Ascension St. Vincent North Region EMS Adult Protocols V3 PDF

Ascension St. Vincent North Region EMS Adult Protocols V3 1  Table of Contents Pg. 4 General Guidelines Pg. 5 Standard of Care Pg. 6-7 DAAM Procedure Pg....

Ascension St. Vincent North Region EMS Adult Protocols V3 1  Table of Contents Pg. 4 General Guidelines Pg. 5 Standard of Care Pg. 6-7 DAAM Procedure Pg. 8 DAAM Pg. 9 Cricothyrotomy Pg. 10-11 Canine Officer Protocol Pg. 12 Allergic Reaction Pg. 13 IV Access Pg. 14 IO Access Pg. 15 Port Access Pg. 16 CPAP/BiPAP Pg. 17-19 Ventilator Protocol Pg. 20 Heated High Flow Nasal Cannula Pg. 21 Reactive Airway Disease Pg. 22 Sepsis Pg. 23 Pain Management Pg. 24 Sedation Pg. 25 Non Agitated Psychosis Pg. 26 Agitated Patient Pg. 27 Restraint Policy Pg. 28 Diabetic Emergency Pg. 29 Chest Pain Pg. 30 Cardiogenic Shock Pg. 31 Bradycardia Pg. 32-35 Tachycardia Pg. 36-38 Cardiac Arrest Pg. 39 Need for Resuscitation Pg. 40 Termination of Resuscitation Pg. 41 Stroke Table of Contents 2  Pg. 42 Pulmonary Edema Pg. 43 Toxicology Pg. 44 Seizure Pg. 45 Nausea Pg. 46-47 Trauma Pg. 48 Burns Pg. 49 Head Injury Pg. 50 Cyanide Poisoning Pg. 51 Carbon Monoxide Poisoning Pg. 52 Spinal Motion Restriction Pg. 53 Spinal Cord Injury Pg. 54 Hypothermia Pg. 55-57 Hyperthermia Pg. 58 Taser Removal Pg. 59 Orogastric Tubes Pg. 60 Sexual Assault Pg. 61 Eclampsia Pg. 62 Pre-Eclampsia Pg. 63-64 Childbirth Pg. 65-66 Post Partum Care Pg. 67-68 Drug List Pg. 69-78 Drip Charts Pg. 79 IBW Chart Table of Contents 3  General Guidelines GENERAL GUIDELINES A standard of care to be delivered to all patients encountered by Ascension St. Vincent North Region EMS personnel: A patient is anyone who has either requested EMS or has had EMS requested for them. Confidentiality of patient information is to be maintained at all times. Administer oxygen to achieve appropriate oxygenation. Since medical history and examination cannot reliably identify all patients infected with blood-borne pathogens, blood and body fluid precautions shall be used for all patients. Personnel are to follow their department's policies concerning Blood and Body Fluid Precautions. The highest medical authority (usually the Paramedic) is responsible for the assessment of all patients (except under extreme circumstances). After making contact with the patient, she/he is your responsibility until a higher or equal medical authority releases you, the patient is deemed nonviable, patient care of a BLS patient is transferred from an ALS provider to a BLS crew (see protocol), or you receive a signed signature of release (SOR). (See Non Transported Patients Protocol, or Determining the Need for Resuscitation Protocol) Upon arrival at the scene, the Paramedic/EMT must determine the history and prior treatment by other persons and/ or agencies before changing treatment. Paramedics and EMTs may only perform the skills and therapies as outlined in the patient care protocols. If online Medical Control orders any other skills or therapies the Paramedic/EMT must have been trained on the skill or therapy and Medical Control must be willing to sign the run report or provide a written note with signature that shows the orders given and scanned into EMS charting system. Optimization of patients before transport is the standard for deciding on whether to transport, considering EMS capability to deal with instability and need for intervening care to truly stabilize patients. Understanding that a risk benefit decision is made balancing a patient's likelihood of decompensating without the lifesaving, intervening actions at the receiving facility. Run reports are to be completed and processed according to current Indiana Medical Commission Rules and Regulations. Verbal report to the receiving facility with transfer of care to an equal or higher level provider is mandatory. If you suspect child abuse/neglect, you are to verbally report it to the receiving nurse and/or physician, then you are to contact the Indiana Department of Child Services 1-800-800-5556 and file a report. If you suspect adult abuse/neglect you are to verbally report it to the receiving nurse and/ or physician, then you are to contact Adult Protective Services 1-800-992-6978 and file a report Communications /Orders: If, in your opinion, the orders you receive are inappropriate and/or dangerous to the patient, question the physician three times and verbally refuse to act. Contact the Ascension St Vincent North Region EMS Medical Director as soon as possible (765) 404-3756 If you are unable to contact the receiving facility, refer to the appropriate protocol for patient care. If an order for a therapy, which you consider to be life saving, is refused, verbally request the order three times. If you continue to be denied, contact your supervising hospital for further instructions. If they cannot be contacted, follow the appropriate protocols. EMS crews need 24-7 access to medication resupply due to the critical nature of supporting life and treatment of morbidity causing conditions. If crew runs out of a medication that cannot be treated with another medication appropriately then the unit is to notify clinical leadership and escalate until plan is provided to be resupplied. Table of Contents 4  Standard of Care A standard of care to be delivered to all patients encountered by Ascension St. Vincent North Region EMS Personnel Universal Precautions Ensure patent airway Administer oxygen to achieve saturation of 92%, max 99% except for head injury (100%) Loosen tight fitting clothing and place patient in position of comfort unless contra-indicated Obtain patient medical history and current medication list Vital signs should be obtained every 5 minutes for unstable patients and every 15 for stable patients. All refusal of transport patients must have one complete set of vital signs documented. Cardiac monitoring should be performed on all patients receiving Advanced Life Support Interventions. 12 Lead ECG should be performed on any patients complaining of chest pain, shortness of breath, altered mental status, stroke, or abdominal pain. Initiate peripheral IV and draw labs on all chest pain, sepsis, or stroke presentations as well as any other patient at the providers discretion. Follow the appropriate protocol as outlined in this document and contact medical control as indicated. Establish invasive access as indicated based on patient presentation. See access protocol. Reassess patients and record vitals signs every 5-15 min as condition warrants Maintain appropriate body temperature with passive and active rewarming within scope Transport to the nearest appropriate facility with unstable patients. Stable patients may be transported to a facility of choice within the region. If you are called by another agency for a specific patient or 911 has been called on behalf of a patient, You must obtain a SOR with full documentation of assessment and vitals. This is regardless of whether the patient reports they did not want an ambulance. Document if patient refuses to sign SOR and document your assessment that patient had capacity to refuse. Table of Contents 5  DAAM Procedure PRE-PROCEDURE: Address immediate Airway/Breathing/Circulation problems Correct hypotension & provide other indicated treatments for patient condition as needed Continuously monitor SP02, ECG, ETCO2 Position Monitor, Prepare BVM (ETCO2 & PEEP), Tube Tamer, Suction & Intubation Roll Position Patient as optimally as possible. Cot preferred. HOB elevated. Ear at sternal notch level. SEDATION Level 1 & 2: Administer Ketamine 1-2 mg/kg IBW slow IV/IO - O: 30s dosing based on hemodynamics, 4 mg/KG IM - O: 30s (4 min IM), D: 5-10m Level 3: Administer Ketamine 1-2 mg/kg IBW slow IV/IO dosing based on hemodynamics or 4 mg/KG IM - O: 30s (4 min IM), D: 5-10m 4 mg/KG IM - O: 30s (4 min IM), D: 5-10m or Versed 0.1mg/kg to a max of 10 mg, give in 5 mg aliquots monitoring for hypotension - O: 2m, D: 15-30m, Etomidate: IV/IO 0.3 mg/kg -O: 1-2 min, D 5-7m (NO REDOSING OF ETOMIDATE) Shock Dose: Ketamine 0.1-0.5 mg/kg O: 30 sec, D: 15-20 min, Etomidate 0.15 mg/kg POSITION - BUHE or "Bed Up Head Elevated" (Level 1 &2). The easiest place to intubate is on the cot. Head elevated ≥15° (Consider increased angle in obese, pulmonary edema, vomit/blood/fluid in airway) Ear to sternal notch positioning PRE-OXYGENATION & DENITRIFICATION- "Resuscitate then Intubate." (Level 1,2,3) Achieve then maintain Sp02 Sat ≥94% for at least 3 mins. Using a timer is highly recommended. If immediate or impending airway compromise suspected not amenable to less invasive interventions, administer paralytic immediately after patient appropriately sedated. You must document reasons for not pre-oxygenating. Switch to standard NC at 15 LPM, continued until airway secured (NP Airway recommended) BVM with high flow oxygen, set PEEP to at least 5 cm/H2O, 2-handed mask seal (Thenar Grip) recommended ○ Adequate breathing & SpO2 ≥94% → BVM seal with no ventilations ○ Adequate breathing & SpO2 20 risk gastric insufflation Table of Contents 6  DAAM Procedure Cont. INTUBATION - Take steps to facilitate first pass success (Level 2&3) Discontinue attempt and treat underlying issue if peri-Intubation hypoxia, bradycardia, or arrest occur. Suction airway first Level 2: VL w/DL as back-up. Level 3: DL or VL. Bougie and/or VL encouraged in HEAVEN criteria ○ Hypoxemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination, Neck mobility issues Successful Confirm placement x 2 methods(ETCO2 is required as one of the methods) Secure ETT tube (C-Collar also recommended) Continuously monitor adequate ventilations Unsuccessful Immediate placement of SGA- this minimizes the number of hands needed to ventilate ○ Ventilate to appropriate EtCO2 and Oxygenation ○ Consider additional time for nitrogen washout but balance with duration of paralytic ○ CHANGE SOMETHING before re-attempt (Switch blade, reposition patient, change DL vs VL, etc) Document what was changed, reason, and grade view & communicate to receiving physician. If unable to ventilate with SGA, attempt reseating SGA x 1 If unsuccessful in reseating, you are in a CAN'T VENTILATE, CAN'T INTUBATE scenario, immediately progress to Cricothyroidotomy POST INTUBATION SEDATION & ANALGESIA Level 1&2: Re-sedate Ketamine 1-2mg/kg IBW slow IV/IO after securing tube within 10 minutes of induction Level 3: May also use Versed 0.1mg/kg - O: 2m (max of 5 mg redosing as needed for appropriate sedation) especially in hypertensive pts, D: 15m but must use immediately after securing tube if using etomidate ○ Repeat every 15 minutes. More frequently PRN. Fentanyl 1mcg/kg for additional analgesia. Repeat as necessary. For prolonged transport, consider Fentanyl gtts l 1mcg/kg/hr Titrate by 0.5 mcg/kg/hr q5 min to max dose of 3 mcg/kg/hr. Consider Ketamine infusion for longer transports - 1mg/kg/hr titrate to effect, Titrate by 0.5 mg/kg/hr q 5 min to a max dose of 4 mg/kg/hr Table of Contents 7  DAAM INDICATIONS Airway protection in immediate or threatened airway (i.e. trauma, swelling, uncontrolled blood/vomitous) Respiratory Failure (Failure in oxygenation and/or ventilation via less invasive interventions) Neuro Protection (i.e. AMS with: Head Trauma, Stroke, Refractory Status Epilepticus, ROSC) SPECIAL CONSIDERATIONS An altered mental status alone does not necessitate intubation Prepare push dose epi prior to intubation in patients with high risk of peri-intubation hemodynamic instability. Continuously monitor ventilations with EtCO2 in conjunction with vitals to ensure high quality ventilation and oxygenation. Following a missed attempt change at least one thing before next attempt You must document failure to reach goal O2 sats, desaturation and missed attempts This protocol is for the induction, paralyzation, and post sedation of patients that need drug assisted airway management. It is not to prohibit intubation of patients that could otherwise be intubated. AIRWAY ESCALATION - "The goal of airway management is to ventilate not intubate." Maintain a conduit to the alveoli that allows for correction of hypoxia or hypoventilation, minimize aspiration, maximizes patient outcome, and takes into consideration task saturation, scope, and skill level. GOALS OF AIRWAY MANAGEMENT: THE AIRWAY CONTINUUM Correct hypoxia as quickly as possible 1: Positioning and supplementary Prevent desaturation 100.4F) and has one of the following criterias are present in patient >18 years old and not pregnant. Use age appropriate parameters for tachycardia and respiratory rate for pediatric patients. Heart Rate greater than 90/min Respiratory Rate greater than 22/min ETCO2 < 25 mmHg Fever: If pt can confirm no tylenol within past 4 hours and has no hx of liver concerns, may give 650 mg PO tylenol Hypotensive Treatment: Correct Hypoxia > 94 % O2 Saturation Establish bilateral peripheral IV Access and Perform Blood Draw Aggressively fluid resuscitate patient up to 30 ml/kg of 0.9 NS or LR. Monitor for signs of Pulmonary Edema. If patient remains hypotensive despite fluid resuscitation of full 30 ml/kg IBW, 2L bolus, or signs of volume overload , initiate vasopressor therapy with target systolic BP of 90 mmHg or MAP of 65 mmHg. ○ Norepinephrine (Levophed). (Mix 8mg in 250 mL of D5W) Begin the infusion at 2 mcg/min, titrating up by 2 mcg/min with a target of systolic BP 90 mmHg or MAP 65 mmHg. If using an Alaris IV Pump then use 0.05 mcg/kg/min as a starting point then titrating up by 0.05 mg/kg/min until target pressure achieved. ○ Push Dose Epinephrine 1:100,000. Give 1-2 ml (10-20 mcg) every 2-4 minutes IV/IO until target pressure achieved. Be aware of severe chronic CHF Look out for:: Pedal Edema ICD placed for low EFs JVD/JVP Other obvious signs. Table of Contents 22  Pain Management PAIN MANAGEMENT INDICATIONS: Patient comfort should be our focus in pre-hospital care. Recommendations for Pain Management include: Extremity injuries. Burns, Chest Pain, Trauma, Abdominal Pain, Severe Back or Flank Pain. Non-traumatic MSK pain w/o risk of surgery/myalgias/muscle spasm- non-opioid strategy Pain Control. Place patient in position of comfort Consider Cryotherapy (Icepack) 650 mg Tylenol if no acetaminophen usage within past 4 hrs. Toradol 15 mg IV or 30 mg IM. Ativan 1 mg IVP for muscular spasm in severe radicular type pain. For severe pain, may consider Ketamine w/o narcotics 0.2 mg/kg IVP based upon ideal body weight. Suspected Kidney Stones: 1st line interventions Place patient in position of comfort 650 mg Tylenol if no acetaminophen usage within past 4 hrs. Toradol 15 mg IV or 30 mg IM. TORADOL is CONTRAINDICATED in patients with a history of peptic ulcer disease or gastrointestinal bleeding, childbearing age female without bilateral tubal ligation/hysterectomy, or history of advanced renal disease. NSAIDS increases risk of bleeding, can cause kidney damage, and are associated with increased risk of premature closure of the ductus arteriosus in pregnancy due to inhibition of prostaglandins. Severe Pain IVP and IO Fentanyl 0.5-1 mcg/kg up to 100 mcg per dose q 10 min up to 3 mcg/kg total. For anyone who is intoxicated or mildly altered consider ½ dose test dose. For over age 65, consider IVP/IO 0.25-0.5 mcg/kg for the first dose keeping in mind that in significant obesity dosing should be based more on ideal body weight. Subsequent doses if pt tolerates 1st dose hemodynamically may be increased to 1 mcg/kg if needed. IV, IO q 10 min up to 3 mcg/kg total. Intranasal Fentanyl 1 mcg/kg IM, IN q 10 minutes up to 3 mcg/kg. Fentanyl is preferred in trauma patients. Dilaudid for severe pain: 0.5-1 mg IV, IO, IM q 15 minutes until pain is tolerable or 2 mg has been received. May use 1 mg aliquots up to 4 mg total for severe burns. Call for more aggressive dosing. Ketamine 0.2 mg/kg IV, ideal body weight IV, IO over 5 minutes may repeat x 1 after 15 minutes. 0.5 mg/kg IN, consider diluting in 50-100 ml NS or D5W for infusion over 10 minutes. Do not exceed 30 mg per dose. Ketamine is SYNERGISTIC with opioids for severe pain but in select cases (other respiratory depressants/ETOH on board) may be the best single option from a safety perspective. NOTE: Prolonged transports may consider Fentanyl drip and Ketamine sub-anesthetic (i.e "pain") drip (NOT TO BE CONFUSED WITH KETAMINE SEDATION INFUSION) For prolonged transports, considered Fentanyl gtts 1mcg/kg/hr Titrate by 0.5 mcg/kg/hr q5 min to max dose of 3 mcg/kg/hr. Ketamine 0.05-0.2 mg/kg/hr (IBW) for additional analgesia. (Pain dose drip) Monitoring Any benzodiazepine, opiate, or ketamine utilization requires continuous monitoring with capnography in addition to SpO2, and Blood pressure monitoring. Stop if patient has mental status changes Table of Contents 23  Sedation SEDATION/ANXIETY INDICATIONS: May be indicated for invasive medical procedures including Cardioversion, Transcutaneous Pacing, and Resedation if pt is already intubated MEDICATIONS VERSED 2-3 MG IV, IO, 5 mg IM, Adults>50 kg 10 mg IN Do not use with HYPOTENSION. May repeat every 15-20 minutes as needed. ATIVAN 0.5-1 MG IVP: Utilize for acute anxiety or difficulty with tolerating BiPAP/CPAP. May repeat q 10 min to max of 3mg. Stop if patient appears drowsy. KETAMINE 1 MG/KG (IBW) IV (If no IV Access: 2 MG/KG IM) Consider Ketamine sedation infusion for longer transports - 1mg/kg/hr titrate to effect, Titrate by 0.5 mg/kg/hr q 5 min to a max dose of 4 mg/kg/hr Note: If utilizing online control (sending physician order) for propofol, please consider fentanyl IVP or drip as propofol has no pain control. Do not limit pain and sedation treatment based on blood pressure limitations. Utilize appropriate hemodynamic resuscitation (fluids, pressors) to resuscitate patient so that pt can be appropriately sedated and pain controlled. Can discuss with online medical control switching to ketamine if necessary. Any benzodiazepine, opiate, or ketamine utilization requires capnography in addition to SpO2, and Blood pressure monitoring. Table of Contents 24  Non-Agitated Psychosis Non-Agitated Psychosis Criteria (all must be satisfied): Patient is in a suspected state of Psychosis that must be documented (ex: flight of ideas, compression of speech, delusional, ideas of reference, auditory hallucination) Pt is acutely agitated or is not able to be de-escalated Management: Approach patient with respect and calmly. Remember that this is an illness that the patient is dealing with more than you are. Clarify for the patient what their choices are based on patient's capacity. Assess patient's capacity to understand their own decisions and the consequences of those decisions AND for Suicidal Ideation/Homicidal Ideation ○ If pt does not have capacity, they must go to hospital. If pt refuses, call medical control. Ask law enforcement for assistance. If law enforcement refuses to assist, call medical control to ask them to talk to law enforcement. Document. MEDICATIONS Ativan 1 mg IVP for anxiety And/or (with goal of maintaining pt who can be aroused from sleep) Haldol 2.5 mg IVP for difficulty with keeping thoughts organized, self-concern for agitation, hallucinations Any benzodiazepine, opiate, or ketamine utilization requires capnography in addition to SpO2, and Blood pressure monitoring. Table of Contents 25  Agitated Patient AGITATED PATIENT Criteria (all must be satisfied): Patient is in a suspected state of alteration secondary to suspected psychosis, drugs, or alcohol --OR--- Pt does not have capacity to understand consequences of decisions --OR-- Pt has engaged with EMS Personnel through transport or scene interaction, is acutely agitated AND will not disengage from EMS Personnel Pt is verbally aggressive with posturing and threatening personnel, bystanders, or themselves. Pt is physically aggressive making physical contact with EMS personnel Management: Approach patient with respect and calmly. Clarify for the patient what their choices are based on patient's capacity. Assess patient's capacity to understand their own decisions and the consequences of those decisions AND for Suicidal Ideation/Homicidal Ideation If law enforcement has requested your assistance, immediately clarify that they are handing patient over to you as a patient. Once a patient is handed off to EMS, all scene efforts by EMS and law enforcement are to be centered on patient assessment and management. There is to be no delay in assessing vitals. Perform full assessment of patient. Attach to monitoring. Cardiovascular collapse is a consideration in agitated patient. EMS personnel need to establish that patient is altered, psychotic, or without capacity to be treated by EMS. Protect patient and staff as appropriate per Restraint policy Table of Contents 26  Restraint Policy RESTRAINT PROTOCOL Criteria (all must be satisfied): Patient is in a suspected state of alteration secondary to suspected psychosis, drugs, or alcohol --OR--- Pt does not have capacity to understand consequences of decisions --OR-- Pt has engaged with EMS Personnel through transport or scene interaction, is acutely agitated AND will not disengage from EMS Personnel Pt is a danger to self or to EMS Personnel or others Pt cannot be verbally de-escalated Intubated patients with risk of grabbing tubes do fit this criteria Soft Restraints: Posey Soft Restraint system may be utilized for all 4 extremities. Curlex may be used as a substitute but must be changed over to Posey product as soon as possible. Spit Hood may be utilized if pt is spitting on personnel if available Deescalate as soon as possible and you may offer to pt to take one extremity out of restraints at a time if patient can deescalate and follow boundaries set for safety If patient has soft restraints placed, they must be transported to a facility that can continue restraints. MEDICATIONS Acutely Psychotic Patients: Haldol is slower (15 min vs 5 min for IM Ketamine) but has a better effect on psychosis VERSED 3 MG IV or 5 mg IM or Do not use with HYPOTENSION or if Significant ETOH on-board HALDOL 5 mg IVP or 10 mg IM. May repeat x1 if pt is not adequately improved wait 10 min for IV Haldol and 20 min for IM Haldol before redosing Stimulant Patients with significant tachycardia (cocaine/methamphetamine): Consider that benzodiazepines are the first line medication for stimulant toxicity including anxiety, chest pain, paranoia (Cocaine, Methamphetamine) Haldol/Versed combination will improve tachycardia and agitation but 12 lead needs to be performed as soon as patient can tolerate due to risk of QTc prolongation with cocaine. Other patients: KETAMINE 1 MG/KG IV (If no IV Access: 2 MG/KG IM). May repeat 1 mg/kg IVP, or 2 mg/kg IM WITH RECOGNITION THAT YOU ARE APPROACHING INDUCTION DOSING AND ARE RISKING PATIENTS AIRWAY. ** Call medical control for additional dosing. *** Any benzodiazepine, opiate, or ketamine utilization requires capnography in addition to SpO2, and Blood pressure monitoring. Table of Contents 27  Diabetic Emergency DIABETIC EMERGENCY INDICATIONS HYPOGLYCEMIA ( BGL 100 mg/dL ○ Must have someone who will remain with the patient and has access to call 911 ○ Patient must have GCS of 15/15 ○ Is not on an oral antihyperglycemic agent. Hyperglycemia > 250 mg/dL with signs of DKA Normal Saline or Lactated Ringers Bolus 1 L. (FLuid bolus is CONTRA-INDICATED in PEDIATRICS). CHF patients and Renal Failure Patients should only receive 250 mL bolus and repeat x 1 Contact Medical Control for further orders if needed Perform DAAM only if absolutely necessary and there is signs of impending respiratory failure Aggressive ventilator management will be needed if DAAM is performed. Table of Contents 28  Chest Pain CHEST PAIN Suspected Cardiac Event or Infarction Apply Cardiac Monitor and perform 12 lead EKG and interpret within 10 minutes of arrival ○ Consider Right Sided EKG for inferior STEMI, looking for ST changes in V4R ○ Consider Posterior EKG if ST depression in V1-V3 Manage any dysrhythmias per their appropriate protocol / ACLS algorithms Give Aspirin 324 mg chewable PO if no contraindications Obtain IV Access and perform Blood Draw for receiving ED. Consider 2 IVs if time allows and concern for STEMI Administer Nitroglycerin 0.4 mg SL as long as SBP> 100. Repeat q 5 minutes with total of (3) three tablets given. Do not give if recent usage of Erectile Dysfunction or Pulmonary Hypertension medications. ○ Sildenafil (Viagra) and Vardenafil (Levitra) < 24 hours / Tadalafil (Cialis) < 48 hours Increased Transport Times-May utilize above protocol as below: Consider administering Nitro Drip beginning at 5 mcg/min and may increase by 5 mcg every five minutes while maintaining SBP of 100 or above. May give Fentanyl 0.5-1 mcg/kg. May repeat q 5-10 minutes as needed. NOTE STEMI patients are best served by transport to the closest appropriate destination capable of 24/7 PCI. Patient must be deemed stable by the Paramedic and Medical Control in order to bypass the closest appropriate 24/7 PCI facility. Regardless of PCI facility report should be called as soon as possible to activate the Cath Lab and confirm absence of diversion. Kokomo If the patient prefers Ascension St. Vincent, contact your on duty Medical Control at Ascension St. Vincent to consult about direct transport to the Ascension St. Vincent Heart Center at 10580 N Meridian St, Indianapolis, IN 46290. Report should be called to the Heart Center at 317-583-5145 as soon as possible to activate the Cath Lab. Williamsport If extreme weather conditions prohibit safe transport to a PCI facility within 180 = 0.8 mg ○ SBP > 220 = 1.2 mg For transport times greater than 10 minutes, begin NTG drip at 5 mcg/min and increase 5mcg every 5 minutes or as patient tolerates as long as blood pressure remains above 100 systolic. Place patient on BiPAP as indicated. If wheezing is present may administer Albuterol 2.5 mg and Atrovent 0.5 mg nebulized in line with the BiPAP device. If patient is not already prescribed Furosemide then administer Furosemide 20 mg VIA SLOW IVP for acute pulmonary edema only. If prescribed Furosemide then give the patient their normal daily dose IVP. BLOOD PRESSURE BELOW 100 SYSTOLIC Refer to the Cardiogenic Shock Protocol The goal is to use vasopressors and inotropic medications to increase BP and maintain perfusion to be able to utilize BiPAP. Contact medical control for further consultation **Per the FDA, onset of diuresis following IV administration of Furosemide is within 5 minutes and peak effect occurs within the first half hour. IV Furosemide protocol is for reducing patients wait times for medication administration in the ED thus improving patient outcomes by providing ED level care in the prehospital setting. Table of Contents 42  Toxicology TOXICOLOGY Suspected Serotonin Reuptake Inhibitor Overdose: (Serotonin Syndrome- can occur from SSRIs, SNRI, Tramadol, MAOIs, and many other drugs) Serotonin Syndrome occurs when too much serotonin is available to receptors ○ Signs: Dilated pupils, restlessness, tremor, tachycardia, fever, jerky movements, confusion, seizures Start 1L fluid bolus If symptomatic Call Med Command and advise ○ If med command agrees, may give 1 mg Ativan q 10 minutes until HR decreases below 100 as long as non-hypotensive and patient remains alert Opiate Overdose: (Opioid Pain Medication and Street Drugs) Search for evidence of the substance ingested or interview bystanders. If patient is unconscious, has pinpoint pupils, and respiratory depression: (Opiates Suspected) initiate IV and give Naloxone 0.5 mg, repeat until patient is able to maintain own airway or max dose of 10 mg. If unable to establish IV, give Naloxone IN 2 mg. May repeat for total of 4 mg. Ventilate patient with BVM and airway adjunct. Provide Suctioning as needed. Prepare to perform intubation if not affective. Tricyclic (TCA) Overdose ( example: Amitriptyline) If patient has QRS duration >0.10 give Sodium Bicarbonate 1 mEq/kg. Call Med command ○ If approved by med command, prepare to give Sodium Bicarbonate until QRS closes to less than 100 ms Prepare for seizure possibility. DAAM may be needed due to AMS. Start NS Bolus prior to induction. Beta Blocker Overdose ( example: Metoprolol) If patient has symptomatic bradycardia: ○ 1 L Fluid Bolus of Normal Saline ○ If Atropine is unsuccessful, Consider glucagon 2-4 mg IVP. (GIVE ZOFRAN FIRST- Will cause vomiting) Usually takes 5-10 mg to be successful. ○ If Glucagon Unsuccessful, Attempt pacing. Calcium Channel Blocker Overdose (examples include: Verapamil, Diltiazem, Nifedipine, amlodipine, nicardipine If patient has bradycardia and hypotension, Administer 1 gram Calcium Chloride Obtain Additional IV, Pt will need High dose insulin GTTS on arrival to ED Organophosphate poisoning (ie. Insecticides, Nerve Agents) Decontaminate the patient with copious amounts of water. MAINTAIN CAREFUL CONTACT PRECAUTIONS. Give Atropine 1 mg IVP every 2-3 minutes until drying of secretions is achieved. Will likely require ALL of your atropine and possible additional truck inventory There is a high likelihood of need for intubation utilizing DAAM due to secretions. Versed for induction would be appropriate (SZ risk) induction agent. Avoid Succinylcholine as paralytic (Prolonged paralysis as long as 7 hrs) Plan for seizure activity. Monitor Pupils if paralyzed. Treat according to seizure protocol Transport Emergently to closest appropriate facility once the patient has been decontaminated. Notify facility early of decon and OD. Note: Consider contacting the Indiana Poison Control Center at 1-800-222-1222. Poison control can be a great resource for information about a substance or medication, however online Medical Control will be necessary to deviate outside of protocols. Table of Contents 43  Seizure SEIZURES Begin Initial Medical Care, consider droplet precautions if hx of fever, severe headache, with neck stiffness, etc. Find out seizure history, evaluate for toxicology etiology (TCA OD, Benadryl OD, organophosphate poisoning). Inquire about medication compliance. Draw blood / perform finger stick and perform blood glucose analysis. If blood sugar indicates, or patient condition and/or history suggest Hypoglycemia, refer to DIABETIC EMERGENCIES Protocol. If seizure activity persists : give Versed IM 10 mg >40 Kg x1, Versed 5 mg IM15 yrs old Significant trauma with a HR greater than 110 and/or SBP less than 90 systolic Suspected life threatening traumatic hemorrhage Contraindications include: Greater than 3 hours since injury* (*If given after 3 hours, known to cause INCREASED mortality). Isolated head injury. Pregnancy. Maintenance TXA Drip will be continued by the receiving facility or aeromedical crew. 1g of TXA should be drawn into a 100 mL bag of NS and ran in over 10 minutes or IVP slowly over 10 min Indications are listed above: *TXA is not to be used in isolated head injuries or GI hemorrhage based on studies that indicate no benefit or increased risk of harm to patient. Orthopedic Trauma: If deformed extremity does not have pulses, may attempt repositioning to neutral inline position with traction to attempt to re-establish pulse. ○ Ideally, performed with pain medication however if BLS crew only and limb is felt to be threatened repositioning may be attempted with patient's permission as it will likely improve pain after repositioning. Table of Contents 46  Trauma Cont. If there is a large open wound or open fracture you may consider Ceftriaxone 1 G in a 100mL bag of NS, over 10 minutes. If possible (based on patient mental status), make certain that the person does not have a penicillin or cephalosporin allergy. Air Ambulance Use: Air Ambulance Transport should be considered for transport to a Trauma Center. In rural areas, scene flights may be indicated and appropriate resources will need time to establish Landing Zone. If time or location do not permit, patient should be transported to the HospitalHelipad. Paramedic will establish with dispatch what channel communication will occur with the flight team on. (Kokomo E-MA 4 Zone 1, WCEMS DMA4 in Zone 1). If an aircraft is not available or has extended ETA, transport may be taken by ground to the nearest trauma center within (45) forty five minutes per the Indiana Trauma Code. May need to transport to the closest appropriate facility if there is a need for blood products or procedure that is beyond the scope of practice by the Paramedic. Table of Contents 47  Burns THERMAL BURNS General Guidelines Begin Standard Trauma Care (MARCH) Remove any material covering burns and any jewelry worn by the patient Cover with clean, dry dressing. Cover large areas with sterile burn sheets. Elevate burned extremities if possible. Provide Pain Management as indicated. Fluid Administration: >14 yrs old: Updated Prehospital American Burn Association Guidelines are for 500 mL/hr Facial / Airway involvement Provide Albuterol if wheezing is present. Follow Drug Assisted Airway Management Protocol if patient has stridor, clear airway swelling, or altered mental status. Clearly Stable patients can be observed closely with EtCO2, SpO2, cardiac monitor, vital rechecks, and revaluations. Observed patients are ALS. DO NOT USE Succinylcholine if burns are OVER 72 hrs old. CRITICAL BURN CRITERIA Combined injury (both partial and full thickness burns) Greater than 10% in ages less than 10 or greater than 50 years. Greater than 20% in all other age groups. Full thickness injury-All burns greater than 5%. All burns involving: hands, face, eyes, ears, feet, perineum, and major joints. Inhalation, electrical or chemical injury. Major trauma or pre-existing disease. NOTE: Patient's meeting criteria should be transferred to St. Vincent Indianapolis Burn Unit by aircraft. Peyton Manning is also accepting Pediatric Trauma and Burns. If an aircraft is not available or has extended ETA, transport may be taken by ground to the nearest trauma center within (45) forty five minutes per the Indiana Trauma Code. May need to transport to the closest appropriate facility if there is a need for blood products or procedure that is beyond the scope of practice by the Paramedic. Table of Contents 48  Head Injury HEAD INJURY General Guidelines Initial management is covered by Trauma Protocol. Identify if patient is isolated head injury vs head injury w/hemorrhage due to organ or large extremity trauma. Check glucose and correct if needed. Cornerstone of management is based on Epic 2.0 study: Aggressively prevent and treat the Three H-Bombs of TBI- Hypoxemia, Hypotension, Hyperventilation. Preventing Hypoxemia: NRB 100% on all patients that are spontaneously breathing w/ AMS or FiO2 of 100% on Ventilator. NC 4-6L titrating to 100% SpO2 on all non-altered patient. NRB if needed. Initiate ASAP. That means as soon as found and wherever found. Example: Apply O2 in car before extrication. Do not be concerned with hyper-oxia as the detrimental effects of hypoxemia vastly outweighs that of hyper-oxia. Patients can deteriorate rapidly and the unexpected "crash" should be prepared for. Preventing Hypotension: If patient has isolated head injury, fluid bolus of 1000 ml IV crystalloid solution may be given to keep SBP>110 ○ Begin before hypotension starts! Repeat as needed with 500 ml bolus to maintain SBP>110 sys. The use of vasopressors to maintain SBP may actually cause an increase in ICP and therefore should be avoided. Use sedatives with caution. Consider dosing at 1/2 the normal dose. Do not give if SBP is low or actively decreasing. Consider using Ketamine as it has less potential for hypotension. Break up pain and sedation into more frequent but smaller doses or consider initiating a drip. Preventing Hyperventilation: ETCO2 monitoring is a must on all TBI patients! If personnel numbers allow designate 1 person to continuously monitor and manage the ETCO2. ○ This person will be the most important person in the TBI care algorithm. If intubating patient, place on the ventilator ASAP and avoid hyperventilation. Start with Vt 5-6 ml/kg IBW and RR of 10. Maintain ETCO2 by gently adjusting volume/rate to target of 40 mmHg with the range 35-45 mmHg. The goal is to aggressively prevent hypocapnia ie ETCO2 65 Significant distracting Injury Intoxication Cervical collar AND either scoop stretcher, vacuum splint, ambulance cot or other similar device to which a patient is safely secured should be provided to patients with: Unconscious or Altered Mental Status secondary to traumatic event Neurological Deficit present Midline deformity that is new secondary to traumatic event Considerations: **Pay attention to patient transfers to not cause undue flexion, extension, or rotation of a possible injured spine. Vacuum mattress is recommended for transfers of injured spine. **Long back boards may be used for extrication and multiple patient purposes only. **During third trimester, transport pt in the left lateral recumbent position while secured into vacuum mattress. **Be careful with C-collar tightness in cardiac arrest and head injury patients. Tight collars are known to increase ICP and decrease cerebral perfusion **Prolonged use of C-collars is known to cause pressure ulcers and there is low quality evidence for the efficacy of the c-collars in preventing further injury Table of Contents 52  Spinal Cord Injury SUSPECTED SPINAL CORD INJURY General Guidelines Begin Standard Trauma Care (MARCH) Check Blood Glucose level If unconscious, or showing signs of increased ICP, elevate HOB to 30 degrees. Protect patients airway and follow Drug Assisted Airway Management protocol as indicated. If performing DAAM it is imperative to prevent hypoxia and hypotension. Treat aggressively. Place patient on End Tidal Capnography and maintain range of 30-35 mmHg. Hypotensive and Bradycardic (Systolic 80) Administer Labetalol 10-20 mg SIVP over 2 minutes. Key Signs/Symptoms of Head / Spinal Cord Injury) 1. Repetitive questioning with supported MOI. 2. Cushings Triad – Bradycardia, irregular breathing, and hypertension 3. CSF fluid present Table of Contents 53  Hypothermia HYPOTHERMIA Criteria: Any patient with a lowered core body temperature PASSIVE REWARMING Heat on high in patient compartment of Ambulance Remove all clothing Wrap Patient in warm blankets PO Warm Fluid with Glucose if patient is alert and oriented. Maintain patent airway or follow airway management protocol if not able. Administer oxygen via non-rebreather if patient has patent airway, otherwise assist with ventilations. Maintain ETCO2 35-45 (rapid correction of Acidosis may induce ventricular fibrillation) Consider decreasing respiratory rate if no capnography NON-INVASIVE ACTIVE REWARMING Covered Hot Packs on accessible high arterial flow areas (neck, axilla, groin) Provide Warmed IV Fluid (Normal Saline or D5W): large bore IV preferred Warmed Humidified Air (Aerosolized warm saline) IF PATIENT IS PULSELESS If no Pulse, begin CPR Remove wet clothes. Apply and secure (tape) hot packs to maintain position. Initiate Warm fluids bolus rate and consider nebulized warm saline Hypothermia Patients are considered viable until rewarmed and pronounced deceased by the physician in the ED. Patient must be transported to the hospital for invasive rewarming Defibrillate as appropriate; consider contacting Medical Control regarding refractory V-fib. Consider Mag Sulfate 2 grams IVP as antiarrhythmic in hypothermia (discuss with Medical Control) Consider Sodium Bicarbonate 1 mEq/kg if you suspect severe lactic acidosis usually present in hypothermia with long down time. May give Epinephrine 1:10,000, 1 mg x1, IVP. Contact medical control prior to any further drug administration Notify the receiving Emergency Department EARLY for the need of rewarming measures to be continued on arrival. Warm and dead is 95F Table of Contents 54  Hyperthermia HYPERTHERMIA Criteria: Any patient with an increased core body temperature General Treatment Remove patient from dangerous environment and move a patient to a cooler environment Place patient in supine position if possible. Initiate the cooling process, fan the patient if possible. AVOID MAKING THE PATIENT SHIVER! If shivering develops, stop the cooling process. Remove any unnecessary clothing, to facilitate cooling. Try to obtain an accurate core temperature. (RECTAL or Tympanic Membrane Temp NOT ORAL) Observe patient closely for possible aspiration and/or seizure activity. Heat Exhaustion Signs & Symptoms ○ Normal Temperature ○ Nausea/ Vomiting ○ Cramps/Thirst ○ Pale/ Clammy Skin Treatment- Use cooling techniques such as: ○ Fanning ○ Apply Cool Wet towels to skin ○ Sponge with tepid water ○ Cool IV Fluids (Cool Oral Fluids if appropriate) EHS( Exertional Heat Stroke) Preferred Cooling Method Signs & Symptoms ○ Hot Temperature/Skin Flushed ○ No Perspiration (Sweating Absent) ○ Stuporous, altered mental status, unconscious ○ EHS( Exertional Heat Stroke) is a unique and emergent hyperthermic condition that occurs in individuals performing intense physical activities. PROTOCOL Perform rapid routine assessment (103), initiate immediate rapid cooling to a temperature less than (103F) within 30 minutes of collapse. If care has not been initiated and EHS is suspected, immediately perform a rectal or TM temperature. If EHS has been confirmed and appropriate cooling has been initiated by an appropriate onsite medical team or athletic trainer, DO NOT interrupt cooling for assessment or transport. Best Practice for cooling an EHS patient is whole-body cold water immersion from the neck down. Immersion in ice water-filled body bag or tarp may yield acceptable cooling rates. Table of Contents 55  Hyperthermia Cont. Ice packs, fans, cold water dousing or shower do not achieve acceptable cooling rates. Rotating ice water towels covering as much of the body surface area as possible should be considered a minimum cooling modality enroute. Discontinue cooling at (102F), Rectal Temperature. If a Rectal temperature is not available. cooling should not be interrupted or delayed in cases of suspected EHS. Cool for a minimum of 20 minutes / clinical improvement if resources available on scene, or transport with best available active cooling method (Body bag with ice water or rotating ice water soaked towels.) DO NOT interrupt cooling for diarrhea, emesis, combativeness, or seizures. IV/IM medications are rarely needed. Transport to the closest receiving facility and notify that EHS is suspected. ★ For events with medical personnel and cooling means on site, the only appropriate standard is to cool the EHS patient in place. Transportation of an EHS patient should only be done if it is impossible to adequately cool the patient, or after adequate cooling has been verified by rectal temperature. ONLY ACCEPTABLE BODY TEMPERATURE MEASUREMENT IS VIA RECTAL or TM TEMPERATURE- NEVER ORAL. EMS MUST ensure early prehospital notification as per CODE STROKE or CARDIAC ARREST PROTOCOL. INITIAL TREATMENT Remove as much clothing as practical and loosen any restrict garments. If alert and orient, give small sips of cool liquids. Monitor and record vital signs and level or consciousness. If altered mental status exists, check blood glucose level. Determine patients core temperature, if possible (rectal temperature preferred) If thermometer not available, assume heat stroke if altered mental status. Diagnosis of hyperthermia is based on clinical signs. If temperature is above 104F or 103F if symptomatic or AMS is present with elevated temperature , begin active cooling by whole body water immersion from the neck down. NOTE: ELDERLY PATIENTS ARE LESS ABLE TO WITHSTAND SUDDEN SHOCKS, SO BEGIN WITH LESS AGGRESSIVE COOLING MEASURES LIKE MISTING OR COOL WET CLOTHS. WHEN YOU REASSESS THE PATIENT, IF THERE IS LITTLE OR NO IMPROVEMENT, USE MORE AGGRESSIVE MEASURES. Discontinue active cooling if shivering occurs that cannot be managed by Paramedics (see below) or temperature is (160 or DBP>110 may give 20 mg IVP Labetalol over 2 minutes. HOLD for maternal heart rate160/110 after 10 minutes, repeat labetalol at 40 mg IVP over 2 minutes. After 10 minutes if BP continues>160/110, ACOG Safe Motherhood initiative would instruct to escalate to 80 mg labetalol over 2 minutes. Call medical command to confirm if they would like you to escalate. If seizures are refractory to magnesium and benzodiazepines, Drug assisted airway management would be appropriate with benzodiazepine post-sedation. Table of Contents 61  Pre-Eclampsia PRE-ECLAMPSIA Pre-eclampsia is diagnosed with multiple BPs >140/90 >4 hrs apart with gestation >20 wks or postpartum160/110 for >15 minutes OR BP >140/90 WITH unremitting headache or vision changes, RUQ pain, or epigastric pain. If patient has severe hypertension or concerning symptoms. Other signs of preeclampsia include: ○ swelling ○ pulmonary edema ○ foamy urine (protein in urine) If maternal heart rate is >60, may consider labetalol 20 mg IVP over 2 minutes with approval of medical control. Medical control may request prophylactic magnesium sulfate for seizure prophylaxis Provide Oxygen Position patient in the left lateral recumbent position if possible. If patient starts seizing, see ECLAMPSIA protocol. Table of Contents 62  Childbirth CHILDBIRTH Childbirth is a natural process. EMS providers called to a possible prehospital childbirth should determine whether there is enough time to transport the expectant mother to the hospital or a pre-hospital childbirth is imminent. If childbirth is imminent, immediately prepare to assist with the delivery using appropriate obstetrical equipment. If delivery begins Control delivery of head so it does not emerge too quickly. Support infant's head as it emerges and protect perineum with gentle pressure. Puncture (with gentle finger pressure) amniotic membrane if it is still intact and visible outside the vagina. Check for cord around the neck. Gently remove cord from around neck if present. With bulb syringe, suction mouth, then nose of infant as soon as head is delivered. As shoulders emerge, guide the head and neck downward to deliver anterior shoulder. Support and lift head and neck slightly to deliver posterior shoulder. The rest of the infant should deliver with passive participation; get a firm hold on the baby. Keep newborn level with the mother's vagina until the cord stops pulsating and is double clamped. See PostPartum Care. Cord wrapped around neonate's neck after presentation of the head Gently apply traction to the cord and remove from the neonate's neck. If it is impossible to remove the cord manually, it may be cut. It should be clamped in two places, and then cut between the clamps. This should be cut only after it is absolutely clear that it cannot be removed from around the baby's neck with traction. Breech delivery: Breech deliveries are best managed in a hospital. If known fetal breech position exists but fetus is not actively delivering, position mother on her left side. Ask if she can avoid pushing and breathe through contractions. This may delay birth until she can be transported to an appropriate facility WITH C-SECTION CAPABILITY. With long transport time, however, delivery may be imminent and unavoidable Position mother by elevating pelvis to facilitate delivery in breech position For a buttocks presentation, allow newborn to deliver to the waist without active assistance (support only). Use hand to prevent explosive delivery. When legs and buttocks are delivered, the head can be assisted out. If the head does not deliver, insert gloved hand into the vagina, palm towards the baby's face and cord between fingers and create an airway. Apply downward traction to deliver the shoulders and head. Also may rotate baby into a side facing position to deliver shoulders one at a time. Have a second provider apply suprapubic pressure to flex baby's head down. Advise mother to push. If this does not work, Consider Mauriceau Maneuver While supporting baby’s body, place two gloved fingers in a “V” shape on the fetal maxilla, applying enough pressure to tuck and flex the child’s head. The maneuver is to tuck--NOT PULL--the head Table of Contents 63  Childbirth Cont. Place your other hand gently over the occiput to aid in flexion Instruct mother to push hard while another EMS provider or support person continues to apply suprapubic pressure to promote flexion of the head and assist with the delivery Umbilical cord prolapsed (TRANSPORT TO OB CENTER WITH C_SECTION CAPABILITIES) Administer oxygen to mother Place mother in extreme Trendelenburg position if possible or on left side as alternative Protect cord, insert gloved hand into vagina and gently push the presenting part off the cord. Cover exposed portion of the cord with saline soaked gauze. Do not attempt to push the cord back unless directed by medical control. This is a surgical emergency, immediate transport and notification of hospital is crucial. Shoulder Dystocia (TRANSPORT TO OB CENTER WITH C-SECTION CAPABILITIES): McRoberts Maneuver Have the mother grasp behind her knees and pull her thighs back as if she were trying to put her knees into her armpits. If mother is unable to perform this maneuver, have another EMS provider or on-scene support person assist Another EMS provider or on-scene support person should then position themselves alongside the mother opposite the side the baby is facing and apply firm pressure straight downwards AND towards the back of the baby's shoulder just above the mother’s pubic bone With both of these maneuvers applied, have the mother push hard. The provider attending to the fetus should guide the head downward with a gentle pressure, but do not stress the neck Limb Presentation (TRANSPORT TO OB CENTER WITH C-SECTION CAPABILITIES): Limb presentations occur when the fetus is in a transverse lie in the uterus, and the arm or leg protrudes from the vagina. This is seen in less than 1% of deliveries and is most often associated with preterm birth and multiple gestation situations. This is a life threatening situation for the fetus" Place mother in knee-chest position (prone, resting on her knees and upper chest), and secure her as well as possible for transport Place on High Flow O2 Consult with Receiving OB as medical control ASAP *Credit to UNM's OB Protocols for significant contribution to these protocols. Table of Contents 64  Post Partum Care POST PARTUM CARE INFANT Continue to suction mouth and nose: spontaneous respirations should begin within 15 seconds after stimulating reflexes. If not, begin artificial ventilations at 30-40 breaths/minute. If no brachial pulse, or pulse less than 60, begin CPR. Contact Medical Control. see NEONATE RESUSCITATION PROTOCOL. Dry baby and wrap in warm blanket. Keep newborn level with mother's vagina for minimum of 60 seconds ○ Baby's lose heat rapidly, maintain Skin to skin contact for mother and newborn. Turn heat on in ambulance. Clamp the umbilical cord 6-8" from newborn abdominal wall and cut the cord between the two clamps, with sterile scalpel found in OB kit. If no sterile cutting instrument is available, do not cut the cord and lay the infant (with cord clamped) on the mother's abdomen. Check the cord ends for bleeding. If there is any bleeding from the cord, re-clamp in another place close to the original clamp. Obtain APGAR Scores at 1 minute and 5 minutes, record for the Hospital. Mother If transport>10 minutes than initiate Oxytocin 30 IU in 500 mL LR over 1 hr to prevent postpartum hemorrhage, may give Oxytocin 10 units IM if unable to get IV. Placenta without oxytocin typically delivers within 20-30 minutes. If delivered, collect placenta in plastic bag and bring to hospital. DO NOT pull on cord to facilitate placental delivery. This allows for analysis if there are genetic concerns. DO NOT delay transport while waiting for placenta to deliver. Palpate for the top of the uterus. Massage the uterus in the lower abdominal wall (fundus) until firm with the tips of your fingers moderately vigorously. This WILL cause discomfort but is the most important step in decreasing hemorrhage by stimulating contraction Maternal Hemorrhage is defined as blood loss greater than 1000 mL or blood loss accompanied by hypovolemia. This is a leading cause of maternal morbidity. ○ If Maternal hemorrhage continues after fundal massage and Oxytocin, 1g TXA over 10 min (IVP or IVPB) may be considered IF patient has delivered within past 3 hours (the earlier the more effective the intervention).Should consider calling receiving facility OB and discussing as med command unless situation is critical. ○ Also note that nursing also stimulate uterine contractions which helps with uterine bleeding. IV Fentanyl should not be a barrier to nursing unless large doses were given. May discuss with online med control OB ○ The triad of death (hypothermia, acidosis, and coagulopathy) has application in hemorrhage in the form of managing the patient's temperature.. If pt is hypothermic perform warming measures. Start 2 large bore IV lines with 1000 ml NACL and run wide open to maintain a systolic blood pressure of 90. Table of Contents 65  Post Partum Care Cont. Initiate transport when delivery of the child is complete, infant is properly assessed and mother can tolerate movement. If the perineum is torn and bleeding, apply direct pressure with sanitary pads, and have patient bring legs together. If quick clot gauze is available, may consider. Table of Contents 66  Drug List Drug Name Supplied Min. Qty. Acetaminophen 650mg tablet 2 Adenosine 6mg/2mL vial 6 Albuterol 2.5mg/3mL single dose tube 6 Amidate 20mg/10mL vial 4 Amiodarone 150mg/3mL vial 6 Ativan 2mg/1mL vial 2 Atropine 1mg/10mL preload 6 Atrovent 0.5mg/3mL single dose tube 6 Aspirin Bottle of 81mg ASA 2 Benadryl 50mg/2mL vial 3 Bottle of Water 1 bottle 1 Calcium Chloride 10% 1G/10mL preload 1 Ceftriaxone 1G powder vial 1 Cardizem 25mg/2mL vial 2 D5W 250 mL 2 Dextrose 10% 250 mL 2 Dextrose 50% 25G/50mL preload 2 Dextrose 25% 2.5G/10mL preload 2 Dilaudid 1mg/1mL tubex 2 Dobutamine 500mg/250mL premixed bag 1 Dopamine 800mg/500mL premixed bag 2 Epinephrine 1:10,000 1mg/10mL preload 12 Epinephrine 1:1,000 1mg/mL ampule 4 Fentanyl 100 mcg/2mL vial 2 Fentanyl 250mcg/5mL vial 2 Glucagon 1mg/1mL vial 2 Haldol 5mg/1mL vial 4 Hydroxocobalamin 5g/250mL vial 1 Labetalol 100mg/20mL vial 1 Lactated Ringers 500 mL 1 Lactated Ringers 1000 mL 2 Lasix 40mg/4mL vial 2 Lidocaine (IO) 100mg/5mL preload 1 Ketamine 500mg/10mL vial 2 Magnesium Sulfate 1G/2mL preload 4 Metoclopramide 10mg/2mL vial 1 Narcan 2mg/2mL preload 4 Nitroglycerin Tablets Bottle 0.4mg Tablets 2 Nitroglycerin Infusion 25mg/250mL premixed bottle 1 Norepinephrine 4mg/4mL vial 4 Normal Saline 0.9% 100 mL 2 Table of Contents 67  Drug List Cont. Normal Saline 0.9% 250 mL 2 Normal Saline 0.9% 500 mL 3 Normal Saline 0.9% 1000 mL 3 Oxytocin 30 units 1 Oral Glucose Tube 2 Pepcid 20mg/2mL vial 2 Racemic Epinephrine 2.25% 1 mL single dose tube 2 Rocuronium 50mg/5mL vial 4 Sodium Bicarbonate 50meq/50mL preload 2 Sodium Bicarbonate 8.4% 10meq/10mL preload 2 Solu-Medrol 125mg/2mL Activial 2 Succinylcholine 200mg/10mL vial 2 Thiamine 100mg/2mL vial 2 Toradol 60mg/1mL vial 2 TXA 1g/10mL vial 1 Versed 5mg/5mL vial 3 Versed 10mg/2mL vial 1 Zofran 4mg/2mL vial 4 Zofran ODT 4mg ODT packets 4 Table of Contents 68  Drip Charts Nitroglycerin Drip 50 mg in 250 mL of D5W (200 mcg/mL) 5 mcg/min 60 gtts set = 1.5 gtts/min or pumped @ 1.5mls/hr 10 mcg/min 60 gtts set = 3 gtts/min or pumped @ 3 mls/hr 15 mcg/min 60 gtts set = 4.5 gtts/min or pumped at 4.5 mls/hr 20 mcg/min 60 gtts set = 6 gtts/min or pumped at 6 mls/hr 25 mcg/min 60 gtts set = 7.5 gtts/min or pumped at 7.5 mls/hr 30 mcg/min 60 gtts set = 9 gtts/min or pumped at 9 mls/hr 35 mcg/min 60 gtts set = 10.5 gtts/min or pumped at 10.5 mls/hr 40 mcg/min 60 gtts set = 12 gtts/min or pumped at 12 mls/hr 45 mcg/min 60 gtts set = 13.5 gtts/min or pumped at 13.5 mls/hr 50 mcg/min 60 gtts set = 15 gtts/min or pumped at 15 mls/hr Table of Contents 69  Drip Charts Epinephrine Drip 1 mg (1 mls of 1:1,000) in NS 250mL bag (4 mcg/mL) 1 mcg/min 60 gtts set = 15 gtts/min or pumped @ 15 mls/hr 2 mcg/min 60 gtts set = 30 gtts/min or pumped @ 30 mls/hr 3 mcg/min 60 gtts set = 45 gtts/min or pumped @ 45 mls/hr 4 mcg/min 60 gtts set = 60 gtts/min or pumped @ 60 mls/hr 5 mcg/min 60 gtts set = 75 gtts/min or pumped @ 75 mls/hr 6 mcg/min 60 gtts set = 90 gtts/min or pumped @ 90 mls/hr 7 mcg/min 60 gtts set = 105 gtts/min or pumped @ 105 mls/hr 8 mcg/min 60 gtts set = 120 gtts/min or pumped @ 120 mls/hr 9 mcg/min 60 gtts set = 135 gtts/min or pumped @ 135 mls/hr 10 mcg/min 60 gtts set = 150 gtts/min or pumped @ 150 mls/hr Push Dose Epinephrine Mix 0.1mg (1mL) of 1:10,000 epinephrine in 9 mL of a NS flush Can give 1-2 mL (10-20 mcg) doses every 2-4 mins IV Target SBP is 90 mmHG of MAP of 65 mmgHG Table of Contents 70  Drip Charts Norepinephrine Drip Mix 8 mg of Norepinephrine (2 Amps of 4 mg/4mL) in 250 mL bag of D5W 2 mcg/min 60 gtts set = 4 gtts/min or pumped @ 4 mL/hr 4 mcg/min 60 gtts set = 8 gtts/min or pumped @ 8 mL/hr 6 mcg/min 60 gtts set = 11 gtts/min or pumped @ 11 mL/hr 8 mcg/min 60 gtts set = 15 gtts/min or pumped @ 15 mL/hr 10 mcg/min 60 gtts set = 19 gtts/min or pumped @ 19 mL/hr 12 mcg/min 60 gtts set = 23 gtts/min or pumped @ 23 mL/hr Table of Contents 71  Drip Charts Amiodarone Drip Mix 150 mg of Amiodarone in 100 mL bag of D5W Run pump at 600 mL/hr to run in over 10 minutes Table of Contents 72  Drip Charts Magnesium Sulfate Drip (Severe Asthma) Mix 2 gram of Magnesium Sulfate in 100 mL bag of D5W Set pump to run at 550 mL/hr - 400 mL/hr to run in over 15-30 minutes Magnesium Sulfate Drip (Eclampsia) Mix 2 grams of Magnesium Sulfate in 100 mL bag of NS Set pump to run at 100 mL/hr to run in over an hour Table of Contents 73  Drip Charts Dobutamine Drip 500mg/250mL in pre-mixed bag (2,000 mcg/mL) mcg/kg/min 50kg 60kg 70kg 80kg 90kg 100 110 120 130 140 kg kg kg kg kg 5 7.5 9 10.5 12 13.5 15 16.5 18 19.5 21 mcg/kg/min 7.5 11 13.5 16 18 20 22.5 25 27 29.2 31.5 mcg/kg/min 10 15 18 21 24 27 30 33 36 39 42 mcg/kg/min 12.5 19 22.5 26 30 34 37.5 41 45 48.7 52.5 mcg/kg/min 15 22.5 27 31.5 36 40.5 45 49.5 54 58.5 63 mcg/kg/min 17.5 26.2 31.5 36.7 42 47.2 52.5 57.7 63 68.2 73.5 mcg/kg/min 20 30 36 42 48 54 60 66 72 78 84 mcg/kg/min For 60 gtts set or mLs/hr Table of Contents 74  Drip Charts Ketamine Drip Sedation 500 mg in 500mL bag of NS (1 mg/1mL) Titrate 0.5mg/kg/hr q 5 mins until desired effect mg/kg 50 kg 60 kg 70 kg 80 kg 90 kg 100 110 120 130 140 kg kg kg kg kg 1 mg/kg 50 60 70 80 90 100 110 120 130 140 1.5 mg/kg 75 90 105 120 135 150 165 180 195 210 2 mg/kg 100 120 140 160 180 200 220 240 260 280 2.5 mg/kg 125 150 175 200 225 250 275 300 325 350 3 mg/kg 150 180 210 240 270 300 330 360 390 410 3.5 mg/kg 175 210 245 280 315 350 385 420 455 490 4 mg/kg 200 240 280 320 360 400 440 480 520 560 For 60 gtts set or mLs/hr Ketamine Pain Drip 500mg in 500 mL of NS (1 mg/1 mL) Dosage based on Ideal Body Weight mg/kg/ 50 kg 60 kg 70 kg 80 kg 90 kg 100 110 120 130 140 kg kg kg kg kg 0.05 mg/kg 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 0.1 mg/kg 5 6 7 8 9 10 11 12 13 14 0.15 mg/kg 7.5 9 10.5 12 13.5 15 16.5 18 19.5 21 0.2 mg/kg 10 12 14 16 18 20 22 24 26 28 For 60 gtts set or mLs/hr Table of Contents 75  Drip Charts Fentanyl Drip 250 mcg in 250 mL of NS (1mcg/1mL) Titrate 0.5 mcg/kg/hr q 5 minutes until desired effect or max dose of 3 mcg/kg/hr mcg/kg 50 kg 60 kg 70 kg 80 kg 90 kg 100 110 120 130 140 kg kg kg kg kg 1 mcg/kg 50 60 70 80 90 100 110 120 130 140 1.5 mcg/kg 75 90 105 120 135 150 165 180 195 210 2 mcg/kg 100 120 140 160 180 200 220 240 260 280 2.5 mcg/kg 125 150 175 200 225 250 275 300 325 350 3 mcg/kg 150 180 210 240 270 300 330 360 390 410 For 60 gtts set or mLs/hr Table of Contents 76  Drip Charts Dopamine Drip 800mg/500mL Pre-Mixed bag (1,600mcg/mL) mcg/kg/min Table of Contents 77  Drip Charts Oxytocin Drip 30 units in 500 mL of LR Run pump at 500 mL/hr to run in over Ceftriaxone Drip Mix 1 gram in 100 mL bag of NS Run at 600 mL/hr to run in over 10 minutes TXA Drip 1 gram mixed in 100 mL of NS Run at 600 mL/hr to run in over 10 minutes Hydroxocobalamin (Cyano Kit) Reconstitute Cyano Kit with 200 mL of NS 70 mg/kg up to a total of 5 Grams over 15 minutes Table of Contents 78  IBW Chart Table of Contents 79