Okaloosa County EMS ALS/BLS Protocols 10.01.2023 PDF

OCEMS Clinical Protocols, Version 10.01.2023 OKALOOSA COUNTY EMS ALS/BLS PROTOCOLS Version 10.01.2023 Patrick Maddox, Public Safety Director Darrel Welborn, EMS Chief Dr. Christopher Tanner, Medical Director Dr. Todd Bell, Medical Director Back to Table of Contents OCEMS Clinical Protocols, Ver...

OCEMS Clinical Protocols, Version 10.01.2023 OKALOOSA COUNTY EMS ALS/BLS PROTOCOLS Version 10.01.2023 Patrick Maddox, Public Safety Director Darrel Welborn, EMS Chief Dr. Christopher Tanner, Medical Director Dr. Todd Bell, Medical Director Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 EMS Protocol Medical Director Signature Form The attached Emergency Medical Protocols are the official Basic and Advanced Life Support Protocols for the Okaloosa County Department of Public Safety and are approved for use by the EMT’s and Paramedics of Okaloosa County, to care for the sick and injured. Reviewed and Approved: _____________________________________ Christopher Tanner, MD Date: October 1st, 2023 ______________________________________ Todd Bell, MD Date: October 1st, 2023 Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 TABLE OF CONTENTS GENERAL INFORMATION Altered Mental Status Statement of Purpose Diabetic Emergency – Hyperglycemia Authorization Diabetic Emergency – Hypoglycemia System Overview Foreign Body Airway Obstruction Guidelines for Treatment Hypertension “Patient” vs “No Patient” Determination Guidelines Hypotension Patient Consent and Refusals Physicians on Scene Beach Operations OCEMS Transport Destinations Interfacility Transfers Infectious Disease Protocol Tiered Response to 911 Calls Overdose Pain Management Respiratory Distress Sepsis Alert Seizures Sickle Cell Crisis Stroke Violent and/or Impaired Patient Communications CARDIAC EMERGENCIES RAPID SEQUENCE INDUCTION Statement of Purpose Indications Contraindications Procedure Bradycardia Cardiac Arrest Cardiac Arrest Algorithm Chest Pain/STEMI Death Scene Management DNRO (Florida DOH Form 1896) MEDICAL PROTOCOLS General Assessment General Pediatric Rules Abdominal Pain/Problems Acute Pulmonary Edema/CHF Allergic Reactions Back to Table of Contents Field Termination High-Performance CPR Narrow Complex Tachycardia Post-ROSC Ventricular Tachycardia OCEMS Clinical Protocols, Version 10.01.2023 ENVIRONMENTAL/EXPOSURES PHARMACOLOGY Chemical Poisoning Narcotics Guidelines Cold Emergency Medication Log Guidelines Dive Accident and Decompression Sickness Adenosine Drowning Albuterol Heat Emergency Amiodarone Marine Stings/Bites Amiodarone Infusion Smoke Inhalation Aspirin Snake Bites Atropine Calcium Chloride GENERAL TRAUMA Dextrose 10% Trauma Guidelines and Scorecard Diltiazem General Trauma Management Diphenhydramine Abdominal Trauma Dopamine Bleeding and Hemorrhagic Shock Dopamine Infusion Burns Epinephrine Chest Trauma Epinephrine Infusion Crush/Reperfusion Injury Fentanyl Eye Trauma Glucagon Head Trauma Glucose (Oral) Spinal Motion Restriction Ipratropium Bromide Trauma Arrest Ketamine Ketamine Administration Guidelines OBSTETRIC EMERGENCIES Lidocaine Antepartum/3rd Trimester Hemorrhage Magnesium Sulfate Breech Birth Midazolam Newborn Management Naloxone Normal Birth Nitroglycerin Prolapsed Cord Ondansetron Pre-Eclampsia and Eclampsia Sodium Bicarbonate Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 Succinylcholine Common Medical Abbreviations Tranexamic Acid Cricothyrotomy Endotracheal Intubation and Confirmation CRITICAL CARE Facility Capabilities Intent Field Medical Documentation Abbreviations and Terms Glasgow Coma Score Chest Tube Management Accessing Implanted Ports in the Acutely Ill Patient ECMO Hemodynamic Monitoring IAPB Mechanical Ventilation Pulmonary Artery Catheters Transvenous Pacemakers VAD (Impella) VAD (Other) Ventriculostomy Monitoring Intraosseous Access Pediatric Intubation Mucosal Atomization Device (MAD) Nasogastric Tube Insertion Needle Cricothyrotomy Accessing PICC Line or Central Venous Catheters Pleural Decompression Pulse Oximeters START Triage/MCI Operations APPENDICES APGAR Scoring Automatic Transport Ventilators The Baker Act and Related Laws Blood Drawing Procedure and Kit Combat Application Tourniquet (C-A-T) Back to Table of Contents START Flow Chart Taser Dart Treatment Protocol 12-Lead Interpretation King Airways CPAP and Bi-Level CPAP OCEMS Clinical Protocols, Version 10.01.2023 GENERAL INFORMATION Statement of Purpose The intention of protocols in a pre-hospital health care delivery system is to facilitate the rapid dispersal of adequate and acceptable measures aimed at stabilizing the sick and injured. These procedures are written to better define the responsibilities of Okaloosa County Paramedics and EMTs, to decrease the chance of confusion at any emergency scene, and to ensure a coordinated and efficient procedure for treatment and transport of patients to a designated medical facility. These protocols are to be followed as closely as possible on each and every patient encountered by all Paramedics and EMT’s when hospital medical direction is not readily available or impractical based on patient condition. If a Paramedic or EMT encounters a medical or trauma situation not specifically covered by these protocols, the Paramedic should follow the standard of care as outlined in the 1998 United States Department of Transportation Paramedic/EMT curriculum and the current AHA ECC Guidelines. Off-duty Okaloosa County Paramedics and EMTs, governed by the Okaloosa County EMS Medical Director(s), may render care as outlined in these protocols within the geographical boundaries of Okaloosa County unless the paramedic/EMT has responded as a representative for an outside First Responder Fire Department or US Military Firefighter. At times, Okaloosa County paramedics and EMTs are required to respond to scenes in counties other than Okaloosa, including disaster aid responses as required by state or federal agencies and mutual aid responses. Okaloosa County paramedics and EMTs are authorized by the Okaloosa County EMS Medical Director(s) to perform within the scope of the Okaloosa County Standing Orders under these circumstances. This policy applies only to Okaloosa County paramedics and EMTs who are on duty and working for an Okaloosa County EMS agency at the time of the incident. Authorization These Protocols have been developed and circulated for use by Okaloosa County EMS Paramedics and EMTs in the pre-hospital emergency care of the sick and injured under authority granted in Chapter 401 Florida Statutes and 64J Florida Administrative Code. Changes to these protocols can only be made and promulgated by the Okaloosa County Medical Director(s). Certified Paramedics approved by the Okaloosa County Medical Director(s) are the only personnel authorized to perform ALS procedures called for in these protocols, except as authorized by the Okaloosa County Medical Director(s). In order for a State Certified Paramedic or EMT to function within the confines of Okaloosa County, he/she shall comply with the following: 1. Must complete all requirements of the field training program under the objectives type-training program. 2. Shall maintain a current AHA BLS for Health Care Providers card or its equivalent, as approved by Florida Administrative Code CH. 64J. 3. EMT’s shall maintain a current EMT certification issued by the Florida Department of Health, Bureau of Emergency Medical Services. 4. Paramedics shall maintain a current Paramedic certification issued by the Florida Department of Health, Bureau of Emergency Medical Services. 5. Paramedics shall maintain a current AHA ACLS card or its equivalent, as approved by Florida Administrative Code CH. 64J. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 If any of the above regulations are not complied with in full, the paramedic or EMT shall not practice under the auspices of the Okaloosa County EMS Medical Director(s). These protocols are to be used by all levels of certification. However, at no time do these guidelines give any healthcare practitioner permission to perform skills or administer medications outside the scope of practice for his/her designated provider level unless specifically stated in the protocol and granted authorization by the Medical Director(s) and the Florida Department of Health, Bureau of Emergency Medical Services. System Overview The paramedic’s and EMT’s safety along with the patient’s care must remain the most important priority. Teamwork, cooperation, and communication are desired and considered essential to our goals. Okaloosa County EMS shall be responsible for primary response of BLS and/or ALS transport units. EMS personnel shall assume immediate control and initiate an EMS command system as deemed appropriate and as specified in the OCEMS Standard Operating Procedure 429.00. If hazardous conditions exist, the Incident Commander shall take immediate steps to control the hazard and protect the patient(s), Fire Department, and non-Fire Department personnel as deemed appropriate. In mass casualty or mutual aid situations, Okaloosa County Paramedics or EMTs may elect to turn patients over to other agencies. The Paramedic or EMT shall provide the transporting agency with all necessary and available information in a timely manner regarding the patient’s condition and treatment rendered. Upon completion of this interaction, the Paramedic or EMT crews will give any assistance necessary to the transport agency to assure continuity of care; quick, safe, proper loading; and transport to the designated medical facility. Guidelines for Treatment The following general measures shall be applied to help promote speed and efficiency when rendering emergency medical care to the sick and injured. These protocols constitute guidelines for treatment and may be altered at the discretion of the supervising hospital physician, providing those revisions are within the standard practice of emergency care. These protocols are not intended to be a manual on the treatment of all medical emergencies or 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 is supported by current guidelines presented in the following disciplines; AHA, ITLS, PHTLS, NRP. In cases where the application of a protocol is unclear, contact medical control for instructions. Lesser invasive procedures should be attempted prior to higher invasive whenever possible. This includes, but is not limited to, attempting IVs prior to IO access. OCEMS is authorized to utilize other fluids in cases of shortage or other exceptions as approved by Okaloosa County Department of Public Safety, Emergency Medical Services Medical Director(s). Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 The following fluids are authorized for use as a substitute for Normal Saline Intravenous administration: • • • • Lactated Ringers D5 / 0.45% Normal Saline D5W 0.45% Normal Saline (Half Normal Saline) “Patient” or “No Patient” Determination Guidelines This guideline is intended to refer to individual patient contacts. In the event of a multiple party 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 injuries. Adult patients indicating that they do not wish assistance for themselves or dependent minors in such a multiple party incident do not necessarily require documentation as patients. No protocol can anticipate every scenario and providers must use best judgement. When in doubt as to whether an individual is a “patient”, err on the side of caution and perform a full assessment and documentation. Person is a minor (Age < 18 yrs) No Person does not meet “competent” criteria (see below) Yes No Acute illness or injury suspected based on appearance, MOI**, etc No Person has a complaint Yes Yes Individual meets definition of a Patient. If patient/guardian is refusing assessment, treatment, and/or transport, individual and documentation must meet all requirements detailed in the Patient Refusal Protocol No rd 3 party (including LEO) indicates individual is ill, injured, or gravely disabled Yes No Person does not meet definition of a patient and does not require refusal **MOI examples requiring patient refusal include, but are not limited to: Rollover MVC, MVC with intrusion into the passenger compartment, MVC involving pedestrians, motorcycles, or bicycles, falls from height greater than 10 feet for adults. Patient Consent and Refusals When applicable, verbal, informed consent should be obtained prior to treatment and transport. Respect the patient’s right to privacy and dignity. Courtesy, concern, and common sense will assure the patient of the best possible care. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 If, due to the patient’s acute or chronic medical conditions, the patient cannot provide verbal, informed consent, the patient can be treated under implied consent. Likewise, if consent cannot be obtained from a parent or legal guardian for a minor patient, the patient can be treated under implied consent. A patient may refuse treatment and/or transport to the hospital if all of the following conditions are met: 1. The patient is competent to make the decision to refuse (see below for determining competency). 2. A clear explanation is given to the patient (and documented in the PCR) regarding the need for emergency care and transportation and the possible consequences that may develop without medical attention. 3. Efforts to encourage the patient to be transported to the hospital shall also be documented in the PCR. 4. At least two sets of vital signs are obtained and documented. 5. The name of the physician contacted (when contact is necessary per protocol) is documented. 6. For patients who were found to have diabetic symptoms that are resolved after treatment and the patient refuses to be transported, a minimum of two post treatment glucose checks that show the patient’s blood glucose level within normal limits shall be obtained and documented. 7. Instructions to the patient to call 911 and seek medical attention and transport to the hospital if their condition deteriorates or if they change their mind regarding transport are documented. 8. The name of the individual signing the patient refusal, if other than the patient, is included in documentation. 9. Obtain a witness signature from a family member, friend, law enforcement officer, or a firefighter is obtained. As a last resort, a fellow EMS provider should sign as a witness on the refusal form. 10. If the patient refuses to sign the electronic EMS refusal, attempt to obtain the signature from a family member, friend, law enforcement, or fire department personnel. Document the name of the individual who signed for the patient in the patient care report narrative. Competent Individual The following individuals are considered competent to refuse treatment and transport: 1. Is awake, alert, and oriented to person, place, and time. 2. Understands the circumstances of the current situation. 3. Does not appear to be under the influence of alcohol, drugs, or other mind-altering substances, or circumstances that may interfere with mental function. 4. Demonstrates the understanding of the consequences of refusing medical treatment and/or transport. 5. Is not a clear danger to self or others. 6. Is 18 years of age or older, or an emancipated minor. Minor Patient Refusing Care and Transport A minor patient cannot refuse transport without the consent of a parent or legal guardian. If a parent or legal guardian is not present, contact may be made via telephone for permission. Document the parent or legal guardian’s name in the patient care report. Emancipated Minor The following individuals are able to make refusal decisions for themselves, assuming all other requirements listed above are met: 1. A person under the age of 18 who has been granted emancipation by the court. 2. A validly married individual. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 Patient Incapable of Competently Objecting to Treatment and Transport Any patient who is incapable of competently objecting to treatment or transport shall be transported for further evaluation and treatment. Police assistance should be sought, if needed. Patient Refusing Transport after Treatment has been Initiated Patients may refuse further treatment or transport after treatment has been rendered. The patient must be competent to refuse (see definition above). Medical Control should be contacted (over a recorded line) in all cases when a patient has been administered any medications (including oxygen and oral glucose) or other advanced treatment (including IV) by EMS personnel and the patient is refusing transport. Once all attempts at convincing the patient of the need for transport have failed, have the patient sign the refusal form and document appropriately. Transporting a Patient Refusing a Specific Treatment/Procedure Required by Protocol If a patient refuses treatment required by OCEMS protocol, the paramedic or EMT shall: 1. Explain the need for the treatment procedure and possible consequences of not allowing this treatment or procedure and document in the PCR. 2. If the patient continues to refuse the treatment or procedure, have the patient initial the treatment refusal section and sign the Refusal Form on the PCR. 3. Attempt to obtain a witness signature, if possible. Physicians on Scene If the patient, or patient’s family, has contacted the patient’s private physician, extreme tact and courtesy must be used. Your primary concern is the patient. Treatment and or transportation should not be delayed or hindered in order to speak with a private physician. If time is critical, have the family inform the physician to contact the destination hospital. No telephone orders may be taken from any physician other than the Okaloosa County Medical Director(s) or the receiving hospital’s ER Physician, unless so authorized by the Okaloosa County Medical Director(s). For the patient’s physician to give orders regarding treatment and or transport, the physician must be on scene and willing to accompany the patient to the hospital. Should a physician be present at an emergency scene and wish to alter the protocols or supervise the care of a patient, he/she must provide a valid Florida Physician’s License and a current ACLS certification card. The physician must be informed that he/she is taking full responsibility of the patient, must sign all medical reports, and must accompany the patient to the hospital. The receiving hospital should be notified prior to relinquishing control to the physician on scene. Physicians who activate the 911 system for treatment of patients in their office, need not provide proof of licensure nor an ACLS card. These physicians may give orders on their patients, providing those orders do not conflict with these protocols or are otherwise not outside the standard of practice for emergency care. Beach Operations Successful resuscitation of patients in cardiac arrest or systemic compromise must be founded on the positive effects of BLS care. All resuscitation efforts made by Beach Safety and first responding Fire Departments staff should, therefore, be limited to providing good effective BLS, rapidly packaging the Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 patient, and transport. The initial focus will be placed on BLS stabilization and transport off the beach to a staging ambulance close to the scene where effective care can be initiated. Based on the forgoing: 1. Beach responders will ensure that all patients are receiving appropriate and effective BLS care, are appropriately packaged, and are being transported to the staging area within a reasonable time after securing access to the patient. 2. ALS equipped beach responders will bring all ALS equipment to the beach. ALS equipped beach responders will initiate ALS care as indicated by the patient’s condition upon arrival at the staging area where EMS transport has not yet arrived. The Staging point for EMS units on Okaloosa Island will be established by Ocean West Tower or Okaloosa Island Fire Command. Destin Fire Command will assign staging points in Destin. EMS ambulance crews shall remain at their assigned staging areas at the beach access ways and shall not come to the scene on the beach unless otherwise requested by on scene incident command. The patient is better served, and resources are more efficiently used when the EMS ambulance crews prepare at the staging area to receive critical patients while lifeguards and fire department first responders package and transport the patient to them. EMS transport and secondary responders will prepare at the staging area for taking over patient care and transporting to the appropriate facility. OCEMS Transport Destinations All patients should be transported to the nearest appropriate facility, except if the patient or legal guardian insists on transport to a more distant facility, or unless specifically addressed in this protocol. If the patient or legal guardian requests transport to a more distant facility than the closest appropriate facility, the consequences of that decision must be thoroughly explained to all parties involved. All details involved in the decision must be recorded on the Patient Care Report and the patient or guardian is to sign the Bypass Form (located in the Refusal form in the Patient Care Report signature tab). In the event a stable patient is requesting transport outside of Okaloosa County, the on-duty Branch Commander shall be contacted for authorization, unless transport was arranged in advance (SHH-EC is considered within our catchment area). Critically Unstable Patients All critically unstable patients must be transported to the nearest licensed hospital with emergency room services. Examples of Unstable patients (not all-inclusive) include: Hemodynamic instability, non-patent airway, lack of IV/IO access in the presence of severe hypotension, pericardial tamponade, tension pneumothorax not managed by needle decompression, contractions less than 3 minutes apart post rupture of amniotic membranes. Under no circumstances should a critically unstable patient be transported to a hospital that is not the closest qualified facility on the basis of telephone orders from the patient’s private physician. Should the patient’s physician object to the treatment and or transport arrangements made by the paramedic or EMT on scene, simply explain that you are following the protocol and refer the Physician to the Okaloosa County Medical Director(s). Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 STEMI Alert Patients All patients with acute ST Elevation Myocardial Infarction (STEMI) shall be transported to the closest facility capable of percutaneous coronary intervention (PCI) within 10 minutes (North Okaloosa Medical Center, HCA Florida Fort Walton-Destin Hospital, Sacred Heart Hospital on the Emerald Coast). Transport immediately upon recognizing a STEMI. Stroke Alert Patients Patients meeting the “Stroke Alert” criteria as determined by the Stroke Alert Checklist shall be transported to a designated stroke hospital (North Okaloosa Medical Center, HCA Florida Twin Cities Hospital, HCA Florida Fort Walton-Destin Hospital, Destin Emergency Room, Sacred Heart HospitalPensacola, Baptist Hospital, HCA Florida West Hospital). Reference the Stroke Patient Destination Algorithm. Trauma Alert Patients Patients meeting “Trauma Alert” status as per the State of Florida Department of Health Scorecard methodology shall be transported to a State Approved Trauma Center (SATC). Refer to the OCEMS Trauma Transport Protocol. Note: In the event that the closest Trauma Center is on BY-PASS Status, then the patient shall be transported to the next closest SATC. If the extended transport time can potentially cause harm to the patient, the patient shall be transported to an Initial Receiving Hospital. Dive Accident/Decompression Injury Patients All Dive Accident/Decompression Injury patients shall be transported to the closest local facility for stabilization and, if needed, transported via interfacility transfer to a hyperbaric chamber facility for definitive care. Obstetrical (OB) Patients All patients with an estimated gestational age greater than or equal to 20 weeks, regardless of complaint, should go to a hospital with OB care unless they meet trauma, stroke, or STEMI transport criteria. Note: Minor falls can lead to an abruption in 6% of all cases. These patients will need monitoring in Labor and Delivery. All medical concerns will have OB concerns as well. Psychiatric Patients Crew and the patient’s safety are paramount. All psychiatric patients transported to or from any facility should be transported on the stretcher with all stretcher straps applied to ensure the patient's safety. In the instance(s) that the facility requesting transport has more than one patient that is to be taken to the same location, the patients that are not on the stretcher shall be seated on the bench seat with the proper seatbelts applied. Alternative Destination for Medical Detoxification Patients meeting the below criteria can be transported to the Bridgeway Center located at 205 Shell Ave in Fort Walton Beach for outpatient medical detoxification: 1. 2. 3. 4. 5. Have a current pattern of substance abuse or dependence Have used alcohol and/or substance that requires medical detoxification Exhibits Acute intoxication or evidence of active withdrawal symptoms. Must be able to participate in requiring minimum supervision Not aggressive, violent, or suicidal Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 6. Not in acute distress and meet the following vital signs: a. Systolic Blood pressure less than 180 and above 90 mmHg b. Diastolic Blood pressure less than 110 mmHg and above 60 mmHg c. SpO2 greater than 92% d. Heart rate between 50 and 100 bpm e. Respiratory rate between 12 and 24 breaths per minute f. Blood Glucose between 70 and 150 mg/dL g. Normal Mentation for the patient 7. If the person has a developmental or mental disability, the disability should not be such magnitude that they cannot function with minimal supervision. 8. If the patient requires medication for a physical or mental health issue, they must bring their own medications. 9. If there are any questions of appropriateness please contact Bridgeway directly at 850-200-0344 Patients can be transported via ambulance, Bridgeway Center (contact number above), and/or law enforcement. Interfacility 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. 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 lock in place prior to transport. ALS OB Transfers An OB patient will be considered ALS if: 1. 2. 3. 4. 5. 6. 7. Has a medicated IV fluid Requires cardiac monitoring Requires advanced airway Greater than 2 cm of cervical dilation is documented Contractions are less than every 5 minutes apart Amniotic fluid is present Birth is imminent Transfers of Critical Patients from Hospitals and Outpatient Surgical Centers Located Within Facilities with Admitting Capabilities This policy is designed to ensure sufficient information is provided to meet the personnel and equipment needs for interfacility transfer of a critical patient by Okaloosa County Emergency Medical Services (OCEMS). The transferring physician/hospital is responsible for the orders to care for the patient until arrival and transfer of care at the receiving hospital. The OCEMS crew responsible for transport must be familiar with the orders covering the care of the patient during transport and must be capable of providing any care required during transport. The EMS Branch Commander and/or EMS Medical Director(s) will Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 assist in assessing critical patient care needs and coordinating transport needs with facilities prior to patient transport. If, after patient contact, any paramedic feels the critical nature of a patient is beyond the scope of their practice or training, he/she should notify the on-duty branch commander immediately and they should not depart the transferring hospital. For critical patients requiring transfer between facilities which are identified by dispatch: Dispatch will: 1. Notify the facility requesting the patient transfer that the EMS Branch Commander will contact them to discuss patient transfer issues. Dispatch will obtain the responsible medical provider’s contact information. The EMS Branch Commander may be contacted by the transferring facility at 850-585-9173 (South Branch) or 850-826-0351 (North Branch). The EMS Medical Director(s) serves as consultant to the EMS supervisor and the transferring facility. The EMS Medical Director may be contacted at 850-585-6555 (Dr Tanner) or 512-568-2955 (Dr Bell). Interfacility transport of critical patients should not occur prior to consultation with the EMS supervisor and/or Medical Director. 2. Notify the EMS Branch Commander of the request for a critical patient transfer and provide the contact information of the responsible medical provider. 3. Dispatch the closest available unit to the facility with the direction that the unit “stand by to load.” For critical patients requiring transfer between facilities which are not identified by dispatch: 1. 2. 3. 4. Dispatch available unit to the facility with “customary instruction” Paramedic on scene identifies the potential critical nature of the patient transfer. The Paramedic will notify dispatch over the radio of the critical patient transfer. The Paramedic will notify the on-duty Branch Commander of the critical patient transfer and provide relevant information regarding the transport. The EMS Branch Commander will: 1. Review the critical patient information to determine the need for additional resources and the appropriateness for transfer by a ground OCEMS unit. 2. Make recommendations and assist with arrangements for an alternative means of transport if other than OCEMS ground transportation is required. 3. Make recommendations and ask for assistance from the transferring hospital when there is a need for additional resources from their staff or facility, which will be required during the OCEMS transport. 4. Consult with EMS Medical Director(s), if needed. 5. Ensure that the OCEMS crew transporting the patient is familiar with the equipment and orders governing the care of the patient during transport. 6. Advise dispatch that the crew is clear to conduct the transport. The OCEMS Paramedic will: 1. Review the orders governing the care of the patient during the transfer to the receiving facility. 2. Ensure that the required patient care falls within the scope of practice of the paramedic and any ancillary staff that are accompanying the transport crew. 3. Be familiar with any medication and equipment that is required for transport. 4. Confirm receipt of the contact information for the medical provider that is assuming patient care at receiving facility. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 Infectious Disease Protocol At all times, paramedics and EMT’s shall use standardized precautions as outlined in OCEMS SOP 303.00 including the following: 1. Gloves to prevent contact with patient’s body fluid. 2. Appropriate masks and protective eyewear during procedures which are likely to generate droplets of body fluids. 3. Gowns during procedures which are likely to generate splashes of body fluids. 4. Proper disposal of sharps at the point of origin in approved containers only (No recapping of needles). 5. Proper cleaning, disinfecting, and disposing of equipment and supplies. 6. Cleansing of hands thoroughly before and after patient contact and after removal of gloves. “Contact” is defined as blood, blood products, or body fluids coming in contact with intact skin. “Exposure” is defined as blood, blood products, or body fluids coming in contact with non- intact skin. Examples of non-intact skin include lacerations, abrasions, puncture wounds, and needle stick injuries. Exposures may also occur through mucous membranes such as; mouth, eyes, nose, and respiratory tract. If personnel become exposed, follow the procedures listed in the OCEMS SOP 303.00. These procedures include: 1. The contaminated area should be washed thoroughly with an appropriate cleaning solution as soon as possible. 2. The employee(s) who have sustained an exposure shall accompany the source patient to the hospital. 3. Advise the ER Physician that an exposure has occurred and request that the source patient be tested. 4. Advise the on-duty EMS supervisor. 5. Complete all applicable paperwork in a timely manner. Tiered Response to 911 Calls: Patient transport by an Emergency Medical Technician in a Basic Life Support Ambulance The following provisions apply exclusively to the entities operating under the Okaloosa County EMS Medical Protocol (Okaloosa County EMS, North Bay Fire Control District, Destin Fire Control District, Okaloosa Island Fire Control District, Fort Walton Beach Fire Department, and Ocean City – Wright Fire Control District). A patient may be treated, transported, and attended by an emergency medical technician at the basic life support level of care if, upon initial assessment it is determined that the patient is: 1. conscious and alert per their baseline 2. all vital signs are stable 3. peripheral intravenous or intraosseous therapy is not required for medication administration or fluid resuscitation Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 A patient must be attended to by a paramedic during transport when, in the clinical judgement of the assessing healthcare provider, the patient requires continuous advanced life support monitoring and/or treatment. If a patient being transported at the basic life support level of care and attended by an emergency medical technician becomes unconscious, has a change in mental status, or becomes unstable, a paramedic will immediately be requested for intercept. The basic life support unit will not delay continuous transportation and will coordinate appropriate initial receiving facility notification and rendezvous with intercepting unit. For a patient that has been examined at the advanced life support level by a paramedic – cardiac monitoring or other advanced life support exam – where the findings are normal or unremarkable in relation to the patient’s overall clinical presentation, and the patient is otherwise determined to be stable, patient care can be turned over to an emergency medical technician for transport to the closest appropriate facility at the basic life support level of care. A patient may be attended by an emergency medical technician when, in the clinical judgement of the assessing healthcare provider, the patient does not require continuous advanced life support monitoring and/or treatment. A critically ill or injured patient requiring immediate advanced life support transport and/or immediate paramedic care to prevent loss of life, and in the absence of an OCEMS advanced life support ambulance, may, at the discretion of the responding Fire Company Officer, be transported to the closest appropriate facility in a basic life support ambulance under the direct care of an advanced life support fire department paramedic. In any such circumstances, the Fire Department paramedic may use either the advanced life support equipment provided in the responding ambulance or the organic advanced life support equipment from the fire apparatus to conduct patient monitoring and provide care. Communications Medical communications are to be established via radio or telephone (via Dispatch patch) with the appropriate facility as soon as possible into the call. Contact can be made during or after the appropriate protocol has been initiated. Orders can only be given by the receiving facility’s ER physician or the Okaloosa County Medical Director(s). Should one of these physician’s give additional orders, the physician's name should be documented on the PCR. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 RAPID SEQUENCE INDUCTION Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 Statement of Purpose The intention of these RSI Protocols in a pre-hospital health care delivery system is to facilitate the rapid airway management in the critical patient. This RSI procedure shall only be utilized when other less invasive airway management techniques have failed or are impractical. Authorization These RSI protocols have been developed and circulated for use by Paramedics in the pre-hospital emergency care of the sick or injured, under authority granted in Chapter 401 Florida Statutes, and 64 J Florida Administrative Code. Changes to these RSI protocols can only be made and promulgated by the Okaloosa County Medical Director(s). These protocols are to be followed as closely as possible on each and every patient who is a candidate for Rapid Sequence Induction. Paralytic Medication Expirations Liquid paralytic agents should be discarded 2 weeks after removal from refrigeration or anytime discoloration or particulate material is noted. The 2-week expiration date should be calculated from the day it was removed from refrigeration and handwritten onto the vial. Indications for RSI 1. 2. 3. 4. 5. Seizure/Convulsive Disorders Multi-System Trauma Head Injury (GCS of 8 or less) Trismus (Lock-jaw) or Clenched teeth Burn Injuries to the Upper Airway Contraindications for RSI Absolute 1. Limited vocal cord visualization due to major facial/laryngeal trauma 2. Patients that cannot be ventilated with a BVM (or some other means) due to trauma or anatomical reasons Relative 1. 2. 3. 4. 5. Excessive weight Mallampati Class of III or IV C-Spine immobilization concerns Large incisors or “Buck Teeth” Thyromental distance (distance from the bottom of the chin to the top of the thyroid cartilage) less than 3 finger widths Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 RSI Procedure 1. Rule out contraindications and anticipate the difficult intubation 2. Prepare intubation equipment, have back-up airway such as the supraglottic airway and cricothyrotomy equipment ready 3. Pre-oxygenate the patient with 100% O2 for at least 2 minutes a. NRB mask is preferred method b. If rate, volume, and/or effort indicate ventilation using the BVM, ensure ventilations are not forceful (causing oxygen to be forced into the stomach) 4. Monitor and record an EKG strip, SpO2, and EtCO2 5. Consider pre-medications for the following circumstances: a. If Bradycardia exists, administer Atropine 1 mg IV/IO, up to 3 mg total until heart rate raises to a normal rate b. If pediatric (less than 16) and Bradycardia exists, administer Atropine 0.02 mg/kg IV/IO (up to 1.0 mg per dose; up to 3 mg total) until heart rate raises to a normal rate 6. Administer Ketamine 1.5 mg/kg (adult and pediatric) IV/IO for sedation a. When given via IV/IO, Ketamine should be drawn up in a 10 mL syringe and diluted with NS to a full 10 mL volume. The Ketamine should then be administered over at least 1-2 minutes, to prevent laryngospasm and other adverse reactions b. Allow medication to take effect (approx. 2 minutes) 7. After Ketamine has taken effect, administer Succinylcholine 1.5 mg/kg (pediatric 2.0 mg/kg) IV/IO 8. After approx. 2 minutes and the Succinylcholine has taken effect, perform the intubation a. If unable to intubate after 3 total attempts, ventilate with the BVM. Then, secure the airway with a back-up device (Supraglottic Airway Device or cricothyrotomy). b. Paramedics can forgo intubation attempts for patients with multisystem trauma and immediately secure the airway with the Supraglottic Airway Device (unless contraindications for the Supraglottic airway device exist). 9. Confirm the airway is secured with auscultation and continuous waveform capnography 10. Secure the airway device in place with a commercial tube holder noting the depth of the tube at the teeth 11. Ventilate the patient to maintain EtCO2 between 35-45mmHg 12. To maintain sedation, administer Ketamine 1.5 mg/kg (adult and pediatric) IV/IO every 10 minutes as needed. a. When given via IV/IO, Ketamine should be drawn up in a 10 mL syringe and diluted with NS to a full 10 mL volume. Ketamine should then be administered over at least 1-2 minutes. 13. Continue to monitor the patient including the pain level and level of sedation. Treat as indicated. Confirm airway patency every time the patient is moved using auscultation and continuous waveform capnography. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 MEDICAL EMERGENCIES Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 GENERAL ASSESSMENT Initial Assessment The initial assessment is utilized to assess life-threatening situations. The Initial Assessment and appropriate therapy should be completed immediately and efficiently upon reaching the patient. The Paramedic will decide if Advanced Life Support measures are warranted. When appropriate, stabilizing therapy (i.e., cervical spine immobilization) should be instituted simultaneously with the survey. The EMT/Paramedic should complete the Initial Assessment within 60 seconds. 1. General Impression: note the patient’s approximate age, gender, weight, activity, position, obvious injuries/distress, and general appearance. 2. Level of Consciousness: utilize the AVPU pneumonic (Alert, Responds to Verbal stimuli, responds to Painful stimuli, and Unresponsive). 3. Airway: Establish and maintain a patent airway. a. If necessary, utilize appropriate devices to maintain the airway: suctioning, OPA, NPA, ETT, and supraglottic airway device. b. If the patient’s airway cannot be secured by a less invasive means, ALS provider should secure it using a surgical cricothyrotomy for adults or needle cricothyrotomy for pediatric patients less than 8 years old or less than 50 kg. c. If airway obstruction is found, proceed to Foreign Body Airway Obstruction protocol 4. Breathing: determine the rate and quality of respirations. Look, listen, and feel for air movement, and auscultate lung sounds. a. If inadequate respiratory effort it found, immediately support the patient’s respirations with positive pressure ventilations using a BVM with 100% supplemental oxygen, PEEP set to 5 cm H2O, and evaluate for underlying cause. b. If necessary to assist with respirations for more than one minute, consider securing the patient’s airway with an ET tube or supraglottic airway device. i. The Supraglottic Airway Device shall be used after 3 initial attempts at intubation are unsuccessful, when indicated as a first line treatment to secure the airway (specified by protocol), or to secure the airway of a patient by a BLS provider. Once placed, it should be left in place unless it becomes displaced. ii. Medications may not be administered via a supraglottic airway device. iii. If airway is secured with an advanced airway device, verify the patency of the adjunct via auscultation of breath sounds and EtCO2 waveform capnography. c. Apply oxygen as indicated to keep patient’s SpO2 level at 94% or greater. d. If the patient’s SpO2 level does not rise to 94% or greater despite the administration of 100% oxygen, then the PEEP can be increased to a maximum of 15 cm H2O. 5. Circulation: assess carotid, femoral, and radial pulses as indicated. If pulseless, perform CPR and proceed to the Cardiac Arrest Protocol. a. Check skin for pallor, diaphoresis, and capillary refill. b. Check neck for jugular vein distention. 6. Hemorrhage: control hemorrhage as appropriate. Perform this step first if exsanguinating hemorrhage is suspected. Baseline Vital Signs Respiratory rate and effort, pulse rate and quality, skin color/temperature, blood pressure (first should be obtained using manual cuff), Glasgow Coma Scale (GCS), blood glucose level (if indicated), pain score, Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 SpO2 level (obtain and record a room air saturation, but do not withhold oxygen to a patient in respiratory distress to obtain a room air saturation). Vital signs should be monitored and recorded frequently on all patients during transport (about every 10 minutes for stable patients and about every 5 minutes for unstable patients). All transported patients shall have at least two sets of vital signs taken and documented. Rapid Trauma Scan and take a quick survey of the patient’s entire body for any critical problems. Expose the head, neck, chest, abdomen, and pelvis to look for significant hemorrhage, respiratory compromise, and other lifethreatening injuries in the trauma patient. For isolated injuries, a focused exam shall be performed on the specific areas. For multi-system trauma and altered mentation, a Rapid Trauma Survey and Detailed exam shall be completed. Detailed Exam The Detailed Exam occurs after the initial assessment has been completed and appropriate action has been taken. It is a complete examination designed to check for specific, although not necessarily lifethreatening injuries. The Detailed Exam can be performed in conjunction with the Initial Assessment or when appropriate throughout patient treatment. The Paramedic should perform and/or check for the following; Utilize SAMPLE and OPQRST to obtain patient history and the history of the present illness/injury. Head-to-Toe Survey Evaluate the entire patient for DCAP-BTLS-IC-PMS (Deformities, contusions, abrasions, penetrations, burns, lacerations, swelling, tenderness, instability, crepitus, pulse, motor, and sensory). Perform the following targeted assessments: 1. Head: Battle’s sign, periorbital ecchymosis, hyphema, pupils, CSF from nose or ears, mouth for broken teeth, dentures, breath odor 2. Neck: Stair-stepping in C1-C7, JVD, Tracheal Deviation 3. Shoulders: Subcutaneous emphysema, nitro patch/paste, pacemaker 4. Chest: Lung sounds, paradoxical movement, heart tones, scars 5. Abdomen: Guarding, rigidity, masses, non-traumatic ecchymosis, palpate all 4 quadrants 6. Hips and Pelvis: Incontinence, priapism a. Do not rock the pelvis 7. Legs: Shortening or rotation, edema of the ankles 8. Arms: Needle tracks, medical alert bracelets, dialysis shunt Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 GENERAL PEDIATRIC GUIDELINES 1. Pediatric cardiac dysrhythmias are usually caused by extra cardiac factors such as hypoxia, hypercarbia, acidosis, or shock. 2. Heart rates may give clues to the problem, (i.e., bradycardia could be an indication of an airway problem. Tachycardia would indicate hypovolemia, through dehydration and/or trauma). 3. Treat the underlying causes. 4. Infants and children less than 8 years old or under 50 kg presenting with serious or lifethreatening medical problems should be transported to the closest appropriate facility. 5. The Handtevy system should be utilized in appropriate situations, as rapidly as possible, for accurate treatment of the pediatric patient. The patient’s age should be used to estimate the patient’s ideal body weight. The Handtevy length-based tape can be used to estimate the appropriate age if the age is unknown or if the patient appears to be larger or smaller than other patients of the same age. 6. If available, pulse oximeters should be utilized on all pediatric patients in distress. 7. Blood glucose testing should be performed on all pediatric patients in distress, and treated as indicated. 8. If intubation is required, utilize an appropriate CO2 monitor. 9. Pediatric patients who do not respond to standard treatment should be evaluated and treated for: a. Hypovolemia b. Hypoxia c. Hypothermia d. Hypoglycemia e. Hydrogen Ion (Acidosis) f. Hypo-/Hyperkalemia g. Hypothermia h. Toxins (Drug Overdose) i. Tamponade (Cardiac) j. Thrombosis (Coronary or Pulmonary) k. Trauma l. Tension Pneumothorax. 10. For children showing signs of shock, (i.e., decreased LOC, pallor, mottling, poor distal perfusion, and/or delayed capillary refill), treat with airway management and oxygenation, and obtain vascular access. Administer fluid bolus at 20 mL/kg. 11. Always contact the receiving facility for further orders. 12. Remember, children are not small adults. They will compensate much longer, but when they decompensate, they do so quickly. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 ABDOMINAL PAIN/PROBLEMS BLS/General Care 1. Perform General Assessment. 2. Monitor the patient’s SpO2 level and administer supplemental oxygen to maintain an SpO2 reading above or equal to 94%. 3. Perform detailed secondary assessment. 4. Place the patient in a position of comfort and obtain a complete history, including obstetric concerns for female patients. 5. Evaluate the patient’s blood glucose level and treat as appropriate. 6. Obtain a 12-lead, if indicated. ALS Care: 1. 2. 3. 4. Monitor and record a 4-lead EKG. Interpret 12-lead if indicated. Obtain IV access with Normal Saline at a KVO rate and administer fluids as needed. If nausea or vomiting is present, administer antiemetic a. Adult: Ondansetron 4 mg IV/IO/IM/SL b. Pediatric: Ondansetron 0.1mg/kg IV/IO/IM up to 4mg 5. Provide pain management per the Pain Management Protocol. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 ACUTE PULMONARY EDEMA/CHF BLS/General Care 1. Perform General Assessment. 2. Monitor the patient’s SpO2 level, EtCO2, and administer supplemental oxygen to maintain an SpO2 reading above or equal to 94%. a. Consider application of CPAP/Bi-Level CPAP and titrate pressure as tolerated. If the patient will not tolerate CPAP/Bi-Level CPAP or displays contraindications for the intervention, apply supplemental O2 via NRB mask at a rate of 10-15 LPM. b. Document SpO2 readings pre- and post-interventions via pulse oximeter. 3. Be prepared to suction and utilize BVM ventilations, as needed. 4. Perform detailed secondary assessment when appropriate. 5. Obtain a 12-lead EKG, if possible. 6. Evaluate the patient’s blood glucose level and treat appropriately. 7. Consider ALS intercept ALS Care 1. If signs and symptoms of cardiogenic shock are present, reference Hypotension protocol. 2. Consider RSI in the case of hypotension, altered level of consciousness, and/or failure of CPAP/Bi-Level CPAP interventions. 3. Place patient in a seated position with legs dependent (lower than the upper body). 4. Monitor and record a 4-lead EKG. Interpret 12-lead EKG. 5. Initiate IV access with Normal Saline at a KVO rate. 6. Administer Nitroglycerin, 0.4 mg SL, repeating every 3-5 minutes until 3 total doses have been administered or patient’s symptoms resolve. a. Do not administer this medication to patients displaying bradycardia/tachycardia, hypotension, or recent use of erectile dysfunction medications (i.e. Viagra, Levitra, Cialis, etc.). 7. Contract Medical Control for further orders. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 ALLERGIC REACTION BLS/General Care 1. Perform General Assessment. 2. If transport is feasible, rapidly transport patient to the closest appropriate medical facility and consider ALS intercept. 3. Monitor the patient’s SpO2 level and administer supplemental oxygen to maintain an SpO2 reading above or equal to 94%. 4. Perform detailed secondary assessment when appropriate. 5. For insect bites, remove any stinger still in place with a scraping motion; do not pinch stingers with tweezers. 6. If patient exhibits respiratory distress: a. Adults and Pediatric Patients greater than or equal to 30 kg: administer Epinephrine 1:1,000, 0.3 mg IM via an auto-injection device (i.e. EpiPen) b. Pediatric Patients less than 30 kg: administer Epinephrine 1:1,000, 0.15 mg IM via an auto-injection device (i.e. EpiPen Jr.) 7. If signs and symptoms of anaphylaxis and hypotension persist following the first dose of epinephrine, and additional dose of IM epinephrine via auto-injection device may be repeated once at the doses and routes noted in Step 6. ALS Care 1. Monitor and record a 4-lead EKG. For generalized allergic reactions characterized by urticaria, administer: a. Adult: Diphenhydramine, 50 mg IM/slow IVP b. Pediatric: Diphenhydramine, 2 mg/kg IO/IM/slow IVP up to 50 mg For generalized allergic reactions characterized by hypotension (systolic greater than 100), respiratory distress, auscultated wheezing, and/or edema of the tongue, administer a. Adults: Epinephrine 1:1,000, 0.3 mg IM, followed by Diphenhydramine, 50 mg IM/IV/IO if not already administered. b. Pediatric: Epinephrine 1:1,000, 0.01 mg/kg IM up to 0.3 mg. Follow dose with Diphenhydramine, 2 mg/kg IM/IV/IO, up to 50 mg, if not already administered. c. Administer fluids to maintain adequate peripheral perfusion as needed. In severe anaphylactic shock where cardiac arrest is imminent and BP is unobtainable, administer: a. Adults: Epinephrine 1:10,000, 0.3 mg slow IV/IO push, followed by Diphenhydramine, 50 mg IM/IV/IO, if not already administered. b. Pediatrics: Epinephrine 1:1,000, 0.01 mg/kg slow IV/IO push. Follow with Diphenhydramine, 2 mg/kg IM/IV/IO, up to 50 mg, if not already administered. c. Epinephrine may be re-administered every 10-15 minutes, as needed. d. Contact medical control for further orders. If patient exhibits signs and symptoms of respiratory distress, consider: a. Adult: nebulized Albuterol, 2.5 mg/3 mL NaCl b. Pediatric: nebulized Albuterol, 1.25 mg/3mL NaCl Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 ALTERED MENTAL STATUS BLS/General Care 1. Perform General Assessment. 2. Monitor the patient’s SpO2 level and administer supplemental oxygen to maintain an SpO2 reading above or equal to 94%. 3. Suction and assist ventilations as needed. 4. If opioid overdose is suspected and respiratory compromise is present administer: a. Adult: Naloxone, 1 mg IN b. Pediatric: Naloxone, 0.2 mg/kg IN c. May be repeated every 2-3 minutes X 2 d. Titrate to respiratory improvement 5. Check patient’s blood glucose level and treat as appropriate. 6. Perform detailed secondary assessment when appropriate. 7. Obtain a 12-lead EKG if appropriate. 8. Consider potential stroke. Reference Stroke Protocol ALS Care 1. Monitor and record a 4-lead EKG and interpret 12-lead EKG if appropriate. 2. Initiate IV access with Normal Saline at a KVO rate. 3. If opioid overdose is suspected and respiratory compromise is present, administer: a. Adults: Naloxone, 0.5 mg IV/IM or 1 mg IN titrate to respiratory improvement. Doses may be repeated every 2-3 minutes for IV/IN administration and 10 minutes for IM, not to exceed a maximum of 10 mg. b. Pediatric: Naloxone, 0.1 mg/kg IV/IO/IM/IN titrate to respiratory improvement. Doses may repeat every 2-3 minutes for IV/IN administration and 10 minutes for IM, not to exceed a maximum of 4 mg. 4. Contact medical control for further orders. Note: The Primary treatment of acute narcotic overdose is airway control. Narcan should not routinely be given if the patient’s respirations are not compromised. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 DIABETIC EMERGENCY – HYPERGLYCEMIA BLS/General Care 1. Perform General Assessment. 2. Perform detailed exam when appropriate. Assess for rapid/deep respirations, warm and dry skin, dry mucus membranes, abdominal pain, fruity/acetone odor on breath. If present, suspect DKA. 3. Administer supplemental oxygen as indicated. 4. Obtain a 12 lead EKG, if time permits. 5. Check blood glucose level via Glucometer, and document on the Patient Care Report. ALS Care 1. Initiate an IV Normal Saline at KVO rate. a. Adult: If blood glucose greater than or equal to 300 mg/dl, administer 500 mL Normal Saline if no pulmonary edema noted. Repeat as needed. b. Pediatric: Not routinely encountered. Contact Medical Control for further orders. 2. Monitor and record an EKG strip. 3. Check blood glucose after administration of fluids and document appropriately. 4. Contact Medical Control for further orders. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 DIABETIC EMERGENCY – HYPOGLYCEMIA BLS/General Care 1. Perform General Assessment. 2. Monitor the patient’s SpO2 level and administer supplemental oxygen to maintain an SpO2 reading above or equal to 94%. 3. Check blood glucose level. 4. Perform detailed secondary assessment, patient history, and vital signs. 5. If patient is hypoglycemic with a BGL less than 60 mg/dL with related symptoms and is able to swallow and manage their own airway, administer Oral Glucose, 15 g PO. ALS Care 1. Monitor and record a 4-lead EKG; obtain a 12-lead EKG if appropriate. 2. Initiate IV access with Normal Saline at a KVO rate. a. Ensure IV patency prior to administering D10. 3. If patient is hypoglycemic with a BGL less than 60 mg/dL with related symptoms and is unable to follow direction, swallow, or manage their own airway, administer: a. Adult: D10, 100 mL IV/IO. b. Pediatric: D10, 5-10 mL/kg IV/IO 4. Reassess BGL and document appropriately. If patient’s BGL remains less than 60 mg/dL after two minutes, repeat dose of D10. 5. If IV access is unobtainable, administer: a. Adult: Glucagon, 1 mg IM or 3 mg IN b. Pediatric (over 20 kg): Glucagon, 1 mg IM c. Pediatric (under 20 kg): Glucagon, 0.5 mg IM 6. If there is no response and there is a high index of suspicion for acute overdose, refer to the Overdose Protocol. 7. Contact medical control for further orders. Back to Table of Contents OCEMS Clinical Protocols, Version 10.01.2023 FOREIGN BODY AIRWAY OBSTRUCTION Note: EMT’s and Paramedics shall follow all current AHA guidelines for foreign body airway obstruction relief Partial Airway Obstruction BLS/General Care 1. 2. 3. 4. 5. Keep patient in position of comfort. Keep patient calm. Monitor SpO2 level, apply supplemental oxygen as indicated. Suction airway (if possible or needed). Proceed to Complete Airway Obstruction if obstruction completely blocks airway. Complete Airway Obstruction in Conscious Adult or Child Patient BLS/General Care 1. Perform abdominal thrusts until the obstruction is dislodged or the patient becomes unconscious. 2. If unable to perform abdominal thrusts due to pregnancy or the patient’s size, perform chest thrusts until the obstruction is dislodged or the patient becomes unconscious. Complete Airway Obstruction in Conscious Infant Patient BLS/General Care 1. Hold the infant facedown with the head slightly lower than the chest. Support the infant’s head and jaw with your hand taking care to avoid compressing the soft tissues