DMEMSMD Protocols January 2024 FINAL v3 2024-05-03.pdf

Denver Metropolitan Prehospital Protocols These protocols are considered the property of the Denver Metro EMS Medical Directors and the contributors listed on the acknowledgements page. Any edits or alterations of this protocol will be the sole resp...

Denver Metropolitan Prehospital Protocols These protocols are considered the property of the Denver Metro EMS Medical Directors and the contributors listed on the acknowledgements page. Any edits or alterations of this protocol will be the sole responsibility of the Agency Medical Director and should adhere to the Colorado State Rule 6 CCR 1015-3 - Emergency Medical Services Chapter Two. The DMEMSMD protocols are collaboratively written and constantly revised to provide the most ideal and up to date EMS care for our community. We recognize that any new protocol version necessitates training and implementation at the level of the individual agency. Careful training and implementation of these changes are strongly encouraged. It is appropriate to allow up to 6 months for any agency to implement protocol changes with each new revision. The DMEMSMD group should be credited and asks to be informed of any such edits or alteration to the most current version of the DMEMSMD protocols. The DMEMSMD group may be notified at their website https://dmemsmd.org through the contact tab. The process that has been initiated in the construction of this revised set of protocols will remain in place. The authors will continue to edit and revise the protocols to reflect the dynamic role of emergency medical services within the medical care community. The authors would like to acknowledge the following for their contribution, talent, and time in this revision of the Denver Metro EMS protocols. January 2024 Denver Metro EMS Medical Directors Kathleen Adelgais, M.D. Dylan Luyten, M.D. Jonathan Apfelbaum, M.D. Maria Mandt, M.D. Jeff Beckman, M.D. Jacob Nacht, M.D. Scott Branney, M.D. Case Newsom, D.O. M. Andres Camacho, M.D. Tom Paluska, M.D. Daniel Cheek, M.D. Gilbert Pineda, M.D. Eugene Eby, M.D. Lara Rappaport, M.D. Andra Farcas, M.D. Jason Roosa, M.D. Sheaffer Gilliam, M.D. C. Samuel Smith, M.D. Eric Hill, M.D. Benjamin Usatch, M.D. Reed Louderback, M.D. Angela Wright, M.D. The Denver Metro EMS Medical Directors would also like to recognize the ongoing contributions by our agency EMS representatives and local EMS educators whose continued input into the protocol document and revisions is essential to its success. The Denver Metro EMS Medical Directors share a rich history of collaborative efforts to establish a regional standard of care for the Denver metropolitan area and beyond. We extend our sincere gratitude to the physicians who, though no longer active in the committee, have dedicated their time and expertise to the development of these protocols. While your names may no longer appear in this protocol set, your legacy and invaluable contributions will forever be remembered and appreciated.  Table of Contents General Guidelines (0001-0999) 0010 Introduction 0015 Age Definitions 0020 Confidentiality 0030 Consent 0040 Physician at the Scene/Medical Direction 0050 Field Pronouncement 0051 Termination of Resuscitation 0060 Advanced Medical Directives 0070 Patient Determination: “Patient or No Patient” 0080 Patient Non-Transport or Refusal 0090 Emergency Department Divert and Advisory 0091 EMResource Hospital Rotation Board Instructions 0100 Mandatory Reporting of Abuse Patients 0110 Free-Standing Emergency Departments as EMS Destination 0120 Base Contact for Physician Consultation 0130 Transportation of the Pediatric Patient 0140 911 Response to Request for Interfacility Transport 0150 Behavioral Health Walk-In Clinic/Withdrawal Management Unit Admit Guidelines 0160 Extended Care Protocol Supplements 0990 Quick Reference for Procedures and Medications Allowed by Protocol Procedures (1000-1999) 1000 Intubation: Oral 1010 Intubation: Nasal 1030 Cricothyrotomy 1040 Pediatric Needle Cricothyrotomy 1050 Supraglottic Airway 1060 Continuous Positive Airway Pressure (CPAP) 1070 Capnography 1080 Needle Thoracostomy for Tension Pneumothorax Decompression 1090 Synchronized Cardioversion 1100 Transcutaneous Cardiac Pacing 1110 Intraosseous Catheter Placement 1120 Tourniquet Protocol 1130 Restraint Protocol 1140 Orogastric Tube Insertion with Advanced Airway  1150 TASER® Probe Removal 1160 Pain Management Respiratory Protocols (2000-2999) 2000 Obstructed Airway 2010 Adult Universal Respiratory Distress 2020 Pediatric Universal Respiratory Distress 2030 Adult Wheezing 2040 Pediatric Wheezing 2050 Pediatric Stridor/Croup 2060 CHF/Pulmonary Edema 2090 Tracheostomy Emergencies Cardiac Protocols (3000-3999) 3000 Medical Pulseless Arrest 3010 Medical Pulseless Arrest Considerations 3020 Neonatal Resuscitation 3030 Post Cardiac Arrest Care 3040 Tachyarrhythmia with Poor Perfusion 3050 Bradyarrhythmia with Poor Perfusion 3060 Chest Pain 3070 STEMI Alert 3080 Hypertension 3090 Ventricular Assist Devices (VAD) General Medical Protocols (4000-4999) 4000 Medical Shock 4010 Universal Altered Mental Status 4020 Syncope 4030 Stroke 4040 Seizure 4050 Hypoglycemia 4060 Pediatric BRUE (Formerly ALTE) 4070 Drug/Alcohol Intoxication 4080 Overdose and Acute Poisoning 4090 Allergy and Anaphylaxis 4100 Non-Traumatic Abdominal Pain/Vomiting 4110 Suspected Carbon Monoxide Exposure 4120 Adrenal Insufficiency 4130 Epistaxis Management 4140 Sepsis  4150 Hyperkalemia Environmental Protocols (5000-4999) 5000 Drowning 5010 Hypothermia 5020 Hyperthermia 5030 Altitude Illness 5040 Insect/Arachnid Stings and Bites 5050 Snake Bite Behavioral Protocols (6000-6999) 6000 Psychiatric/Behavioral Patient 6010 Agitated/Combative Patient 6011 Hyperactive Delirium with Severe Agitation 6015 Post Sedation 6020 Transport of the Handcuffed Patient Obstetric Protocols (7000-7999) 7000 Childbirth 7010 Obstetrical Complications Trauma Protocols (8000-8999) 8000 General Trauma Care 8010 Traumatic Pulseless Arrest 8020 Traumatic Shock 8030 Head Trauma 8040 Face and Neck Trauma 8050 Spinal Trauma and Spinal Motion Restriction (SMR) 8055 Suspected Spinal Injury with Protective Athletic Equipment in Place 8060 Chest Trauma 8070 Abdominal and Pelvic Trauma 8080 Extremity Trauma 8090 Burns 8100 Special Trauma Scenarios: Sexual Assault and Abuse/Neglect 8110 Trauma in Pregnancy Medication Protocols (9000-9999) 9000 Medication Administration Guidelines 9005 Acetaminophen 9010 Adenosine 9020 Albuterol Sulfate 9030 Amiodarone  9040 Antiemetics 9050 Aspirin 9060 Atropine Sulfate 9070 Benzodiazepines 9075 Butyrophenones 9080 Calcium 9090 Dextrose 9100 Diphenhydramine 9110 Dopamine 9115 DuoDote™ 9120 Epinephrine 9130 Glucagon 9150 Hemostatic Agents 9160 Hydroxocobalamin 9170 Ipratropium Bromide 9180 Lidocaine 2% 9190 Magnesium Sulfate 9200 Methylprednisolone 9210 Naloxone 9220 Nitroglycerin 9225 NSAID 9230 Opioids 9240 Oral Glucose 9250 Oxygen 9260 Phenylephrine 9270 Racemic Epinephrine 9280 Sodium Bicarbonate 9290 Topical Ophthalmic Anesthetics Appendix A: Crisis Management Protocols (10000-10999) 10010 Viral Epidemic/Pandemic Screening, Treatment, and Transport 10020 Viral Epidemic/Pandemic Treat in Place Guideline Appendix C: RETAC Trauma Triage Algorithms Foothills and Mile-High Trauma Triage Algorithms Extended Care Supplements (Requires Medical Director Approval for Agency Use) 2000X Respiratory Extended Care 8000X Trauma Extended Care 3000X Cardiac Extended Care 9000X Medication Extended Care 4000X Medical Extended Care  Table of Contents 0010 GENERAL GUIDELINES: INTRODUCTION INTRODUCTION The following protocols have been developed and approved by the Denver Metro EMS Medical Directors (DMEMSMD) group. These protocols define the standard of care for EMS providers in the Denver Metropolitan area, and delineate the expected practice, actions, and procedures to be followed. No protocol can account for every clinical scenario encountered, and the DMEMSMD recognize that in rare circumstances deviation from these protocols may be necessary and in a patient’s best interest. Variance from protocol should always be done with the patient’s best interest in mind and backed by documented clinical reasoning and judgment. Whenever possible, prior approval by direct verbal order from base station physician is preferred. Additionally, all variance from protocol should be documented and submitted for review by the agency’s Medical Director in a timely fashion. The protocols are presented in an algorithm format. An algorithm is intended to reflect real-life decision points visually. An algorithm has certain limitations, and not every clinical scenario can be represented. Although the algorithm implies a specific sequence of actions, it may often be necessary to provide care out of sequence from that described in the algorithm if dictated by clinical needs. An algorithm provides decision-making support, but need not be rigidly adhered to and is no substitute for sound clinical judgment. In order to keep protocols as uncluttered as possible, and to limit inconsistencies, individual drug dosing has not been included in the algorithms. It is expected the EMTs will be familiar with standard drug doses. Drug dosages are included with the medications section of the protocols as a reference. If viewing protocol in an electronic version, it will be possible to link directly to a referenced protocol by clicking on the hyperlink, which is underlined. PROTOCOL KEY EMT AEMT Boxes without any color fill describe actions applicable to all certification levels. Boxes with orange fill are for actions for intermediate level or higher, and blue- filled boxes are for Paramedic level. When applicable, actions requiring Base Intermediate Paramedic Contact are identified in the protocol. Teaching points deemed sufficiently important to be included in the protocol are Teaching points separated into grey-filled boxes with a double line border. TRAINING AND EDUCATION These protocols define the treatments, procedures, and policies approved by the Denver Metro EMS Physician Group. In Colorado, the scope of practice and acts allowed for EMT, EMT-IV, AEMT, EMT-I and Paramedic certifications are defined by the Colorado Department of Public Health and Environment, Chapter Two - Rules Pertaining to EMS Practice and Medical Director Oversight. These protocols do not supersede Chapter Two allowances, but in some instances may vary from Chapter Two depending on medical directors’ preference. The curriculum for initial EMS provider training may not cover some of the treatments, procedures and medications included in these protocols. Therefore, it is the responsibility of the EMS agency and Medical Director to ensure the initial training, verification, and maintenance of these skills falling outside traditional EMS education with all agency providers. This may be of additional importance when training and orienting newly hired providers prior to independent practice. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0015 GENERAL GUIDELINES: AGE DEFINITIONS INTRODUCTION For the purposes of these clinical care protocols, the following age guidelines will be used. These are general guidelines, however individual protocols, including medication dosages, may deviate from these age ranges. ADULT Adult patients are considered 12 years of age or older. GERIATRICS Geriatric patients will be considered 65 years of age or older. Geriatric Geriatric Protocol specific indications will be indicated by a green box. PEDIATRICS Pediatric patients are those less than 12 years of age. Infant is defined as Pediatric Protocol less than 1 year of age. Neonate is defined as less than one month of age. Pediatric specific indications will be noted by a purple box. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0020 GENERAL GUIDELINES: CONFIDENTIALITY CONFIDENTIALITY A. The patient-physician relationship, the patient-registered nurse relationship, and the patient-EMT relationship are recognized as privileged. This means that the physician, nurse, or EMT may not testify as to confidential communications unless: 1. The patient consents 2. The disclosure is allowable by law (such as Medical Board or Nursing Board proceedings, or criminal or civil litigation in which the patient's medical condition is in issue) B. The prehospital provider must keep the patient's medical information confidential. The patient likely has an expectation of privacy, and trusts that personal, medical information will not be disclosed by medical personnel to any person not directly involved in the patient's medical treatment. 1. Exceptions i. The patient is not entitled to confidentiality of information that does not pertain to the medical treatment, medical condition, or is unnecessary for diagnosis or treatment. ii. The patient is not entitled to confidentiality for disclosures made publicly. iii. The patient is not entitled to confidentiality with regard to evidence of a crime. C. Additional Considerations: 1. Any disclosure of medical information should not be made unless necessary for the treatment, evaluation or diagnosis of the patient. 2. Any disclosures made by any person, medical personnel, the patient, or law enforcement should be treated as limited disclosures and not authorizing further disclosures to any other person. 3. Any discussions of prehospital care by and between the receiving hospital, the crewmembers in attendance, or at in-services or audits which are done strictly for educational or performance improvement purposes, will fall under the “Carol J. Shanaberger Act” Colorado Revised Statutes §25-3.5-901 et seq., provided that all appropriate criteria have been met for the agencies peer protection program. Further disclosures are not authorized. 4. Radio communications should not include disclosure of patient names. 5. This procedure does not preclude or supersede your agency’s HIPAA policy and procedures. 6. Any communication from the prehospital setting to the receiving hospital or other facility or care provider should be kept in compliance with HIPAA including all smart technology, SMS messaging, wireless communication or otherwise. No personal identifier information should be transmitted over non-HIPAA compliant secure means. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0030 General Guidelines: Consent No General Principles Conscious adult? Patient does not have An adult in the State of Colorado is decision-making-capacity, 18 years of age or older. Yes treat under implied or involuntary consent Every adult is presumed capable of making medical treatment Determine presence of decisions. This includes the right to decision-making-capacity make "bad" decisions that the prehospital provider believes are not in the best interests of the C: Choose / Communicate No patient. A call to 9-1-1 itself does not Can the patient communicate a prevent a patient from refusing choice? treatment. A patient may refuse Yes medical treatment (IVs, oxygen, medications), but you should try to U: Understand No inform the patient of the need for therapies, offer again, and treat to Does the patient understand the the extent possible. risks/ benefits/ alternatives/ The odor of alcohol on a patient’s consequences of the decision? breath does not, by itself, prevent a Yes patient from refusing treatment. R: Reason No Is the patient able to reason and Values provide logical explanation for the decision? Attempt to assess if the patient’s decision is in line with how they Yes have approached the other questions they have been asked V: Values No during assessment Is the decision in accordance If possible, obtain collateral from with the patient’s values friends or family to determine if the system? patient’s decision is in line with other decisions or conversations Yes An example question to assess values: “How did you reach your Decision-making-capacity intact decision to accept (or reject) care?” Involuntary Consent In rare circumstances a person other than the patient may authorize consent. This may include: Court order (Guardianship) Law enforcement officer may authorize transport of prisoners in custody or detention in order to be evaluated but cannot dictate treatment decisions. Persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled. It is sufficient to assume the patient lacks decision-making-capacity if there is a reasonable concern when any person appears to have a mental illness and, as a result of such mental illness, appears to be an imminent danger to others or to himself or herself or appears to be gravely disabled. Effort should be made to obtain consent for transport from the patient, and to preserve the patient’s dignity throughout the process. However, the patient may be transported over his or her objections and treated under involuntary consent if the patient does not comply. Contact Base if there are any questions or concerns about decision-making-capacity. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0030 General Guidelines: Consent General Principles: Minors A. A parent, including a parent who is a minor, may consent to medical or emergency treatment of his/her child. There are exceptions: 1. Neither the child nor the parent may refuse medical treatment on religious grounds if the child is in imminent danger as a result of not receiving medical treatment, or when the child is in a life- threatening situation, or when the condition will result in serious handicap or disability. 2. Minors may seek treatment for medical care related to the intended live birth of a child; contraception; abortion; prevention, diagnosis, and treatment for sexually transmitted infections/HIV; evaluation and/or treatment after sexual assault; and treatment for addiction to or use of drugs, emergency treatment for intoxication, and treatment for alcoholism without consent of parents. 3. Minors 15 years or older may seek treatment for mental health without parents’ consent. 4. The consent of a parent is not necessary to authorize hospital or emergency health care when a first responder in good faith relies on a minor's consent, if the minor is at least 15 years or older, and a. Is living separate and apart from his or her parents, and managing his or her own financial affairs; or b. They have contracted a lawful marriage B. When in doubt, your actions should be guided by what is in the minor's best interests and BASE CONTACT. Procedure: Minors A. A parent or legal guardian may provide consent to or refuse treatment in a non- life-threatening situation. B. When the parent is not present to consent or refuse: 1. If a minor has an injury or illness, but not a life-threatening medical emergency, you should attempt to contact the parent(s) or legal guardian. If this cannot be done promptly, transport. 2. If the child does not need transport, they can be left at the scene in the custody of a responsible adult (e.g., teacher, social worker, grandparent). It should only be in very rare circumstances that a child of any age is left at the scene if the parent is not also present. 3. If the minor has a life-threatening injury or illness, transport and treat per protocols. If the parent objects to treatment, CONTACT BASE immediately and treat to the extent allowable, notify law enforcement to respond and assist. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0040 GENERAL GUIDELINES: PHYSICIAN AT THE SCENE/MEDICAL DIRECTION Purpose A. To provide guidelines for prehospital personnel who encounter a physician at the scene of an emergency General Principles A. The prehospital provider has a duty to respond to an emergency, initiate treatment, and conduct an assessment of the patient to the extent possible. B. A physician who voluntarily offers or renders medical assistance at an emergency scene is generally considered a "Good Samaritan." However, once a physician initiates treatment, he/she may feel a physician-patient relationship has been established. C. Good patient care should be the focus of any interaction between prehospital care providers and the physician. Procedure A. See algorithm below and sample note to physician at the scene Special notes A. Every situation may be different, based on the physician, the scene, and the condition of the patient. B. CONTACT BASE when any question(s) arise. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0040 GENERAL GUIDELINES: PHYSICIAN AT THE SCENE/MEDICAL DIRECTION NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMS PROVIDERS THANK YOU FOR OFFERING YOUR ASSISTANCE. The prehospital personnel at the scene of this emergency operate under standard policies, procedures, and protocols developed by their Medical Director. The drugs carried and procedures allowed are restricted by law and written protocols. After identifying yourself by name as a physician licensed in the State of Colorado and providing identification, you may be asked to assist in one of the following ways: 1. Offer your assistance or suggestions, but the prehospital care providers will remain under the medical control of their base physician, or 2. With the assistance of the prehospital care providers, talk directly to the base physician and offer to direct patient care and accompany the patient to the receiving hospital. Prehospital care providers are required to obtain an order directly from the base physician for this to occur. THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY. Medical Director Agency Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0040 GENERAL GUIDELINES: PHYSICIAN AT THE SCENE/MEDICAL DIRECTION PHYSICIAN AT THE SCENE/MEDICAL DIRECTION ALGORITHM EMS arrives on scene EMT attempts patient care Physician reports on patient Physician wants to help or is involved in and relinquishes patient care or will not relinquish patient care Prehospital provider identifies self and Provide care per protocol level of training Physician willing to just Physician requests or help out performs care inappropriate or inconsistent with protocols Provide general instructions and utilize Shares Physician at the physician assistance Scene/Medical Direction Note with physician and advise physician of your responsibility to the patient Physician does not Physician relinquish patient care complies and continues with care inconsistent with protocols Provide care per protocol CONTACT BASE for Medical Consult Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0050 GENERAL GUIDELINES: FIELD PRONOUNCEMENT Purpose A. To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the prehospital setting. EMS may transport any patient perceived to be viable, or if scene dynamics or public perception necessitates transport. General Principles A. Agency policy determines base contact requirements for patients for whom resuscitation efforts are being withheld. B. Medical Arrest: 1. EMS providers should try their best to determine a patient’s end-of-life wishes and honor them. Refer to Advanced Medical Directives protocol for discussion of advanced directives and decision making about appropriateness of performing or withholding resuscitation efforts. a. Do not attempt resuscitation for patients with a “No CPR” directive based on the patient’s wishes or compelling reasons to withhold resuscitation as covered in Advanced Medical Directives protocol. b. Do not attempt resuscitation for patients with definite signs of death, such as dependent lividity, rigor mortis, decomposition. C. Traumatic Arrest: 1. Do not attempt resuscitation if there is evidence of a non-survivable injury and no sign of life. Examples of non-survivable injuries include decapitation, evidence of massive head, chest, or abdominal trauma, or massive burn with charring. 2. Blunt trauma: consider field pronouncement if there are no signs of life. Signs of life include spontaneous movement, breathing, presence of a pulse, or reactive pupils. 3. Penetrating trauma: consider field pronouncement if there are no signs of life, and the arrest duration is suspected to be > 10 minutes. 4. Exceptions to the above recommendations to consider field pronouncement include arrests with the following mechanisms/scenarios: a. Hypothermic arrest b. Drowning w/ hypothermia and submersion < 60 min c. Lightning strike and electrocution d. Avalanche victim e. Pregnant patient with estimated gestational age ≥20 weeks Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0051 GENERAL GUIDELINES: TERMINATION OF RESUSCIATION FOR MEDICAL PULSELESS ARREST Purpose A. To provide guidelines for termination of resuscitation (TOR) for patients in medical pulseless arrest in the prehospital setting. EMS may transport any patient perceived to be viable, or if scene dynamics or public perception necessitates transport. B. For termination of efforts of newly born after field delivery, refer to the Neonatal Resuscitation protocol. General Principles A. Resuscitate according to Universal Pulseless Arrest Algorithm on scene (unless unsafe) until one of the following endpoints is met: 1. Return of spontaneous circulation (ROSC). 2. No ROSC despite 30 minutes of ALS care or BLS care with an AED. If shockable rhythm still present, continue resuscitation and transport to closest emergency department. 3. Contact base for TOR at any point if the effort is considered futile despite adequate CPR with ventilation and no reversible causes have been identified. B. For BLS-only providers, contact base for TOR when all of the following criteria met: 1. No AED shock advised 2. No ROSC 3. Arrest unwitnessed by either EMS or bystanders 4. No bystander CPR before EMS arrival C. The following patients found pulseless and apneic warrant resuscitation efforts beyond 30 minutes and should be transported: 1. Hypothermic arrest 2. Drowning w/ hypothermia and submersion < 60 min 3. Lightning strike and electrocution 4. Avalanche victim 5. Pregnant patient with estimated gestational age ≥20 weeks D. Once the patient is pronounced, they become a potential coroner’s case. From that point on the patient should not be moved and no clothing or medical devices (lines, tubes etc.) should be removed or altered pending coroner evaluation. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0060 General Guidelines: Advanced Medical Directives General Principles: 1. These guidelines apply to both adult and pediatric patients. 2. It is the intention of this guideline to protect the welfare of patients and to respect the appropriate exercise of professional judgments made in good faith by EMS personnel. In cases where there is doubt, contact base physician for consult. 3. From Colorado State Statute: Any EMS personnel who in good faith complies with a CPR directive shall not be subject to civil or criminal liability or regulatory sanction for such compliance pursuant to (CRS Section 15-18.6-104) 4. EMS providers should try their best to determine a patient’s end-of-life wishes and honor them. These wishes may not be written down or documentation may be unavailable. In cases where no documentation exists, consider if compelling reasons to withhold resuscitation exist. Example of compelling reasons to withhold resuscitation may include when written information is not available, yet the situation suggests that the resuscitation effort will be futile, inappropriate, and inhumane and the family, life partner, caregiver, or healthcare agent indicates that the patient would not wish to be resuscitated. 5. Specific examples where resuscitation efforts should be withheld or stopped include: a. A readily available “No CPR” directive based on the patient’s wishes: i. According to CO State Rules this could include: personally written directive, wallet card, “No CPR” bracelet, Healthcare Agent verbal request, MOST form, or other document or item of information that directs that resuscitation not be attempted. Photocopied, scanned, faxed copies are valid. b. The resuscitation may be stopped if after a resuscitation effort has been initiated, the EMS practitioner is provided with a Do Not Resuscitate directive or compelling reasons that such an effort should have been withheld. c. Suspected suicide does not necessarily invalidate an otherwise valid No CPR directive, DNR order, etc. When in doubt, contact base. 6. “Do Not Resuscitate” does not mean “do not care.” A dying patient for whom no resuscitation effort is indicated should still be provided with comfort care which may include the following: a. Clearing the airway (including stoma) of secretions. b. Provide oxygen using nasal cannula or facemask and other non-invasive measures to alleviate respiratory distress. c. Pain management. d. Transport to the hospital as needed to manage symptoms with the No CPR directive in place Additional Considerations 1. Document the presence of the CPR Directive on the incident report. Describe the patient’s medical history, presence of an advanced directive (if any), or verbal request to withhold resuscitation. 2. Mass casualty incidents are not covered in detail by these guidelines. (See State Trauma Triage Algorithm). 3. If the situation appears to be a potential crime scene, EMS providers should disturb the scene as little as possible and communicate with law enforcement regarding any items that are moved or removed from the scene. 4. Mechanisms for disposition of bodies by means other than EMS providers and vehicles should be prospectively established in each county or locale. 5. In all cases of unattended deaths occurring outside of a medical facility, the coroner should be contacted immediately. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0070 GENERAL GUIDELINES: PATIENT DETERMINATION: “PATIENT OR NO PATIENT” Yes General Guidelines Person is a minor (Age < 18 years) This protocol is intended to refer to individual patient contacts. In the event of a multiple party No incident, such as a multi-vehicle collision, it is expected that a reasonable effort will be made to identify those parties with acute illness or Person lacks decision- Yes injuries. Adult patients indicating that they do not making capacity wish assistance for themselves or dependent (Refer to consent protocol) minors in such a multiple party incident do not necessarily require documentation as patients. No No protocol can anticipate every scenario and providers must use best judgment. When Acute illness, injury, or Yes in doubt as to whether individual is a intoxication suspected based “patient”, err on the side of caution and on appearance perform a full assessment and documentation No Yes Person has a complaint resulting in a call for help No rd 3 party caller indicates Yes individual is ill, injured or gravely disabled No Person does not meet Individual meets definition of definition of a patient, and a Patient does not require PCR or (PCR Required) refusal of care No Yes Able to safely assess and provide care? Refer to psychiatric/behavioral Standard care per protocol and agitated/combative protocols Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0080 GENERAL GUIDELINES: PATIENT NON-TRANSPORT OR REFUSAL EMS A person who has decision-making capacity Dispatch may refuse examination, treatment, and transport Refer to General Guidelines: Consent for complete decision-making capacity guidelines If in doubt about patient decision-making Cancelled Arrived on scene capacity, CONTACT BASE for physician consult. PTA (see Patient Determination) Documentation Requirements for Refusal Confirm decision-making capacity EMS assistance offered and declined Risks of refusal explained to patient Patient understands risks of refusal Not a patient Patient Name of Base Station physician authorizing refusal of care unless standing order refusal Signed refusal of care against medical advice document, if possible Any minor with any complaint/injury is a patient and requires a PCR Ambulance No Ambulance Transport Transport Alternative Dispositions: Determine if Intoxicated patients: refer to Standing Order Drug/Alcohol Intoxication Refusal (SOR) Follow agency specific protocols if applicable Standing Order Refusal Base Contact Required < 5 years old High Risk Patients No base contact required if ALL criteria met: < 18 years old unless Base Contact is strongly parent/guardian on scene recommended whenever, in the 18 and older, or 5 and If uncertain about clinical judgement of the EMS older if parent/guardian patient’s decision-making provider, the patient is at high on scene capacity risk of deterioration without Patient has decision- Unable to safely assess medical intervention. making-capacity and provide care Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0090 GENERAL GUIDELINES: EMERGENCY DEPARTMENT ED DIVERT & CAPACITY NOTIFICATIONS (OPEN, ADVISORY, CRITICAL, ED DIVERT, CLOSED) Purpose A. To provide a standard approach to EMS destination decision making that is practical for field use and maintains equity for patients, EMS, and hospitals. B. To facilitate unobstructed access to hospital emergency departments (ED) for ambulance patients C. To allow for optimal destination policies in keeping with general EMS principles and Colorado State Trauma System Rules and Regulations. General EMS Principles A. EMResource, an internet-based tracking system, is used to manage diversion in the Denver Metro area. The EMResource screen should be routinely monitored for situational awareness of ED capacities to receive patients. B. The RETAC Prehospital Trauma Triage Algorithm Guidelines should be followed C. The only time an ambulance can be diverted from a hospital is when that hospital is posted on EMResource as being on official ED Divert (RED) or Closed (BLACK) status. D. The following are appropriate reasons for an EMS provider to override ED Divert (RED) and, therefore, deliver a patient to an emergency department that is on ED Divert status: 1. All alerts (trauma, cardiac, stroke, sepsis, etc), cardiac arrests, imminent OB or imminent airway emergencies. 2. Specialty care needs such as pediatric, obstetric, and burn patients 3. If the patient’s condition and/or system constraints do NOT allow transport to a hospital outside of the EMS agency’s service area. 4. EMS providers always have the discretion to override and transport to the closest facility if they determine the patient’s condition warrants. E. There are EMResource notifications that are considered Advisory (YELLOW) or Critical (ORANGE). These notifications are informational only and are intended to inform field personnel that a hospital on an Advisory or Critical status may not be able to optimally care for a patient due to a specific resource limitation (such as Psych, ICU) or overall capacity limitation in the availability of staffed ED beds (ED) F. The following resource limitations may be seen with Advisory (YELLOW) or Critical (ORANGE) and listed in the Comment section of EMResource: 1. ICU (Intensive Care Unit) 4. OR (Operating Room) 2. Psych (Psychiatric) 5. Trauma, Stroke, STEMI 3. OB (Obstetrics) 6. ED (Emergency Department staffed beds) G. Prehospital personnel should take into consideration hospital ED capacity notifications, when possible, considering the patient’s condition, travel time, weather, and system constraints. Patients with specific problems that fall under a specific resource limitation (such as Psych) should be transported to a hospital not experiencing that resource limitation when feasible. EMResource Hospital ED Load Leveling Rotation Board Notifications Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  0090 GENERAL GUIDELINES: EMERGENCY DEPARTMENT ED DIVERT & CAPACITY NOTIFICATIONS (OPEN, ADVISORY, CRITICAL, ED DIVERT, CLOSED) Denver Metro Patient Load Leveling Guideline A. All hospitals and free-standing emergency departments (FSED) are grouped in EMResource by regions. The Denver Metro area consists of North, East, West, South, Central, and Boulder regions. 1. Regional Saturation exists when all hospitals within a region are either on Critical (ORANGE) or ED Divert (RED) status excluding FSED. B. The following guidelines are to be considered when one Denver Metro region experiences Regional Saturation. 1. All Denver Metro dispatch centers track hospital destinations in the EMResource Hospital ED Load Leveling Rotation Board view to establish a real time rolling count of 911 EMS transports to hospitals over a 24-hour period. This would begin at the time of regional saturation to 08:00 the following day, then repeat at 24-hour time intervals until the Critical (ORANGE) and/or ED Divert (RED) regional saturation is resolved. 2. Dispatch centers may restructure facilities on the EMResource Hospital Load Leveling Rotation Board view to accommodate the distribution of patients to hospitals within their geographic area. 3. FSED are not included in hospital destination tracking or the hospital ED load leveling rotation board. However, to decrease the burden on hospitals, EMS providers are encouraged to transport appropriate patients per FSED protocol. 4. The closest appropriate hospital destinations will still apply for patients meeting criteria for overriding ED Divert (RED) as outlined in this protocol. 5. Hospital distribution of stable patients not meeting ED Divert (RED) override criteria are considered in the Hospital ED Load Leveling Board procedure as per EMResource Hospital ED Load Leveling Board Instructions 6. Patients may be transported out of the primary region at the EMS providers discretion, if it is in the patient’s best interest and the EMS system constraints allow. Likewise, EMS providers always have the discretion to override the load leveling board and transport to the closest facility if they determine the patient’s condition warrants. 7. A hospital that experiences a significant infrastructure issue such as loss of power, flooding, etc. preventing the facility from receiving patients, it should be listed as Closed (BLACK) status in EMResource and be exempt from load leveling until functional again. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024  Table of Contents EMResource Hospital ED Load Leveling Board Instructions Purpose: The purpose of the EMResource Hospital ED Load Leveling Board is to ensure timely ambulance destination assignments within a region (zone) and avoiding significant travel distance for an EMS service transporting a patient to hospital. This will ONLY be utilized when ALL HOSPITALS are either on ED Divert (RED) or Critical (ORANGE) within a particular region. Freestanding emergency departments (FSED) will not be used in the rotation nor does this apply to ED advisories and thus will not need to be tracked. Once all hospitals in a region are on ED Divert or Critical, patient transports by EMS will be distributed in an equitable fashion across facilities as determined through the coordination with local dispatch centers, EMS agencies, and hospitals in a region. When the load leveling procedure is activated, EMS patient transports to hospital emergency departments will be tracked on the EMResource Hospital ED Load Leveling Board. The following situations (which exist under all circumstances) remain intact and override load leveling: 1. All alerts (trauma, cardiac, stroke, sepsis, etc.), cardiac arrests, imminent OB or imminent airway emergencies. 2. Specialty care needs such as pediatric, obstetric, and burn patients 3. If the patient’s condition and/or system constraints do NOT allow transport to a hospital outside of the EMS agency’s service area. 4. EMS providers always have the discretion to override and transport to the closest facility if they determine the patient’s condition warrants. Free-standing emergency departments (FSED) should be utilized for transport of all appropriate patients as delineated by agency protocols and local medical direction. After the hospital ED load leveling process is begun, all EMS providers, dispatch centers and Emergency departments should have constant monitoring of the EMResource screen. As per local protocol, the EMS provider may continue to use their current local dispatch centers for communication and patient destination decisions if EMResource is not available on scene. Once Regional Saturation is triggered, the dispatch center will open the EMResource screen under the “view” tab. The EMResource Hospital ED Load Leveling Board will continually and automatically sort facilities within a region and list the “next up hospital” on the top of the list for that region. 1. Once you log into EMResource, click on “View” Click on “View” Hospital ED Load Leveling Board Instructions.docx Page 1 of 3 Created: 03-Dec-2021 Rev: 13-Dec-2021 Table of Contents  Table of Contents EMResource Hospital ED Load Leveling Board Instructions 2. Scroll down the list and find the “Hospital ED Load Leveling” and click. Click on Hospital ED Load Leveling view 3. Find the region that your ambulance is transporting to. The hospital that is eligible for the next patient will automatically be sorted to the top of the list by the Hospital Rotation Board. PSAP/EMS should notify transporting ambulance of “Next Up” status and await ambulance destination decision. Click in the area of the “Hospital Next” Column on the dash (--) or number to assign a patient to the next up hospital. This will bring up the popup box for you to enter the number of patients and any comments, which are optional. Click SAVE. Click in this area, on a number or dash, to enter number when assigning a patient Hospital ED Load Leveling Board Instructions.docx Page 2 of 3 Created: 03-Dec-2021 Rev: 13-Dec-2021 Table of Contents  Table of Contents EMResource Hospital ED Load Leveling Board Instructions 4. The number you enter should be how many patients that are being transferred by that ambulance. So, if the number was a three and you are transferring one patient enter a four. If the number was a five and you are transferring two patients in the ambulance enter the number 7. Comments are not required. Click SAVE to exit. 5. The facility you just entered a number for will go to the bottom of the list. If it was a higher number than the rest, it will stay out of the rest of the rotation. Hospital will drop to bottom of the list. 6. Now it’s time to move on to the next facility in the rotation and complete steps 1 through 5 again. MCI Events – In case a MCI Event occurs, hospitals will be requested to input appropriate numbers for Red, Yellow, and Green patients that they are willing to accept above any Hospital ED Load Leveling in place. Hospitals entering numbers will receive patients. Hospitals may elect to enter zeros (0) depending on their status. After hospitals entering numbers have been exhausted, the ED Load Leveling plan will be utilized for remaining patients Hospital ED Load Leveling Board Instructions.docx Page 3 of 3 Created: 03-Dec-2021 Rev: 13-Dec-2021 Table of Contents  Table of Contents 0100 GENERAL GUIDELINES: MANDATORY REPORTING OF ABUSE PATIENTS Purpose A. To provide guidelines for the reporting of suspected abuse patients. Definition of Abuse and Reporting Requirements: A. Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation OR an act or failure to act which presents an imminent risk of serious harm. B. An at-risk elder or at-risk adult with intellectual and developmental disability per Colorado Revised Statutes §18-6.5-102, or child who are suspected to be victims of abuse, neglect, or exploitation, as defined in Colorado Revised Statutes §19-3-304, should be reported in a manner consistent with agency guidelines/procedures in a timely manner. Any “suspected” or known incident of abuse, neglect, or exploitation must be reported. Types of Abuse: A. Types of maltreatment: 1. neglect (majority of cases) 2. physical abuse 3. sexual abuse 4. emotional abuse 5. exploitation (e.g. sex trafficking) Role of Mandated Reporter: A. A mandatory reporter has reasonable cause to know or suspect that someone has been subjected to abuse, neglect, or exploitation. At time of concern, report the information to the department of human services (DHS) where the patient lives and/or if there is concern that the person is at risk in their own home, and to law enforcement where the crime was committed (follow agency specific guidelines). B. Mandatory reporters that do not report abuse, neglect, or exploitation can be: 1. Charged with a class 3 misdemeanor 2. Liable for damages proximately caused by failing to report What to report: A. The name, address, age, sex, and race of the child, at-risk elder, or at-risk adult with intellectual and developmental disability B. The name(s) and address(es) of the person(s) responsible for the suspected abuse, neglect, or exploitation—if known C. A description of the concern(s) D. The nature and extent of any injuries—if known E. The family composition, including any siblings or others in the household – if known F. The name, address and/or contact phone number, and occupation of the person making the report G. Any other information reporting person feels is important. Additional Information: A. Protecting patient confidentiality does not legally justify a failure to report. B. There is established immunity for reporters “acting in good faith”. C. For children, the Colorado Child Abuse and Neglect Hotline is 1-844-CO-4-KIDS (844-264-5437). Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0110 GENERAL GUIDELINES: FREE-STANDING EMERGENCY DEPARTMENTS AS EMS DESTINATION Purpose A. A freestanding emergency department (FSED) is a facility that is structurally separate and distinct from a hospital and provides emergency care. There are two types of FSEDs: 1. A hospital outpatient department (HOPD), also referred to as an off-site hospital-based or satellite emergency department (ED), these may be either hospital owned or hospital affiliated. 2. The second type of FSED is the independent freestanding emergency centers (IFECs). B. The number of FSEDs is increasing rapidly with an ever-changing regulatory and health care environment. These facilities have various capability and capacity and the range of accepting ambulance patient is also variable. C. For this reason, the appropriate utilization of these facilities as an ambulance destination should be at the discretion of the local agency and agency medical director. Recommendations A. Hemodynamically stable patients may be considered for transport to a hospital-affiliated FSED with the following exceptions: 1. No OB patients > 20 weeks estimated gestational age 2. No trauma patients meeting RETAC trauma center destination guidelines. 3. No alerts (e.g. STEMI, Stroke, Sepsis). 4. No post-cardiac arrest patients with ROSC unless uncontrolled airway B. Give consideration to the fact that elderly patients often require hospitalization for conditions such as falls, generalized weakness, dehydration, syncope. These patients should be targeted for full function hospital to avoid secondary transport C. A psychiatric patient may exceed the capability of the FSED. The facility may not have security available or be able to provide psychiatric evaluation. These patients should be transported to facilities with the capabilities to meet patient’s needs. D. When time and conditions allow, patients whom pre-hospital providers presume to require inpatient management may be transported to a hospital emergency department to avoid subsequent patient transfers. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0120 GENERAL GUIDELINES: BASE CONTACT FOR PHYSICIAN CONSULTATION Purpose A. To explain the DMEMS Medical Directors' expectations regarding base physician contact. General Principles A. “BASE CONTACT” is contact with a physician who is familiar with the protocols. B. The DMEMSMD protocols function as standing order treatment guidelines designed to reflect CDPHE Chapter 2 Rules pertaining to EMS practice and Medical Director oversight. Protocols are to be used as guidelines and cannot account for every patient scenario. Deviation from protocol may at times be justified and in the patient’s best interest. The DMEMSMD place great faith in the training and expertise of our EMS colleagues and therefore wide latitude is granted throughout the protocol. C. Base contact for physician consultation is not the same as emergency department pre- notification of patient arrival and handoff. Base contact may be used in multiple care scenarios including but not limited to forewarning of unstable or complicated patients, patient refusal, and medical consultation and discussion. D. Throughout the protocol patient “BASE CONTACT” is used to signify the need for call in. These algorithm points are set and agreed upon by the DMEMSMD and reflect critical decision points in care where communication with physician support is expected. Preferred Base Contact Times. A. The DMEMSMD group feels strongly that access to medical consultation should be readily available at all times and utilized in the following circumstances: 1. Any time “BASE CONTACT” is required or recommended per protocol. 2. Unusual presentations or patient care situations not addressed in the protocols and outside an area of familiar care by the individual prehospital provider. 3. Necessary deviation from protocol deemed to be in the best interest of the patient. 4. For selected patient care refusals as indicated by General Guidelines: Patient Non- Transport or Refusal. 5. During the care of critically ill patient who is not responding to protocol/ algorithmic treatment. Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 0130 GENERAL GUIDELINES: TRANSPORTATION OF THE PEDIATRIC PATIENT General Principles: For the purpose of the protocols, pediatric patients are defined as 2 years old common causes of wheezing in infants and Bronchiolitis most common Asthma most common children, respectively, you Viral illness characterized by fever, Presentation suggests asthma: should consider pulmonary copious secretions and respiratory wheezing, prolonged expiratory phase, and non-pulmonary causes distress typically seen November decreased breath sounds, accessory of respiratory distress, through April muscle use, known hx of asthma or especially if patient not albuterol use responding as expected to Most important interventions are to provide supplemental oxygen and treatment: suction secretions adequately Examples: pneumonia, In children > 12 months of age with a pulmonary edema, congenital strong family history of asthma, a trial heart disease, anaphylaxis, Give nebulized albuterol + ipratropium pneumothorax, sepsis, of albuterol may be warranted. If May give continuous neb for severe metabolic acidosis (e.g.: DKA, clinically responsive, consider steroids respiratory distress toxic ingestion), foreign body and additional bronchodilators (albuterol + ipratropium) aspiration, and croup. Yes Is response to treatment adequate Administer oxygen to obtain saturations > 90% No Nasal Aspirators Nasal suction with 3 mL saline Nasal aspirators are safe Transport in position of comfort and effective. Monitor SpO2, RR, retractions, mental Severe exacerbation Nasal aspiration with status saline significantly IM epinephrine if no response to neb improves upper and severe distress respiratory tract If worsening respiratory distress despite Start IV symptoms. above therapies, re-suction nostrils and IV methylprednisolone assist ventilations with BVM 20mL/kg NS bolus BLS airway preferred in pediatrics Yes Is response to treatment adequate? IV methylprednisolone No Will help resolve acute asthma exacerbation over hours, without Assess for pneumothorax immediate effect. In severe Assist ventilations with BVM exacerbations, it may be given prehospital but should not be given BLS airway preferred in pediatrics for mild attacks responding well to bronchodilators. IM epinephrine Continue monitoring and assessment Is indicated for the most severe en-route attacks deemed life-threatening and Be prepared to assist ventilations as needed not responding to inhaled Contact Base for medical consult if bronchodilators. deterioration Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 2050 PEDIATRIC STRIDOR/CROUP Characteristics of Croup: Pediatric Universal Respiratory Distress protocol and prepare for immediate EMT AEMT Most common cause of transport stridor in children Child will have stridor, barky cough, and URI EMT-I Paramedic symptoms of sudden, often nocturnal onset Most often seen in children Minimize agitation: Extended Care Supplement < 9 years old Transport in position of comfort, Agitation worsens the interventions only as necessary stridor and respiratory Considerations with distress Stridor: Stridor is a harsh, usually Check SpO2, give oxygen as needed inspiratory sound caused by narrowing or obstruction of the upper airway Causes include croup, foreign body aspiration, allergic reactions, trauma, infection, mass Are symptoms severe and croup most Epiglottitis is exceedingly likely? rare. May consider in the No unimmunized child. Stridor at rest or biphasic stridor Treatment is minimization Severe retractions of agitation. Airway SpO2 < 90% despite O2 manipulation is best done Altered LOC in the hospital. Cyanosis Yes Give nebulized epinephrine If signs of poor perfusion AND/OR hypotension for age, see Medical Shock protocol and begin fluid resuscitation Continue monitoring and assessment en route Contact Base for repeat dose of nebulized epinephrine and medical consult as needed Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 2060 CHF/PULMONARY EDEMA EMT AEMT Universal Respiratory Distress Protocol EMT-I Paramedic CHF/Pulmonary edema Obtain 12 lead ECG: rule out unstable Therapeutic Goals: rhythm, STEMI Maximize oxygenation Decrease work of breathing Identify cardiac ischemia Give nitroglycerin (NTG) (Obtain 12 lead ECG) Special Notes: In general diuretics have little role in initial treatment Yes of acute pulmonary edema Is oxygenation and ventilation and are no longer adequate? considered first line therapy. No Morphine has been associated with worse outcomes in patients with Start CPAP protocol CHF and is no longer indicated Yes Is response to treatment adequate? No If failing above therapy: Remove CPAP and ventilate with BVM Consider pneumothorax Consider alternative diagnoses/complications Consider advanced airway Continue monitoring and assessment Transport Contact base for medical consult as needed Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 2090 TRACHEOSTOMY EMERGENCIES Adult or Pediatric Universal Respiratory Distress Protocol EMT AEMT EMT-I Paramedic Tracheostomy in Place Tracheostomy Removed Attempt repositioning and supplemental oxygen Attempt to replace the tracheostomy tube if trach is mature (at least 6 weeks old) If the tracheostomy tube cannot be inserted easily, withdraw the tube, and attempt to pass a smaller size If gurgling, rhonchi, or mucous present: tracheostomy tube, if available. Preoxygenate with 3-5 BVM breaths If smaller tracheostomy tube is not available, or If inner cannula present, remove while stabilizing cannot be inserted easily, place ETT in stoma if trach tracheostomy flange is mature (at least 6 weeks old) and advance until Measure suction catheter to length of inner cannula balloon is within trachea (generally 3-6 cm) Confirm placement by continuous waveform Instill 1-2 mL saline and suction for ≤10 seconds capnography, presence, and symmetry of breath sounds, and rising SpO2 Replace inner cannula if removed Begin ventilations with supplemental oxygen through tracheostomy If unable to place tube and patient hypoxic or in respiratory distress, begin BVM over nose and mouth If patient still has signs of inadequate oxygenation and and occlude the stoma with a gloved finger. ventilation: Remove tracheostomy, deflating cuff if needed If patient has additional tracheostomy tubes readily If unable to oxygenate or ventilate, attempt to place available, gently insert the same size tracheostomy advanced airway through mouth and occlude stoma with tube with the obturator in place. Do not force the tube. gloved finger. If the tracheostomy tube cannot be inserted easily, Place ETT balloon below level If oral ETI is performed, advance ETTofballoon stoma below withdraw the tube, and attempt to pass a smaller size level of stoma tracheostomy tube, if available. If smaller tracheostomy tube is not available, or cannot be inserted easily, place ETT in stoma if trach is Transport in position of comfort and monitor mature (at least 6 weeks old) and advance until Reassess for signs of deterioration balloon is within trachea Provide oxygen and ventilator support as needed Confirm placement by continuous waveform Contact Base if patient is not improving with treatment capnography, presence, and symmetry of breath sounds, and rising SpO2 Always utilize family members, both for information and for assistance ETT Recommended Sizes – Length Based Types of tracheostomies include cuffed, uncuffed, Color Pink to Blue (Newborn to 50 For most pediatric patients without Upper abdominal pain concerning for signs of shock, no IV is required and ACS pharmacologic pain management Unstable vital signs in the adult patient should be limited Monitor and transport Frequent reassessment for deterioration and response to Elderly Patients: treatment Much more likely to have life- threatening cause of symptoms Shock may be occult, with absent tachycardia in setting of severe hypovolemia Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 4110 SUSPECTED CARBON MONOXIDE EXPOSURE EMT AEMT ABCs EMT-I Paramedic Symptoms of CO, Yes 100% FiO2 hypoxia, and/or pregnancy and transport General Guidelines: No Signs and Symptoms of CO exposure include: Measure COHb% Headache, dizziness, coma, (SpCO) altered mentation, seizures, visual changes, chest pain, tachycardia, arrhythmias, dyspnea, N/V, “flu-like illness” The absence or low readings of COHb is not a reliable predictor SpCO 0-5% SpCO 5-15% SpCO > 15% of toxicity of other fire byproducts In smoke inhalation victims, consider cyanide treatment with hydroxocobalamin as per indications No further Contact Base 100% FIO2 The fetus of a pregnant woman is evaluation of for consult and transport at higher risk due to the greater SpCO is affinity of fetal hemoglobin to CO. needed With CO exposure, the pregnant woman may be asymptomatic while the fetus may be in distress. In general, pregnant patients exposed to CO should be transported. People who smoke may have SpCO of up to 10% baseline COHb Severity Signs and Symptoms 5-20% Mild Headache, nausea, vomiting, dizziness, blurred vision Confusion, syncope, chest pain, dyspnea, tachycardia, tachypnea, 21-40% Moderate weakness Dysrhythmias, hypotension, cardiac ischemia, palpitations, 41-59% Severe respiratory arrest, pulmonary edema, seizures, coma, cardiac arrest >60% Fatal Death Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 4120 ADRENAL INSUFFICIENCY PROTOCOL Patient at risk for adrenal insufficiency EMT AEMT (Addisonian crisis): Identified by family or medical alert bracelet Chronic steroid use Congenital Adrenal Hyperplasia EMT-I Paramedic Addison’s disease Assess for signs of acute adrenal crisis: Chronic corticosteroid use is a common cause Pallor, weakness, lethargy for adrenal crisis, carefully assess for steroid use Vomiting, abdominal pain in patients with unexplained shock. Hypotension, shock Congestive heart failure Administration of steroids are life-saving and necessary for reversing shock or preventing cardiovascular collapse Patients at risk for adrenal insufficiency may All symptomatic patients: show signs of shock when under physiologic Check blood glucose and treat stress which would not lead to cardiovascular hypoglycemia, if present collapse in normal patients. Such triggers may Start IV and give oxygen include trauma, dehydration, infection, If signs of poor perfusion AND/OR myocardial ischemia, etc. hypotension for age, see Medical Shock protocol and begin fluid resuscitation If no corticosteroid is available during transport, notify receiving hospital of need for immediate corticosteroid upon arrival Under Chapter 2 Rule: specialized prescription Give corticosteroid medications to address an acute crisis may be given by all levels with a direct VO, given the route of administration is within the scope of the provider. This applies to giving hydrocortisone for adrenal crisis, for instance, if a patient or family Continue to monitor for development of member has this medication available on scene. hypoglycemia Contact base for direct verbal order Contact base for consult if patient not responding to treatment Monitor 12 lead ECG for signs of hyperkalemia Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 4130 EPISTAXIS MANAGEMENT Active nosebleed EMT AEMT EMT-I Paramedic ABCs General Guidelines: Most nose bleeding is from an anterior source and may be easily controlled, however, may require up to 30 minutes Tilt head forward of constant pressure. Have patient blow Avoid phenylephrine in patients with nose to expel clots known CAD. Anticoagulant/antiplatelet therapies, e.g., aspirin, clopidogrel (Plavix), warfarin (Coumadin), will make Spray each nostril with epistaxis much harder to control. Note phenylephrine if your patient is taking these, or other, Compress nostrils with anticoagulant/antiplatelet medications. clamp or fingers, Posterior epistaxis is a true emergency pinching over fleshy and may require advanced ED part of nose, not bony techniques such as balloon nasal bridge tamponade or interventional radiology. Transport in position Do not delay transport. Be prepared of comfort, usually for potential airway issues. sitting upright For patients on home oxygen via nasal cannula, place the cannula in the patient’s mouth while nares are clamped or compressed for nosebleed. IV access and IV fluid bolus if signs of hypoperfusion, shock Approved by Denver Metro EMS Medical Directors January 1, 2024. Next review July 2024 Table of Contents  Table of Contents 4140 SEPSIS PROTOCOL Evaluate and identify potential sepsis – is there suspected or confirmed infection? EMT AEMT EMT-I Paramedic ABCs Common Infection Sites with Complete set of vital signs Severe Sepsis Monitoring including SpO2 and Respiratory waveform capnography Bacteremia (unspecified site) O2 as appropriate Genitourinary (more prevalent with females) Abdominal Device-related Soft tissue/wound Evaluate potential SIRS Criteria: Central nervous system Temp < 36C (96.8F) or > 38C (100.4F) Endocarditis HR > 90 (or tachycardic for age) RR > 20 or mechanical ventilation (or tachypneic for age) Are there two or more SIRS criteria? No Yes Is there evidence of hypoperfusion? (ANY Routine Care ONE OF THE FOLLOWING): IV, O2, monitor Hypotension for Systolic BP < 90 Consider fluid bolus if sepsis suspected age mmHg No Transport to closest appropriate hospital Altered mental MAP