OCEMS ALS Protocol v01_16_2023.pdf

Advanced Life Support Protocols EMERGENCY MEDICAL SERVICES 01.16.2023 Patrick Maddox, Public Safety Director Darrel Welborn, EMS Chief Dr. Christopher Tanner, Medical Director Dr. Todd Bell, Medical Director 01.16.2023 Okaloosa County Emergency Medical Services EMS Protocol Medical Director Si...

Advanced Life Support Protocols EMERGENCY MEDICAL SERVICES 01.16.2023 Patrick Maddox, Public Safety Director Darrel Welborn, EMS Chief Dr. Christopher Tanner, Medical Director Dr. Todd Bell, Medical Director 01.16.2023 Okaloosa County Emergency Medical Services EMS Protocol Medical Director Signature Form The attached Emergency Medical Protocols are the official Advanced Life Support Protocols for the Okaloosa County Department of Public Safety and are approved for use by the Paramedics of Okaloosa County, to care for the sick and injured. Reviewed & Approved : ________________________________ Date : ______________________________ Date : ______________________________ Christopher Tanner, MD ________________________________ Todd Bell, MD Authorization Signature Form I. General Information: 1-21 Edition: 01.16.2023 II. RSI Procedure: 22-26 Okaloosa County Dept. of Public Safety 90 College Blvd East III. Medical Emergencies: 27-58 Niceville, Florida 32578 850-651-7150 www.myokaloosa.com IV. Toxic Chemical: 58-66 V. Trauma: 67-83 VI. Environmental: 84-88 VII. Obstetrical: 89-96 VIII. Pediatrics: 97-113 EMERGENCY MEDICAL SERVICES IX. Pharmacology: 114-126 X. Critical Care Transport: 127-142 XI. Appendix: 143-174 01.16.2023 OKALOOSA COUNTY EMERGENCY MEDICAL GUIDELINES 01.16.2023 Table of Contents I) General Information: Statement Of Purpose and Authorization: 1 Guidelines For Treatment: 2 - 5 Consent: 2 Blood Drawing Procedure: 4 DNRO and System Overview: 5 Patient Refusals: 6-8 Beach Operations: 9 Transport Destinations: 10 Interfacility Transfer of Critical Patients: 11-14 Infectious Disease Protocol: 15-16 General Patient Assessment: 17-19 Airway Maintenance: 20-21 Tiered Response & Transport: 21a II) Rapid Sequence Induction: 22-26 III) Medical Emergencies: Abdominal Pain/ Nausea, Vomiting, Diarrhea: 27 Acute Pulmonary Edema/CHF: 28 Allergic Reactions: 31 Altered Mental Status: 32 Asystole: 33 Bradycardia- Stable : 34 Bradycardia- Unstable: 35 Cardiac (STEMI) Alert and 12-Lead EKG Indication: 36 01.16.2023 Table of Contents III) Medical Emergencies Continued IV)Toxic Chemical/Gas Exposure: Cardiac Arrest: 37 Carbon Monoxide Poisoning/ Hydrofluoric Acid: 59 Chest Pain: 38 Chlorine/Chloramine: 61 Hazardous Materials Classification System: 62 CPAP: 39 Diabetic Emergencies: 40-41 Hypertension: 42 Hypotension: 43 Overdose: 44 Overdose-Cocaine: 45 Pain Management (Adult): 46 PEA: 47 Respiratory Distress: 48 Sepsis Alert: 48a Seizure: 49 Sickle Cell Crisis: 49a Stroke: 50-52 SVT- Stable : 53 SVT- Unstable: 54 V-Fib/ Pulseless V-Tach: 55 V-Tach- Stable : 56 V-Tach- Unstable : 57 Violent and/or Impaired Patient : 58 Organophosphate: 63 Smoke Inhalation: 64-65 WMD Awareness Level (Chemical Bioterrorist Agents): 66 V) General Trauma Protocol: Definitions/Trauma Arrest: 67 Management Sequence: 68 Transport Guidelines/ Criteria: 69 Adult Scorecard: 70 Pediatric Scorecard: 71 Guidelines Continued/ By-pass status: 72 Abdominal/Head Injury: 73 Bleeding and Hemorrhagic Shock Burn Classification/ Chart: 74-77 Chest Trauma: 78 Crush Injuries: 79 Eye Emergencies: 80 Spinal Motion Restriction: 81-82 Trauma Arrest: 83 01.16.2023 Table Of Contents VI) Environmental Emergencies: VIII) Pediatric Medical Emergencies: Dive Accident/Submersion Injury: 84 General Rules: 97 Drowning/Near Drowning: 85 Normal Vital Sign Chart: 98 Heat and Cold related emergencies: 86 Abdominal Pain: 99 Marine Stings: 87 Allergic Reaction: 100 Snake Bite: 88 Altered Mental Status: 101 VII) Obstetric Emergencies: Ante partum/3rd Trimester Bleeding: 89 Breech Birth: 90 New Born Management: 91 Infant Resuscitation Chart: 92 Normal Delivery: 93-94 Prolapsed Cord: 95 Toxemia: 96 Asystole: 102 Bradycardia: 103 Croup/ Epiglottitis: 104 Overdose: 105 Pain Management: 106 Respiratory Distress: 107 Seizures: 108 Shock: 109-110 SVT: 111 V-Fib/ Pulseless V-Tach: 112 V-Tach with Pulses: 113 Violent &/or Impaired- Pediatrics 113a 01.16.2023 Table Of Contents IX) Pharmacology: Adult Medication Dosages/Packaging: 114-116 Pediatric Medication Dosages/ Packaging: 117-118 Amiodarone Infusion: 119 Cardizem Infusion: 120 Dopamine Infusion: 121 Epinephrine Infusion: 122 Ketamine Administration Guidelines: 123 Medication Log: 124-125 “Rave Drugs” : 126 X) Critical Care Transport: Intent: 128 Abbreviations and Terms: 129 Blood & Blood Products: 130 Chest Tube Management: 131 Extracorporeal Membrane Oxygenation (ECMO): 132 Hemodynamic Monitoring: 133 Intra-Aortic Balloon Pump (IABP): 134 Mechanical Ventilation: 135 Pulmonary Artery Catheter: 136 Respiratory Insufficiency: 137 Stroke/ CVA/ TIA: 138 Transvenous Pacemaker: 139 Ventricular Assist Device (Impella): 140 Ventricular Assist Device (all others): 141 Ventriculostomy Monitoring: 142 XI) Appendix: Appendix (A) APGAR Scoring Table: 143 Appendix (B) Automatic Transport Ventilators: 144 Appendix (C) Baker Act/Related Laws: 145 Appendix (D) Law Enforcement Blood Drawing Kit: 146 Appendix (E) Combat Application Tourniquet: 147 Appendix (F) Common Medical Abbreviations: 148-149 Appendix (G) Cricothyrotomy: 150 Appendix (H) DNRO Form: 151-152 Appendix (I) ETT Confirmation Adjuncts: 153 Appendix (J) Field Medical Documentation: 154 Appendix (K) Field Termination: 155 Appendix (L) Glasgow Coma Score (GCS): 156 Appendix (M) Port Access Procedures: 157 Appendix (N) Initiation/Discontinuation of CPR: 158-159 Appendix (O) Pediatric Intubation: 160 Appendix (P) MAD: Mucosal Atomization Device: 161 Appendix (Q) Nasogastric Tube insertion: 162 Appendix (R) Needle Cricothyrotomy: 163 Appendix (S) PICC Line Access: 164 Appendix (T) Pleural Decompression: 165 Appendix (U) Pulse Oximeters: 166 Appendix (V) START Triage/ Pediatric “Jump START” quick reference: 167-169 Appendix (W) Taser Dart Treatment Protocol: 170 Appendix (X) 12-Lead Interpretation/ Placement: 171-172 Appendix (AA) King Airway: 173 Appendix (BB) Hepatitis A Vaccination Procedure: 174 01.16.2023 I. General Information 01.16.2023 I. General Information Statement Of Purpose The intention of Advanced Life Support 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, to decrease the chance of confusion at any emergency scene and to ensure a coordinated and efficient procedure for treatment and transport to a designated medical facility. These protocols are to be followed as closely as possible on each and every patient encountered by all Paramedics when hospital medical direction is not readily available or impractical based on patient condition. If a Paramedic 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 curriculum and the current AHA ECC Guidelines. Off duty Okaloosa County Paramedics, 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 has responded as a representative for an outside First Responder Fire Department or US Military Firefighter. At times, Okaloosa County paramedics 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 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, who are on duty, working for an Okaloosa County EMS agency at the time of the incident. Authorization These Advanced Life Support Protocols have been developed and circulated for use by Okaloosa County EMS Paramedics in the pre-hospital emergency care of the sick and injured, under authority granted in Chapter 401 Florida Statutes, and 64 J 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). I. General Information Page 1 01.16.2023 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. A) When applicable, verbal consent should be obtained prior to treatment. Respect the patient’s right to privacy and dignity. Courtesy, concern, and common sense will assure the patient of the best possible care. B) Paramedics should transport all patients treated with ALS measures to the hospital. Patients have the right to refuse all, or any portion of treatment or transport. Patients refusing transport after ALS measures are instituted require contact with Medical Control. All refused treatments and/or transports must be completely and accurately documented in the PCR. C) Appropriate therapy must be continued during transport if indicated. Vital signs should be monitored and recorded frequently on all patients during transport. All transported patients shall have at least two sets of vital signs taken and documented. Emergency personnel should bring medication bottles with the patient and/or accurately document the medications and dosages for the receiving facility. D) All critically unstable patients must be transported to the nearest licensed hospital with emergency room services. Examples of Unstable patients (not all-inclusive): 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 < 3 minutes apart post rupture of amniotic membranes. All other 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 individual protocols. Reference: Specialty Hospital Transport Destination Protocol, Page 10 I. General Information (Guidelines for Treatment) Page 2 01.16.2023 Guidelines for Treatment E) The consequences of this decision must be thoroughly explained to all parties involved. All details involved in the decision must be recorded on the Patient Care Report. F) 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 on scene, simply explain that you are following the protocol and refer the Physician to 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. Refer to OCEMS SOP 441.00. G) If the family has contacted the 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). H) In the event OCEMS depletes its stock of Normal Saline due to the nation wide shortage of Normal Saline for IV administration, authorization is granted for the following exception to the Okaloosa County Department of Public Safety, Emergency Medical Services Division Protocol. The following fluids are authorized for use as a substitute for Normal Saline Intravenous administration: Lactated Ringers 1000cc or 500cc bags D5w/.45 Normal Saline 1000cc or 500 cc bags D5w or .45 Normal Saline (Half Normal Saline) Any of the above can be used in emergency situations in place of normal saline. Saline locks should be used for routine IV starts when fluid resuscitation is not indicated. I. General Information (Guidelines for Treatment) Page 3 01.16.2023 Guidelines for Treatment I) Should a physician 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. J) 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. Should an ER Physician give additional orders, the physician's name should be documented on the Patient Care Report. K) Medical communications are to be established via radio or telephone (via Dispatch patch) with the appropriate facility ASAP into the call. Contact can be made during or after the appropriate protocol has been initiated. Orders can only be given by the receiving facilities 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 Patient Care Report. L) Blood Drawing Procedure: Blood specimens will be drawn by certified Paramedics for blood alcohol analysis upon request of an authorized Law Enforcement Officer. The blood should only be drawn with a sealed kit provided by the Officer. The following information must be documented on a Patient Care Report: 1) Officer’s name, 2) Officer’s ID number, 3) Kit opened by the Paramedic, or in the presence of the Paramedic, 4) Type of skin prep used, 5) Number of tubes drawn, 6) All tubes placed back in kit, 7) Kit resealed by Paramedic or in the presence of the paramedic, 8) Note any problems with the incident. See Appendix. The Okaloosa County Medical Director(s) should be notified if the blood drawing procedure conflicts with patient care. I. General Information (Guidelines for treatment) Page 4 01.16.2023 Guidelines for Treatment M) Properly executed DO NOT RESUSCITATE ORDERS (Reference Appendix I, Page136-137) will be honored. If CPR has been initiated and a valid DNRO is discovered, resuscitation efforts should be ceased. If necessary, contact Medical Control for guidance. N) Lesser invasive procedures should be attempted prior to higher invasive whenever possible. This includes, but is not limited to, attempting I.V.’s prior to I.O. access. System Overview Patient 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 may elect to turn patients over to other agencies. The Paramedic 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 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. I. General Information (System Overview) Page 5 01.16.2023 “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. Yes Person is a minor (Age < 18 yrs) No Yes Person does not meet “competent” criteria (see page 7) No Acute illness or injury suspected based on appearance, MOI**, etc No Yes Yes Person has a complaint Individual meets definition of a Patient. If patient/guardian is refusing assessment, treatment, and/or transport, individual and documentation must meet all requirements detailed on Page 6 Patient Refusals No 3rd party (including LEO) indicates individual is ill, injured, or gravely disabled No Yes 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 passenger compartment, MVC involving pedestrians or motorcycles, falls from height >10 feet for adults I. General Information (“Patient” or “No Patient” Guidelines) Page 5a 01.16.2023 Patient Refusals 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. 2) A clear explanation is given to the patient regarding the need for emergency care and transportation and the possible consequences that may develop without medical attention. 3) A patient care report using the SOAP format is completed. 4) Efforts to encourage the patient to be transported to the hospital are documented. 5) At least two sets of vital signs are obtained and documented. 6) The name of the physician contacted (when contact is necessary per protocol) is documented. 7) For diabetic refusals, include 2 glucose checks. 8) 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. 9) The name of the individual signing the patient refusal, if other than the patient is included in documentation. 10) 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 witness the signature. 11) 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. I. General Information Page 6 01.16.2023 Patient Refusals Competent Individual The following individuals are considered competent to refuse treatment and transport: 1) One who is awake, alert, and oriented to person, place, and time. 2) One who 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) One who is not a clear danger to self or others. 5) 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 narrative. 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. I. General Information Page 7 01.16.2023 Patient Refusals 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 Medical Control should be contacted in all cases when a patient has been administered any medications (including oxygen) or other advanced treatment (including IV) by EMS personnel, and the patient is refusing transport. Once all attempts at convincing the patient the need for transport have failed, have the patient sign a refusal and document appropriately. Transporting a Patient Refusing a Specific Treatment/Procedure Required by OCEMS Protocols The following procedure should be followed when a patient refuses treatment required by OCEMS protocol: 1) Explain the need for the treatment procedure and possible consequences of not allowing this treatment or procedure. 2) If the patient continues to refuse the treatment or procedure, have the patient sign a “Transport and Refusal Treatment” on the Patient Care Report (PCR). 3) Attempt to obtain a witness signature, if possible. I. General Information Page 8 01.16.2023 Beach Operations Medical emergencies on the Gulf-side beaches of Okaloosa Island and Destin 1) 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 and rapidly packaging 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 ALS care can be initiated. Based on the forgoing: a) 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. b) 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. 2) Staging points for EMS –Ambulance and secondary responders on Okaloosa Island will be established by Ocean West Tower or Okaloosa 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 command on scene. The patient is better served and resources are more efficiently used when the EMS Ambulance crews make preparations 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 make preparations at the staging area for taking over patient care and transporting to the appropriate facility. I. General Information Page 9 01.16.2023 OCEMS Transport Destinations 1) STEMI Alert (Cardiac Alert): 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. Transport immediately upon recognizing a STEMI. 2) Stroke Alert: Patients meeting the “Stroke Alert” criteria as determined by the STROKE ALERT CHECKLIST (Pg 52) shall be transported to a designated stroke hospital (North Okaloosa MC, Twin-Cities Hosp., Fort Walton Beach MC, Destin ER, SHH-P) 3) Trauma Alert: Patients meeting “Trauma Alert” status as per the State of Florida DOH Scorecard methodology (Reference Pg 70-72) shall be transported to a State Approved Trauma Center (SATC). Refer to the OCEMS Trauma Transport Policy. Note: In the event that a Trauma Center is on BY-PASS Status, then the patient shall be transported to the closest Initial Receiving Hospital (IRH). 4) Dive Accident/Decompression Injury: All Dive Accident/ Decompression Injury patients shall be transported to the closest local facility for stabilization and, if needed, transported via interfacility to a hyperbaric chamber facility for definitive care. 5) OB Patient: All patients with an estimated gestational age greater than or equal to 20-weeks, regardless of complaint, should go to an OB hospital unless they meet trauma, stroke, or cardiac 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. 6) Psychiatric Patients: Crew and the patients 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. 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). I. General Information (Transport Destinations) Page 10 01.16.2023 Interfacility Transfers of Critical Patients from Hospitals and Outpatient Surgical Centers located within facilities with admitting capability This policy is designed to assure 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 the transport. The EMS Branch Commander and/or EMS Medical Director(s) will 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. I. General Information (Interfacility Transfers of Critical Patients) Page 11 01.16.2023 Interfacility Transfer of Critical Patients From Hospitals and Outpatient Surgical Centers located within facilities that have patient admitting capability For critical patients requiring transfer between facilities: (When 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 or 850-826-4717. 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 will 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”. (When Not identified by Dispatch) 1. Dispatch closest available unit to the facility with “customary instruction” 2. Paramedic on scene has identified the potential critical nature of the patient transfer. 3. The Paramedic will notify dispatch over the radio of the critical patient transfer. 4. The Paramedic will notify the on duty Branch Commander of the critical patient transfer and provide relevant information regarding the transport. I. General Information (Interfacility Transfer of Critical Patients) Page 12 01.16.2023 Interfacility Transfer of Critical Patients From Hospitals and Outpatient Surgical Centers located within facilities that have patient admitting capability 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 of 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. Assure that the OCEMS crew transporting the patient is familiar with the equipment and orders governing the care of the patient during transport. 6. Advised 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. Assure 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. I. General Information (Interfacility Transfer of Critical Patients) Page 13 01.16.2023 Interfacility Transfer of Critical Patients from Hospitals and Outpatient Surgical Centers located within facilities with admitting capability The EMS Branch Commander will: 1. Review the critical patient information to determine the need for additional resources and the appropriateness for transfer by ground OCEMS unit. Make recommendation and assist with arrangement of alternative transportation if other than OCEMS ground transportation required. 2. Make recommendation to the transferring hospital of any additional resources from their staff or facility, which will be required during the OCEMS transport. If the patients care falls outside the paramedics scope of practice and no hospital staff is available to accompany the patient, an assessment should be made to determine if the OCEMS Critical Care Transport Team would be a better resource to utilize. 3. Consult with EMS Medical Director(s) as needed. 4. Assure OCEMS transport crew and any hospital staff and other staff accompanying patient during transport are familiar with the orders governing the care of the patient during transport and equipment and medications necessary to accomplish the care of the patient during transport. 5. Clear transport crew to transport patient in coordination with dispatch. The OCEMS Paramedic will: 1. Assess patient for potential critical nature if not identified as such by dispatch. If critical, get medical provider contact information and contact dispatch. If dispatched as “stand by to load”, transport patient after consultation with EMS Branch Commander or EMS Medical Director(s). 2. Review the orders governing the care of the patient during transfer to the receiving facility. 3. Assure required care falls within the scope of practice of the paramedic, any ancillary staff accompanying the transport crew, and the equipment available prior to departure, and designate plan of care during transport. 4. Assure receipt of the contact information for medical provider assuming care at receiving facility. I. General Information (Interfacility Transfer of Critical Patients) Page 14 01.16.2023 Infectious Disease Protocol A) At all times, use standardized precautions as outlined in OCEMS SOP 303.00 including the following: 1) Wearing of gloves to prevent contact with patient’s body fluid. 2) Wearing of appropriate masks and protective eyewear during procedures likely to generate droplets of body fluids. 3) Wearing of gowns during procedures likely to generate splashes of body fluids. 4) Proper disposal of sharps 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 include; lacerations, abrasions, puncture wounds, and needle stick injuries. Exposures may also occur through mucous membranes such as; mouth, eyes, nose, and respiratory tract. I. General Information (Infectious Disease Protocol) Page 15 01.16.2023 Infectious Disease Protocol B) 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 E.R. Physician that an exposure has occurred and request that the source patient be tested. 4) Advise the on duty EMS supervisor. 5) Contact Risk Management ASAP. 6) Complete all applicable paperwork in a timely manner. I. Infectious Disease Protocol Page 16 01.16.2023 General Patient Assessment The current American Heart Association Guidelines for BLS standards should be utilized for all patients Initial Assessment: The initial assessment is utilized to assess for life-threatening situations. The Initial Assessment and appropriate therapy should be completed immediately and efficiently upon reaching the patient. The Paramedic will decide if ALS 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, checking and or performing the following: General Impression: Note the patient’s approximate age, gender, weight, activity, position, obvious injuries/ distress, and general appearance. LOC: Utilize AVPU, A-Alert, V-Responds to verbal stimuli, P-Responds to painful stimuli, U-Unresponsive Assess Airway: Consider C-Spine precautions. Establish and maintain a patent airway. Determine the rate and quality of respirations. Breathing: Reference Respiratory Distress Protocol Pg 48 1) Look, listen, and feel for air movement 2) Support respirations as needed/indicated The 4-Abdominal Quadrants RUQ Liver-Gallbladder 3) Auscultate lung sounds RLQ Appendix-R OvaryBladder if distended LUQ Spleen-portion of the Liver- Pancreas Stomach LLQ L-Ovary-Bladder if distended Remember: Universal Precautions and Body Substance Isolation I. General Information (Patient Assessment) Page 17 01.16.2023 General Patient Assessment Circulation: Assess Carotid and Femoral pulses. If indicated perform CPR. Check pallor, diaphoresis, and capillary refill. Check the neck for Jugular Vein Distention. Skin temperature should also be evaluated during the assessment. Hemorrhage: Control hemorrhage as appropriate- may be performed first if exsanguinating hemorrhage present. Baseline Vitals: Respirations, Pulse, Skin color/temperature, Blood Pressure Rapid Trauma Survey: 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 life-threatening injuries in the trauma patient. For isolated injuries, a focused exam shall be performed on the specific areas. For multiple 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 life-threatening 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 to obtain patient history S- Signs, Respirations, Pulse, BP, SaO2, Skin color and Temperature A- Allergies M- Medications, bring medications to the hospital and document on the Medical Report. P- Past medical history L- Last oral intake E- Events leading up to this incident I. General Information (Patient Assessment) Page 18 01.16.2023 General Patient Assessment Head-to-toe Survey: Utilize DCAP-BTLS-IC-PMS (Scan the body for the following) • Head: Battle’s sign, DCAP, periorbital ecchymosis, hyphema, pupils, CSF from nose or ears, mouth for broken teeth, dentures, breath odor • Neck: stair-stepping in C1-C7, JVD, TD, DCAP, BTLS • Shoulders: Sub-Q emphysema, DCAP, BTLS, IC, nitro patch/ paste, pacemaker • Chest: lung sounds, paradoxical movement, heart tones, scars, DCAP, BTLS, IC • Abdomen: guarding, rigidity, masses, Cullen Sign, Grey Turner, palpate all 4 Quadrants, DCAP, BTLS. • Hip and Pelvis : incontinence, priaprism, DCAP, BTLS, IC, (NO PELVIC ROCK) • Extremities: Legs, shortening or rotation, edema of the ankles, DCAP, BTLS, IC, PMS Arms, needle tracks, medical alert bracelets, dialysis shunt, radial pulse, DCAP, BTLS, IC, PMS • Back: check the back from the head to the feet, DCAP, BTLS, IC, D = Deformities B = Burns T = Tenderness P = Pulse C = Contusions L = Lacerations I = Instability M = Motor A = Abrasions S = Swelling C = Crepitus S = Sensation P = Penetrations “Cullen Sign” is bruising around the umbilicus. “Grey Turner” is bruising at the flanks. I. General Information (Patient Assessment) Page 19 01.16.2023 Airway Maintenance and Oxygen Administration In reference to specific treatment protocols as “Secure an Airway and administer supplemental oxygen as indicated,” the following guidelines should be followed: Airway Management: Clear obstructed airways using the appropriate techniques. If necessary, utilize an appropriate airway device to maintain the airway: OPA, NPA, ETT, King Airway, Cricothyrotomy. NOTE: To minimize interruptions in chest compressions, the airways of patients in cardiac arrest shall be secured using the King Airway in lieu of intubation attempts (unless contraindications are found) EXCEPT when drowning/near-drowning is suspected. Foreign Body Obstruction: If BLS measures and the Heimlich Maneuver do not clear the airway, attempt Endotracheal Intubation and push the foreign obstruction into one lung. Ventilate the patient’s other lung and provide rapid transport. Check ETT placement by Auscultation, end tidal CO2 detector, and continuous waveform capnography. Capnography may not be accurate if little or no circulation exists. Normal CO2 is 35-45 mmHg. If the obstruction cannot be cleared using BLS procedures, the Heimlich Maneuver, or pushed with an ETT, perform a Cricothyrotomy procedure. Reference Appendix G, Pg 134 (or Appendix S, Pg 146 for pediatrics). The decision to perform this procedure should be made quickly into the call, as to prevent hypoxia and potential neurological damage. Assisting Respirations: If it is necessary to assist respirations for more than one minute, consider intubating the patient as indicated or secure the airway with the King Airway. An Automatic Transport Ventilator or BVM with reservoir connected to 100% oxygen should be utilized when assisting respirations with 15 LPM. Difficult Intubations may require the administration of sedatives and paralytics. Reference the Rapid Sequence Induction Protocol, Section II, Pages 22-26. When ventilating a patient with a BVM, a positive end expiratory pressure (PEEP) valve should be used. Providers should initially set the PEEP valve to 5 cm H2O when starting to ventilate the patient. If the patient’s SpO2 level does not rise to 94% or above, then the PEEP can be increased to a maximum of 15 cm H2O. Post-resuscitation, all efforts should be made to maintain an SaO2 of >94%, but <100%, avoiding hypoxia and hyperoxia. Immobilize the head of all intubated patients I. General Information (Airway Maintenance) Page 20 01.16.2023 Airway Maintenance and Oxygen Administration Secondary Airways: The King Airway 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. The King Airway should be left in place unless deemed misplaced (do not attempt to intubate after King Airway placement). Medications shall not be administered via the King Airway. Cricothyrotomy: A surgical procedure for adult patients; Needle Cricothyrotomy is utilized for the pediatric patient < 8 y/o and/ or 50kg. This procedure is to be used only after all other airway measures have failed or are not practical. Appendix G, Pg 134 (or Appendix S, Pg 146 for pediatrics). Suctioning: As indicated to clear an airway Oxygen administration: 1) Nasal Cannula (NC) 2 – 6 LPM 2) Non-rebreather (NRM) 10 – 15 LPM 3) Pediatric simple face mask (minimum of 6 LPM must be used) The pulse oximeter should be applied on all patients with cardiac, respiratory, or neurological complaints before administering oxygen. Document the room air SaO2 on the Patient Care Report. Patients with known COPD and CO2 retention and patients in minimal respiratory distress should receive low-flow O2. The EMT may administer intranasal (IN) Narcan to combat respiratory insufficiency secondary to a suspected opioid overdose. In cardiac arrest, standard resuscitative measures should take priority over Narcan administration, with a focus on high-quality CPR (compressions plus ventilation). I. General Information (Airway Maintenance) Page 21 01.16.2023 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 conscious and alert per their normal state, all vital signs are stable, and peripheral intravenous or intraosseous therapy is not required for medication administration or fluid resuscitation. A patient must be attended 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, blood glucose testing, 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. The healthcare provider may turn patient care over to the OCEMS paramedic or Medical Commander only when physically present, regardless of whether continuous advanced life support monitoring and/or treatment are required. In such circumstances, it is the responsibility of the OCEMS paramedic or Medical Commander to determine the appropriate level of transport for the patient and ensure its execution. In the event that the there is a disagreement between the fire department paramedic and the EMS paramedic regarding the level of transport, the medical commander will be contacted on EMS TAC-1 for further guidance. The ultimate decision for transport level rests with the Medical Commander. 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. I. General Information (Tiered Response & Transport) Page 21a 01.16.2023 II. Rapid Sequence Induction 01.16.2023 II. Rapid Sequence Induction (RSI) 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 Medications 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. II. Rapid Sequence Induction (RSI) Page 22 01.16.2023 Indications for RSI Seizure/Convulsive Disorders Multi-System Trauma Head Injury (GCS 8 or Less) Trismus (Lock-jaw) or Clenched teeth Burn Injuries to the Upper Airway Contraindications For RSI Absolute: Limited vocal cord visualization, due to major facial/laryngeal trauma Patients that cannot be ventilated with a Bag Valve Mask (or some other means) due to trauma or anatomical reasons II. RSI (Indications) Page 23 01.16.2023 Contraindications of RSI Thyromental Distance: The distance from the bottom of the chin, to the top of the Thyroid Cartilage Relative: Excessive weight Mallampati Class of III or IV C-Spine immobilization concerns Thyromental Distance Large incisors or “Buck-teeth” Thyromental distance of < 3 finger widths Mallampati Classifications I II III IV Mallampati Classification, relates to the size of the patient’s mouth, tongue, and pharynx. II. RSI (Contraindications) Page 24 01.16.2023 RSI Procedure… 1) Rule out contraindications and anticipate the difficult intubation. 2) Prepare intubation equipment, have back-up airway such as the King Airway and Cricothyrotomy equipment ready. 3) Pre-oxygenate the patient with 100% O2 x2 minutes. a) NRBM is preferred method b) If rate, volume, and/or effort indicate, ventilate using the BVM. Ensure ventilations are not forceful (causing oxygen to be forced into the stomach). 4) Monitor and record an EKG strip, SaO2, and ETCO2. 5) Administer Ketamine 1.5mg/kg (adult and pedi) IV/IO for sedation. *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. * Allow medication to take effect (approx 2 minutes) Continued….. II. RSI (RSI Procedure) Page 25 01.16.2023 RSI Procedure continued 6) Consider additional medications for the following circumstances: * If Bradycardia exists, administer Atropine 1 mg IV/IO, up to 3mg Total until normocardic. * If pediatric (< 16) and Bradycardia exists, administer Atropine 0.02mg/kg IV/IO (up to 1.0mg per dose; up to 3mg Total) until normocardic. * If Increased ICP suspected or acute Asthma present, administer Lidocaine 1.0 mg/kg IV/IO 3 minutes prior to intubation attempts unless contraindicated. 7) After 2 minutes and the Ketamine takes effect, administer Succinylcholine 1.5 mg/kg (pedi 2.0 mg/kg) IV/IO, after an additional 2 minutes and the Succinylcholine takes 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 (King Airway or surgical cricothyrotomy). b) Paramedics shall forgo intubation attempts for patients with multisystem trauma and immediately secure the airway with the King Airway (unless contraindications for the King Airway exist). 8) Confirm intubation with auscultation, continuous waveform capnography, and end tidal CO2 detector, then secure tube in place noting the depth at the teeth. Ventilate patient to maintain EtCO2 between 35-45 mmHg (30-35 mmHg if Cerebral Herniation suspected) 9) To keep the patient sedated, and 10 minutes after the first administration of Ketamine, administer Ketamine 1.5mg/kg (adult and pedi) IV/IO before the patient begins to wake. Doses can be repeated every 10 minutes as needed to keep the patient sedated. *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. 10) Continue to monitor the patient, pain level, and sedation level. Treat as indicated. Confirm ETT placement by utilizing clinical techniques: Visualization, Auscultation, and continuous Waveform EtCO2. Normal CO2 is 35 to 45 mmHg II. RSI (Procedure) Page 26 01.16.2023 III. Medical Emergencies 01.16.2023 Abdominal Pain/ Nausea & Vomiting 1) Perform initial assessment. 2) Perform detailed exam. 3) Obtain a complete history, including potential for pregnancy if female. 4-Abdominal Quadrants 4) Secure an airway and administer supplemental oxygen as indicated. 5) Monitor and record an EKG strip. Obtain 12 lead EKG if indicated (refer to Pg 36). 6) Initiate IV 0.9% NaCl KVO. Administer fluids as needed. 7) Administer Ondansetron 4mg IV/ IM for adult patients with prolonged nausea and/or vomiting* *confirm with the patient that they have not had any previous history of adverse reactions or actual allergies to Ondansetron prior to administration. 8) Evaluate blood glucose level, treat as appropriate. 9) Manage the patient’s pain using the Adult Pain Management Protocol RUQ Liver-Gallbladder RLQ Appendix-R OvaryKidney/ureter LUQ Spleen-portion of the Liver- Pancreas Stomach LLQ L-Ovary-Bladder if distended •Causes of abdominal pain can rarely be determined in the field •Consider catastrophic causes of abdominal pain such as a ruptured Abdominal Aortic Aneurysm or Ectopic pregnancy, when signs of shock are present. •In cases when prolonged nausea and vomiting is present, conduct orthostatic vital signs and administer fluids as appropriate. III. Medical Emergencies (Abdominal Pain/ Nausea) Page 27 01.16.2023 Acute Pulmonary Edema/CHF 1) Perform initial exam. 2) Perform detailed exam, when appropriate. If S/S of Cardiogenic shock are present (BP < 90 systolic) reference the Cardiac-related Hypotension Protocol, Pg 43 3) Secure an airway and administer supplemental oxygen as indicated. Apply pulse oximeter and document pre and post SaO2 readings. 4) If the L.O.C. is normal, administer Continuous Positive Airway Pressure (CPAP). If Altered LOC, provide positive pressure ventilations with BVM as needed. Consider RSI. 5) Place patient in the seated position with legs dependent (lower than the upper body). 6) Monitor and record an EKG strip. Every attempt at obtaining a 12 lead EKG should be made. 7) Initiate IV 0.9% NaCl KVO rate. 8) Evaluate blood glucose level, treat as appropriate. 9) Administer Nitroglycerin 0.4mg SL. Repeat every 3-5 minutes until max dose of 3 metered doses, Note: Contraindicated in patients taking any of the ED medications, i.e., Viagra, Levitra, and Cialis, or marked bradycardia or tachycardia, or hypotension. 10) Contact Medical Control for further orders. Suspect Pneumonia in the elderly patient presenting with a temperature of > 100° F III. Medical Emergencies (Acute PE/CHF) Page 28 01.16.2023 Allergic Reactions Including generalized reactions to insect stings 1) Perform initial assessment. 2) Perform detailed exam, when appropriate. 3) Secure an airway and administer supplemental oxygen as indicated. Consider nebulized Albuterol treatment at 2.5mg/3mL NS if patient exhibits S/S of respiratory distress. 4) Monitor and record an EKG strip. 5) Initiate IV 0.9% NaCl appropriate rate. 6) Generalized allergic reactions characterized by Uticaria (rash), administer Benadryl 50mg IM or slow IVP. 7) Generalized allergic reactions characterized by any of the following: Hypotension (< 100 systolic), respiratory distress, wheezes, and edema of the tongue, administer Epinephrine 1:1,000 0.3mg (0.3mL’s) IM. Administer Benadryl 50mg slow IVP. Administer fluids to maintain adequate peripheral perfusion, as needed. 8) In severe anaphylactic shock (all S/S of a severe allergic reaction coupled with cardiovascular collapse) where cardiac arrest is imminent and a BP is unobtainable: Administer Epinephrine 1:10,000 0.3mg (3mL’s) slow IV/IO push, followed by Benadryl 50mg slow IV/IO push, if not already given. Administer fluids to maintain adequate peripheral perfusion, as needed. 9) Contact Medical Control for further orders. Epinephrine acts by constricting blood vessels, which in turn increases the blood pressure. It also widens the airway. Benadryl does not stop the reaction however, it does relieve some of the symptoms. True Anaphylaxis is a medical emergency and requires immediate treatment in the Emergency Room. III. Medical Emergencies (Allergic Reactions) Page 31 01.16.2023 Altered Mental Status 1) Perform initial assessment. 2) Check for signs of head trauma, and perform detailed exam when appropriate. 3) Secure an airway and administer supplemental oxygen as indicated. Normal blood glucose levels range from 60mg/dl – 120mg/dl 4) Monitor and record an EKG strip. 5) Initiate an IV 0.9% NaCl KVO rate. Note: If a LOC is related to seizure activity, reference the Seizure Protocol, Pg 49. 6) Check blood glucose level via Glucometer, and document on the Patient Care Report. 7) If patient blood glucose <60mg/dl, administer D10 100mL IV/IO. Oral glucose may be given if the patient is conscious and able to swallow. 8) Check blood glucose after administration of D10, and document appropriately. 9) If patient remains less than 60mg/dl after 2 minutes, administer an additional 100 Ml of D10 and facilitate transport. Do not remain on scene to obtain a refusal. 10) If IV access is unobtainable, administer Glucagon 1mg IM. 11) If no response, and there is a high index of suspicion for acute opiate or narcotic pain killer overdose, administer Narcan in 0.5mg IVP/IM (or 1mg IN) increments until improvement of respiratory status. May repeat in 2-3 minutes for IV/IN use and repeated in10 minutes for IM use, not to exceed 10mg cumulative dose. 12) Contact Medical Control for further orders. The primary treatment of acute narcotic overdose is airway control. Once the airway is controlled, Narcan takes on only a secondary role. If drug overdose is strongly suspected, give Narcan prior to D10 The EMT may administer intranasal (IN) Narcan III. Medical Emergencies (Altered Mental Status)Page 32 01.16.2023 ASYSTOLE If Asystole is confirmed in two leads, inquire or search for a valid DNRO. Do not delay initiation of care during this search (Reference Appendix I, P-136-137) 1) Perform initial assessment and CPR (30:2) at a rate of 100-120 compressions per minute. 2) Perform a detailed exam, when appropriate. 3) Obtain a EKG, and confirm Asystole in at least 2 leads. Record an EKG strip. If there is the possibility that V-Fib exists, follow the appropriate protocol. 4) Secure an airway and administer supplemental oxygen as indicated. 5) Initiate IV/ IO 0.9% NaCl KVO rate. Administer fluids as indicated. 6) Administer Epinephrine 1:10,000 1mg IV/ IO or 2mg ETT. (IV preferred). Repeat Epinephrine every 3-5 minutes as long as it is indicated. 7) If there is an indication of high vagal tone or organophosphate poisoning consider and administer Atropine 1mg IV/ IO or 2mg ETT. Circulate with CPR, repeat every 3-5 minutes to a total of 3mg (6mg maximum via ETT). 8) Consider and treat possible causes (Reference the Cardiac Arrest Protocol, Pg 37). 9) Contact Medical Control for further orders. If complexes are restored at any time during therapy, follow the appropriate protocol III. Medical Emergencies (Asystole) Page 33 01.16.2023 Bradycardia - Stable <60 BPM No signs or symptoms of being hemodynamically compromised 1) Perform initial assessment. 2) Perform detailed exam and be prepared to apply pacer pads, when appropriate. 3) Secure an airway and administer supplemental oxygen as indicated. 4) Monitor and record an EKG strip. Obtain 12 lead EKG. 5) Initiate IV 0.9% NaCl KVO. 6) Monitor patient. Proceed to unstable protocol if patient begins to exhibit signs or symptoms of being hemodynamical