BLS EMS Only .pdf

General Patient Care (GPC) 2.1 The General Patient Care section shall apply to all patient encounters unless otherwise noted in any specific treatment protocol. A. RESPONSE Review the dispatch information an...

General Patient Care (GPC) 2.1 The General Patient Care section shall apply to all patient encounters unless otherwise noted in any specific treatment protocol. A. RESPONSE Review the dispatch information and select appropriate response. B. SCENE ARRIVAL AND SIZE-UP 1. Consider Body Substance Isolation (BSI). 2. Consider Personal Protective Equipment (PPE). 3. Evaluate the scene safety. 4. Determine the number of patients. 5. Consider the need for additional resources. C. PATIENT APPROACH 1. Determine the Mechanism of Injury (MOI)/Nature of Illness (NOI). 2. If appropriate, begin triage and initiate Mass Casualty Incident (MCI) procedures. D. INITIAL ASSESSMENT Rapidly develop a general impression of the patient on first contact: General Patient Care 2.1 1. Identify the critically unstable patient – any patient in extremis or with imminent risk for deterioration to arrest: a) New onset of altered mental status (AVPU not alert) b) Airway compromise c) Acute respiratory distress d) Signs of poor perfusion e) Any other patient judged by the clinician to be in extremis or at risk for deterioration to cardiac arrest 2. If you have identified a critically unstable patient: a) STOP ALL MOVEMENT OF PATIENT b) DO NOT INITIATE TRANSPORT c) PROCEED TO CRITICALLY UNSTABLE PATIENT PROTOCOL IMMEDIATELY For pediatric patients, use the Pediatric Assessment Triangle. Appearance Work of Breathing Circulation to Skin www.miemss.org 152175 951 of Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) 3. Assess mental status a) Alert b) Responds to Verbal stimuli c) Responds to Painful stimuli d) Unresponsive 4. Airway a) Stabilize cervical spine when appropriate b) Open and establish airway using appropriate adjunct. c) Place patient in appropriate position. d) Suction airway as needed, including tracheostomy tubes. e) If a patent airway cannot be established, the patient must be transported to the closest appropriate hospital-based emergency department or designated free- standing emergency medical facility. EMS clinicians should remain available to assist with patient transfer, if the hospital determines such a transfer is appropriate. f) In infants and young children, inspiratory stridor is an indication of upper airway foreign body or partial airway obstruction. Request ALS rendezvous. Transport the patient rapidly and with caution. Have foreign body airway removal equipment ready for immediate use in case the patient’s airway becomes obstructed. General Patient Care 2.1 5. Breathing a) Determine if breathing is adequate and assess oxygen saturation (SpO2) with pulse oxim- eter. (1) If patient’s ventilations are not adequate, provide assistance with 100% oxygen using Bag-Valve-Mask (BVM). (i) For patients 13 years of age and older, deliver 1 breath every 6 seconds (10 breaths per minute). (ii) For neonates and patients less than 13 years of age, deliver 1 breath every 3 seconds (20 breaths per minute). (iii) For newly born patients (first hour after delivery), refer to Newly Born Protocols 5.2 and 5.3. (2) The decision to oxygenate will be based on the patient’s clinical condition. (i) If the patient has SpO2 less than 94%, administer supplemental oxygen, titrated to SpO2 level of 94%. (ii) Supplemental oxygen is not needed if SpO2 greater than or equal to 94% unless the patient is in respiratory distress, acutely dyspneic, or suffering from suspected CO poisoning. Patients in severe respiratory distress may benefit from high-flow oxygen from a nonrebreather (NRB). (iii) Unless in respiratory distress, avoid administration of high-flow oxygen to patients presenting with the following conditions: (a) STEMI / angina (b) CVA / stroke (c) Post-arrest (iv) CO exposure: Apply 100% oxygen via NRB mask. Maintain SpO2 at 100%. Release Date July 1, 2023 162175 952 of www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 (3) Utilize continuous ETCO2 waveform monitoring in all intubated patients. (4) Measure carbon monoxide level with a co-oximeter, if appropriate and available. Percent O2 Saturation Ranges General Patient Care 94–100% Normal Give oxygen as necessary 91–93% Mild Hypoxia Give oxygen as necessary 86–90% Moderate Give 100% oxygen Hypoxia Assisting Ventilations if necessary less than Severe Hypoxia Give 100% oxygen or equal to Assist Ventilations 85% If indicated, Intubate INACCURATE OR MISLEADING SpO2 READINGS MAY OCCUR IN THE FOLLOWING PATIENTS: HYPOTHERMIC, HYPOPERFUSION (SHOCK), CO POISONING, HEMOGLOBIN ABNORMALITY, ANEMIA, AND VASOCONSTRICTION. b) Hyperventilate the head-injured patient only if signs/symptoms of herniation are present, General Patient Care 2.1 including posturing, loss of pupillary light response, dilation of one or both pupils, vomit- ing, hypertension, bradycardia, and/or irregular respirations. (1) If hyperventilating, use the following rates: (i) Adult (including adolescent 13 years of age or older): 20 breaths per minute (ii) Child (1-12 years of age): 30 breaths per minute (iii) Infant (less than 1 year of age): 35 breaths per minute (2) Use ETCO2 monitoring. (i) Maintain ETCO2 between 35-40 mmHg for any patient with significant head injury (ii) For patients with significant head injury and signs of herniation, adjust ventila- tions to achieve ETCO2 of 30-35 mmHg. 6. Circulation a) Assess pulse. (1) Patients within the first hour after delivery, refer to Newly Born protocol. (2) Patients from one hour after birth up to those who have not reached their 13th birthday, refer to the Universal Algorithm for Pediatric Emergency Cardiac Care for BLS. (3) Patients 13 years of age or greater, refer to the Universal Algorithm for Adult Emergency Cardiac Care for BLS. (4) If pulseless, stay on scene and immediately initiate high-quality continuous HPCPR. (i) Ensure frequent clinician rotations and minimal interruptions (less than 10 seconds). (ii) Mechanical CPR devices may be used, if available, for patients 13 years of age and older only. (iii) Perform CPR while preparing for rhythm analysis and defibrillation. www.miemss.org 172175 953 of Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) HPCPR Reference Chart for All Ages Component Adults and Adolescents Children (Age 1 Year to Puberty) Infants (Age Less Than 1 Year, Excluding Newborns) Compression- 1 rescuer ventilation ratio 30:2 without advanced Continuous compressions at 2 or more rescuers airway a rate of 100-120/min. Give 1 15:2 breath every 6 seconds Compression- Continuous compressions at a rate of 100-120/min. (10 breaths/min). ventilation ratio Give 1 breath every 3 seconds (20 breaths/min). WITH advanced airway Compression rate 100-120/min Compression depth At least 2 inches (5 cm). Com- At least one-third At least one-third pression depth should be no anterior-posterior diameter of anterior-posterior diameter of more than 2.4 inches (6 cm). chest. About 2 inches (5 cm). chest. About 1½ inches (5 cm). Hand placement 2 hands on the lower half of the 2 hands or 1 hand (optional for 1 rescuer breastbone (sternum). very small child) on the lower half 2 fingers in the center of the of the breastbone (sternum). chest, just below the nipple line. 2 or more rescuers 2 thumb-encircling hands in the center of the chest, just below the nipple line. General Patient Care 2.1 b) Assess for and manage profuse bleeding, using a method appropriate for the patient’s injuries: (1) Direct pressure (2) Wound packing (3) Hemostatic gauze (4) Tourniquet or junctional tourniquet (with jurisdictional training) c) Assess skin color, temperature, and capillary refill. d) Initiate cardiac monitoring as appropriate. 7. Disability a) Assess for pulse, motor and sensory function in all extremities b) Assess GCS for trauma patients c) Determine the need for Spinal Motion Restriction. (1) Patients who have a blunt trauma with a high-energy mechanism of injury that has potential to cause spinal cord injury or vertebral instability and one or more the fol- lowing should receive spinal motion restriction. - Midline spinal pain, tenderness, or deformity - Signs and symptoms of new paraplegia or quadriplegia - Focal neurological deficit - Altered mental status or disorientation - Distracting injury: Any injury (e.g., fracture, chest, or abdominal trauma) associated with significant discomfort that could potentially distract from a patient’s ability to accurately discern or define spinal column pain or tenderness. (2) In addition to the above indicators for adults, the below apply to children who have not yet reached their 15th birthday. Release Date July 1, 2023 182175 954 of www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 - Neck pain or torticollis - High-impact diving incident or high-risk motor vehicle crash (head on col- lision, rollover, ejected from the vehicle, death in the same crash, or speed greater than 55 mph) - Substantial torso injury - Conditions predisposing to spine injury d) If NO to all of the above, transport as appropriate. e) Infant or child car seats may not be used as a spinal immobilization device for the pediatric patient. f) If patient is unable to communicate or appropriately respond to the above questions, apply Spinal Motion Restriction protocol. 8. Exposure To assess patient’s injuries, remove clothing as necessary, considering condition and environment. 9. Assign Clinical Priority a) Priority 1 — Critically ill or injured person requiring immediate attention; unstable patients with life-threatening injury or illness. b) Priority 2 — Less serious condition yet potentially life-threatening injury or illness, requir- General Patient Care 2.1 ing emergency medical attention but not immediately endangering the patient’s life. c) Priority 3 — Non-emergent condition, requiring medical attention but not on an emergency basis. d) Priority 4 — Does not require medical attention. e) In the event of a multiple casualty incident, the Simple Triage and Rapid Treatment (START and/or JumpSTART) technique will be instituted for rapid tagging and sorting of patients into priority categories for both treatment and transport. 10. Normal Vital Signs Chart AGE ESTIMATED HEART RESPIRATORY SYSTOLIC WEIGHT RATE RATE B/P Premature Less than 3 kg 160 Greater than 40 60 Newborn 3.5 kg 130 40 70 3 mo. 6 kg 130 30 90 6 mo. 8 kg 130 30 90 1 yr. 10 kg 120 26 90 2 yrs. 12 kg 115 26 90 3 yrs. 15 kg 110 24 90 4 yrs. 17 kg 100 24 90 6 yrs. 20 kg 100 20 95 8 yrs. 25 kg 90 20 95 10 yrs. 35 kg 85 20 100 12 yrs. 40 kg 85 20 100 14 yrs. 50 kg 80 18 110 ADULT Greater than 50 kg 80 18 120 www.miemss.org 192175 955 of Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) E. HISTORY AND PHYSICAL EXAMINATION/ASSESSMENT 1. Conduct a Focused Examination/Detailed Examination/Ongoing Assessment. 2. Collect and transport documentation related to patient’s history (example: Emergency In- formation Form, Medic Alert, EMS DNR/MOLST, or jurisdictional form). 3. Clinicians should obtain and document a contact telephone number for one or more in- dividuals who have details about the patient’s medical history so that the physician may obtain and validate additional patient information. 4. Obtain an EKG when appropriate. ALL HEALTH CARE CLINICIANS ARE OBLIGATED BY LAW TO REPORT CASES OF SUS- PECTED CHILD OR VULNERABLE ADULT ABUSE AND/OR NEGLECT TO EITHER THE LOCAL POLICE OR ADULT/CHILD PROTECTIVE SERVICE AGENCIES. DO NOT INITIATE REPORT IN FRONT OF THE PATIENT, PARENT, OR CAREGIVER (MD CODE, FAMILY LAW, § 5-704). UNDER MARYLAND LAW, EMS CLINICIANS ARE PROTECTED FROM General Patient Care 2.1 LIABILITY IF THEY MAKE A REPORT OF CHILD/VULNERABLE ADULT ABUSE AND NE- GLECT IN GOOD FAITH (COURTS AND JUDICIAL PROCEEDINGS ARTICLE § 5-620). F. TREATMENT PROTOCOLS 1. Refer to ALL appropriate protocols. 2. Patients who have had an impaled conducted electrical weapon used on them will be transported to the nearest appropriate facility without dart removal (exception: Tactical EMS). ANY conducted electrical weapon dart impalement to the head, neck, hands, feet, or genitalia must be stabilized in place and evaluated by a physician. 3. Clinicians may assist the patient or primary caregiver in administering the patient’s pre- scribed rescue medication. a) BLS clinicians may assist with the administration of the patient’s fast-acting bronchodi- lator MDI and sublingual nitroglycerin. b) ALS clinicians may administer the patient’s prescribed benzodiazepine for seizures, Factor VIII or IX for Hemophilia A or B, or reestablish IV access for continuation of an existing vasoactive medication. c) Clinicians should obtain on-line medical direction to administer other prescribed rescue medications not specifically mentioned in The Maryland Medical Protocols for Emergency Medical Services (e.g., hydrocortisone (Solucortef) for adrenal insufficiency). The rescue medication must be provided by the patient or caregiver and the label must have the pa- tient’s name and the amount of medication to be given. 4. For patients with fever documented by EMS as greater than 100.4 F (38 C), clinicians may treat with acetaminophen. DO NOT ADMINISTER ORAL MEDICATIONS (EXCEPT ORAL GLUCOSE) TO PATIENTS WITH AN ALTERED MENTAL STATUS. Release Date July 1, 2023 202175 956 of www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 5. For pediatric patients a) Pediatric section of the treatment protocol will be used for children who have not reached their 15th birthday (trauma) or their 18th birthday (medical), except as otherwise stated in the treatment protocol. b) Medication dosing (1) Pediatric doses apply to patients weighing less than 50 kg. (2) For pediatric patients equal to or greater than 50 kg, utilize adult dosing. c) The developmental age of the infant/child must be considered in the communication and evaluation for treatment. Destination consideration: For those patients who are 18 years of age or older who receive specialized care at a pediatric facility, consider medical consultation with a Pediatric Base Sta- tion for patient destination. d) Infants and children must be properly restrained prior to and during transport. e) A parent/guardian/care taker may remain with a pediatric patient during transport, but must be secured in a separate vehicle restraint system at all times during transport. f) For patients with fever documented by EMS as greater than 100.4 F (38 C), clinicians may treat with acetaminophen. General Patient Care 2.1 G. COMMUNICATIONS 1. Hospital Notification: A brief communication to the ED for notification of an inbound patient. a) All Priority 1, Priority 2, and Specialty Alert patients require hospital notification via EMRC. (Note: All communications via EMRC/SYSCOM are recorded.) b) For Priority 3 patients, notification may be made via EMRC or EOC/EMS communica- tion system in accordance with the standard operating procedures of the local jurisdic- tion. 2. Medical Consultation: a bi-directional communication via EMRC between an authorized hospital-based physician (or EMSOP medical director) and prehospital EMS clinician for the purpose of incorporating the physician’s knowledge and experience into ongoing patient care. Medical consultation: a) Shall be obtained when required by a specific protocol b) Should be obtained when a clinician has reached the end of their therapeutic or diag- nostic capabilities without adequate effect from their treatments c) Is available at any time for any patient for any reason 3. If medical consultation is genuinely unavailable, or if the time necessary to initiate consul- tation significantly compromises patient care, the clinician shall proceed with additional protocol-directed care, so long as transport will not be significantly delayed. “Exceptional Call” must be indicated on the Patient Care Report (PCR). www.miemss.org 212175 957 of Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) 4. Suggested elements for notifications and medical consults: a) Assigned patient priority (1 to 4) b) Age c) Chief complaint d) Clinician impression e) Pertinent patient signs and symptoms f) HR, RR, BP, Pulse Ox (do not use “within normal limits” or “stable” in description) g) Pertinent physical findings h) ETA In addition, for specialty center patients: Trauma a) Number of victims, if more than one b) GCS, including motor GCS score c) Patient Trauma Decision Tree Category (Alpha, Bravo, Charlie, Delta) General Patient Care 2.1 Stroke d) Last known well time e) Specific neurological findings (sensory, motor, cognitive) f) Upon positive assessment using the Cincinnati Stroke Scale, a STROKE alert shall be made and the LAMS score will be included in the consult. STEMI g) 12-lead interpretation h) Duration of symptoms 5. Mass Casualty Incident (MCI) Communications a) When a local jurisdiction declares an MCI, it is extremely important to maximize patient care resources and reserve EMS communications for emergent situations. Except for extraordinary care interventions, EMS clinicians may perform all skills and administer medications within protocol during a declared MCI. When the MCI condition is institut- ed, the “Exceptional Call” box must be checked on the PCR. b) During an MCI, the EMS Officer-in-Charge (OIC) shall designate an EMS Communicator, who shall establish appropriate communications. c) Reference the Multiple Casualty Incident/Unusual Event Protocol. H. REASSESSMENT 1. Reassess unstable patients frequently (recommended every 5 minutes). 2. Reassess stable patients at a minimum of every 15 minutes. 3. Reassess patients being discharged to home or long-term care at the beginning and end of the transport or more frequently, at the clinician’s discretion. Release Date July 1, 2023 222175 958 of www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 I. DISPOSITION 1. Destination a) Priority 1 patients shall be triaged according to Maryland Medical Protocols to the clos- est appropriate hospital-based emergency department, designated trauma, or desig- nated specialty referral center. Critically unstable patients in need of immediate life-sav- ing interventions that cannot be provided in the field shall, with the approval of EMS system medical consultation, be diverted to the closest facility (including freestanding emergency medical facility) capable of immediately providing those interventions. b) Priority 2 patients shall be triaged according to the Maryland Medical Protocols to the closest appropriate hospital-based emergency department, designated trauma or desig- nated specialty referral center unless otherwise directed by EMS system medical con- sultation. Stable Priority 2 patients may be referred to a freestanding emergency medical facility. c) Stable Priority 3 or 4 patients who do not need a time-critical intervention may be trans- ported to the local emergency department or freestanding emergency medical facility. d) Patients Under Investigation (PUI) for an Emerging Infectious Disease (EID) at a residence should be transported directly to an Assessment Hospital unless total transport time is no longer than 45 minutes greater than transport to the nearest Frontline Hospital ED. If transport time is longer than 45 minutes greater than transport to the nearest Frontline General Patient Care 2.1 Hospital ED, the patient must be transported to the closest appropriate Frontline hospi- tal. Priority 1 and Priority 2 patients with unresolved symptoms that cannot be managed outside the hospital should be taken to the closest Frontline Hospital. Receiving hospital notification of all suspected PUI patients should be done as early as possible to allow for hospital staff to prepare. Helicopter transport is NOT indicated for the PUI patient. e) For Priority 2 and Priority 3 patients not meeting a specialty center destination care protocol, the EMS clinician should ask if the patient has had a hospital admission (in- patient service) within the last 30 days. If the answer is yes, the EMS clinician should transport (repatriate) the patient to that hospital as long as that hospital is not more than 15 additional minutes further than nearest hospital (or greater if allowed for by the EMS Operational Program). 2. Mode of transport (air, land, water) a) Medevac patients with indications for specialty referral center should be flown to the appropriate type of specialty center if not more than 10–15 minutes further than the closest trauma center. (Patients with an airway, breathing, or circulatory status who would be jeopardized by going an additional 10–15 minutes should go to the closest trauma center.) b) Consider utilization of a helicopter when the patient’s condition warrants transport to a trauma or specialty referral center and the use of a helicopter would result in a clinically significant reduction in time compared with driving to a trauma/specialty center. ALL REQUESTS FOR SCENE HELICOPTER TRANSPORTS SHALL BE MADE THROUGH SYSCOM. FOR TRAUMA DECISION TREE CATEGORY CHARLIE OR DELTA, RECEIVING TRAUMA CENTER MEDICAL CONSULTATION IS REQUIRED WHEN CONSIDERING WHETHER HELICOPTER TRANSPORT IS OF CLINICAL BENEFIT. www.miemss.org 232175 959 of Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) c) If the time of arrival at the trauma or specialty referral center via ground unit is less than 30 minutes, there will generally be no benefit in using the helicopter, especially for Trauma Decision Tree categories Charlie and Delta. d) Refer to the Trauma Decision Tree when considering use of aeromedical transport. Provide SYSCOM with the patient’s category (Alpha, Bravo, Charlie, or Delta). e) On-line medical direction should be obtained from the local trauma center and the specialty referral center when transport to the specialty center would require more than 10–15 min- utes additional transport time. (1) Pediatric Trauma Patients: Indications as per the pediatric section of the Trauma protocols. (2) Spinal Trauma Patients: Indications as per Spinal Motion Restriction protocol. (3) Burn Patients: Indications as per Burn protocol. Special note: Isolated burn patients without airway injury or other associated trauma should normally be flown to a burn center, regardless of the location of the closest trauma center. (4) Hand Injury Patients: Indications as per Hand Trauma protocol. Special note: Medevac patients with appropriate indications for hand center referral should normally be flown to the hand center, regardless of the location of the clos- est trauma center. General Patient Care 2.1 3. Status Evaluate the need for emergent versus non-emergent transportation. DO NOT WAIT ON-SCENE FOR ADVANCED LIFE SUPPORT. ATTEMPT TO RENDEZVOUS EN ROUTE TO THE HOSPITAL. J. TRANSFER OF CARE/RENDEZVOUS AND TRANSITION OF PATIENT CARE ALS TO BLS The ALS clinician-patient relationship is established when the ALS clinician initiates patient assessment and 4. ALS medication(s)* is/are administered or 5. ALS procedure(s)* is/are performed or 6. Upon ALS clinician assessment of the patient there is potential risk of deterioration. * Based on the medication or procedure as listed in protocol 9.2: Procedures, Medical Devices, and Medications for EMS and Commercial Services. ALS clinicians may only terminate their EMS clinician-patient relationship when they are as- sured that the patient will continue to receive care at the same or greater levels, or when they have documented with on-line medical direction that the patient’s condition has improved and that patient care may be transferred safely to an EMS clinician with a lower scope of practice. BLS clinicians have the right to decline the transition of patient care. When consensus between the clinicians cannot be gained, ALS shall get on-line medical direction. Clinicians will relay assessment findings and treatment provided to the individual(s) assuming Release Date July 1, 2023 242175 960 of www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 responsibility for the patient(s). Should an ALS clinician perform an EKG (of any type), it shall be imported into the patient care report and a copy shall be sent with the BLS unit to the re- ceiving facility. K. DOCUMENTATION A Patient Care Report (PCR) will be completed and delivered to the receiving facility as soon as pos- sible, ideally upon transfer of care. If this is not immediately possible, clinicians must provide docu- mentation of the patient’s prehospital care on a template and in a format provided or approved by MIEMSS for inclusion in the patient care record before leaving the receiving facility, then deliver the completed PCR within 24 hours after dispatch, in compliance with COMAR 30.03.04.04. Only the unit that pronounces death will select the “Dead on Scene” option in the PCR (eMEDS®) and thus all other units will report “Operational Support Only.” If no interventions are performed, the highest level EMS clinician on scene will pronounce death and document “Dead on Scene.” If BLS care was rendered by a BLS unit and then termination of resuscitation and pronouncement of death occurred, the BLS unit will select “Dead at Scene with BLS Intervention” option on the eMEDS® PCR. If ALS care was rendered by an ALS unit and then termination of resuscitation and pronounce- ment of death occurred, the ALS unit will select “Dead at Scene with ALS Intervention” option on the eMEDS® PCR. General Patient Care 2.1 L. CONFIDENTIALITY Patient confidentiality must be maintained at all times. M. PROFESSIONAL CONDUCT All patients should be treated with dignity and respect in a calm and reassuring manner. www.miemss.org 252175 961 of Release Date July 1, 2023 Back to Contents  2.2 General Patient Care (GPC) – HISTORY AND PHYSICAL EXAMINATION General Patient Care: History and Physical Examination 2.2 Release Date July 1, 2023 262175 962 of www.miemss.org Back to Contents  General Patient Care (GPC) – DETAILED AND ONGOING ASSESSMENTS 2.2 General Patient Care: Detailed and Ongoing Assessments 2.2 www.miemss.org 272175 963 of Release Date July 1, 2023 Back to Contents  2.3 General Patient Care (GPC) – START TRIAGE ALGORITHM General Patient Care: START Triage Algorithm 2.3 Source: U.S. National Library of Medicine Release Date July 1, 2023 282175 964 of www.miemss.org Back to Contents  General Patient Care (GPC) – JumpSTART TRIAGE ALGORITHM 2.3 General Patient Care: JumpSTART Triage Algorithm 2.3 Source: U.S. National Library of Medicine ©Lou Romig MD, 2002 www.miemss.org 292175 965 of Release Date July 1, 2023 Back to Contents  2.4 General Patient Care (GPC) – CRITICALLY UNSTABLE PATIENT a) INDICATIONS Adult patients (18 years of age or older) who are identified to be in extremis or are at risk for deterioration to cardiac arrest at any point during their care. These patients can include, but are not limited to, patients with: (1) New onset altered mental status (AVPU – not alert) (2) Airway compromise (3) Acute respiratory distress (4) Signs of poor perfusion (5) Any other patient judged by the clinician to be in extremis or at risk for deterioration to cardiac arrest b) BLS (1) Cease all efforts at patient movement until treatments in this protocol are General Patient Care: Critically Unstable Patient 2.4 complete. (2) Obtain a complete patient assessment, including pulse oximetry. (3) Consider the need for more resources, if available, including multiple ALS clinicians. (4) Control life-threatening external hemorrhage. (5) Manage the patient’s airway and ventilation (e.g., BVM with or without OPA/NPA) as indicated and tolerated. (6) Treat hypoxia and respiratory distress aggressively. c) ALS (1) Initiate ETCO2 monitoring. (2) Obtain 12-lead EKG, if appropriate for patient condition. (3) Obtain vascular access and support perfusion with IV fluids and vasopressors as indicated. (4) Address any other life threats noted on physical exam. (5) Continue General Patient Care, including transport. Release Date July 1, 2023 302175 966 of www.miemss.org Back to Contents  Treatment Protocols Treatment Protocols Treatment Protocols www.miemss.org 312175 967 of Release Date July 1, 2023 Back to Contents  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