EMS Protocol Manual - Printing PDF

TABLE OF CONTENTS Foreword.................................................................................................................................................................................... 5 Terms and...

TABLE OF CONTENTS Foreword.................................................................................................................................................................................... 5 Terms and Conventions.............................................................................................................................................................. 8 ADULT TREATMENT PROTOCOLS...................................................................................................................................... 10 General Adult Assessment................................................................................................................................................ 11 CLARK COUNTY EMS SYSTEM General Adult Trauma Assessment................................................................................................................................... 13 Abdominal Pain/Flank Pain, Nausea & Vomiting.............................................................................................................. 15 EMERGENCY MEDICAL CARE Allergic Reaction............................................................................................................................................................... 17 Altered Mental Status/Syncope........................................................................................................................................ 19 PROTOCOLS 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 Overdose/Poisoning.......................................................................................................................................................... 43 Pain Management............................................................................................................................................................. 45 Pulmonary Edema/CHF..................................................................................................................................................... 47 EFFECTIVE: January 6, 2025 Respiratory Distress.......................................................................................................................................................... 49 (Replaces July 1, 2024 Version) Seizure............................................................................................................................................................................... 51 Sepsis................................................................................................................................................................................ 53 Shock................................................................................................................................................................................. 55 Smoke Inhalation.............................................................................................................................................................. 57 STEMI (Suspected)............................................................................................................................................................ 59 Stroke (CVA)...................................................................................................................................................................... 61 Tachycardia/Stable............................................................................................................................................................ 63 PO BOX 3902 – LAS VEGAS, NV 89127 Tachycardia/Unstable....................................................................................................................................................... 65 Ventilation Management.................................................................................................................................................. 67 PEDIATRIC TREATMENT PROTOCOLS................................................................................................................................ 69 General Pediatric Assessment........................................................................................................................................... 70 General Pediatric Trauma Assessment............................................................................................................................. 72 Abdominal/Flank Pain, Nausea & Vomiting...................................................................................................................... 74 Allergic Reaction............................................................................................................................................................... 76 Altered Mental Status....................................................................................................................................................... 78 Behavioral Emergencies.................................................................................................................................................... 80 Bradycardia....................................................................................................................................................................... 82 Burns................................................................................................................................................................................. 84 PEDIATRIC TREATMENT PROTOCOLS (Cont.) PROCEDURES PROTOCOLS (Cont.) Cardiac Arrest (Non-Traumatic)........................................................................................................................................ 86 Tracheostomy Tube Replacement……………………………………………………………………………………………………………………………..147 Cold Related Illness........................................................................................................................................................... 88 Traction Splint................................................................................................................................................................. 148 Epistaxsis........................................................................................................................................................................... 90 Vagal Maneuvers............................................................................................................................................................. 149 Heat Related Illness........................................................................................................................................................... 92 Vascular Access............................................................................................................................................................... 150 Neonatal Resuscitation..................................................................................................................................................... 94 FORMULARY............................................................................................................................................................... 151 Overdose/Poisoning.......................................................................................................................................................... 96 APPENDICES.............................................................................................................................................................. APP Pain Management............................................................................................................................................................. 98 First Response Low-Risk Alpha Evaluate and Release Form (example)............................................................................. A Respiratory Distress........................................................................................................................................................ 100 Release of Medical Assistance............................................................................................................................................B Seizure............................................................................................................................................................................. 102 Scope of Practice.................................................................................................................................................................C Shock............................................................................................................................................................................... 104 Telemetry Radio Map......................................................................................................................................................... D Smoke Inhalation............................................................................................................................................................ 106 Mass Casualty Incident ………………………………………………………………………………………………………………………………………………….E 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 Destination.......................................................................................................................................... 122 Prehospital Death Determination................................................................................................................................... 123 Public Intoxication........................................................................................................................................................... 124 Quality Improvement Review......................................................................................................................................... 125 Termination of Resuscitation.......................................................................................................................................... 126 Transport Destinations.................................................................................................................................................... 127 Trauma Field Triage Criteria............................................................................................................................................ 128 Waiting Room Criteria..................................................................................................................................................... 130 PROCEDURES PROTOCOLS.......................................................................................................................................... 131 Cervical Stabilization....................................................................................................................................................... 132 Electrical Therapy/Defibrillation..................................................................................................................................... 133 Electrical Therapy/Synchronized Cardioversion............................................................................................................. 134 Electrical Therapy/Transcutaneous Pacing..................................................................................................................... 135 Endotracheal Intubation................................................................................................................................................. 136 Extraglottic Device.......................................................................................................................................................... 138 First Response Evaluate/Release.................................................................................................................................... 139 Hemorrhage Control...................................................................................................................................................... 140 Medication Administration............................................................................................................................................. 141 Needle Cricothyroidotomy.............................................................................................................................................. 142 Needle Thoracostomy..................................................................................................................................................... 143 Non-Invasive Positive Pressure Ventilation (NIPPV)………………………………………………………………………………………………….. 144 Patient Restraint............................................................................................................................................................. 145  Protocol Key: FOREWORD Caution / Warning / Alert Pediatric Treatment Consideration (for patients less than 12 years of age) EMERGENCY MEDICAL SERVICES Telemetry Contact Required PROTOCOL MANUAL Specific Protocol 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 E EMT Licensed Attendant and above may perform these steps provide guidance for ALL prehospital care providers and emergency department physicians within the Clark County EMS System. A AEMT Licensed Attendant and above may perform these steps The GOAL of the manual is to STANDARDIZE prehospital patient care in Clark County. It is to be P Paramedic Licensed Attendant 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 Definition of a patient: in the Clark County Emergency Medical Services Regulations and these protocols (Appendix C). A patient is any individual that meets at least one of the following criteria: NOTHING contained within these protocols is meant to delay rapid patient transport to a receiving 1) A person who has a complaint or mechanism suggestive of potential illness or injury; facility. Patient care should be rendered while en-route to a definitive treatment facility. 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 The General Assessment protocols must be followed in the specific sequence noted. For all other potential illness or injury. treatment protocols, the algorithm defines the care every patient should receive, usually in the order described. Pediatric patient considerations: 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 For patients 94% prescribed; may repeat · The administration of nitroglycerin is contraindicated for any patient who has used erectile X2 dysfunction medications within the last 48 hours. 0.4 mg SL; may repeat P q 5 min X 2 Pain Management for P QI Metrics continued pain · 12-Lead ECG within 5 minutes of patient contact. · Pain reassessed with every intervention. Nitroglycerin is contraindicated in any patient · Pain control documented. Consider antiemetic for with hypotension, bradycardia, tachycardia nausea/vomiting: (HR>100bpm) in the absence of heart failure, A ONDANSETRON evidence of a right ventricular infarction, and use 4 mg ODT/IM/IV/IO of erectile dysfunction medications within the last 48 hours. Caution is advised in patients with METOCLOPRAMIDE Inferior Wall STEMI and a right-sided ECG should 10 mg slow IV bolus be performed to evaluate RV infarction. over 1-2 minutes or IM P or PROCHLORPERAZINE Refer to Arrhythmia and Shock Protocols as Up to 10 mg IV/IM/IO needed Transport and re-notify receiving facility STEMI (Suspected) (Revised and approved by MAB 06/1/2022) STEMI (SUSPECTED) (Revised and approved by MAB 6/1/2022) 59 60  History Signs and Symptoms Differential Stroke (CVA) · Previous CVA, TIAs · Previous cardiac/vascular surgery · AMS · Weakness, paralysis · AMS · TIA · Associated diseases: diabetes, · Blindness or other sensory loss Seizure HTN · Aphasia, dysarthria · Hypoglycemia General Adult Assessment · CAD · Syncope · Tumor · Atrial Fibrillation · Vertigo, dizziness · Trauma · Medications · Vomiting · Dialysis/ Renal Failure E Blood glucose testing · History of trauma · Headache · Seizures · Respiratory pattern change · Hypertension, hypotension Document: 1. Last known normal (onset) Pearls 2. Witness with phone number · Recommended exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro. E · Determine time of onset of symptoms or last time patient was seen normal · Transport to an appropriate Stroke Center or Endovascular Treatment Center Perform and document RACE Stroke Scale Results Stroke Centers NIR Capable Centers QI Metrics · Centennial Hills · Centennial Hills · Complete the RACE · Henderson · Henderson Hospital assessment in less than five · MountainView · Southern Hills Hospital minutes · Southern Hills · Spring Valley · Time of symptom onset · Spring Valley · St Rose Siena documented Findings suggestive Yes · St Rose Siena · Sunrise · Blood glucose documented No of RACE ≥ 5 · St Rose San Martin · UMC · 12-Lead EKG completed RACE = 1-4 LVO based on · Summerlin · Valley · Scene time 0.12 sec Undifferentiated Regular Torsades Pearls Irregular Rhythm Regular Rhythm Monomorphic VT Monomorphic VT De Pointes · Recommended exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Suspected to be SVT Neuro. With Aberrancy · Carefully monitor patients as you treat them; stable tachycardia may convert to unstable rhythms/conditions quickly. Vagal Vagal P P · Sedate patients prior to cardioversion, if time allows. Maneuvers Maneuvers AMIODARONE MAGNESIUM P 150 mg in 50 ml SULFATE NS over 10 min P Successful? Successful? 2 gm IV/IO in 50 ml NS over 10 min Consider NS or Administer P LR Bolus 500- P ADENOSINE Successful? Yes Successful? 1000 ml 6 mg rapid IVP/IO No No Successful? Successful? Synchronized Defibrillation Yes Cardioversion Consider Consider Sedation and P Sedation: Analgesia: ETOMIDATE 0.15 No No For medications and mg/kg IV/IO P dosages, please refer AMIODARONE to the Electrical 150 mg in 50 ml Administer Therapy/Synchronized NS P ADENOSINE Cardioversion P 12mg rapid IVP/IO Over 10 min With Procedure Protocol Physician Order Only Continue General Adult Assessment Tachycardia/Stable (revised and MAB approved 12/1/2021) Tachycardia / Stable 64 63  Tachycardia / Unstable History · Medications (aminophylline, diet Signs and Symptoms · Cardiac arrest Differential · Heart disease (WPW, valvular) pills, thyroid supplements, · Heart rate >150 · Sick sinus syndrome (Mental Status Changes, No Palpable Radial Pulse) decongestants, digoxin) · Diet (caffeine) · Dizziness, CP, SOB · Diaphoresis · MI · Electrolyte imbalance · Drugs (cocaine, · CHF · Exertion, fever, pain, emotional stress General Adult Assessment methamphetamines) · Hypoxia · Past medical history · Hypovolemia Narrow Complex P Cardiac monitor Wide Complex · Syncope/near syncope · Drug effect, overdose ≤0.11 Sec A Vascular Access ≥0.12 Sec · History of palpitations/racing · Hyperthyroidism heart Torsades de Pointes (Polymorphic Pearls Monomorphic VT Ventricular · Recommended exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Tachycardia) Neuro. If IV established, administer · If patient is in arrest, efforts should focus on quality chest compressions and rhythm P Synchronized Cardioversion correction. ADENOSINE Consider sedation and 12 mg rapid IVP/IO Defibrillate analgesia: For medications and · Administer Adenosine at a proximal IV site, rapidly followed by a saline flush. P Consider sedation: P dosages,refer to Electrical Therapy/ Synchronized ETOMIDATE Cardioversion Procedures.15 mg/kg IV/IO Protocol Rhythm change? Yes Rhythm Rhythm Yes change? change? No No No Synchronized Cardioversion MAGNESIUM AMIODARONE Consider sedation: SULFATE P P P 150 mg in 50 ml NS ETOMIDATE 2 gm IV/IO in 50 ml over 10 min 0.15 mg/kg IV/IO NS over 10 min Rhythm Rhythm Yes change? change? Rhythm change? Yes No No Repeat Repeat Synchronized No defibrillation; assess Cardioversion or P need for repeat P defibrillate if VT not Repeat Synchronized sedation resolved; assess need Cardioversion; assess for repeat sedation P need for repeat sedation Rhythm Rhythm Yes change? change? Rhythm change? Yes No No No Continue General Adult Assessment Tachycardia / Unstable Tachycardia / Unstable 65 66  Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital Ventilation Management endotracheal intubations are considered high risk. If ventilation/oxygenation is adequate, transport may be the best option. The most important airway device and the most difficult to use correctly and effectively is the Bag Valve Mask (not the laryngoscope). Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques. Use supplemental Basic Airway Maneuvers Respiratory Distress and/or DIFFICULT AIRWAY ASSESSMENT: oxygen to maintain -Open Airway Chin Lift/Jaw Thrust Tracheostomy Tube E an oxygen saturation -NPA or OPA as needed Replacement Protocol Difficult BVM Ventilation-MOANS: Difficult Mask seal due to facial hair, anatomy, blood or secretions/trauma; Obese -Suction as needed if needed of >94% or late pregnancy; Age >55; No teeth (roll gauze and place between gums and cheeks to improve seal); Stiff or or >90% for patients increased airway pressures (asthma, COPD, obese, pregnant). Consider Cervical Stabilization on home oxygen for chronic conditions Consider Altered Mental Status/Syncope Difficult Laryngoscopy-LEMON: Look externally for anatomical distortions (small mandible, short neck, large tongue); Evaluate 3-3-2 Rule (Mouth open should accommodate 3 patient fingers, mandible to neck junction should accommodate 3 patient fingers, chin-neck junction to thyroid prominence should accommodate 2 patient fingers); Mallampati (difficult to assess in the field); Obstruction / Obese or late pregnancy; Neck mobility. Administer oxygen E BVM as needed Difficult Extraglottic Device Placement-RODS: Restricted mouth opening; Obstruction / Obese or late pregnancy; Distorted or disrupted airway; Stiff or increased airway pressures (asthma, COPD, obese, pregnant). Intervention Yes Nasotracheal intubation: Orotracheal intubation is the preferred choice. Procedure requires patient to have No spontaneous breathing. Contraindicated in anatomically disrupted or distorted airways, increased intracranial effective? pressure, severe facial trauma, basal skull fracture, head injury. A Extraglottic Airway Obtain Vascular Access Endotracheal Intubation ECG Monitor Pearls For Nasotracheal Intubation Prep the Nostrils With · Consider preoxygenation/lung denitrogenation with a non-rebreather, a nasal cannula at 15 LPM, or NIPPV prior to PHENYLEPHRINE 1-2 Sprays Each Yes intubation (as patient condition allows). Or · Severe hypotension (SBP94% · Patients sustaining traumatic injuries shall be transported in accordance with the Trauma Field Triage Criteria Protocol. E BVM if O2 sat ≤94% · Patients sustaining burn injuries shall be transported in accordance with the Burns Protocol. · Pediatric patients (4 J/kg to 10 J/kg until conversion occurs. Adult paddles/pads may be used in Contraindications: None children weighing more than 10 kg. Key procedural considerations: A. Biphasic device: The initial and subsequent attempts shall be at the energy level(s) suggested by the device manufacturer and/or the agency’s medical director. B. Monophasic device: 1. Ventricular dysrhythmias: 100 J escalating to 200, 300, and 360 2. Supraventricular dysrhythmias: 50 J with subsequent attempts at 100 J Initial attempt at pediatric cardioversion shall be at 0.5 J/kg. If unsuccessful, cardioversion should be attempted at 2 J/kg. Adult paddle/pads may be used in children weighing more than 10 kg. Electrical Therapy/Defibrillation (revised and approved by MAB 04/06/2022) Electrical Therapy/Synchronized Cardioversion(Revised and approved by MAB 12/04/2024) 133 134 Electrical Therapy/Transcutaneous Pacing Endotracheal Intubation LEVEL: Paramedic LEVEL: Paramedic Indications: This procedure may be performed on any patient experiencing: A. Hemodynamically unstable bradycardia 1. All intubations MUST have initial, en route, and at transfer of care End-Tidal CO2 B. Unstable clinical condition that is likely because of bradycardia detection/capnography performed and recorded on the PCR. C. For pacing readiness (i.e. standby mode) in the setting of MI with 2. All intubation attempts MUST be documented on the PCR. bradycardia, second degree type II AV block, third degree AV block, new left or right alternating BBB or bifascicular block D. Overdrive pacing of tachycardias refractory to drug therapy or electrical cardioversion Indications: This procedure may be performed on any patient in whom attempts at basic airway and ventilatory support are unsuccessful AND who has at least one of the following: Contraindications: None A. Hypoxia B. Respiratory arrest/failure C. Inability to maintain airway patency Adjunctive therapy: In the conscious patient with a systolic blood pressure of >90mmHg consider: Sedation: Midazolam 0.1 mg/kg IN/IM/IV/IO, max dose 5 mg. May repeat X 1 after 5 min at 0.05 mg/kg, max dose 2.5 mg. Further doses with Physician Order or; Contraindications: Absolute Contraindications: None Diazepam 5 mg IV/IO. May repeat after five minutes with physician order. Relative Contraindications: A. Presence of gag reflex Analgesia: Morphine Sulfate up to 0.1 mg/kg slow IV/IO to a maximum single B. Suspected narcotic overdose/hypoglycemia prior to administration of dose of 10 mg. May repeat after 10 minutes or; Naloxone/Glucose Fentanyl up to 1 mcg/kg IN/IM/IV/IO to a maximum single dose of 100 mcg. May repeat dose after 10 minutes with physician order or; Check and prepare the Hydromorphone up to 1 mg IV/IO. May repeat dose after endotracheal airway device prior ten minutes with physician order or; to insertion Ketamine 0.2 mg/kg IM/IV/IN/IO no repeat dose. Key procedural considerations: Key procedural considerations: A. Position head properly. A. Apply pacing pads, begin pacing at a rate of 60 beats per minute at the B. Insert blade while displacing tongue and elevate mandible with laryngoscope. lowest available current. C. Introduce ET tube and advance to proper depth. B. Increase current by 20 milliamp increments until electrical capture. D. Inflate cuff to proper pressure and disconnect syringe. C. In the event of electrical capture and no pulses, continue pacing E. Ventilate patient and confirm proper placement. and CPR. F. Verify proper tube placement by secondary confirmation such as capnography or colorimetric device. Pediatric pacing is by telemetry physician order only G. Secure device or confirm that the device remains properly secured. Electrical Therapy/Transcutaneous Pacing(Revised and approved by MAB 12/04/2024) Endotracheal Intubation (Revised and approved by MAB 6/1/2022) 135 136  Endotracheal Intubation (Cont.) Extraglottic Airway Device LEVEL: Paramedic LEVEL: AEMT/Paramedic Indications: Nasotracheal Intubation: This procedure may be performed on any patient in which attempts at basic airway Contraindications: and ventilatory support are unsuccessful AND who has at least one of the following: A. Apnea or near-apnea A. Hypoxia B. Suspected basilar skull, nasal, or midface fractures B. Respiratory arrest/failure C. Coumadin anticoagulation therapy or hemostatic disorders C. Obtundation D. Upper neck hematomas D. Failed endotracheal intubation E. Should NOT be attempted in children Adjunctive Therapy: Contraindications: Prep the nostrils with: A. Gag reflex 1) Phenylephrine 2-3 drops (or 1-2 sprays in each nostril), B. History of esophageal trauma, or known esophageal disease or C. Recent ingestion of a caustic substance Oxymetazoline 2 sprays in each nostril. D. Tracheostomy or laryngectomy and E. Suspected foreign body obstruction 2) Lidocaine 2% lubricant. Check and prepare the extraglottic airway Check and prepare the device prior to insertion endotracheal airway device prior to insertion Key procedural considerations: A. Pre-oxygenate the patient. B. Position the patient’s head in a neutral or slightly flexed position if no suspected spinal injury (if a spine injury is suspected, maintain a neutral, in-line head Key procedural considerations: position). A. Position patient semi-Fowler, sitting or supine. C. Perform a tongue-jaw lift. B. Insert lubricated ET tube into dilated nostril and advance straight back D. Insert device to proper depth. NEVER force. If device does not advance, (posteriorly). readjust the insertion. C. Listen to end ET tube for sounds of patient’s breathing. E. Secure device in the patient (inflate cuff(s) with proper volume(s) and D. During inhalation, smoothly advance tube through glottic opening. immediately remove syringe). E. Inflate cuff to proper pressure and disconnect syringe. F. Ventilate patient and confirm proper ventilation (correct lumen and proper F. Verify proper tube placement by secondary confirmation such as capnography insertion depth) by auscultation bilaterally over lungs and over epigastrium. or colorimetric device. G. Adjust ventilation as necessary (ventilate through additional lumen or slightly G. Secure device or confirm that the device remains properly secured. withdraw tube until ventilation is optimized). H. Verify proper tube placement by secondary confirmation such as capnography or colorimetric device. I. Secure device or confirm that the device remains properly secured. Endotracheal Intubation (Revised and approved by MAB 6/1/2022) Extraglottic Airway Device 137 138  First Response Evaluate/Release Hemorrhage Control LEVEL: AEMT/PARAMEDIC LEVEL: EMT/AEMT/Paramedic *Note: Use of Tranexamic Acid is Paramedic only* Hemorrhage: Inclusion Criteria: This procedure may be performed on any patient that has bleeding from an A. Coded and dispatched using MPDS as an Alpha or Omega category extremity, junctional hemorrhage or torso hemorrhage. B. Patient age ≥ 18 ≤ 65 C. Full assessment performed by first response Extremity Hemorrhage – Tourniquet Application: D. Patient deemed to have decision making capacity A. Apply tourniquet proximal to the bleeding site. E. Normal vital signs including SpO2 B. Absolute contraindication: Bleeding has stopped F. Patient has a phone, ability and willingness to call 9-1-1 if their condition C. If bleeding is not controlled, consider additional tightening or applying a second worsens tourniquet proximal side by side to the first. G. In the opinion of the AEMT/paramedic and the patient it is safe to release D. Wound packing does not preclude you from placing a tourniquet. until an ambulance arrives Junctional Hemorrhage – Wound Packing: A. Junctional Hemorrhage Defined: hemorrhage occurring at the junction of an extremity with Exclusion Criteria: the torso, and/or the base of the neck. A. Abnormal vital signs including SpO2 B. Use direct pressure and an appropriate pressure dressing with deep wound packing (plain B. Pregnancy gauze or, if available, hemostatic gauze). C. Any high risk complaints/symptoms C. Absolute Contraindication: Hemostatic gauze use on hemorrhaging abdominal wounds. a. Chest pain b. Signs/symptoms of possible stroke Torso Hemorrhage – Consider Tranexamic Acid for blunt or penetrating chest or abdominal trauma with c. Allergic reaction suspected blood loss. Paramedic Administration Only. d. Shortness of breath 1. Dose: Adults: 1 g IV/IO over 10 min for patients with SBP110 e. Abdominal pain/flank pain above umbilicus age >35 2. Tranexamic Acid is ideally given within the first hour of injury. f. Syncope, near syncope, dizziness 3. Tranexamic Acid administration is contraindicated if the chest or abdominal injury occurred more g. Seizure than three hours prior to proposed administration. h. History or sign of head trauma i. Active bleeding Tourniquet Placement Junctional Hemorrhage j. Threat to self or others k. Overdose or ingestional error l. Patients meets Trauma Field Triage Criteria D. No SNHD EMS Protocol indication for obtaining EKG or placing the patient on a cardiac monitor EMS patient care record must be completed within four hours of clearing the call The Field Response Low-Risk Alpha Evaluate and Release Form must be completed and a copy left with the patient for inclusion in the secondary responder’s patient care report First Response Evaluate and Release Hemorrhage Control (revised and MAB approved 08/05/2024) 139 140  Medication Administration Needle Cricothyroidotomy LEVEL: EMT/AEMT/Paramedic (based on medication) LEVEL: Paramedic Indications: This procedure may be performed on any patient that requires the administration Indications: of a medication. This procedure may be performed on any patient with: A. Total airway obstruction by any BLS or ALS procedures, OR Key procedural considerations (GENERAL): B. Inability to be adequately ventilate with any provider level emergency care A. Inquire about allergies and previous medication reactions procedures prior to the attempt. B. Check and recheck medication C. Solution clarity and expiration date D. Right drug Contraindications: Right patient A. Inability to identify landmarks (cricothyroid membrane) Right dose B. Underlying anatomical abnormality (tumor) Right time C. Tracheal transection Right route D. Acute laryngeal disease due to infection or trauma Right documentation E. Dispose of syringe and other material in proper container Intravenous and Intraosseous Bolus Medications - Pediatric needle cricothyroidotomy is by Telemetry Physician order only. Key procedural considerations: - You MUST use a 14 gauge over-the-needle catheter attached to a 10 cc syringe A. Identify and cleanse injection site closest to the patient or commercial cricothyroidotomy device. B. Administer correct dose at proper push rate C. Turn IV on and adjust drip rate to TKO/KVO Key procedural considerations: Intramuscular and Subcutaneous Drug Administration *Please follow Manufacturer’s Instructions* Key procedural considerations: A. Position patient supine (if possible), hyperextending the head. A. Needle should be 20 gauge or smaller B. Locate cricothyroid membrane and clean site thoroughly. B. Locate administration site C. Stabilize cricoid and thyroid cartilages with one hand. Deltoid muscle D. Puncture needle/catheter at a 90° angle and then change insertion angle to 45°up Vastus lateralis (lateral thigh) muscle to the stopper; gently aspirate with attached syringe. Ventrogluteal or dorsogluteal muscles (buttocks) E. When syringe is able to aspirate air, stop advancing needle. IM SQ F. Remove the stopper from the cannula and advance the cannula only until the Pull skin tight Pinch to lift skin slightly phlange is flush with the patient’s neck. Remove the metal needle from the Insert needle at a 90° angle to the skin Insert needle at a 45° angle to the skin cannula. Remove the syringe. Advance into muscle layer Advance into subcutaneous layer G. Secure the cannula with the neck strap. H. Apply connecting tube and attach to BVM and ventilate patient. Mucosal Atomizer Device (MAD) Administration Medications: Fentanyl, Ketamine, Midazolam, Naloxone Hydrochloride Key procedural considerations: A. Using the free hand, hold the crown of the head stable. B. Place the tip of the MAD snugly against the nostril, aiming slightly up and outward (toward the top of the ear). C. Briskly compress the syringe to deliver half the medication into the nostril. D. Move the device over to the opposite nostril and administer the remaining medication. Medication Administration Needle Cricothyroidotomy 141 142  Needle Thoracostomy Non-Invasive Positive Pressure Ventilation (NIPPV) LEVEL: Paramedic Indications: LEVEL: Paramedic/AEMT This procedure may be performed on any patient who has evidence of a tension pneumothorax, demonstrated by the following criteria: Indications: 1. Severe/progressive respiratory distress and/or increased resistance to bagging, This process may be performed on any patient 18 years old or older in CHF, AND unilateral diminished/absent breath sounds, AND: Respiratory Distress with Bronchospasm, and pneumonia, who has TWO of the A. Hypotension with signs of shock, or following: B. Persistent hypoxia despite supplemental oxygen, or A. Retractions or accessory muscle use C. Jugular venous distention, or B. Respiratory rate >25 per minute D. Tracheal deviation (late sign) C. SpO2 < 94% 2. Any traumatic cardiac arrest with chest or abdominal trauma and undergoing resuscitation should have bilateral needle thoracostomy performed as soon as Contraindications: possible. A. Apnea Contraindications: None B. Vomiting or active GI bleed C. Major trauma/pneumothorax D. Altered Mental Status Needle Decompression is permitted in pediatric patients. Use device per Key procedural considerations: manufacturer A. Select and identify insertion site: instructions 1. Primary site is the 4th intercostal space in the mid-axillary line of the affected side. a. Needle should be placed within the “triangle of safety”. Key procedural considerations: Insertion site must be above the nipple line as the nipple lies flat against the A. Assess patient and document VS, SpO2 and ETCO2 if available prior chest wall with the arm abducted. to applying oxygen. Paramedics must document ETCO2. b. In females, the breast can displace the nipple inferiorly. If displaced, B. Select the appropriate size face mask for the patient. the clinician should identify where the nipple would lie if flat against the chest C. Inform the patient about procedure process. wall. This will be superior to the inframammary fold/crease. When in doubt, D. If using CPAP, gradually increase the flow rate, slowly reaching the a more superior site is preferred. desired CPAP pressure. Secure face mask onto patient’s face using 2. Alternate site is the 2nd intercostal space in the mid-clavicular line of the the head harness. affected side. E. If using bilevel ventilation, select bilevel on the device, and set C. Use appropriate size needle and length. appropriate EPAP level and other device settings as appropriate. D. Prep site with appropriate disinfectant (e.g. iodine, chlorhexidine, alcohol) F. Check the mask and tubing for leaks. E. Place tip of needle on top of appropriate rib and insert over top of rib into G. Reassess patient and document every five minutes. intercostal space. H. If the patient develops any of the contraindications or requires F. Advance needle into pleural space and remove needle. Leave catheter in place. definitive airway control, discontinue NIPPV and provide necessary G. Consider attaching a one-way valve, if available. airway control. Needle Thoracostomy (revised and approved by MAB 04/03/2024) Non-Invasive Positive Pressure Ventilation (NIPPV)(Revised and approved by MAB 12-06-2023) 143 144  Patient Restraint Patient Restraint (cont.) LEVEL: EMT/AEMT/PARAMEDIC Key Procedural Considerations: · Treat the patient with respect. Attempts to verbally reassure or calm the patient should be done prior to the use of restraints. To the extent possible, explain what is being done and why. · Acceptable restraints are “hard-type” restraints made of padded leather material or “soft-type” Indications: restraints made of padded soft cloth or Velcro and which are manufactured for the purpose of restraint. A. Patient exhibiting behaviors or actions that may pose a danger to the patient or others. Gauze (e.g. kerlix), tape, or hard plastic ties should not be used. B. Restraints MAY be indicated for patients who meet any of the following criteria: · Any restraint device used must allow for rapid removal if necessary for management of the patient’s 1. A patient who is significantly impaired (e.g. intoxication, medical illness, injury, psychiatric condition, medical condition, including airway, breathing, or circulation. dementia, etc) and lacks decision-making capacity regarding his or her own care. · Restraints should be secured to the frame of the gurney. Avoid securing restraints to moveable parts 2. A patient who exhibits violent, combative, or uncooperative behavior who does not respond to such as rails, levers, etc. verbal de-escalation and such behavior poses a danger to themselves or others either directly or by · Apply restraints to the extent necessary to allow treatment of, and prevent injury to, the patient. Under- interfering with emergency treatment. restraint may place both patient and clinician at greater risk. Restraints may be applied to all four 3. A patient who is suicidal, homicidal, or on a mental health hold and who exhibits behaviors or actions extremities, or both upper extremities, or to one upper and one lower extremity. that may pose a danger to themselves or others. · Patients shall be restrained in the supine position. C. Restraints should only be used when less restrictive techniques are unsuccessful, impractical, or likely to · The patient’s upper extremities should be restrained at the wrist, either at the patient’s sides or with one endanger the patient or others. arm above the patient’s head and the other to the side. · The patient’s lower extremities should be restrained at the ankles in the extended and uncrossed position. Contraindications: None · If necessary, straps may be placed across the patient’s pelvis and/or legs. · Gurney seatbelts/straps may be used as designed, but must not restrict breathing/chest movement. Additional straps may not be placed on the patient’s neck, chest, or abdomen, and patient should not be sandwiched by any device. Precautions: · After application of restraints, check all restrained limbs for circulation as soon as possible after · Under no circumstances are patients to be restrained in the prone position. application, and then at least every 15 minutes. During the time that a patient is in restraints, continuous · Patients may not be restrained with their arms behind their backs or in an ankle-to-wrist (hog-tied) attention to the patient’s airway, circulation, and vital signs is mandatory. Apply ECG, SpO2 and EtCO2 manner, or in any other position which impairs their airway or breathing. monitors if available. · Only reasonable force is allowable, i.e. the minimum amount of force necessary to control the patient and · The restrained patient must be under constant observation by a licensed EMS clinician at all times and prevent harm to the patient and others. Try alternative methods first (e.g. verbal de-escalation). may not be left unattended. · Restraints shall be used only when necessary to prevent a patient from injuring themselves or others, · Consider de-escalation of restraints if appropriate in the judgment of the EMS clinician. including EMS personnel, and only if safe treatment and transportation of the patient cannot be accomplished without restraints. · Any attempt to restrain a patient involves risk to the patient and the EMS clinician. Efforts to restrain a patient should only be done with adequate assistance present. · Handcuffs are not appropriate medical restraints and should only be placed by law enforcement QI Metrics: personnel. If handcuffs have been placed by law enforcement, a law enforcement officer must accompany Whenever restraints have been applied in the field, EMS Personnel should document the following in the the patient to the hospital in the transporting EMS vehicle. patient care report (PCR): · Paramedics only – Consider pharmacologic sedation, if indicated. Refer to Behavioral Emergencies · The reason restraints were needed, including previous attempts to control patient prior to restraint use. protocol. · The type of restraint used and which extremities were restrained. · The condition of the patient while restrained, including cardiac and respiratory status an circulatory status of restrained extremities. Re-evaluations during transport must be documented. · Condition of the patient at the time of transfer of care to emergency department staff. · Any injury to patient or to EMS personnel. Patient Restraint Patient Restraint 145 146  Tracheostomy Tube Replacement Traction Splint LEVEL: Paramedic LEVEL: EMT/AEMT/Paramedic Indications: Indications: This procedure may be performed on any patient that has A TRACHEOSTOMY TUBE This procedure may be performed on any patient with an isolated midshaft and WHO HAS: femur fracture. A. Hypoxia B. Respiratory arrest/failure C. Obtundation Contraindications: D. Secretions unable to be cleared by suctioning A. Pelvic fracture or instability B. Knee, lower leg, or ankle instability Contraindications: None Key procedural considerations: A. Assess motor, sensory, and circulatory function in the involved extremity. Key procedural considerations: B. Apply traction splint per the manufacturer’s guidelines. A. If the patient or family has a replacement tube available, it may be used. If a C. Initiate mechanical traction to match manual traction. replacement tube is not available, an endotracheal tube of a similar outer D. Reassess motor, sensory, and circulatory function in the involved extremity. diameter may be used. E. Exercise care when applying traction not to reintroduce bone ends into the body. B. Premoisten the tube with water soluble lubricant. C. Extend the neck and, if necessary, place a roll between the patient’s shoulder blades to aid in visualizing the stoma. D. If the tube cannot be placed easily, withdraw the tube; administer oxygen and positive pressure ventilation. NEVER force the tube. E. Secure the device to the patient. F. If the tube cannot be easily placed, a suction catheter may be used as a guide. Tracheostomy Tube Replacement Traction Splint 147 148  Vagal Maneuvers Vascular Access LEVEL: AEMT/Paramedic, EMTs holding EMT-IV endorsement LEVEL: Paramedic Vascular access attempts should not unnecessarily delay transport Attempts should be completed en route. The patient MUST be attached to a cardiac monitor All attempts are to be documented on the PCR. and MUST have vascular access prior to performing the procedure EMTs with IV endorsement are only to perform skill under direction of paramedic or AEMT Indications for Peripheral Vascular Access: Indications: This procedure may be performed on any patient whenever there is a potential need for: This procedure may be performed on any patient who is experiencing Supraventricular A. Intravenous drug administration Tachycardia with adequate perfusion. B. Need to administer IV fluids for volume expansion Contraindications: None Key procedural considerations: Contraindications: A. Saline locks may be used when appropriate and flushed with a 3 cc bolus of NS as needed. None B. Extension tubing should be used on all IV lines. Key procedural considerations: A. Approved methods include: Indications for Intraosseous Access (Paramedic for Adult/ Peds, AEMT for Adult, Unc/Unresponsive Peds only) 1. Valsalva maneuver Critically ill or injured patient who requires IV drugs/fluids and in whom a peripheral line cannot be 2. Head-down tilt with deep inspiration immediately established. 3. Activation of the “diving reflex” by facial immersion in ice water (unless ischemic heart disease is present) Contraindications: 4. Carotid massage (only on patients under 40 years of age) A. Placement in, or distal to a fractured bone. B. In infants and young children, the most effective vagal maneuver is the application B. Previous significant orthopedic procedure at the site; prosthetic limb or joint; of ice to the face. IV access is not mandatory prior to vagal maneuvers in children. IO catheter use in past 48 hours of the target bone. C. Infection at the area of insertion. D. Absence of adequate anatomical landmarks. Paramedic may administer lidocaine 1% or 2% preservative-free for anesthetic in a patient responsive to pain. 1) Prime IO extension tubing set with lidocaine (EZ IO, EZ Connect priming volume is 1ml) 2) Slowly infuse lidocaine 40mg (PEDIATRIC dose: 0.5 mg/kg not to exceed 40 mg) IO over 120 seconds. 3) Allow lidocaine to dwell in IO space for 60 seconds. 4) Flush IO with 5-10 ml normal saline. 5) Slowly administer an additional dose of lidocaine IO (20mg) over 60 seconds. (Pediatric dose: 0.25 mg/kg, not to exceed 20 mg) 6) Consider systemic pain medication for patients not responding to IO lidocaine. Key procedural considerations: Only 1 (one) attempt is permitted per extremity Indications for use of Previously Established Central Line Access: This procedure may be performed on any critically ill or injured patient who requires IV drugs or IV fluids AND in whom a peripheral line cannot be established. Contraindications: Inability to freely aspirate blood out of the catheter. Key procedural considerations: Central line access (Implantable Ports, Port-A-Caths, Medports) A. May only be used if the device has already been accessed and IV fluid set-up has been established and running.