Okaloosa County EMS BLS Medical/Trauma Protocols Mar 2022 PDF

OKALOOSA COUNTY DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMS BLS Medical / Trauma Protocols Revised Mar 1, 2022 Department of Public Safety Division of EMS-Patient Care Protocols TABLE OF CONTENTS SECTION I: PREFACE, GENERAL TREATMENT GUIDELINES SECTION II: MEDICAL/TRAUMA PROTOCOLS PROTOCOL TITLE...

OKALOOSA COUNTY DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMS BLS Medical / Trauma Protocols Revised Mar 1, 2022 Department of Public Safety Division of EMS-Patient Care Protocols TABLE OF CONTENTS SECTION I: PREFACE, GENERAL TREATMENT GUIDELINES SECTION II: MEDICAL/TRAUMA PROTOCOLS PROTOCOL TITLE Abdominal Pain Abdominal Trauma Airway Obstruction Allergic Reaction Altered Mental Status Asthma Burns-Chemical Burns-Thermal Chest Pain Colenterate Envenomation COPD CVA/TIA Death Scene Diabetic Emergency Dysbarism Electric Shock Head Trauma Hyperthermia Hypothermia Musculoskeletal Nerve Agent Antidote Kit Obstetrics-Abnormal Delivery Obstetrics-Normal Delivery Overdose Physical Restraint Pre-Eclampsia / Eclampsia Pulmonary Edema Seizure Snake Bite Submersion Injury/Near Drowning Thoracic Trauma Trauma Arrest SECTION IV: PROTOCOL UPDATE LOG PROTOCOL DATE November 2017 November 2017 November 2017 February 2022 November 2017 November 2017 November 2017 November 2017 February 2022 November 2017 November 2017 February 2022 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 November 2017 PREFACE The Medical Operations Protocols are not intended to be a manual on the treatment of all medical emergencies or necessarily an instruction manual. The orders and protocols include instructions for certain procedures characteristic to field treatment and especially those instances where special care must be exercised. In no way is this manual meant to interfere with specific procedures ordered by an Emergency Department Physician. The foundation of the protocols are supported by current guidelines presented in the following disciplines: AHA, PHTLS, NRP. In cases where the application of a protocol is unclear, contact medical control for instructions. In order for a State Certified Emergency Medical Technician to function within the confines of Okaloosa County, he/she shall comply with the following: 1. Must complete a minimum of 120 hours of field training under the module typetraining program, which may be extended as needed by the training office. 2. Shall maintain a current AHA CPR for Health Care Providers card or its equivalent, as approved by Florida Administrative Code CH. 64J. 3. Shall maintain current EMT certification issued by the Florida Department of Health, Bureau of Emergency Medical Services. If any of the above regulations are not complied with in full, the EMT shall not practice under the auspices of the Okaloosa County EMS Medical Director. AUTHORITY: Christopher Tanner, M.D. Okaloosa County EMS Medical Directors have authorized these Medical Operation Protocols and Treatment Protocols. Effective Date: February, 2021 Medical Director: GENERAL TREATMENT GUIDELINES 1 of 3 TITLE: GENERAL TREATMENT GUIDELINES 1. All standing orders outlined within the OCEMS BLS Protocols must be explicitly followed. Standing orders should not be exceeded nor is the management to be altered without the authorization of a physician. 2. When an emergency medical technician receives a private physician’s order, which exceeds the OCEMS BLS Protocols, the EMT should explain that the order exceeds the OCEMS BLS protocols and request another order that falls within the acceptable scope outlined. 3. Documentation of procedures and at least two sets of vital signs are the responsibility of the on scene responder. 4. Generally, the initial assessment and initial therapy should be completed as quickly as possible after establishing patient contact. The patient should be enroute to the hospital within 15 minutes and critical patients within 10 minutes. 5. Try to always obtain verbal consent from the patient prior to treatment. Respect the patient’s right to privacy and dignity. Courtesy, concern, and common sense will assure the patient of the best possible care. 6. Accurate documentation using the agency Patient Care Report (PCR) is crucial. This must include a description of the chief complaint, brief history, vital signs (at least two sets), mental status and emergency management. The narrative will be completed before leaving the hospital. If an electronic printout of the PCR is not left at the ED prior to your departure, a simplified written encounter form can be left in its place. This form will have the pertinent information needed to include the narrative for the accepting facility. 7. Hypertension - the purpose of this definition is to outline the management of patients whose systolic blood pressure is abnormally and dangerously elevated, and there are no findings of neurologic impairment. a. Criteria for Hypertension: Blood Pressures that exceed 200 Systolic or 120 Diastolic. 8. Oxygenation- For the purpose of this protocol, the statement of "Give supplementary oxygen when indicated" is defined as: a. Titration of oxygen administration to achieve oxygen saturation values of 94% or greater by pulse oximetry. 9. Spinal Motion Restriction- Spinal motion restriction is defined as “application of a cervical collar and maintenance of the spine in neutral alignment.” The long spine boards shall only be used as an extrication device and no longer be considered a therapeutic intervention. GENERAL TREATMENT GUIDELINES 2 of 3 Emergency Medical Technician BLS Protocols In accordance with Florida Administrative Code Ch. 64J, the Medical Director may authorize an EMT instead of a paramedic to attend a BLS patient on an ALS permitted ambulance under the following conditions: 1. The Medical Director determines what type of BLS patient an EMT may attend and develops BLS Protocols for use by the EMT when attending that patient. The on-scene paramedic shall conduct the initial assessment of the patient to determine if the patient’s condition meets the criteria in the BLS Protocols. This survey shall be documented on the PCR and shall identify the paramedic who conducted the survey. 2. The patient care report for any patient care or transport shall clearly state whenever the EMT attends the patient. In accordance with 64J the Medical Director has developed the following BLS Protocols for EMT’s operating under their direction; 1. It is not mandatory for an EMT to attend a BLS patient. 2. The EMT will document in the narrative section of the patient care report what criteria defined the patient as BLS. a. The EMT will sign the report. b. The paramedic will review the report before being closed. c. The paramedic must perform and document the initial ALS assessment. Unless operating strictly on the BLS ambulance: 1. It is acceptable for an EMT to attend a BLS patient without the initial assessment of a paramedic. 2. The EMT will document in the narrative section of the patient care report what criteria defined the patient as BLS. a. The EMT will sign the report. BLS (911) Patients: A BLS patient is defined, as a person that has stable vital signs, is conscious, does not require IV therapy and does not require EKG monitoring. An EMT may attend a patient only having a saline lock in place or a standard maintenance infusion of normal saline at KVO. At any time an EMS unit must respond lights and sirens to the receiving facility, a paramedic MUST attend the patient. Transfers: Any patient returning to a nursing home, residence or psychiatric facility will be classified as a BLS patient. The EMT will monitor and reassess the patient every ten (10) minutes. The EMT will be responsible for notifying the paramedic or supervisor of any changes in patient stability during transport to the receiving facility. GENERAL TREATMENT GUIDELINES 3 of 3 Obstetrical (OB) Transfers: BLS OB Transfers An OB patient transfer will be BLS if the patient has had no history of complications with her current health or the current pregnancy. In cases when the EMT attends the patient during transport, they will monitor and reassess the patient every 10 minutes. The EMT is responsible for notifying the paramedic or supervisor of any changes while enroute to the destination facility. It is preferred that the OB patients have an IV in place prior to transport. ALS OB Transfers An OB patient will be considered ALS if: 1. Has a medicated IV fluid 2. Requires cardiac monitoring 3. Requires advanced airway 4. Greater than 2 cm of cervical dilation is documented 5. Contractions are less than every 5 minutes apart 6. Amniotic fluid is present 7. Birth is imminent ABDOMINAL PAIN 1 of 2 TITLE: ABDOMINAL PAIN A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Onset and duration - Location and radiation - History of current complaint - Recent admit into the hospital for any reason - Quality - History of GI or abdominal complications (GI bleed, kidney or gallbladder stones) - Menstrual history - Gynecologic history - Previous trauma - Current medications - Medical illnesses - Allergies - Surgery - Abnormal ingestion 2. SIGNS/ SYMPTOMS - Nausea - Vomiting (bloody, coffee-ground, etc.) - Constipation - Urinary Problems - Fever - Diarrhea - Cullens signs - Grey-Turner signs - Pale - Diaphoresis - Abdominal tenderness - Guarding - Abdominal distention - Pulsatile mass - Emesis - Abnormalities associated with percussion - Rectal bleeding ABDOMINAL PAIN 2 of 2 B. STABILIZATION BLS 1. A-B-Cs: Maintain airway, as appropriate 2. Give the patient nothing by mouth 3. Place patient in position of comfort 4. Monitor SaO2 and vital signs 5. Give supplementary oxygen when indicated 6. Suction and assist ventilation if necessary C. SPECIAL CONSIDERATIONS 1. Cause of abdominal pain can rarely be determined in the field. 2. Consider catastrophic causes of abdominal pain such as ruptured aneurysm, ectopic pregnancy, especially if hypovolemia is present. 3. In cases where the patient has displayed prolonged nausea and vomiting, conduct orthostatic vital signs. ABDOMINAL TRAUMA1 of 2 TITLE: ABDOMINAL TRAUMA A. PRESENTATION 1. HISTORY/POSSIBLE CAUSES - Route, type, time, quantity of exposure - Mechanism of injury (blunt or penetrating) - Blunt trauma: amount and direction, deceleration vs. compression - Penetrating trauma: size of object, bullet caliber and trajectory, type of weapon. - Motor vehicle crash: size of vehicle, speed of vehicle, damage to vehicle, impact damage, patient compartment intrusion, seatbelt use, appropriate child restraints/ car seat usage, airbag deployment, ejection, type( frontal, rear, lateral, rotational, rollover). - Vehicle versus pedestrian: size and speed of vehicle, damage to the vehicle, location of patient in relation to the vehicle, post accident impact with other vehicles. - Motorcycle accident: speed of motorcycle, speed and size of other vehicles involved, damage to motorcycle, damage to other involved vehicles, type of impact ( head-on, angular, ejection), use and condition of protective equipment, clothing worn by rider(s), post accident impact with other vehicles/objects, distance thrown, passengers. - Falls: reason for fall (medical or other), length of fall, type of surface the patient landed on, which part of the body struck first. - Sports injuries: what forces acted on the patient, condition and use of protective gear, speed of vehicle and/or impact with other objects(ATV, skates, skateboard, wave-runner, etc.) - Blast injuries: Primary(pressure wave)distance from blast, size of blast Secondary(flying objects) objects that could have struck the patient. Tertiary(patient impact) Objects that the patient may have struck, distance thrown. - SAMPLE - Number of people involved. 2. SIGNS/ SYMPTOMS: - Abdominal pain - Altered mental status (agitation, confusion, lethargy) - Unconsciousness - Hematochezia (frank blood in the stool) - Hematemesis (blood in emesis) - Hematuria (blood in urine) - Abdominal tenderness to palpation - Pain in the shoulder(s) - Back/flank tenderness ABDOMINAL TRAUMA2 of 2 - Abdominal rigidity Abdominal distention Abdominal guarding Signs and symptoms of shock B. STABILIZATION: BLS 1. ABC’s: Initially open airway using jaw trust maneuver if indicated Maintain airway as needed, consider OPA, NPA 2. Stabilize cervical spine as appropriate 3. Immediately treat any threat to life 4. Monitor SaO2 and vital signs 5. Give supplementary oxygen when indicated 6. Control bleeding as appropriate: 7. Cover eviscerations with sterile dressing soaked with sterile normal saline 8. Impaled objects are stabilized in place 9. Package patient for transport: Spinal Motion Restriction 10. For hypotensive patients, place in trendelenburg C. SPECIAL CONSIDERATIONS: 1. Resuscitation of a fetus involves aggressive resuscitation of the mother. AIRWAY OBSTRUCTION 1 of 1 TITLE: AIRWAY OBSTRUCTION PROTOCOL A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Foreign body aspiration (food, toy, coin, etc) - Food ingestion - Mucous Plug - Regurgitation of stomach contents into pharynx - Trauma - Tongue (unconscious patient) - Anaphylaxis 2. SIGNS/ SYMPTOMS - Stridor - Universal Signs exhibited - Cough - Difficulty speaking - Difficulty swallowing - Abnormal respiratory presentation - Cyanosis - Drooling - Edema - Inability to ventilate after readjustment B. STABILIZATION Complete Airway Obstruction BLS 1. Initiate AHA guidelines for airway obstruction: A-B-Cs- initially open airway using jaw thrust maneuver, if indicated. Maintain airway, as appropriate 2. Use abdominal or chest thrusts, gravity, suction, and airway positioning techniques to clear airway. 3. Monitor SaO2, measure vital signs 4. Give supplementary oxygen when indicated 5. Suction and assist ventilations, if necessary Partial Airway Obstruction BLS 1. Initiate AHA guidelines for airway obstruction: Maintain airway, as appropriate 2. Place patient in position of comfort 3. Monitor SaO2, measure vital signs 4. Give supplementary oxygen when indicated 5. Suction and assist ventilations as needed ALLERGIC REACTION / ANAPHYLAXIS 1 of 1 TITLE: ALLERGIC REACTION/ ANAPHYLAXIS A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Exposure, ingestion or contact (sting, drugs, foods, plants, etc.) - Reaction to medications - Ingested shellfish - Unknown allergens 2. SIGNS/ SYMPTOMS - Itching - Rash - Swelling - Respiratory distress - Abdominal pain - Nausea, vomiting - Syncope - Weakness - Anxiety - Wheezing - Chest tightness - Hypotension (severe cases) - Angioedema B. STABILIZATION BLS 1. Primary Assessment- Assess airway, breathing and circulation and manage as indicated. 2. If transport capable, rapidly transport the patient to an appropriate medical facility. Consider ALS intercept. 3. History, physical exam, vital signs 4. For insect bites, remove stinger with scraping motion; do not pinch the stinger with tweezers. 5. If patient exhibits respiratory distress administer: a. Adult or Pediatric 30 kg or greated (approximately a 9 year old)- EPINEPHRINE 0.3 mg 1:1,000 IM via an auto-injection device (i.e. EpiPen) b. Pediatric less than 30 kg (less than 9 years old)- EPINEPHRINE 0.15 mg 1:2,000 IM via an auto-injection device (i.e. EpiPen Jr) c. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine, additional IM epinephrine can be repeated once at the doses and routes noted above. ALTERED MENTAL STATUS 1 of 1 TITLE: ALTERED MENTAL STATUS A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Acidosis, alcohol - Epilepsy - Infection - Overdose - Uremia (kidney failure) - Trauma, tumor - Insulin (hypoglycemia or diabetes ketoacidosis) - Psychosis - Stroke 2. SIGNS/ SYMPTOMS - Abrupt or bizarre behavior changes - Alcohol odor to breath - Abnormal pupil response, suggestive of drug ingestion - Hallucinations - Evidence of trauma - Medical alert tag B. STABILIZATION BLS 1. A-B-C’s: initially open airway using jaw thrust maneuver, if indicated. Maintain airway as needed 2. Place patient in position of comfort 3. Monitor SaO2, measure vital signs 4. Give supplementary oxygen when indicated 5. Suction and assist ventilations as needed 6. If opioid overdose suspected and respiratory compromise present, administer Naloxone 1mg per nare intranasally C. SPECIAL CONSIDERATIONS 1. There are generally only two mechanisms capable of producing alterations in mental status: a. Structural lesions that depress consciousness by destroying or encroaching upon the substance of the brain. b. Toxic-metabolic states, involving either the presence of circulating toxins or metabolites or the lack of metabolic substances (oxygen, glucose, or thiamine). These states produce diffuse depression of both cerebral hemispheres, with or without depression within the brainstem. ASTHMA 1 of 2 TITLE: ASTHMA A. PRESENTATION 1. HISTORY/POSSIBLE CAUSES - Anxiety - Onset: rapid or gradual - Duration - Inhaler use - Tobacco abuse - COPD - Asthma - Cough - Pulmonary infections - Airway hyper-responsiveness - Physical/environmental stresses - Changes/non-compliance with medications - Dietary indiscretion - Fever 2. SIGNS/ SYMPTOMS: - Altered mental status (agitation, confusion, lethargy) - 1-2 word dyspnea - Dyspnea - Anxiety - Cough - Chest tightness - Diaphoresis - Exacerbation with exertion - Wheezes - Pulsus paradoxus - Use of respiratory accessory muscles - Tripod positioning - Tachycardia - Tachypnea - Prolonged expiratory time - Poor air movement noted during auscultation B. STABILIZATION BLS 1. Primary Assessment- Assess airway, breathing and circulation and manage as indicated. 2. History, physical exam, vital signs 3. Monitor pulse oximetry and end-tidal CO2 (EtCO2) as an adjunct to other forms of respiratory monitoring. 4. Give supplemental oxygen to maintain SpO2 level 94% or greater. 5. Suction the nose and/or mouth (via bulb, Yankauer, suction catheter) if excessive secretions are present. ASTHMA 1 of 2 6. If transport capable, initiate transport to an appropriate medical facility. Consider ALS intercept. C. SPECIAL CONSIDERATIONS 1. Pneumothorax in the asthmatic patient is rare, but is possible and should be considered. 2. Rapid airway management of a patient with significant signs of hypoxia is paramount. 3. Quiet or absent breath sounds in the asthmatic patient in respiratory distress is an ominous sign. Aggressive airway management is paramount in these cases and should be initiated promptly. 4. Pulsus paradoxus is determined in the field by assessing the patient's pulse. If the pulse becomes weak or absent during the inspiration, this is referred to as pulsus paradoxus. It is caused by an increase in intrathoracic pressure. BURNS-CHEMICAL 1 of 2 TITLE: BURNS - CHEMICAL A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Description of scene (lines/piping, pooling of chemicals around victim, victim immersed in agent, spurting agents from containers, toxic fumes and / or vapors, etc.) - Type of chemical (acid, alkali, mixed, other, unknown) - Duration of exposure - Medical illnesses - Current medications - Allergies 2. SIGNS/ SYMPTOMS - Skin pain - Eye irritation, pain, or lacrimation - Difficulty breathing - Dependent on type of chemical exposed B. STABILIZATION BLS 1. A-B-C’s: Maintain airway as needed 2. Monitor SaO2, measure vitals signs 3. Give supplementary oxygen when indicated a. Provide 100% O2 if toxic inhalation, significant flame, smoke exposure or respiratory distress presents 4. Suction and assist ventilations as needed 5. Remove victim’s contaminated clothing, shoes, socks and jewelry 6. Irrigate burn area with a continuous flow of water for at least 30 minutes during transport, unless patient’s condition is life threatening requiring immediate interventions. 7. Cover burned area with sterile dressing 8. If dry substance is causing the burn, brush the substance off the skin prior to irrigation C. SPECIAL CONSIDERATIONS Dry Lime: Do NOT wash burn area with water, because the combination will create a highly corrosive liquid. - Use a leather extrication glove to brush dry lime from victim’s clothing, hair, skin, remove victim’s clothing and jewelry. - Use water only AFTER above steps are completed and if large quantities of water from a shower or hose are immediately available for copious flushing. - BURNS-CHEMICAL 2 of 2 Carbolic acid: - This chemical is not water-soluble; if available, an alcohol product (rubbing alcohol, bottled alcohol product) should be used for initial wash of unbroken skin; followed with long, steady water wash. - If alcohol is not available, use water only if large quantities of water from a shower or hose are immediately available for copious flushing. Sulfuric Acid/Sodium Metals: - These chemicals produce heat when mixed with water and may explode; do NOT use water lavage unless a hose or shower is available. - For mild burns, after initial flushing, wash burn area with mild soapy water. Hydrofluoric Acid: - Burns may be delayed for up to several hours, depending on concentration and duration of contact; all exposed victims should be treated even if asymptomatic. - If victim is symptomatic, begin water wash immediately. - Systemic toxicity with severe hypocalcemia and cardiac arrhythmias may occur from dermal absorption. White or Yellow Phosphorus: - Phosphorus burns on contact with moist air, dermal burns may be smoking, and continued injury will occur. - Rescuers must avoid direct skin contact with phosphorus; use a leather extrication glove to brush off all non-adherent material, do NOT apply ointments, as they may increase systemic phosphorus absorption. - After thorough irrigation with water, the burned area should be immersed in water, if possible, to stop the burning process. Eye Burns: - IMMEDIATELY flush eyes and surrounding areas with copious amounts of water for at least 15 minutes avoid washing chemical into unaffected eye or back into affected eye, irrigate well underneath eyelids. - Remove victim’s contact lenses, if present. - Continue eye wash during transport, especially if victim complains about renewed burning or irritation. - After flushing, cover both eyes with saline moistened pads. - Eye burns from cement are strong alkali burns and require copious flushing until all material is removed. - Note that in the event that the patients eye injury is severe requiring immediate ophthalmology intervention, contact medical control for transport orders. BURNS-THERMAL 1 of 2 TITLE: BURNS- THERMAL A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Duration of exposure - Elapsed time since exposure - Pertinent past medical history - S.A.M.P.L.E. - Initial pain level - Flame - Scald - Steam - Gas - Flash - Electrical 2. SIGNS/ SYMPTOMS - Altered consciousness - Dyspnea or respiratory arrest - Chest pain or cardiac arrest - Severe pain to affected area. (3° burns will be painful on borders.) - 1- Tissue is erythematous and painful - 2- Burned area characteristically has blisters and is very painful. - 2- Epidermis and portions of dermis are involved - 2- Adnexal structures often are involved - 3- Characterized by charring of skin or translucent white color, with coagulated vessels visible below B. STABILIZATION BLS 1. Extinguish then remove any smoldering or burning clothing 2. A-B-C’s: Initially open airway using jaw thrust maneuver as indicated. Maintain airway as needed. 3. Monitor SaO2, measure vital signs 4. Give supplementary oxygen when indicated 5. Estimate area and type of burn using rule of nines, evaluate for trauma alert criteria 6. Perform Spinal Motion Restriction, when indicated 7. Cover burns with dry sterile dressings 8. Remove jewelry BURNS-THERMAL 2 of 2 C. SPECIAL CONSIDERATIONS 1. Major Burn: - 2° - Partial thickness > 25% BSA in adults, >20% BSA in children. - 3° - Full thickness > 10% BSA in adults and children. - All 2° - partial thickness or burns to hands, feet, face, eyes, ears, or genitalia. - Inhalation burns - Burns associated with trauma alerts. 2. Moderate Burn: - 2° - Partial thickness burn 15 – 25 % BSA in adults, 10 – 20 % BSA in children. - 3° - Full thickness < 10% in adults and children. 3. Minor Burn: - 2° - Partial thickness burn < 15 % BSA in adults, < 10% BSA in children. - 3° - Full thickness < 2% BSA in all patients CHEST PAIN 1 of 2 TITLE: CHEST PAIN A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - History of current event - Onset - Provokes - Quality - Severity - Time of onset - Interventions prior to arrival - History of CAD - Investigate underline medical history - Pulmonary Edema - Chest Wall Pain - Pericarditis - Recent admit into the hospital for any reason - Trauma - Pneumothorax - Anxiety - Ischemic CVA within one year - Hemorrhagic CVA ever - Aortic Aneurysm - Active GI bleed - Intracranial neoplasm - Lung problems - Asthma, pneumonia, pneumothorax (collapsed lung), pulmonary embolism (blood clot) - Stomach problems - Ulcers, heartburn, hiatal hernia, gastritis (inflammation of stomach lining) - Blood vessel problems - Aortic dissection - Chest wall problems - Pulled/strained muscles, inflammation of sternum-rib joints - Heart problems - Palpitations, heart attack, pericarditis/myocarditis (inflammation of heart muscle or lining) 2. SIGNS/ SYMPTOMS - Chest pain - Diaphoresis - Rales - Shortness of breath - Various locations of thoracic pain with radiation - Nausea and vomiting CHEST PAIN 2 of 2 B. STABILIZATION BLS 1. Primary Assessment - Assess airway, breathing and circulation and manage as indicated. 2. History, physical exam, vital signs 3. If suspected ACS chest pain and no allergy, administer ASPIRIN 324 mg PO. 4. Obtain a 12-lead EKG, if possible, for documentation. 5. If possible, the 12-lead EKG may be transmitted for remote interpretation by a physician or screened for STEMI by properly trained EMS providers, with or without the assistance of computer interpretation. 6. If the 12-lead EKG is found to show a potential STEMI, the patient shall be transported to a PCI capable facility (as long as the patient is stable). 7. Advance notification should be provided to the receiving hospital for patients identified as having STEMI. 8. If the patient has prescribed NITROGLYCERIN, the EMT may assist the patient to take his/her own NITROGLYCERIN at the prescribed dose every 3-5 minutes to a maximum of 3 doses. The patient’s BP should be assessed after each dose and maintain a systolic reading above 100, as well as a Heart Rate between 60 bpm and 140 bpm. COLENTERATE ENVENOMATION 1 of 2 TITLE: COLENTERATE ENVENOMATION Background: Coelenterates are animals classified in the phylum of aquatic invertebrates, which is responsible for more envenomations than any other marine phylum. Almost 9000 species of coelenterates exist; approximately 100 are toxic to humans. Coelenterates have a gastrovascular cavity with a single opening, which functions for both digestion and circulation. Another feature is the presence of stinging cells called nematocysts. The phylum is divided into 4 major classes, as follows: • • • • Hydrozoa (Portuguese man-of-war, fire corals) Scyphozoa (true jellyfish) Cubozoa (box jellyfish) Anthozoa (sea anemones) A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Time of bite/sting - Age and size of the patient - Location of the injury - Treatment provided prior to EMS arrival - Medical illnesses B. STABALIZATION 1. 2. 3. 4. 5. 6. 7. 8. 9. Manage airway as appropriate (see respiratory distress protocol) Manage anaphylaxis as appropriate (anaphylaxis protocol) Inactivate nematocysts and remove tentacles to prevent further injury. It is not necessary to capture the organisms responsible for the envenomation. If tentacles are present on the patient, they can be saved and preserved for identification. Treatment is directed by the severity of the injury. Severe systemic symptoms may require respiratory and cardiovascular support. Provide reassurance to the patient. Immobilize the envenomated area to minimize uptake of venom. Utilize EMS issued sting treatment kit as appropriate. COLENTERATE ENVENOMATION 2 of 2 C. SPECIAL CONSIDERATIONS 1. Reactions to venom are presumed to be toxic rather than allergic because pain occurs immediately. 2. Information surrounding the envenomation should be collected, including time of envenomation, nature of the incident, and a description of the animal and symptoms. 3. Toxicity varies with the age of the patient, underlying health of the patient, potency of the venom, number of nematocysts triggered, and the amount of skin surface involved. 4. Consider envenomation lesions in patients with unexplained near drowning or in patients who collapsed in the water. COPD 1 of 2 TITLE: COPD A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Anxiety - Onset: rapid or gradual - Duration - Home oxygen use - Dyspnea at rest or with exertion - Tobacco abuse - COPD - CHF - Asthma - Post myocardial infarction - Cough - Recurrent pulmonary infections - Hypertension - Angina - Dysrhythmias - Airway hyper-responsiveness - Physical/environmental stressors - Changes/non-compliance with medications - Dietary indiscretion - Anemia - Fever - Pulsus paradoxus 2. SIGNS/ SYMPTOMS Emphysemia - Anatomically thin frame - Hyperinflation of chest (barrel chest) - Breathing may display pursed lips - Wheezing - Distant heart sounds - Decreased breath sounds - Tachycardia - Clubbed fingernails - BP may be normal - Coughing is not usually present or productive - Sudden increase in shortness of breath, especially with cold/damp weather, respiratory infections, and other environmental stressors - Color may be pink due to polyeythemia - Altered mental status (agitation, confusion, lethargy) - 1-2 word dyspnea COPD 2 of 2 - Tachypnea - Prolonged expiratory phase - Decreased chest wall movement Chronic Bronchitis - Cyanosis - Productive cough - Dyspnea - Tachycardia - May be obese - Use of respiratory accessory muscles - Coarse rhonchi and wheezing may be heard on auscultation B. STABILIZATION BLS 1. 2. 3. 4. C. A-B-C’s: maintain airway as needed. Monitor SaO2 and vital signs. Give supplementary oxygen when indicated Be prepared to suction and utilize bag valve mask ventilation as needed. ON-LINE MEDICAL CONTROL CONTACT 1. Once a COPD patient has received supplemental oxygen or medications from OCEMS, medical control “must” be contacted prior to allowing the patient to refuse ambulance transport. D. SPECIAL CONSIDERATIONS 1. COPD is the fourth leading cause of death in this country. Patients with COPD are susceptible to multiple insults that can rapidly lead to acute deterioration of their chronic disease process. Prompt and accurate recognition/treatment of these patients may be the only action that prevents impending respiratory failure. CVA / TIA 1 of 2 TITLE: CVA / TIA A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Post status CVA, with known deficits - Exact time of onset of symptoms - Duration of symptoms - Progression of deficits - Past medical history - Diabetes - Cardiovascular disease - Surgeries (when) - Trauma (when) - Cancer history (location of tumors) - Hypertension - Pregnant - LMP - Method of birth control - Smoking history - S.A.M.P.L.E. - Ischemic CVA within one year - Hemorrhagic CVA ever - AAA - Active GI bleed - Intracranial neoplasm 2. SIGNS/ SYMPTOMS - Hypertension + sudden neurological changes - Sudden severe headache - Altered consciousness - Seizures - Neurological deficits not accompanied by trauma - Abnormal pupil response - Facial drooping Abnormal tongue movement - Aphasia. - Acute vertigo - Loss of balance or coordination CVA / TIA 2 of 2 B. STABILIZATION BLS ABC’s: Maintain airway as needed Monitor SaO2 and vital signs including assessing the patient’s blood glucose level Give supplementary oxygen when indicated Perform Cincinnati Stroke Scale and follow “Stroke Destination Decision Algorithm” from Okaloosa ALS Protocol (page 50b) to determine the proper patient destination. 5. Provide rapid transport to the appropriate facility by the fastest means possible (utilize helicopter if appropriate). If patient is determined to be a “Stroke Alert”, be sure to give advance notification to the facility via radio report. 1. 2. 3. 4. D. SPECIAL CONSIDERATIONS 1. All patients who are deemed unstable must be transported to the closest medical facility. 2. In all cases where a patient meets Stroke Alert criteria, there is no need to contact the medical facility that will be bypassed in order to transport the patient to a facility designated as a neurological receiving facility. DEATH SCENE 1 of 1 TITLE: DEATH SCENE A. PRONOUNCEMENT OF DEATH 1. The EMT may withhold resuscitative efforts if any condition below is found: a. Dependent Lividity b. Rigor Mortis c. Blunt or Penetrating Trauma found without signs of life (see Trauma Arrest Protocol below) d. Decomposition e. A valid Florida DRNO is discovered (see below) 2. A patient’s personal physician may communicate via the telephone that resuscitative efforts should not be initiated or resuscitative efforts should be discontinued on a patient. The contacted physician must be licensed in the state of Florida and agree to accept the responsibility for pronouncing the patient dead. 3. Neither family nor law enforcement officers have the right to refuse resuscitative attempts for the patient. B. PRE-HOSPITAL DO NOT RESUSCITATE ORDER 1. Certified EMT’s and Paramedics working for a licensed EMS provider shall honor a DNRO when responding to a call for assistance provided that the EMT or paramedic is presented either a completed Florida Pre-hospital DRNO Form (HRS Form 1896 on YELLOW paper) or Patient Identification Device (small section on bottom of HRS Form 1896 that can be detached—also must be on YELLOW paper). C. HOMICIDE OR SUICIDE CASES 1. In possible homicide or suicide cases, do not remove or cut clothing, unless absolutely necessary. Do not disturb the death scene, unless absolutely necessary. Do not dispose of any clothing if removed. If the EMT and / or paramedic has a question as to how to proceed with any EMS situation, contact the EDMCP or the on-duty Branch Commander. DIABETIC EMERGENCY 1 of 2 TITLE: DIABETIC EMERGENCY A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Known IDDM/ Pregnancy induced - Recent Infection - Known history of DKA - Recent illness - Nausea - High volume vomiting - Known Infection - Dehydration - CVA - Trauma - Surgery - Myocardial infection - UTI - ETOH - Medication changes 2. SIGNS/ SYMPTOMS Diabetic Ketoacidosis signs and symptoms (DKA) - Increased thirst - Polyuria - Polydipsia - Nocturia - Malaise/lethargy - Nausea/vomiting - Decreased perspiration - Fatigue - Anorexia or increased appetite - Confusion - Fever - Dysuria - Chills - Ketotic breath - Abdominal tenderness - Coma - Kussmaul respirations - Shortness of breath - Decreased reflexes Hypoglycemia Signs and Symptoms - Headache - Inability to concentrate - Visual disturbances - Dizziness DIABETIC EMERGENCY 2 of 2 - Lethargy Coma Anxiety Tremulous Diaphoresis B1. STABILIZATION DKA BLS 1. A-B-C’s: Maintain airway, as appropriate 2. Evaluate for Kussmaul respirations, warm and dry skin, dry mucus membranes, abdominal pain, fruity/acetone odor to the breath 3. Monitor SaO2 and vital signs; obtain BGL 4. Give supplementary oxygen when indicated B2. STABILIZATION HYPOGLYCEMIA BLS 1. Primary Assessment - Assess airway, breathing and circulation and manage as indicated. 2. History, physical exam, vital signs including assessing the patient’s blood glucose level 3. If HYPOGLYCEMIC (glucose < 60 mg/dL) with related symptoms and patient is able to swallow and self-protect his/her own airway: a. Adult: Administer ORAL GLUCOSE 15 gm PO b. Pediatric: Administer ORAL GLUCOSE 0.5-1.0 gm/kg C. SPECIAL CONSIDERATIONS 1. Urinary tract infections (UTIs) are the single most common infection associated with DKA. DYSBARISM 1 of 1 TITLE: DYSBARISM A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Location- Ocean, lake, river, quarry, cave - Timing- Time dives occurred, length of dives, surface intervals, safety stops, and type of timing used (e.g., watch with tables, dive computer). - Activities over the past 72 hours prior to dive-Especially flying - Depth- Deepest point, approximate time spent at that depth, and rate of ascent. - Work-Currents, distance swam, water temperature, and primary activity (e.g., wreck diving, artifact recovery). - Gases and equipment-Compressed air, rebreathing equipment, and mixed gases - Problems - Violation of no-decompression limit dive tables, equipment, entanglement, dizziness, marine bites or stings - Condition - Physical condition before, during, and after the dive (eg, fatigue, alcohol ingestion, fever, vertigo, nausea, overexertion, pulled muscles) - First aid received - Oxygen, positioning, medications, and fluids 2. SIGNS AND SYMPTOMS - Chest pain - Dyspnea - Cough - Joint pain - Cramps - Headache - Dizziness - Fatigue - Nausea & vomiting - Paralysis - Sinus complications B. STABILIZATION BLS 1. A-B-C’s; initially open airway using jaw thrust maneuver as indicated. Maintain airway as needed. 2. Complete Rest; place patient in position of comfort- preferably supine. 3. Do NOT place patient in Trendelenberg position 4. Monitor SaO2 and vital signs 5. Give supplementary oxygen when indicated 6. Suction and assist ventilations, if necessary. ELECTRICAL SHOCK 1 of 1 TITLE: ELECTRICAL SHOCK / BURNS A. PRESENTATION 1. HISTORY/POSSIBLE CAUSES - Scene size up - Type electrical exposure (AC/DC, AMPS, volts) - Duration of contact - Elapsed time since exposure - Pertinent past medical history - SAMPLE history - Cardiac complaints 2. SIGNS/ SYMPTOMS - Altered consciousness - Dyspnea or respiratory arrest - Chest pain or cardiac arrest - Soft tissue damage - Various degrees of soft tissue damage - Cardiac rhythm disturbances - Hearing loss - Nausea, vomiting - Headache - Airway edema - Stridor - Apparent exit wound - Seizures - Otherwise diverse signs and symptoms based on voltage exposed B. STABILIZATION BLS 1. A-B-Cs: Initially open airway using jaw thrust maneuver as indicated. Maintain airway as needed 2. Evaluate affected percentage of BSA and document 3. Monitor SaO2 and vital signs 4. Give supplementary oxygen when indicated 5. Cover burns with dry sterile dressings 6. Apply Spinal Motion Restriction, if indicated C. SPECIAL CONSIDERATIONS 1. Immobilize all patients suffering high voltage electrical shock. HEAD TRAUMA 1 of 2 TITLE: HEAD TRAUMA A. PRESENTATION 1. HISTORY/POSSIBLE CAUSES - Route, type, time, quantity of exposure - Mechanism of injury (blunt or penetrating) - Blunt trauma: amount and direction, deceleration vs. compression - Penetrating trauma: size of object, bullet caliber and trajectory, type of weapon. - Motor vehicle crash: size of vehicle, speed of vehicle, damage to vehicle, impact damage, patient compartment intrusion, seatbelt use, appropriate child restraints/ car seat usage, airbag deployment, ejection, type (frontal, rear, lateral, rotational, rollover). - Vehicle versus pedestrian: size and speed of vehicle, damage to the vehicle, location of patient in relation to the vehicle, post accident impact with other vehicles. - Motorcycle accident: speed of motorcycle, speed and size of other vehicles involved, damage to motorcycle, damage to other involved vehicles, type of impact (head-on, angular, ejection), use and condition of protective equipment, clothing worn by rider(s), post accident impact with other vehicles/objects, distance thrown, passengers. - Falls: reason for fall (medical or other), length of fall, type of surface the patient landed on, which part of the body struck first. - Sports injuries: what forces acted on the patient, condition and use of protective gear, speed of vehicle and/or impact with other objects (ATV, skates, skateboard, wave runner, etc.) - Blast injuries: Primary (pressure wave) distance from blast, size of blast Secondary (flying objects) objects that could have struck the patient. Tertiary (patient impact) objects that the patient may have struck, distance thrown. - SAMPLE History Number of people involved. 2. SIGNS & SYMPTOMS - Altered mental status (agitation, confusion, lethargy) - Nausea/vomiting - Blurred or double vision - Numbness or tingling of extremities - Focal neurological deficits - Unconsciousness - Seizures - Headache HEAD TRAUMA 2 of 2 - Abnormal gait Unequal pupils Hypertension Bradycardia Abnormal respiratory pattern Battle’s sign Periorbital ecchymosis (raccoon eyes) CSF leakage Cushing’s phenomenon Airway obstruction B. STABILIZATION BLS 1. A-B-C’s: Initially open airway using jaw thrust maneuver if indicated maintain airway as needed, consider OPA 2. Stabilize cervical spine as appropriate 3. Immediately treat any threat to life 4. Monitor SaO2 and vital signs 5. Give supplementary oxygen when indicated 6. Control bleeding as appropriate 7. Cover penetrating injuries and evisceration with sterile dressing soaked with sterile normal saline 8. Impaled objects are stabilized in place 9. Package patient for transport: spinal motion restriction 10. For isolated head injuries, elevate head of backboard 15 degrees HYPERTHERMIA 1 of 2 TITLE: HYPERTHERMIA A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Onset and Duration - Patient age - Patient attire - Activity level - Air temperature, humidity - Drug or alcohol use - Trauma - Past medical history - Current medications - Allergies - Obesity 2. SIGNS/ SYMPTOMS- HEAT EXHAUSTION - Symptoms often are nonspecific and may be insidious in onset; these symptoms often resemble a viral illness. - Fatigue and weakness - Nausea and vomiting - Headache and myalgias - Dizziness - Muscle cramps and myalgias - Irritability - Weakness - Vomiting - Orthostatic pulse and blood pressure changes - Sweating (absent or present) - Piloerection - Tachycardia 3. SIGNS/ SYMPTOMS -HEAT STROKE - Assume that any patient presenting with an elevated temperature, signs of CNS dysfunction, and a history of heat exposure has heatstroke and treat immediately. - All the findings of heat exhaustion may be present in heatstroke. - The patient's temperature is usually higher than 41°C (106°F). - The patient may exhibit signs, including tachycardia, increased pulse pressure, decreased cardiac output, and decreased diastolic blood pressure. Tachyarrhythmias may not be amenable to cardioversion. - CNS dysfunction includes seizure, coma, delirium, bizarre behavior, hallucinations, and decerebrate rigidity, fixed and dilated pupils. - Skin findings may range from warm and dry to diaphoretic. HYPERTHERMIA 2 of 2 - - B. Respiratory symptoms include tachypnea, alkalosis, and respiratory decompensation secondary to acute respiratory distress syndrome (ARDS). Unlike malignant hyperthermia, heatstroke is not characterized by muscular rigidity. Muscle cramps or flaccidity may be noted. STABILIZATION BLS 1. A-B-C’s: Maintain airway as needed 2. Institute appropriate cooling measures- Heat stroke, cool as rapidly as possible to minimize end organ damage (heat stroke). 3. Apply tepid water to the patient and fan the patient to promote evaporative cooling. 4. Apply ice packs to the patient’s neck, axillae, and groin. Alternatively, cover the patient with a wet sheet. 5. Transport the patient with air conditioning turned on high- avoid shivering. 6. Give supplementary oxygen when indicated 7. Suction and assist ventilations as needed. 8. Monitor SaO2, measure vital signs, to include orthostatics C. SPECIAL CONSIDERATIONS 1. Do NOT spend excessive time on-scene cooling the patient. HYPOTHERMIA 1 of 2 TITLE: HYPOTHERMIA A. PRESENTATION 1. HISTORY/ POSSIBLE CAUSES - Length of exposure - Wet or dry - Air/water temperature - Wind - History and time at which the patient presented with changes in mental status - Drug or alcohol use - Medical illnesses - Current medications - Allergies 2. SIGNS/SYMPTOMS Mild hypothermia (32-35°C or 89.6-95°F) - Tachycardia - Vasoconstriction - Tachycardia - Ataxia - Dysarthia - Loss of fine motor coordination - Lethargy - Confusion - Shivering Moderate hypothermia (28-32°C or 82.4-89.6°F) - Shivering stops - Delirium - Reflexes slowed - Level of consciousness diminishes - Bradycardia - J waves on ECG - Cold dieresis Severe hypothermia (<28°C or 82.4°F) - Unresponsiveness or coma - Hypotension - Very cold skin - Pulmonary edema - May appear dead - Ventricular fibrillation - Loss of reflexes HYPOTHERMIA 2 of 2 B. STABILIZATION BLS 1. A-B-Cs: initially open airway using jaw thrust maneuver, if indicated Maintain airway as appropriate 2. Monitor SaO2 and vital signs 3. Give supplementary oxygen when indicated 4. Suction airway and assist ventilations as needed 5. Warm as appropriate: Passive, Active (see special considerations) C. SPECIAL CONSIDERATIONS 1. The cornerstone of treatment is rewarming the patient. 2. Passive external warming: The patient is insulated from heat loss and allowed to generate heat by themselves. This method is useful for mild cases with no underlying disease. 3. Active external warming: External heat is applied to the patient's skin in a noninvasive manner. It is useful in milder cases. Because the vasoconstricted extremities hold pooled blood, warming of the extremities may result in a reversal of the vasoconstriction and may release incompletely rewarmed blood back to the central circulation. This return of relatively cold blood to a warmer core may cause temperature after-drop or arrhythmias. 4. Hypothermia may accompany drug use or an overdose and usually is caused by exposure to cold associated with inadequacy of the patient's response mechanisms. MUSCULOSKELETAL TRAUMA 1 of 2 TITLE: MUSCULOSKELETAL TRAUMA A. PRESENTATION 1. HISTORY/POSSIBLE CAUSES - Route, type, time, quantity of exposure - Mechanism of injury (blunt or penetrating) - Blunt trauma: amount and direction, deceleration vs. compression - Penetrating trauma: size of object, bullet caliber and trajectory, type of weapon. - Motor vehicle crash: size of vehicle, speed of vehicle, damage to vehicle, impact damage, patient compartment intrusion, seatbelt use, appropriate child restraints/ car seat usage, airbag deployment, ejection, type (frontal, rear, lateral, rotational, rollover). - Pedestrian vs. vehicle: size and speed of vehicle, damage to the vehicle, location of patient in relation to the vehicle, post accident impact with other vehicles. - Motorcycle accident: speed of motorcycle, speed and size of other vehicles involved, damage to motorcycle, damage to other involved vehicles, type of impact (head-on, angular, ejection), use and condition of protective equipment, clothing worn by rider(s), post accident impact with other vehicles/objects, distance thrown, passengers. - Falls: reason for fall (medical or other), length of fall, type of surface the patient landed on, which part of the body struck first. - Sports injuries: what forces acted on the patient, condition and use of protective gear, speed of vehicle and/or impact with other objects (ATV, skates, skateboard, wave-runner, etc.) - Blast injuries: Primary(pressure wave)distance from blast, size of blast Secondary (flying objects) objects that could have struck the patient. Tertiary (patient impact) Objects that the patient may have struck, distance thrown. - SAMPLE History Number of people involved. 2. SIGNS & SYMPTOMS - Pain - Swelling - Lacerations - Abrasions - Contusions - Amputations - Signs and symptoms of shock - Altered metal status (agitation, confusion, lethargy) - Deformity MUSCULOSKELETAL TRAUMA 2 of 2 - Decreased capillary refill Decreased pulse, motor and/or sensory distal to injury site Crepitus Avulsions Obvious fractures (closed or compound) Compartment syndrome Pallor Airway obstruction B. STABILIZATION BLS 1. A-B-C’s: Initially open airway using jaw thrust maneuver if indicated Maintain airway as needed, consider OPA, NPA 2. Stabilize cervical spine as appropriate 3. Immediately treat any life threats 4. Monitor SaO2 and vital signs 5. Give supplementary oxygen when indicated 6. Control bleeding as appropriate 7. Cover penetrating injuries with sterile dressing soaked with sterile normal saline 8. Impaled objects are stabilized in place 9. Package patient for transport: spinal motion restriction 10. Pulse, motor and sensory check (PMS) before and after splinting 11. Stabilize and splint factures 12. For hypotensive patients, place in trendelenburg C. SPECIAL CONSIDERATIONS 1. 2. 3. 4. Employ supplemental oxygen to keep SaO2 greater than 94% Hip injuries are to be immobilized for transport. Multiple fractures can be life threatening Do not attempt to reduce fractures in the field. Splint fractures in the position found with PMS checks before and after splinting. For patients that do not have a pulse distal to their injury site, contact medical control for treatment orders. NERVE AGENT ANTIDOTE KIT 1 of 3 TITLE: NERVE AGENT ANTIDOTE KIT A. PRESENTATION 1. HISTORY/POSSIBLE CAUSES - Exposure to nerve agents: Tabun (GA), Sarin, (GB), Soman (GD), GF, and VX - Organophosphate poisoning (insecticide) - Inhalation - Ingestion - Skin and Eye Contact 2. SIGNS/ SYMPTOMS: - Rhinorrhea (Running Nose) - Chest Tightness - Miosis (Pinpoint Pupils) - Headache - Shortness of Breath - Excessive Salivation - Excessive Sweating - Nausea / Vomiting - Abdominal Cramps - Involuntary Defecation and Urination - Muscle Twitching - Confusion - Seizures - Generalized Muscular Twitching - Generalized Weakness - Flaccid Paralysis - Coma - Respiratory Failure - Death B. SCENE SAFETY: Respiratory protection: Pressure-demand, self-contained breathing apparatus (SCBA) is recommended in response situations that involve exposure to any nerve agent vapor or liquid. Skin protection: Chemical-protective clothing and butyl rubber gloves are recommended when skin contact is possible because nerve agent liquid is rapidly absorbed through the skin and may cause systemic toxicity. Rapid decontamination is critical to prevent further absorption by the patient and to prevent exposure to others. NERVE AGENT ANTIDOTE KIT 2 of 3 C. STABILIZATION Atropine - (2mg) auto-injector (atropine stops the effect of the nerve agent by blocking the effects of over stimulation at certain nerve receptors. Atropine must be given first until its effects become apparent (*Atropinization); sometimes more than one injector of atropine is used before giving any 2-PAM C1). 1. Mild Exposure-administer one (1) Atropine auto-injector (2mg) IM, may repeat every 3-5 minutes until symptoms improve. 2. Moderate Exposure - administer two (2) Atropine auto-injectors (4mg) IM, may repeat every 3-5 minutes until symptoms improve. 3. Severe Exposure - administer three (3) Atropine auto-injectors (6mg) IM, may repeat every 3-5 minutes until symptoms improve. 2- PAM C1 - (Pralidoxime Chloride - 600mg) auto-injector (*2-PAM C1 compliments the action of atropine by removing the nerve agent which restores normal skeletal muscle contraction). 1. Mild Exposure - if symptoms do not improve within 5 minutes following administration of Atropine, administer one (1) 2-PAM auto-injector (600 mg) IM, one (1) time only. 2. Moderate Exposure - administer one (1) 2-PAM auto-injector (600 mg) IM, may repeat x1 in 5-10 minutes if symptoms do not improve. 3. Severe Exposure - administer three (3) 2-PAM auto-injectors (1800 mg) IM. 1. Hold the auto-injector with your thumb and two fingers (pencil writing position). DO NOT touch the needle end. 2. Position the green (needle) end of the auto-injector against the injection site (thigh or buttocks). DO NOT inject into areas near the hip, knee, or femur. 3. Apply firm even pressure (not a jabbing motion) to the auto-injector until it pushes the needle into your thigh (or buttocks). Using a jabbing motion may result in an improper injection or injury. Take care not to hit any objects in pockets. 4. Hold the auto-injector firmly in place for at least ten (10) seconds. Firm pressure automatically triggers the coiled spring mechanism. This plunges the needle through the clothing into the muscle and at the same time injects the antidote into the muscle tissue. 5. Carefully remove the Atropine auto-injector from the injection site and place in a sharps container. NERVE AGENT ANTIDOTE KIT 3 of 3 6. Pull the 2-PAM C1 auto-injector (the larger of the two) out of the clip and inject yourself in the same manner described in Steps 1 through 5, holding the black (needle) end against the injection site. DO NOT touch the needle end. 7. Repeat the above steps using the second and third MARK I sets, as necessary. 8. Document doses given as appropriate to the situation (on triage tag and / or PCR) and dispose of discharged auto-injector in similar fashion as all used sharps. 9. Massage the injection site if time permits. D. SPECIAL CONSIDERATIONS In cases of very severe exposure, all three auto-injector sets (atropine and 2-PAM should be administered in rapid succession). It is important that the injections be given into a large muscle area. Accidental injections into the hand WILL NOT deliver an effective dose of the antidote, especially if the needle goes through the hand. * Atropinization is often referred to as the nerve agent antidote poisoning because of the chemical effects on the body’s system. Watch for the following signs of atropinization: • A pulse above 90. • Dry mouth. • Pupils that are dilated. (Pupil dilation may be unequal) • CAUTION: If the eyes are contaminated there may be little or no pupil dilation. OBSTRETRIC-ABNORMAL DELIVERY 1 of 2 TITLE: OBSTETRICS - ABNORMAL DELIVERY A. PRESENTATION 1. HISTORY - Date of last menstrual period/ estimated delivery date - Ruptured membranes- Time and description - Vaginal fluid drainage, bleeding - Prenatal care - Age - Number of prior pregnancies (gravida) - Number of live births (para) - Problems with current pregnancy - Problems with previous pregnancies - Medical illnesses - Current medications - Allergies - Evidence of drug or alcohol abuse with current pregnancy - When was the last time the patient felt fetal movement - Evidence of uterine contractions and distance between each - Prior ultrasonographic examinations and results, and bleeding during pregnancy or labor (If findings are positive, be alert for placenta previa.) B. TREATMENT 1. Breech presentation 2. Prolapsed umbilical cord 3. Limb presentation BREECH PRESENTATION 1. Provide supportive care ** LOAD AND GO** 2. Three types of vaginal breech deliveries exist. - Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant. - Partial breech extraction: Fetus descends spontaneously to where umbilicus is at the vaginal introitus; then, the fetus is extracted completely. - Total breech extraction: The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible. As mentioned earlier, it is imperative that the cervix be fully dilated and effaced before the infant is delivered past its umbilicus. The presence of the feet at the vulva is not an indication to the physician to proceed with active extraction. OBSTRETRIC-ABNORMAL DELIVERY 2 of 2 PROLAPSED UMBILICAL CORD 1. Provide supportive care ** LOAD AND GO** 2. Insert two fingers of a sterile gloved hand to raise the presenting part of the cord. 3. Check the cord for pulsations 4. Place mother in Trendelenberg or knee-chest position. 5. Apply a dressing moistened with sterile saline to the exposed cord. 6. ** Do not attempt to push the cord back** 7. Contact medical control prior to departure and provide an update of patient’s stability and current condition LIMB PRESENTATION 1. Provide supportive care **LOAD AND GO** 2. Place mother on left side in Trendelenberg position. 3. Elevate hips with a pillow. 4. Never attempt to push the presented limb back into the vagina. 5. Contact medical control prior to departure and provide an update of the patient’s stability and current condition. C. SPECIAL CONSIDERATION 1. Apgar scoring is used to provide a rough estimate of the baby's immediate adaptation to extrauterine life. The score aids in determination of whether the baby is viable independently or needs help (resuscitation). Apgar scores should be documented at 1, 5, and 10 minutes in all neonates. If the 5minute score is less than 7, continue scoring every 5 minutes for 20 minutes. However, if the child requires resuscitation, waiting to do a 1minute score is not indicated. Assign scores in each of the following categories and total them for the Apgar score. - Appearance - 0 for blue or pale, 1 for body pink and limbs blue, and 2 for pink all over Pulse - 0 for absent, 1 for less than 100 per minute, 2 for more than 100 per minute Grimace - 0 for no response, 1 for some motion, 2 for crying Activity - 0 for limp, 1 for some weak motion, 2 for active Respiration - 0 for none, 1 for weak cry, 2 for strong cry OBSTRETRIC-NORMAL DELIVERY 1 of 3 TITLE: OBSTETRICS - NORMAL DELIVERY A. PRESENTATION 1. HISTORY/CAUSES - Date of last menstrual period/ estimated delivery date - Ruptured membranes- Time and description - Vaginal fluid drainage, bleeding - Prenatal care - Age - Number of prior pregnancies (gravida) - Number of live births (para) - Problems with current pregnancy - Problems with previous pregnancies - Medical illnesses - Current medications - Allergies - Evidence of drug or alcohol abuse with current pregnancy - When was the last time the patient felt fetal movement - Evidence of uterine contractions and distance between each - Prior ultrasonographic examinations and results, and bleeding during pregnancy or labor (if findings are positive, be alert for placenta previa.) B. TREATMENT 1. 2. 3. If the delivery is imminent, prepare patient for delivery prior to transport. Monitor vital signs, blood loss, and time uterine contractions. Prepare for transport and notify the receiving facility and provide the following information: a. Name of the patient b. Age of the patient c. Patients doctor d. Patients last menstrual period e. Estimated delivery date f. Number of weeks pregnant g. Current condition of the patient and stability h. Estimated time of arrival 4. Administer supplemental oxygen as patient condition warrants 5. Delivery procedures: a. Open sterile obstetric kit b. Drape patient, ensure patient privacy c. Apply sterile gloves and other PPE d. As head emerges, gently support the baby’s head to prevent an explosive delivery- DO NOT pull or push baby. OBSTRETRIC-NORMAL DELIVERY 2 of 3 e. In the event that membranes cover the baby’s head after delivery, the sac should be opened (using scissors) and removed from the baby’s face. f. Observe for the umbilical cord around the baby’s neck. It should be gently slipped over the head. g. If unable to remove cord from around the neck, clamp and cut cord carefully. h. After the head has been delivered, suction the airway with a bulb syringe (mouth and then nose). * Note that if there are any signs of meconium aspiration, immediately begin meconium suction techniques*. i. Deliver shoulders and body. j. Clamp the cord approximately 6 inches from the baby and place a second clamp 3 inches from the first clamp. k. Cut the cord using the OB kit provided scalpel. l. Inspect the cord for artery and vein characteristics and document. m. Dry baby, wrap in a blanket to preserve body heat, insuring the baby’s head is covered. n. Notify dispatch immediately at the end of the second stage of labor and record and document the time in the PCR. 6. Care for the baby after delivery: a. Position head downward to aid in drainage, suction as appropriate b. In normal deliveries, the baby should begin to spontaneously breathe upon delivery. c. In cases where the baby does not breath sp