Coral Springs Parkland Fire Department Protocols PDF

Revision Date: August 1, 2020 Table of Contents Revision Date: August 1, 2020 Standing Orders General Information p. 10 Patient Assessment p. 13 Ventilatory Assistance p. 16 Transport Destinations p. 18 Helicopter Transport Criteria p. 21 ALS Medical Emergencies BACK TO TABLE OF CONTENTS Acute Adren...

Revision Date: August 1, 2020 Table of Contents Revision Date: August 1, 2020 Standing Orders General Information p. 10 Patient Assessment p. 13 Ventilatory Assistance p. 16 Transport Destinations p. 18 Helicopter Transport Criteria p. 21 ALS Medical Emergencies BACK TO TABLE OF CONTENTS Acute Adrenal Insufficiency p. 23 Allergic Reaction p. 24 Diabetic Emergencies p. 26 Dystonic Reaction p. 28 Fluid Resuscitation/Dehydration p. 29 Hyperkalemia p. 30 Nausea/Vomiting p. 31 Respiratory Distress p. 32 Seizure p. 35 Sepsis p. 37 Stroke p. 39 Table of Contents 2 Table of Contents Revision Date: August 1, 2020 Cardiac Emergencies Atrial Fibrillation & Atrial Flutter p. 42 Bradycardia p. 43 Cardiogenic Shock p. 45 Chest Pain p. 46 STEMI Alert p. 47 CHF (Pulmonary Edema) p. 49 Supraventricular Tachycardia p. 50 Wide Complex Tachycardia p. 52 Polymorphic V-tach/Torsades p. 55 Left Ventricular Assist Device p. 57 Cardiac Arrest BACK TO TABLE OF CONTENTS Standing Orders p. 60 Adult Cardiac Arrest p. 62 Adult Post Resuscitation p. 64 Pediatric Cardiac Arrest p. 66 Pediatric Post Resuscitation p. 67 Special Considerations p. 68 Table of Contents 3 Table of Contents Revision Date: August 1, 2020 Overdose Emergencies Standing Orders p. 72 Beta Blockers p. 73 Calcium Channel Blockers p. 74 Cocaine p. 75 Digitalis Toxicity p. 76 Narcotics p. 77 Tricyclic Antidepressants p. 78 Chemical Control Chemical Restraint p. 80 Pain Management p. 82 Delayed Sequence Intubation p. 84 Environmental Emergencies BACK TO TABLE OF CONTENTS Decompression Sickness p. 86 Non-Fatal Drowning p. 87 Heat Emergencies p. 88 Carbon Monoxide Exposure p. 89 Cyanide Exposure p. 90 Organophosphate Poisoning p. 91 Table of Contents 4 Table of Contents Revision Date: August 1, 2020 Trauma BACK TO TABLE OF CONTENTS Standing Orders p. 93 Eye Emergencies p. 96 Bites & Stings p. 97 Pelvis & Closed Fractures p. 98 Open Fractures p. 99 Bleeding Control p. 100 Blood Transfusion—Whole Blood p. 101 Head Injuries p. 102 Chest Trauma p. 103 Crush Injury p. 104 Hemmorhagic Shock p. 105 Neurogenic Shock p. 106 Trauma in Pregnancy p. 107 Trauma Arrest Standing Orders p. 108 Burn Injuries p. 109 START Triage (Adult) p. 111 JumpSTART Triage (Pediatric) p. 112 Trauma Alert Criteria (Adult) p. 113 Trauma Alert Criteria (Pediatric) p. 114 Table of Contents 5 Table of Contents Revision Date: August 1, 2020 Obstetrical BACK TO TABLE OF CONTENTS Standing Orders p. 116 1st & 2nd Trimester Complications p. 117 3rd Trimester Complications p. 118 Pre-Eclampsia/Eclampsia p. 119 Meconium Staining p. 120 Normal Delivery p. 121 Delivery Complications p. 122 Table of Contents 6 Editors & Contributors Revision Date: August 1, 2020 FIRE CHIEF  Chief Michael McNally DIVISION CHIEF OF EMERGENCY MEDICAL SERVICES  Chief Juan Cardona MEDICAL DIRECTORS  Dr. Peter Antevy, MD, Medical Director  Dr. Kenneth Scheppke, MD, Associate Medical Director  Dr. Paul Pepe, MD, Associate Medical Director EDITORS  Dr. Peter Antevy, MD, Medical Director  EMS Division Chief Juan Cardona  Assistant EMS Chief John Whalen  Lieutenant Lazaro Ojeda  Lieutenant Karl Kellenberger  Lieutenant Kevin O’Connell  Lieutenant Caroline Quevillon  Lieutenant Johana Cinque  Lieutenant Janet Neita CONTRIBUTORS  Data Analyst Sharon Maraj SPECIAL RECOGNITION: A special thank you to Dr. Ken Scheppke and staff of Palm Beach County Fire Rescue for permission to utilize their protocol template. BACK TO TABLE OF CONTENTS Editors & Contributors 7 Medical Directors Revision Date: August 1, 2020 The following Emergency Medical Services Protocols are the Official Advanced and Basic Life Support Protocols for Coral Springs Parkland Fire Department and are approved for such use by Paramedics and EMTs of the department to care for the sick and injured. Only those Paramedics and EMTs approved by the Medical Director shall be authorized to utilize these protocols. Peter M. Antevy, MD Medical Director Kenneth A. Scheppke, MD Associate Medical Director Paul E. Pepe, MD Associate Medical Director BACK TO TABLE OF CONTENTS Medical Directors 8 Revision Date: August 1, 2020 BACK TO TABLE BACK TO TABLE OF OF CONTENTS CONTENTS Medical Emergencies Standing Orders 99 General Information Revision Date: August 1, 2020 INFORMATION These EMS protocols have been developed for use of the City of Coral Springs and Parkland Fire Department. It is recognized that the EMS protocols cannot address every possible scenario and may require therapy not otherwise specified. Therefore, all frontline, personnel are given the authority to deviate from the ALS protocols as needed. Clear documentation of the deviation is required. Good judgment and the patient’s best interest must always be considered. The EMS provider may consult medical direction at any time if he/she deems necessary. The following will be general information that may apply to most patients. This information is for both adult and pediatric patients. BACK TO TABLE OF CONTENTS General Information 10 General Information continued… Revision Date: August 1, 2020 MEDICATION ADMINISTRATION & MEDICATION ROUTES ADULT & PEDIATRIC Prior to administering any medication, inquire about medication allergies or adverse reactions to medications. A true allergy to a medication causes a rash, SOB, swelling of the tongue, face and/or throat.  Follow the 6 Rights of drug administration: Person Drug Dose Time Route Documentation INTRAOSSEOUS SITES (EZ-IO) An IO should be placed for patients with emergency medical conditions that require urgent vascular access in whom an IV is not immediately obtainable or is deemed to have insufficient access Adult:  Proximal Humerus (only if the surgical neck can be palpated)  Proximal Tibia  Distal Tibia Pediatric:  Proximal Humerus (only if the surgical neck can be palpated)  Distal Femur  Proximal Tibia  Distal Tibia IM INJECTIONS All IM injections shall be administered in the lateral thigh, medication can be delivered through clothing. Adults:   21-23 gauge 1.5 inch needle 4mL maximum per site Pediatric:  23 gauge 1 inch needle  1mL maximum per site  If > 1mL needs to be administered, split the dose between both thighs MUCOSAL ATOMIZATION DEVICE (MAD) The following medications can be administered via the MAD.  Desired dose: 0.3mL - 0.5mL per nostril, Max 1mL per nostril BACK TO TABLE OF CONTENTS General Information Versed Glucagon Fentanyl Ketamine Narcan 11 General Information continued… Revision Date: August 1, 2020 PEDIATRIC    Patients who have not reached puberty are considered pediatric patients and shall be treated under the pediatric guideline section of these protocols Patients who have reached puberty shall be treated as an adult IO is the preferred method of vascular access during pediatric cardiac arrest PUBERTY Female puberty is defined as breast development. Male puberty is defined as underarm, chest or facial hair. THE HANDTEVY SYSTEM The Handtevy system shall be utilized in the resuscitation and treatment of all pediatric patients. The child’s age should be used as the primary reference point for determining the appropriate patient care. If the child appears shorter or taller than stated age or if the age is unknown use the Handtevy system length based tape  Refer to the Handtevy system for the following:  Medication Dosages/Infusions  Equipment  Electrical Therapy  Vital Signs PEDIATRIC AGE CLASSIFICATIONS Neonates: Birth to 1 month Infants: 1 month to 1 year Children: 1 year to puberty PEDIATRIC TRANSPORT DECISIONS Trauma patient—15 years of age or younger Medical patient—17 years of age or younger BACK TO TABLE OF CONTENTS General Information 12 Patient Assessment Revision Date: August 1, 2020 ADULT & PEDIATRIC MENTAL STATUS (AVPU) Alert: to person, place, time, and event (AAOX4) Patient with AMS consider possible causes: AEIOU-TIPS Verbal: responds only to verbal stimuli Pain: responds only to painful stimuli Unresponsive MENTAL STATUS (GCS) Alcohol Epilepsy (Seizures) Insulin (Hyper-/Hypoglycemia) Overdose/Oxygenation Uremia (Kidney Failure) Trauma Infection (Sepsis) Psychiatric AIRWAY / BREATHING  Assess Airway, if breathing is present without compromise, continue assessment  If spontaneous breathing is present with compromise or patient is not breathing provide ventilatory support. Refer to Ventilatory Assistance Protocol CIRCULATION ADULT & PEDIATRIC    Assess pulse (carotid, brachial or radial pulse) Assess capillary refill Assess skin (color, condition and temperature) Refer to the “Cardiac Arrest” algorithm for all patients found pulseless Refer to the “Bradycardia” protocol for pediatric patients found bradycardic with signs of poor perfusion and AMS BACK TO TABLE OF CONTENTS Patient Assessment 13 Patient Assessment continued… Revision Date: August 1, 2020 PHYSICAL ASSESSMENT    All patients shall receive a physical exam Physical exams include primary and secondary assessments When injuries or abnormalities are found, focused exam shall be conducted and refer to specific protocol VITAL SIGNS: All patients shall receive a minimum of 2 sets of vitals if time allows. Patients being cared for over an extended period of time should also have the appropriate number of vital sign assessments           Pulse (rate, rhythm and quality) Respirations (rate and quality) Skin (color, temp, condition) Monitor Temperature Lung Sounds Pulse Oximetry Blood Pressure (capillary refill) Pupillary response EtCO2 Blood Glucose Level (BGL)     Unstable patients shall receive vitals every 5 minutes A manual blood pressure shall be taken to confirm any abnormal or significant changes of an automatic blood pressure cuff reading Blood pressure shall be checked before and after administration of a drug Hypotension for adults is defined as Systolic BP < 90 mm Hg ETC O2 - Monitoring  Shall be utilized for the following patients:  Patients requiring ventilatory support (e.g., BVM, ET tube, SGA, CPAP)  Patients in respiratory distress  Patients with Altered Mental Status  Patients who have been sedated  Patients who have received pain medication  Seizure patients  Suspected Sepsis  Cardiac arrest GLUCOSE           BACK TO TABLE OF CONTENTS A BGL shall be documented for the following patients: History of diabetes Altered mental status General weakness Seizure Syncope/lightheadedness Dizziness Poisoning Stroke Cardiac arrest Patient Assessment 14 Patient Assessment continued… Revision Date: August 1, 2020 ECG MONITORING All ALS patients shall be continuously monitored in Lead II 12 lead ECG shall be performed on the following patients:  Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort  Palpitations  Syncope, lightheadedness, general weakness, or fatigue  CHF, SOB, hypertension or hypotension  Unexplained diaphoresis or nausea  Any heart rate less than 50 or greater than 150  12 lead ECGs shall be repeated every 10 minutes and upon ROSC  When transporting, leave cables connected until patient is turned over to the Emergency Department (ED) staff PATIENT HISTORY Obtain the following information:  CHIEF COMPLAINT: Why did the person call 911?  S.A.M.P.L.E. HISTORY (S.A.M.P.L.E) SIGNS & SYMPTOMS ALLERGIES MEDICATIONS: Prescribed, over the counter, or not prescribed to patient PAST MEDICAL HISTORY (patient’s and immediate family’s) LAST ORAL INTAKE EVENTS PRECEDING  HISTORY OF THE PRESENT ILLNESS (O.P.Q.R.S.T.A) ONSET: Did the symptoms appear gradually or suddenly? PALLIATIVE: What makes the symptoms better? PROVOKE: What makes the symptoms worse? PREVIOUS: Previous similar episodes? QUALITY: (What kind of pain?) pressure, squeezing, aching, dull, etc. RADIATION: Does the pain or discomfort radiate? Where? SEVERITY OF PAIN: 1-10 scale (utilize “Faces” pain scale for pediatrics) TIME: What time did the symptoms begin? ASSOCIATED: What are the associated signs & symptoms? BACK TO TABLE OF CONTENTS Patient Assessment 15 Ventilatory Assistance Revision Date: August 1, 2020 INFORMATION If spontaneous breathing is present with compromise or not breathing maintain airway patency: ADULT & PEDIATRIC AIRWAY POSITIONING: Medical patient:  Position patient with external auditory meatus (a.k.a. “The Earhole”) on the same external plane as the sternal notch  Trauma patient with suspected spinal cord injury: Modified jaw thrust Assist ventilations with a bag-valve mask (BVM) attached to supplemental oxygen at 15-25 lpm  Suction as needed  Apply and monitor pulse oximeter / ETCO2 If air exchange is inadequate and there is suspicion of foreign body airway obstruction (FBAO) follow FBAO protocol. If unconscious, insert OPA, NPA as needed. Consider supraglottic device. NASOPHARYNGEAL AIRWAY (NPA):  Semi-conscious patients with an intact gag reflex shall insert NPA, unless contraindicated OROPHARYNGEAL AIRWAY (OPA):  Unresponsive patients without a gag reflex shall insert OPA, unless contraindicated VENTILATORY RATES ADULT PEDIATRIC Patients with a pulse 1 breath / 6 seconds 1 breath / 3 seconds Patients without a pulse 1 breath / 10 seconds 1 breath / 6 seconds Patients with ICP/ Herniation Maintain EtCO2 between 35-45 mm Hg and SpO2 > 90% while continuously monitoring BP ATTENTION In certain patients, excessive ventilation rates may be harmful. Overzealous positive pressure ventilation can impair:  Venous return  Cardiac output  Cerebral perfusion Ultimately the patients SpO2 and EtCO2 should determine the ventilation rate for the patient (ideally EtCO2 should be 35-45 mm Hg). BACK TO TABLE OF CONTENTS Ventilatory Assistance 16 Ventilatory Assistance continued… Revision Date: August 1, 2020 OXYGEN ADMINISTRATION DO NOT withhold Oxygen if the patient is dyspneic or hypoxic SpO2: Maintain SpO2 of 94% for all patients  Exception: Maintain SpO 2 of 90% for COPD, Asthma & ICP/Cerebral Herniation The following patients regardless of SpO2 shall receive 15 LPM via NRB:      All 3rd trimester pregnancy trauma patients All head injury patients Decompression sickness Carbon Monoxide exposure Cyanide exposure WARNING DO NOT ATTEMPT TO AGGRESIVELY NORMALIZE CAPNOMETRY/ETCO2 READINGS IN THE FOLLOWING PATIENTS:    Cardiac arrest pre/post ROSC Bronchospasm (i.e., asthma, COPD) High EtCO2 levels are acceptable and even desired in these patients FOREIGN BODY AIRWAY OBSTRUCTION:    Apply abdominal thrusts on a conscious patient until unresponsive Unresponsive patient receives chest compressions INFANTS: Apply chest compressions and back blows If unable to relieve the FBAO, visualize it with a laryngoscope and extract the foreign body with magill forceps If unable to extract FBAO or adequately ventilate, perform a cricothyroidotomy or needle cricothyroidotomy on Pediatrics If air exchange is adequate with a partial airway obstruction, DO NOT interfere, instead encourage the patient to cough up the obstruction Attention IF SPONTANEOUS BREATHING IS NOT PRESENT AFTER REMOVAL OF FBAO; THERE IS FAILURE TO VENTILATE; FAILURE TO MAINTAIN AIRWAY PATENCY OR RAPID DETERIORATION OF CLINICAL PRESENTATION REFER TO: DELAYED SEQUENCE INTUBATION PROTOCOL BACK TO TABLE OF CONTENTS Ventilatory Assistance 17 Transport Destinations Revision Date: August 1, 2020 INFORMATION: Every effort shall be made to encode patient information to the receiving facility including patients being transported by Air Rescue, especially priority patients such as Cardiac Arrests and any Medical Alerts. Priority 1:   Patients in Cardiac or Respiratory Arrest Trauma Alerts (Level 1 ONLY)  Trauma patients who arrest in the presence of Fire Rescue personnel, shall be transported to the closest Trauma Center Priority 2:  Unstable patients with immediate life-threatening conditions requiring immediate attention by ER personnel on arrival.  All “ALERTS”: STEMI CARDIAC, STROKE, SEPSIS, NON-STEMI CARDIAC, LEVEL 2 TRAUMA  (Excludes Level 1 Trauma) Priority 3:  Stable patients with no immediate life-threatening conditions WARNING Placing patients in the prone position is contraindicated due to the risks of asphyxiation. However, impalement or other situations may mandate the prone position. In these instances, clear documentation of justification and attention to airway maintenance is mandatory. ADULT PRIORITY 1 PATIENTS  CARDIAC ARREST with ROSC:  Transport to the closest STEMI facility  CARDIAC ARREST without ROSC:  Transport to the closest ED (excluding free standing ED’s)  TRAUMA ALERT (LEVEL 1):   BACK TO TABLE OF CONTENTS Shall be transported to the closest Trauma Center. If on bypass, transport patient to the next closest Trauma Center.  A minimum of 2 paramedics must accompany a TRAUMA ALERT patient in the back of the rescue, provided it does not cause a significant delay in transport.  On-scene times for TRAUMA ALERT patients should be < 10 minutes. On-scene times > 10 minutes shall have the reason for the delay documented in the ePCR report.  If ground transport is > 20 minutes transport by air, if available. PREGNANT TRAUMA ALERT (LEVEL 1): Transport to BHMC by air when possible Transport Destinations 18 Transport Destinations continued… Revision Date: August 1, 2020 PRIORITY 2 PATIENTS  Shall be transported to the closest appropriate ED  LEVEL 2 TRAUMA PATIENTS:  Shall be transported to the closest Trauma Center. If on bypass, transport patient to the next closest Trauma Center.  A minimum of 2 paramedics should accompany a LEVEL 2 TRAUMA patient in the back of the rescue if available, provided it does not cause a significant delay in transport.  PREGNANT LEVEL 2 TRAUMA - visibly or by history of gestation > 20 weeks:  Pregnant patients meeting Trauma Alert criteria should be transported to Broward Health Medical Center by air whenever possible STEMI ALERTS:  Shall be transported to the closest STEMI facility   Patient presentations that are indicative of myocardial ischemia that DO NOT meet “STEMI Alert Criteria” should still be transported to a STEMI facility.  STROKE ALERTS:  All Stroke Alerts shall be transported to a Comprehensive Stroke Center  SEPSIS ALERT:  All Sepsis Alerts shall be transported to closest ED (excluding free standing ED’s). HYPERBARIC CHAMBER (if needed) Contact St Mary's or Mercy for UNSTABLE PATIENTS:   INTUBATED INTERFACILITY TRANSFERS:  Should be both paralyzed and sedated by the sending facility  If the sending facility physician refuses to administer paralytics, the EMS Officer in charge must:  Follow the Delayed Sequence Intubation protocol  Accompany the patient to the receiving facility PRIORITY 3 PATIENTS  FREE STANDING ED’S: Stable patients may be transported to a “Free Standing ED” after determining that the patient meets Free Standing ED transport criteria: FREE STANDING E.D. TRANSPORT INCLUSION CRITERIA The following conditions are acceptable impressions that are suitable for transport to the freestanding emergency department: Stable patients with medical or trauma complaints not likely to require emergent admission or acute surgical intervention. These include, but are not limited to:  Minor respiratory complaints without abnormal breath sounds and/or SaO2  Fever, chills, cough, congestion flu-like symptoms Non-medical chest pain (without other profound signs and symptoms, abnormal EKG, multiple or complicated pre-existing medical conditions).    Isolated musculoskeletal or orthopedic injuries Urinary symptoms  Nausea/vomiting/diarrhea complaints without signs of shock BACK TO TABLE OF CONTENTS Transport Destinations 19 Transport Destinations continued… Revision Date: August 1, 2020 FREE STANDING E.D. TRANSPORT INCLUSION CRITERIA....continued  Isolated head trauma in adults without acute neurological deficits or high index of suspicion of a more complex problem   General abdominal or flank pain without signs of acute abdomen or surgical emergency Traumatic injuries not likely to require urgent surgical intervention  Soft tissue injuries, lacerations, puncture wounds  Minor gynecological complaints (pelvic pain without signs of shock or severe pain or symptoms consistent with acute abdomen).  Pediatric patients with general medical complaints without significant signs and symptoms of shock, cardiac symptoms, impending respiratory failure, altered mental status or have complicated pre-existing conditions likely to require admission to a pediatric facility.   OBSTETRICAL:  Obstetrical (OB) patients are defined as gestation > 20 weeks  Unstable OB patients should be transported to the closest OB ED  Stable OB patients should be transported to the OB ED of their choice BAKER ACT PATIENTS: Baker Act patients shall be transported to the closest appropriate ED for medical clearance  PEDIATRICS FOR THE PURPOSES OF MEDICAL TRANSPORTS, A PEDIATRIC PATIENT IS 17 YEARS OLD OR YOUNGER AND FOR TRAUMA TRANSPORTS A PEDIATRIC PATIENT IS CONSIDERED 15 YEARS OLD OR YOUNGER PRIORITY 1 PATIENTS    RESPIRATORY ARREST: Transport to the closest Pediatric ED CARDIAC ARREST with/without ROSC: Transport to the closest Pediatric ED TRAUMA ALERT (LEVEL 1):     Shall be transported to the closest Pediatric Trauma Center. If on bypass, transport patient to the next closest Pediatric Trauma Center. A minimum of 2 paramedics must accompany a TRAUMA ALERT patient in the back of the rescue, provided it does not cause a significant delay in transport. On-scene times for TRAUMA ALERT patients should be < 10 minutes. On-scene times > 10 minutes shall have the reason for the delay documented in the ePCR report. If ground transport is > 20 minutes transport by air, if available. PRIORITY 2 PATIENTS  LEVEL 2 TRAUMA PATIENTS: < 16 YEARS OLD  Shall be transported to the closest Pediatric Trauma Center. If on bypass, transport patient to the next closest Pediatric Trauma Center.  A minimum of 2 paramedics should accompany a LEVEL 2 TRAUMA patient in the back of the rescue if available, provided it does not cause a significant delay in transport. BACK TO TABLE OF CONTENTS Transport Destinations 20 Helicopter Transport Criteria Revision Date: August 1, 2020 ADULT & PEDIATRIC Air Rescue is available through Broward Sherriff’s Office Fire Rescue. “STAND BY” status is no longer an operational term. Air Rescue is on a “Go” or “No-Go” status. If Air Rescue is needed they should be requested as soon as possible. Approximate dispatch to launch time: 5-7 mins. Air Rescue can be canceled at anytime. HELICOPTER TRANSPORT CRITERIA:  Pre-hospital ground transport to a Trauma Center is > 20 minutes  Pre-hospital scene extrication time of a trauma patient is > 20 minutes  Mass Casualty Incidents (MCI) involving multiple patients with traumatic injuries  Use of blood products at the scene  STROKE ALERTS:  If ground transport is > 40 minutes, transport by air if available  All pediatric Stroke Alerts shall be transported to Joe DiMaggio (preferred) or Broward Health Medical Center HELICOPTER MAY BE USED:  For patients weighing 350lbs-500lbs, discretion should be used as to whether air transport is the preferred method of transport  The flight crew must be capable of loading, unloading, and treating the patient within the confines of the aircraft  The flight crew has final authority to accept or reject the transport HELICOPTER SHALL NOT BE USED:  Bariatric patient known or estimated to be five-hundred pounds (500lbs) (227kg) or greater  Patient who is unable to lay supine (when clinically indicated for air transport)  Patient who is combative and cannot be physically and/or chemically restrained  Hazmat contaminated patient  Patients in police custody BACK TO TABLE OF CONTENTS Helicopter Transport Criteria 21 Revision Date: August 1, 2020 BACK TO TABLE OF CONTENTS Medical Emergencies 22 Acute Adrenal Insufficiency Revision Date: August 1, 2020 INFORMATION  Adrenal insufficiency or Addison’s disease is an endocrine disorder that occurs when the adrenal glands do not produce sufficient amounts of cortisol and other glucocorticoid hormones needed to respond to stress and inflammatory reactions. Early Signs and Symptoms include:     Pallor Dizziness Headache Weakness/lethargy    Abdominal pain Nausea/vomiting Hypoglycemia (Check BGL during assessment) ADULT  NORMAL SALINE:  1L IV/IO, titrate to maintain SBP ≥ 90 mmHg  Repeat 1x prn  SOLU-MEDROL  125mg IV/IO/IM, over 2 minutes for IV/IO usage IF PATIENT REMAINS HYPOTENSIVE  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration PEDIATRIC   NORMAL SALINE:  20 mL/kg IV/IO, titrate to maintain age appropriate SBP, New born: 10 mL/kg IV/IO  Repeat 1x prn SOLU-MEDROL  2 mg/kg IV/IO/IM, over 2 minutes for IV/IO usage  Max dose 125mg IF PATIENT REMAINS HYPOTENSIVE  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration BACK TO TABLE OF CONTENTS Acute Adrenal Insufficiency 23 Allergic Reaction Revision Date: August 1, 2020 INFORMATION   Allergic reactions are characterized by any of the following:  Generalized urticaria  Airway swelling, respiratory distress, bronchospasm, tongue and/or facial swelling  Nausea, vomiting, or diarrhea  Loss of radial pulse or SBP of < 90 mm Hg Determine the source of the allergic reaction (insect, food, medications, etc.) ADULT MILD – Generalized Urticaria ONLY  BENADRYL:  50mg IV/IO/IM, SLOW IV/IO usage  Dilute with 9mL NORMAL SALINE for IV/IO administration MODERATE – Airway Swelling/Respiratory Distress/ Bronchospasm/Tongue AND/OR Facial Swelling   EPINEPHRINE (1:1,000, 1mg/mL):  0.3mg (0.3mL) IM  May repeat 2x prn, in 5 minute intervals  Precaution - DO NOT administer within 5 minutes of Epi-Pen administration BENADRYL:  50mg IV/IO/IM, SLOW for IV/IO usage  Dilute with 9mL NORMAL SALINE for IV/IO administration  ALBUTEROL + ATROVENT  Albuterol 2.5mg via nebulizer  Atrovent 0.5 mg via nebulizer  May repeat 2x prn  SOLU-MEDROL:  125mg IV/IO/IM, over 2 minutes for IV/IO usage SEVERE – Loss of a Radial Pulse or SBP of < 90 mmHg  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration  NORMAL SALINE: (in conjunction with above)  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients    BENADRYL: as noted above ALBUTEROL + ATROVENT: as noted above SOLU-MEDROL: as noted above BACK TO TABLE OF CONTENTS Allergic Reaction 24 Allergic Reaction continued… Revision Date: August 1, 2020 PEDIATRIC MILD – Generalized Urticaria ONLY  BENADRYL:  1 mg/kg IV/IO/IM, over 2 minutes IV/IO usage  Dilute with 9mL NORMAL SALINE for IV/IO administration  Max dose 50mg MODERATE – Airway Swelling/Respiratory Distress/ Bronchospasm/Tongue AND/OR Facial Swelling  EPINEPHRINE (1:1,000, 1mg/mL):  0.01 mg/kg IM, max single dose 0.3mg  May repeat 2x prn, in 5 minute intervals  Precaution - DO NOT administer within 5 minutes of Epi-Pen administration  BENADRYL:  1mg/kg IV/IO/IM over 2 minutes for IV/IO usage  Dilute with 9mL of NORMAL SALINE for IV/IO administration  Max dose 50mg ALBUTEROL + ATROVENT  Albuterol 2.5mg via nebulizer, < 1 y/o 1.25mg  Atrovent 0.5 mg via nebulizer, < 1 y/o 0.25mg  May repeat prn   SOLU-MEDROL:  2 mg/kg IV/IO/IM, over 2 minutes for IV/IO usage  Max dose 125mg SEVERE – Loss of a Brachial/Radial Pulse or age appropriate hypotension  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration  NORMAL SALINE:  20mL/kg IV/IO, assess lung sounds and BP frequently. New born: 10 mL/kg IV/IO  May repeat 2x prn, for age appropriate hypotension    BENADRYL: as noted above ALBUTEROL + ATROVENT: as noted above SOLU-MEDROL: as noted above BACK TO TABLE OF CONTENTS Allergic Reaction 25 Diabetic Emergencies Revision Date: August 1, 2020 INFORMATION  Diabetic patients taking oral hypoglycemic medications should be transported (e.g., Glyburide, Glimepiride, and Glipizide). ADULT BGL < 60 mg/dL  ORAL GLUCOSE:     15g PO May repeat 1x prn Contraindication - Patients who are not conscious enough to swallow DEXTROSE 10% (D10) :   100 mL IV/IO, May repeat 1x prn, Max dose 200 mL Retest glucose BGL < 60 mg/dL IN CARDIAC ARREST  DEXTROSE 10% (D10) :  250 mL IV/IO. Rapid infusion IF UNABLE TO PROVIDE ABOVE TREATMENT  GLUCAGON:  1mg IN or IM if available BGL > 300 mg/dL WITH SIGNS & SYMPTOMS OF DKA  Symptoms of Diabetic Ketoacidosis (DKA) include:         Nausea/Vomiting Abdominal pain General weakness Kussmaul Respirations (deep rapid respirations) AMS Hypotension Tachycardia with an acetone smell on the patient’s breath NORMAL SALINE:    BACK TO TABLE OF CONTENTS 1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently. May repeat 1x prn Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients Diabetic Emergencies 26 Diabetic Emergencies continued... Revision Date: August 1, 2020 PEDIATRIC Neonates: BGL < 40 mg/dL BGL < 60 mg/dL   ORAL GLUCOSE: Child 3 years or older  15g, if able to swallow and follow commands  Contraindication:  Patients who are not conscious enough to swallow DEXTROSE 10% (D10) :  5mL/kg IV/IO using 10 gtt/set, Max single dose: 100mL  May repeat 1x prn, Max of 200 mL IF UNABLE TO PROVIDE ABOVE TREATMENT  GLUCAGON:  < 20kg   0.5mg IM/IN (if available) ≥ 20kg  1mg IM/IN (if available) BGL > 300 mg/dL WITH SIGNS & SYMPTOMS OF DKA  NORMAL SALINE:   20mL/kg IV/IO, assess lung sounds and BP frequently, New born: 10 mL/kg IV/IO May repeat 2x prn, for BGL > 300 mg/dl BACK TO TABLE OF CONTENTS Diabetic Emergencies 27 Dystonic Reaction Revision Date: August 1, 2020 INFORMATION  Dystonic reactions are characterized by intermittent spasmodic or sustained involuntary contractions of muscles in the:  Face  Neck  Trunk  Pelvis  Extremities  Even the larynx  The following classes of medications are typically responsible for dystonic reactions:  Antipsychotic (e.g., Haldol, Risperdal, etc...)  Antiemetic (e.g., Compazine, Reglan, Phenergan, etc...)  Antidepressant (e.g., Prozac, Paxil, etc...)  A dystonic reaction can occur immediately or be delayed for hours to days. ADULT  BENADRYL:  50mg IV/IO/IM, over 2 minutes for IV/IO usage  Dilute with 9mL NORMAL SALINE for IV/IO administration PEDIATRIC  BENADRYL:  1mg/kg IV/IO/IM, over 2 minutes for IV/IO usage  Dilute with 9mL NORMAL SALINE for IV/IO administration  Max dose 50mg BACK TO TABLE OF CONTENTS Dystonic Reaction 28 Fluid Resuscitation/Dehydration Revision Date: August 1, 2020 INFORMATION  Indications for fluid resuscitation:  Hypotension  Fatigue  Dark Color Urine  Dry Mouth  Headache  Prolonged vomiting or diarrhea  Non-traumatic bleeding (vaginal or GI)  Suspected Rhabdomyolysis  Paramedic discretion ADULT  NORMAL SALINE:  1L IV/IO, titrate to desired effect.  For trauma patients, use LACTATED RINGERS for the first 1 Liter.  Assess lung sounds and BP frequently.  May repeat 1x prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients PEDIATRIC  NORMAL SALINE:  20mL/kg IV/IO, assess lung sounds and BP frequently, New born: 10 mL/kg IV/IO  May repeat 2x prn, for age appropriate hypotension BACK TO TABLE OF CONTENTS Fluid Resuscitation/Dehydration 29 Hyperkalemia Revision Date: August 1, 2020 INFORMATION  Consider hyperkalemia in patients with a history of renal failure/dialysis who are pre-dialysis and present with any of the following:  General weakness  Cardiac arrhythmias & ECG abnormalities:  Tall peaked T-waves (most prominent early sign)  Sine wave  Wide complex QRS  Regular Really Wide Complex Tachycardia (RRWCT)  Severe bradycardia  High degree AV blocks SINE WAVE PEAKED T-WAVE ADULT FOR PATIENTS PRESENTING WITH ANY OF THE ABOVE CARDIAC ARRHYTHMIAS & ECG ABNORMALITIES  CALCIUM CHLORIDE:  Dilute: 1g of Calcium Chloride in a 100mL D5W Bag using a 10 gtt/set  Administer over 2 minutes IV/IO  Precaution – DO NOT administer in same IV/IO line as SODIUM BICARBONATE without thoroughly flushing  ALBUTEROL:  2.5mg via nebulizer  Continuous treatments (if an advanced airway is utilized, administer via in-line nebulization) SODIUM BICARBONATE:  50 mEq IV/IO, over 2 minutes  Precaution – DO NOT administer in same IV /IO line as CALCIUM CHLORIDE without thoroughly flushing  IF PATIENT IS HYPOTENSIVE  NORMAL SALINE:  500mL IV/IO, titrate to effect. Assess lung sounds frequently.  May repeat 1x prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients PEDIATRIC  Call for orders BACK TO TABLE OF CONTENTS Hyperkalemia 30 Nausea / Vomiting Revision Date: August 1, 2020 INFORMATION:  Consider differential diagnosis:  Cardiac  Stroke  Diabetic  Head Injury  Other ADULT  NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x prn  Precautions: Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients  ZOFRAN:  4mg IV/IO/IM/PO, over 2 minutes for IV/IO usage  May repeat 1x prn , Max dose 8 mg  Precaution: Caution shall be used when the patient has QTc > 460  Zofran may cause headache, lightheadedness/dizziness PEDIATRIC  NORMAL SALINE:  20mL/kg IV/IO, assess lung sounds and BP frequently, New born: 10 mL/kg IV/IO  May repeat 2x prn, for age appropriate hypotension  Precautions: Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients  ZOFRAN: ODT disintegrating tablet—Oral Note: Zofran ODT (PO) DO NOT ADMINISTER to patients less than 20kg  20kg—39kg: 4 mg Sublingual, may NOT repeat  40kg or more: 4 mg Sublingual, may repeat in 10-15 mins max dose 8mg Injection—IV or IM  Less than 40 kg: 0.1mg/kg over 2 minutes for IV/IO/IM   40 kg or more: 4mg over 2 minutes for IV/IO/IM, may repeat in 30 mins, Max dose 8mg Precautions: Zofran may cause headache, lightheadedness/dizziness BACK TO TABLE OF CONTENTS Nausea / Vomiting 31 Respiratory Distress Revision Date: August 1, 2020 INFORMATION  Patients with COPD & Asthma have prolonged exhalation secondary to bronchospasm, which causes air trapping resulting in hypercapnia (high levels of CO2). Therefore, EtCO2 guidelines should be disregarded for these patients, as it is more important to maintain SpO2 levels at 90%. Trying to maintain normal EtCO2 levels in these patients puts them at risk for developing Auto PEEP, which can result in a pneumothorax or hypotension.  Auto PEEP occurs during assisted ventilations when air goes in before the patient is allowed to fully exhale. This causes the lungs to expand like a balloon, putting the patient at risk for a pneumothorax. In addition, increasing intrathoracic pressure can decrease venous return to the heart which can result in hypotension.  COPD or Asthma patients who develop poor bag compliance or hypotension during positive pressure ventilations should have positive pressure ventilations discontinued to allow the patient to completely exhale before resuming positive pressure ventilations.   If patient has an advanced airway, disconnect BVM to allow patient to exhale Positive pressure ventilations should be discontinued for:   Adults: 20-40 seconds Pediatric: 10-20 seconds The following protocols will include but not limited to the treatments of the following conditions:      COPD (INCULDES: EMPHYSEMA & BRONCHITIS) ASTHMA PNEUMONIA CROUP EPIGLOTTITIS BACK TO TABLE OF CONTENTS Respiratory Distress 32 Respiratory Distress continued… Revision Date: August 1, 2020 ADULT BRONCHOSPASM SECONDARY TO COPD, ASTHMA & PNEUMONIA  ALBUTEROL + ATROVENT:  Albuterol 2.5mg via nebulizer. May be administered simultaneously with CPAP  Atrovent 0.5 mg via nebulizer.  May repeat 2x prn  SOLU-MEDROL: (excluding Pneumonia)  125mg IV/IO/IM, over 2 minutes for IV/IO usage FOR SEVERE ASTHMA NOT RESPONDING TO ABOVE TREATMENT  EPINEPHRINE (1:1,000, 1mg/mL):  0.3mg (0.3mL) IM  May repeat 2x prn, in 5 minute intervals  MAGNESIUM SULFATE:  Dilute: 2g of Magnesium Sulfate in a 100mL D5W Bag using 10 gtt/set  Administer over 10 minutes IV/IO nd rd  Contraindication - 2 and 3 Degree Heart Blocks  Precaution - Rapid infusion may cause hypotension MODERATE OR SEVERE RESPIRATORY DISTRESS: (INCLUDING COPD, ASTHMA, AND PNEUMONIA)   CPAP - 10 cm H₂O for CHF CPAP - 2.5—5 cm H2O for ASTHMA, PNEUMONIA, COPD  Contraindications:  SBP < 90mm Hg  Patients without spontaneous respirations  Patients with a decreased LOC (lethargic)  Patients < 30 kg * NOTE: If patient is septic, administer fluids. Refer to Sepsis Protocol WARNING Immediately remove the CPAP for the asthmatic patient whose condition worsens after applying the CPAP. BACK TO TABLE OF CONTENTS Respiratory Distress 33 Respiratory Distress continued… Revision Date: August 1, 2020 PEDIATRIC BRONCHOSPASM  ALBUTEROL + ATROVENT  Albuterol 2.5mg via nebulizer, < 1 y/o 1.25mg  Atrovent 0.5 mg via nebulizer, < 1 y/o 0.25mg  May repeat 2x prn  SOLU-MEDROL:  2mg/kg IV/IO/IM, over 2 minutes for IV/IO usage  Max dose 125 mg FOR SEVERE ASTHMA NOT RESPONDING TO ABOVE TREATMENT  EPINEPHRINE (1:1,000, 1mg/mL):  0.01mg/kg IM, max single dose 0.3mg  May repeat 2x prn, in 5 minute intervals  ALBUTEROL + ATROVENT  Albuterol 2.5mg via nebulizer  Atrovent 0.5 mg via nebulizer  May repeat prn  MAGNESIUM SULFATE:  Dilute: 50mg/kg in a 100mL D5W bag using a 10 gtt/set  Administer over 5-10 minutes IV/IO  Max dose 2g total  Precaution - Rapid infusion may cause hypotension nd rd  Contraindication - 2 and 3 Degree Heart Blocks FOR CROUP/EPIGLOTTITIS  EPINEPHRINE (1:1,000, 1mg/mL):  3mg (3mL total) delivered via nebulizer  Precautions:  DO NOT stress the patient  DO NOT attempt to intubate or place an OPA or NPA  Ventilate via BVM as needed  Expedite transport to closest Comprehensive Pediatric ED BOTH HAVE STRIDOR AND/OR A “BARKY” COUGH Croup: BACK TO TABLE OF CONTENTS Epiglottitis:  Usually < 3 years old  Usually 3-6 years old  “Sick” for a couple of days  Sudden onset  Low grade fever  High grade fever Respiratory Distress 34 Seizure Revision Date: August 1, 2020 INFORMATION  Consider the possible causes:  Meningitis  Drugs  Fever  Alcohol  Head Trauma  Diabetic  Hemorrhagic stroke  Poisoning  Monitoring of EtCO2 shall be performed to determine the patient’s respiratory status.  Obtain blood glucose level  Refer to the “Eclampsia” protocol, for pregnant patients. ADULT IF ACTIVELY SEIZING  VERSED:  5mg IV/IO  May repeat 1x prn, in 5 minutes if seizure reoccurs or does not subside. Max total dose 10mg  10mg IN/IM  Contraindication - Hypotension BP 22) AND/OR EtCO2 (< 25 mm Hg) = 1 point WARNING It is imperative once sepsis is identified, that the patient is kept from becoming hypotensive, as an episode of hypotension significantly increases morbidity and mortality. WARNING  Pneumonia patients with rales still require IV fluids.  Monitor EtCO2 and SpO2 during fluid administration. BACK TO TABLE OF CONTENTS Sepsis 37 Sepsis continued... Revision Date: August 1, 2020 ADULT SEPSIS ALERT: START 2 IVs WHEN POSSIBLE    NORMAL SALINE:  1L IV/IO, regardless of blood pressure, assess lung sounds and BP frequently  MUST repeat 1x if time permits, TOTAL of 2 L  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients CEFTRIAXONE (ROCEPHIN) (ADMINISTER BOTH ANTIBIOTICS):  Dilute: 2g of Rocephin in a 100mL bag of D5W  Administer over 10 minutes IV/IO by utilizing a 10 gtt/set  Contraindication:  Allergy to Cephalosporin antibiotics (e.g., Ancef, Ceclor, Cefdinir, Keflex)  Pediatric Patients GENTAMICIN (ADMINISTER BOTH ANTIBIOTICS):  80 mg IM  Contraindication:  Allergy to Cephalosporin antibiotics (e.g., Ancef, Ceclor, Cefdinir, Keflex)  Pediatric Patients IF PATIENT REMAINS HYPOTENSIVE  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration PEDIATRIC  NORMAL SALINE:  20mL/kg IV/IO, assess lung sounds and BP frequently, New born: 10 mL/kg IV/IO  May repeat 2x prn, for age appropriate hypotension IF PATIENT REMAINS HYPOTENSIVE (AGE APPROPRIATE HYPOTENSION)  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration BACK TO TABLE OF CONTENTS Sepsis 38 Stroke Revision Date: August 1, 2020 INFORMATION  Assess patient for stroke signs and symptoms, including BGL Assessment  If Stroke suspected, patient shall receive a R.A.C.E. assessment.  Call a STROKE ALERT if:  Symptoms are within 24 hours with any of the following:  R.A.C.E. (plus) assessment score > 0  Any patient who awakes with stroke symptoms  If the onset of symptoms are unable to be determined, transport patient as a STROKE ALERT  Obtain the following information:  Last time seen asymptomatic  Witness name  Witness phone number(s)  Patient’s medications  All Stroke Alerts shall ONLY be transported to a COMPREHENSIVE STROKE CENTER  Immediate notification of a Stroke Alert with the R.A.C.E (plus) score needs to be relayed to the COMPREHENSIVE STROKE CENTER.  Minimize the Stroke Alert on-scene time to 10 minutes or less when possible ITEM ASSESSMENT R.A.C.E. "+" (plus) SCORE MOTOR Facial Palsy Ask the patient to show their teeth: “Smile” 0 – Absent (symmetrical movement) 1 – Mild (slightly asymmetrical) 2 – Moderate to Severe (completely asymmetrical) Arm Motor Function Extend the arms of the patient 90 degrees (if sitting) or 45 degree (if supine) palms up 0 – Normal to mild (limb upheld > 10 seconds) 1 – Moderate (limb upheld < 10 seconds) 2 – Severe (patient unable to raise arms against gravity) Leg Motor Function Extend the leg of the patient 30 degrees (if supine) 1 leg at a time 0 – Normal to mild (limb upheld > 5 seconds) 1 – Moderate (limb upheld < 5 seconds) 2 – Severe (patient unable to raise leg against gravity) Head and Eye Gaze Observe range of motion of eyes and look for Deviation head turning to 1 side. CORTICAL Aphasia Agnosia 0 – Absent (normal eye movement to both sides, and no head deviation was observed) 1 – Present (eyes and/or head deviation to 1 side was observed) 0 – Normal (performs both tasks correctly or no difficulty talking) Difficulty following commands: Ask patient to 1 – Moderate (performs 1 task correctly or some difficulty talking) “Close your eyes” and “Make a fist” Difficulty talking: Ask patient to repeat sim2 – Severe (performs neither task or unable to talk) Ask the patient: “Who’s arm is this?” when 0 – Normal appropriate or correct answer showing him or her the weak arm or “Do you 1 – Moderate (does not recognize limb or cannot move it) feel weakness in this arm?” 2 – Severe (both of them) If Cortical Signs are present add a "+" (plus) sign next to total score and include the verbiage "plus" with encode. R.A.C.E. SCALE TOTAL: Max Score of 11 ALL ITEMS SHALL BE EVALUATED REGARDLESS OF LEFT OR RIGHT WEAKNESS BACK TO TABLE OF CONTENTS Stroke 39 Stroke continued... Revision Date: August 1, 2020 ADULT  POSITIONING: Supine  All patients shall be placed in a supine position o  Exception: the below patients shall be placed with head elevated 15  A diagnosed intracerebral hemorrhage (interfacility transport)  Patient is short of breath  OXYGEN:  2 LPM NC if pulse oximetry less than 94%  If the patient is in respiratory distress, manage airway as needed and consider advanced airway intervention  IV ACCESS:  Establish an 18g catheter, the antecubital is preferred  NORMAL SALINE:  500mL IV/IO, regardless of the blood pressure  TRANSPORT TO COMPREHENSIVE STROKE CENTER (ie. Cleveland Clinic, FMC, Broward Health North) PEDIATRIC  POSITIONING: Supine  All patients shall be placed in a supine position o  Exception: the below patients shall be placed with head elevated 15  A diagnosed intracerebral hemorrhage (interfacility transport)  Patient is short of breath  OXYGEN:  2 LPM NC if pulse oximetry less than 94%  If the patient is in respiratory distress, manage airway as needed and consider advanced airway intervention  IV ACCESS:  Establish an appropriate sized catheter  The antecubital is preferred  NORMAL SALINE:  20mL/kg IV/IO, regardless of the blood pressure, New born: 10 mL/kg IV/IO  Max dose 250mL  TRANSPORT:  ALL PEDIATRIC Stroke Alerts SHALL be transported to Joe DiMaggio (preferred) or Broward Health Medical Center BACK TO TABLE OF CONTENTS Stroke 40 Revision Date: August 1, 2020 BACK TO TABLE BACK TO TABLE OF OF CONTENTS CONTENTS Medical Emergencies Cardiac Emergencies 41 41 Atrial Fibrillation/Flutter Revision Date: August 1, 2020 INFORMATION  Rapid atrial fibrillation and atrial flutter are defined as ventricular rates > 150 beats per minute. ADULT  Obtain a 12-lead and leave cables connected STABLE  CARDIZEM:  10 mg IV/IO, over 2 minutes, dilute in 10 mL syringe  If no response in 5 minutes, repeat with 15 mg IV/IO, over 2 minutes  Contraindication:  Hypotension (BP less than 90)  Wide complex QRS  History of WPW  Sick sinus syndrome  Heart blocks  Precautions:  Use with caution for patients taking beta blockers  May cause hypotension, see treatment below UNSTABLE (HYPOTENSION) < 90 mmHg systolic  NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients IF PATIENT BECOMES NORMOTENSIVE AFTER FLUID ADMINISTRATION  CARDIZEM: as noted above IF PATIENT REMAINS HYPOTENSIVE AFTER FLUID ADMINISTRATION  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration CARDIZEM INDUCED HYPOTENSION  NORMAL SALINE: as noted above  CALCIUM CHLORIDE:  500mg IV/IO, over 2 minutes PEDIATRIC  Call for orders BACK TO TABLE OF CONTENTS Atrial Fibrillation/Flutter 42 Bradycardia Revision Date: August 1, 2020 INFORMATION  Bradycardia is defined as a heartrate < 50 beats per minute ADULT  Obtain a 12-lead to rule out an MI and leave cables connected STABLE  Monitor and transport UNSTABLE (HYPOTENSIVE) < 90 mmHg systolic  ATROPINE:  0.5mg IV/IO  May repeat prn, in 3 minute intervals, max total dose 3mg  Contraindication - Bradycardia in the presence of an MI, 2nd degree block Type II, and 3rd Degree block  NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x prn  Precaution - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients IF PATIENT DETERIORATES OR HYPOTENSION PERSISTS AFTER 2 DOSES OF ATROPINE  TRANSCUTANEOUS PACING:  Initial rate of 60 beats per minute and increase milliamps until capture is gained  Increase the rate as needed until the patient is hemodynamically stable SEDATION FOR TRANSCUTANEOUS PACING DO NOT DELAY TRANSCUTANEOUS PACING TO ESTABLISH IV ACCESS  VERSED:  5 mg IV/IO  May repeat 1x prn. Max total dose 10mg  10mg IM/ IN  Contraindication - Hypotension  Precautions:  May administer Versed post pacing if patient becomes normotensive  Monitor for respiratory depression IF PATIENT REMAINS HYPOTENSIVE AFTER ATROPINE OR TRANSCUTANEOUS PACING  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration BACK TO TABLE OF CONTENTS Bradycardia 43 Bradycardia continued... Revision Date: August 1, 2020 PEDIATRIC  Obtain a 12-lead and leave cables connected STABLE  OXYGENATION:  Ensure adequate oxygenation first, as hypoxia is most likely to be the cause of the bradycardia  Monitor and transport UNSTABLE (AMS AND AGE APPROPRIATE HYPOTENSION)  Ensure adequate oxygenation and ventilation first, as hypoxia is most likely to be the cause of the bradycardia   VENTILATION: Neonates:  1 breath every 3 seconds for at least 30 seconds Infants/Children:  1 breath every 3 seconds for at least 1 minute CHEST COMPRESSIONS: (IF PATIENT REMAINS UNSTABLE AFTER VENTILATIONS AND THE HEART RATE REMAINS BELOW 60 BEATS PER MINUTE)  220 compressions every 2 minutes IF NO RESPONSE TO OXYGENATION, VENTILATION, AND CHEST COMPRESSIONS  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration IF BRADYCARDIC AND AGE APPROPRIATE HYPOTENSION PERSISTS AFTER INITIAL DOSE OF EPINEPHRINE  TRANSCUTANEOUS PACING:  Initial rate of 80 beats per minute and increase milliamps until capture is gained  Increase the rate as needed until the patient is hemodynamically stable SEDATION FOR TRANSCUTANEOUS PACING  DO NOT DELAY TRANSCUTANEOUS PACING TO ESTABLISH IV ACCESS  VERSED:  0.1mg/kg IV/IO, over 30 seconds, max single dose 5 mg  May repeat 1x prn. Max total dose 10mg  0.2 mg/kg IN/IM, max single dose of 5mg  May repeat either route 1x prn, in 5 minutes. Max total dose 10mg  Contraindication - Hypotension  Precaution - Monitor for respiratory depression BACK TO TABLE OF CONTENTS Bradycardia 44 Cardiogenic Shock Revision Date: August 1, 2020 INFORMATION  Cardiogenic shock can be characterized as the following:  A condition in which the heart suddenly can’t pump enough blood to meet the body’s needs  Most often caused by a severe heart attack  Rare, but often fatal if not treated immediately ADULT  Obtain a 12-lead and leave cables connected LEFT VENTRICULAR FAILURE: PULMONARY EDEMA AND HYPOTENSION  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration RIGHT VENTRICULAR FAILURE: POSITIVE V4R, CLEAR LUNG SOUNDS WITH HYPOTENSION  NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x prn  Precaution - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients IF PATIENT REMAINS HYPOTENSIVE AFTER FLUID ADMINISTRATION  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000): as noted above PEDIATRIC IF UNSTABLE (AMS AND AGE APPROPTIATE HYPOTENSION)  NORMAL SALINE:  20 mL/kg IV/IO, assess lung sounds and BP frequently, New born: 10 mL/kg IV/IO  May repeat 2x prn, for age appropriate hypotension  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration BACK TO TABLE OF CONTENTS Cardiogenic Shock 45 Chest Pain Revision Date: August 1, 2020 INFORMATION  Assume chest pain to be cardiac in nature until ruled out. ADULT    Obtain a 12-lead and leave cables connected The right hand and right wrist should be avoided for vascular access if at all possible. These sites may be utilized for cardiac catheterization. The right AC and anywhere on the left is acceptable  ASPIRIN:  162 mg— 324 mg PO  Contraindications:  < 16 years old  Active GI bleeding  FENTANYL:  100mcg IV/IO/IN/IM  May repeat 2x prn, in 5 minute intervals, max total dose 300mcg  Contraindication - Pregnancy near term (32 weeks or greater) or in active labor  Precautions:  History of opiate abuse or drug seeking behavior  Monitor patient for respiratory depression  Discontinue if patient becomes drowsy  Can be reversed with NARCAN if necessary IF PAIN/DISCOMFORT PERSISTS AFTER MAXIMUM FENTANYL ADMINISTRATION OR DRUG SEEKING BEHAVIOR IS SUSPECTED  NITROGLYCERIN:  0.4mg SL  May repeat 2x prn, in 5 minute intervals  Contraindications:  SBP < 90 mm Hg  Heart Rate < 50 beats per minute or > 100 beats per minute  EDD (Viagra and Levitra within 24 hours and Cialis within 48 hours).  Right Ventricular Infarction (positive V4R) (refer to the “Cardiogenic Shock” protocol for right ventricular failure)  STEMI PEDIATRIC  Call for orders Patients experiencing chest pain shall have multiple 12-leads performed throughout assessment and transport. BACK TO TABLE OF CONTENTS Chest Pain 46 STEMI Alert Revision Date: August 1, 2020 INFORMATION   This protocol may be run concurrent with the chest pain protocol as applicable. STEMI Symptoms can be various and include:  Discomfort of the chest, arm, neck, back, shoulder or jaw  Syncope or near syncope  General weakness  Unexplained diaphoresis  SOB  Nausea/Vomiting STEMI ALERT CRITERIA  ST-Segment Elevation in 2 or more contiguous leads:  Convex (frown face) or straight morphology (any of the following):  2mm or greater in V2 and V3  1mm or greater in all other leads  Concave (smiley face) morphology  2mm or greater in any lead  All STEMI Alerts shall be transported as priority 2 STEMI ALERT DISQUALIFIERS  The following are STEMI mimics:  Left Bundle Branch Block (QRS complexes > 0.12)  Unless new onset confirmed by EKG  Pacemaker with QRS complexes > 0.12  Left Ventricular Hypertrophy (LVH)  Pericarditis  Early repolarization  < 2mm of elevation with a concave (smiley face) morphology  Patient presentations indicative of myocardial ischemia that DO NOT meet “STEMI Alert Criteria” should still be transported as a CARDIAC ALERT LEFT VENTRICULAR HYPERTROPHY FORMULA (LVH)  Count the small boxes of VI and V2 (“S” wave), the largest negative deflection from the isoelectric line (whichever is larger)  Count the small boxes of V5 or V6 (“R” wave), the largest positive deflection from the isoelectric line (whichever is larger)  Add the 2, if the result is > 35, suspect LVH BACK TO TABLE OF CONTENTS STEMI Alert 47 STEMI Alert continued... Revision Date: August 1, 2020 V4R  A V4R shall be completed on patients with ST segment elevation in 2 or more Inferior Leads (II, III, AVF) RIGHT VENTRICULAR FAILURE: POSITIVE V4R, CLEAR LUNG SOUNDS WITH HYPOTENSION   NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently  May repeat 1x prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients If pulmonary edema and hypotension present, refer to Cardiogenic Shock Protocol WITH OR WITHOUT CHEST PAIN  ASPIRIN  162 mg— 324 mg PO  Contraindications:  < 16 years old  Active GI bleeding BACK TO TABLE OF CONTENTS STEMI Alert 48 CHF (Pulmonary Edema) Revision Date: August 1, 2020 INFORMATION  Signs & Symptoms:  Hypertension  Tachycardia  Orthopnea (SOB while lying flat)  Rales  Pedal Edema ADULT Obtain a 12-lead and leave cables connected  NITROGLYCERIN:  0.8mg SL (2 tablets), as long as BP is > 90 mmHg  May repeat with 0.4mg SL (1 tablet), 1x prn, every 5 minutes, Max dose 1.2mg  Contraindications:  SBP < 90 mmHg  Heart Rate < 50 beats per minute  EDD (Viagra and Levitra within 24 hours and Cialis within 48 hours).  STEMI  Right Ventricular Infarction (positive V4R)  (refer to the “Cardiogenic Shock” protocol for right ventricular failure)  CPAP - (10 cm H₂O):  Contraindications:  SBP < 90 mm Hg  Patients without spontaneous respirations  Patients with a decreased LOC (lethargic)  Patients < 30 kg PEDIATRIC  Call for orders BACK TO TABLE OF CONTENTS CHF (Pulmonary Edema) 49 Supraventricular Tachycardia Revision Date: August 1, 2020 INFORMATION  The distinction between Sinus Tachycardia (ST) and Supraventricular Tachycardia (SVT) can be difficult at very rapid rates. Utilize the following criteria to assist in determination of Sinus Tachycardia vs SVT:  SVT will generally have no discernible P-waves or there may be P-waves just after the QRS complex  History that favors Sinus Tachycardia (e.g., dehydration, fever, pain, anxiety, physical activity, exertional heat stroke, etc.)  Vagal maneuvers may gently slow down Sinus Tachycardia but will either not affect SVT OR abruptly break the SVT (SVT shouldn't gently terminate).  Adult:  QRS width < 0.12 (3 small boxes)  Rate > 150 beats per minute after Sinus Tachycardia has been ruled out  Pediatric:  QRS width < 0.09 (2 small boxes)  SVT in pediatrics is considered > 180 beats per minute  SVT in infants is considered > 220 beats per minute ADULT  Obtain a 12-lead and leave cables connected STABLE (AAOX4 WITH/WITHOUT HYPOTENSION)  VAGAL MANEUVERS (ie. Blow into a 10mL syringe)  ADENOSINE:  12mg rapid IV/IO, with a simultaneous 10mL NORMAL SALINE flush  If not resolved , after 2 minutes, 12mg rapid IV/IO with simultaneous 10mL flush  Print ECG during administration  Contraindication:  Heart Transplant  Patients taking Tegretol (Carbamazepine)  Patients with a history of second or third degree AV block (except in patients with a functioning artificial pacemaker)  Sick Sinus Syndrome without cardiac pacemaker in place  Active bronchospasm IF SVT FAILS TO CONVERT OR ADENOSINE IS CONTRAINDICATED  CARDIZEM:  10mg IV/IO, over 2 minutes, dilute in 10 mL syringe  If no response in 5 minutes, repeat with 15 mg IV/IO, over 2 minutes  Contraindication:  Hypotension  Wide complex QRS  History of WPW or sick sinus syndrome  Cardiovert WPW instead if unstable  Heart Blocks  Precautions:  Use with caution for patients taking beta blockers  May cause hypotension, see treatment on following page BACK TO TABLE OF CONTENTS Supraventricular Tachycardia 50 Supraventricular Tachycardia cont... Revision Date: August 1, 2020 CARDIZEM INDUCED HYPOTENSION   NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients CALCIUM CHLORIDE:  500mg IV/IO, over 2 minutes UNSTABLE (ALTERED MENTAL STATUS WITH HYPOTENSION) NOTE  DO NOT DELAY CARDIOVERSION TO ESTABLISH IV ACCESS Zoll Joules: Adult  VERSED (consider for sedation): Synchronized Cardioversion  5 mg IV/IO 70j, 120j, 150j, 200j  May repeat 1x prn. Max total dose 10mg  10mg IM/IN  SYNCHRONIZED CARDIOVERSION:  100j, 200j, 300j, 360j  If cardioversion fails, call for orders  Contraindication - A-Fib or A-Flutter  Precaution - A brief trial of ADENOSINE can be used prior to cardioversion for a diagnostic tool if you suspect the underlying rhythm to be A-Fib or A-Flutter PEDIATRIC  Obtain a 12-lead and leave cables connected STABLE (AAOX4 WITH/WITHOUT AGE APPROPRIATE HYPOTENSION)   VAGAL MANEUVERS (ie. Blow into a 10 mL syringe) ADENOSINE:  0.1mg/kg rapid IV/IO, with a simultaneous 10mL NORMAL SALINE flush  Max dose 6mg  If no change in 1 minute:  0.2mg/kg rapid IV/IO, with a simultaneous 10mL NORMAL SALINE flush  Max dose 12mg  Print ECG during administration  Contraindication - A-Fib or A-Flutter UNSTABLE (ALTERED MENTAL STATUS WITH AGE APPROPRIATE HYPOTENSION)    DO NOT DELAY CARDIOVERSION TO ESTABLISH IV ACCESS VERSED (consider for sedation):  0.1mg/kg IV/IO, over 30 seconds, max single dose 5 mg  0.2 mg/kg IN/IM, refer to Handtevy  May repeat 1x prn. Max total dose 10mg SYNCHRONIZED CARDIOVERSION:  0.5j/kg  If not effective, increase to 1j/kg, then 2j/kg  If cardioversion fails, call for orders  Contraindication - A-Fib or A-Flutter BACK TO TABLE OF CONTENTS Supraventricular Tachycardia 51 Wide Complex Tachycardia Revision Date: August 1, 2020 INFORMATION ECG FEATURES THAT FAVOR A DIAGNOSIS OF WIDE COMPLEX TACHYCARDIA (WCT):  WCT has no discernible P waves  Precordial concordance: All chest leads point in the same direction (either positive OR negative)  Negative Lead V6  Backward frontal plane axis: II, III, and aVF are negative, aVL and aVR are positive  Presence of capture beats or fusion beats (sinus beats that interrupt the WCT)  Rate usually > 120 beats per minute  QRS width > 0.12 (3 small boxes) WCT ADULT  Obtain a 12-lead and leave cables connected STABLE WIDE COMPLEX TACHYCARDIA (WCT)  AMIODARONE INFUSION:  Dilute: 150mg of AMIODARONE in a 100mL bag of D5W  Administer over 10 minutes IV/IO using a 10 gtt/set  Administer all 150mg, even if the WCT terminates  May repeat 1x prn, Max dose of 300mg  Contraindications:  Marked sinus bradycardia  Cardiogenic Shock nd rd  2 and 3 Degree Heart Blocks  Hypotension  QTc > 460 UNSTABLE WCT (with contraindication to Amiodarone) OR QTC > THAN 460    DO NOT delay cardioversion to establish IV access NOTE VERSED (consider for sedation): Zoll Joules: Adult  5 mg IV/IO, 10 mg IM/IN Synchronized Cardioversion  May repeat 1x prn. Max total dose 10mg 70j, 120j, 150j, 200j SYNCHRONIZED CARDIOVERSION:  100j, 200j, 300j, 360j  If a WCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed  Contraindication - WCTs that are irregularly-irregular BACK TO TABLE OF CONTENTS Wide Complex Tachycardia 52 Wide Complex Tachycardia cont... Revision Date: August 1, 2020 WCT PATIENT’S WHO CONVERT AFTER CARDIOVERSION  Immediate 12 lead to rule out any contraindications to AMIODARONE  AMIODARONE INFUSION: as noted on the previous page (if not already administered)  Only for patient’s who convert after (any of the following):  2 cardioversions by Fire Rescue  2 or more shocks by their Implantable Cardioverter (ICD)  DO NOT administer Amiodarone if the patient has already received Amiodarone PEDIATRIC   Pediatrics that have a QRS width ≥ 0.09 (2.25 boxes) Obtain a 12-lead and leave cables connected STABLE WIDE COMPLEX TACHYCARDIA  AMIODARONE INFUSION:  Dilute: 5mg/kg of AMIODARONE in a 100 mL bag of D5W, max single dose 150mg  Administer over 10 minutes IV/IO using a 10 gtt/set  May repeat 1x prn  Contraindications:  Marked sinus bradycardia  Cardiogenic Shock nd rd  2 and 3 Degree Heart Blocks  Hypotension  QTc > 460 UNSTABLE WIDE COMPLEX TACHYCARDIA (AGE APPROPRIATE HYPOTENSION)  DO NOT delay cardioversion to establish IV access  VERSED (consider for sedation):  0.1mg/kg IV/IO, over 30 seconds, max single dose 5 mg  0.2 mg/kg IN/IM, refer to Handtevy  May repeat 1x prn. Max total dose 10mg  SYNCHRONIZED CARDIOVERSION:  0.5j/kg  If no response, increase to 1j/kg, then 2j/kg  If a WCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed  Contraindication - WCTs that are irregularly-irregular PATIENT’S WHO CONVERT AFTER CARDIOVERSION  Immediate 12 lead to rule out any contraindications to AMIODARONE  AMIODARONE INFUSION: as noted above (if not already administered)  Only for patient’s who convert after (any of the following):  2 cardioversions by Fire Rescue  2 or more shocks by their Implantable Cardioverter (ICD) administer  DO NOT administer Amiodarone if the patient has already received Amiodarone BACK TO TABLE OF CONTENTS Wide Complex Tachycardia 53 Regular Really Wide Complex Tachycardia Revision Date: August 1, 2020 INFORMATION ECG FEATURES THAT FAVOR A DIAGNOSIS OF REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT):  RRWCT in adults has a QRS width ≥ 0.20 (5 small boxes or 1 large box)  Rate usually < 120 beats per minute RRWCT ADULT & PEDIATRIC STABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT)  CALCIUM CHLORIDE:  ADULT: 1g IV/IO in a 100ml bag of D5W, over 2 minutes  PEDIATRIC: 20mg/kg IV/IO over 2 minutes  Precaution – DO NOT administer in same IV/IO line as SODIUM BICARB without thoroughly flushing  SODIUM BICARBONATE:  ADULT: 100 mEq, IV/IO, over 2 minutes  PEDIATRIC: 1 mEq/kg IV/IO, over 2 minutes, Max single dose 50 mEq  May repeat 1x prn, in 5 minutes, Max total dose 100 mEq  Precaution – DO NOT administer in same IV /IO line as CALCIUM CHLORIDE without thoroughly flushing UNSTABLE RRWCT (HYPOTENSION)    DO NOT delay cardioversion to establish IV access NOTE VERSED (consider for sedation): Zoll Joules: Adult  5 mg IV/IO Synchronized Cardioversion  May repeat 1x prn. Max total dose 10mg 70j, 120j, 150j, 200j  10 mg IM/IN SYNCHRONIZED CARDIOVERSION:  ADULT: 100j, 200j, 300j, 360j  PEDIATRIC: 0.5j/kg, 1j/kg, 2j/kg  If a WCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed  Contraindication - WCTs that are irregularly-irregular IF UNSTABLE RRWCT FAILS TO CONVERT AFTER CARDIOVERSION OF 360J  CALCIUM CHLRIDE : as noted above  SODIUM BICARBONATE: as noted above  SYNCHRONIZED CARDIOVERSION: with max joules as noted above BACK TO TABLE OF CONTENTS Regular Really Wide Complex Tachycardia 54 Polymorphic V-Tach/Torsades Revision Date: August 1, 2020 INFORMATION  Torsades de Pointes is an uncommon form of V-Tach characterized by a changing in amplitude or “twisting” of the QRS complexes.  Risk factors for Torsades:  Congenital long QT syndrome  Female gender  Renal/Liver failure  Medications that cause QT interval prolongation (e.g., anti-dysrhythmics, calcium channel blockers, psychiatric drugs, antihistamines) ADULT  Obtain a 12-lead and leave cables connected STABLE POLYMORPHIC V-TACH  MAGNESIUM SULFATE:  Concentration: 1g/2mL (500mg/mL)  Dilute: 2g of Magnesium Sulfate in a 100mL bag of D5W  Administer IV/IO utilizing a 60 gtt set, run wide open (runs approx. over 2 min) nd rd  Contraindication – 2 and 3 Degree Heart Blocks  Precaution - Rapid infusion may cause hypotension IF RHYTHM CONVERTS AFTER INITIAL DOSE OF MAG, START A MAINTENANCE INFUSION:  1 g in 250mL bag of NORMAL SALINE at 30-60 gtts/min with 60 gtt/set UNSTABLE POLYMORPHIC V-TACH (HYPOTENSION)   DO NOT delay defibrillation to establish IV access DEFIBRILLATION: 200j, 300j, 360j  If a PVT converts with defibrillation and later returns to a PVT, use the last successful energy setting and increase as needed NOTE Zoll Joules: Adult Defibrillation 120j, 150j, 200j IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED  MAGNESIUM SULFATE:  Concentration: 1g/2mL (500mg/mL)  Dilute: 2g of Magnesium Sulfate in a 100mL bag of D5W  Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 100 gtts/min (1.6 gtts/sec) nd rd  Contraindication – 2 and 3 Degree Heart Blocks  Precaution - Rapid infusion may cause hypotension Torsades BACK TO TABLE OF CONTENTS Polymorphic V-Tach 55 Polymorphic V-Tach/Torsades continued… Revision Date: August 1, 2020 PEDIATRIC  Obtain a 12-lead and leave cables connected STABLE POLYMORPHIC V-TACH  MAGNESIUM SULFATE:  Concentration: 1g/2mL (500mg/mL)  Dilute: 50mg/kg in a 100mL bag of D5W  Administer desired dose, over 10 minutes IV/IO utilizing a 10 gtt set delivering 100gtts/min (1.6 gtts/sec)  Refer to Handtevy  Max dose 2g nd rd  Contraindication – 2 and 3 Degree Heart Blocks  Precaution - Rapid infusion may cause hypotension UNSTABLE POLYMORPHIC V-TACH (AGE APPROPRIATE HYPOTENSION)   DO NOT delay defibrillation to establish IV access DEFIBRILLATION:  2j/kg, 4j/kg, 6j/kg, 8j/kg. Refer to Handtevy  If a PVT converts with defibrillation and later returns to a PVT, use the last successful energy setting and increase as needed IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED  MAGNESIUM SULFATE:  Concentration: 1g/2mL (500mg/mL)  Dilute: 50mg/kg in a 100mL bag of D5W  Administer desired dose, over 10 minutes IV/IO utilizing a 10 gtt set delivering 100gtts/min (1.6 gtts/sec)  Refer to Handtevy  Max dose 2g nd rd  Contraindication – 2 and 3 Degree Heart Blocks  Precaution - Rapid infusion may cause hypotension BACK TO TABLE OF CONTENTS Polymorphic V-Tach 56 Left Ventricular Assist Device Revision Date: August 1, 2020 INFORMATION Left Ventricular Assist Devices (LVADs), also known as Heart Pumps, are surgically implanted circulatory support devices designed to assist the pumping action of the heart. Caring for these patients is complicated and every effort should be made to contact the patient’s primary caretaker (spouse, guardian etc.) and the LVAD coordinator during your evaluation. Patients with a properly functioning LVAD may NOT have a detectable pulse, measurable blood pressure or accurate oxygen saturation. ADULT  Every effort should be made to contact the patient’s primary caretaker (spouse, guardian etc.) and the LVAD coordinator immediately  The phone number for LVAD coordinator will be on the device and the equipment carrying bag  If needed, assist patient (caretaker) in replacing the device’s batteries or cables.  Locate patient’s emergency “bag” with backup equipment  Take all equipment associated with the LVAD system to the ED  Treat Non–LVAD associated conditions in accordance with the appropriate protocol  AUSCULTATE:   Determine the type of device, assess alarms, auscultate for pump sounds  Patients with a properly functioning LVAD may NOT have a detectable pulse, measurable blood pressure or accurate oxygen saturation  Auscultate chest and upper abdominal quadrants. Continuous humming sound = pump is working. Locate the driveline site on the patient’s abdomen  DO NOT cause any trauma to the driveline site or wires  If there is bleeding at the driveline site, apply direct pressure HYPO-PERFUSION  NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and check perfusion frequently.  May repeat 1x, prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients BACK TO TABLE OF CONTENTS Left Ventricular Assist Device 57 Left Ventricular Assist Device cont… Revision Date: August 1, 2020 ADULT UNRESPONSIVE PATIENTS  ONLY perform chest compressions when the patient’s LVAD is not working and no other options exist to restart the LVAD  Evaluate unresponsive patients carefully for reversible causes by assessing:  A.E.I.O.U.-T.I.P.S. (refer to pg. 13, Patient Assessment)  H’s & T’s (Refer to Cardiac Arrest Standing Orders)  CHECK BGL  CHEST COMPRESSIONS:  Position hands to the right of the sternum to avoid LVAD dislodgement  Contraindication:  DO NOT use the LUCAS Compression Device Precaution - Performing Chest Compressions risks rupturing of the ventricular wall leading to fatal hemorrhage  TRANSPORT PACKAGING AN LVAD PATIENT:  Be aware of the cables, controller, and batteries. It may be best to place the stretcher straps under the LVAD cables to avoid creating torque on the device. At a minimum, be aware of this extra hardware.  Transport to the closest appropriate LVAD facility.  Currently Holy Cross Medical Center, Cleveland Clinic, Broward Health Medical Center, or Memorial Regional BACK TO TABLE OF CONTENTS Left Ventricular Assist Device 58 Revision Date: August 1, 2020 BACK TO TABLE BACK TO TABLE OF OF CONTENTS CONTENTS Medical Emergencies CARDIAC ARREST 59 59 Cardiac Arrest Standing Orders Revision Date: August 1, 2020 INFORMATION    There is no scientific basis in trying to resuscitate an unwitnessed Asystolic patient who has succumbed to the dying process of a terminal illness. Consideration should be given to not starting resuscitation efforts in these cases. All witnessed cardiac arrest patients must be transported.  Exception: Hospice/DNR patients In general, when the scene is safe, all Cardiac Arrests should be worked on scene. ADULT & PEDIATRIC DETERMINATION OF DEATH  The Paramedic may determine that the patient is dead/non-salvageable and decide not to resuscitate if:  At least 1 of the following conditions is present:  Lividity  Rigor mortis  Tissue decomposition  A valid DNRO is presented or discovered OR  If all of the following are present:  Suspected down time > 30 minutes  Asystole  Pupils fixed and dilated  Apneic  Without hypothermic mechanism for arrest CARDIAC ARREST CAUSES Cardiac Etiology: Non-Cardiac Etiology:  AMI  ALL PEDIATRICS  Cardiac arrhythmias  Hypoxia (e.g., Narcotic OD, FBAO, Hanging)  Cocaine Overdose  Drowning  Electrocution (Alternating Current)  CHF MICCR – MINIMALLY INTERRUPTED CARDIO-CEREBRAL RESUSCITATION      Emphasis is placed on minimizing interruptions in compressions to no more than 5 seconds Perform all assignments in Pit Crew fashion and make all efforts to obtain a ROSC prior to leaving the scene Once available, apply the LUCAS Compression Device with minimal interruptions to chest compressions and set to continuous compressions if applicable. Patient should be placed on the scoop stretcher for transport purposes When possible elevate the patients head 15° or utilize Head-Up CPR Device if available DO NOT turn off the LUCAS Compression Device for defibrillations, or advanced airway procedures BACK TO TABLE OF CONTENTS Cardiac Arrest Standing Orders 60 Cardiac Arrest Standing Orders cont.. Revision Date: August 1, 2020 ADULT & PEDIATRIC (continued) MEDICATIONS  Medications should be delivered as soon as possible after the rhythm check (during compressions) and circulated for 2 minutes  Follow all IVP medication administrations with:  NORMAL SALINE: 10 mL flush  Search for possible causes and treat accordingly (i.e., H’s & T’s, BGL, etc.) NASOGASTRIC TUBE (PEDIATRICS)   When assisting ventilations, an NG tube may be placed If this obstructs an upgraded airway, the NG tube shall be removed and reinserted in the appropriate port TERMINATION OF EFFORTS (ADULT ONLY):  Consider terminating efforts when:  “Persistent Asystole” for 15 minutes NOTE: Call Medical Director  EtCO2 of < 10 mm Hg with good quality CPR for orders to Terminate Efforts  Patient is normothermic  NORMAL SALINE:  500 mL has been administered  1 DEFIBRILATION  360 joules (can be performed at any time during the arrest)  All reversible causes have been addressed  All ALS interventions have been completed       Hydrogen Ion (Acidosis): Hyperkalemia (Renal Failure): Hypoglycemia: Hypoxia: Hypovolemia: Hypothermia: Toxins or Tablets (OD): Tension Pneumothorax: BACK TO TABLE OF CONTENTS H’s Ventilation Calcium Chloride, Sodium Bicarb, Albuterol Glucose Oxygen & Ventilate Fluid Bolus Warming T’s Opiates (Narcan) Beta Blockers (Glucagon) Tricyclic Antidepressants (Sodium Bicarb) Calcium Channel Blocker (Calcium Chloride) Bilateral Pleural Decompression Cardiac Arrest Standing Orders 61 Adult Cardiac Arrest Revision Date: August 1, 2020 ESTABLISH RESPONSIVENESS No respirations/gasping WARNING DURING COMPRESSIONS CHECK PULSE INTUBATION Intubation should only be performed if you are unable to successfully manage the patient’s airway with the i-gel NO PULSE Begin chest compressions  Apply defibrillator pads  Continue compressions during defibrillator charge  Shock or “Dump”  Charge defibrillator every 2 minutes AIRWAY Deliver 2 full ventilations with BVM PATENT FBAO Insert an i-Gel  NOTE Zoll Joules: Adult Apply ResQPod if not contraindicated  Apply ETCO2 filter line  Ventilate 1 breath every 10 seconds Attempt to remove FBAO with laryngoscope and Magill forceps. If obstruction cannot be removed, perform a surgical cricothyrotomy V-FIB/V-TACH TORSADES DRUG THERAPY/ELECTRICAL THERAPY DEFIBRILLATE EVERY 2 MIN, PRN 200j, 300j, 360j AMIODARONE Defibrillation 1ST Dose – 300mg IV/IO 120j, 150j, 200j In 5 minutes if indicated Continue cycles of compressions, rhythm check, defibrillation prn, medication administration, repeat sequence. Consider H’s and T’s. 2nd Dose – 150mg IV/IO EPI (1:10,000) – ADMINISTER ONLY AFTER 2ND DEFIBRILLATION (REFER TO REFRACTORY V-FIB/V-TACH) 1 mg IV/IO May repeat every 5 minutes prn or every other 2 min assessment ASYSTOLE/PEA DRUG THERAPY EPI (1:10,000) 1mg IV/IO Repeat every 3-5 minutes prn. Max total dose 4 mg’s. BACK TO TABLE OF CONTENTS Adult Cardiac Arrest Max total dose 4mg’s TORSADES MAG SULFATE 2G IV/IO, in 100cc bag with 10gtts/set, wide open 62 Adult Cardiac Arrest Position #1  Primary Assessment  Begin cycles of 220 compressions  Pauses after #2 charges the monitor while LUCAS is applied  Can move/help Position #3 with Airway        Revision Date: August 1, 2020 Position #3  Manually opens the airway  If unwitnessed by EMS, give 2 ventilations to ensure no FBO  Insert IGel followed by ETCO2 filter line  Ventilate 1 breath every 10 seconds Position #2 Removes shirt from patient Applies combo pads and operates monitor Charges monitor after combo pads are applied Pushes shock button if indicated, dump if not Applies LUCAS Can move/help Position #4 with IO/meds Charges monitor at 2 minutes, shock or dump BACK TO TABLE OF CONTENTS continued…     Position #4 IO (Humeral Head for Adults) Prepares medications Administers medications during chest compressions Can assist upgrading the airway after 6 minutes Adult Cardiac Arrest Position #5  Applies scoop stretcher  Prepares stretcher for transfer of the patient  Prepares truck for crew prior to transfer  If possible, elevate the head 15 degrees on the stretcher     Position #6 Gather info for report Consoles family Ensures no equipment is left on scene Ensures the scene is clean before departing 63 Adult Post Resuscitation Revision Date: August 1, 2020 ADULT POST ARREST  Patients with a ROSC should be managed in the following order:  12 LEAD  RATE: Reference specific protocol  IF BRADYCARDIC: TRANSCUTANEOUS PACING:  Initial rate of 60 beats per minute and increase milliamps until capture is gained  Increase the rate as needed until the patient is hemodynamically stable  RHYTHM: Reference specific protocol  BLOOD PRESSURE: (Goal is to maintain a SBP of 90 mm Hg)  NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x, prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients  If patient remains hypotensive:  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration  Apply ICE PACKS to the axilla and groin for patients who remain unresponsive  Contraindication– Trauma BACK TO TABLE OF CONTENTS Adult Post Resuscitation 64 Adult Post Resuscitation continued… Revision Date: August 1, 2020 If cardiac arrest was a result of VF/VT, NO AMIODARONE was administered and 2 shocks were delivered:  AMIODARONE INFUSION:  Dilute: 150mg of AMIODARONE in a 100mL bag of D5W  Administer over 10 minutes IV/IO by utilizing a 10 gtt set  Administer all 150mg, even if the WCT terminates  May repeat 1x prn  Contraindications:  Marked sinus bradycardia  Cardiogenic Shock nd rd  2 and 3 Degree Heart Blocks  Hypotension  QTc > 460 If Cardiac Arrest was a result of Torsades and NO Magnesium Sulfate was administered:  MAGNESIUM SULFATE:  Dilute: 2g of Magnesium Sulfate in a 100mL bag of D5W  Administer over 10 minutes IV/IO by utilizing a 10 gtt set nd rd  Contraindication – 2 and 3 Degree Heart Blocks  Precaution - Rapid infusion may cause hypotension Torsades BACK TO TABLE OF CONTENTS Adult Post Resuscitation 65 Pediatric Cardiac Arrest Revision Date: August 1, 2020 ESTABLISH RESPONSIVENESS No respiration/gasping DURING COMPRESSIONS WARNING CHECK PULSE   INTUBATION Continue compressions during defibrillator charge NO PULSE Intubation should only be performed if you are unable to successfully manage the patient’s airway with the i-gel Apply defibrillator pads Begin chest compressions    Shock or “Dump” Charge defibrillator every 2 minutes Assess rhythm and defibrillate as needed AIRWAY Deliver 2 full ventilations with BVM PATENT FBAO Attempt to remove FBAO with laryngoscope and Magill forceps. If obstruction cannot be removed, perform a surgical cricothyrotomy INSERT AN I-GEL  Apply ResQPod if not contraindicated V-FIB/V-TACH TORSADES DRUG  Apply ETCO2 filter line THERAPY/ELECTRICAL THERAPY  Ventilate 1 breath every 6 seconds  Utilize the metronome or ResQPod blinking light to synchronize ventilations DEFIBRILLATE EVERY 2 MIN, PRN 2j/kg - subsequent energy levels are: increase by 2j/kg not to exceed 10 j/kg if unable to convert V-FIB/V-TACH/TORSADES AMIODARONE Continue cycles of compressions, rhythm check, defibrillation prn, medication administration, repeat sequence. Consider H’s and T’s. 5mg/kg every five minutes Max single dose 300 mg. May repeat 2x EPI (1:10,000) – ADMINISTER ONLY AFTER 2ND DEFIBRILLATION (REFRACTORY V-FIB/V-TACH) ASYSTOLE/PEA DRUG THERAPY EPI (1:10,000)  0.01mg/kg IV/IO  May Repeat every 5 minutes prn.  Max total dose 4 mg’s. BACK TO TABLE OF CONTENTS 0.01 mg/kg IV/IO May repeat every 5 minutes prn or every other 2 min assessment Max total dose 4mg’s TORSADES NORMAL SALINE MAG SULFATE  20mL/kg IV/IO  New born: 10 mL/kg IV/IO  May repeat 2x, prn 50mg/kg IV/IO, 100cc bag with 10gtt/set Pediatric Cardiac Arrest over 10 min 66 Pediatric Post Resuscitation Revision Date: August 1, 2020 PEDIATRIC POST ARREST  Patients with a ROSC should be managed in the following order:  Remove ResQPOD from the ETT or i-gel  12 LEAD  RATE: Reference specific protocol  RHYTHM: Reference specific protocol  BLOOD PRESSURE: (Refer to the Handtevy system)  NORMAL SALINE:  20mL/kg IV/IO. Assess lung sounds and BP frequently  May repeat 2x prn, for age appropriate hypotension  If patient remains hypotensive:  PUSH-DOSE PRESSOR EPINEPHRINE (1:100,000):  Dilute: Discard 9 mL’s of Epi 1:10,000 (0.1mg/mL) and draw up 9 mL’s of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg/mL.  Administer 1 mL/minute IV/IO, titrate to maintain age appropriate SBP  May repeat 1x prn, max total dose 0.2mg (20 mL)  Contraindication - Hypotension secondary to blood loss except in DSI  Precautions:  DO NOT administer faster than 1mL/minute  Push-Dose Pressor Epinephrine has a rapid (1 minute) onset, short (5-10 minute) duration  Monitor heart rate and blood pressure throughout administration  Apply ICE PACKS to the axilla and groin for patients who remain unresponsive  Contraindication– Trauma POST V-FIB/V-TACH CONSIDERATIONS IF NO IVP AMIODARONE WAS ADMINISTERED AND 2 SHOCKS HAVE BEEN DELIVERED  AMIODARONE INFUSION:  Dilute: 5mg/kg of AMIODARONE in a 100mL bag of D5W, max single dose 150mg  Administer over 10 minutes IV/IO by utilizing a 10 gtt set  May repeat 1x prn  Contraindications:  Marked sinus bradycardia  Cardiogenic Shock nd rd  2 and 3 Degree Heart Blocks  Hypotension  QTc > 460 POST TORSADES CONSIDERATIONS IF MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED  MAGNESIUM SULFATE:  Dilute: 50mg/kg in a 100mL bag of D5W  Administer over 10 minutes IV/IO by utilizing a 10gtt set  Max dose 2g nd rd  Contraindication - 2 and 3 Degree Heart Blocks  Precaution - Rapid infusion may cause hypotension BACK TO TABLE OF CONTENTS Pediatric Post Resuscitation 67 Special Considerations Revision Date: August 1, 2020 INFORMATION  The below treatments are in addition to standard therapy. ADULT HYPERKALEMIA    CALCIUM CHLORIDE:  1g IV/IO Slow IVP  Precaution – DO NOT administer in same IV/IO line as SODIUM BICARBONATE without thoroughly flushing ALBUTEROL:  2.5mg via nebulizer  Continuous treatments (if an advanced airway is utilized, administer via in-line nebulization) SODIUM BICARBONATE:  50 mEq IV/IO  Precaution – DO NOT administer in same IV/IO line as CALCIUM CHLORIDE without thoroughly flushing EXCITED DELIRIUM   SODIUM BICARBONATE:  50 mEq IV/IO COLD NORMAL SALINE (if available):  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x, prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients THIRD TRIMESTER PREGNANCY    During CPR also manually displace the uterus towards the left All third trimester patients in cardiac arrest should be treated per protocol Transport to the closest OB hospital  Exception: Trauma alerts BACK TO TABLE OF CONTENTS Special Considerations 68 Special Considerations continued... Revision Date: August 1, 2020 ADULT CPR INDUCED CONSCIOUSNESS POST-CARDIAC ARREST   Defined as patients without a spontaneous heartbeat who gain consciousness while receiving CPR KETAMINE:  Dilute: 200mg of Ketamine in a 100mL bag of D5W  Administer IV/IO utilizing a 10 gtt set, run wide open  May repeat 1x prn  Contraindications:  Pregnant patients  Penetrating eye injury  Non-traumatic chest pain HYPOGLYCEMIA  D10: 250mL IV/IO, rapid infusion REFRACTORY V-FIB/V-TACH  Defined as persistent V-Fib/V-Tach with no transient interruption of V-Fib/V-Tach after 5 defibrillations  DO NOT administer any additional Epinephrine to this patient  If ALL 3 of the below treatments have failed to convert the refractory V-Fib/V-Tach:  5 or more standard defibrillations have been delivered  Correctable causes (i.e., H’s & T’s) have been addressed  450mg of AMIODARONE has been administered  DOUBLE SEQUENTIAL DEFIBRILLATION:  Apply an additional set of external defibrillations pads anterior/lateral OR anterior/posterior depending on where the initial pads were placed  Verify both monitors/defibrillators are attached and confirm V-FIB/V-TACH rhythm on both monitors  Charge both monitors to the maximum energy setting and ensure all team members are clear of the patient  Defibrillate by pressing both shock buttons as synchronously as possible  Repeat every 2 minutes until termination of Refractory V-Fib/V-Tach  ESMOLOL:  40mg IV/IO over 1 minute  ESMOLOL INFUSION (IF REFRACTORY V-FIB/V-TACH IS STILL PRESENT):  Dilute: 60mg of ESMOLOL in a 100mL bag of D5W  Administer over 10 minutes IV/IO by utilizing a 10 gtt set BACK TO TABLE OF CONTENTS Special Considerations 69 Special Considerations continued... Revision Date: August 1, 2020 ADULT & PEDIATRIC ELECTROCUTION (ALTERNATING CURRENT)  Immediate DEFIBRILLATION as applicable  Consider Selective Spinal Restriction  Transport patient as a Trauma Alert LIGHTNING STRIKE (DIRECT CURRENT) Lightening-strike patients have a 9 in 10 chance of surviving. If multiple victims are struck, conduct your triage in a reverse manner from what you would normally do in a MCI. Lightning Strike patients who are apneic or in cardiac arrest should receive priority.  Immediate DEFIBRILLATION as applicable  Consider Selective Spinal Restriction  Transport patient as a Trauma Alert CYANIDE EXPOSURE  Any firefighter who suffers cardiac arrest during or within 6 hours after a fire incident, shall be treated for a Cyanide Exposure  Refer to the “Cyanide Exposure” protocol for Cyanokit dosing HANGING  Consider Selective Spinal Restriction  Transport to closest facility DROWNING  No drowning victim is to be pronounced dead at the scene if the possibility of hypothermia exists  Remove patient’s wet clothes, dry, and cover with blankets BACK TO TABLE OF CONTENTS Special Considerations 70 Revision Date: August 1, 2020 BACK TO TABLE BACK TO TABLE OF OF CONTENTS CONTENTS Medical Emergencies Overdose Emergencies 71 71 Overdose Standing Orders Revision Date: August 1, 2020 INFORMATION  The goal for effectively managing patients with an overdose/poisoning is to:       Support the ABCs Terminate seizures Terminate any lethal cardiac arrhythmias Reverse the toxic effects of the poison/medication with a specific antidote The treating paramedic should consider contacting the Florida Poison Control Center at 1-800-222-1222 as soon as possible for additional treatment recommendations.  Treatment recommendations from Florida Poison Control should be followed.  Document the directed treatment and the name of the representative on the ePCR Report. WARNING  Use caution when supporting blood pressure with fluids. Many medications depress myocardial contractility and heart rate, which predispose the patient to heart failure even with boluses as little as 500mL. Assess lung sounds and blood pressure frequently.  It may be necessary to limit the amount of fluids the patient receives. BACK TO TABLE OF CONTENTS Overdose Standing Orders 72 Beta Blockers Revision Date: August 1, 2020 INFORMATION  Signs & Symptoms:        Bradycardia Hypotension Cardiac arrhythmias Hypothermia Hypoglycemia Seizures Common Beta Blockers:  Atenolol  Carvedilol  Metoprolol  Propranolol Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. ADULT  Obtain a 12-lead and leave cables connected ISOLATED HYPOTENSION   NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients Refer to the “Bradycardia” protocol, if applicable PEDIATRIC  Obtain a 12-lead and leave cables connected ISOLATED HYPOTENSION  NORMAL SALINE:  20 mL/kg IV/IO. Assess lung sounds and BP frequently, New born: 10 mL/kg IV/IO  May repeat 2x prn, for age appropriate hypotension BACK TO TABLE OF CONTENTS Beta Blockers 73 Calcium Channel Blockers Revision Date: August 1, 2020 INFORMATION  Common Calcium Channel Blockers:  Norvasc  Cardizem  Cardene  Procardia Signs & Symptoms:        Hypotension Syncope Seizure AMS Non-Cardiogenic Pulmonary Edema Bradycardia Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. ADULT  Obtain a 12-lead and leave cables connected ISOLATED HYPOTENSION   CALCIUM CHLORIDE:  1g IV/IO, over 2 minutes NORMAL SALINE:  1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently.  May repeat 1x, prn  Precautions - Particular care must be taken in the presence of significant coronary heart disease, CHF, and renal failure patients HYPOTENSION WITH BRADYCARDIA OR NON-RESPONSIVE TO ABOVE TREATMENT  Refer to the “Bradycardia” protocol, if applicable PEDIATRIC  Obtain a 12-lead and leave cables connected ISOLATED HYPOTENSION   CALCIUM CHLORIDE:  20mg/kg IV/IO, over 2 minutes  May repeat every 10 minutes until symptoms resolve, max dose 1g NORMAL SALINE:  20 mL/kg IV/IO. Assess lung sounds and BP frequently, New born: 10 mL/kg IV/IO  May repeat 2x prn, for age appropriate hypotension HYPOTENSION WITH BRADYCARDIA OR NON-RESPONSIVE TO ABOVE TREATMENT  Refer to the “Bradycardia” protocol, if applicable BACK TO TABLE OF CONTENTS Calcium Channel Blockers 74 Cocaine Revision Date: August 1, 2020 INFORMATION  Signs & Symptoms:  Tachycardia  Supraventricular and ventricular cardiac arrhythmias  Chest pain/STEMI  HTN  Seizures  Excited delirium  Hyperthermia  Dilated pupils  Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. ADULT  Obtain a 12-lead and leave cables connected PATIENTS PRESENTING WITH STABLE SVT, WCT, CHEST PAIN, HTN, OR SEIZURES Hypertension: SBP > 160 mmHg OR DBP > 110 mmHg   VERSED:  5mg IV/IO  May re