Clark County EMS System Emergency Medical Care Protocols PDF

CLARK COUNTY EMS SYSTEM EMERGENCY MEDICAL CARE PROTOCOLS EFFECTIVE: January 6, 2025 (Replaces July 1, 2024 Version) PO BOX 3902 – LAS VEGAS, NV 89127  TABLE OF CONTENTS Foreword......................................

CLARK COUNTY EMS SYSTEM EMERGENCY MEDICAL CARE PROTOCOLS EFFECTIVE: January 6, 2025 (Replaces July 1, 2024 Version) PO BOX 3902 – LAS VEGAS, NV 89127  TABLE OF CONTENTS Foreword....................................................................................................................................................................................5 Terms and Conventions..............................................................................................................................................................8 ADULT TREATMENT PROTOCOLS...................................................................................................................................... 10 General Adult Assessment................................................................................................................................................11 General Adult Trauma Assessment...................................................................................................................................13 Abdominal Pain/Flank Pain, Nausea & Vomiting..............................................................................................................15 Allergic Reaction...............................................................................................................................................................17 Altered Mental Status/Syncope........................................................................................................................................19 Behavioral Emergencies....................................................................................................................................................21 Bradycardia.......................................................................................................................................................................23 Burns.................................................................................................................................................................................25 Cardiac Arrest (Non- Traumatic)........................................................................................................................................27 Chest Pain (Non-Traumatic) and Suspected Acute Coronary Syndrome……………………………………………………………………….29 Childbirth/Labor................................................................................................................................................................31 Cold Related Illness...........................................................................................................................................................33 Epistaxis............................................................................................................................................................................35 Heat-Related Illness..........................................................................................................................................................37 Hyperkalemia (Suspected)................................................................................................................................................39 Obstetrical Emergency......................................................................................................................................................41 PEDIATRIC TREATMENT PROTOCOLS (Cont.) Cardiac Arrest (Non- Traumatic)........................................................................................................................................86 Cold Related Illness...........................................................................................................................................................88 Epistaxsis...........................................................................................................................................................................90 Heat Related Illness...........................................................................................................................................................92 Neonatal Resuscitation.....................................................................................................................................................94 Overdose/ Poisoning..........................................................................................................................................................96 Pain Management.............................................................................................................................................................98 Respiratory Distress........................................................................................................................................................100 Seizure.............................................................................................................................................................................102 Shock...............................................................................................................................................................................104 Smoke Inhalation............................................................................................................................................................106 Tachycardia/ Stable.......................................................................................................................................................... 108 Tachycardia/ Unstable.....................................................................................................................................................110 Ventilation Management................................................................................................................................................112 OPERATIONS PROTOCOLS........................................................................................................................................... 114 Communications.............................................................................................................................................................115 Do Not Resuscitate (DNR/POLST)....................................................................................................................................117 Documentation...............................................................................................................................................................119 Hostile Mass Casualty Incident.......................................................................................................................................120 Inter-Facility Transfer of Patients by Ambulance............................................................................................................121 Pediatric Patient PROCEDURES PROTOCOLS (Cont.) Tracheostomy Tube Replacement………………………………………………………………………………………………………………… …………..147 Traction Splint.................................................................................................................................................................148 Vagal Maneuvers.............................................................................................................................................................149 Vascular Access...............................................................................................................................................................150 FORMULARY............................................................................................................................................................... 151 APPENDICES.............................................................................................................................................................. APP First Response Low-Risk Alpha Evaluate and Release Form (example)............................................................................. A Release of Medical Assistance............................................................................................................................................B Scope of Practice.................................................................................................................................................................C Telemetry Radio Map......................................................................................................................................................... D Mass Casualty Incident ………………………………………………………………………………………………………………………………… ……………….E  FOREWO RD MEDICAL EMERGENCY SERVICES PROTOCOL MANUAL Optimal prehospital care results from a combination of careful patient assessment, essential prehospital emergency medical services, and appropriate medical consultation. The purpose of this manual is to provide guidance for ALL prehospital care providers and emergency department physicians within the Clark County EMS System. The GOAL of the manual is to STANDARDIZE prehospital patient care in Clark County. It is to be understood that these protocols are guidelines. Nothing contained in these protocols shall be construed to expand the scope of practice of any licensed Attendant beyond that which is identified in the Clark County Emergency Medical Services Regulations and these protocols (Appendix C). NOTHING contained within these protocols is meant to delay rapid patient transport to a receiving facility. Patient care should be rendered while en-route to a definitive treatment facility. The General Assessment protocols must be followed in the specific sequence noted. For all other treatment protocols, the algorithm defines the care every patient should receive, usually in the order described. To maintain the life of a specific patient, it may be necessary, in rare instances, for the physician providing on-line medical consultation, as part of the EMS consultation system, to direct a prehospital provider in rendering care that is not explicitly listed within these protocols, to include administering a patient’s own medications which are not part of the approved formulary. To proceed with such an order, both the telemetry physician and the provider must acknowledge and agree that the patient's condition and extraordinary care are not addressed elsewhere within these medical protocols, and that the order is in the best interest of patient care. Additionally, the provider must feel capable, based on the instructions given by the telemetry physician, of correctly performing the directed care. Whenever such care is provided, the telemetry physician and the provider must immediately notify the Office of EMS & Trauma System (OEMSTS) of the extraordinary care situation. In addition, the provider must immediately, upon completion of the call, make available the prehospital care record and documentation specifying the nature of the deviation and the ordering physician’s name to the OEMSTS. All such incidents will be entered into the Quality Improvement Review process. Occasionally a situation may arise in which a physician's order cannot be carried out, e.g., the provider feels the administration of an ordered medication would endanger the patient, a medication is not available, 5 or a physician's order is outside of protocol. If this occurs, the provider must immediately notify the telemetry physician as to the reason the order cannot be carried out, and indicate Protocol Key: Caution / Warning / Alert Pediatric Treatment Consideration (for patients less than 12 years of age) Telemetry Contact Required Specific Protocol E EMT Licensed Attendant and above may perform these steps A AEMT Licensed Attendant and above may perform these steps P Paramedic Licensed Attendant Definition of a patient: A patient is any individual that meets at least one of the following criteria: 1) A person who has a complaint or mechanism suggestive of potential illness or injury; 2) A person who has obvious evidence of illness or injury; or 3) A person identified by an informed 2nd or 3rd party caller as requiring evaluation for potential illness or injury. Pediatric patient considerations: For patients 94% P Pain Management as indicated Radio Contact for all Trauma Center Transport to closest patients, Code 3 returns, need for facility for: telemetry physician & as per protocol - Airway emergencies (inability to adequately Transport per Disposition Criteria, if ventilate) applicable General Adult Assessment Protocol 11  Pearls  For all scenes where patient needs exceed available EMS resources, initial assessment and treatment shall be in accordance with an approved triage methodology.  Correct life-threatening problems as identified.  If the ability to adequately ventilate a patient cannot be established, the patient must be transported to the nearest emergency department.  Never withhold oxygen from a patient in respiratory distress.  Contact with online medical control should be established by radio. Telephone contact may only be used if the call is routed via a recorded phone patch through FAO at 702-382-9007. Disposition  Patients sustaining traumatic injuries shall be transported in accordance with the Trauma Field Triage Criteria Protocol.  Patients sustaining burn injuries shall be transported in accordance with the Burns Protocol.  Pediatric patients (94% BVM if O2 sat ≤ 94% Palpabl N Ye e radial o s pulse? Vascular Access A Vascular Access A 1 L NS or LR bolus IV/IO E Secondary Survey Suspected tension P Needle Decompression pneumothorax E Apply 3-sided occlusive dressing Sucking chest E Hemorrhage Control wound Immobilize fractures; Control active E assess distal hemorrhaging pulse Raise Head of bed 30 E Obvious fractures degrees Capnography – ETCO2 35 P mm Hg Suspected traumatic brain injury Cover with gauze; wet E trauma dressing for abdominal evisceration Open wounds P Pain Management Transport & Radio Contact to appropriate Trauma Center based on TFTC General Adult Trauma Assessment Protocol (revised and MAB approved 4/7/2021) 13 History Signs and Differential (life  Time and mechanism of Symptoms threatening)  Tension pneumothorax  injury Damage to structure or  Pain, Swelling Deformity, lesions,  Flail chest vehicle bleeding  Pericardial tamponade  Location in structure or  AMS or unconscious  Open chest wound vehicle  Hypotension or shock  Hemothorax  Others injured or dead  Arrest  Intra-abdominal  Speed and details of MVC bleeding  Restraints/protective  Pelvis/femur fracture equipment  Spine fracture/cord  Past medical history injury  Medications  Head injury  Extremity fracture  HEENT (airway obstruction)  Hypothermia Pearls  Recommended exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro.  Transport destination is based on the Trauma Field Triage Criteria Protocol.  Transport should not be delayed for procedures; ideally procedures should be performed enroute when possible.  BVM is an acceptable method of ventilating and managing an airway if pulse oximetry can be maintained ≥90%.  Geriatric patients should be evaluated with a high index of suspicion; occult injuries may be present and geriatric patients can decompensate quickly. General Adult Trauma Assessment Protocol (revised and MAD approved 4/7/2021) 14  Abdominal / Flank Pain, Nausea & Vomiting General Adult Assessment P 12-Lead ECG if age >35 yrs Signs of Ye hypovole s mia? N o Consider an A Antiemetic: Vascular Access ONDANSETRON Nausea 4 mg A 500 ml NS or LR Ye or ODT/IM/IV/IO bolus IV/IO; may s DROPERIDO vomitin repeat up to 2000 g? L ml 1.25 mgor METOCLOPRA IM/IV/IO P MIDE N 10 mg slow IVP o over 1-2 minutes or IM or Consider PROCHLORPER Chest Pain (Non AZINE Traumatic) and Suspected Up to 10 mg Acute Coronary Syndrome IV/IM/IO Consider P Pain Management Continue General Adult Assessment Abdominal / Flank Pain, Nausea & Vomiting Protocol (Revised and MAB approved 6/1/2022) 15 Histor Signs and Differen y Symptoms tial  Liver (Hepatitis)  Ag Medical/surgical  Pain location Tenderness  Gastritis e history  Nausea  Gallbladder  Onset  Vomiting  MI  Quality  Diarrhea  Pancreatitis  Severity  Dysuria  Kidney stone  Fever  Constipation  Abdominal aneurysm  Menstrual history  Vaginal  Appendicitis bleeding/discharge  Bladder/prostate disorder  Pregnancy  Pelvic (PID, ectopic pregnancy, ovarian cyst)  Spleen enlargement  Bowel obstruction  Gastroenteritis  Ovarian and testicular torsion Pearls  Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Back, Extremities, Neuro.  Neuro disorders or signs of hypoperfusion/shock in the presence of abdominal pain may indicate an aneurysm.  Document mental status and vital signs prior to administration of antiemetics & pain management.  Repeat vital signs after each fluid bolus  In patients ≥35 years old consider cardiac origin. Perform a 12-Lead ECG.  Consider retroperitoneal palpation for kidney pain.  Abdominal pain in women of childbearing age should be considered pregnancy until proven otherwise. Abdominal / Flank Pain, Nausea & Vomiting Protocol (Revised and MAB approved 6/1/2022) 16  Allergic Reaction General Adult Assessment No Evidence of Yes (Mild) anaphylaxis? (Moderate/Sever e) A Vascular Access EPINEPHRINE E Assist patient with own auto-injector EPINEPHRINE DIPHENHYDRAMIN A 1:1000, 0.5 mg IM; A may repeat q E 50 mg IM/IV/IO/PO 15 min up to max 1.5 mg ALBUTEROL Reassess patient q 5 E Assist patient with MDI min ALBUTEROL 2.5 mg in 3 ml SVN, A repeat as needed OR; LEVALBUTEROL 1.25 mg SVN, repeat as needed Ventilation P Management Cardiac monitor Allergic Reaction – mild immune response to an allergen with symptoms such as hives or local swelling/itching. Vascular access 500 ml NS or LR Anaphylaxis – moderate/severe reaction A bolus IV/IO; may meeting either of these criteria: repeat up to 2000  Exposure to known or likely allergen with DIPHENHYDRAMINE hypotension OR respiratory compromise 50 mgmlIM/IV/IO/PO  Two or more of the following after exposure to likely allergen: skin/mucosal changes (hives, flushing, edema); Pt in persistent shock? If respiratory compromise (SOB, wheezing, Yes, then stridor, hypoxia); hypotension or signs of shock; persistent GI symptoms (abdominal PUSH DOSE pain, vomiting) EPINEPHRINE 1:100,000 P 10 mcg IV/IO, may repeat q 2-5 min to maintain SBP>90 ( 1 ml of 1:100,000 Continue General Adult Solution) Assessment Allergic Reaction Protocol (Revised and approved by MAB 10/2/2024) 17 History Signs and Differential  Onset and Symptoms  Urticarial (rash  location Insect sting or bite  Itching or Coughing/  only) Anaphylaxis (systemic  Food allergy/exposure hives wheezing or effect)  Medication respiratory  Shock (vascular effect) allergy/exposure distress  Angioedema (drug  New clothing, soap,  Throat or chest induced) detergent constriction  Aspiration/airway  Past history of reactions  Difficulty obstruction  Past medical history swallowing  Asthma/COPD  Medication history  Hypotension/  CHF Pearls shock  Recommended Exam:  Edema Mental Status, Skin, Heart, Lung.   Anaphylaxis is an acuteNausea/vomiting and potentially lethal multisystem allergic reaction.  Epinephrine is a first-line drug that should be administered in acute anaphylaxis (moderate / severe symptoms). IM Epinephrine (1:1,000) should be administered in priority before or during attempts at IV or IO access.  Contact Medical Control for refractory anaphylaxis.  Consider ETCO2 monitoring.  Hypovolemia or distributive shock should be addressed with a fluid bolus prior to the administration of push-dose pressors.  While there are no absolute contraindications to epinephrine, it should be used with caution in elderly patients, patients with known cardiovascular disease, or significant tachycardia or hypertension, and should be administered only when the patient’s signs and symptoms are severe.  Remove trigger if still present (sting, food, etc)  Never give epinephrine 1:1000 (IM concentration) through IV/IO route.  Always perform ECG monitoring when administering epinephrine. QI Metrics:  Epinephrine given appropriately.  Airway assessment documented. Allergic Reaction Protocol (Revised and approved by MAB 10/2/2024) 18  Altered Mental Status / Syncope General Adult Assessment BG 60 mg/dl A Vascular Access ORAL GLUCOSE Cardiac monitor E if patient protecting N P o 12-Lead ECG airway D10, 25 g IV/IO ; (250 mL of 10% A solution) ; may Consider NS or LR repeat x 1 in 5 min GLUCAGON A 500 ml IV/IO; 1 mg IM for no IV may repeat up to access 2000 ml Improved Consider mental the status? followin g: Ye s Signs of Stroke Other treatment stroke? protocols as indicated Signs of Shock hypoperfusion? Signs of a Seizure seizure of post-ictal Signs of trauma state? General Trauma or head injury? Cardiac Appropriate causes/ cardiac known protocol disease? Poisoning/ Overdose Unresponsive with respiratory depression & suspected narcotic overdose Altered Mental Status / Syncope (revised and MAB approved 4/7/2021) 19 Histo Signs and Symptoms Differen ry  Known diabetic, Medic  Decreased mental tial  Head trauma Alert tag status or lethargy  CNS (stroke, tumor, seizure,  Drugs or drug  Changes in baseline infection) paraphernalia mental status  Cardiac (MI, CHF)  Report of drug use or  Bizarre behavior  Hypothermia toxic ingestion  Hypoglycemia  Infection  Past medical history  Hyperglycemia  Thyroid  Medications  Irritability  Shock (septic, metabolic,  History of trauma traumatic)  Change in condition  Diabetes  Changes in feeding or  Toxicological or ingestion sleep habits  Acidosis/Alkalosis  Environmental exposure  Hypoxia  Electrolyte abnormality  Psychiatric disorder Pearls  Recommended Exam: Mental Status, HEENT, Skin, Heart, Lung, Abdomen, Back Extremities, Neuro.  Pay careful attention to the head exam for signs of injury.  Be aware of AMS as presenting sign of an environmental toxin or Haz- Mat exposure, and protect personal safety and that of other responders.  Do not let alcohol confuse the clinical picture; alcohol is not commonly a cause of total unresponsiveness to pain.  If narcotic overdose or hypoglycemia is suspected, administer Narcan 0.4-2mg or Glucose prior to advanced airway procedures. Altered Mental Status / Syncope (revised and MAB approved 4/7/2021) 20  Behavioral Emergency Consider medical Scene Safety causes for the patient’s behavior: General Adult 1.Hypoxia Assessment 2.Intoxication / Overdose Approach patient using 3.Hypoglycemia / the SAFER Electrolytes 4.Head Injury Request law enforcement 5.Postictal State and/or extra units for potentially violent Categorize level of patient agitation and risk of violence using patients IMC-RASS scale Mild-Agitated but Agitated and cooperative/ disruptive/dangero redirectable IMC- us IMC-RASS +3 or RASS +1 or +2 +4 Severe- Moderate- Verbal de- Significantly Agitated and escalation agitated and danger to techniques presents self/ others serious imminent Evaluate for MIDAZOLAM danger to Select ONE and treat 2.5 -5 mg self/others reversible IN/IM/IV causes / IO May repeat X1 MIDAZOLAM P after 5 min at KETAMINE 3- 2.5- 2.5 mg 4 mg IM 10 mg IM P P OR max total and/or DROPERI dose 400 DROPERI DOL Cardiac/ mg DOL 5-10 2.5-5 ETCO2 mg mg IM IV/IO or 5 mg monitorin g IM Cardiac/ETCO2 Patient Monitoring Restraint Patient Restraint Continue General Adult Assessment Behavioral Emergency (revised and MAB approved 04/03/2024) 21  History Signs and Symptoms Differential  Situational  Anxiety, agitation,  AMS  crisis Psychiatric  confusion Affect change,  differential Alcohol intoxication illness/medications hallucinations  Toxin/substance abuse  Injury to self or threats to  Delusional thoughts,  Medication effect or others bizarre behavior overdose  Medic Alert tag  Combative, violent  Withdrawal syndromes  Substance abuse/overdose  Expression of  Depression  Diabetes suicidal/  Bipolar homicidal  Schizophrenia thoughts  Anxiety disorder Pearls  Pharmacological sedation is a medical procedure that results from a medical assessment. Sedation is never to be utilized to control behavior for the purpose of law enforcement initiatives or assistance.  Law enforcement assistance should be requested on all calls involving potentially violent patients.  Under no circumstances are patients to be transported restrained in the prone position.  Patients may not be transported with their arms restrained behind their back or in an ankle-to-wrist (hog-tied) manner.  The clinician should be ready to resuscitate the patient in case of inadvertent changes in respiratory or hemodynamic status. Patients should be continuously monitored with all available adjuncts when possible, including HR, ECG, RR, SpO2, BP, ETCO2, perfusion state, mental state.  Physical restraints, including gurney straps, should never restrict chest wall movement.  Patients expressing suicidal or homicidal ideation or who are otherwise a danger to themselves or others may not refuse transport. Contact law enforcement if necessary to initiate legal hold.  EMS providers are not to remove taser darts unless there is a need to do so to administer medical care. Dart removal is part of the education to use the device and is the responsibility of the person or agency who deploys the device. Dystonic Reaction  Condition causing involuntary muscle movements or spasms typically of the face, neck and upper extremities.  Typically an adverse reaction to drugs such as Haloperidol (may occur with administration).  When recognized, administer Diphenhydramine 50 mg IM/IV/IO. S.A.F.E.R.  Stabilize the situation by containing and lowering the stimuli.  Assess and acknowledge the crisis.  Facilitate the identification and activation of resources (chaplain, family, friends or police).  Encourage patient to use resources and take actions in his/her best interest.  Recovery or referral – leave patient in care of responsible person or professional, or transport to appropriate facility. Improved Montgomery County Richmond Agitation Sedation Scale (IMC- RASS) Behavioral Emergency (Revised and approved by MAB 04/03/2024) 22  Bradycardia General Adult Assessment A Vascular Access Cardiac monitor/12-Lead ECG P Consider and treat underlying cause, if identified, e.g., hypoxia, hyperkalemia, hypothermia, ACS, drug toxicity Persistent HR < 50 causing: Altered Observe Mental Status N and Hypotension O Monitor Chest Pain Signs of Shock YE Stable with no high S Unstable and/or high grade AV block or grade AV block wide complex and/or wide complex Transcutaneous P ATROPINE 1 mg Pacing For IV/IO sedation and P analgesia medications, refer to the Electrical Therapy/ TranscutaneousPaci ng Procedures Protocol. PUSH DOSE And/OR Adequate treatment N P EPINEPHRINE effect? O 10 mcg IV/IO, may repeat q 2- 5 min to maintain HR/BP May repeat P ATROPINE 1 mg Note: If unstable or IV/IO q 3-5 min, peri-arrest, do not total max dose 3 mg delay pacing while obtaining vascular access Bradycardia (Revised and MAB approved 4/3/2024) 23 History Signs and Symptoms Differen  Past medical  HR 20% BSA burn present; NS or LR 500 ml fluid Contact Medical bolus if signs of A Direction at Burn Center hypoperfusion, OR >20% for further drip rates or BSA burn present; additional boluses Contact Medical Direction at Burn Center for further drip rates or additional boluses P Cardiac monitor P Pain Management P Pain Management Consider Smoke Inhalation Transport to closest appropriate Burn Care Center: Sunrise Hospital UMC Trauma Center Burns (Revised and MAB approved 4/7/2021) 25  History Signs and Differential Symptoms  Superficial (1st degree) – red and  Type of exposure Inhalational injury(heat, gas, chemical)  Burns, Dizziness  painful Thickness (2nd degree) – Partial  pain, of Time swelling injury  Loss of consciousness blistering  Past medical history &  Hypotension/shock  Full Thickness (3rd degree) – medications  Airway painless/charred or leathery skin  Other trauma compromise/distress  Thermal  Loss of consciousness  Wheezing  Chemical  Tetanus/immunization status  Singed facial or nasal  Electrical hair  Radiation Pear  Hoarseness or voice  Lightning ls  Burn patients are trauma patients; evaluate changesfor multisystem trauma.  Assure whatever has caused the burn, is no longer contacting the injury. (Stop the burning process!)  Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, Neuro.  Consider early intubation with patients experiencing significant inhalation injuries.  Potential CO exposure should be treated with 100% oxygen. (For patients in which the primary event is CO inhalation, transport to a hospital equipped with a hyperbaric chamber is indicated [when reasonably accessible].)  Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling. Elevate extremity.  Burn patients are prone to hypothermia - never Early apply ice or cool burns; must maintain normal body Intubation temperature. Burns in Mouth Indications  Consider ETCO2 monitoring.  Hoarseness, Signs of Airway Stridor, Total BSA ≥ 40% Dysphagia Obstruction Altered Mentation  Extensive Deep Facial Significant Risk of Burns Edema  Signs of Respiratory Compromise -Accessory Muscle Use Patients meeting -Inability the following criteria shall be transported to the closest to Clear 1 appropriate Second degree Secretions Care Burn burns >10% body surface Center:. area (BSA). -Poor OxygenationAny Third degree burns. 2 Burns that involve the face, hands, feet, genitalia, perineum,. or major joints. Electrical burns including lightning injury. 3 Chemical burns.. Circumferential 4 burns. Inhalation. burns. 5 Burn injury with. Fluid concomitant Resuscitation 6 trauma Adults 13 years and above 500 ml NS or LR bolus  Contact Burn Center Medical Direction for additional boluses or. drip rates or if it is a prolonged transport. 7. Pearls (Chemical) 8 Pearls (Electrical)  Certainly 0.9% NaCl Sol’n or Sterile Water is  Do not contact the patient until you are certain the source of the. electric shock has been disconnected. preferred; however if it is not readily available,  Attempt to locate contact points, (entry wound where the AC do not delay; use tap water for flushing the source contacted the patient; an exit at the ground point); both affected area or other immediate water sources. sites will generally be full thickness. Flush the area as soon as possible with the  Cardiac monitor; anticipate ventricular or atrial irregularity to include V-Tach, V-Fib, heart blocks, etc. cleanest, readily available water or saline  Attempt to identify the nature of the electrical source (AC vs DC), the solution using copious amounts of fluids. amount of voltage and the amperage the patient may have been exposed to during the electrical shock. Burns (Revised and MAB approved 4/7/2021) 26  Cardiac Arrest (Non- Traumatic) General Adult Assessment IF HYPOXIA IS Refer to Termination of Meets criteria for THE CAUSE OF THE Ye Resuscitation or Prehospital Death ARREST, EARLY s DNR/POLST Protocol as Determination or VENTILATIO N N IS appropriate DNR/POLST present? o RECOMMEN If witnessed by EMS or CPR in progress and patient is DED unresponsive with no pulse, begin chest compressions at a rate of 30:2 until an advanced airway is successfully placed. E Apply AED and defibrillate, if prompted Insert NPA or OPA and E begin BVM at 8 BPM P Apply cardiac monitor P VF/VT Ye Rhythm N P Asystole/PEA P Defibrillate s shockable? o E Continue CPR for Continue CPR E 2 min for 2 min A Vascular Access A Vascular Access EPINEPHRINE 1:10,000 A 1 mg IV/IO q 3-5 Rhythm min; ETT Administration shockable? requires 2 to 2.5 Yes Defibrillate if times the dose E prompted Consider A (AED) Extraglottic Airway Device P Defibrillate Consider P Endotracheal E Continue CPR for 2 Intubation min Rhythm EPINEPHRINE 1:10,000 shockable? 1 mg IV/IO q 3- A 5 min ETT Administration No requires 2 to 2.5 E Continue CPR for times the dose 2 min Consider P Address H’s & A Extraglottic Airway Device N T’s P Consider o Ye Rhythm Endotracheal N N Rhythm Intubation shockable? shockable? s o o E Yes Defibrillate if Ye prompted (AED) s P Defibrillate Use VF/VT E Continue CPR for 2 Use Asystole/PEA side as side as min indicated indicated AMIODARONE Check pulse, if organized 300 mg IV/IO; may rhythm If patient remains P repeat one dose unresponsive to of 150 mg if resuscitation efforts, refractory after 5th consider Termination of shock; Address Resuscitation Protocol H’s & T’s Cardiac Arrest (Non-Traumatic) (revised and approved by MAB 06/01/2022) 27 History Signs and Differential  Events leading to Symptoms  Medical vs.  arrest Estimated down time  Unresponsive Apneic  Trauma VF vs. Pulseless VT  Past medical history  Pulsele  Asystole  Medications ss  PEA  Existence of terminal  Primary cardiac event vs. illness respiratory or drug overdose Pearls  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Crews should consider using a “pit crew” approach with predefined roles and crew resource management principles.  Consider early IO placement if IV is difficult.  Ventilation rate should be 8-10 breaths per minute. Hyperventilation can worsen patient outcomes.  Continuous waveform capnography should be monitored throughout resuscitation for confirmation and monitoring of advanced airways (when present), as well as monitoring effectiveness of chest compressions.  Mechanical chest compression devices may be utilized if available. If utilized, the mechanical CPR device should be applied in a manner that minimizes interruptions in compressions, keeping breaks in CPR to less than 10 seconds. Use mechanical CPR devices per manufacturer’s guidelines. Manual CPR must be initiated before the application of a CPR device. Ideally, complete 2 rounds of manual compressions before application.  If a patient is pregnant at or over 20 weeks estimated gestational age OR if the fundus is palpable above the umbilicus, apply the following interventions: During CPR, an additional rescuer should apply continuous manual leftward lateral displacement of the uterus to reduce pressure on the inferior vena cava and improve venous return. Vascular access should beLeftobtained above the diaphragm. If no ROSC after two rounds uterine displacement using 1-handed technique.. of BLS/ACLS, consider immediate transport to the nearest Emergency Department for possible Resuscitative Cesarean Delivery (RCD). Terry L. Vanden Hoek et al. Circulation. 2010;122:S829 -S861 Terry L. Vanden Hoek et al. Circulation. 2010;122:S829 -S861 Copyright © American Heart Association, Inc. All rights reserved. Copyright © Am erican Heart Association, Inc. All rights reserved. H’s & T’s (reversible causes)  Hypovolemia – Volume infusion  Hypoxia – Oxygenation & ventilation, CPR  Hydrogen ion (acidosis) – Ventilation, CPR  Hypokalemia  Hyperkalemia -Calcium chloride, sodium bicarbonate, albuterol  Hypothermia - Warming  Tension pneumothorax – Needle decompression  Tamponade, cardiac – Volume infusion  Toxins – Agent specific antidote  Thrombosis, pulmonary – Volume infusion  Thrombosis, coronary – Emergent PCI Cardiac Arrest(Non-Traumatic) (Revised and Approved by MAB 6/1/2022) 28  Chest Pain (Non Traumatic) and Suspected Acute Coronary Syndrome General Adult Assessment 12-Lead ECG within 5 P minutes of patient contact Non- Diagno STE stic 12- MI Lead ECG A Vascular Access Refer to Oxygen STEMI E Keep SpO2 >94% (Suspected) ASPIRIN E 324 mg PO NITROGLYCERIN Assist pt with own E medication as prescribed; may Nitroglycerin is contraindicated in repeat X2 any patient with hypotension, 0.4 mg SL; bradycardia, tachycardia (HR>100 P May repeat q 5min bpm) in the absence of heart failure, X2 evidence of a right ventricular Pain Management for P infarction, and use of erectile continued pain dysfunction medications within the last 48 hours. Caution is advised in Consider antiemetic patients with Inferior Wall STEMI for and a right-sided ECG should be A nausea/ performed Refer to to evaluate RV Arrhythmia andinfarction. Shock vomiting: Protocols as ONDANSETR needed METOCLOPRAMIDE ON 10 mg slow IV bolus 4 mg over 1-2 ODT/IM/IV/IOor minutes P IM or PROCHLORPER AZINE Up to 10 mg IV/IM/IO Transport to hospital of patient’s choice Chest Pain (Non Traumatic) and Suspected Acute Coronary Syndrome (Revised 29 and MAB approved 12/7/2022)  History Signs and Symptoms Differential  Age  CP, pressure, ache,  Trauma versus medical  Medications: Viagra, vise-like pain, tight  Anginal versus MI Levitra, Cialis  Location, substernal,  Pericarditis  Past medical history epigastric, arm, jaw,  Pulmonary embolism of MI, angina, neck, shoulder  Asthma, COPD diabetes  Radiation of pain  Pneumothorax  Allergies  Pale, diaphoresis  Aortic dissection or  Recent physical  Shortness of breath aneurysm exertion  Nausea, vomiting,  GE reflux or hiatal  Palliation, dizziness hernia provocation  Time of onset  Esophageal spasm  Quality  Chest injury or pain  Region, radiation,  Pleural pain referred  Drug overdose  Severity (1-10) (cocaine,  Time of onset, methamphetamine) duration, repetition Pearls  Recommended exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro.  Diabetics, geriatrics, and female patients often have atypical pain. Have a high index of suspicion.  Perform a 12-Lead ECG on all patients 35 years old or older experiencing vague jaw/ chest/ abdominal discomfort.  Perform a 12-Lead ECG within 5 minutes of patient contact.  The administration of nitroglycerin is contraindicated for any patient who has used erectile dysfunction medications within the last 48 hours.  Nitroglycerin is contraindicated in any patient with hypotension, bradycardia, or tachycardia in the absence of heart failure and evidence of a right ventricular infarction.  Avoid the use of nitroglycerin in patients with a suspected aortic dissection. QI Metrics  12-Lead ECG within 5 minutes of patient contact.  Pain reassessed after every intervention.  Pain control documented. Chest Pain (Non Traumatic) and Suspected Acute Coronary Syndrome (Revised and 30 approved by MAB 12/7/2022)  Childbirth / Labor General Adult Assessment Pregnant patient with signs of impending delivery (see pearls) Normal Limb Breech Cord Presentat Presentation Presentation Presentation ion Puncture amniotic Position sac if not Place patient Support patient in already in left lateral body of Trendelenbur broken recumbent baby during g and position delivery of slightly on Deliver and head left side support the head Wrap cord and Attempt Attempt keep it Suction A Vascular A Vascular moist mouth, then nose; if Access Access Insert gloved meconium hand to lift present, baby off cord; repeat obtain and several times document Attempt Deliver A cord pulse Vascular upper Access shoulder, then lower shoulder Deliver remainder of the baby Clamp and cut Attempt Patient A umbilical Vascular hypoperfus cord Access ing? If multiple births, Ye repeat s steps Administer 500 Deliver placentaA ml NS or LR; N repeat as needed not to exceed o 2000 ml Continue General Adult Assessment Childbirth / Labor Protocol (revised and MAB approved 4/7/2021) 31 Histo Signs and Differential ry  Due date Symptoms  Abnormal presentation  Time contractions  Spasmodic Vaginal discharge or  (breech, limb) Prolapsed cord started/ pain bleeding  Placenta duration/frequency  Crowning or urge to previa  Rupture of push  Abruptio membranes  Meconium placenta (meconium)  Time and amount of any vaginal bleeding  Sensation of fetal movement  Pre-natal care  Past medical and delivery history  Medications  Gravida/Para status Pearls  High risk pregnancy  Recommended exam (of mother): Mental Status, Heart, Lungs, Abdomen, Neuro.  Document all times (delivery, contraction duration and frequency).  Some bleeding is normal; copious amounts of blood or free bleeding is abnormal.  Record APGAR at one and five minutes after birth.  APGAR of 7-10 is normal, while 4-7 requires resuscitative measures. APGAR Score Score=1 Score=2  Activity/Muscle =0 Arms/legs Active Tone  Pulse Absen flexed Below movement t  Grimace/Reflex Irritability 100 Grimace Above 100 No response Absen Blue-Grey, pale all Normal, except Sneeze, cough, pulls  Appearance/Skin Colort over Absent extremities Slow, away Normal over  Respiration irregular entire body Good, crying Childbirth / Labor Protocol (revised and MAB approved 4/7/2021) 32  Cold-Related Illness E General Adult Assessment Remove from environment Temperature E measurement (if available) Remove wet clothing Dry/warm Hypothermia/ patient Passive warming Frost measures Bite Localized Cold Systemic Injury Hypothermia Monitor and Awake Unresponsi reassess with/without ve E General wound altered mental care status DO NOT rub skin Respirat Respirat Ye to warm DO NOT ory ory s Distres allow refreezing distres s? s N o E Active warming Ye Pulse measures s present? A Vascular Access P Cardiac monitor N o NS or LR bolus 500 A Cardiac ml IV/IO; repeat to effect Arrest SBP >90; maximum 2000 ml General Adult Trauma Assessment Shock (Non-Trauma) Monitor and reassess Continue General Adult Assessment Cold-Related Illness (revised and MAB approved 4/7/2021) 33 History Signs and Differen  Age, very young Symptoms tial  and old to decreased Exposure  AMS/coma Cold, clammy  Sepsi Environmental temperatures, but may  Shivering s exposure occur in normal  Extremity pain  Hypoglycemia temperatures  Bradycardia  Stroke  Past medical  Hypotension or  Head injury history/medications shock  Spinal cord injury  Drug or alcohol use  Infections/sepsis  Time of exposure/wetness/wind chill Pearls  Recommended exam: Mental Status, Heart, Lung, Abdomen, Extremities, Neuro.  Extremes of age are more prone to cold emergencies.  Obtain and document patient temperature.  If temperature is unknown, treat the patient based on suspected temperature.  Active warming includes hot packs that can be used on the armpit and groin; care should be taken not to place the packs directly on the skin.  Warm saline or lactated ringers IV may be used.  Recognize the cardiac arrest resuscitation guidelines for the hypothermic patient. Hypothermia Categories  Mild 90°- 95° F (33°- 35° C)  Moderate 82°- 90° F (28°- 32° C)  Severe 90; max E Continue cold water 2000 ml immersion if appropriately P Cardiac monitor initiated Poor Vascular Access perfusi on? NS or LR A bolus 500 ml IV/IO; Ye repeat to effect s SBP >90; max N 2000 ml Exit to Poor o YE P Cardiac monitor appropriate perfusi Shock or S on? Trauma Protocol as indicated Monitor and N reassess O Continue General Adult Assessment Heat-Related Illness (revised and MAB approved 4/3/2024) 37 History Signs and Differen  Age, very old and Symptoms tial  young Exposure to increased  AMS/coma Hot, dry, or sweaty  Fever Dehydration temperatures and/or skin  Medications humidity  Hypotension or  Hyperthyroidism  Past medical shock  DTs history/medications  Seizures  Heat cramps, heat exhaustion,  Time and duration of  Nausea heat stroke exposure  CNS lesions or tumors  Poor PO intake, extreme exertion Pearls  Fatigue and/or  muscle Recommended exam: Mental Status, Skin, Heart, Lung, Abdomen, cramping Extremities, Neuro.  Extremes of age are more prone to heat emergencies.  Cocaine, amphetamines, and salicylates may elevate body temperatures.  Sweating generally disappears as body temperatures rise over 104° F (40° C).  Intense shivering may occur as patient is cooled.  Active cooling includes application of cold packs or ice (not directly on skin), fanning either by air conditioning or fanning.  Cold saline is not to be administered for the treatment of hyperthermia unless directed by telemetry physician.  Cold water immersion is the preferred method of active cooling. Some providers such as certified athletic trainers and event medical personnel are prepared to initiate cold water immersion prior to EMS arrival. If cold water immersion was initiated due to documented hyperthermia, these patients should not be removed from cold water immersion prior to their rectal temperature reaching 102.2F (39C) or mental status returning to baseline unless it is required to manage other emergent issues such as airway. Heat Cramps  Consist of benign muscle cramping caused by dehydration and is not associated with an elevated temperature. Heat Exhaustion  Consists of dehydration, salt depletion, dizziness, fever, AMS, headache, cramping, N/V. Vital signs usually consist of tachycardia, hypotension and elevated temperature. Heat Stroke  Consists of dehydration, tachycardia, hypotension, temperature >104° F (40° C), and AMS. Active Cooling Measures  Cold packs  Ice (do not place directly onto patient’s skin)  Fanning  Air Conditioning Heat-Related Illness (revised and MAB approved 4/3/2024) 38  Hyperkalemia (Suspected) General Adult Assessment Cardiac monitor P 12-Lead ECG ALBUTEROL 2.5 mg in 3 ml continuous A SVN OR; LEVALBUTER OL 1.25 mg in 3 ml Continuous SVN Bradycardia, Peaked T N Ye waves, o s Widened QRS, or Cardiac Arrest Continue to monitor CALCIUM CHLORIDE 1 g slow IVP/ IO Other treatment P protocols as SODIUM BICARBONATE indicated 50 mEq slow IVP/ IO Continue General Adult Assessment Hyperkalemia (Suspected) (revised and approved by MAB 12/6/2023) 39 History Signs and Differential  History of renal Symptoms  Cardiac  failure of History  Cardiac  disease Renal dialysis  conduction Irritability failure  Trauma, crush  disturbances Abdominal  Dialysis injury distension  Trauma  Nausea  Diarrhea  Oliguria  Weakness Pearls  Patients must have suspected hyperkalemia OR electrocardiographic findings consistent with hyperkalemia (bradycardia with widening QRS complexes) BEFORE initiating treatment.  Hyperkalemia is defined as a potassium level higher than 5.5 mmol/L.  Potassium of 5.5 - 6.5 mmol/L - Tall tented T waves.  Potassium of 6.5 - 7.5 mmol/L - Loss of P waves.  Potassium of 7.5 - 8.5 mmol/L - Widening QRS.  Potassium of >8.5 mmol/L - QRS continues to widen, approaching sine wave. Hyperkalemia (Suspected) 40  Obstetrical Emergency General Adult Assessment If refractory to MAGNESIUM SULFATE, give MIDAZOLAM IN/IM/IV/IO; MAGNESIU 0.1 mg/kg, max dose 5 Pregnant M SULFATE P mg; repeat X 1 after 5 patient Ye P IV/IO s min at 0.05 mg/kg, max exhibiting 4 g in 50 dose 2.5 mg Further seizures? ml NS doses require over 20 physician min order IN/IM/IV/I O Or N DIAZEPAM o 5mg IV; May Repeat q 5 Min Additional doses require physician order Pregnant MAGNESIU Transpor M patient Ye P SULFATE t to exhibiting s IV/IO Appropri pre- 2 g in 50 ate eclampsia? ml NS Facility over 10 min Follow appropri ate protocol Obstetrical Emergency (revised and approved by MAB 10/06/2021) 41 History Signs and Differential  Medical Symptoms  Pre-eclampsia/  history Hypertension medication  Vaginal Abdominal pain  eclampsiaprevia Placenta  Prenatal care  bleeding Seizures  Placenta abruptio  Prior pregnancies/births  Hypertension  Spontaneous  Previous pregnancy  Severe headache abortion complications  Visual changes  Edema of the hands or face Pearls  Recommended exam: Mental Status, Heart, Lung, Abdomen, Neuro.  Severe headache, vision changes or RUQ pain may indicate pre- eclampsia.  In the setting of pregnancy hypertension is defined as >140 systolic or >90 diastolic or a relative increase of 30 systolic and 20 diastolic from the patient’s normal pre- pregnancy BP.  Maintain left lateral position.  Ask patient to quantify bleeding - number of pads used per hour.  Any pregnant patient involved in a MVC should be seen by a physician for evaluation.  Postpartum eclampsia/pre-eclampsia commonly presents up to 48 hours after childbirth. If symptomatic, treat as eclampsia/pre-eclampsia.  May present up to 6 weeks after childbirth, Assess for history or pre-eclampsia/ eclampsia during pregnancy or delivery. Obstetrical Emergency 42  Overdose/Poisoning General Adult Assessment E A Ventilation Management P A Consider Vascular Access P Cardiac Monitor Consider potential cause of signs/symptoms Opia Dysto Cyanid Calcium te nic TCA/ Beta Organophosp e Channel OD Reacti ASA Block hate