2024 Delaware ALS Protocols PDF

Statewide Standard Treatment Protocols Delaware Advanced Life Support Protocols, Guidelines, Policies and Standing Orders Effective: November 1, 2024 Approved by the EMS Medical Directors: April 17, 2024 Approved by the Advanced Life Support Subcommittee of the Board of Medical Licensure and Discipline: May 31, 2024 Approved by the Board of Medical Licensure and Discipline: July 9, 2024 1|P a ge State of Delaware Department of Health and Social Services Division of Public Health Office of Emergency Medical Services 2022 Statewide Standard Treatment Protocols, Guidelines, Policies and Advanced Life Support Standing Orders Steven Blessing, MA Director Division of Public Health Robert A. Rosenbaum, MD., FACEP, FAEMS Emergency Medical Services & Preparedness Section Medical Director State EMS Medical Director, Office of Emergency Medical Services Division of Public Health 2|P a ge CONTENTS INTRODUCTION ________________________________________________________________ 7 PARAMEDIC SCOPE OF PRACTICE _______________________________________________ 8 MINIMUM SKILLS AND PROCEDURES ____________________________________________ 10 PARAMEDIC RADIO/TELEPHONE REPORT GUIDELINES _____________________________ 11 PARAMEDIC DOCUMENTATION RECORDS POLICY _________________________________ 12 ADULT GENERAL PATIENT CARE ________________________________________________ 13 ACUTE RESPIRATORY DISTRESS ________________________________________________ 16 PULMONARY EDEMA DUE TO CONGESTIVE HEART FAILURE ________________________ 17 NON-INVASIVE MECHANICAL VENTILATION (NIMV) 18 ALTERED MENTAL STATUS _____________________________________________________ 19 BUPRENORPHINE 21 HYPERTENSIVE CRISIS ________________________________________________________ 22 SUSPECTED STROKE __________________________________________________________ 23 SEIZURE (ACTIVE) _____________________________________________________________ 25 ALLERGIC/ADVERSE REACTION/DYSTONIC REACTION _____________________________ 26 NON-TRAUMATIC HYPOTENSION ________________________________________________ 28 SEPSIS ______________________________________________________________________ 29 ACUTE CORONARY SYNDROMES (ACS) __________________________________________ 30 ST ELEVATION MYOCARDIAL INFARCTION (STEMI) _________________________________ 31 HEMOYNAMICALLY COMPROMISING BRADYCARDIA _______________________________ 32 STABLE TACHYCARDIA ________________________________________________________ 33 UNSTABLE TACHYCARDIA ______________________________________________________ 34 GENERAL ADULT CARDIAC ARREST BUNDLE OF CARE _____________________________ 35 PEDIATRIC AND ADULT TRAUMATIC CARDIAC ARREST _____________________________ 37 TERMINATION OF RESUSCITATIVE EFFORTS & TELEMETRIC PRONOUNCEMENT OF DEATH ________________________________ 38 GUIDELINES REGARDING DO NOT RESUSCITATE ORDERS __________________________ 41 VENTRICULAR FIBRILLATION (VF) AND/OR PULSELESS VENTRICULAR TACHYCARDIA (VT) _____________________________ 42 ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA) _______________________________ 44 REFUSAL OF SERVICE _________________________________________________________ 46 ALS RELEASE TO BLS __________________________________________________________ 47 PEDIATRIC GENERAL PATIENT CARE ____________________________________________ 48 PEDIATRIC ACUTE RESPIRATORY DISTRESS ______________________________________ 52 PEDIATRIC ALTERED MENTAL STATUS ___________________________________________ 53 PEDIATRIC SEIZURES (ACTIVE) _________________________________________________ 54 PEDIATRIC SHOCK AND HYPOTENSION __________________________________________ 55 PEDIATRIC ALLERGIC REACTION ________________________________________________ 56 PEDIATRIC BRADYCARDIA______________________________________________________ 57 PEDIATRIC TACHYCARDIA ______________________________________________________ 58 PEDIATRIC CARDIOPULMONARY RESUSCITATION GUIDELINES ______________________ 59 PEDIATRIC VENTRICULAR FIBRILLATION (VF) AND/OR PULSELESS VENTRICULAR TACHYCARDIA _________________________________ 60 PEDIATRIC ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA) _____________________ 62 PEDIATRIC AND ADULT TRAUMA ________________________________________________ 63 ADULT BLOOD ADMINISTRATION 68 PEDIATRIC BLOOD ADMINISTRATION 70 PEDIATRIC AND ADULT SMOKE INHALATION ______________________________________ 71 PEDIATRIC AND ADULT POST RESUSCITATION CARE WITH TARGETED TEMPERATURE MANAGEMENT ____________________________ 72 3|P a ge SELECTIVE SPINAL MOTION RESTRICTION________________________________________ 73 PATIENT RESTRAINT __________________________________________________________ 74 PEDIATRIC AND ADULT AIRWAY MANAGEMENT ___________________________________ 76 PEDIATRIC AND ADULT PAIN MANAGEMENT ______________________________________ 80 SUSPECTED EMERGING INFECTIOUS DISEASE (EID) 82 ALS EQUIPMENT INVENTORY 85 MEDICATION LIST 87 ALS INTER-FACILITY TRANSPORT 89 APPENDIX A - IDEAL/PREDICTED BODY WEIGHT TABLES (ARDSnet) 95 APPENDIX B – SAVE-A-LIFE 96 APPENDIX C – VAN STROKE SCALE 97 APPENDIX D – CLINICAL OPIOID WITHDRAWAL SCALE (COWS) 98 APPENDIX E – SHOCK INDEX 99 APPENDIX F – HOSPITAL CONTACT LIST 101 4|P a ge ALPHABETIZED CONTENTS BY KEYWORD ACS - ACUTE CORONARY SYNDROMES 30 AIRWAY MANAGEMENT – PEDIATRIC AND ADULT 76 ALLERGIC REACTION - PEDIATRIC 56 ALLERGIC/ADVERSE REACTION/DYSTONIC REACTION 26 ALTERED MENTAL STATUS 19 ALTERED MENTAL STATUS - PEDIATRIC 53 ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA) 44 ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA) – PEDIATRIC 62 BLOOD ADMINISTRATION - ADULT 68 BLOOD ADMINISTRATION – PEDIATRIC __________________________________________ 70 BLS RELEASE 47 BODY WEIGHT TABLES (ARDSnet) – APPENDIX A 95 BRADYCARDIA – HEMOYNAMICALLY COMPROMISING 32 BRADYCARDIA – PEDIATRIC 57 BUPRENORPHINE 21 CARDIAC ARREST BUNDLE OF CARE – ADULT 35 CHF - PULMONARY EDEMA/CONGESTIVE HEART FAILURE 17 COWS - CLINICAL OPIOID WITHDRAWAL SCALE – APPENDIX D 98 CPR -CARDIOPULMONARY RESUSCITATION GUIDELINES - PEDIATRIC 59 DO NOT RESUSCITATE ORDERS - GUIDELINES 41 DOCUMENTATION RECORDS POLICY 12 EMERGING INFECTIOUS DISEASE (EID) – SUSPECTED 82 EQUIPMENT INVENTORY 85 GENERAL PATIENT CARE - ADULT 13 GENERAL PATIENT CARE - PEDIATRIC 48 HOSPITAL CONTACT LIST – APPENDIX F 101 HYPERTENSIVE CRISIS 22 HYPOTENSION – NON-TRAUMATIC 28 INTER-FACILITY TRANSPORT 89 MEDICATION LIST 87 MINIMUM SKILLS AND PROCEDURES 10 PAIN MANAGEMENT – PEDIATRIC AND ADULT 80 PATIENT RESTRAINT 74 POST RESUSCITATION CARE WITH TARGETED TEMPERATURE MANAGEMENT – PEDIATRIC AND ADULT 72 REFUSAL OF SERVICE 46 REPORT GUIDELINES – RADIO/TELEPHONE 11 RESPIRATORY DISTRESS (ACUTE) - ADULT 16 RESPIRATORY DISTRESS (ACUTE) -PEDIATRIC 52 SAVE-A-LIFE – APPENDIX B 96 SCOPE OF PRACTICE - PARAMEDIC 8 SEIZURE (ACTIVE) 25 SEIZURES (ACTIVE) - PEDIATRIC 54 SPINAL MOTION RESTRICTION - SELECTIVE 73 SEPSIS 29 SHOCK AND HYPOTENSION - PEDIATRIC 55 SHOCK INDEX – APPENDIX E 99 SMOKE INHALATION – PEDIATRIC AND ADULT 71 STEMI – ST ELEVATION MYOCARDIAL INFARCTION 31 5|P a ge STROKE – SUSPECTED 23 TACHYCARDIA - PEDIATRIC 58 TACHYCARDIA - STABLE 33 TACHYCARDIA – UNSTABLE 34 TERMINATION OF RESUSCITATIVE EFFORTS & TELEMETRIC PRONOUNCEMENT OF DEATH 38 TRAUMA – PEDIATRIC AND ADULT 63 TRAUMATIC CARIAC ARREST – PEDIATRIC AND ADULT 37 VAN STROKE SCALE – APPENDIX C 97 VENTRICULAR FIBRILLATION (VF) AND/OR PULSELESS VENTRICULAR TACHYCARDIA (VT) 42 VENTRICULAR FIBRILLATION (VF) AND/OR PULSELESS VENTRICULAR TACHYCARDIA (VT) – PEDIATRIC 60 6|P a ge INTRODUCTION The standing orders of the Statewide Standard Treatment Protocol have been developed for use by paramedics while functioning in the Delaware Paramedic Services System. These Standing Orders replace the previous set and are initially effective on November 1, 2024. The Standing Orders are specific and should not be open to alteration. However, while many of the common, frequently encountered medical emergencies have been addressed by specific standing order, it is recognized that not all patient presentations are clear-cut, nor will all patients benefit from "recipe" treatment approaches. Standing orders do not replace the need for sound clinical judgment or the need to contact medical control as soon as possible. Standing orders are not intended to provide definitive treatment but are intended to stabilize the patient prior to transport to the hospital for definitive treatment. Deviation from standing orders may be undertaken only by direct order from an approved medical control physician serving as Medical Command within an approved facility. The intent of these orders is two-fold: 1) promotion of statewide standardization of prehospital advanced life support services, and 2) provision of guidelines under which paramedics may initiate life-saving treatments prior to establishing contact with medical control. The ultimate goal of the Delaware Paramedic System is to deliver viable patients to the hospital, thereby creating a positive impact on health care in Delaware. Unless marked specifically as optional, these standing orders and equipment list are to be complied with by all paramedic agencies. All Delaware paramedic agencies must be in compliance with the ability to perform the standing orders within a period of time determined by the State EMS Director. PARAMETERS OF PARAMEDIC PRACTICE Paramedics are not authorized, in the State of Delaware, to function as independent providers of advanced life support services. Paramedics function as physician extenders and, as such, participate in the practice of medicine. Paramedics may only perform advanced life support procedures when functioning as members of an on-duty Advanced Life Support (ALS) unit. Such a response unit must be from a state approved paramedic service whose paramedics are functioning under the license of the State Emergency Medical Service's Medical Director. The prehospital provision of ALS services by a paramedic in any other situation constitutes the unlawful practice of medicine. Off duty paramedics who respond to a scene are considered good Samaritans and are only expected to perform at the level of a first responder unless activated by an agency policy or procedure. These situations include but are not limited to performing ALS skills while serving on Basic Life Support (BLS) units, carrying ALS equipment in personal vehicles for the purpose of responding to medical emergencies, and offering or providing paramedic services in settings other than those described above. 7|P a ge PARAMEDIC SCOPE OF PRACTICE Delaware paramedics serve as physician extenders in providing prehospital advanced life support within the state, and as specified in reciprocity agreements, in surrounding states. The underlying objective of all paramedic activities is the rapid treatment, stabilization, and transport of the sick and injured to appropriate receiving facilities. The paramedic is authorized to provide all "first responder" and basic life support interventions in addition to the advanced life support procedures specified by this statewide standard treatment protocol, as approved by the Board of Medical Licensure and Discipline. Unless an imminent threat to life or limb necessitates immediate treatment, it is in the patient’s best interest for the paramedic to obtain the chief complaint, history of present illness, pertinent past medical history, list of medications, and conduct a directed physical examination. Information gathered during the assessment is then used to guide treatment. Paramedics respond to all calls to which they are dispatched, whether the nature of the call is medical or trauma. Paramedics evaluate and treat prehospital patients utilizing guidelines specified by these protocols. Communication is to be established with medical control as soon as possible, even if treatment of the patient does not require authorization by medical control. Treatments that do require authorization by medical control shall not be carried out on the paramedic's own initiative except under exceptional circumstances where communication with medical control is not immediately obtainable and, in the opinion of the paramedic, the patient's life may be jeopardized by further delay. At no time shall paramedics perform procedures beyond their scope of training or practice. A list of procedures ordinarily accomplished by protocol and verbal order of medical control follows and clearly defines the scope of paramedic practice. All patients evaluated by the paramedics are to be transported to the hospital. The only exceptions to this rule occur when patient care is released to another EMS agency; the patient receives an appropriate treatment and then refuses transportation to a hospital or when the patient refuses service. In some instances, medical control must be contacted for authorization per standing order. In cases of anticipated, actual, or pending public health need, paramedics may be authorized by the Director of Public Health, and the State EMS Medical Director to give immunizations and vaccinations against infectious/communicable diseases. Specific immunization standing orders, administrative procedures and modifications to protocols must be authorized and signed by the Director of Public Health the State EMS Director and the State EMS Medical Director. This standing order must meet or exceed the policy standards and guidelines established by the National Vaccine Advisory Committee of the Centers for Disease Control (CDC). Participation in the vaccination program by Delaware Paramedic Agencies is elective. Use of the standing orders within the Statewide Standard Treatment Protocol is straightforward. When ALS providers functioning as Delaware paramedics encounter a patient meeting the proper criteria as described in the order, treatment should be initiated. The orders are designed to permit paramedics to render emergent treatment of the sick and injured. Treatment should proceed through the protocol until the patient's condition changes or stabilizes. If the change in patient condition meets the criteria for a different standing order, treatment should be altered accordingly. Once the patient is stabilized, or the orders have been completed, medical control contact should be considered. Medical control may be contacted at any point during patient care, preferably early in the course of therapy, but must be contacted in all cases, preferably before transportation is initiated, unless the trauma protocol is in use. 8|P a ge “Any person, agency, organization, or entity who knows or in good faith suspects child abuse or neglect shall make a report in accordance with § 904 of this title (Title 16 of Delaware Code). For purposes of this section, "person" shall include, but shall not be limited to, any physician, any other person in the healing arts including any person licensed to render services in medicine, osteopathy or dentistry, any intern, resident, nurse, school employee, social worker, psychologist, medical examiner, hospital, health care institution, the Medical Society of Delaware or law enforcement agency." Child Abuse Reporting Phone Contact:1-800-292-9582 or www.iseethesigns.org Any person having reasonable cause to believe that an adult person is infirm or incapacitated as defined in § 3902 of this title (Title 31 of Delaware Code) and needs protective services as defined in § 3904 of this title shall report such information to the Department of Health and Social Services. Division of Services for Aging and Adults with Physical Disabilities (DSAAPD): 1-800-223- 9074. National Human Trafficking Resource Center Hotline 1-888-373-7888 If an EMS provider has reasonable cause to suspect that a person is a potential victim of human trafficking, report the concern. National Human Trafficking Resource Center Hotline 1-888-373- 7888 (24 hours). The NHTRC call takers are trained to assist by discussing a case in a HIPAA compliant manner. 9|P a ge MINIMUM SKILLS AND PROCEDURES The following are skills and procedures that all paramedics must demonstrate proficiency in for initial certification and must maintain proficiency in for recertification. Procedures that are allowed only with approval by medical control are marked by an asterisk (*). All equipment/devices carried by or utilized by ALS agencies require the written approval of the State EMS Medical Director or his/her designee. 1. Patient assessment (primary and secondary surveys) 2. Obtaining vital signs including temperatures 3. Airway control (manual) 4. Use of airway adjuncts (nasopharyngeal and oropharyngeal airways) 5. Spine immobilization/stabilization 6. Cardio-pulmonary resuscitation 7. Bleeding control 8. Splinting of fractures and dislocations 9. Endotracheal intubation (oral and nasal) 10. Obtaining IV access (includes use of saline locks and accessing central lines) 11. Medication, vaccine and immunization administration (parenteral, intraosseous, endotracheal, intranasal, nebulized, oral, sublingual, and transdermal) 12. Calculation of drug dosages 13. Defibrillation/cardioversion (includes use of SAED) 14. Dysrhythmia recognition and treatment 15. External cardiac pacing 16. Use of suction equipment 17. Application of oxygen delivery devices (includes use of CPAP/BiPAP) 18. Use of bag-valve-mask device 19. Application of cardiac monitors 20. Venipuncture to obtain blood samples. 21. Vaginal delivery 22. Eye irrigation 23. External jugular cannulation 24. Use of Magill forceps to remove foreign body from the obstructed airway. 25. Pulse oximetry and CO-oximetry 26. Capnography (nasal and endotracheal) 27. 12 lead electrocardiogram (ECG) 28. Blood glucose determination and other point of care testing devices as approved by the State of Delaware Medical Directors. 29. Valsalva maneuvers (to control supraventricular tachycardia) 30. Intraosseous access for fluid/medication administration 31. Use of approved rescue airway device 32. Gastric tubes 33. Surgical/Needle cricothyrotomy 34. Needle chest decompression 35. *Presumptive diagnosis of death* 36. Use of pelvic compression devices 37. Use of approved ventilator device 38. Use of IV infusion pumps 39. Use of tourniquets and approved hemostatic agents. 40. Use of approved mechanical chest compression device 41. Provision of post resuscitation care 10 | P a g e 42. Application of Junctional Tourniquet (Optional) 43. Use of impedance threshold device (ITD) 44. Administration of blood products 45. Use of Point of Care Ultrasound (Optional) 46. BiPAP (Optional) PARAMEDIC RADIO/TELEPHONE REPORTS GUIDELINES The paramedic report to medical control should be brief and concise. The goal is to provide enough vital information to medical control so that they may provide informed direction for the patient’s continued care and plan for the patient’s disposition. Reports generally should not exceed thirty (30) seconds in duration in order to provide economical use of time by the paramedic, the medical control physician, and nursing personnel. The paramedic is to first attempt to contact the Delaware Medical Control facility of intended patient disposition. If a paramedic does not obtain a timely response, they may contact a second Delaware Medical Control facility for orders or consultation. If an out of state hospital is the intended destination, the EMS provider should contact the closest Delaware Medical Control facility. Delaware Medical Control facilities may be contacted by radio, phone, or approved alternative telemedicine method. Receiving facility should be contacted on all calls when specialized equipment or personnel is needed. ALS Priority I patients or patients requiring online medical direction for orders or consultation must have phone or radio consultation with receiving facility. Priority II and III patients being treated under standard orders only do not require Medical Control contact. Follow local agency SOP and facility request for reports. A paramedic may seek expert consultation via online medical control at any time, for any patient, for any reason. The following report format is acceptable: Paramedic unit number. Specific notification or requests such as (DFI, DOPA, TOR, Trauma Alert, Trauma Code, Cardiac Arrest, Stroke Alert, Heart Alert, CPAP/BiPAP, Sepsis Alert, etc.) Estimated time of arrival. Priority. Patient age. Patient sex. Chief complaint and related past medical history (i.e., patient with chest pain, history of MI and CABG or patient with altered mental status and history of insulin dependent diabetes). Vital signs. Significant physical findings (i.e., patient with shortness of breath found to have wheezing and to be hot to the touch, or the patient complaining of leg pain who has deformity of the mid- thigh without distal pulses). Care rendered. Response to care. Orders requested. Run case number is required for DOPA or relay information as soon as possible prior to leaving shift. 11 | P a g e PARAMEDIC DOCUMENTATION RECORDS POLICY At the time of patient delivery to an approved healthcare facility, the paramedic must give a verbal report to a physician or nurse at the patient’s bedside and leave identified copies of all pertinent ECGs, rhythm strips, and printed patient trend data. All IV bags that have been mixed with a medication must be labeled at time of ED disposition. EMS providers must complete, without exception, a State of Delaware PCR on each patient contact, and shall document all relevant findings, and treatments. In the absence of extraordinary circumstances, a PCR should be submitted to the receiving facility within four (4) hours of patient disposition. EMS providers must complete and submit a PCR to the receiving facility prior to going off duty. A completed PCR is also necessary to identify EMS providers in the event of a potential infectious disease exposure. Documentation requirements apply to all 911 service providers and ALL non-911 service providers including interfacility transport companies. 12 | P a g e ADULT GENERAL PATIENT CARE INDICATIONS: Any adult (age 15 years of age and greater) patient requiring pre-hospital medical evaluation by a prehospital healthcare provider in the State of Delaware. A patient is an individual who is sick, injured, wounded, or otherwise incapacitated or helpless and seeks immediate medical attention for whom EMS has been activated. A person that denies the need for medical treatment and/or transport, but any reasonable EMS provider can see that a person(s) has an obvious injury or illness, should be considered a patient, and treated as such. The Adult General Patient Care protocol will be followed in conjunction with all other applicable protocols. The most current version of the American Heart Association Guidelines for Cardiopulmonary Resuscitation is considered the standard for CPR within these protocols. Respond using lights and sirens utilizing guidance of Priority Medical Dispatch® (PMD®) protocols and following discretion to limit use of lights and sirens currently approved by Delaware EMS Medical Directors. Perform scene survey. Delaware EMS Medical Directors recommend that all EMS crews carry “room” carbon monoxide detectors with an audible alert on their first-in bag for provider and patient protection. Observe universal precautions: Follow your agency’s infection control policy. Delaware EMS Medical Directors recommend wearing masks when caring for patients with active coughing. Consider masking the patient pending respiratory status. Consider the need for additional resources. Determine responsiveness using AVPU. Evaluate Airway, Breathing, Circulation, and Disability, Exposing the patient as necessary. Secure a patent airway appropriately. Manage cervical spine appropriately. Treat life-threatening conditions as necessary per specific treatment protocols. Contact Medical Control for consideration of a needle chest decompression for non- traumatic tension pneumothorax patients. Monitor patient via the use of pulse oximetry and/or capnography (nasal prong/ET), as appropriate. Administer oxygen as appropriate (maintain a SpO2 of at least 92%). Obtain medical history (HPI, PMH, allergies, and medications). Evaluate blood pressure, pulses, respiratory rate, and tactile (or measured) temperature. Reassess with a frequency indicated by patient condition. Monitor blood glucose levels as appropriate. 13 | P a g e Monitor cardiac rhythm and/or 12 lead ECG as appropriate. Assign treatment priority and make transport decision. Establish intravenous access with normal saline infused as appropriate. Consider intraosseous access if IV access cannot readily be obtained for Priority 1 patients in extremis that are in need of medication or fluid resuscitation: Administer 20 – 40 mg lidocaine IO over 1 minute in the conscious patient if not contraindicated. Administer 10 mL NSS rapid IO push. All IV medications can be administered IO. Consider the insertion of an orogastric tube after the patient is successfully intubated. Consider the administration of 4-8 mg Zofran (Ondansetron) ODT, IV or IM for nausea or vomiting. After 10 minutes, consider the administration of 1.25 mg Droperidol slow IVP for nausea or vomiting refractory to Zofran. Secure patient in ambulance using appropriate equipment per ambulance design and agency standard operating procedures. Consider proposed receiving facility’s diversion status and inform patient (family) as appropriate. Transport patient to an appropriate medical facility via appropriate mode of transportation without delay. Transport should be made safely and, in a manner, as to prevent further injury through the appropriate use of lights and sirens or no lights and sirens. The highest medically trained practitioner engaged in patient care will determine the medically appropriate mode of transportation based upon the patient’s presenting medical condition. This practitioner will communicate with the transporting EMS vehicle’s operator and advise him/her as to the transport mode to be utilized. Patients should be taken to the approved facility’s emergency department, labor and delivery area, other specialty care area, or to an inpatient bed if arranged prior to arrival at the facility. If there are questions or doubts as to the appropriate facility or point of delivery, the medical control physician will be the arbitrator. All unstable patients should be transported directly to an emergency facility. Patients are to be transported to Delaware Office of EMS approved facilities within the EMS agency’s usual operations area. On scene direction of medical care is provided by the Delaware EMS provider with the highest level of licensure. Patient care does not end until transfer of care of the patient to an appropriately trained health care provider is completed and the patient care report is made available and completed in the approved electronic reporting system. Document relevant findings and treatments. 14 | P a g e All IV bags that have been mixed with a medication must be labeled at time of ED disposition. Priority I Patient suffering from an immediate life or limb threatening injury or illness. It is the consensus of the EMS medical directors that during transport to the hospital lights and sirens are not medically indicated for many Priority I patients. Priority II Patients suffering from an injury or illness that if left untreated could potentially threaten life or limb. It is the consensus of the EMS medical directors that during transport to the hospital, lights and sirens are not medically indicated for Priority II patients. Priority III Patient suffering from an injury or illness that requires medical attention but does not threaten life or limb. It is the consensus of the EMS medical directors that during transport to the hospital, lights and sirens are not medically indicated for Priority III patients. “Any person, agency, organization, or entity who knows or in good faith suspects child abuse or neglect shall make a report in accordance with § 904 of this title (Title 16 of Delaware Code). For purposes of this section, "person" shall include, but shall not be limited to, any physician, any other person in the healing arts including any person licensed to render services in medicine, osteopathy or dentistry, any intern, resident, nurse, school employee, social worker, psychologist, medical examiner, hospital, health care institution, the Medical Society of Delaware or law enforcement agency." Child Abuse Reporting Phone Contact:1-800-292-9582 or www.iseethesigns.org Any person having reasonable cause to believe that an adult person is infirm or incapacitated as defined in § 3902 of this title (Title 31 of Delaware Code) and is in need of protective services as defined in § 3904 of this title shall report such information to the Department of Health and Social Services. Division of Services for Aging and Adults with Physical Disabilities (DSAAPD): 1-800-223- 9074. If an EMS provider has reasonable cause to suspect that a person is a potential victim of human trafficking, report the concern. National Human Trafficking Resource Center Hotline 1-888-373-7888 (24 hours). The NHTRC call takers are trained to assist by discussing a case in a HIPAA compliant manner. National Human Trafficking Resource Center Hotline 1-888-373-7888 The approved pharmacology manual should be used for medication reference. Zofran (Ondansetron®) ODT means oral dissolving tablet. CO-oximetry may be performed as an option by agencies carrying CO monitoring equipment. It should be noted that the General Patient Care protocol above is a guideline to be followed in as much as it aids in providing appropriate and timely medical care. The ALS provider may change the order or omit steps listed above as dictated by sound judgment of the care provider and/or presentation of the patient(s). The following information should be passed on in either verbal or written form at the time of patient transfer: HPI, PMH, allergies, medications, vital signs, SpO2, EtCO 2, cardiac rhythm, prehospital treatments, and patient's response to those treatments. 15 | P a g e ACUTE RESPIRATORY DISTRESS INDICATIONS: Acute exacerbation of asthma, emphysema, COPD, and reactive airway disease; cough, shortness of breath, air hunger, wheezing, diminished breath sounds, retractions, and tachypnea, accessory muscle usage. Apply Non-Invasive Mechanical Ventilation (NIMV): CPAP (or BiPAP in systems utilizing BiPAP) for an alert patient who is able to maintain patent airway and is in severe respiratory distress. Consider early utilization of NIMV for an alert patient who is able to maintain a patent airway but is in moderate or persistent respiratory distress. If the patient presents with rhonchi or rales, consider the use of Pulmonary Edema protocol. Consider nasal prong capnography. Moderate to Severe Respiratory Distress If the patient who is short of breath has a history of asthma, COPD, or other reactive airway disease, is actively wheezing, or is otherwise suspected of having acute bronchospasm: Administer up to 5 mg of albuterol via nebulizer or through NIMV circuit. Administer 0.5 mg nebulized ipratropium bromide (Atrovent) with albuterol. For continued symptoms, repeat albuterol. For moderate/severe respiratory distress secondary to asthma or COPD, administer 125 mg methylprednisolone (Solu-Medrol) IV/IM. In extreme circumstances, consider the administration of 25 mg Ketamine IV to allow for NIMV tolerance. May repeat in 5 minutes if needed. If no IV, may give Ketamine 25-50 mg IM to allow NIMV tolerance. For patients less than 60 years of age in pending respiratory failure: Consider the administration of 0.5 mg epinephrine (1 mg/mL) IM. Contact Medical Control for the consideration of administration of 0.5 mg. epinephrine (1 mg/mL) IM for patients older than 60 years of age. For pending respiratory failure secondary to asthma, consider the administration of 2 g magnesium sulfate IV over 10 minutes. Mild Respiratory Distress If the patient who is short of breath has a history of asthma, COPD, or other reactive airway disease, is actively wheezing, or is otherwise suspected of having acute bronchospasm: Administer up to 5 mg of albuterol via nebulizer. Administer 0.5 mg nebulized ipratropium bromide (Atrovent) with albuterol. Administer prednisone 60 mg PO in combination with Maalox 50 mg or other PO fluid. For continued symptoms, repeat albuterol. 16 | P a g e PULMONARY EDEMA DUE TO CONGESTIVE HEART FAILURE INDICATIONS: Afebrile, shortness of breath, air hunger, tachypnea, tachycardia, elevated blood pressure, rales, neck vein distention, and diaphoresis. Consider nasal prong capnography. Apply early NIMV for an alert patient who is able to maintain a patent airway but is, or continues to be, in moderate to severe respiratory distress. For systems using BiPAP Apply BiPAP device per manufacturer’s instructions. Follow non-invasive ventilation protocol on page 18. IV must be established prior to NTG administration for patients with a systolic BP less than 150 mmHg. Administer 0.8 mg nitroglycerin (NTG) SL. Repeat NTG 0.8 mg every 3-5 minutes. Apply 1” nitroglycerin paste if systolic blood pressure is greater than 120 mmHg. If systolic blood pressure (SBP) is less than 120 mmHg, discontinue NTG administration until SBP recovers to greater than 120 mmHg. Perform and interpret 12 lead ECG. Assessment and management of airway and breathing precedes the performance of a 12 lead ECG. Withhold nitrates and Contact Medical Control if the patient relates taking sildenafil (Viagra/Revatio) or vardenafil (Levitra) within the last 24 hours or tadalafil (Cialis), Adcirca for pulmonary hypertension or any other prescription erectile dysfunction drugs within the last 48 hours. Afebrile is defined as no history of recent fever and no tactile temperature or a measured temperature outside the range of 36-38°Celsius (96.8° F to 100.4° F). Early NIMV or BiPAP at the point of contact, as the first ALS procedure, is preferable to the delay of initiation in the ambulance. 17 | P a g e NON-INVASIVE MECHANICAL VENTILATION (NIMV) INDICATIONS: Patients who are 15 years of age or older, presenting with respiratory distress or failure due to respiratory infection, pulmonary edema, congestive heart failure, COPD, or asthma. The patient must have a patent, self-maintained airway, and spontaneous respirations. CONTRAINDICATIONS: Active vomiting, facial or cranial trauma, facial burns, severe epistaxis, inability to clear secretions, or any circumstance in which endotracheal intubation or a surgical airway is immediately indicated. PROCEDURES: Ensure emergency equipment is immediately available and an alternate airway management plan has been established. Assure patent airway. Perform appropriate patient assessment, including obtaining vital signs, pulse oximeter (SpO2) reading, ETCO2, and cardiac rhythm. Apply BiPAP device per manufacturer's instructions. Set initial inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) to decrease patient respiratory effort and adjust as needed. Choose the appropriately sized mask for patient. Start with IPAP at 10 cm H20 (max 15 cm H20). Start with EPAP at 5 cm H20 (max 8 cm H20) if using BiPAP. Pressure support to be no less than 5 cm H2O (Difference of IPAP-EPAP). Set back-up ventilatory rate of 8 BPM or higher. (If equipped). Set FiO2 to appropriate level to maintain an SpO2 of 94 - 99%. Continually reassess the patient after placing the NIMV device. Recheck the mask for leaks and adjust as needed. o Monitor continuous pulse oximetry. o Monitor continuous ETCO2 with nasal prongs. o Monitor HR, BP, and ECG If the patient deteriorates and meets one or more of the contraindications above, then discontinue the use of NIMV. 18 | P a g e ALTERED MENTAL STATUS INDICATIONS: Incomprehensible speech, inappropriate verbal responses, inability to follow verbal commands, decreased responsiveness, or unresponsiveness. If blood sugar less than 60 mg/dL, proceed to hypoglycemia section. If suspected opioid overdose, proceed to opioid overdose section. Contact Medical Control for consideration of sodium bicarbonate for tricyclic antidepressant overdose, glucagon for beta blocker overdose, and calcium chloride for calcium channel blocker overdose. Hypoglycemia If patient is awake and able to speak and swallow Administer 15-24 g of oral glucose. If the patient is unable to follow commands and swallow: Obtain IV access. Administer 10% dextrose in 50 mL (5 g) boluses 1 minute apart, to a maximum of 250 mL OR (25 g) IVP until: o the patient has a return to normal mental status and o the patients’ blood glucose is at least 90 mg/dL If patient has persistently altered mental status and blood glucose less than 90 mg/dL despite treatment, repeat dosing regimen above. If patient has persistently altered mental status and blood glucose less than 90 mg/dL at 15 minutes, transport to the hospital should not be delayed. If no IV access, administer 1 mg glucagon IM or IN If a glucometer fails or is not immediately available and hypoglycemia is a suspected cause of altered mental status, administer appropriate dose of dextrose or glucagon. Suspected hypoglycemia patients who become fully alert and oriented with stable vital signs that wish to be transported to a facility may be released to BLS without a call in to Medical Control if the BLS unit is carrying oral glucose. An IV may be transported by BLS if converted to an IV lock. For patients who wish to refuse transport after being treated for hypoglycemia, Medical Control contact is NOT required if: Patient is alert and oriented. Repeat glucose level above 80 mg/dl Able to consume a carbohydrate-rich meal. It is preferred that the patient be left with an adult who can monitor their safety. Hypoglycemia suspected to be caused by exercise or missed meal. The patient takes insulin and is NOT prescribed any other oral medications for diabetes. 19 | P a g e Opioid Overdose Altered mental status with adequate respiration. Administer supplemental oxygen to maintain SP02 above 94%. Use EtCO2 monitoring along with pulse oximetry to ensure adequate oxygenation with ventilation. Withhold naloxone (Narcan) unless the patient displays respiratory depression and cannot be aroused with tactile stimuli. Respiratory failure (hypoventilation, loss of airway reflexes, SPO2 less than 92%) Assist the patient’s ventilation with a BVM connected to 100% oxygen for two minutes. Use EtCO2 monitoring along with pulse oximetry to ensure adequate oxygenation and ventilation. If respiratory depression continues with assisted ventilation, administer up to 2 mg naloxone (Narcan) IV, IN, or IM. Consider tiered dosing at 0.4 mg per dose. If inadequate respiration continues, administer a second dose up to 2 mg naloxone (Narcan) IV, IN, or IM. Total ALS dosage of up to 6 mg naloxone is authorized. For continued respiratory depression: o Initiate transport. Consider co-ingestion or other cause of respiratory depression. o Contact Medical Control for consideration of additional doses of naloxone (Narcan) for continued respiratory depression. Suspected opiate overdose patients that wish to be transported to a facility may be released to BLS without a call in to medical control if the BLS unit is carrying naloxone. An IV may be transported by BLS IF converted to an IV lock. Discuss buprenorphine administration with patients agreeable to discussion. See Buprenorphine protocol page 21. Considerations for refusal: If the patient regains full consciousness after treatment, they should be encouraged to be transported to the hospital to monitor for relapse and receive counseling about substance abuse treatment. For patients who wish to refuse transport after being treated for Opioid overdose, Medical Control contact is NOT required if: Patient is alert and oriented. Suspicion of opioid ingestion through injection or inhalation It is preferred that the patient be left with an adult who can monitor their safety. Has been given information about resources for treatment and opioid rescue kit (if available) If there are any patient care concerns, Contact Medical Control for assistance. 20 | P a g e BUPRENORPHINE INDICATIONS: Opioid overdose 18 years old or older, requiring administration of naloxone. After explanation of the treatment, the patient expresses interest in buprenorphine administration and is agreeable to treatment for Opioid addiction. EXCLUSIONS: Patient is unwilling to give name AND date of birth, pregnancy, methadone dose less than 48 hours ago, altered mental status and unable to give consent. Perform Clinical Opioid Withdrawal Scale (COWS). If COWS score is greater than 5 OR the patient was opiate-free for 72 hours prior to the overdose, Administer Buprenorphine bundle. Administer 16 mg buprenorphine SL. Administer 4-8 mg ondansetron (Zofran) ODT or IV as needed for nausea. If after 10 minutes the symptoms worsen or persist, Contact Medical Control to administer additional 8mg buprenorphine SL. Maximum dose of 24 mg buprenorphine. Provide the patient Medication Assisted Treatment (MAT) brochure and provide a clinic appointment, transport to the hospital, or obtain a refusal of service. See Appendix D Clinical Opioid Withdrawal Score (COWS) 21 | P a g e HYPERTENSIVE CRISIS INDICATIONS: Three blood pressures measured five minutes apart with a diastolic BP of greater than 120 mmHg or a MAP greater than 150 mmHg, associated with any of the following: nausea/vomiting, headache, or visual disturbances. Contact Medical Control for consideration of the administration of 10 mg Labetalol (Trandate) IV slowly over two (2) minutes. Reassess vital signs. If after ten (10) minutes of initial dose the diastolic BP remains greater than 120 mmHg, Contact Medical Control for the consideration of administration of a repeat dose of 10-20 mg Labetalol (Trandate) IV slowly over two (2) minutes. For hypertension secondary to suspected pre-eclampsia: INDICATIONS: pregnancy greater than 20 weeks gestation (up to 6 weeks post-partum) AND SBP greater than 160 or DBP greater than 110 lasting more than 15 minutes. Must also have associated pre-eclampsia symptoms: o headache o confusion o visual changes o epigastric pain o shortness of breath o focal neurological deficits Contact Medical Control for order to administer Labetalol (Trandate) 20 mg over 2 minutes. Target BP140/90. o Contact Medical Control for the consideration of administration of a repeat dose of 10-20 mg Labetalol (Trandate) IV 10 minutes after first dose. Administer 5 g Magnesium Sulfate IV over 20 minutes concurrent with first dose of Labetalol. Withhold Labetalol for CHF, any heart block, bradycardia, suspected cocaine abuse, patients in cardiogenic shock, CVA, or asthmatics. MAP = (2 x diastolic + systolic) / 3 22 | P a g e SUSPECTED STROKE INDICATIONS: Abnormalities in VAN Stroke Assessment altered mental status, seizure, speech deficit, facial droop, headache, paresthesia, and hemiparesis in the absence of trauma, weakness, ataxia, visual disturbances, nausea, vomiting, general malaise, abnormal pupillary function, or other symptoms of suspected cerebral ischemia or hemorrhage. Administer oxygen via nasal cannula at a quantity sufficient to maintain the oxygen saturation equal to 94%. Place patient flat if tolerated (to augment cerebral perfusion), or in a low to semi-Fowler’s position if airway or secretion concerns. In patients with thunderclap headache, blown pupil, or other signs of intracranial hemorrhage, raise HOB to semi-Fowler’s position. If blood sugar is less than 60 mg/dl, administer up to 25 g of dextrose IV. o Follow Altered Mental Status Hypoglycemia Treatment Standing Order Administer 1mg Glucagon IM, IN if the blood sugar is less than 60 mg/dl and an IV cannot be established. Obtain family contact information, preferably a cell phone number. Determine time of onset of symptoms. Onset is defined as the last time the patient was verified to be their neurologic baseline, or Last Known Well (LKW). Perform VAN Stroke Assessment: Determine if patient has arm and/or leg drift, unilateral weakness, or paralysis. If no weakness noted, assessment ends. o Patient is VAN negative. If arm and/or leg drift, unilateral weakness, or paralysis is present, continue with the VAN Assessment. o V – Visual Disturbance: Does the patient have double-vision, visual field cut, or new loss of vision? o A – Aphasia: Does the patient have difficulty forming words, or difficulty understanding/following commands? Does the patient have difficulty recognizing objects correctly? o N – Neglect: Refers to patient’s senses and gaze. Does the patient present with a gaze deviation or inability to cross midline? Is the patient unable to feel both sides at the same time when touched, unable to recognize their own arm, or ignoring one side? If patient has arm and/or leg weakness AND any visual/aphasia/neglect symptoms, patient is VAN positive. If patient has arm and/or leg weakness and NO visual/aphasia/neglect symptoms, patient is VAN negative. 23 | P a g e VAN is a screening tool to identify patients with stroke secondary to emergent large vessel occlusion, who may benefit from mechanical thrombectomy. VAN negative patients may still have acute stroke. Contact Medical Control for all suspected stroke patients. Early notification of Stroke Alert to receiving hospital is paramount with stroke patients. Transport to nearest appropriate State of Delaware or Joint Commission certified Stroke Center without delay as follows and request prehospital stroke alert for the following categories: VAN Negative and LKW less than 4.5 hours go to nearest certified Stroke Center. VAN Positive and LKW less than 4.5 hours contact local medical control to discuss destination. VAN Positive and LKW greater than 4.5 hours but less than 22 hours (including wake up stroke or unknown LKW) or considering hemorrhagic stroke consider direct transport to certified Thrombectomy Capable or Comprehensive Stroke Center. Communicate to receiving facility the use of anticoagulants. Perform and interpret 12 lead ECG if time permits. Appendix C: VAN Stroke Scale Page 97 24 | P a g e SEIZURES (ACTIVE) INDICATIONS: Generalized vs partial If no IV access: Administer 10 mg midazolam (Versed) IM Check blood sugar. Obtain IV access. If blood sugar less than 60 mg/dl, administer up to 25 g dextrose IV OR administer 1 mg glucagon IM if an IV cannot be established. Follow Altered Mental Status Hypoglycemia Treatment Standing Order If patient continues to seize after 5 minutes, repeat 5mg midazolam (Versed) IM. If IV established prior to seizure: Administer 5 mg midazolam (Versed) IV slowly. If blood sugar less than 60 mg/dl, administer up to 25 g dextrose IV. o Follow Altered Mental Status Hypoglycemia Treatment Standing Order If patient continues to seize after 5 minutes, repeat up to 5 mg midazolam IV. A patient may be given a total of 3 doses of midazolam to control seizure. For seizures secondary to eclampsia: Initiate all treatments above. Administer 5 g Magnesium Sulfate IV over 20 minutes concurrent with first dose of midazolam. Contact Medical Control for consideration of additional midazolam (Versed) if the patient continues to have seizures. 25 | P a g e ALLERGIC/ADVERSE REACTIONS/DYSTONIC REACTION Severe Allergic Reaction INDICATIONS: Generalized allergic manifestations such as urticaria or a p o s s i b l e allergic exposure with: Airway obstruction (partial or complete) OR Systolic blood pressure less than 90 mmHg with clinical evidence of shock OR Gastrointestinal symptoms, such as severe abdominal pain, vomiting and diarrhea. Give 0.5 mg epinephrine (1 mg/mL) IM, may repeat every 5 minutes times three (3), as needed. Establish intravenous access using normal saline and administer a fluid bolus of 1000 mL. Reassess patient – if acute respiratory obstruction persists or systolic blood pressure is less than 90 mmHg with clinical evidence of shock, consider administration of 0.25 mg epinephrine (0.1 mg/mL) * IV over a one-minute interval. Administer a second intravenous bolus of 1000 mL normal saline if systolic blood pressure remains less than 90 mmHg with continued evidence of clinical shock. Administer 50 mg diphenhydramine (Benadryl) IV/IM. Administer 125 mg methylprednisolone (Solu-Medrol) IV/IM. *Epinephrine 0.25 mg (0.1 mg/mL) may be mixed in a 100 mL bag of NSS and run wide open as an alternative to direct push of epinephrine. Moderate Allergic Reaction INDICATIONS: Generalized allergic manifestations such as urticaria or history of an allergic exposure without airway compromise or shock. Gastrointestinal symptoms, such as abdominal pain, vomiting and diarrhea, may also occur in moderate allergic reactions. Consider the administration of 50 mg diphenhydramine (Benadryl) IV, IM, or PO. Consider the administration of prednisone 60 mg PO in combination with Maalox 50 mg or other PO fluid. 26 | P a g e Angioedema INDICATIONS: Angioedema is a soft, painless, non-itchy swelling that usually involves the lips, tongue, or cheeks. It typically develops rapidly and can become a serious event requiring emergency treatment, if the swelling spreads to the larynx and results in severe breathing difficulty. Consider Tranexamic Acid 1gram Infusion. Dystonic Reaction INDICATIONS: Reaction to a neuroleptic medication resulting in intermittent spasmodic or sustained involuntary contractions of muscles in the face, neck, trunk, pelvis, extremities, and the larynx. Consider the administration of 50 mg diphenhydramine (Benadryl) IV, IM, or PO. 27 | P a g e NON-TRAUMATIC HYPOTENSION INDICATIONS: Pulse greater than 50 BPM AND systolic blood pressure less than 90 mmHg AND clinical evidence of shock (altered mental status, pale/cool/clammy skin, tachypnea, absent peripheral pulses, or poor capillary refill). Consider using the Shock Index (HR/SBP) (Appendix E) to determine the severity of the illness. Shock indexes greater than 1 (HR higher than SBP) are associated with increased mortality. Consider stabilization of the patient on scene prior to extrication or transport. Appropriately manage Airway, Breathing, and Unstable Bradycardia/Tachycardia prior to treating non- traumatic hypotension. If DFI is indicated, ensure adequate fluid and vasopressor resuscitation prior to DFI. Initiate large bore IV or IO access and rapidly infuse mL bolus of NSS. Reassess for signs of clinical improvement after each fluid bolus. Repeat fluid bolus of NSS 500 mL up to 2000 mL total. If no signs of clinical improvement after the initial fluid bolus and MAP is less than 65 mmHg, consider a 10-50 mcg/min Norepinephrine infusion for continued hypotension. Begin infusion at 20 mcg/min. Titrate by 10 mcg/min every 5 minutes to maintain MAP greater than 65 mmHg. Continue NSS infusion concurrently with Norepinephrine infusion. If unable to obtain IV access initially, do not delay obtaining IO access if appropriate. Withhold additional fluid if the patient develops signs of acute CHF/Pulmonary Edema. Consider additional IV access after initial resuscitation. 28 | P a g e SEPSIS INDICATIONS: Suspicion of infection/sepsis AND 2 or more of the systemic inflammatory response syndrome (SIRS) criteria: Patients should have a EtCO2 monitored if two or more of the following are present: Temperature greater than 38°C (100.4° F) or less than 36°C (96.8° F) Heart rate greater than 90 BPM Respiratory rate greater than 20 Hypotension If EtCO2 less than 25 mm/Hg: Initiate two large bore IV catheters and rapidly infuse 1000 mL bolus of NSS. Withhold fluid if patient develops signs of acute CHF. Continue infusion of fluid up to 30 mL/kg bolus NSS After a minimum of 1000 mL of fluid consider a 10-50 mcg/min norepinephrine infusion for continued hypotension not due to hypovolemia. Titrate norepinephrine to maintain MAP greater than 65 mmHg. Provide early notification of suspected sepsis patient to receiving hospital. 29 | P a g e ACUTE CORONARY SYNDROMES (ACS) INDICATIONS: Classic anginal chest pain OR patients whose 12 lead is suspicious for ischemia. Suspect ACS for the following presentations: classic anginal chest pain, atypical chest pain, or anginal equivalents such as dyspnea, palpitations, syncope or pre-syncope, general malaise, or DKA. All of these patients should have 12 lead performed and interpreted. Administer 324 mg aspirin PO if the patient has not taken an equivalent dosage within the last 60 minutes, even if patient is pain free. IV must be established prior to NTG administration for patients with a systolic BP less than 120 mmHg (use cautiously for patients not currently prescribed NTG.) Administer 0.4 mg nitroglycerin (NTG) SL. Repeat 0.4 mg NTG every 3-5 minutes until pain, signs of ischemia, or injury resolves. Apply 1” nitroglycerin paste if systolic blood pressure is greater than 120 mmHg. Discontinue NTG therapy if systolic blood pressure (SBP) is less than 90 mmHg. Apply 1" nitroglycerin paste early in patient contact, even if patient is pain free. If chest pain, signs of ischemia or anxiety continue after the administration of three (3) nitroglycerin and if systolic BP is greater than 90 mmHg, consider administration of up to 200 mcg fentanyl (administered in up to 100 mcg increments given every five (5) minutes). If patient displays persistent ventricular ectopy (defined as runs of V-Tach or R-on-T PVCs) refractory to oxygen and NTG administration, consider administration of 150 mg amiodarone IV infused over 10 minutes. Withhold amiodarone if the heart rate or pulse is less than 50 beats per minute. Perform serial 12 lead ECG throughout transport as indicated. The 12 lead ECG may be deferred initially in order to stabilize the hemodynamically unstable patient. Withhold nitrates and Contact Medical Control if the patient relates taking sildenafil (Viagra/Revatio) or vardenafil (Levitra) within the last 24 hours or tadalafil (Cialis, Adcirca for pulmonary hypertension), or any other prescription erectile dysfunction drugs within the last 48 hours. 30 | P a g e ST ELEVATION MYOCARDIAL INFARCTION (STEMI) INDICATIONS: Suspicion of ACS and a prehospital 12 lead diagnosis of STEMI. Suspect STEMI for the following presentations: classic anginal chest pain, atypical chest pain, or anginal equivalents such as dyspnea, palpitations, syncope or pre-syncope, general malaise, or DKA. All of these patients should have 12 lead EKG performed and interpreted. Administer 324 mg aspirin PO if the patient has not taken an equivalent dosage within the last 60 minutes, even if patient is pain free. Transport when practical to an emergent Percutaneous Coronary Intervention (PCI) capable facility for patients diagnosed with STEMI. Notify receiving hospitals as soon as possible when STEMI is identified. IV must be established prior to NTG administration for patients with a systolic BP less than 120 mmHg (use cautiously in patients not currently prescribed NTG). Administer 0.4 mg nitroglycerin (NTG) SL. Repeat 0.4 mg NTG every 3-5 minutes until 12 lead signs of injury resolve. Discontinue NTG therapy if systolic blood pressure (SBP) is less than 90 mmHg. Apply 1" nitroglycerin paste early in patient contact, even if patient is pain free. Consider administration of up to 200 mcg fentanyl (administered in up to 100 mcg increments given every five (5) minutes) if systolic BP is greater than 90 mmHg (may be administered as soon as IV is established). If patient displays persistent ventricular ectopy (defined as runs of V-Tach or R-on-T PVCs) refractory to oxygen and NTG administration, consider administration of 150 mg amiodarone IV infused over 10 minutes. Withhold amiodarone if the heart rate or pulse is less than 50 beats per minute. Perform serial 12 lead EKG throughout transport as indicated. The 12 lead EKG may be deferred initially in order to stabilize the hemodynamically unstable patient. Withhold nitrates and Contact Medical Control if the patient relates taking sildenafil (Viagra/Revatio) or vardenafil (Levitra) within the last 24 hours or tadalafil (Cialis, Adcirca for pulmonary hypertension), or any other prescription erectile dysfunction drugs within the last 48 hours. 31 | P a g e HEMODYNAMICALLY COMPROMISING BRADYCARDIA INDICATIONS: Pulse less than 50 BPM with clinical evidence of shock (i.e., altered mental status, pale/cool/clammy skin, ischemic chest discomfort, systolic blood pressure less than 90 mmHg OR absence of radial pulses bilaterally). Obtain 12-lead EKG as soon as practicable. Administer 1 mg atropine IV. Repeat 1 mg atropine IV every 3-5 minutes until a maximum of 3 mg of atropine is administered or the pulse rate is 50 BPM or greater. Initiate transcutaneous cardiac pacing (TCP). Do not delay while awaiting IV access. Set rate at 80 per minute. Rapidly increase the output (MA) until capture occurs, or the maximum MA is reached. If electrical or mechanical capture is achieved, do not give atropine, unless capture is lost, and bradycardia recurs. If the patient is experiencing discomfort due to pacing administer 0.25 mg/kg Ketamine IV/IO, repeat at 20 minutes if needed. Infuse up to a 1000 mL bolus of NSS. Frequently reassess vital signs and lung sounds. Withhold fluid if patient develops signs of acute CHF. Consider epinephrine IV 2-10 mcg/min if pacing and atropine prove to be ineffective. Titrate epinephrine infusion to a systolic BP of greater than 90 mm/Hg. Contact Medical Control for orders to administer calcium chloride and possibly sodium bicarbonate if the patient has a history of chronic renal failure and either hemodialysis or peritoneal dialysis. 32 | P a g e STABLE TACHYCARDIA INDICATIONS: A wide complex tachycardia (QRS greater than 0.12 seconds) presumed to be ventricular tachycardia (VT), with a rate exceeding 150 BPM or a narrow complex tachycardia with a rate exceeding 120 BPM (QRS less than 0.12 seconds) other than sinus tachycardia. There should be no evidence of trauma, hypovolemia, fever or sepsis. For purposes of this Standing Order, STABLE is defined as a patient with a systolic blood pressure greater than 90 mmHg. Obtain 12-lead EKG. If the rhythm is a wide complex tachycardia at a rate exceeding 150 BPM: Administer 150 mg amiodarone IV infused over 10 minutes. If the rhythm is a narrow complex tachycardia, other than sinus tachycardia, atrial fibrillation or atrial flutter, at a rate exceeding 150 BPM: Consider modified Valsalva maneuver. (Carotid massage may not be performed). Administer 6 mg adenosine (Adenocard) IV rapidly. If there is no response to the initial 6 mg dose, administer 12 mg adenosine. If there is no response to the second dose, administer 12 mg maximum adenosine. Administer 0.25 mg/kg diltiazem (Cardizem) IV (dose is 25 mg) over 2 minutes. If there is no response to the initial dose of diltiazem after 15 minutes, Contact Medical Control for consideration of administration of 0.35 mg/kg diltiazem IV (maximum dose of 35 mg) over 2 minutes. If the rhythm is a narrow complex atrial fibrillation or atrial flutter at a sustained rate exceeding 120 BPM and the patient is without signs or symptoms of congestive heart failure: Administer 0.25 mg/kg diltiazem (Cardizem) IV (maximum dose is 25 mg) over 2 minutes. If there is no response to the initial dose of diltiazem after 15 minutes, Contact Medical Control for consideration of administration of 0.35 mg/kg diltiazem IV (maximum dose of 35 mg) over 2 minutes. If diltiazem is not available: Metoprolol 5 mg IV given over 1-2 minutes. May be repeated every 5 minutes as needed for a total of three (3) doses or 15 mg. Contact Medical Control for orders to administer calcium chloride and possibly sodium bicarbonate if the patient has a history of chronic renal failure and either hemodialysis or peritoneal dialysis. Adenosine: potentiated by dipyridamole (Persantine), use half (1/2) doses. Use with caution with patients on carbamazepine (Tegretol), digoxin and verapamil. Use Diltiazem (Cardizem) with caution when patients are on digoxin. 33 | P a g e UNSTABLE TACHYCARDIA INDICATIONS: A wide complex tachycardia (QRS greater than 0.12 seconds) presumed to be ventricular tachycardia (VT), with a rate exceeding 150 BPM, or a narrow complex tachycardia (QRS less than 0.12 seconds) other than sinus tachycardia, with a rate exceeding 150 BPM. There should be no evidence of trauma, hypovolemia, fever or sepsis. For purposes of this Standing Order, UNSTABLE is defined as systolic blood pressure less than 90 mmHg OR radial pulses are absent bilaterally, with clinical evidence of shock. Patients with altered mentation and clinical evidence of shock are UNSTABLE, even if the systolic blood pressure is greater than 90 mmHg. Obtain 12-lead EKG as soon as practicable. Consider adenosine administration for narrow complex tachycardia if IV access is readily available. Consider, only if IV is already established, the administration of up to 0.1 mg/kg (up to a max of 10 mg) etomidate (Amidate©) IV prior to cardioversion of an alert patient. Perform synchronized cardioversion using 100 joules. Perform synchronized cardioversion using 200 joules. Perform synchronized cardioversion using 300 joules. Perform synchronized cardioversion using 360 joules. Contact Medical Control for additional cardioversion attempts past the fourth attempt. Infuse up to a 1000 mL bolus of NSS. Frequently reassess vital signs and lung sounds. Withhold fluid if patient develops signs of acute CHF Upon successful conversion, perform and interpret 12 lead EKG. For wide complex tachycardia, administer 150 mg amiodarone IV infused over 10 minutes: If there is no response to cardioversion, OR upon successful conversion, AND if needed for a recurrence. Contact Medical Control for orders to administer calcium chloride and possibly sodium bicarbonate if the patient has a history of chronic renal failure and either hemodialysis or peritoneal dialysis. Biphasic devices may use FDA approved/recommended energy settings. 34 | P a g e GENERAL ADULT CARDIAC ARREST BUNDLE OF CARE Resuscitation should be initiated for all patients who do not meet the Withholding or Terminating Resuscitation or Guidelines Regarding Do Not Resuscitate Standing Order This standing order includes intervention guidelines for all patients in cardiac arrest and may be used as a checklist for a “pit crew” team approach to ensure interventions in bundle are performed. 1. Confirm arrest – check pulse for up to 5-10 seconds. 2. Minimize patient movement but ensure adequate space to rotate compressors. 3. Initiate chest compressions: Compress at least two inches and allow for complete chest recoil. Perform continuous 100 – 120 compressions per minute. i. Turn on metronome or compression feedback device and set to continuous compressions. ii. Do not pause compressions for ventilation. Pause compressions to check rhythm every two minutes for no more than 5-10 seconds. Charge defibrillator prior to rhythm check. Interpret rhythm and apply applicable standing order: i. Ventricular Fibrillation/Pulseless Ventricular Tachycardia ii. Pulseless Electrical Activity iii. Asystole iv. Return of Spontaneous Circulation Rotate compressors during each rhythm check OR earlier based on provider fatigue. Apply mechanical CPR device based on local medical direction if available. i. Compressions should be interrupted no more than 10 seconds during application. 4. Provide ventilation with a BVM. Ventilate on the upstroke of every 10th compression (8-10 breaths per minute) Compress BVM with one hand. Place an oral or nasal adjunct. Use two-handed mask seal if personnel and space allow. Monitor waveform capnography (BVM or nasal prong circuit) If no capnography waveform, reassess mask seal, upper airway patency, and suction. Monitor ETCO2 for compression quality. Attempt to maintain ETCO2 above 20 mmHg. Consider rotating compressors if ETCO2 decreases during compression cycle. 5. Obtain IV or IO access (IV preferred if accessible and timely) 6. Refer to Airway Management Protocol to consider placement of advanced airway. 7. Resuscitation should generally be performed on scene for at least 20 minutes prior to moving the patient unless there is an extenuating circumstance (space in the residence, safety threat, etc.) or ROSC. Refer to Withholding/Terminating Resuscitation Standing Order for patients still in arrest after 20 minutes. 35 | P a g e Use of a mechanical CPR device is strongly recommended for transport of patients requiring ongoing CPR. Lights and sirens are not indicated when transporting patients in cardiac arrest. 8. Refer to rhythm-specific standing order: Ventricular Fibrillation/Pulseless Ventricular Tachycardia Pulseless Electrical Activity Asystole Return of Spontaneous Circulation Withholding or Termination of Resuscitation Place advanced airway If ventilation with BVM effective, defer advanced airway until after at least three two-minute cycles of compressions and rhythm checks, vascular access is obtained, and medications are administered (generally at least six minutes) If ventilation with a BVM is still unsuccessful after repositioning, suction, and reattempting attempting mask seal, place a supraglottic airway prior to vascular access. If at any time the patient receiving high quality resuscitation presents with neurological responsiveness and/or consciousness, consider the administration of 0.5 mg/kg Ketamine IV/IO (maximum 50 mg) for the purpose of sedation. 36 | P a g e PEDIATRIC AND ADULT TRAUMATIC CARDIAC ARREST INDICATION: Patients of at least 5 years of age who initially present as pulseless and apneic, secondary to penetrating traumatic injuries or exsanguination, that do not meet criteria for field pronouncement (injuries incompatible with life). Rapid assessment of signs of life including neurological function and cardiac electrical activity should be performed. Exceptions: Blunt Traumatic Arrest: Contact Medical Control in instances when patient is pulseless, apneic, and asystolic, and termination of resuscitative efforts may be considered. Initiation of transport should NOT be delayed. Begin Treatment and continue resuscitation throughout transport. Scene time goals should remain consistent with other traumatic injuries. CPR may be paused for a maximum of four minutes to complete the rapid and simultaneous management of reversible causes, such as hemorrhage control, restoration of circulating blood volume, airway management, and needle decompression. Conventional resuscitation may occur simultaneously with the following lifesaving interventions, but only if it doesn’t interfere with their application nor divert providers from other more effective duties. Hemorrhage Control: Utilization of direct pressure, tourniquets, junctional tourniquets, and pelvic binders as indicated for cessation of hemorrhage. Airway Management: Placement of advanced airway device and ventilation via BVM and capnography monitoring. For patients presenting with injuries resulting in inability to intubate or ventilate, consider surgical airway placement. Needle Decompression (Bilateral): Adults: 14 g x 3.25” - Preferred Site: 5th Intercostal space at anterior axillary line Pediatrics: 14 g x 1.50” - Preferred Site: 4th Intercostal space at anterior axillary line Volume Management: Initiation of 20mL/kg crystalloid solution rapidly infused. Whole Blood: Contact Medical Control to consider administration of Whole Blood in traumatic cardiac arrest patients meeting criteria as outlined in the pediatric and adult Whole Blood protocols on pages 68- 70. CPR in the prehospital setting may be discontinued when the following criteria apply: Patients remain in cardiopulmonary arrest who, despite effective chest compressions AND o Resuscitative efforts are no less than 20 minutes. o Have not had any return of spontaneous circulation. o Have advanced airway placed (with EtCO2 of less than 10 mmHg) o Have received rhythm specific ACLS therapy. o With persistent asystole for at least 15 minutes, or o Persistent wide complex PEA with underlying causes being treated. o Absence of Hypothermia o A decision is made in conjunction with on-line medical control that resuscitation should be terminated and the DOPA protocol will be followed. 37 | P a g e TERMINATION OF RESUSCITATIVE EFFORTS & TELEMETRIC PRONOUNCEMENT OF DEATH INDICATIONS: Upon arrival at the scene of a patient with an illness or injury, the paramedics will follow applicable standing orders. If resuscitative efforts have been initiated, paramedics should proceed with patient assessment. CPR shall be initiated unless one or more of the following criteria apply: Resuscitation would place the rescuer at significant risk of physical injury. The rescuer is presented with an apparently valid Delaware's Medical Orders for Scope of Treatment (DMOST) signed by a physician. Comparable forms from other states may be applicable and Medical Control should be contacted. Obvious signs of death are present: o Injuries which are obviously incompatible with life ▪ Decapitation ▪ Body fragmentation ▪ Severe crush injury to head without vital signs ▪ Severe crush injury to chest without vital signs ▪ Severe thermal burns without vital signs ▪ Gunshot wounds to the head without vital signs o Decomposition of the body ▪ Skeletonization ▪ Severe bloating without vital signs ▪ Skin slough without vital signs o Absence of signs of life* 1. Pulselessness 2. Apnea 3. Fixed and dilated pupils 4. Dependent lividity 5. Generalized rigor mortis (Expected to begin 2-12 hours after presumed death) 6. Asystole on the ECG monitor * All must be present for a "medical patient" to be pronounced. ** In the case of blunt trauma patients, the medical control physician may waive requirement #4 and #5. CPR in the prehospital setting may be discontinued when the following criteria apply: Patients remain in cardiopulmonary arrest who, despite effective chest compressions AND o Resuscitative efforts are no less than 20 minutes. o Have not had any return of spontaneous circulation. o Have advanced airway placed (with EtCO2 of less than 10 mmHg) o Have received rhythm specific ACLS therapy. ▪ With persistent asystole for at least 15 minutes, or ▪ Persistent wide complex PEA with underlying causes being treated. 38 | P a g e o Absence of Hypothermia A decision is made in conjunction with on-line medical control that resuscitation should be terminated and the DOPA protocol will be followed. For patients not meeting the criteria for initiation of cardiopulmonary resuscitation, withhold resuscitation and initiate medical consultation in order to complete the State of Delaware's Dead on Paramedic Arrival (DOPA) documentation. Resuscitation may be terminated without medical control during a Multi-Casualty Incident on patients with non-salvageable injuries as determined by START® Triage. This is reserved for events where EMS resources are required for stabilization of living patients. Formal DOPA protocol will be initiated once resources allow. Only the medical control physician may pronounce a patient dead, while in direct contact with the paramedic. It is not acceptable for the information on death pronouncement to be transmitted from the paramedic to the physician through an intermediary. The medical control physician must be physically present at the radio or telephone to receive the information directly from the paramedic. Once the medical control physician has pronounced the patient dead, the paramedic will notify the appropriate police department and the Division of Forensic Science if not already being completed by appropriate authority. Removal of the decedent, once properly pronounced, is performed only if authorized by jurisdictional police agencies and the Medical Examiner. Once the patient is pronounced dead, the paramedic will obtain a case number from the dispatch center. In situations where more than one patient has been pronounced dead, identification will be assured by using the case number followed by a letter, beginning with "A" and progressing in alphabetical order (i.e., case #234567-A, #234567-B, #234567-C, etc.). The case number is to be used by the paramedic to identify the decedent to the medical control physician for purposes of completing the death certificate. Upon pronouncement of a patient's death, the medical control physician will immediately complete a death certificate (under pronouncing physician section). The physician will include the assigned case number on the left upper margin of the death certificate. The death certificate will then be placed in a secure, but convenient location within the medical command facility, to be retrieved by the Medical Examiner's Investigator when the death falls within the jurisdiction of the Medical Examiner, or by the family-assigned funeral director in non-Medical Examiner's cases. A base report will be completed in the usual manner. After the patient has been pronounced dead, the paramedic will place a tag or hospital type band around the patient's right ankle (any extremity is acceptable if right ankle is not present or accessible). The band should contain the following written information: Case/Incident number Paramedic identification number 39 | P a g e Medical command facility name Medical control physician identification number Time and date of death pronouncement Other information deemed appropriate by the paramedic crew The paramedic will notify the responsible family member that the patient is dead. Paramedics are encouraged to utilize appropriate support services to assist family members in grieving. Upon arrival of the police, paramedic supervisor or the investigator for the Medical Examiner, the paramedics and ambulance attendants will return to active status. In the case of a nursing home facility resident DOPA, the patient may be turned over to a Registered Nurse or on duty clinical supervisor and units may return to active status. Patient under Hospice care may be turned over to a Hospice representative. Prior to completion of his/her work shift, the paramedic will file a complete, standard run report detailing in the usual manner the pertinent aspects of the case. This paramedic run report is to be completed within 12 hours or by the end of shift if a lessor timeframe. The circumstances of death must be investigated by the Division of Forensic Science Medical Examiner and/or the police having jurisdiction over the geographic area of pronouncement. Should the death be deemed a Medical Examiner's case, the Division of Forensic Science Medical Examiner's shall be responsible for the transportation of the body and the collection and completion of all necessary legal documents. Should the case not be deemed a Medical Examiner's case, the body may be transported by a licensed funeral director to the funeral home of the family's choosing. The collection and completion of all necessary legal documents shall be coordinated by the funeral director. The decedent may be taken to a hospital emergency department in select circumstances. 40 | P a g e GUIDELINES REGARDING DO NOT RESUSCITATE ORDERS INDICATIONS: Current guidelines for do not resuscitate orders. Living Will* Living wills do not apply to out-of-hospital care. A living will has no impact on the decision of whether or not to initiate or continue resuscitative efforts or any other care. Do Not Resuscitate Order (DNR) Contact Medical Control immediately. Prehospital Advance Care Directive (PACD) Contact Medical Control immediately. Delaware Medical Orders for Life-Sustaining Treatment (DMOST) A DMOST form is a medical order sheet based on the person’s current medical condition and wishes. The DMOST form will clearly indicate the patients wished concerning life-sustaining treatment and CPR. Comparable forms from other states may be applicable and Medical Control should be contacted. *If a question should arise regarding DNR's, PACDs, DMOST or living wills at any time during treatment, Contact Medical Control. 41 | P a g e VENTRICULAR FIBRILLATION (VF) and/or PULSELESS VENTRICULAR TACHYCARDIA (VT) In the absence of effective CPR on arrival and when response time is greater than four (4) minutes, perform 2 minutes of CPR prior to first defibrillation or intubation. For monitored patients with EMS witnessed VF or pulseless VT perform chest compressions only until pads are placed, then perform up to three (3) stacked shocks before resuming CPR. Defibrillate using 360 joules every 2 minutes. Perform CPR between each defibrillation attempt. Ensure adequate pad contact and seal during defibrillation attempts. Press firmly on pads before each defibrillation attempt. For patients with a history of chronic renal failure, or the paramedic strongly suspects underlying hyperkalemia: Administer 1 g calcium chloride IV. Follow with a 100 ml NSS flush if administering through same IV line. Administer 50 mEq sodium bicarbonate IV. After the third defibrillation attempt, consider changing defibrillation vector (sternum/apex configuration to anterior/posterior or vice versa). Administer 1 mg epinephrine (0.1mg/mL) IV. Repeat 1 mg epinephrine (0.1mg/mL) IV/IO every 3-5 minutes. Administer 2 g magnesium sulfate IV/IO over 1-2 minutes if Torsade de Pointes is identified or if hypomagnesemia is suspected. Administer 300 mg amiodarone IV/IO. Refractory or Recurrent VF and/or pulseless VT: (EXCLUSIONS: Patient less than 15 years old, traumatic cardiac arrest). Definitions: Refractory: Ventricular fibrillation or pulseless ventricular tachycardia that fails to respond to 3 defibrillation attempts, 3 mg epinephrine, and 300 mg amiodarone. Recurrent: Ventricular Fibrillation or pulseless ventricular tachycardia that recurs greater than 4 times without sustained periods of ROSC. Administer 0.5 mg/kg esmolol hydrochloride IV/IO. May repeat x1 after 5 minutes if needed. Administer 150 mg amiodarone 10 minutes after initial dose. Continue to utilize pad placement and joule settings that successfully converted rhythm previously in cases of Recurrent VF/ pulseless VT. Maximum dose epinephrine 6 mg total 42 | P a g e Compressions will not be interrupted for longer than 10 seconds for intubation or other procedures. Intubation should be performed during pulse/rhythm check or during compressions and should be deferred until later in the resuscitation. Consider early use of rescue airway device for anticipated difficult intubation. With return of spontaneous circulation: Administer 150 mg amiodarone IV infused over 10 minutes if patient has received one dose or less of amiodarone. Refer to Post Resuscitation Care Protocol Guidelines Biphasic devices may use FDA approved/recommended energy settings. It is the consensus of the EMS medical directors that during transport to the hospital, lights and sirens are not medically indicated for cardiac arrest patients. Reversible causes: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo / hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (pulmonary), thrombosis (cardiac). 43 | P a g e ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) This protocol is focused on the Medical Cardiac Arrest. Traumatic Cardiac Arrest should refer to the Traumatic Cardiac Arrest Protocol In the absence of effective CPR on arrival and when response time is greater than four (4) minutes, perform 2 minutes of chest compressions prior to first defibrillation or intubation. Administer 1 mg epinephrine (0.1 mg/mL) IV. Repeat 1 mg epinephrine (0.1 mg/mL) IV every 3 to 5 minutes if asystole or PEA continues. For patients with a history of chronic renal failure, or the paramedic strongly suspects underlying hyperkalemia. Administer 1 g calcium chloride IV. Follow with a 100ml NSS flush if administering through same IV line. Administer 50 mEq sodium bicarbonate IV. Infuse up to 1000 mL bolus of NSS. Compressions will not be interrupted for longer than 10 seconds for intubation or other procedures. Intubation should be performed during pulse/rhythm check or during compressions and should be deferred until later in the resuscitation. Consider early use of rescue airway device for anticipated difficult intubation. EtCO2 less than 10 mmHg increase effectiveness of compressions EtCO2 above 20 mmHg is ideal for resuscitation. Narrow Complex PEA (QRS less than 0.12 seconds): Consider possible tension pneumo and perform bilateral chest needle decompressions Consider mechanical causes such as cardiac tamponade, mechanical hyperinflation, PE, hypovolemia, AMI, or pump failure. Wide Complex PEA QRS greater than 0.12 seconds or Asystole: Consider metabolic causes – Tricyclic OD, Severe hyperkalemia, Acidosis, Calcium Channel Blocker OD, Acute MI, Pump failure. With return of spontaneous circulation or suspected Pseudo PEA: Maintain a MAP of 90 mmHg using an 10-50 mcg/min norepinephrine infusion. Refer to Post Resuscitation Care Protocol Confirmed ROSC- Refer to SAVE-A-LIFE Appendix B Page 96 Consider termination of efforts in patients who despite effective chest compressions, airway management, three rounds of rhythm specific ACLS therapy, and no less than 20 minutes of resuscitation efforts remain in cardiac arrest without any return of spontaneous circulation. A decision is made in conjunction with on-line Medical Control that resuscitation should be terminated and the DOPA protocol will be followed. A witnessed cardiac arrest in narrow complex PEA should be transported. Systems utilizing POCUS may terminate efforts under guidance of their POCUS protocol, and in coordination with OLMC. 44 | P a g e Guidelines It is the consensus of the EMS medical directors that during transport to the hospital, lights and sirens are not medically indicated for cardiac arrest patients. Reversible causes: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo / hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (pulmonary), thrombosis (cardiac). 45 | P a g e REFUSAL OF SERVICE INDICATIONS: Paramedics often respond to scenes where the patient wishes to decline service. It is important that the paramedic obtains the patient’s informed consent before leaving the scene; otherwise, the paramedic might be exposed to legal liability for abandonment of the patient. A patient is an individual who is sick, injured, wounded, or otherwise incapacitated or helpless and seeks immediate medical attention for whom EMS has been activated. A person that denies the need for medical treatment and/or transport, but any reasonable EMS provider can see that a person(s) has an obvious injury or illness, should be considered a patient and treated as such. Contact Medical Control for patients presenting or having originally presented with: Suspicion of ongoing intoxication by drugs or alcohol Past medical history or suspicion of dementia Any intervention performed by any other healthcare provider A summons of EMS to a health care facility or call initiated by a health care provider. Suspicion of acute mental disease or suicidal or homicidal ideation Suspicion of a significant head injury Respiratory distress Abnormal vital signs (normal vital signs are defined as a heart rate between 60-110 BPM, systolic blood pressure greater than 100 mmHg, respiratory rate 12-20 BPM, and a SpO2 reading greater than 92% on room air) Altered mental status who remain altered. An age less than 18 years Medical control is not required for all other patients unless concerns exist regarding the welfare of the patient. In the case of suspected patient coercion, domestic violence, abuse, etc. contact law enforcement. Inform the patient about needed treatment and possible outcomes. Every effort should be made to persuade the patient to consent to needed health care. Consider involving family, medical control and law enforcement. Coercing a patient or family into a Refusal of Services will lead to loss of EMS provider privilege by the State EMS Medical Director and a report to the Delaware Board of Medical Licensure and Discipline. Discussion of refusal should be initiated by the patient or their representative. Only EMS calls that are originally dispatched as “service call or public assist” can be entered into the Delaware Electronic Medical Reporting system as such. Obtain a signed Refusal of Service form and document the informed consent process, concerns, and, if applicable, the physician number on the appropriate report(s). 46 | P a g e ALS RELEASE TO BLS INDICATIONS: A patient is an individual who is sick, injured, wounded, or otherwise incapacitated or helpless and seeks immediate medical attention for whom EMS has been activated. A person that denies the need for medical treatment and/or transport, but any reasonable EMS provider can see that a person(s) has an obvious injury or illness, should be considered a patient, and treated as such. NOTE: The ALS provider must accompany patients in cases where ALS treatment is warranted, but the patient refuses to consent to these treatments. In these situations, if conditions change during transport, the patient may consent to treatment later. An ALS provider must perform a complete assessment and history on the patient. Some of the patient history may be provided by other responders on scene (i.e., BLS provider). After completing the assessment and history, the ALS provider may transfer the care to the BLS provider for transport to the hospital without contacting Medical Control UNLESS any of the following conditions exist: o Acute change in mental status o Respiratory distress o Chest pain of suspected cardiac origin o Suspicion of intoxication by drugs or alcohol o Abnormal vital signs (acceptable vital sign range for this protocol is defined as a heart rate between 60-110 BPM; systolic blood pressure between 100-180 mmHg: respiratory rate between 12-20 BPM; and a Sp02 reading of greater than 92% on room air) o Suspicion of significant head injury or traumatic injury o ALS was not initially dispatched but was later requested by BLS. o BLS has administered nitroglycerine, bronchodilator, or epinephrine. If the ALS provider performs any invasive procedure or provides medication, Medical Control must be consulted prior to transferring care. Prior to releasing the patient for BLS transport, the BLS provider must be given a full report related to patient condition, assessment findings and history. The attending BLS provider must agree to transport the patient without ALS accompanying. If any uncertainty exists on the part of the BLS provider,

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