Protocol General.pdf

General Responsoft EMS Protocols General Page 26 General 10/13/2020 General Chemical restraint is preferred over physical restraint. Behavioral General Scene Safety Treat suspected medical or trauma problems per appropriate protocol If patient is sedated, use Capnography Universal Patien...

General Responsoft EMS Protocols General Page 26 General 10/13/2020 General Chemical restraint is preferred over physical restraint. Behavioral General Scene Safety Treat suspected medical or trauma problems per appropriate protocol If patient is sedated, use Capnography Universal Patient Assessment Hyperglycemia/Hypoglycemia Unconscious/Unknown Overdose Neurological Trauma (Head) Causes of Excited Delirium Drug related, Stimulant drugs: Cocaine Amphetamines Club Drugs Hallucinogens, Adverse Drug Reaction, Drug Withdrawal, Hypoglycemia, Head Trauma, Hypoxia, Hypoventilation, Shock, Psychiatric, New drug, Off Drugs, Other Medical Delirium, Infection, Dementia Attempt to remove patient from stressful environment Verbal techniques (reassurance, calm, establish rapport) Explain all movements and procedures. Look for a possible cause. For patients who are agitated and/or combative consider Physical and Chemical restraint as needed per the Chemical Restraint Protocol An alternative to Ketamine is: Midazolam. Midazolam should be used in patients in which Ketamine is contraindicated or ineffective or if there is suspicion that the agitation may be related to underlying seizure activity. Responsoft EMS Protocols Page 27 10/13/2020 Chemical Restraint Part A General General Clinical Indications 1. Therapeutic: to control the patient’s ventilation, intracranial pressure, or heat production. Additional benefits are to decrease anxiety and minimize discomfort of invasive or uncomfortable procedures. 2. Safety: to insure that the combative patient is not a threat to himself or crew members and that necessary treatments or procedures are not compromised. The sedated patient experiences both physiologic consequences of the medication and loss of important physical clues. 1. Whenever possible, establish baseline vitals. 2. Determine the Sedation Assessment score Sedation Assessment Tool (SAT)1 Score Responsiveness Speech +3 Combative, Violent, Out of control Continual loud outbursts +2 Very anxious and agitated Loud outbursts +1 Anxious/restless Normal -> talkative 0 Awake and calm/cooperative Speaks normally -1 Asleep but rouses if name is called Slurring or prominent slowing -2 Responds to physical stimulation Few recognizable words -3 No response to stimulation Nil Responsoft EMS Protocols Page 28 10/13/2020 General Chemical Restraint Part B 3. Determine correct medication, dose and route SAT +2: Consider SAT +1:: Consider Midazolam (Versed) Midazolam (Versed) 5 mg IVP 2 mg IVP Midazolam (Versed) Midazolam (Versed) 10 mg IN, IM 5 mg IN, IM OR General Ketamine - If vial is 100 mg / mL, dilute to 50 mg / mL for IV use Ketamine (Ketalar) (50 mg/mL) mg/kg IVP 11 mg/kg Ketamine (Ketalar) (50 mg/mL) mg/kg IM 22 mg/kg Ketamine (Ketalar) (100 mg/mL) 22 mg/kg mg/kg IM SAT +3: Consider dispatching an EMS Officer on any run with a SAT score of +3 Ketamine - If vial is 100 mg / mL, dilute to 50 mg / mL for IV use Ketamine (Ketalar) (50 mg/mL) mg/kg IVP 22 mg/kg Ketamine (Ketalar) (50 mg/mL) 44 mg/kg mg/kg IM Ketamine (Ketalar) (100 mg/mL) 4 4 mg/kg mg/kg IM 4. Obtain and document vital signs  Pulse Oximetry  BP  EtCO2  Continuous Cardiac Monitor 5. Repeat and document vitals every 5 minutes 6. Monitor patient throughout transport In considering whether patient meets criteria for Ketamine- is there immediate danger to self or others In most cases, the target level of sedation to aim for post-sedation is: SAT 0 to -1. The most common exception requiring deeper sedation will be for medical assisted intubation ( 1 Calver, L.A., Stokes, B. & Isbister, G.K. (2011). ‘Sedation assessment tool to score acute behavioral disturbance in the emergency department’. Emergency Medicine Australasia, vol. 23, pp. 732-740). NOTE: This is a consensus protocol on the care and management of acute behavioral emergencies from the following central Ohio EMS medical directors: Robert Lowe, MD (Columbus Division of Fire), Ashley Larrimore, MD & Michael Dick, MD (Ohio State University Center for EMS), Eric Cortez, MD (OhioHealth EMS), Frank Orth, DO and Paul Zeeb, MD (MEC EMS). Protocol approved November 1, 2021 for implementation with next affiliated agency's(ies') protocol update Responsoft EMS Protocols Page 29 10/13/2020 General Epistaxis-Nosebleed Epistaxis can be a symptom of hypertension. Be thorough in your evaluation while treating this minor problem. Universal Patient Assessment Place patient in either a standing or upright seated position. If patient is recumbent in bed and unable to sit up, have patient turn head to the side. General Controlling significant bleeding or hemodynamic instability should take precedence over obtaining a lengthy history. Note the duration, severity of the hemorrhage, and the side of initial bleeding. Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, family history, easy bruising, or prolonged bleeding after minor surgical procedures. Recurrent episodes of epistaxis, even if self-limited, should raise suspicion for significant nasal pathology. www.emedicine.medscape.com Have the patient tilt their head forward (chin to chest) and have the patient hold firm pressure on the nares. The patient should hold pressure for ten (10) minutes. Afrin (Oxymetazoline) 0.05% - 2 - 3 puffs/nares on side of bleeding. Responsoft EMS Protocols Page 30 10/13/2020 Hyperglycemia/Hypoglycemia General In DKA patients, Kussmaul respiration helps correct acidosis. Patients with an EtCO2 of less than 29 were found to be in acidosis 95% of the time, whereas no patients with EtCO2 of 36 or higher were in acidosis. General Universal Patient Assessment Spinal Injury Assessment IV/IO IV/IO Cardiac Monitor Blood Glucose No Glucose < 60 mg/dl Dextrose Dextrose10% 10% 100 ml boluses IVP, IO Until patient awake &/or follow up blood sugar > 60 mg/dl Glucose 60 - 240 mg/dl Glucose > 240 mg/dl signs of dehydration Normal Normal Saline Saline bolus 500 ml Bolus See: Unconscious/Unknown May be repeated x 2 with no signs of CHF, Pulmonary Edema Glucagon 1 mg IM, IN (if no IV access) If patient conscious consider Oral Glucose 15 gm PO Return to baseline? Yes Reassess glucose and monitor If Patient refuses transport See: Diabeticof Safe Discharge Safe Discharge Diabetic Patients No Repeat Dextrose may be given up to a total dose of 100 ml per bolus Offer transportation to hospital. Responsoft EMS Protocols Page 31 10/13/2020 General Non-Traumatic Shock/Dehydration Dehydration is an abnormal decrease in the total body water. It is accompanied by a disturbance in the balance of essential electrolytes. Universal Patient Assessment General Dehydration may follow prolonged fever, diarrhea, vomiting, acidosis, and any condition which there is rapid depletion of body fluids. For heart rate less than 60 and BP less than 90 mmHg systolic with patient symptomatic, follow Bradycardia Protocol ? IV/IO IV/IO Auscultate lungs frequently for rales. If rales or dyspnea increase, terminate fluid bolus. In any patient without rales or dyspnea who has a systolic BP less than 90 mmHg or less than 90 mmHg with signs of shock 0.9 NS Fluid Bolus 20 ml/kg 20 ml/kg May repeat x 2 Titrate to effect Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes Responsoft EMS Protocols Page 32 10/13/2020 Pain Control General General Universal Universal Patient Patient Assessment Assessment Information to Record 1. Time of arrival 2. Heart Rate and Blood Pressure and Respiratory Rate 3. Glasgow Coma Scale 4. Time of each dose of analgesia 5. Dosage of each administration of analgesia 6. Time and results of pain assessments 1-10 scale Assess Pain Severity: 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain. Document description of pain, examples: sharp, dull, stabbing, constant, intermittent, alleviating factors. Patient care according to Protocol based on Specific Complaint Indication for Medication IV/IO IV/IO Monitor and reassess No Indications for Use: Chest pain, especially in acute M.I., pain associated with trauma, burns, known history of kidney stones, and abdominal pain, Acute (not chronic) musculoskeletal pain, etc. Yes Fentanyl Continuous Pulse Oximetry 1 mcg/kg IVP, IO Maximum single dose 100 mcg Maximum total 200 mcg Patient may have additional Fentanyl in 100 mcg mcg/kg IN 1.5 mcg/kg doses to total additional Maximum of 200 mcg. May repeat original dose every 3 – 5 minutes Maximum 200 mcg Patient must be transported to hospital if Fentanyl administered. In case of major trauma, major thermal injuries and intubated patients, Maximum cumulative total dose of fentanyl permitted is 400 mcg. 100 mcg per bolus dose for all cases except first dose for RSI. Additional pain medication option: Ketorolac (Toradol) 15 mg IVP (or 30 mg IM) ONCE only Contraindicated if: cardiac cause of chest pain suspected, allergy to NSAID, advanced Renal disease, failure, or kidney transplant or confirmed or suspected active bleeding (trauma, GI bleeding, etc.) For severe / excruciating / painful discomfort caused from a fracture / dislocation / subluxation Consider, if Fentanyl is not sufficient or ineffective: Monitor and reassess Anticipate use for major burns and major trauma. Ketamine Responsoft EMS Protocols Page 33 0.2 mg/kg mg/kg IVP, IO Maximum 40 mg 10/13/2020 Sepsis General Are there signs and symptoms of acute infection/sepsis? Suspect sepsis if any of the following are present. Sepsis > Age 16 1. Pneumonia 2. Urinary Tract Infection 3. Abdominal pain or distension 4. Meningitis 5. Indwelling medical device or intravenous line 6. Cellulitis, septic arthritis, infected wound 7. Recent chemotherapy 8. Organ transplant (kidney, heart, lung etc) 9. Age > 65 years General Universal Universal Patient Patient Assessment Assessment Oxygen Oxygen should be administered to maintain SpO2 >94% Modified Trendelenburg Position (feet up), if tolerated. Initiate treatment for sepsis if all 3 criteria met: 1. Infection suspected 2. Two or more of the following: a. Temperature > 100.4 F (38 C) or < 96.8 F (36 C) b. Heart rate > 90 bpm c. Respiratory rate > 20 3. ETCO2 < 25 mmHg If not in Acute Pulmonary Edema/CHF Initiate 30 30 ml/kg ml/kg Normal Saline rapid IV bolus Auscultate the lungs frequently for rales. If rales appear or dyspnea increases at any time, terminate the fluid bolus. Request receiving facility initiate a “Sepsis Alert” as part of radio report. If the systolic blood pressure remains < 90 mmHg after Normal Saline bolus Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes Responsoft EMS Protocols Page 34 10/13/2020 General Fainting, "blacking out," or syncope is the temporary or transient loss of consciousness followed by the return to full recovery, but may encounter a short period of confusion. This loss of consciousness is accompanied by loss of muscle tone that can result in falling or slumping over. Unconscious/Unknown Universal Patient Patient Assessment Assessment Universal Spinal Injury Assessment (If necessary) General Possible causes of syncope include: Hypoglycemia, Toxicity (alcohol, drugs, medications) CVA, underlying cardiac dysrhythmias, history of head trauma and seizure. IV/IO IV/IO Cardiac Monitor Blood Glucose Glucose 60 - 240 mg/dl Consider Naloxone if signs and symptoms of opiate overdose (decreased/absent respirations, pinpoint pupils) Glucose < 60 mg/dl See: Hyperglycemia/Hypoglycemia Naloxone (Narcan) 0.4 - 2 mg IVP, IO, IN May repeat every 5 minutes as needed Administer in lowest dose as needed to maintain adequate respirations Consider other causes: Head injury, Overdose Stroke, Hypoxia Responsoft EMS Protocols Page 35 10/13/2020 General Universal Patient Assessment General The Universal Patient Care Protocol should be used as primary guide to all patient assessment. Scene Safety & BSI (body substance isolation) Adult Adult Primary Primary Assessment Assessment Patient Assessment-Medical Patient Assessment-Trauma Documentation of Vitals Signs per guideline (Temperature if appropriate) Adult Airway Airway Protocol Adult Consider Pulse Oximetry & Capnography Consider: Carbon Monoxide Poisoning Nausea & Vomiting Nausea & Vomiting Ondansetron (Zofran) Ondansetron (Zofran) 4 mg IVP, IO 8 mg PO (2 Tablets) Pain PainControl Control Protocol Cardiac Monitor / 12 Lead ECG Transmit 12 Lead ECG If monitor capable of transmitting EKG, transmit all EKGs to receiving hospital. Repeat 12 Lead ECG for any significant change in cardiac rhythm (SVT, VF, VT) Appropriate Protocol Responsoft EMS Protocols Page 36 10/13/2020