. IALS agencies may carry dextrose for the treatment of hypoglycemia in adults in any concentration between 10 – 50%. 25 gm of dextrose is: 250 mL of 10% dextrose, 100 mL of 25% dextrose, 50 mL of 50% dextrose Performance Parameters: A. Review for proper use of naloxone and glucose and documentation of neurologic assessment/ response to treatment. Effective 03/31/2024 7002iA-3 of 3 THIS PAGE LEFT INTENTIONALLY BLANK Pennsylvania Department of Health Medical & OB/GYN 7002iP - IALS - Peds ALTERED LEVEL OF CONSCIOUSNESS - PEDIATRIC STATEWIDE IALS PROTOCOL Initial Patient Contact - See Protocol #201 Administer Oxygen 1 Manage Airway/Ventilate, if needed 2,3 Monitor Pulse Oximetry 4 Assess Glasgow Coma Scale Check glucose meter YES NO < 60 mg/dL Initiate IV NSS Evidence of opiate overdose 5 10% Dextrose per Pediatric Dose Chart IV/IO 11 AND If IV access is not obtainable, Respiratory depression Glucagon, adult, 1 mg, IM/IN Glucagon peds, IM/IN,See Pediatric Dose Chart NO YES (If glucagon is available) Naloxone per Pediatric Dose Chart IM/ IN/ IV/ IO 6,7,8 NO Patient becomes alert 9 (maximum dose 2 mg) May repeat dose after 2-4 min. YES Respiratory rate AND TRANSPORT 10 YES Level of consciousness improves 9 CONTACT MEDICAL COMMAND Pediatric Dose Chart – for Altered Mental Status AGE (years) 90. 7. Naloxone can be administered IM or intranasally. IN administration should be done via an atomizing device with dose split evenly between each nostril. Effective 03/31/2024 7002iP-2 of 3 Pennsylvania Department of Health Medical & OB/GYN 7002iP - IALS - Peds 8. The goal of each naloxone dose is return of adequate spontaneous respirations – the goal is not consciousness or walking. Do not give additional doses if patient breathing spontaneously with adequate oxygen saturation. Larger individual doses of naloxone can precipitate opiate withdrawal with the potential for a violent or combative patient that is difficult to manage at the scene and once the patient is admitted to the hospital. If no response to dose of naloxone, dose may repeat in 2-4 minutes to a total of 4 mg. Some opioids may require higher doses of naloxone. Principles related to naloxone use include: a. Assisting ventilation with BVM should occur prior to and during naloxone administration if needed. b. If inadequate spontaneous ventilation after a total of up to 4 2mg naloxone by any route, efforts should be focused on adequate BVM ventilation and placement of advanced airway, if possible. 9. Indicators of improved mental status include: a. Orientation to person, place and time b. Increased alertness c. Increased d. If no response to dose responsiveness to questions 10. For patients refusing transport, adhere to Refusal of Treatment/Transport Protocol #111. 11. IALS agencies may carry dextrose for the treatment of hypoglycemia in children in any concentration between 10-25%. Patients awaken in a similar amount of time whether using 10 or 25%. For neonates, 25% dextrose dose should be diluted with equal amounts of NSS for 12.5% dextrose at 4 mL/kg (or administer 5 mL/kg of 10% dextrose for any age). Performance Parameters: A. Review for proper use of naloxone and glucose and documentation of neurologic assessment/ response to treatment. Effective 03/31/2024 7002iP-3 of 3 THIS PAGE LEFT INTENTIONALLY BLANK