BLS EMS Only - Protocol PDF

3.1-A Adult Emergency Cardiac Care for BLS – Algorithm BLS Cardiac: Adult Emergency Cardiac Care for BLS – Algorithm 3.1-A Release Date July 1, 2023...

3.1-A Adult Emergency Cardiac Care for BLS – Algorithm BLS Cardiac: Adult Emergency Cardiac Care for BLS – Algorithm 3.1-A Release Date July 1, 2023 322175 968 of www.miemss.org Back to Contents  3.1-P Pediatric Emergency Cardiac Care for BLS – Algorithm BLS UNIVERSAL ALGORITHM FOR PEDIATRIC EMERGENCY CARDIAC CARE FOR BLS Greater than 1 hour old and less than 13 years of age If less than 1 hour old, refer to Newly Born Protocol Cardiac: Pediatric Emergency Cardiac Care for BLS – Algorithm 3.1-P Stay on Scene Oxygen as needed Begin HPCPR VENTILATE as needed Attach AED with pediatric capability Target ventilations rate to 20 bpm 100-120 compressions/minute Vital Signs 100% oxygen History & Physical Detailed Assessment Defibrillate 1 time Resume HPCPR Resume HPCPR immediately immediately for 2 minutes for 2 minutes Release Date July 1, 2023 342175 969 of www.miemss.org Back to Contents  3.2-A Adult Bradycardia Algorithm Indications l Slow heart rate, less than 60 bpm l Bradycardic patients may also present with serious signs and symptoms including: n Chest pain or shortness of breath n Altered/decreased level of consciousness n Hypotension or hypoperfusion n Congestive heart failure or pulmonary congestion n Acute myocardial infarction BLS l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. Cardiac: Adult Bradycardia Algorithm 3.2-A Release Date July 1, 2023 362175 970 of www.miemss.org Back to Contents  Pediatric Bradycardia Algorithm (If less than 1 hour old, refer to Newly Born Protocol) 3.2-P Indications l Slow heart rate (refer to Normal Vital Signs Chart) BLS l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. l Begin CPR if HR less than 60 with signs of poor perfusion despite oxygenation and ventilation Cardiac: Pediatric Bradycardia Algorithm 3.2-P www.miemss.org 372175 971 of Release Date July 1, 2023 Back to Contents  3.3-A Adult Tachycardia Algorithm – Irregular Rhythm BLS l Place patient in position of comfort. l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. Cardiac: Adult Tachycardia Algorithm – Irregular Rhythm 3.3-A Release Date July 1, 2023 382175 972 of www.miemss.org Back to Contents  Adult Tachycardia Algorithm – Regular Rhythm 3.3-A BLS l Place patient in position of comfort. l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. Cardiac: Adult Tachycardia Algorithm – Regular Rhythm 3.3-A www.miemss.org 392175 973 of Release Date July 1, 2023 Back to Contents  Pediatric Tachycardia Algorithm 3.3-P (If less than 1 hour old, refer to Newly Born Protocol) BLS l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. Cardiac: Pediatric Tachycardia Algorithm 3.3-P Release Date July 1, 2023 402175 974 of www.miemss.org Back to Contents  3.4-A Cardiac Arrest – Adult Indications l Adult patients (medical arrest: 13 years of age and older; trauma arrest: 15 years of age and older) who are unconscious, apneic, and pulseless BLS l Perform high-quality uninterrupted chest compressions (manual or mechanical) as soon as possible and until defibrillator available. l Apply AED as soon as available. l Follow machine prompts regarding rhythm analyses and shocks. l Limit breaks in compressions to 10 seconds or less for rhythm analysis periods and during shocks; perform compressions while defibrillator is charging. l On-scene resuscitation: Patients who are found in arrest or who arrest prior to transport and are attended to by BLS clinicians must only be resuscitated in place (with minimal movement, no attempts at patient loading, and no attempts at transport) until the follow- ing have been accomplished: n Medical etiology: the patient has received a minimum of five two-minute cycles of chest compressions and rhythm interpretation n Traumatic etiology: patient has received treatments for reversible causes per Trauma Protocol: Trauma Arrest protocol l Exemptions from on-scene resuscitation: Cardiac: Cardiac Arrest – Adult 3.4-A n Physical barriers prevent resuscitation n Clinicians are in danger n Pregnant patients n Patients in cardiac arrest thought to be secondary to hypothermia or submersion l Following the initial on-scene resuscitation above, clinicians may continue on-scene re- suscitation until termination of resuscitation or transport the patient at any time. Clinicians should ensure that a mechanical CPR device is in place (if available) prior to transport. l Pregnancy: For pregnant patients greater than 20 weeks gestation in cardiac arrest, provide constant left lateral uterine displacement. Release Date July 1, 2023 422175 975 of www.miemss.org Back to Contents  Cardiac Arrest – Pediatric 3.4-P Indications l Pediatric patients (medical arrest: less than 13 years of age; trauma arrest: less than 15 years of age) who are unconscious, apneic, and pulseless BLS l Perform high-quality uninterrupted chest compressions (manual or mechanical) as soon as possible and until defibrillator available. l Apply AED as soon as available. l Follow machine prompts regarding rhythm analyses and shocks. l Limit breaks in compressions to 10 seconds or less for rhythm analysis periods and during shocks; perform compressions while defibrillator is charging. l On-scene resuscitation: Patients who are found in arrest or who arrest prior to transport and are attended to by BLS clinicians must only be resuscitated in place (with minimal movement, no attempts at patient loading, and no attempts at transport) until the follow- ing have been accomplished: n Medical etiology: the patient has received a minimum of fifteen two-minute cycles of chest compressions and rhythm interpretation n Traumatic etiology: patient has received treatments for reversible causes per Trauma Protocol: Trauma Arrest protocol l Exemptions from on-scene resuscitation: Cardiac: Cardiac Arrest – Pediatric 3.4-P n Physical barriers prevent resuscitation n Clinicians are in danger n Pregnant patients n Patients in cardiac arrest thought to be secondary to hypothermia or submersion l Following the initial on-scene resuscitation above, clinicians may continue on-scene resuscitation until termination of resuscitation or transport the patient at any time. Clini- cians should ensure that a mechanical CPR device is in place (if available) for patients 13 years of age and older prior to transport. l Pregnancy: For pregnant patients greater than 20 weeks gestation in cardiac arrest, provide constant left lateral uterine displacement. www.miemss.org 452175 976 of Release Date July 1, 2023 Back to Contents  3.4-P Pediatric Cardiac Arrest Algorithm (BLS) BLS PEDIATRIC HIGH PERFORMANCE CPR (HPCPR) Assess Patient (less than 10 seconds) Remain on Scene Begin HPCPR Unresponsive Not Breathing No pulse Clinician # 1 Start Chest Compressions (100-120/min) Cardiac: Pediatric Cardiac Arrest Algorithm (BLS) 3.4-P Ventilations 2 Breaths: 30 Compressions Call for AED/Defibrillator Clinician #2 2 minute Attach AED/Defibrillator cycles Assume Ventilation Role - 2 Breaths: 15 compressions Place Airway Adjunct Suction Continue HPCPR for 2-minute Clinician #3 or More cycle – less than10 second pause BLS – HPCPR Coach for coordinated activities BLS – Family Support Check pulse ALS – Establish IO Check rhythm (AED) ALS – Administer medication Shock if indicated ALS – Establish ALS airway Change compressors Pediatric HPCPR Team Member Initial Roles Essentials of High Performance CPR for When 2 or More Clinicians Are Present Pediatrics Clinician #1: 1. Ensure proper chest compression rate Chest compressions at 100-120 per minute 100-120/min Call for AED 2. Ensure proper compression depth Less than 1 year – 1 ½ inches (4 cm) Clinician #2: Greater than or equal to 1 year – Ventilate at 2 breaths:15 compressions 2 inches (5 cm) Attach AED 3. Minimize interruptions (less than 10 second pause) Clinician #3 or MORE: 4. Ensure full chest recoil Assume timekeeper role 5. Coordinate 2 minute cycles Assume AED role 6. Rotate Compressor IO Access Medications *Once an advanced airway is in place: Establish ALS Airway Less than 13 years of age: 1 ventilation every Family Support 3 seconds interposed asynchronously 13 years and older: 1 ventilation every 3 seconds interposed asynchronously for patients less than 13 years of age Release Date July 1, 2023 462175 977 of www.miemss.org Back to Contents  3.5-A Return of Spontaneous Circulation (ROSC) – Adult Indications l Patients 18 years of age and older who have been revived from cardiac arrest (return of pulses) due to a medical etiology l For patients resuscitated from traumatic arrest, refer to Multiple/Severe Trauma protocol. BLS l Verify presence of a carotid pulse. If any doubt exists as to whether a carotid pulse is present, initiate CPR and refer to appropriate Cardiac Arrest protocol. l If apneic or inadequate respirations, continue to support ventilations. l Frequently reassess vital signs. Treat any abnormalities in accordance with appropriate shock, respiratory, or cardiac protocols. l Rendezvous with ALS or transport to the closest ED. l If available and not already in place, apply mechanical CPR (mCPR) device in standby Cardiac: Return of Spontaneous Circulation (ROSC) – Adult 3.5-A mode. Release Date July 1, 2023 502175 978 of www.miemss.org Back to Contents  Return of Spontaneous Circulation (ROSC) – Pediatric 3.5-P Indications l Pediatric patients less than 18 years of age who have been revived from cardiac arrest (return of pulses) due to a medical etiology l For patients resuscitated from traumatic arrest, refer to Multiple/Severe Trauma protocol. BLS l Verify presence of a carotid pulse. If any doubt exists as to whether a carotid pulse is present, initiate CPR and refer to appropriate Cardiac Arrest protocol. l If apneic or inadequate respirations, continue to support ventilations. l Frequently reassess vital signs. Treat any abnormalities in accordance with appropriate shock, respiratory, or cardiac protocols. l Rendezvous with ALS or transport to the closest ED. l For patients 13 years of age and older, apply mechanical CPR (mCPR) device in standby mode, if available and not already in place. Cardiac: Return of Spontaneous Circulation (ROSC) – Pediatric 3.5-P www.miemss.org 512175 979 of Release Date July 1, 2023 Back to Contents  Termination of Resuscitation – Adult 3.6-A Indications l Patients who are in cardiac arrest due to medical or traumatic etiology Exclusions l The following patients should receive care according to appropriate protocol, without TOR, and transport to the closest appropriate facility: n Pregnant patients n Patients in cardiac arrest that is suspected to be due to hypothermia or submersion BLS l If the patient meets the criteria listed in the Pronouncement of Death in the Field proto- col, EMS clinicians should terminate resuscitation efforts. l BLS clinicians may terminate resuscitation for adult patients (age 18 or older) if: n ALS resources are genuinely unavailable, and n The patient has received a minimum of 15 two-minute cycles of HPCPR, and n During the five AED analyses immediately prior to TOR there was “no shock advised.” Clinical Pearls Cardiac: Termination of Resuscitation – Adult 3.6-A l If the patient does not meet TOR criteria, continue resuscitation and re-evaluate at the next rhythm check. l For traumatic arrest patients, asystole and resuscitations lasting longer than 10 minutes are inde- pendent predictors of mortality. Treatment of the trauma arrest patient should focus on identifying and treating reversible causes during that narrow resuscitative window. TOR and transport deci- sions should only be made after administering time-sensitive therapies. www.miemss.org 532175 980 of Release Date July 1, 2023 Back to Contents  Termination of Resuscitation – Pediatric 3.6-P Indications l Patients who are in cardiac arrest due to medical or traumatic etiology Exclusions l The following patients should receive care according to appropriate protocol, without TOR, and transport to the closest appropriate facility: n Pregnant patients n Patients in cardiac arrest that is suspected to be due to hypothermia or submersion BLS l If the patient meets the criteria listed in the Pronouncement of Death in the Field proto- col, EMS clinicians should terminate resuscitation efforts. l May not terminate resuscitation for pediatric medical arrest patients (under age 18 years). l May terminate resuscitation for pediatric traumatic arrest patients (under age 15 years) if: n ALS resources are genuinely unavailable, and Cardiac: Termination of Resuscitation – Pediatric 3.6-P n The patient has received a minimum of 15 two-minute cycles of HPCPR, and n During the five AED analyses immediately prior to TOR there was “no shock advised.” Clinical Pearls l If patient does not meet TOR criteria, continue resuscitation and reevaluate at the next rhythm check. www.miemss.org 572175 981 of Release Date July 1, 2023 Back to Contents  3.7 Pronouncement of Death in the Field Indications l EMS clinicians may use this protocol to pronounce the death of a patient when one or more of the following criteria have been met: n Decapitation n Rigor mortis n Decomposition n Dependent lividity n Pulseless, apneic patient in a multi-casualty incident where system resources are required for the stabilization of living patients t Patient may be “black tagged” by BLS or ALS, but asystole must be confirmed by ALS prior to formal pronouncement of death. n Pulseless, apneic patient with an injury not compatible with life t Exception: Obviously pregnant female patient should have resuscitation initiated and be transported to the closest appropriate facility. n EMS clinician has terminated resuscitation per the Termination of Resuscitation protocol Cardiac: Pronouncement of Death in the Field 3.7 BLS l Confirm that the patient is unresponsive, pulseless, and apneic. l Document the exact time and location of the pronouncement of death. l Notify law enforcement and follow local jurisdictional policies. l Organ donor: If the deceased patient is an organ donor and law enforcement has released the body to the family, please assist the family in calling Infinite Legacy, 800 923-1133. l If death is pronounced during transport, deliver the patient to the hospital and follow hospital policies. Law enforcement must be notified, as they may need to notify the medical examiner’s office. Clinical Pearls l Health General Article §5-202 provides that: an individual is dead if, based on ordinary standards of medical practice, the individual has sustained either: n Irreversible cessation of circulatory and respiratory functions; or n Irreversible cessation of all functions of the entire brain, including the brain stem Release Date July 1, 2023 602175 982 of www.miemss.org Back to Contents  EMS DNR/MOLST 3.8 Indications l A MOLST Form or Acceptable EMS DNR Order is presented to EMS by family/caregivers or found on scene, and n Patient is in cardiac or respiratory arrest, or n Patient is non-verbal or lacks medical decision-making capacity BLS l Resuscitation status: n Attempt CPR – if cardiac or respiratory arrest occurs: perform CPR, artificial ven- tilation, and all medical efforts that are indicated during arrest in order to restore or stabilize cardiopulmonary function n MOLST A-1 – if cardiac or respiratory arrest occurs: do not attempt resuscitation (no CPR) t Prior to arrest: maximal restorative efforts including intubation n MOLST A-2 – if cardiac or respiratory arrest occurs: do not attempt resuscitation (no CPR) t Prior to arrest: comprehensive efforts to prevent arrest excluding intubation n MOLST B – if cardiac or respiratory arrest occurs: do not attempt resuscitation (no CPR) Cardiac: EMS DNR/MOLST 3.8 t Prior to arrest: limited, palliative care only l Acceptable DNR Orders n Maryland MOLST Form or Bracelet t May be an original, copy, or electronic format for patient care decisions, however, sending facility must provide paper copy to EMS prior to patient transport n Maryland EMS/DNR Form or Bracelet t There is no expiration on older versions of DNR forms. n Medic Alert DNR Bracelet or Necklace n Out-of-state EMS/DNR Form n Oral DNR Order from EMS System Medical Consultation n Oral DNR Order from other on-site physician, physician assistant, or nurse practi- tioner l Unacceptable DNR Orders n Advanced directives (without a MOLST or DNR Order) or other oral or written re- quests shall not be honored by EMS without EMS System Medical Consultation l Revocation of DNR Orders n An EMS/DNR Order may be revoked at any time by: t Physical cancellation or destruction of all EMS/DNR Order devices; or t A verbal statement by the patient made directly to EMS clinicians requesting re- suscitation or palliative care only. In this case, EMS/DNR devices do not need to be destroyed. EMS clinicians must thoroughly document the revocation. A verbal revocation by the patient is only good for the current response for which it was issued. n An authorized decision-maker, other than the patient, cannot revoke an EMS/DNR Order verbally. t Decision-makers with the authority to revoke an EMS/DNR Order must either void or withhold all EMS/DNR Order devices if they wish resuscitation for the patient. If there is any confusion, the EMS clinician should consult a Base Station. www.miemss.org 612175 983 of Release Date July 1, 2023 Back to Contents  3.8 EMS DNR/MOLST (continued) BLS l EMS DNR Medical Protocols n Perform limited patient assessment. t Check for a palpable pulse. t Check for respirations in an unresponsive patient. t Check for MOLST form or other acceptable EMS/DNR Order. n Resuscitate/Do Not Resuscitate Criteria t If MOLST form or other acceptable EMS/DNR Order is present and the patient is in cardiac or respiratory arrest, no resuscitative measures shall be initiated. t If MOLST form or other acceptable EMS/DNR Order is not present, revoked, or otherwise void, EMS clinician shall treat and transport the patient, as appropriate. l If EMS clinicians believe that resuscitation or further resuscitative efforts are futile, they may initiate the Termination of Resuscitation protocol. t If the patient is conscious and able to communicate directly to EMS clinicians that they revoke the MOLST or other EMS/DNR Order verbally, then EMS clinicians shall treat and transport the patient, as appropriate. t If the EMS/DNR patient (Option A-1, A-2, B) experiences respiratory or cardiac arrest, EMS shall withhold or withdraw further resuscitation and provide support to the family and caregivers. Cardiac: EMS DNR/MOLST 3.8 n MOLST A-1 – Maximal Restorative Care, including intubation t Prior to respiratory or cardiac arrest: the Option A-1 patient shall receive the full scope of interventions permissible under The Maryland Medical Protocols for Emergency Medical Services, including: intubation, CPAP/BiPAP, cardiac moni- toring, cardioversion, cardiac pacing, IVs, and medications in attempt to forestall cardiac or respiratory arrest. t If respiratory or cardiac arrest occurs: do not initiate CPR or any resuscitative efforts. Withhold or withdraw resuscitative efforts if they were already in progress prior to discovery of the MOLST or EMS/DNR Order. n MOLST A-2 – Comprehensive Efforts, excluding intubation t Prior to respiratory or cardiac arrest: same as option A-1, except no intubation is permitted t If respiratory or cardiac arrest occurs: no CPR, same as option A-1 n MOLST B – Palliative Care t Prior to respiratory or cardiac arrest, provide supportive treatment:  Respiratory  Open and maintain airway using chin lift, jaw thrust, finger sweep, naso- pharyngeal or oropharyngeal airway, Heimlich maneuver, or laryngoscopy with Magill forceps for suspected airway obstruction, but no intubation, cricothyroidotomy, or tracheostomy  Oxygen: may provide passive oxygen via nasal cannula or non-rebreather mask, but no positive pressure oxygen via BVM, demand valve or ventila- tor. Pulse oximetry and capnography may be used.  Ventilator patients: if the patient is found on an outpatient ventilator and is not in cardiac arrest, maintain ventilator support during transport to the hospital  If the patient on an outpatient ventilator is found in cardiac arrest, con- tact online medical direction before disconnecting the ventilator.  Suction as necessary  Position for comfort Release Date July 1, 2023 622175 984 of www.miemss.org Back to Contents  EMS DNR/MOLST (continued) 3.8 BLS External bleeding   Standard treatment; direct pressure, tourniquet  No IVs  Immobilize fractures with devices to minimize pain  Uncontrolled pain or other symptoms (e.g., severe nausea)  Allow patient, family or other health care clinicians to administer patient- prescribed medications. Document this on the PCR.  Patient controlled analgesia (PCA) systems shall be maintained and monitored.  For the patient with significant pain or pain with prolonged transport, initiate the Pain Management protocol.  Existing IV lines shall be maintained in place.  Transport: upon request of the patient, family or caregivers, EMS clinicians may transport Option B EMS/DNR patients to a specified inpatient hospice facility for pain control, symptom management or respite care (in lieu of transport to a hospital-based emergency department). EMS clinicians must notify the hospice facility prior to transport. n Documentation Cardiac: EMS DNR/MOLST 3.8  A copy of the MOLST or other acceptable EMS/DNR Order must be transported with the patient to the emergency department or inpatient hospice facility.  MOLST or EMS/DNR order status must be documented in the patient care report. n Non-transported EMS/DNR Patients  Follow local operational procedures for handling deceased patients.  Do not remove DNR or Medical Alert Bracelets or Necklaces from the patient; leave the original MOLST or EMS/DNR Order with the patient.  Law enforcement or medical examiner’s office need to be notified only in the case of sudden or unanticipated death that occurs:  By violence  By suicide  As the result of an accident  Suddenly, if the deceased was in apparent good health, or  In any suspicious or unusual manner MC l An oral DNR Order from EMS System Medical Consultation is acceptable if a MOLST or DNR form is not present. l Obtain medical consultation if the MOLST or DNR form instructions are unclear or the form is unreadable. www.miemss.org 632175 985 of Release Date July 1, 2023 Back to Contents  3.8 EMS DNR/MOLST (continued) EMS DNR Flowchart EMS/DNR Order Presented: 1. Maryland EMS/DNR Order Form 2. Other State EMS/DNR Order Form 3. Maryland EMS/DNR Bracelet Insert 4. Medic Alert DNR Bracelet or Necklace 5. Oral DNR Order from medical consultation 6. Oral DNR Order from other on-site physician, physician assistant, or nurse practitioner 7. Maryland MOLST form 8. Maryland MOLST Bracelet Insert Cardiac: EMS DNR/MOLST Flowchart 3.8 If spontaneous respirations are ABSENT, OR palpable pulse is ABSENT, OR patient meets “Pronouncement of Death” criteria: DO NOT ATTEMPT RESUSCITATION If spontaneous respirations AND palpable pulse are PRESENT: DETERMINE DNR CARE OPTION “A” OR “B” If OPTION “A” or “A (DNI)”: If OPTION “B”: Treat in accordance with Treat in accordance with all Maryland Protocols Maryland Palliative Care Protocol If patient loses spontaneous res- pirations or palpable pulse, withdraw resuscitative efforts. Release Date July 1, 2023 642175 986 of www.miemss.org Back to Contents  Chest Pain/Acute Coronary Syndrome, Suspected – Adult & Pediatric 3.9 Indications l Angina or anginal equivalents l Chest pain, pressure or discomfort l Pain or discomfort in the upper abdomen, arm, or jaw l Shortness of breath l Unexplained diaphoresis BLS l Place patient in position of comfort. l Administer aspirin 324 mg or 325 mg chewed, if not given prior to EMS arrival. Cardiac: Chest Pain/Acute Coronary Syndrome, Suspected – Adult & Pediatric 3.9 l Assist with administration of patient-prescribed nitroglycerin (BLS) 0.4 mg SL. n May be repeated in 3-5 minutes if chest pain persists, blood pressure is greater than 90 mmHg, and pulse is between 60-150 bpm. Maximum 3 doses total (patient and EMT-assisted) l Assess and treat for shock if indicated. Clinical Pearls Nitroglycerin is contraindicated for any patient having taken medication for pulmonary artery hypertension (e.g., Adcirca® or Revatio®) or erectile dysfunction (e.g., Viagra®, Levitra®, or Cialis®) within the past 48 hours. www.miemss.org 652175 987 of Release Date July 1, 2023 Back to Contents  Cardiac Emergencies: Implantable Cardioverter Defibrillator (ICD) 3.10 Malfunction – Adult & Pediatric Indications l Patient must meet both criteria: n Three or more distinct ICD shocks and n Obvious device malfunction with at least one EMS clinician-witnessed inappropriate shock (e.g., Cardiac: Cardiac Emergencies: Implantable Cardioverter Defibrillator (ICD) Malfunction – Adult & Pediatric 3.10 alert patient in atrial fibrillation with rapid ventricular rate or SVT) BLS l Place patient in position of comfort. l Assess and treat for shock, if indicated. Clinical Pearls l If the patient is in cardiac arrest, perform CPR and use the AED as appropriate despite the patient’s ICD, which may or may not be delivering shocks. l If the patient has a combination ICD and pacemaker, deactivating the ICD may or may not deactivate the pacemaker. Release Date July 1, 2023 662175 988 of www.miemss.org Back to Contents  ST Elevation Myocardial Infarction (STEMI) – Adult 3.11 Indications l Patient with acute coronary syndrome (ACS) symptoms, including angina or angina equivalents such as shortness of breath, chest, epigastric, arm or jaw pain or discomfort, diaphoresis, and/or nausea and meets one of the following criteria on diagnostic quality EKG: n New ST elevation of 1 mm (or greater) in two or more anatomically contiguous leads OR n Posterior MI: ST depression greater than 1 mm in V1-V3 BLS l Not applicable; ALS protocol only Cardiac: ST Elevation Myocardial Infarction (STEMI) – Adult 3.11 www.miemss.org 672175 989 of Release Date July 1, 2023 Back to Contents  Ventricular Assist Device (VAD) Protocol 3.12 Indications l Adult patients who have an implantable ventricular assist device (VAD), including left ventricular assist device (LVAD), right ventricular assist device (RVAD), or biventricular assist device (BiVAD) and have symptoms of cardiovascular compromise or cardiac arrest BLS l Assess level of consciousness and vitals n Note: most VAD patients will not have a palpable pulse or detectable systolic and diastolic blood pressures due to the nature of the pump n An automated blood pressure cuff may be used which may obtain a mean arterial pressure (MAP). The normal range for MAP is between 60 and 90 mmHg. l Check for breathing and assist ventilation if necessary. l Assess for perfusion: check skin color, skin temperature, capillary refill, MAP, and mental status. l Altered mental status/adequate perfusion. If the patient has altered mental status, but Cardiac: Ventricular Assist Device (VAD) Protocol 3.12 has other signs of adequate perfusion, assess for causes of altered mental status (4.4). n Check blood glucose and refer to Hypo/Hyperglycemia (4.7). n If concern for overdose, refer to Overdose/Poisoning-Adult (7.7-A). l Unresponsive/abnormal perfusion. If the patient is unconscious/unresponsive, not breathing, has delayed capillary refill, and unable to obtain a MAP, initiate manual chest compressions and ventilations per Cardiac Arrest-Adult protocol (3.4-A). l Assess for alarms, which can be audible or reported by the patient/bystander. l Listen for pump sound “hum” or “whirling sound” over the chest. l Assess VAD. n Check power and connections from the controller to the batteries and driveline. n Contact patient’s VAD coordinator, using phone number on the device, and/or VAD- trained companion, who will likely be the best source of information for need to return to tertiary care center. t Johns Hopkins (cell phone): 410-382-6885 t MedStar (pager): 202-801-9796 t University of Maryland (phone): 410-328-4903 n Change VAD batteries and/or controller, if indicated. t If VAD batteries require changing, only change ONE at a time. l Transport the “backup bag” with batteries and a second controller with the patient. l For VAD-related complications or suspected cardiac/respiratory conditions: transport to the medical facility where the VAD was placed, if patient’s clinical condition and time allows. l For all other conditions: transport to closest appropriate emergency department without manipulating the device. www.miemss.org 692175 990 of Release Date July 1, 2023 Back to Contents  Abuse/Neglect 4.1 Indications l Injuries or burns in a pattern suggesting intentional infliction l Injuries in various stages of healing or injuries scattered over multiple areas of the body l Patient, parent, or caregiver responding in an inappropriate manner to the situation l Malnutrition or extreme lack of cleanliness of the patient or environment l Bulging of fontanels and altered mental status in infants BLS l Stabilize and treat injuries according to the appropriate protocol l Discourage patient from washing if sexual abuse is suspected l Document the following in the patient care report: n All statements made by the patient, parent, or caregiver; include verbatim statements in quotation marks n Any abnormal behavior on the part of the patient, parent, or caregiver n The condition of the environment and other residents present n Document the time the police or social service agency was notified along with the name and identifier, if possible n Document the name of the receiving health care clinician (RN, PA, or MD) l Report all cases of suspected child or vulnerable adult abuse or neglect directly to either the local police or social service agency, as required by law. Do not initiate the report in Medical: Abuse/Neglect 4.1 front of the patient, parent, or caregiver. Clinical Pearls l Maryland EMS clinicians are protected from liability if they make a report of child or vulnerable adult abuse and neglect in good faith. www.miemss.org 712175 991 of Release Date July 1, 2023 Back to Contents  4.2-A Agitation – Adult Indications l Mild symptoms – Patient is agitated but cooperative and making rational decisions. No immediate concern for patient or clinician safety. l Moderate symptoms – Patient is irrational and exhibiting behavior that puts themselves or clinicians at risk. l Severe symptoms – Patient is physically violent and presents an immediate and imminent threat to themselves or others. BLS l Maintain scene safety and have a low threshold for requesting law enforcement. l Assess patient’s capacity and risk for self-harm l Place the patient in supine position (face up) as soon as practical. l Consider causes of agitation (medical, head trauma, psychiatric, drug/alcohol ingestion) l Mild Agitation n Attempt verbal de-escalation and provide emotional support by using SAFER Model: t Stabilize the situation by containing and lowering the stimuli. t Assess and acknowledge the crisis. t Facilitate the identification and activation of resources (chaplain, family, friends, or police). t Encourage patient to use resources and take actions in their best interest. Medical: Agitation – Adult 4.2-A t Recovery or referral – leave patient in care of responsible person/professional or transport. Release Date July 1, 2023 722175 992 of www.miemss.org Back to Contents  4.2-P Agitation – Pediatric Indications l Mild symptoms – Patient is agitated but cooperative and making rational decisions. No immediate concern for patient or clinician safety. l Moderate symptoms – Patient is irrational and exhibiting behavior that puts themselves or clinicians at risk. l Severe symptoms – Patient is physically violent and presents an immediate and imminent threat to themselves or others. BLS l Maintain scene safety and have a low threshold for requesting law enforcement. l Assess patient’s capacity and risk for self-harm. l Place the patient in a supine position (face up) as soon as practical. l Consider causes of agitation (medical, head trauma, psychiatric, drug/alcohol ingestion). l Mild Agitation n Attempt verbal de-escalation and provide emotional support by using SAFER Model: t Stabilize the situation by containing and lowering the stimuli. t Assess and acknowledge the crisis. t Facilitate the identification and activation of resources (chaplain, family, friends, or police). Medical: Agitation – Pediatric 4.2-P t Encourage patient to use resources and take actions in their best interest. t Recovery or referral – leave patient in care of responsible person/professional or transport. Release Date July 1, 2023 742175 993 of www.miemss.org Back to Contents  4.3-A Allergic Reaction – Adult Indications l Mild symptoms: localized swelling and itching at the site l Moderate symptoms: hives and/or mild wheezing l Severe symptoms: diffuse wheezing, pharyngeal swelling, dyspnea, hypoperfusion, abnormal skin color, stridor, and/or loss of peripheral pulses (Refer to Anaphylaxis protocol) BLS l Mild symptoms (if history of life-threatening allergic reaction to same allergen) n Epinephrine auto-injector (BLS) 0.3 mg IM OR n If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.5 mg IM. l Moderate symptoms n Epinephrine auto-injector (BLS) 0.3 mg IM OR n If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.5 mg IM. n Albuterol (BLS) inhaler (2 puffs inhaled) or nebulized albuterol (BLS). May repeat dose one time, as needed, within 30 minutes. Medical: Allergic Reaction – Adult 4.3-A MC l Additional doses of epinephrine auto-injector, epinephrine, albuterol, ipratropium, diphenhydramine beyond those listed above require medical consultation. Clinical Pearls l Re-check dosing and concentration of epinephrine prior to administration. l Epinephrine 1 mg/mL (previously known as 1:1,000) is appropriate for the IM route only. l Epinephrine should never be given by IV route, except for an epinephrine infusion for patients in anaphylaxis or for patients in cardiac arrest. Release Date July 1, 2023 762175 994 of www.miemss.org Back to Contents  Allergic Reaction – Pediatric 4.3-P Indications l Mild symptoms: localized swelling and itching at the site l Moderate symptoms: hives and/or mild wheezing l Severe symptoms: diffuse wheezing, pharyngeal swelling, dyspnea, hypoperfusion, abnormal skin color, stridor, and/or loss of peripheral pulses (Refer to Anaphylaxis protocol) BLS l Mild symptoms (if history of life-threatening allergic reaction to same allergen) n Less than 5 years of age: pediatric epinephrine auto-injector (BLS) 0.15 mg IM in the lateral thigh OR t If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.15 mg IM in the lateral thigh n 5 years of age or greater: epinephrine auto-injector (BLS) 0.3 mg IM in the lateral thigh OR t If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.5 mg IM in the lateral thigh l Moderate symptoms: n Less than 5 years of age: Medical: Allergic Reaction – Pediatric 4.3-P t Pediatric epinephrine auto-injector (BLS) 0.15 mg IM in the lateral thigh OR t If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.15 mg IM in the lateral thigh n 5 years of age or greater: t Epinephrine auto-injector (BLS) 0.3 mg IM in the lateral thigh OR t If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.5 mg IM in the lateral thigh n Albuterol (BLS) inhaler (2 puffs inhaled) or albuterol (BLS) nebulizer. May repeat dose one time, as needed, within 30 minutes. t For infants and children less than 2 years of age, administer nebulized albuterol (BLS) 1.25 mg. t For patients 2 years of age or greater, administer nebulized albuterol (BLS) 2.5 mg. MC l Additional doses of epinephrine auto-injector, epinephrine, albuterol, ipratropium, diphenhydramine beyond those listed above require medical consultation. www.miemss.org 772175 995 of Release Date July 1, 2023 Back to Contents  Altered Mental Status 4.4 BLS Check Cardiac Arrest No Pulse Pulse (3.4) Pulse Present Assess vital signs Physical exam Assess for signs of trauma Check blood glucose Medical: Altered Mental Status 4.4 Fever/ Numbness/ Suspected Blood glucose Recent seizure activity, tachycardia/ weakness/ OD/Tox < 70 or > 300 history of seizures low BP/ speech abnormality/ Environmental suspected sepsis suspected stroke Tox/ Hypo/ Seizures Sepsis Stroke Environmental Hyperglycemia (4.11) (4.12) (4.14) (7.1-7.10) (4.7) www.miemss.org 792175 996 of Release Date July 1, 2023 Back to Contents  4.5-A Anaphylaxis – Adult Indications l Acute onset of severe illness after exposure to a known allergen with two or more of the following: n Urticaria (hives) or acute swelling of the mucosa (e.g., tongue, airway, stridor, lips) n Respiratory compromise n Hypotension n GI symptoms, such as persistent nausea/vomiting, abdominal pain, or diarrhea l Acute onset of severe illness after exposure to a known allergen with hypotension BLS l Epinephrine auto-injector (BLS) 0.3 mg IM OR l If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.5 mg IM in the lateral thigh. l Albuterol (BLS) inhaler (2 puffs inhaled) or albuterol (BLS) 2.5 mg nebulized for wheezing/ bronchospasm/shortness of breath. May repeat dose one time, as needed, within 30 minutes. Medical: Anaphylaxis – Adult 4.5-A MC l Additional doses of epinephrine auto-injector, epinephrine, albuterol, ipratropium, diphenhydramine beyond those listed above require medical consultation. l If blood pressure goals are not met upon reaching epinephrine infusion rate of 2 mL/min (120 drops/min), obtain medical consultation. Clinical Pearls l Re-check dosing and concentration of epinephrine prior to administration. l Epinephrine 1 mg/mL (previously known as 1:1,000) is appropriate for the IM route only. l Epinephrine should never be given by IV route, except for an epinephrine infusion for patients in anaphylaxis or for patients in cardiac arrest. Release Date July 1, 2023 802175 997 of www.miemss.org Back to Contents  Anaphylaxis – Pediatric 4.5-P Indications l Acute onset of severe illness after exposure to a known allergen with two or more of the following: n Urticaria (hives) or acute swelling of the mucosa (e.g., tongue, airway, stridor, lips) n Respiratory compromise n Hypotension n GI symptoms, such as persistent nausea/vomiting, abdominal pain, or diarrhea l Acute onset of severe illness after exposure to a known allergen with hypotension BLS l Epinephrine (BLS) n Less than 5 years of age: t Pediatric epinephrine auto-injector (BLS) 0.15 mg IM in the lateral thigh OR t If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.15 mg IM in the lateral thigh n 5 years of age or greater: t Epinephrine auto-injector (BLS) 0.3 mg IM in the lateral thigh OR t If BLS epinephrine OSP approved, epinephrine (BLS) (1 mg/mL) 0.5 mg IM in the lateral thigh Medical: Anaphylaxis – Pediatric 4.5-P l Albuterol (BLS) – for wheezing/bronchospasm/shortness of breath. n Less than 2 years of age: albuterol (BLS) inhaler (2 puffs) inhaled or albuterol (BLS) 1.25 mg nebulized. May repeat dose one time, as needed, within 30 minutes. n 2 years of age or greater: albuterol (BLS) inhaler (2 puffs) inhaled or albuterol (BLS) 2.5 mg nebulized. May repeat dose one time, as needed, within 30 minutes. www.miemss.org 812175 998 of Release Date July 1, 2023 Back to Contents  Anaphylaxis – Pediatric 4.5-P (continued) MC l Additional doses of pediatric epinephrine auto-injector, epinephrine, albuterol, ipratropium, diphenhydramine beyond those listed above require medical consultation. l Consider pediatric epinephrine infusion for refractory anaphylactic shock. Clinical Pearls l Re-check dosing and concentration of epinephrine prior to administration. l Epinephrine 1 mg/mL (previously known as 1:1,000) is appropriate for the IM route only. l Epinephrine should never be given by IV route, except for an epinephrine infusion for patients in anaphylaxis or for patients in cardiac arrest. Medical: Anaphylaxis – Pediatric 4.5-P Release Date July 1, 2023 822175 999 of www.miemss.org Back to Contents  Apparent Life-Threatening Event/ Brief Resolved Unexplained Event (ALTE/BRUE) 4.6 Indications l Infant or child less than 2 years of age l Episode that is frightening to the observer that includes some combination of the following: n Apnea n Skin color change (cyanosis, pallor, erythema) n Marked change in muscle tone n Choking or gagging not associated with feeding or witnessing foreign body aspiration Medical: Apparent Life-Threatening Event/Brief Resolved Unexplained Event (ALTE/BRUE) 4.6-P BLS l Perform assessment using the Pediatric Assessment Triangle l Obtain a description of the event including nature, duration, and severity l Assess the environment for possible causes l When obtaining the medical history, include questions to identify any: current medica- tions, chronic diseases, current or recent infections, evidence of seizure activity, gastro-esophageal reflux, or recent trauma l Apply oxygen and be prepared to support ventilation during transport MC l If the parent or guardian refuses medical care or transport, clinician SHALL consult with a Pediatric Base Station physician Clinical Pearls l Most patients will appear stable upon assessment. However, this episode may be a sign of serious underlying illness or injury. All suspected ALTE/BRUE patients should be transported for further medical evaluation. www.miemss.org 83 2175 1000 of Release Date July 1, 2023 Back to Contents  4.7-A HYPOglycemia/HYPERglycemia – Adult Indications l Blood glucose less than 70 mg/dL or greater than 300 mg/dL l Patient-reported low or high blood glucose l Diabetic patients with other medical symptoms (e.g., vomiting) l Altered mental status l Alcohol intoxication, suspected l Seizure l Stroke symptoms l Unresponsive patients l Cardiac arrest BLS l Check blood glucose level l If blood glucose is less than 70 mg/dL, administer 10-15 grams of oral glucose between the patient’s gum and cheek. Medical: HYPOglycemia/HYPERglycemia – Adult 4.7-A l Administer additional dose of 10-15 grams of oral glucose if not improved after 10 minutes. Release Date July 1, 2023 84 2175 1001 of www.miemss.org Back to Contents  HYPOglycemia/HYPERglycemia – Pediatric 4.7-P Indications l Blood glucose less than 70 mg/dL or greather than 300 mg/dL l Patient-reported low or high blood glucose l Diabetic patients with other medical symptoms (e.g., vomiting) l Altered mental status l Alcohol intoxication, suspected l Seizure l Stroke symptoms l Unresponsive patients l Cardiac arrest l Pediatric bradycardia BLS l Check blood glucose level Medical: HYPOglycemia/HYPERglycemia – Pediatric 4.7-P l If blood glucose is less than 70 mg/dL, administer 10-15 grams of oral glucose between the patient’s gum and cheek. l Administer additional dose of 10-15 grams of oral glucose if not improved after 10 minutes. www.miemss.org 85 2175 1002 of Release Date July 1, 2023 Back to Contents  4.8-A Hyperkalemia – Adult Indications l Renal failure or chronic kidney disease patients or history of poorly-functioning kidneys l Renal dialysis patients who are hemodynamically unstable or patients suspected of having elevated potassium with EKG changes (peaked T waves, wide QRS complexes, or bradycardia) l Crush syndrome (entrapped patients with prolonged extrication time) BLS l Place patient in position of comfort. l Assess and treat for shock, if indicated. Medical: Hyperkalemia – Adult 4.8-A Release Date July 1, 2023 86 2175 1003 of www.miemss.org Back to Contents  Hyperkalemia – Pediatric 4.8-P Indications l Renal failure or chronic kidney disease patients or history of poorly-functioning kidneys l Renal dialysis patients who are hemodynamically unstable or patients suspected of having elevated potassium with EKG changes (peaked T waves, wide QRS complexes, or bradycardia) l Crush syndrome (entrapped patients with prolonged extrication time) BLS l Place patient in position of comfort. l Assess and treat for shock, if indicated. Medical: Hyperkalemia – Pediatric 4.8-P www.miemss.org 87 2175 1004 of Release Date July 1, 2023 Back to Contents  4.9-A Nausea/Vomiting – Adult Indications l Nausea l Vomiting l Active motion sickness l Medication side effect/complication l Prevention of nausea/vomiting (e.g., penetrating eye injury, high risk for aspiration, opioid administration) BLS l Place patient in position of comfort or in left lateral position, with consideration for spinal motion restriction if required. l Allow patient to inhale vapor from an isopropyl alcohol wipe 3 times every 15 minutes, as needed and tolerated. Medical: Nausea/Vomiting – Adult 4.9-A Release Date July 1, 2023 88 2175 1005 of www.miemss.org Back to Contents  Nausea/Vomiting – Pediatric 4.9-P Indications l Nausea l Vomiting l Active motion sickness l Medication side effect/complication l Prevention of nausea/vomiting (e.g., penetrating eye injury, high risk for aspiration, opioid administration) BLS l Place patient in position of comfort or in left lateral position, with consideration for spinal motion restriction if required. l Allow patient to inhale vapor from an isopropyl alcohol wipe 3 times every 15 minutes, as needed and tolerated. Medical: Nausea/Vomiting – Pediatric 4.9-P www.miemss.org 89 2175 1006 of Release Date July 1, 2023 Back to Contents  4.10-A Pain Management – Adult Indications l Patient presents with a painful condition that would benefit from treatment with an analgesic. This includes DNR/MOLST patients and patients being pre-medicated for a painful procedure. n Mild to moderate pain: Pain rated in the 1-5 range on a scale of 1-10. Isolated musculoskeletal injuries such as sprains and strains. n Moderate to severe pain: Pain rated in the 5-10 range on a scale of 1-10. BLS l Measure level of pain. Ask patient to rate their pain on a scale from 0 (no pain) to 10 (worst pain imaginable). Patients who have a difficult time communicating their condition can be asked to rate their pain using the FACES scale. Pain Rating Scale Hurts 10 - Worst Pain Possible Worse Unbearable (Unable to do any activities Medical: Pain Management – Adult 4.10-A because of pain) 9 Hurts 8 - Intense/Dreadful/Horrible Whole Lot (Unable to do most activities because of pain) 7 - Severe Pain Hurts Even More 6 - Miserable/Distressing (Unable to do some activities because of pain) 5 - Moderate Pain Hurts 4 - Nagging/Uncomfortable Little Worse (Can do most activities with rest periods) 3 Hurts 2 - Mild Pain Little Bit Annoying (Pain is present but does not limit activity) 1 No Hurt 0 - No Pain l Allow patient to remain in position of comfort unless contraindicated by patient’s condition. l Mild to Moderate Pain (1-5 on FACES scale): n Acetaminophen for mild to moderate pain. t FOUR unit doses of 160 mg/5 mL each for a total of 640 mg/20 mL OR t 325 mg pill or tablet X 2 for a total of 650 mg with sips of water as tolerated by the patient. No repeat doses. Release Date July 1, 2023 90 2175 1007 of www.miemss.org Back to Contents  Pain Management – Adult (continued) 4.10-A Medical: Pain Management – Adult 4.10-A Clinical Pearls l Administration of pain medication does not eliminate the need for transport of the patient to the hospital to receive a comprehensive evaluation of the cause of their pain and appropriate defini- tive treatment. l Ketamine is indicated only for musculoskeletal and back pain. Do not administer for chest pain, abdominal/flank pain, or for headaches. l Chest pain that is thought to be due to acute coronary syndrome should initially be managed with nitroglycerin. If pain remains refractory to nitroglycerin, consider the use of opioid analgesia. Avoid opioids for patients with suspected exacerbation of congestive heart failure. l Use opioid analgesia with caution in the management of the multiple trauma patient. Observe for evidence of hypotension and correct with fluid boluses. Reassess vital signs after administration of the medicine. l Use analgesia with caution in the management of patients with altered mental status. Observe for respiratory depression and take steps to ensure a stable airway. l Patients who have received a parenteral (IV/IO/IM/IN) dose of opioid, benzodiazepine, or ket- amine from sending facility or ALS must be transported by ALS: n If any of the above medications were given within the past 1 hour OR n If the patient has an altered mental status without return to their baseline after receiving any of above medications OR n If the patient has potential for respiratory compromise (RR less than 14, oxygen saturation less than 94%, clinician judgment) after receiving any of the above medications. www.miemss.org 91 2175 1008 of Release Date July 1, 2023 Back to Contents  4.10-P Pain Management – Pediatric Indications l Patient presents with a painful condition that would benefit from treatment with an analgesic. This includes DNR/MOLST patients and patients being pre-medicated for a painful procedure. n Mild to moderate pain: Pain rated in the 1-5 range on a scale of 1-10. Isolated musculoskeletal injuries such as sprains and strains. Pain related to childhood illnesses such as headache, ear infection, and pharyngitis. n Moderate to severe pain: Pain rated in the 5-10 range on a scale of 1-10. BLS l Measure level of pain. Ask older children to rate their pain on a scale from 0 (no pain) to 10 (worst pain imaginable). Young children can be asked to rate their pain using the FACES scale, which provides 5 levels of pain perception. Pain Rating Scale Hurts 10 - Worst Pain Possible Worse Unbearable Medical: Pain Management – Pediatric 4.10-P (Unable to do any activities because of pain) 9 Hurts 8 - Intense/Dreadful/Horrible Whole Lot (Unable to do most activities because of pain) 7 - Severe Pain Hurts Even More 6 - Miserable/Distressing (Unable to do some activities because of pain) 5 - Moderate Pain Hurts 4 - Nagging/Uncomfortable Little Worse (Can do most activities with