2022 EMS SOPs PDF

2 Region IX 2 0 STANDARD OPERATING PROCEDURES/ 0 2...

2 Region IX 2 0 STANDARD OPERATING PROCEDURES/ 0 2 2 STANDING MEDICAL ORDERS 2 2 NORTHWEST COMMUNITY EMS SYSTEM EDITION Healthcare delivery requires structure (people, equipment, education) and process (policies, protocols, procedures) that, when integrated, produce a system (programs, organizations, cultures) that leads to optimal outcomes (patient survival and safety, quality, satisfaction). An effective system of care comprises all of these elements -structure, process, system, and patient outcomes -in a framework of continuous quality improvement (AHA, 2020). These protocols have been developed and approved through a collaborative process involving the Advocate Lutheran General; Greater Elgin Area, McHenry Western Lake County, Northwest Community, Saint Joseph, and Southern Fox Valley EMS Systems to reduce variation in practice and establish a Region-wide System of care. Intended use: Written practice guidelines/pathways of care approved by the EMS Medical Directors (EMS MDs) to be initiated by System EMS personnel for off-line medical control. Standing medical orders to be used by Emergency Communications Registered Nurses (ECRNs) when providing online medical control (OLMC). Medium to large scale multiple patient incidents, given that usual and customary forms of communication are contraindicated as specified in the Region IX disaster plan. System members are authorized to implement these orders to their scope of practice. OLMC communication shall be established without endangering the patient. Under no circumstances shall emergency EMS care be delayed while attempting to establish contact with a hospital. In the event that communications cannot be established, EMS personnel shall continue to provide care to the degree authorized by their license, these protocols, drugs/equipment available, and their scope of practice granted by the EMS MD. Patient care is by nature unpredictable. Online ED physicians have the latitude to deviate from these guidelines if it is believed that deviation is in the best interest of the patient. Such deviations should not detract from the high level of patient care expected from EMS personnel or cause foreseeable risk to a patient, bystanders or EMS personnel. If a patient situation is not covered by these standing orders, initiate Initial Medical or Initial Trauma Care and contact the nearest hospital with System OLMC privileges as soon as possible for a physician's instructions.  Northwest Community EMSS SOPs 2022 Table of Contents GENERAL PATIENT MANAGEMENT Eye emergencies / Facial trauma 50 Introduction 1 Head trauma 51-52 EMS Scopes of Practice 2 Musculoskeletal trauma 53 General Patient Assessment | IMC | N /V 3-4 Spine trauma/Equipment removal guidelines 54-55 Pain mgt | Drug alternatives | Inopressors 5 Multiple Patient Incidents (MPIs) 56 OLMC Report/Handoff Reports 6 START & JumpSTART 57 Withholding/Withdrawing Care | POLST | POA 7 Hazardous Materials Incidents (radiation exp.) 58 Elderly patients 8 Chemical Agents (Adult & peds) 59 Extremely obese patients 9 CHEMPACK plan | Requests 60 RESPIRATORY Active Assailant Response 61-62 Adult Foreign Body Airway Obstruction 10 Transport LEO/Canine| Widespread dx outbreak 63 Advanced airways | DAI 11 Adult ABUSE | Neglect | Maltreatment | Trafficking 64 Allergic Rxn. | Anaphylaxis | Bites-envenomations 12 Trauma in pregnancy 65 Asthma | COPD 13 OB Pts w/ tracheostomy/laryngectomy (adult & peds) 14 Childbirth (Uncomplicated) 66 Acute Resp. Conditions (Flu) | Pulm. embolism 15 Newborn and postpartum care 67 CARDIAC Delivery complications 68 Acute Coronary Syndromes/STEMI 16 Newborn resuscitation 69 Bradycardia with a Pulse 17 OB complications 70 Narrow QRS Complex Tachycardia 18 PEDS Wide Complex Tachycardia with a Pulse 19 Peds Initial Assessment/Medical Care 71 Cardiac Arrest Management (Adult & Peds) 20-21 Peds IMC – Circulation/perfusion | GCS 72 HF | Pulmonary Edema | Cardiogenic Shock 22 Peds Secondary assessment | sedation | VS 73-74 Ventricular Assist Device (VAD) 23 Children with Special Healthcare needs 75 MEDICAL Peds Airway Adjuncts 76 Acute Abdominal | Flank Pain 24 Peds FB Airway Obstruction 77 Dialysis | Chronic Renal Failure 24 Peds Respiratory Arrest | SIDS | BRUE 78 Alcohol Intoxication/Withdrawal 25 Peds Allergic Rx | Anaphylactic Shock 79 Altered Mental Status | Syncope & Pre-syncope 26 Peds Asthma 80 Drug Overdose/Poisoning 27-28 Peds Croup | Epiglottitis | RSV | Bronchiolitis 81 Carbon monoxide (HBO) | Cyanide exposure 29 Peds Cardiac SOPs 82-84 Environmental: Cold related 30 Peds Medical SOPs 85-88 Submersion/Drowning | SCUBA | High altitude 31 Peds Seizure | Sepsis & Septic Shock 89-90 Environmental: Heat-related 32 Peds ITC/Trauma score/Trauma SOPs/Abuse 91-93 Glucose / Diabetes Emergencies 33 APPENDIX 94-117 Hypertension / Hypertensive crisis 34 CPR/Resuscitation Guidelines | Capnography 94 BHE | Decisional capacity | Suicide screen 35-37 Drug appendix | Routes | “Rights“ |Cross check 95-105 Stroke | TIA – Assessment checklist 38-39 Peds Drug tables | Defib J | D10% | Fentanyl 106-108 Seizures 40 Ketamine dose chart 109 Shock - Septic 41 Norepinephrine dose/drip chart 110 Shock – Hypovolemic 42 12-lead changes based on location of STEMI 111 TRAUMA (Adult and Peds) Abbreviations | Acronyms | Symbols 112-113 Initial trauma care (ITC) | GCS | RTS 43-44 Differential of COPD/HF | CPAP indications 114 Triage & transport criteria (table) 45 Biologic, Nuclear, Incendiary & Chem agents 115 Cardiac arrest due to Trauma 46 Hospital contact information 116 Conducted electrical weapon (Taser) 46 Hospital Designations for Specialty Transports 117 Burns all types | Blast injuries 47-48 Pain scales 118 Chest trauma 49  Introduction Assumptions 1. All EMS personnel will function within their scope of practice as defined by the National EMS Scope of Practice Model; IDPH, and practice privileges awarded by their local EMS MD. 2. These SOPs are evidence-based and are revised as standards of practice or clinical practice guidelines change. They include, but are not limited to, guidelines from the Ntl Assoc. of EMS Physicians, Am Heart Assoc., Am Coll of Surgeons, Am Coll of Em Physicians, Brain Trauma Foundation, Centers for Disease Control and Prevention, EMS for Children; the Ntl EMS Education Standards, Ntl EMS Scope of Practice Model and EMS Core Content. 3. Italicized options may not be used in all Systems. Refer to System-specific SOP documents. Those marked NR are non- region protocols that may or may not be adopted by each System or substituted with a System-specific document. 4. Levels of acuity: Definitions match the Model of Clinical Practice of Emergency Medicine; in the Ntl EMS Core Content: Acuity level is essential for identifying care priorities in an EMS setting. They are coded to NEMSIS standards and should be documented as such in the ePCR. CRITICAL pts are TIME-SENSITIVE with black box notations in the SOPs. CRITICAL: Symptoms of a life-threatening illness or injury with a high probability of mortality if immediate intervention is not begun to prevent further airway, respiratory, hemodynamic, and/or neurologic instability. EMERGENT: Symptoms of illness or injury may progress in severity or result in complications w/ a high probability for morbidity if treatment is not begun quickly. These may be identified as time-sensitive on a case-by-case basis. LOWER ACUITY: Symptoms of an illness or injury that have a low probability of progression to a more serious disease or development of complications. 5. Stable: Maintains a steady-state of equilibrium with VS that support adequate oxygenation, ventilation, perfusion, & mentation General guidelines 1. Abandonment: EMS personnel shall not knowingly abandon a patient. Abandonment is the unilateral termination of a health practitioner-patient relationship and/or the unreasonable discontinuation of care by the health care provider when there is still a need for continuing medical attention, contrary to the patient’s will, and/or without the patient’s knowledge. Abandonment for EMS purposes includes executing an inappropriate refusal, releasing a patient to a less qualified individual, or discontinuing needed medical monitoring before patient care is assumed by other professionals of equal or greater licensure than the level of care required by the patient. 2. Consent: Permission to render care. A pt with legal and decisional capacity (see Behavioral Emerg SOP for assessment) or a legal decision-maker must consent for treatment unless an emergency justifies Rx without consent. Consent must be expressed (written or verbally) or clearly implied via gestures indicating a desire for treatment. A pt's lack of refusal or physical resistance will be taken as consent. 3. Implied Consent (emergency doctrine): Consent is automatically assumed if a patient is unresponsive, is in danger of losing life or limb, and is unable to make a rational informed decision (lacks capacity). Involuntary consent: Pts who are mentally ill, lacking capacity and experiencing a BHE, persons in law enforcement custody experiencing a true emergency, or under a Court Order for Detention and Examination (“Writ”) in a Mental Health Emergency. 4. Minors: Patients 3 months or extremely obese: 5 chest thrusts REPEAT IF NO RESPONSE: 3. If successful: complete Initial Medical Care and transport 4. If still obstructed: Continue step #2 while enroute until FB expelled or patient becomes unconscious UNCONSCIOUS Note: When efforts to clear the airway are successful complete Initial Medical Care 2. If no effective breathing: Attempt to ventilate. If obstructed: reposition head, reattempt to ventilate. 3. If unsuccessful: Begin CPR  Look into mouth when opening the airway to begin CPR  Use finger sweep (or suction) to remove visible foreign body ALS 4. As soon as equipment is available: Visualize airway w/laryngoscope and attempt to clear using forceps or suction 5. Intubate; attempt to push the FB into right mainstem bronchus, pull ETT back and ventilate left lung 6. If still obstructed and unable to intubate or ventilate adequately: Consider cricothyrotomy  Per SOP: ≥13 yrs: Needle or surgical | ≤12 yrs: Needle  Per OLMC only: 8-12 yrs: Surgical  Transport; attempt to ventilate with 15 L O2/BVM NWC EMSS 2022 SOP 11 Rev. 3-11-24  ADVANCED AIRWAYS | DRUG-ASSISTED INTUBATION (DAI) Purpose DAI: Achieve rapid ETI in patients with intact airway reflexes via use of medications that facilitate intubation Consider indications for ADV airway placement:  Actual or potential airway impairment or aspiration risk that cannot be mitigated by other interventions  Actual/ impending ventilatory failure (HF, pulmonary edema, COPD, asthma, anaphylaxis; shallow/labored effort; SpO2 ≤ 90; EtCO2 ≥ 60)  Increased WOB (retractions, use of accessory muscles) resulting in severe fatigue  GCS ≤ 8 due to an acute condition unlikely to be self-limited Self-limiting conditions: seizures, hypoglycemia, postictal state, select drug OD (GHB, ecstasy) or TBI  Unable to ventilate/oxygenate effectively with BLS airways and BVM  Need for ↑ inspiratory pressure or PEEP to maintain gas exchange & CPAP contraindicated  Need for sedation to control ventilations Contraindications/restrictions Coma with absent airway reflexes or known hypersensitivity/allergy to use of sedatives: Use in pregnancy could be potentially harmful to fetus; consider risk/benefit 1. IMC: SpO2 & EtCO2 before and after airway intervention | Confirm patent IV / IO; ECG monitor Consider & Rx causes of impairment | Suction, manual maneuvers | BLS airways: + Gag: NPA | No gag: OPA 2. Prepare pt: Position for optimal view and access (head up to 45° unless contraindicated) | Assess for difficult intubation 3. PREOXYGENATE 3 minutes (O2 wash in; nitrogen wash out) Apply ETCO2 NC 15 L; maintain before and during procedure – If 2 O2 sources add: RR ≥10 / AWAKE / good ventilatory effort: Consider CPAP at 5-10 PEEP if not contraindicated RR 100, CVD/HTN; on beta blockers, digoxin, MAO inhibitors; or pregnant  May repeat in 5 minutes prn; DO NOT DELAY TRANSPORT waiting for a response Consider need for CPAP 3. If wheezing: ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN/mask. Add O2 6 L/NC if SpO2 < 94 [BLS] 4. DIPHENHYDRAMINE 50 mg IVP; if no IV give IM [ALS] | PO if no airway compromise or vomiting [BLS] CRITICAL: Severe SYSTEMIC Reaction/ANAPHYLACTIC SHOCK : Above + Time Severely impaired airway/severe dyspnea; decreased/absent lung sounds; CV collapse/HYPOTENSION sensitive pt (Adult: SBP < 90; MAP < 65 or 30% decrease from baseline), dysrhythmias; AMS, pre-syncope, syncope/coma 2. IMC special considerations: (Resuscitate before intubate)  IMMEDIATELY: EPINEPRINE (1 mg/1 mL) 0.5 mg IM (anterolateral thigh) [BLS]  If awake w/ spontaneous ventilatory effort: Consider C-PAP if MAP at least 60: 5-7 cm PEEP If respiratory distress persists and CPAP contraindicated/not tolerated: Rx per ADV Airway SOP  Attempt vascular access after epinephrine IM If No IV / IO: May repeat EPI (1 mg/1 mL) 0.5 mg IM q. 5 min prn | Max total dose 2 mg | Additional doses: OLMC As soon as vascular access is successful: 3. IV NS consecutive 200 mL IVF challenges up to 20 mL/kg; Goal: SBP ≥ 90 (MAP ≥ 65); reassess after each 200 mL + EPINEPHRINE (1 mg/10 mL) titrate in 0.1 mg IVP/IO doses q. 1 min prn to a max total dose [all routes] of 2 mg Reassess after each 0.1 mg (1 mL) | Additional doses: OLMC If on beta blockers & not responding to EPI: GLUCAGON 1 mg IVP / IO [ALS] IN / IM [BLS] 4. If wheezing: ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN/mask. Add O2 6 L/NC if SpO2 < 94 [BLS] 5. DIPHENHYDRAMINE 50 mg IVP/IO; if no IV / IO give IM If cardiac arrest occurs – Begin quality CPR; prolonged CPR indicated while S&S of anaphylaxis resolve  Give IVF as rapidly as possible (20 mL/kg; max 2 L) PLUS  EPINEPHRINE (1 mg/10 mL) IV / IO per cardiac arrest SOP (Above dose limit does not apply) NWC EMSS 2022 SOP 13 Rev. 3-11-24  ASTHMA | COPD 1. IMC special considerations:  Assess ventilation/oxygenation, WOB, accessory muscle use, degree of airway obstruction/resistance, speech, cough (productive or non-productive – color), cerebral function, fatigue, hypoxia, CO2 narcosis, and cardiac status  Medications: Time and amount of last dose; duration of this attack  If wheezing without Hx of COPD/Asthma: Consider FB aspiration, pulmonary embolus, vocal cord spasm, HF/ pulmonary edema. See appendix for differential. If probable cardiac cause (PMH: CVD): Rx per Cardiac SOPs. Assess for pneumonia, atelectasis, pneumothorax or tension pneumothorax If tension pneumothorax (↓ BP, unilaterally absent lung sounds): Needle pleural decompress affected side  Airway/Gas exchange: Assess need for DAI/BIAD if near apnea, coma/depressed mental status, exhaustion, severe hypoxia (SpO2 < 90); hypercapnia (EtCO2 ≥ 60) | CR instability | Impending respiratory failure/arrest If chronic hypercarbic state (COPD): Rx ventilatory failure w/ acute resp. acidosis carefully Eliminate only extra CO2 (above chronic hypercarbic norms) causing acute ventilatory failure Do not hyperventilate and do not over-correct: If rapidly ventilated to EtCO2 of 35-45, pt may suffer lethal dysrhythmias from Ca binding | Slowly reduce PaCO2. If assisted: Ventilate at 6 - 8 BPM (slower rate, smaller tidal volume (6-8 mL/kg), shorter inspiratory time & longer expiratory time to allow complete exhalation | Target SpO2: 92% (COPD) If cardiac arrest: Option: briefly disconnect from BVM and compress chest wall to relieve air-trapping (Class IIa)  Monitor ECG: Bradycardia signals deterioration LOWER ACUITY to EMERGENT: Mild to Moderate distress with wheezing and/or cough variant asthma 2. ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN or mask BLS  Add O2 6 L/NC if patient is hypoxic (Asthma: SpO2 < 94%; COPD: SpO2 < 92%) & using a HHN  Begin transport as soon as neb is started - do not wait for a response  Continue nebulizer therapy enroute | May repeat X 1 CRITICAL (Severe distress): Severe SOB, orthopnea, accessory muscle use, speaks in syllables, Time tachypnea, lung sounds diminished or absent; exhausted; HR & BP may be dropping sensitive pt 2. IMC special considerations: [BLS] BLS Prepare resuscitation equipment; anticipate rapid patient deterioration. If immediate intubation not needed: O2 /C-PAP 5-10 cm PEEP; use 15 L/NRM or assist w/ 15 L/BVM if CPAP unavailable or contraindicated If SBP falls < 90 (MAP < 65): Titrate PEEP values downward to 5 cm; remove C-PAP if MAP < 60 History of ASTHMA History of COPD 3. EPINEPHRINE (1 mg/1 mL) 0.3 mg IM [BLS] 3. ALBUTEROL 2.5 mg & BLS  Caution: HR > 100, CVD/HTN; on beta blockers, IPRATROPIUM 0.5 mg /HHN/ mask/ BVM digoxin, or MAO inhibitors; pregnant; or significant side Begin transport as soon as neb is started effects to albuterol Do not wait for a response  Begin transport as soon as Epi is given Continue nebulizer therapy enroute Do not wait for a response  May repeat X 1 in 10 min if minimal response May repeat X 1 as needed Follow immediately with ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN, mask or BVM; continue enroute [BLS] May repeat X 1 as needed. 4 If severe distress persists: MAGNESIUM (50%) 2 g in 16 mL NS (slow IVP/IO) or in 50 mL NS (IVPB) | Give over 10 min - Max 1 g / 5 min Cover site with cold moist gauze/cold pack to relieve burning NWC EMSS 2022 SOP 14 Rev. 3-11-24  Pts w/ TRACHEOSTOMY | LARYNGECTOMY Adult or peds with Respiratory Distress 1. IMC special considerations: Assess the following:  Airway patency & lung sounds; RR; WOB; oxygenation by skin color & temp, SpO2 , EtCO2 (if available); ineffective airway clearance as evidenced by crackles, wheezes; or stridor; need to suction  Type & size of trach or laryngectomy tube (marking on tube flange) |  tube position  Tracheostomy cuff to ensure that it is deflated unless on a ventilator or if pt has excessive secretions  Tracheostomy/laryngectomy site - Redness, swelling; character & amount of secretions; purulence, bleeding, subcutaneous emphysema - Tracheostomy ties - should be secure but not too tight - Need of tracheostomy care 2. If airway patent and respiratory effort/ventilation adequate:  Support ABCs, complete IMC; suction as needed to clear secretions  Maintain adequate humidity to prevent thick, viscous secretions (if “artificial nose” available at scene)  Position head of stretcher up 45 degrees or sitting position as patient tolerates 3. Partial dislodgement of trach tube: Deflate cuff (if air-filled); advance tube into stoma until flange is flat against neck; reinfate cuff; secure trach tube 4. Complete dislodgement:  Completely deflate cuff; remove inner cannula if double lumen tube  Insert obturator  Lubricate tube including cuff with water soluble gel  Gently advance tube into stoma until flange is flat against neck  Remove obturator and replace inner cannula; secure trach tube In an emergency, insert an appropriately sized ETT into stoma until cuff just passes stoma; assess patency Caution: A fresh trach or laryngectomy (100°F (37.8°C), productive cough, isolated crackles; SpO2 < 95%; HR >100 Standard precautions / Disinfection 1. For close contact (w/in 6 feet of pt): Droplet / Aerosolization Precautions and BSI  Nonsterile gloves for contact w/ potentially infectious material; hand hygiene immediately after glove removal  Surgical/procedural mask on pt and mask on each EMS responder (surgical/procedural, N95, or other respirator per CDC / IDPH / Local policy)  Wear disposable isolation gown and eye protection when required by CDC/IDPH guidelines Consider when splashes or sprays of respiratory secretions or other infectious material are possible 2. Disinfect stethoscope heads and other frequently-handled items after each patient 3. General recommendation for ambulance: Thoroughly clean all planes and crevices; spray with System- approved disinfectant registered by the EPA to kill viruses (coronavirus, norovirus, rotavirus, adenovirus) and TB If using a spray, hold dispenser 10” from surface and atomize with quick short strokes, spraying evenly on (potentially) contaminated areas until wet. Allow wet dwell time per manufacturer’s instructions. Prefer products with 1 minute dwell time. After that, wipe down with a clean towel dampened with clean water then dry thoroughly. Remove/clean residue that may be left behind from disinfectant. Mild illness/low risk for complications: 4. IMC: Supportive care. If w/in 24 hours of onset, encourage pt to contact PCP to receive anti-viral agent. Encourage rest, fluids, and non-aspirin OTC pain relievers and fever reducers. Cough suppressants, decongestants, and antihistamines may alleviate symptoms. Moderate to Severe S&S | High risk for complications Respiratory/ventilatory failure with severe hypoxemia and hypercarbia may occur in pts with associated pneumonia or exacerbation of underlying comorbid diseases 5. Give 15 L O2 / NRM or CPAP as indicated for ventilatory distress; acute lung injury or ARDS | Assist with BVM if ventilatory failure | Consider need for ALBUTEROL / IPRATROPIUM standard dose / HHN or in-line neb 6. Assess for SEPSIS: Time-sensitive pt. Risk factors for serious complications Asthma; COPD; cystic fibrosis; pulm. fibrosis Adults 65 years and older Endocrine disorders (diabetes mellitus) Children < 5 yrs old, but especially those < 2 yrs Heart disease (CAD, HF, cardiomyopathies) Pregnant women and up to 2 weeks post-partum Kidney, liver, metabolic disorders People in congregate living facilities Neurological and neurodevelopmental conditions Immunocompromised state Obesity with a BMI of 30 or higher Coagulation disorders Pulmonary embolism: Difficult to diagnose, and potentially lethal if missed. Time sensitive pt. Size/location determines S&S. Consider possible PE if: Hx: Previous venous thromboembolism (VTE) or pulmonary embolism; venous stasis (obesity, surgery or prolonged immobilization w/in last 30 days); recent trauma/damage to lining of vessels (CV disease: atherosclerotic changes; HTN, injected drug use; central line; or other IV medical device, inflammation from direct infection, diabetes; smoking); hypercoagulable state (malignant: cancer currently active or considered cured w/in last year; hematologic (pregnant), or medication induced (oral hormone use). Also consider presence of air, fat or amniotic fluid as source of emboli. S&S Acute onset pleuritic chest pain; unilateral lower limb pain/edema; tachypnea disproportionate to fever and tachycardia;  SpO2; small, square capnography waveform and very low reading (increased dead space and hyperventilation); HR ≥100; SBP may drop due to HF; cough may be productive with hemoptysis; shock IMC based on the patient presentation, VS, and signs of shock/instability. 12 L ECG. Definitive Rx (at hospital) of an embolus due to blood clot may be fibrinolysis or thrombectomy – limit scene time NWC EMSS 2022 SOP 16 Rev. 3-11-24  Chest Pain/Acute Coronary Syndrome (ACS) with or w/o pain; Time sensitive ST-segment Elevation Myocardial Infarction (STEMI) pt Typical S&S: Pain, discomfort or tightness in the chest, neck, jaw, teeth, back, arm, or abdomen of suspected cardiac origin. May also present w/ dyspnea, sweating, nausea, vomiting, dizziness, fatigue, or weakness and may be associated with presyncope, syncope, acute HF, or shock = medical emergency. Populations with atypical S&S: Elderly, women, diabetics, recent thoracic surgery or trauma Defer ASA and NTG and use PAIN MGT SOP in pts w/ thoracic trauma or surgery within last 72 hours unless 12-L ECG changes suggest acute ischemia 1. Begin immediate IMC BLS  Decrease O2 demand - limit activity, do not allow to walk; sit up, loosen tight clothing  If dyspnea, hypoxemia, or obvious signs of HF, titrate O2 to achieve SpO2 of 94%  Cardiac monitor; assess for rate, rhythm, pump, or volume problem; hypoperfusion & CR compromise Rx per appropriate SOP.  Obtain medication Hx; Is pt taking beta-or calcium channel blockers, clonidine, digoxin, anticoagulants, or meds for erectile dysfunction or pulmonary HTN (vasodilators) 2. ASPIRIN 324 mg (4 tabs 81 mg) chewed and swallowed while prepping for 12 L ECG Indication: Cardiac ischemia due to suspected ACS regardless of chest pain Contraindications: Drug appendix + confirmed adequate dose taken after symptom onset; chest pain after trauma 4. 12-L ECG w/in 5 min of pt contact | Ensure good skin prep & interface | Correct lead placement Clear tracing w/o artifact: capture while stationary - may transmit while moving  Call STEMI alert ASAP if + 12 L ECG changes present (See appendix) Communicate & document: Clinical S&S (OPQRST) Pt age, gender, DNR status PCP/cardiologist if known Meds PMH of AMI, PCI/stent/CABG, chronic kidney disease, or contrast allergy (GWTG) ECG rhythm and 12 L findings (transmit/download tracing; if unable - read interpretation to OLMC)  Repeat 12 L ECG every 10 min if ongoing pain/symptoms  Provide ECGs to treating personnel at receiving hospital NONE to MILD CR compromise + EMERGENT: Moderate CR compromise + pain/discomfort present pain/discomfort present Alert, oriented, well-perfused & SBP > 100 Alert, oriented, perfused & SBP 90-100 4. NITROGLYCERIN (NTG) 0.4 mg SL [BLS] 4. Complete IMC: (unless contraindicated – see drug appendix) IV NS 200 mL fluid challenge if lungs clear 5. Complete IMC: IV NS TKO 5. NITROGLYCERIN 0.4 mg SL (unless contraindicated) [BLS] 6. Pain persists | SBP ≥100 (MAP ≥65): Repeat NTG 0.4 mg SL every 3-5 min X 2; monitor for SE [BLS] 7. Pain persists | SBP ≥90 (MAP ≥65) after NTG or NTG contraindicated: Rx per PAIN Mgt. SOP 8. Transport to primary PCI hospital/STEMI-Receiving Center if transport time ≤ 30 min Goal: First EMS contact to balloon inflation (initial device used) within 90 min (or current AHA guidelines) Monitor closely | Clinical deterioration may be rapid: dysrhythmias, chest pain, SOB, decreased LOC syncope, shock/hypotension | Prepare for CPR and defibrillation CRITICAL (Severe CR compromise): AMS + S&S hypoperfusion; SBP < 90 (MAP 150, AMS, SBP < 90 (MAP < 65), SOB, ongoing chest pain, shock, pulmonary edema, HF or ACS sensitive Immediate cardioversion is seldom needed for HR 0.10 sec): Refer to Wide Complex Tachycardia with a Pulse SOP (next page)  DC cardioversion is ineffective in junctional and ectopic atrial tachycardias  *PSVT & A-flutter often respond to lower energy levels, start with 50 J NWC EMSS 2022 SOP 19 Rev. 3-11-24  WIDE COMPLEX TACHYCARDIA with a PULSE (QRS 0.12 sec or wider) – VT; SVT with aberrancy, WPW; Torsades de pointes 1. Assess for hypoperfusion, cardiorespiratory compromise, acidosis 2. IMC: Support ABCs as needed Obtain, review and transmit 12-L ECG per ACS SOP if available | Determine rhythm & stability ASAP If unconscious: defer vascular access until after cardioversion 3. If possible ACS & alert with gag reflex: ASPIRIN per ACS SOP Time Low Acuity to EMERGENT: None to moderate cardiorespiratory/perfusion compromise sensitive Alert, HR > 150, SBP > 90 (MAP> 65), no evidence of tissue hypoperfusion or shock pt Regular Monomorphic VT; polymorphic VT w/ normal QT interval; WPW; Polymorphic VT w/ prolonged QT (Torsades de points): Irregular wide complex tachycardia; AF w/ aberrancy; AF w/ WPW (short PR, delta wave) 4. AMIODARONE 150 mg mixed with 7 mL NS slow IVP 5. MAGNESIUM (50%) 2 g in16 mL NS (slow IVP) or in or in 50 mL NS IVPB over 10 min. May repeat. 50 mL NS (IVPB) | Give over 10 min - Max 1 g / 5 min. Complete dose even if rhythm converts. Cover IV site with cold moist gauze or cold pack to 5. OLMC only: ADENOSINE 6 mg rapid IVP + 10 mL NS relieve burning flush | Contraindication: polymorphic, irregular rhythm Chest pain: NTG per ACS SOP if HR drops to ≤ 100 | If pain persists: Rx per PAIN Mgt. SOP CRITICAL: Severe cardiorespiratory/perfusion compromise (unstable) Time Instability must be related to HR > 150 + one or more of these: Altered sensorium, SBP < 90 (MAP 10 min) phases CPR  If indicated, start high quality, minimally interrupted MANUAL CPR w/in 10 seconds of arrest recognition. Use audible prompt for correct rate + real-time CPR feedback device until a mechanical CPR device is deployed  13+ yrs/no contraindications after manual CPR started: Deploy Mechanical CPR device ASAP (if available and meets protocol) to maintain uninterrupted chest compressions | Pause compressions < 5 sec to place device  No CPR device or contraindicated: Continue 2 person manual CPR (adult, child, infant) CPR caveats: - DNR status unclear: Start CPR; stop if valid POLST/DNR order is presented or per OLMC order - LifeVest® on: Disconnect batteries | remove vest | resuscitate per SOP - Pulseless & VAD placed: SpO2 | DO NOT disconnect batteries | See VAD SOP; call VAD Coord for instructions - Pregnant & fundus at navel or higher: CPR + manual left lateral uterine displacement; stop magnesium if running  GIVE OXYGEN: BLS airways: Maintain manual airway positioning + NPA/OPA | O2 15 L/ NC EtCO2 sensor Hold BV mask over EtCO2 NC w/ tight mask seal to reduce O2 leak  13+ yrs: Add RQP above mask to maintain negative intrathoracic pressure unless contraindicated Contraindications: Flail chest, pulse present; children ≤12 years  Place SpO2 central sensor; observe (trend) reading and pleth waveform Immediate vs. Delayed BLS Positive Pressure VENTILATIONS (PPV) Ventilate immediately: Cardiac arrest caused by hypoxic event (asthma, anaphylaxis, O2 w/o ventilations (ApOx): submersion, drug OD etc.), unwitnessed arrest; pregnant, peds ≤12 years EMS witnessed arrest and/or Adult 10 BPM (asthma 6-8 BPM) | child (1 breath q. 6 sec) each over 1 second; see found in a shockable rhythm: visible chest rise (adult: 500-600 mL) + bilateral breath sounds midaxillary lines Manual airways + O2 as above Avoid hyperventilation, high airway pressure (≥25 cm H2O) & gastric distention No ventilations for first 3 mins. EARLY DEFIBRILLATION (VF & Pulseless VT) APPLY DEFIB PADS on exposed chest w/o interrupting compressions (anterolateral or anteroposterior) Connect to cardiac monitor [ALS] / AED [BLS] (See Peds IMC p. 72 for peds pad sizes)  RHYTHM: Does monitor sense native rhythm with CPR in progress?  CPR device + monitor senses ECG: No pause in compressions to ID rhythm  NO CPR device/monitor does not sense ECG: Palpate femoral pulse for 5 sec with compressions in progress | pause compressions ≤ 5 sec. to check rhythm | Resume compressions immediately Can’t ID rhythm: Print strip during pause; resume compressions; read ECG from printed strip Not shockable: Continue compressions Shockable: DEFIBRILLATE immediately JOULES (rapidly measure child with length-based tape)  Adult and peds ≥ 50 kg: Monitor-specific joules (see bottom of next page)  Peds < 50 kg: 2 J/kg then 4 J/kg | subsequent shocks ≥ 4 J/kg not to exceed 10 J/kg or adult max Defibrillation caveats - Perishock pause: With CPR device: None | NO CPR device: ≤ 5 sec (Pre-charge w/ compressions ongoing) | Discharge current after a compression - not a ventilation | Immediately resume compressions - NO CPR device: Change compressors q. 2 min (immediately after defib or sooner if fatigued) - NO rhythm/pulse check until after 2 min of CPR unless evidence of ROSC - Continue to defibrillate shockable rhythms per above procedure in 2 minute cycles - If very fine VF and/or EtCO2 low or decreasing: CPR quality – attempt to improve perfusion/ventilation - Persistent/refractory VF: Change defib pad location if possible NWC EMSS 2022 SOP 21 Rev. 3-11-24  ALS interventions: Priority order – IV/IO access | EPINEPHRINE | Adv. airway 1. VASCULAR ACCESS: 3. Consider ADVANCED Airway 3 min after preox May consider IO (approved site) if attempts at IV ETI (preferred in adults) limit 2 attempts per DAI SOP/BIAD (adults & peds) access are unsuccessful or not feasible. Place w/o pausing CPR | Cont. O2 15 L/EtCO2 NC until placed NS TKO unless IVF indicated per condition Keep head of bed flat if using CPR device When placed, give meds w/o CPR interruption Confirm correct placement & secure / ADV airway SOP 2. Early EPINEPHRINE (Non-shockable rhythm: as Tower of Power: Airway | EtCO2 | HEPA filter (product- soon as feasible | Shockable: after initial defibs) dependent) | ITD (RQP) | Zoll Accu-vent | BVM (D/C NC EtCO2) EPINEPHRINE (1 mg/10 mL) IVP / IO Repeat every 6 min as long as CPR continues PPV: O2 15 L/BVM at 10 BPM with continuous chest  Adult: 1 mg (each dose) compressions. Volume only to see visible chest rise and  Peds: 0.01 mg/kg (0.1 mL/kg) (max 1 mg/dose) bilateral breath sounds at midaxillary lines. May adjust peds to Use dosing chart in Appendix 20 BPM based on SpO2 / EtCO2. Don’t over ventilate. Antidysrhythmic agent only if SHOCKABLE RHYTHM AMIODARONE IVP/IO Adult: 300 mg Peds: 5 mg/kg (Max 300 mg) Rhythm persists after 5 min: Adult: 150 mg Peds: 5 mg/kg (May repeat up to 3 total doses) Consider & Rx reversible causes: Hs & Ts (May use ultrasound to ID reversible causes or ROSC)  Hypoxia (ventilate/O2)  Tamponade, cardiac  Hypothermia (core rewarm)  Thrombosis (coronary/pulmonary)  Hypovolemia/dehydration (IVF boluses)  Tension pneumothorax (pleural decompression)  Hypo/hyperkalemia (bicarb-responsive acidosis (DKA; TCA /ASA OD, cocaine, diphenhydramine):  Toxins Opioid OD: NALOXONE SODIUM BICARB 1 mEq/kg (max 50 mEq) IVP/IO Adult: 1 mg IVP/IO; repeat q. 2 min. up to 4 mg from EMS (routine use of sodium bicarb in an undifferentiated Peds 0.1 mg/kg IVP/IO (max 1 mg); repeat as above cardiac arrest is not recommended) Additional doses: OLMC Return of spontaneous circulation (ROSC): Rapid, sustained rise in EtCO2 (≥40); pt moves; wakes up Time- FOCUS: Oxygenation, circulatory support, lung-protective ventilation, adequate sedation; 12 L ECG sensitive pt  Remove RQP | Assess VS + SpO2 & EtCO2: palpate pulse & watch SpO2 pleth for 5 min to detect PEA  Support ABCs; Target SpO2 (92-98%), EtCO2 (35-45) | Adult SBP > 90 (MAP > 65) | Child SBP >70 + (2 X age) PPV prn 10 BPM w/ visible chest rise; do not hyperventilate even if ↑ EtCO2 If ETI/BIAD placed and pt remains unconscious: Assess need for pain mgt/sedation (RASS score) per DAI SOP Obtain12 L ECG (as soon as feasible - target within 8 min) after ROSC (call alert if STEMI) Emergent Rx if hypotensive | cardiogenic shock | mechanical circulatory support needed If lungs clear: IV NS 20 mL/kg up to 1 L while prepping… NOREPINEPHRINE drip (IV/IO) Concentration: 4 mg in 1,000 mL NS (4 mcg/mL) | Use of IV pump preferred Adult: Initial dose: 8 mcg/min (2 mL/min) titrated to reach SBP ≥ 90 (MAP ≥ 65) Peds: Initial dose: 0.1 mcg/kg/min (max 1 mcg/kg/min up to 8 mcg/min) titrated to SBP >70 + (2 X age in yrs) Higher doses (10 mcg/min) RARELY needed – contact OLMC. Assess BP (MAP) q. 2 min until target BP is reached (don’t overshoot) | Then reduce drip rate incrementally to maintain at BP targets Maintenance: 2 to 4 mcg/min (0.5 mL to 1 mL/min) or less | Continue to reassess BP q. 5 min.  Monitor for SEIZURES: Rx per SOP |  GLUCOSE level: Rx HYPERGLYCEMIA SOP; avoid hyperglycemia Determination of Death | TERMINATION OF RESUSCITATION (TOR) | Must be approved by OLMC physician BLS TOR Rule: Arrest Unwitnessed by EMS/1st responders | No ROSC before transport | no AED shocks (intentionally) delivered ALS TOR Rule: Arrest unwitnessed by anyone | No bystander CPR | No ROSC after full ALS | No defib before transport Addtl. Considerations: Normothermic pt. remains in persistent monitored asystole for ≥ 30 min despite resuscitation | EtCO2 remains ≤ 10 mmHg for 20 min in pts with advanced airways & no reversible causes of arrest identified If TOR denied: Transport with CPR in progress after 30 min of resuscitation on scene If TOR granted: Note time resuscitation was terminated | Follow System policy for patient disposition Adult Defibrillator Joule recommendations If ICD is delivering shocks, wait 30-60 sec. for cycle to complete. LifePak 200 – 300 - 360 Place pads at least 1” from implanted device. Philips 150 – 170 - 200 Zoll all series 120 – 150 - 200 NWC EMSS 2022 SOP 22 Rev. 3-11-24  HEART FAILURE | PULMONARY EDEMA | CARDIOGENIC SHOCK  HF: Structural or functional impairment of ventricular filling or ejection of blood. Assess for hypoperfusion and cardiorespiratory (CR) compromise.  Obtain PMH/comorbidities: CAD/ACS/AMI, HTN, valvular heart disease, rhythm-related (tachycardia, PVCs, RV pacing); cardiomyopathies, infiltrative disease (amyloid/sarcoid/excess iron); rheumatic or autoimmune /endocrine or metabolic causes; myocarditis (infectious, toxin or medication, immunological, hypersensitivity); cardiotoxicity with cancer; SUD (alcohol, cocaine, and methamphetamine); or pregnancy-related. Consider pulmonary embolism.  Assess for clinical congestion: JVD, orthopnea, peripheral edema; auscultate lung sounds all lobes, front & back; report timing/location of wheezes/crackles | Differentiate HF from COPD/asthma by PMH, meds, S&S, EtCO2 PULMONARY EDEMA: Low Acuity to Emergent | Mild to moderate CR compromise | Alert, (SBP ≥ 90 & DBP ≥ 60) (MAP ≥ 65) 1. IMC special considerations: BLS  Position patient sitting upright at 90˚ (if tolerated); dangle legs over sides of stretcher  C-PAP 5-10 cm PEEP | If SBP < 90 (MAP < 65): Titrate PEEP down to 5 cm; remove if MAP < 60 If resp. distress & CPAP contraindicated/not tolerated: Assess need for ADV airway [ALS]; O2 15 L/NRM 2. 12-L ECG & ASPIRIN 324 mg (4 tabs 81 mg) PO per ACS SOP unless contraindicated 3. NITROGLYCERIN 0.4 mg SL | If SBP ≥ 90 (MAP ≥ 65): Repeat NTG 0.4 mg SL q. 3-5 min – no dose limit May be given if HR > 100 in pulmonary edema | monitor BP closely 4. Severe anxiety: MIDAZOLAM (standard dose) per ACS SOP ALS CARDIOGENIC SHOCK (CRITICAL): Pump failure due to PMH above &/or drugs with Time SBP < 90; MAP < 65 + S&S hypoperfusion sensitive pt 1. IMC special considerations:  Assess need for advanced airway to ↓ WOB, protect airway, or if PPV indicated  Assess for hypovolemia / dehydration 2. If hypovolemic and/or dehydrated - lungs clear + ventilations unlabored: NS IVF in 200 mL increments up to 1 L; attempt to achieve SBP ≥ 90 (MAP ≥ 65) | Frequently reassess lung sounds 3. NOREPINEPHRINE 8 mcg/min (2 mL/min) IVPB/IO per inopressor SOP | Use of IV pump preferred 4. If possible ACS: (alert with gag reflex): ASPIRIN 324 mg (4 tabs 81 mg) PO per ACS SOP [BLS] Sampling of drugs prescribed for patients with CV disease/Heart Failure ACE Inhibitors (ACEi): Benzapril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril, monopril, lisinopril (Prinivil/Zestril), moesipril (Univasc), perindopril (Aceon), quinapril, accupril, Ramipril (Altace), trandolapril (Mavik) Angiotensin Receptor Blockers (ARB): candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan) Angiotensin Receptor-Neprilysin Inhibition (ARNi): Sacubitril-valsartan HCN Channel blocker: Ivabradine (Colanor, Lancora, Procoralan) Anticoagulants: apixaban (Eliquis), aspirin, argatroban, bivalirudin (Angiomax), clopidogrel (Plavix ), dabigatran (Pradaxa), endoxaban (Savaysa/Lixiana), eptifibatide (Integrilin), lepirudin (Refludan), presugrel (Effient), rivaroxaban (Xarelto), ticagrelor (Brilinta), ticlodipine (Ticlid), warfarin (Coumadin, Jantoven); SUBQ route: dalteparin (Fragmin), enoxaparin (Lovenox), fondaparinux (Arixtra), tinzaparin (Innohep); Heparin (IV & SUBQ) Beta Blockers: acebutolol (Sectral), atenolol (Tenormin), betaxolol (Betopic,Kerlone), bisoprolol (Zebeta), carvedilol (Coreg), esmolol (Brevibloc), labetalol (Normodyne, Trandate), levobunolol (Betagan), metoprolol (Lopressor/Toprol), Kapspargo Sprinkle (metoprolol succinate extended-release), nadolol (Corgard), pembutolol, pindolol (Visken), propranolol (Inderal), timolol (Blocadren, Timoptic), sotalol (Betapace) Calcium channel blockers: amlodipine (Norvasc), felodipine, diltiazem (Cardizem), nicardipene (Cardene), nifedipine (Procardia, Adalat), verapamil (Calan, Isoptin) Diuretics: amiloride (Midamor), bumetanide (Bumex), chlorothiazide (Diuril), diazide, furosemide (Lasix), hydrochlorothiazide (Hydrodiuril), indapamide (Lozol), metolazone (Zaroxolyn), Polythiazide, torsemide Mineralocorticoid Receptor Antagonists (MRAs): spironolactone (Aldactone); eplerenone (Inspra); finerenone (Kerendia) Sodium-glucose cotransporter-2 inhibitors: canagliflozin (Invokana); dapagliflozin (Farxiga); empagliflozin (Jardiance) Vasodilators: hydralazine (Apresoline), isosorbide dinitrate (Isordil), minoxidil (Loniten), nesiride (Natrecor), Nitrates/NTG Aldosterone antagonists: (K sparing diuretics) Eplerenone, spironolactone (Aldactone); triamterene (Dyrenium) NWC EMSS 2022 SOP 23 Rev. 3-11-24  Ventricular Assist Device (VAD) Purpose: Improve survival and minimize morbidity in patients with end stage heart failure (HF). The current generation of VADs have a number of components in common: an inflow cannula is inserted in the left ventricular (LV) apex that drains blood from the LV to the pump; an electrically actuated continuous-flow (CF) pump with a single rotating impeller suspended within a tube propels blood forward by spinning at high speeds; and an outflow cannula carries blood back to the arterial circulation, typically by way of the ascending aorta. The power supply for the VAD is a percutaneous lead that traverses the skin and connects the external power system with the internal pump. The external components generally consist of a power source (i.e., batteries or an alternating current power unit) and a small portable controller that controls pump speed and monitors device function. 1. CALL VAD Coordinator listed on patient information sheet for instructions EMS personnel are authorized to follow directions of the VAD Coordinator 2. Patient may/may not have a peripheral pulse or normal BP at any time; SpO2 registers if perfusion is present 3. Evaluate perfusion based on mental status, skin signs 4. CHEST COMPRESSIONS ARE ALLOWED if patient is unconscious and non-breathing - see below. Follow all other BLS and ALS protocols. 5. Patients with VADs may tolerate sustained ventricular arrhythmias with minimal hemodynamic instability because the VAD maintains cardiac output during arrhythmic events. Patient may be defibrillated, as necessary for V-fib with loss of consciousness, without disconnecting the pump. 6. Do not defibrillate over the pump; defibrillate at nipple line or above. Anterior-posterior pad placement preferred. 7. ECG waveforms may have a lot of artifact due to the device. 8. Patients will often have pacemakers and/or Internal Cardioverter Devices (ICDs). 9. Waveforms may be flat; without amplitude in spite of accurate readings – i.e. pulse ox. 10. Patient should have a binder with record of daily VAD parameters. 11. Patients will be on anticoagulation medications and are at risk for thromboembolic events. 12. NO MRIs - CT Scans are ok; avoid water submersion; avoid contact with strong magnets or magnetic fields 13. Never remove both sources of power (batteries) at the same time! NWC EMSS 2022 SOP 24 Rev. 3-11-24  Acute ABDOMINAL | FLANK PAIN 1. IMC special considerations:  Inspect, auscultate, palpate abdomen in all quadrants  Compare pulses in upper vs. lower extremities  Note/record nature & amount of vomiting/diarrhea, vaginal/urethral/rectal lesions/discharge; jaundice  Vomiting precautions  Adjust IV rate to maintain hemodynamic stability  Document OPQRST of pain; menstrual history in females of childbearing age; last BM; orthostatic VS; travel history  Rx per PAIN Mgt. SOP LOWER ACUITY: NONE to MILD cardiorespiratory compromise Alert, SBP ≥ 90 (MAP ≥ 65), no evidence of tissue hypoperfusion or shock 2. Transport in position of comfort EMERGENT to CRITICAL: Moderate to Severe cardiorespiratory compromise Time Altered sensorium, signs of hypoperfusion. sensitive pt 2. IMC special considerations: Consider need for NS IVF challenges if pt severely dehydrated/hypovolemic: (Ex: appendicitis, cholecystitis, pancreatitis, hepatitis, cirrhosis, upper/lower GI bleed, bowel obstruction, sepsis) 3. If suspected abdominal aortic aneurysm (AAA): Do not give IV fluid challenges unless SBP < 80 (MAP 12% abnormal, ( 93.2° F): Cover with blankets; protect head from heat loss Active external rewarming (T 82°- 93.2° F): Passive + surface warming devices (wrapped hot packs to axillae, groin, neck, & thorax; warming mattress if available) | Passive rewarming alone inadequate for these pts 3. Warm NS IVF challenges in 200 mL increments (Peds: 10 mL/kg) to maintain hemodynamic stability SEVERE Hypothermia (CRITICAL): Core temp < 30°C (86° F), coma, muscle rigidity, Time cardiac dysrhythmias: bradycardia, VF (cardiac arrest/absent pulse); hypotension, slowed RR to apnea, sensitive pupils fixed & dilated, no shivering pt 2. ITC special considerations:  Core rewarming (generally not available in field). Rewarm trunk only with hot packs; avoid rewarming extremities  Consider need for ADV airway: If indicated; use gentle technique to prevent vagal stimulus and VF  O2 12-15 L/NRM or BVM (warm O2 to 42˚ C / 107.6° F if possible); do NOT hyperventilate - chest will be stiff  Vascular access: Warm NS 200 mL (peds 10 mL/kg) IVP/IO fluid challenges up to 1 L May require large volume replacement due to leaky capillaries, fluid shift, and vasodilation as rewarming occurs 3. If unresponsive with apnea or no normal breathing (only gasping) check for a pulse.  Pulse not definitely felt in 30 seconds: Start CPR - TRIPLE ZERO CANNOT BE CONFIRMED until rewarmed unless obviously dead (rigor mortis or non-survivable injury) | Treat per CARDIAC ARREST SOP + rewarming 4. ROSC: Support CV status per CARDIAC ARREST SOP | Look for & treat causes of severe hypothermia  If induced hypothermia (TTM) indicated: Continue to warm to goal temp of 34° C / 93.2° F  If hypothermia contraindicated (trauma patient); continue rewarming to normal temp 5. Transport very gently to avoid precipitating VF NWC EMSS 2022 SOP 31 Rev. 3-11-24  Environmental: SUBMERSION/DROWNING (Adult & Peds) Notes:  All victims of submersion who require any form of resuscitation (including rescue breathing alone) should be transported to the hospital for evaluation and monitoring, even if they appear to be alert and demonstrate effective cardiorespiratory function at the scene (Class I, LOE C).  All persons submerged ≤ 1 hour should be resuscitated unless signs of obvious death. 1. ITC special considerations:  Rescue and removal: Ensure EMS safety during the rescue process; only rescuers with BLS appropriate training and equipment should enter moving or deep water to attempt rescue - Wear protective garments if water temp is < 70˚ F | Attach a safety line to the rescue swimmer - In-water ventilations may be considered by trained rescuers, preferably with a flotation device | chest compressions should not be attempted in the water - Keep pt. in a horizontal position if possible. Cold-induced hypovolemia, cold myocardium, and impaired reflexes may cause significant hypotension. - If hypothermic: Appropriate rewarming indicated concurrent with resuscitation  SMR only if circumstances/clinical S&S suggest a spine injury  SpO2 may be unreliable, particularly after cold water immersion, but can increase FiO2 to meet ITC targets EMERGENT: Awake with good respiratory effort, yet congested and increased work of breathing: 2. O2 /C-PAP to deliver 5-10 cm PEEP | Use 15 L/NRM if CPAP unavailable or contraindicated If SBP < 90 (MAP < 65) or hypotensive for age: Titrate PEEP down to 5 cm; remove C-PAP if MAP < 60 CRITICAL: If unresponsive and ineffective ventilations with a pulse: 2. Suction prn; PPV using BLS airways and BVM | Abdominal thrusts contraindicated Pts usually respond after PPV; consider ADV Airway if pt. unresponsive to PPV CRITICAL: If unresponsive, apneic, and pulseless: 2. CPR using traditional A-B-C approach as soon as removed from water | Rx per Cardiac Arrest SOP  Suction prn: Vomiting is common in those who require compressions & ventilations  Remove wet clothing / dry pt. ASAP – especially the chest before applying pads and defibrillating  If pt is cold: refer to HYPOTHERMIA SOP 3. Evaluate for ↑ ICP: (↑ SBP, widened PP; ↓ pulse, abnormal respiratory pattern, gaze palsies, HA, vomiting) If present; Rx per Head Trauma SOP 4. Enroute: Complete ITC: IV NS TKO [ALS] SCUBA | Diving-related emergencies: Consider decompression illness if any of these S&S present even if an apparently safe dive according to the tables or computer Serious Neurological: Dysfunction involving bladder, bowel, gait, or coordination (ataxia), reflexes, mental status (dysphasia, mood, memory, orientation, personality), vision, hearing (tinnitus), consciousness, strength, vertigo Cardiopulmonary: Cough, hemoptysis, dyspnea, voice change Mild Neurological: Paresthesia, numbness, tingling, altered sensation Pain: Ache, cramps, discomfort, joint pain, pressure, spasm, stiffness Lymphatic or Skin: Edema, itching, rash, burning sensation, marbling Constitutional/Nonspecific: Dizziness, fatigue, HA, N /V, chills, diaphoresis, malaise, restlessness. ITC special considerations:  Position supine or in recovery position  Consider transport to a hyperbaric chamber: See Carbon Monoxide Poisoning SOP for chamber locations.  If assistance is needed: Divers Alert Network (DAN) (919) 684-9111 High Altitude Travel and Altitude Illness: See https://wwwnc.cdc.gov/travel/yellowbook/2020/noninfectious-health- risks/high-altitude-travel-and-altitude-illness NWC EMSS 2022 SOP 32 Rev. 3-11-24  Environmental: HEAT EMERGENCIES (Adult & Peds) HEAT CRAMPS OR TETANY (Lower acuity) 1. IMC: IV may not be necessary; if cramps severe/vomiting and/or oral electrolyte replacement unavailable; IV NS 2. Move patient to a cool environment | Remove excess clothing | Do NOT massage cramped muscles HEAT EXHAUSTION (EMERGENT to CRITICAL): Heavy sweating; weakness; cool, pale, Time moist skin; fast, weak pulse; N / V, syncope (If AMS, see Heat Stroke below) sensitive pt 1. IMC special considerations:  NS IVF in consecutive 200 mL increments (peds 10 mL/kg) to maintain SBP ≥ 90 (MAP ≥ 65) or normal for age  Vomiting precautions; ready suction; consider need for ONDANSETRON (standard dosing per IMC SOP)  Monitor ECG  Monitor and record mental status; seizure precautions 2. Move patient to a cool environment | Remove as much clothing as possible HEAT STROKE (CRITICAL): High body temperature (above 103°F); hot, red, dry or moist skin; Time rapid pulse; AMS, possible unconsciousness sensitive pt 1. IMC special considerations:  Anticipate ↑ ICP; check bG for hypoglycemia  If SBP 110 / normal for age / or above: IV NS TKO (may use cold NS); elevate head of stretcher 10˚-15˚  If signs of hypoperfusion: - Place supine with feet elevated (do NOT place in Trendelenburg position) - NS IVF challenges in 200 mL increments (peds 10 mL/kg) up to 1 L to maintain SBP ≥ 90 (MAP ≥ 65) or normal for age unless contraindicated | Caution: Patient at risk for pulmonary and cerebral edema  Monitor ECG 2. Move to a cool environment | Initiate rapid cooling (avoid shivering):  Remove as much clothing as possible  Chemical cold packs (CCP) to cheeks, palms, soles of feet If additional CCP available, apply to neck, lateral chest, groin, axillae, temples, and/or behind knees  Sponge or mist with cool water and fan 3. If generalized tonic/clonic seizure activity: MIDAZOLAM standard dose for seizures (adult and peds) Medications/substances that predispose to heat emergencies:  Anticholinergics (atropine), antihistamines (diphenhydramine)  Beta blockers, antihypertensives, cardiovascular drugs  Tranquilizers, antidepressants, antipsychotics, phenothiazines (Thorazine), MAO inhibitors  ETOH, LSD, PCP, amphetamines, cocaine  Diuretics NWC EMSS 2022 SOP 33 Rev. 3-11-24  GLUCOSE | DIABETIC Emergencies 1. IMC special considerations:  PMH; type of diabetes; presence of automated insulin delivery (AID) systems; glucose monitoring devices  Determine general compliance; time and last doses of medications prescribed for DM mgt and last oral intake  Obtain/record blood glucose (bG) level on all pts with S&S of hypo or hyperglycemia, AMS or neuro deficits Reference ranges: Neonates > 3 days to adults: Fasting: 70-99 mg/dL Non-fasting: 70-139 mg/dL S&S Hypoglycemia Pallor; diaphoresis; shakiness; weakness, fatigue; hunger, anxiety, nervousness, irritability, difficulty Mild: concentrating; HA; dizziness; numbness, tingling around mouth and lips; nausea, rapid HR, palpitations Irritability, agitation, confusion; ataxia; motor weakness; difficulty speaking or slurred speech; elderly patients Moderate may present with S&S of a stroke Severe Lethargy, confusion to coma; seizures; inability to swallow; cold limbs / hypothermia Blood glucose ≤ 70 or S & S of hypoglycemia Hypoglycemic patients with AMS are considered nondecisional. When hypoglycemia is corrected and confirmed by a repeat bG reading, they can be re-assessed for ability to refuse care. 2. If GCS 14-15 and able to swallow safely (+ gag reflex): up to 15 g of a rapidly-absorbed oral carbohydrate if available [BLS] | May repeat in 15 minutes. Options include (not limited to) any one of the following:  Glucose tablets (5 g per tablet) | Glucose gel (15 g per tube)  Sweetened fruit juice: 12 g carbs / 4 oz (120 mL) | Regular soda (not diet): 18 g carbs / per 6 oz (180 mL)  Honey: 17 g carbs / 1 T (15 mL) | Granulated sugar: 12.5 g sugar / 1 T 3. IF AMS & cannot swallow safely | bG borderline 60-70: DEXTROSE 10% (25 g/250 mL) IVPB rapidly (wide open) – infuse up to 12.5 g (125 mL or ½ IV bag) If bG < 60 (no S&S pulmonary edema – if lungs congested see cautions in appendix): DEXTROSE 10% (25 g/250 mL) IVPB rapidly (wide open) – infuse up to 25 grams (entire 250 mL) If S&S of hypoglycemia fully reverse and pt becomes decisional after a partial dose, reassess bG If > 70; close clamp to D10% and open NS TKO Approved alternative if D10% unavailable: D50% (25 g/50 mL): See drug appendix 4. Assess patient response 5 minutes after dextrose administration: Mental status (GCS) and bG level If ≥ 70: Ongoing assessment If < 70: Repeat D10% in 5 g (50 mL) increments at 5 -10 min intervals Reassess bG and mental status every 5 min after each increment 5. If no IV/IO: GLUCAGON 1 mg IN/IM [BLS] 6. If decisional pt refuses transport after bG normalized: Advise pt to eat & call PCP before EMS leaves scene Time DIABETIC KETOACIDOSIS (DKA) or HHNS (CRITICAL) sensitive pt Pts may be hyperglycemic and NOT be in DKA or HHNS. They must present with at least dehydration + hyperglycemia  Dehydration: Tachycardia, hypotension, ↓ skin turgor, warm, dry, flushed skin, N/V, abdominal pain  Acidosis: AMS, Kussmaul ventilations, seizures, peaked T waves, and ketosis (fruity odor to breath)  Hyperglycemia: Elevated blood sugar; most commonly 240 or above Diabetic ketoacidosis (DKA) presents with all 3: More common in pts with T1D Hyperosmolar hyperglycemic nonketotic syndrome (HHNS): More common with T2D | Very high bG levels + severe dehydration, but NO acidosis or ketosis 2. IMC special considerations: EMS shall not assist any patient in administering insulin  Monitor ECG for dysrhythmias and changes to T waves  Vascular access: NS wide open up to 1 L unless contraindicated (HF, bilateral crackles) Assess lung sounds & respiratory effort after each 200 mL in elderly or those w/ Hx CVD or CKD Attempt to maintain SBP ≥ 90 (MAP ≥ 65); monitor for development of cerebral and pulmonary edema NWC EMSS 2022 SOP 34 Rev. 3-11-24  HYPERTENSION  Hypertensive emergencies include a spectrum of presentations in which uncontrolled high BPs lead to progressive or impending end-organ dysfunction.  Hypertensive urgencies and emergencies both have BP elevations (SBP > 160) | Only hypertensive emergencies have life-threatening end-organ damage that requires rapid antihypertensive medications S&S:  Hypertensive urgency: Headache, epistaxis, faintness, and psychomotor agitation  Hypertensive emergency: Above + Causes and S&S suggesting end-organ dysfunction - Neurologic damage due to hypertensive encephalopathy, stroke, SAH or intracranial hemorrhage Assess for headache, visual disturbances, seizures, AMS, weakness/paralysis - Cardiovascular damage due to myocardial ischemia/infarction; LV dysfunction, acute pulmonary edema; or aortic dissection: Assess for chest pain, dyspnea, JVD; back pain; pulse deficits between limbs - Other organ system dysfunction may lead to acute renal failure, retinopathy, or eclampsia - Assess for seizures, peaked T waves, and hematuria - Ask about drug use (cocaine/methamphetamine); assess for S&S of delirium w/ extreme agitation 1. IMC special considerations: Rx the patient, not the number | Use correct BP cuff size & technique  Assess BP in supine and sitting positions unless contraindicated ( for volume depletion)  Assess BP in both arms: a significant difference may suggest aortic dissection  Maintain head and neck in neutral alignment; do not flex neck or knees  Assess and record baseline 12 L ECG; GCS, and neuro signs; repeat q. 15 min or if changes occur  Assess for Hx of trauma, HTN, CVD, ACS, aortic aneurysm, CKD, DM, pregnancy, or adrenal tumor HYPERTENSIVE URGENCY No evidence of end organ damage or focal neurologic deficits 2. Transport without drug therapy to reduce BP 3. If severe headache: Adult: FENTANYL or ACETAMINOPHEN standard dose per PAIN Mgt SOP HYPERTENSIVE EMERGENCY (SBP > 160) plus Time Non-traumatic origin; evidence suggesting end-organ dysfunction present sensitive pt DO NOT use drug therapy solely to rapidly lower BP in chronically hypertensive pts: Needs IV BP control at hospital 2. IMC special considerations:  Assess stroke scale. If positive for stroke  Stroke SOP  Keep patient as quiet as possible; reduce environmental stimuli  If GCS ≤ 8: Assess need for ADV airway  Elevate head of stretcher 10˚-15˚  Seizure/vomiting precautions; suction only as needed  Repeat VS before and after each intervention 3. If chest pain or pulmonary edema: NITROGLYCERIN 0.4 mg per ACS SOP [BLS] | Contact OLMC for repeat dose 4. If generalized tonic/clonic seizure activity:  Not pregnant: MIDAZOLAM standard dose for seizures  Pregnant: MAGNESIUM SULFATE per Eclampsia SOP 5. Continue treating per appropriate SOP based on etiology and clinical S&S NWC EMSS 2022 SOP 35 Rev. 3-11-24  PSYCHIATRIC | Behavioral Health Emergencies (BHE): May be critical Decisional capacity | Risk assessment | Care (Adult & Peds) SCENE SAFETY: If safety in jeopardy, request law enforcement protection; withdraw until scene is safe for EMS.  Assess for imminent risk of harm to self or others: verbal; non-verbal, or written threats/threatening behavior (shaking fists, intentionally slamming doors, punching walls, destroying property, vandalism, sabotage, theft, or throwing objects), self-injurious behaviors, disordered eating, physical attacks (hitting, shoving, biting, pushing or kicking). Extremes include rape, arson, and use of lethal force).  Inspect environment for clues suggesting substance use; suicide notes, plans to harm others  General pt appearance; hygiene, grooming, odors | Inspect for Medic alert jewelry; impairment; trauma  Collateral information from informants: History (if known) and recent mood, behavior, or thought changes  Consider use of the Richmond Agitation Sedation Scale (RASS) – See bottom of 3rd page BHE SOP DECISIONAL CAPACITY / RISK ASSESSMENT Ability to understand and appreciate the nature and consequences of a decision re: medical Rx or foregoing life-sustaining treatment and the ability to reach and communicate an informed decision (755 ILCS 40/10 , as amended by P.A. 90-246). Capacity can be influenced by medications, pain, time of day, mood, medical or mental illness. If any S&S below are abnormal/impaired the pt may lack capacity Attempt to assess if changes are new (acute) or features of chronic dx and how grossly abnormal EMS interprets the exam findings to be. Has pt been declared an emancipated minor?  Yes  No Has pt been declared legally incompetent?  Yes  No Alertness (Abn. GCS 13 or less): E (3 or 4 OK): V (5): M (6) Total: Orientation X 4: Answers accurately person, place, time, and situation (Abn. X 3 or less / 4) Speech: Speaks with normal rate, volume, articulation, content | (Disorganized, repetitive utterances?) Affect: Mood/emotional response (sad, depressed, flat, anxious, irritable, angry, elated, inappropriate, and incongruent with speech content) Behavior: Posture, gestures, abnormal movements, repetitive behaviors; is pt. quiet, restless, inattentive, hyperactive, agitated, violent? Is pt cooperative and able to remain in control? Cognition: Intellectual ability/thought processes - Note if linear, confused, disorganized, obsessive thoughts, not making sense; evidence of delusions, delirium, dementia, hallucinations, phobias, suicidal or homicidal ideations. Memory: Immediate, recent, remote (amnesia/dementia?) Insight: Can pt articulate lucid and logical implications of the situation and consequences to their choices? Do they understand relevant information? Can they draw reasonable conclusions based on facts and communicate a safe and rational alternative choice to recommended care? Assess for and Rx causes of AMS per symptom-specific SOP (Consider baseline/normal ranges for pt) BALANCE/Coordination – Ataxia (upper or lower extremities); tremors | EYES: Nystagmus - Denies PMH or unable to obtain PMH - A: Alcohol/drugs/toxins (substance use); ACS/HF, arrhythmias, anticoagulation, anemia Look for medical causes - E: Endocrine/exocrine, particularly thyroid/liver/renal/adrenal dx; electrolyte/fluid imbalances; ECG: dysrhythmias/prolonged QT - I: Insulin disorders: glucose for hypo or hyperglycemia (DKA/HHNS) - O: O2 deficit (hypoxia –  SpO2), opioids/OD, occult blood loss (GI/GU) - U: Uremia; other renal causes including hypertensive problems HPI/ PMH - T: (recent) Trauma, temperature changes (hypo-hyperthermia) - I: Infections, neurologic and systemic (sepsis) - P: Psychological*; poisoning; perfusion deficits; massive pulmonary embolism - S: Space occupying lesions (epi or subdural, SAH, tumors); stroke, shock (hypotension), seizures Neuro: Delirium, dementia (Alzheimer’s dx), developmental impairment, autism, Parkinson’s dx; migraine/other HA Metabolic: Acidosis ( EtCO2), vitamin/dietary deficiencies; disordered eating / malignancies *Psych/behavioral: Anxiety or mood disorders; PTS, mental health crisis; personality and bipolar disorders; delusions, psychosis; hallucinations (auditory, visual, tactile) Determine decisional capacity + mental health safety risk □ Low risk: Flat affect; low suicide risk; thoughts disordered (confused) with insight, cooperative Risk □ Medium risk: Intoxicated, disinhibited, no insight, unpredictable, cooperative □ High risk: Violent; agitated; aggressive, uncooperative; no insight | high risk to self/others IMC special considerations | MEDICAL care = MEDICAL decision | Work collaboratively w/ mental health / LEO personnel C A 1. Priority: PT & PERSONNEL SAFETY | Recognize warning signs | Use least risk/force possible to protect all R from injury; facilitate assessment | Rx life-threats; and/or safely transport. E Do not antagonize | Maintain dignity to extent possible | Maintain safe distance unless urgent interventions indicated Inform pt of intent to touch them for an assessment or safety hold | PPE/source control | consider early O2 NWC EMSS 2022 SOP 36 Rev. 3-11-24  May be PSYCH | BHE Care cont.| Sedation | Restraint | Suicide screen critical 2. Provide low stimulus & calm environment; limit responders to minimum safe levels, isolate from bystanders prn 3. Empathetic communication | Use concise, simple words | Set boundaries and clear limits (mutual respect) 4. If pt lacks decisional capacity | poses medium-high risk to self or others: DO NOT LEAVE ALONE Provide continuous visual observation and ability to intervene immediately | Rx per implied consent 5. If S&S of anxiety | verbal aggression and confrontation | Cooperative | Low-medium safety risk: - Verbally redirect and de-escalate when possible with coaching & reassurance - Unsuccessful: If BP (MAP) normal for pt/age: MIDAZOLAM (anxiety/sedation dose) If suspect use of alcohol, opioids, or CNS depressants: reduce MIDAZOLAM total dose to 0.1 mg/kg 5. If physical aggression/violent | severe agitation | UNcooperative | High safety risk to self or others: C  Inform pt that violence or abuse cannot be tolerated | Take all threats seriously A  Verbal de-escalation | Use barriers for protection | Self-defense when appropriate R  If unsuccessful & unsafe: KETAMINE (Sedation dose): Estimate pt wt carefully | Caution if active psychosis E  RESTRAINT (Physical hold/mechanical restraints per protocol): Humane, judicious & safe - Indications: Pt poses imminent risk of harm to self, others, or environment - Must not be punitive | Position to maximize airway/ventilations & minimize aspiration risk - Ensure peripheral perfusion distal to restraint | Allow for rapid removal if ABCs compromised - Avoid injury | Never use prone, hogtie (hobble) positioning nor place under backboard or mattress - Cardiac arrest can happen quickly | Watch for sudden giving up, quiet compliance, collapse - In an emergency: apply restraints; then confirm necessity with OLMC | Document thoroughly - If applicable: Describe how restraint was applied by others and EMS assessment of pt safety Cont. monitoring/frequently reassess: GCS, RASS, airway, VS; SpO2; EtCO2; WOB; ECG; at least q. 5 min Document untoward events after sedation or restraint | Watch for complications of delirium w/ severe agitation 6. Provide pre-arrival notification & report ASAP Suicide Screen: Explore risk of suicide/harm to others (current, recent, or lifetime SI attempts); warning signs/behavior changes; mitigating/protective factors/support systems. Bring suicide notes to hospital. Possible RISK FACTORS for suicide Mental health or illness disorders (esp. depression and bipolar disorder) Previous suicide attempts or self-inflicted injury | Access to lethal means coupled with suicidal thoughts Hx of trauma, loss, marginalizing experiences (adverse childhood experiences; family history of suicide, bereavement, or economic loss); discrimination based on socioeconomic factors, race/ethnicity or gender/sexual identity Serious illness, or physical or chronic pain or impairment; substance use Social isolation; barriers to healthcare; pattern/history of aggressive or antisocial behavior; family or peer conflict Discharge from inpatient psychiatric care, particularly within first weeks and months after discharge Always ask questions #1 & #2 In past month 1. Wish to be dead: Have you wished you were dead or wished you could go to sleep and not wake up? 2. Suicidal thoughts: Have you actually had any thoughts about killing yourself? If YES to #2, answer questions 3, 4, 5 & 6 If NO to #2, go directly to question 6 3. Suicidal thoughts w/ method (no plan or intent to act): Have you thought about how you might do this? 4. Suicidal intent, no specific plan: Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them? 5. Suicidal intent with plan: Have you started to work out or have worked out the details of how to kill yourself? Do you intend to carry out this plan? ALWAYS ASK QUESTION #6 In past 3 mos. 6. Have you done anything, started to do anything, or prepared to do anything to end your life? Ex: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, held a gun but changed your mind, cut yourself, tried to hang yourself, etc. Any YES must be taken seriously. If YES to #4, #5 or #6, immediately transport to appropriate HC facility. Check pts and bystanders for items that could be used to make a suicide attempt or harm others. Observe for hanging anchor points and minimize use of items that can be used for self-injury: bandages, sheets, plastic bags, IV & O2 tubing. National Suicide Prevention Lifeline: Call 988 | Veterans: 1-800-273-8255; press 1 for live chat or text 838255 NWC EMSS 2022 SOP 37 Rev. 3-11-24  PSYCH | BHE cont.: Documentation | Contested collaborative care decisions May be critical Transport without consent | Agitation scoring tool Documentation in addition to usual history and exam (ImageTrend worksheet)  Who called EMS? What happened? ▪ Types of threat alleged or observed: verbal or physical (nature)  Where/when did event happen? ▪ Witnesses; others involved; account of situation/statements by pt  Preceding factors (prior events) ▪ Verify injuries sustained: emotional/physical  Decisional capacity/risk assessment findings ▪ Evidence to support risk assessment (notes/social media posts)  Suicide screen (if applicable) ▪ Scene factors/observations to support risk concerns  Interventions (type and nature)/responses ▪ Pt’s stated preferences regarding Rx if different from EMS  Any challenges encountered during the call ▪ LEO/mental healthcare worker presence/engagement  Pt’s access to lethal means of harm ▪ Patient disposition BHE pts may not dissent to care/transport if:  EMS has access to the pt + they lack legal or decisional capacity; and/or  Pt poses an imminent risk to self (suicide/self-injurious behaviors), others, or meets self-neglect emergency criteria (see SOP Introduction); and/or  Remains acutely & severely hemodynamically unstable/ in physiologic distress with AMS after care. If any of the above are present - transport under implied consent Caveats on contested collaborative care decisions/EMS safety issues - Non-medical persons cannot compel EMS practitioners to provide or withhold any EMS care. - EMS personnel have no duty to place themselves at risk of bodily harm in the absence of law enforcement assistance and protection. - OLMC cannot compel EMS to act in a way that subjects them to risk of harm – which may mean leaving a high-risk patient at the scene when EMS access has been denied, LEOs decline to assist, and/or there is reason to believe the pt may have access to lethal weapons. EMS shall not seek OLMC approval of a refusal if the above applies. Rather, they shall report the following: We are on scene with a person who has denied us access to provide a reasonable assessment and law enforcement has declined to intervene. [OR] We have determined that this person has legal and decisional capacity and they appear to pose no imminent risk to self or others and decline to be transported at the present time. They have been informed of the benefits of Rx/transport, given disclosure of the risks of dissenting, alternatives for care, and they demonstrate appropriate insight. They persist in declining our assistance. We are therefore leaving them in their current environment. Disposition □ Treat/transport w/ express consent  Treat/transport w/ implied consent  Decisional pt refused care/transport  No care d/t EMS safety concerns Modified Richmond Agitation Sedation Scale (RASS) Used for Behavioral Health Emergency patients prior to / during / after sedation Score Responsiveness Speech +4 Combative, violent, out of control Continual loud outbursts or growling +3 Very anxious and agitated Loud outbursts +2 Agitated, overstimulated but self-controlled Fast speech; flight of ideas +1 Anxious or restless Normal, talkative 0 Awake, alert, calm, cooperative Normal -1 Drowsy, asleep, rouses to voice Slurring or slowing -2 Light sedation; rouses to physical stimulation Marked slowing; few recognizable words -3 Moderate sedation; responds to pressure stimulus Words or no speech -4 Deep sedation; no response to stimulus – hold further med No speech Complications of delirium w/ severe agitation: Stroke, STEMI, hypoglycemia, hyperthermia, rhabdomyolysis, trauma NWC EMSS 2022 SOP 38 Rev. 3-11-24  STROKE | TRANSIENT ISCHEMIC ATTACK Time sensitive pt 1. IMC special considerations:  History of present illness/PMH | Complete BEFAST STROKE SCREEN + LVO assessments – See next page Attempt to determine baseline status: dementia, pre-existing limitations/deficits, unable to care for self?  Support ABCs as needed; O2 if SpO2 < 94% or O2 sat unknown; avoid hypoxia and hyperoxia  Seizure/vomiting precautions; suction prn  Maintain head/neck in neutral alignment; do not use pillows. If SBP > 100: Elevate head of bed 10° - 15°  Monitor ECG; acquire 12 L if possible  IV: 18 g AC. (Max 2 attempts); avoid excess fluid loading  Repeat VS frequently & after each intervention. Anticipate HTN & bradycardia due to ↑ ICP. Do NOT Rx HTN or give atropine for bradycardia if SBP > 90 (MAP > 65)  Provide comfort and reassurance; establish means of communicating with aphasic patients  Limit activity; do not allow pt to walk; protect limbs from injury 2. If generalized tonic/clonic seizure activity: Observe and record seizure activity per Seizure SOP MIDAZOLAM standard dose for seizures 3. If AMS, seizure activity, or neurologic deficit: Assess blood glucose If ≤ 70 or S & S of hypoglycemia: Treat per Glucose Emergencies SOP 4. Minimize scene time 24 hrs Time: T Time of S&S discovery: Earliest time pt known to have new S&S Time: Level of consciousness: AMS? GCS: E V M Total GCS: Orientation: Answers accurately: Name, age, month of year; location, situation X (1-4) Responds to commands: open/close eyes Y N Gross hearing – Note new onset unilateral hearing deficit; sound sensitivity R L Say “Ah”, palate rises, uvula midline; Stick out tongue: remains midline (note abnormalities) R L Agnosia: Inability to recognize an object (part of body) or person Other R L Neglect: One sided extinction (visual, auditory, sensory) Motor: Lift leg. Normal | Abnormal: drift to no effort against gravity R L Sensory: Focal changes/deficits (face, arms, legs); paresthesias, numbness R L ANS: Sweating only one side R L Neck stiffness (cannot touch chin to chest; vomiting Y N Blood glucose level - List reading: Y N  None  A-Fib/Flutter  AVM, tumor, aneurysm  Bleeding disorders  CAD/Prior MI/Heart/vascular dx  Carotid stenosis  Pregnant (or up to 6 wks. post- partum)  Depression  Diabetes  Drug/Alcohol Abuse PMH  Dyslipidemia  Family Hx stroke  HF  Hormone RT  HTN  Migraine  Obesity  Previous stroke  Previous TIA:  Previous intracranial surgery/bleed  Serious head trauma  *Prosthetic valve  PVD  Renal failure  Sleep apnea  Smoker/tobacco use Anticoagulant use in 48 hrs:  warfarin/Coumadin/Jantoven  apixaban/Eliquis  argatroban  dabigatran/Pradaxa  desirudin/Privask  edoxaban/Savaysa  enoxaparin/Lovenox  fondaparinux/Arixtra  LMW heparin  lepirudin/Refludan  rivaroxaban/Xarelto MEDS Platelet inhibitors:  ASA  clopidogrel/Plavix  dipyridamole/Aggrenox  prasugel/Effient  ticagrelor/Brilinta  ticlodipine/Ticlid  Cocaine/other vasoconstrictors (amphetamines: PCP) Destination options if primary impression is stroke: □ Nearest hospital: Patient unstable □ Nearest SC (Primary or Comp.) BEFAST +/ LVO not suspected OR LKN > 24 hours | Transport time to CSC > 30 min □ Nearest Comprehensive SC LVO cortical signs | SAH/ICH suspected + LKN ≤ 24 hours + Transport time ≤ 30 min Stroke alert called to (OLMC hospital) Time: Receiving hospital Comprehensive SCs (Thrombectomy up to 24 hrs after onset S&S)  ABMC  LGH  NCH  CDH/MSU NWC EMSS 2022 SOP 40 Rev. 3-11-24  SEIZURES History:  History /frequency / type of seizures  Prescribed meds and patient compliance; amount and time of last dose  Recent or past head trauma; fall, predisposing illness/disease; recent fever, headache, or stiff neck  History of ingestion/drug or alcohol SUD; time last used Consider possible etiologies:  Anoxia/hypoxia Anticonvulsant withdrawal/noncompliance  Cerebral palsy or other disabilities Infection (fever, meningitis, encephalitis)  Eclampsia Metabolic (glucose, electrolyte disorders, acidosis)  Stroke/cerebral hemorrhage Toxins/intoxication/SUD; OD | Withdrawal; DTs  Trauma/Abuse Tumor | ↑ ICP Secondary assessment Observe and record the following  Presence of an aura  Focus of origin: one limb or whole body  Simple or complex (conscious or loss of consciousness)  Partial/generalized  Progression and duration of seizure activity  Eye deviation prior to or during seizure  Abnormal behaviors (lip smacking)  Incontinence or oral trauma  Duration and degree of postictal coma, confusion 1. IMC special considerations:  No bite block. Vomiting/aspiration precautions; suction prn  Protect patient from injury; do not restrain during tonic/clonic movements  Position on side during postictal phase unless contraindicated 2. If generalized tonic/clonic seizure activity: Benzodiazepine administration takes precedence over bG determination in pts who are actively seizing MIDAZOLAM 2 mg increments slow IVP q. 30-60 sec (0.2 mg/kg IN) up to 10 mg IVP/IN titrated to stop seizure  If IV/IO unable/IN contraindicated: 5-10 mg (0.1-0.2 mg/kg) IM (single dose)  All routes: May repeat to a max total dose of 20 mg prn if SBP ≥ 90 (MAP ≥ 65) unless contraindicated  If hypovolemic, elderly, debilitated, chronic Dx (HF/COPD); on opioids/CNS depressants: ↓ total dose to 0.1 mg/kg If pregnant with possible eclampsia: Rx with MAGNESIUM SULFATE per Eclampsia SOP 3. Identify and attempt to correct reversible precipitating causes (see above) Assess/record blood glucose l If ≤ 70 or S&S of hypoglycemia: Treat per Glucose Emergencies SOP NWC EMSS 2022 SOP 41 Rev. 3-11-24  SEPSIS and SEPTIC SHOCK Time sensitive pt 1. IMC special considerations:  Rapidly assess for risk factors | S&S suggesting infection* | Infectious source - IF YES  SpO2: Use central sensor if pt has poor peripheral perfusion (cold hands)  Assess EtCO2 - Correlations EtCO2 ≤ 31 = Lactate 2 | Suggests hyperventilation; poor perfusion; and/or metabolic acidosis EtCO2 < 25 = Lactate ≥ 4 (metabolic distress)  Assess qSOFA: Quick Sequential [Sepsis-related] Organ Failure Assessment criteria - AMS (GCS < 15); assess for disorientation/agitation and/or GCS 1 or more points below patient’s baseline - RR ≥ 22 (adult) SBP ≤ 100 (adult) (note if ≥ 2 criteria are present)  Trend pulse pressures (PP) (normal 30-50) + MAP (normal 70-110) q. 5 min Can crash rapidly | Elderly & those with HTN cannot tolerate hypotension for even a short time  Assess S&S of fluid depletion: Orthostatic VS changes if not hypotensive; poor skin turgor, dry mucosa Vascular access: 18 g AC preferred if inopressor needed | IVF- See below  Assess blood glucose: Anticipate hyperglycemia and electrolyte abnormalities (6-24 hrs):  RR; hyperdynamic phase with high cardiac output; SBP 25% < normal; fever, Warm stage vasodilation, skin: hot, dry, flushed Cold Stage (ominous/late): AMS; T< 96.8° F; skin cold; mottling;  HR & RR; profound hypotension *Indicators suggesting infection: Fever; warm skin Fatigue, altered mental status Cough, dyspnea Sore throat, ear ache Diarrhea Dysuria, foul smelling/cloudy urine Local redness, warmth, swelling, unhealed wounds etc. If infection, no sepsis: Cardio-resp. support | Rx specific conditions per appropriate SOP or OLMC SEPSIS: Suspect infection + EtCO2 ≤ 31 + ≥ 2 qSOFA criteria: (SBP 90-100 | MAP > 65) 2. Call OLMC with a Sepsis alert per local policy/procedure 3. NS 200 mL boluses to achieve SBP ≥ 100 mmHg (max 1 L) SEPTIC SHOCK: Sepsis + SBP < 90 (MAP < 65) or hypotensive for pt (40 mmHg < baseline); or EtCO2 ≤ 25 2. Call OLMC with a Sepsis alert per local policy/procedure. 3. IV/IO NS 200 mL boluses in rapid succession (max: 20 mL/kg) to SBP ≥ 90 (MAP ≥ 65) Reassess VS / skin signs / EtCO2 after each bolus to assess for fluid responsiveness and S&S of volume overload 4. If hypotension persists after 500 mL IVF – add inopressor while continuing IVF (2nd IV line needed) NOREPINEPHRINE drip IV (lg. vein) / IO: Conc: 4 mg in 1,000 mL NS (4 mcg/mL) | Use of IV pump preferred Initial dose: 8 mcg/min (2 mL/min) titrated to SBP ≥ 90 (MAP ≥ 65) Higher doses (10 mcg/min) RARELY needed – contact OLMC. Assess BP (MAP) q. 2 min until target BP reached (don’t overshoot) | Then reduce dose (drip rate) incrementally just to maintain at BP targets Maintenance: 2 to 4 mcg/min (0.5 mL to 1 mL/min) or less | Continue to reassess BP q. 5 min. At risk populations: ≥ 65 or < 1 yr, or weakened immune systems (cancer, HIV/AIDS); indwelling devices; chronic steroid use; sickle cell disease, splenectomy; bedridden or immobile); recent trauma, surgery, or dental work; breached skin integrity (wounds, burns); IV drug use; females - recent birth, miscarriage, abortion; PID, post-organ transplant; chronic disease: DM, cirrhosis, autoimmune, renal Results in a systemic immune/inflammatory response leading to massive vasodilation and capillary leak that causes hypoperfusion | Other concer