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 Overdose/Poisoning.......................................................................................................................................................... 43 Pain Management............................................................................................................................................................. 45 Pulmonary Edema/CHF..................................................................................................................................................... 47 Respiratory Distress.......................................................................................................................................................... 49 Seizure............................................................................................................................................................................... 51 Sepsis................................................................................................................................................................................ 53 Shock................................................................................................................................................................................. 55 Smoke Inhalation.............................................................................................................................................................. 57 STEMI (Suspected)............................................................................................................................................................ 59 Stroke (CVA)...................................................................................................................................................................... 61 Tachycardia/Stable............................................................................................................................................................ 63 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.) 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 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 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  FOREWORD EMERGENCY MEDICAL 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, 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 on the prehospital care record what was ordered, the time, and the reason the order could not be carried out. In addition, the provider must immediately notify the OEMSTS, and upon completion of the call, make available the prehospital care record to the OEMSTS. All such incidents will be entered into the Quality Improvement Review process. 5 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 patients, Code 3 Transport to closest facility for: returns, need for telemetry physician & as per protocol - Airway emergencies (inability to adequately ventilate) Transport per Disposition Criteria, if 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% E BVM if O2 sat ≤ 94% Palpable No Yes radial pulse? Vascular Access A Vascular Access A 1 L NS or LR bolus IV/IO E Secondary Survey Suspected tension pneumothorax P Needle Decompression Sucking chest wound E Apply 3-sided occlusive dressing Control active hemorrhaging E Hemorrhage Control Immobilize fractures; assess distal Obvious fractures E pulse E Raise Head of bed 30 degrees Suspected traumatic brain injury Capnography – ETCO2 35 mm Hg P Open wounds Cover with gauze; wet trauma E dressing for abdominal evisceration 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 Symptoms Differential (life threatening) · Time and mechanism of injury · Pain, Swelling · Tension pneumothorax · Damage to structure or vehicle · Deformity, lesions, bleeding · Flail chest · Location in structure or vehicle · AMS or unconscious · Pericardial tamponade · Others injured or dead · Hypotension or shock · Open chest wound · Speed and details of MVC · Arrest · Hemothorax · Restraints/protective equipment · Intra-abdominal bleeding · Past medical history · Pelvis/femur fracture · Medications · Spine fracture/cord injury · 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 Yes hypovolemia? No Consider an Antiemetic: A ONDANSETRON Vascular Access 4 mg ODT/IM/IV/IO Nausea or A 500 ml NS or LR bolus IV/IO; Yes vomiting? may repeat up to 2000 ml DROPERIDOL 1.25 mg IM/IV/IO or METOCLOPRAMIDE P 10 mg slow IVP over 1-2 No minutes or IM or PROCHLORPERAZINE Up to 10 mg IV/IM/IO Consider Chest Pain (Non Traumatic) and Suspected Acute Coronary Syndrome Consider P Pain Management Continue General Adult Assessment Abdominal / Flank Pain, Nausea & Vomiting Protocol (Revised and MAB approved 6/1/2022) 15 History Signs and Symptoms Differential · Age · Pain location · Liver (Hepatitis) · Medical/surgical history · Tenderness · Gastritis · Onset · Nausea · Gallbladder · Quality · Vomiting · MI · Severity · Diarrhea · Pancreatitis · Fever · Dysuria · Kidney stone · Menstrual history · Constipation · Abdominal aneurysm · Vaginal bleeding/discharge · Appendicitis · Pregnancy · Bladder/prostate disorder · 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 (Mild) Evidence of anaphylaxis? Yes (Moderate/Severe) A Vascular Access EPINEPHRINE E Assist patient with own auto-injector EPINEPHRINE 1:1000, 0.5 mg IM; DIPHENHYDRAMINE A A may repeat q 15 min 50 mg IM/IV/IO/PO up to max 1.5 mg ALBUTEROL Reassess patient q 5 min E Assist patient with MDI ALBUTEROL 2.5 mg in 3 ml SVN, repeat as needed A OR; LEVALBUTEROL 1.25 mg SVN, repeat as needed Ventilation Management P 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 bolus IV/IO; Anaphylaxis – moderate/severe reaction meeting either of these A may repeat up to 2000 ml criteria: · Exposure to known or likely allergen with hypotension OR DIPHENHYDRAMINE respiratory compromise 50 mg IM/IV/IO/PO · Two or more of the following after exposure to likely allergen: skin/mucosal changes (hives, flushing, edema); respiratory compromise (SOB, wheezing, stridor, hypoxia); Pt in persistent shock? If Yes, then hypotension or signs of shock; persistent GI symptoms (abdominal pain, vomiting) PUSH DOSE EPINEPHRINE 1:100,000 10 mcg IV/IO, may repeat P q 2-5 min to maintain SBP>90 ( 1 ml of 1:100,000 Solution) Continue General Adult Assessment Allergic Reaction Protocol (Revised and approved by MAB 10/2/2024) 17 History Signs and Symptoms Differential · Onset and location · Itching or hives · Urticarial (rash only) · Insect sting or bite · Coughing/wheezing or · Anaphylaxis (systemic effect) · Food allergy/exposure respiratory distress · Shock (vascular effect) · Medication allergy/exposure · Throat or chest constriction · Angioedema (drug induced) · New clothing, soap, detergent · Difficulty swallowing · Aspiration/airway obstruction · Past history of reactions · Hypotension/shock · Asthma/COPD · Past medical history · Edema · CHF · Medication history · Nausea/vomiting Pearls · Recommended Exam: Mental Status, Skin, Heart, Lung. · Anaphylaxis is an acute 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 No P if patient protecting airway 12-Lead ECG D10, 25 g IV/IO ; (250 mL of 10% solution) ; A may repeat x 1 in 5 min Consider NS or LR 500 ml GLUCAGON A IV/IO; 1 mg IM for no IV access may repeat up to 2000 ml Improved mental Consider the status? following: Yes Signs of stroke? Stroke Other treatment protocols as indicated Signs of hypoperfusion? Shock Signs of a seizure of Seizure post-ictal state? Signs of trauma or head General Trauma injury? Cardiac causes/ Appropriate cardiac known disease? protocol Unresponsive with Poisoning/Overdose respiratory depression & suspected narcotic overdose Altered Mental Status / Syncope (revised and MAB approved 4/7/2021) 19 History Signs and Symptoms Differential · Known diabetic, Medic Alert tag · Decreased mental status or · Head trauma · Drugs or drug paraphernalia lethargy · CNS (stroke, tumor, seizure, infection) · Report of drug use or toxic · Changes in baseline mental · Cardiac (MI, CHF) ingestion status · Hypothermia · Past medical history · Bizarre behavior · Infection · Medications · Hypoglycemia · Thyroid · History of trauma · Hyperglycemia · Shock (septic, metabolic, traumatic) · Change in condition · Irritability · Diabetes · Changes in feeding or sleep · Toxicological or ingestion 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 causes for the Scene Safety patient’s behavior: 1. Hypoxia General Adult Assessment 2. Intoxication / Overdose 3. Hypoglycemia / Electrolytes 4. Head Injury Approach patient using the SAFER 5. Postictal State Request law enforcement and/or extra units for potentially violent patients Categorize level of patient agitation and risk of violence using IMC-RASS scale Mild-Agitated but Agitated Agitated and and disruptive/dangerous disruptive/dangerous cooperative/redirectable IMC-RASS IMC-RASS +3 +3 or or +4 +4 IMC-RASS +1 or +2 Severe-Significantly Moderate-Agitated Verbal de-escalation agitated and presents and danger to self/ techniques serious imminent others danger to self/others Evaluate for and treat MIDAZOLAM Select ONE reversible causes 2.5 -5 mg IN/IM/IV/ IO May repeat X1 after 5 min at 2.5 mg MIDAZOLAM 2.5- P OR KETAMINE 3-4 mg 10 mg IM DROPERIDOL IM and/or P P 2.5-5 mg IV/IO or 5 max total dose DROPERIDOL mg IM 400 mg 5-10 mg IM Cardiac/ETCO2 monitoring Cardiac/ETCO2 Monitoring Patient Restraint Patient Restraint Continue General Adult Assessment Behavioral Emergency (revised and MAB approved 04/03/2024) 21  History Signs and Symptoms Differential · Situational crisis · Anxiety, agitation, confusion · AMS differential · Psychiatric illness/medications · Affect change, hallucinations · Alcohol intoxication · Injury to self or threats to others · Delusional thoughts, bizarre · Toxin/substance abuse · Medic Alert tag behavior · Medication effect or overdose · Substance abuse/overdose · Combative, violent · Withdrawal syndromes · Diabetes · Expression of suicidal/ · Depression homicidal thoughts · Bipolar · Schizophrenia · 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 Consider and treat underlying cause, P if identified, e.g., hypoxia, hyperkalemia, hypothermia, ACS, drug toxicity Persistent HR < 50 causing: Altered Mental Status Observe and Hypotension NO Monitor Chest Pain Signs of Shock YES Stable with no high grade AV block Unstable and/or high grade AV or wide complex block and/or wide complex Transcutaneous Pacing P ATROPINE 1 mg IV/IO For sedation and analgesia medications, refer to the P Electrical Therapy/ TranscutaneousPacing Procedures Protocol. And/OR PUSH DOSE EPINEPHRINE Adequate treatment effect? NO P 10 mcg IV/IO, may repeat q 2- 5 min to maintain HR/BP May repeat ATROPINE 1 mg P IV/IO q 3-5 min, total max Note: If unstable or peri-arrest, dose 3 mg do not delay pacing while obtaining vascular access Bradycardia (Revised and MAB approved 4/3/2024) 23 History Signs and Symptoms Differential · Past medical history · HR 20% BSA A burn present; Vascular Access Contact Medical Direction at Burn NS or LR 500 ml fluid bolus if signs of Center for further drip rates or hypoperfusion, OR >20% BSA burn additional boluses A present; 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 Symptoms Differential · Type of exposure (heat, gas, chemical) · Burns, pain, swelling · Superficial (1st degree) – red and painful · Inhalational injury · Dizziness · Partial Thickness (2nd degree) – blistering · Time of injury · Loss of consciousness · Full Thickness (3rd degree) – painless/charred · Past medical history & medications · Hypotension/shock or leathery skin · Other trauma · Airway compromise/distress · Thermal · Loss of consciousness · Wheezing · Chemical · Tetanus/immunization status · Singed facial or nasal hair · Electrical · Hoarseness or voice changes · Radiation · Lightning Pearls · Burn patients are trauma patients; evaluate for 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 apply ice or cool burns; must maintain normal body temperature. · Consider ETCO2 monitoring. Early Intubation Indications · Signs of Airway Obstruction Burns in Mouth · Hoarseness, Stridor, Dysphagia Total BSA ≥ 40% · Extensive Deep Facial Burns Altered Mentation · Signs of Respiratory Compromise Significant Risk of Edema -Accessory Muscle Use -Inability to Clear Secretions -Poor Oxygenation Patients meeting the following criteria shall be transported to the closest appropriate Burn Care Center: 1. Second degree burns >10% body surface area (BSA). 2. Any Third degree burns. 3. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 4. Electrical burns including lightning injury. 5. Chemical burns. 6. Circumferential burns. 7. Inhalation burns. 8. Burn injury with concomitant trauma Fluid Resuscitation · 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. Pearls (Electrical) Pearls (Chemical) · Do not contact the patient until you are certain the source of the electric shock has · Certainly 0.9% NaCl Sol’n or Sterile Water is preferred; been disconnected. however if it is not readily available, do not delay; use tap · Attempt to locate contact points, (entry wound where the AC source contacted the water for flushing the affected area or other immediate water patient; an exit at the ground point); both sites will generally be full thickness. sources. Flush the area as soon as possible with the cleanest, · Cardiac monitor; anticipate ventricular or atrial irregularity to include V-Tach, V-Fib, readily available water or saline solution using copious heart blocks, etc. amounts of fluids. · Attempt to identify the nature of the electrical source (AC vs DC), the 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 THE Refer to Termination of Resuscitation Meets criteria for Prehospital Death CAUSE OF THE ARREST, EARLY Yes or DNR/POLST Protocol as appropriate Determination or DNR/POLST present? VENTILATION IS RECOMMENDED No If witnessed by EMS or CPR in progress and patient is 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 begin BVM E at 8 BPM P Apply cardiac monitor P VF/VT Yes Rhythm shockable? No P Asystole/PEA P Defibrillate E Continue CPR for 2 min Continue CPR E for 2 min A Vascular Access A Vascular Access EPINEPHRINE 1:10,000 1 mg IV/IO q 3-5 min; A ETT Administration requires 2 to 2.5 times the Rhythm shockable? dose Yes Consider A Defibrillate if prompted Extraglottic Airway Device E Consider (AED) P Endotracheal Intubation P Defibrillate E Continue CPR for 2 min EPINEPHRINE 1:10,000 Rhythm shockable? 1 mg IV/IO q 3-5 min A ETT Administration requires 2 to 2.5 times the No dose E Continue CPR for 2 min Consider A Extraglottic Airway Device P Address H’s & T’s Consider P Endotracheal Intubation No Yes Rhythm shockable? No No Rhythm shockable? Yes E Defibrillate if prompted Yes (AED) P Defibrillate Use VF/VT side as E Continue CPR for 2 min Use Asystole/PEA side as indicated indicated AMIODARONE Check pulse, if organized rhythm 300 mg IV/IO; may repeat If patient remains unresponsive to P one dose of 150 mg if resuscitation efforts, consider refractory after 5th shock; Termination of Resuscitation Protocol Address H’s & T’s Cardiac Arrest (Non-Traumatic) (revised and approved by MAB 06/01/2022) 27 History Signs and Symptoms Differential · Events leading to arrest · Unresponsive · Medical vs. Trauma · Estimated down time · Apneic · VF vs. Pulseless VT · Past medical history · Pulseless · Asystole · Medications · PEA · Existence of terminal illness · Primary cardiac event vs. 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 be obtained above the diaphragm. If no ROSC after two rounds of BLS/ACLS, consider immediate transport to the nearest Emergency Department for possible Resuscitative Cesarean Delivery (RCD). Left uterine displacem ent using 1-handed technique.. Terry L. Vanden Hoek et al. Circulation. 2010;122:S829 -S861 Terry L. Vanden Hoek et al. Circulation. 2010;122:S829 -S861 Copyright © Am erican Heart Association, Inc. All rights reserv ed. Copyright © Am erican Heart Association, Inc. All rights reserv ed. 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 minutes of P patient contact Non- Diagnostic STEMI 12-Lead ECG A Vascular Access Refer to Oxygen STEMI (Suspected) E Keep SpO2 >94% ASPIRIN E 324 mg PO NITROGLYCERIN Assist pt with own E medication as prescribed; may repeat X2 Nitroglycerin is contraindicated in any patient 0.4 mg SL; with hypotension, bradycardia, tachycardia P May repeat q 5min X2 (HR>100 bpm) in the absence of heart failure, evidence of a right ventricular infarction, and use Pain Management for of erectile dysfunction medications within the last P 48 hours. Caution is advised in patients with continued pain Inferior Wall STEMI and a right-sided ECG should be performed to evaluate RV infarction. Consider antiemetic for nausea/vomiting: A ONDANSETRON Refer to Arrhythmia and Shock Protocols as 4 mg ODT/IM/IV/IO needed METOCLOPRAMIDE 10 mg slow IV bolus over 1-2 minutes or IM P or PROCHLORPERAZINE Up to 10 mg IV/IM/IO Transport to hospital of patient’s choice Chest Pain (Non Traumatic) and Suspected Acute Coronary Syndrome (Revised and MAB approved 12/7/2022) 29  History Signs and Symptoms Differential · Age · CP, pressure, ache, vise-like · Trauma versus medical · Medications: Viagra, Levitra, pain, tight · Anginal versus MI Cialis · Location, substernal, · Pericarditis · Past medical history of MI, epigastric, arm, jaw, neck, · Pulmonary embolism angina, diabetes shoulder · Asthma, COPD · Allergies · Radiation of pain · Pneumothorax · Recent physical exertion · Pale, diaphoresis · Aortic dissection or aneurysm · Palliation, provocation · Shortness of breath · GE reflux or hiatal hernia · Quality · Nausea, vomiting, dizziness · Esophageal spasm · Region, radiation, referred · Time of onset · Chest injury or pain · Severity (1-10) · Pleural pain · Time of onset, duration, · Drug overdose (cocaine, repetition methamphetamine) 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 approved by MAB 12/7/2022) 30  Childbirth / Labor General Adult Assessment Pregnant patient with signs of impending delivery (see pearls) Normal Limb Presentation Breech Presentation Cord Presentation Presentation Puncture amniotic Position patient in sac if not already Place patient in left Support body of Trendelenburg and broken lateral recumbent baby during slightly on left side Deliver and support position delivery of head the head Wrap cord and keep it moist Suction mouth, then nose; if meconium Insert gloved hand present, repeat Attempt Attempt to lift baby off cord; several times A Vascular Access A Vascular Access obtain and document cord Deliver upper pulse shoulder, then lower shoulder Deliver remainder Attempt of the baby A Vascular Access Clamp and cut umbilical cord If multiple births, repeat steps Deliver placenta Attempt Patient A Vascular Access hypoperfusing? Yes Administer 500 ml NS or A LR; repeat as needed No not to exceed 2000 ml Continue General Adult Assessment Childbirth / Labor Protocol (revised and MAB approved 4/7/2021) 31 History Signs and Symptoms Differential · Due date · Spasmodic pain · Abnormal presentation (breech, limb) · Time contractions started/ · Vaginal discharge or bleeding · Prolapsed cord duration/frequency · Crowning or urge to push · Placenta previa · Rupture of membranes · Meconium · Abruptio 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 · High risk pregnancy Pearls · 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=0 Score=1 Score=2 · Activity/Muscle Tone Absent Arms/legs flexed Active movement · Pulse Absent Below 100 Above 100 · Grimace/Reflex Irritability No response Grimace Sneeze, cough, pulls away · Appearance/Skin Color Blue-Grey, pale all over Normal, except extremities Normal over entire body · Respiration Absent Slow, irregular Good, crying Childbirth / Labor Protocol(revised and MAB approved 4/7/2021) 32  Cold-Related Illness E General Adult Assessment Remove from environment Temperature measurement (if available) E Remove wet clothing Dry/warm patient Passive warming measures Hypothermia/Frost Bite Localized Cold Injury Systemic Hypothermia Monitor and reassess Awake with/without Unresponsive General wound care altered mental status E DO NOT rub skin to warm DO NOT allow refreezing Respiratory Respiratory Yes distress? Distress No E Active warming measures Yes Pulse present? A Vascular Access P Cardiac monitor No NS or LR bolus 500 ml IV/IO; A repeat to effect SBP >90; maximum 2000 ml Cardiac Arrest 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 Symptoms Differential · Age, very young and old · AMS/coma · Sepsis · Exposure to decreased · Cold, clammy · Environmental exposure temperatures, but may occur in · Shivering · Hypoglycemia normal temperatures · Extremity pain · Stroke · Past medical history/medications · Bradycardia · Head injury · Drug or alcohol use · Hypotension or shock · Spinal cord injury · 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 2000 ml E Continue cold water immersion if appropriately initiated P Cardiac monitor Vascular Access Poor NS or LR bolus perfusion? A 500 ml IV/IO; repeat to effect SBP >90; max 2000 ml Yes P Cardiac monitor No Exit to appropriate Poor Shock or Trauma YES perfusion? Protocol as indicated Monitor and reassess NO Continue General Adult Assessment Heat-Related Illness (revised and MAB approved 4/3/2024) 37 History Signs and Symptoms Differential · Age, very old and young · AMS/coma · Fever · Exposure to increased · Hot, dry, or sweaty skin · Dehydration temperatures and/or humidity · Hypotension or shock · Medications · Past medical history/medications · Seizures · Hyperthyroidism · Time and duration of exposure · Nausea · DTs · Poor PO intake, extreme exertion · Heat cramps, heat exhaustion, heat stroke · Fatigue and/or muscle cramping · CNS lesions or tumors Pearls · Recommended exam: Mental Status, Skin, Heart, Lung, Abdomen, 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 SVN OR; A LEVALBUTEROL 1.25 mg in 3 ml Continuous SVN Bradycardia, Peaked T waves, No Yes Widened QRS, or Cardiac Arrest Continue to monitor CALCIUM CHLORIDE 1 g slow IVP/ IO Other treatment protocols as P indicated SODIUM BICARBONATE 50 mEq slow IVP/ IO Continue General Adult Assessment Hyperkalemia (Suspected) (revised and approved by MAB 12/6/2023) 39 History Signs and Symptoms Differential · History of renal failure · Cardiac conduction · Cardiac disease · History of dialysis disturbances · Renal failure · Trauma, crush injury · Irritability · Dialysis · Abdominal 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; 0.1 mg/kg, max dose 5 mg; repeat X 1 after 5 min at 0.05 mg/kg, max MAGNESIUM dose 2.5 mg Further doses require Pregnant patient SULFATE IV/IO P physician order Yes P exhibiting seizures? 4 g in 50 ml NS IN/IM/IV/IO over 20 min Or DIAZEPAM 5mg IV; May Repeat q 5 Min Additional doses require physician order No Pregnant patient MAGNESIUM Transport to SULFATE IV/IO exhibiting Yes P 2 g in 50 ml NS Appropriate pre-eclampsia? over 10 min Facility Follow appropriate protocol Obstetrical Emergency (revised and approved by MAB 10/06/2021) 41 History Signs and Symptoms Differential · Medical history · Vaginal bleeding · Pre-eclampsia/eclampsia · Hypertension medication · Abdominal pain · Placenta previa · Prenatal care · Seizures · Placenta abruptio · Prior pregnancies/births · Hypertension · Spontaneous abortion · Previous pregnancy complications · Severe headache · 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 Opiate Dystonic Cyanide Calcium OD Reaction TCA/ASA Beta Blocker Organophosphate Channel OD OD Toxicity Blocker OD NALOXONE ATROPINE E 2-4 mg DIPHENHYDRAMINE Wide Bradycardic Bradycardic