2018-20 Common EMS Protocols PDF

COMMON EMS PROTOCOLS HOME PAGE Version 1.7 ADULT PROTOCOLS................................................. page 3 ADULT TRAUMAS.................................................. page 181 PEDIATRIC PROTOCOLS...................................... page 211 PEDIATRIC TRAUMAS........................................... page 315 MEDICATIONS SECTION....................................... page 339 MEDICATION CHARTS.......................................... page 407 PROCEDURES....................................................... page 419 ADMINISTRATIVE SECTION................................. page 557 ADULT ALGORITHMS............................................ page 611 PEDIATRIC ALGORITHMS..................................... page 671 UPDATES............................................................... INSERTS Page 1 of 1 2018-20 EMERGENCY MEDICAL SERVICES COMMON PROTOCOLS Frederick M. Keroff, MD, FACEP MEDICAL DIRECTOR Coral Gables, Hialeah, and Miami Beach Paul J. Adams, DO, MA, FACOEP MEDICAL DIRECTOR City of Miami and Village of Key Biscayne Armando Clift, MD, FAAEM ASSOCIATE MEDICAL DIRECTOR City of Miami and Village of Key Biscayne HIALEAH FIRE DEPARTMENT 83 EAST 5TH STREET HIALEAH, FL 33010 "Committed to serve and protect our community" EMERGENCY MEDICAL SERVICES MEDICAL OPERATIONS MANUAL 2018-20 EDITION Version 1.7 Patrick Flynn, Fire Chief Frederick Keroff, M., FACEP, Medical Director Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne 2018-20 i Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ACKNOWLEDGEMENTS Acknowledgements Protocol Review Committee The following individuals have worked countless hours on this version of the 2017-18 Common EMS Protocols. Their dedication, expertise, commitment, and professionalism have made the production of this state-of-the-art Protocol Manual possible. Frederick M. Keroff................................................................... Medical Director, CGFD/HFD/MBFD Patrick Flynn................................................................................................................. Fire Chief, HFD Emmanuel Louis...........................................................................................EMS Division Chief, HFD Randy Smith............................................................................................................. EMS Captain, HFD Carlos Castellanos......................................................................................................... Lieutenant, HFD Patricia Tassy.............................................................................................................. QA Officer, HFD Robert Bedell..........................................................................................Rescue Division Chief, MBFD Evan Prentiss....................................................................................... Rescue Division Captain, MBFD Sal Frosceno................................................................................................... EMS Coordinator, MBFD Kenny Anderson................................................................................................... EMS Captain, CGFD Jason Barger.............................................................. Division Chief of Professional Standards, CGFD Xavier Jones............................................................................................................... Lieutenant, CGFD Paul Adams............................................................................................ Medical Director, MFR/KBFR Armando Clift........................................................................ Assistant Medical Director, MFR/KBFR Robert Hevia......................................................Assistant Fire Chief, Health and EMS Division, MFR Christian Guzman..................................................... Deputy Captain, Health and EMS Division MFR Joseph Beraldi........................................................................................EMS Training Instructor, MFR Jose Siut.................................................................................................EMS Training Instructor, MFR Dan Feeney........................................................................................................... EMS Captain, KBFR Theodore Pautauros.......................................................................................... EMS Lieutenant. KBFR Justin Connors................................................................................................... EMS Lieutenant, KBFR “High quality standards, patient safety, and customer service establish the foundation that we embrace as our vision of patient care and treatment. Through high compliance with evidence based practices, these results continue to drive change in our service delivery model. With disciplined science, the “art” of emergency pre=hospital medicine is practiced. We are accountable to continuously improve ourselves, our practice, and our organizations to better serve our patients.” – SF Page 1 of 1 ii Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS MEDICAL DIRECTOR OVERRIDES MEDICAL DIRECTOR OVERRIDES CITY OF MIAMI AND VILLAGE OF KEY BISCAYNE The following EMS protocols/procedures and medications will not be used by personnel from the City of Miami Fire Department until available for use. 1. Ativan 2. Cardene 3. Fentanyl 4. Nitrous Oxide 5. Racemic Epinephrine 6. Tetracaine Eye Drops 7. Scoop Stretcher’s 8. T- Pod 9. Oral Gastric tubes 10. BIG IO 11. Cook decompression kit The City of Miami Fire Department will use the following protocols/procedures and medications as a substitute. 1. Versed will be used in place of Ativan 2. Morphine will be used in place of Fentanyl 3. Backboard will be used in place of a scoop stretcher 4. EZ IO will be used in place of BIG IO 5. ARS Needle will be used in place of the Cook decompression kit Page 1 of 1 iii Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS HOME PAGE Version 1.7 ADULT PROTOCOLS................................................. page 3 ADULT TRAUMAS.................................................. page 181 PEDIATRIC PROTOCOLS...................................... page 211 PEDIATRIC TRAUMAS........................................... page 315 MEDICATIONS SECTION....................................... page 339 MEDICATION CHARTS.......................................... page 407 PROCEDURES....................................................... page 419 ADMINISTRATIVE SECTION................................. page 557 ADULT ALGORITHMS............................................ page 611 PEDIATRIC ALGORITHMS..................................... page 671 UPDATES............................................................... INSERTS Page 1 of 1 1 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne 2 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT MEDICAL MENU 1. ABDOMINAL PAIN................................................................................................. page 5 2. ABUSE REPORTING AND COMMUNITY SERVICE............................................. page 9 3. AGITATED PATIENT – EXCITED DELIRIUM SYNDROME................................. page 11 4. AICD / AUTOMATIC IMPLANTABLE CARDIOVERTER / DEFIBRILLATOR....... page 15 5. AIRWAY MANAGEMENT..................................................................................... page 17 6. ALCOHOL INTOXICATION.................................................................................. page 25 7. ALLERGIC / SYSTEMIC REACTIONS................................................................. page 28 8. BACK PAIN........................................................................................................... page 33 9. BAKER ACT / MARCHMAN ACT......................................................................... page 37 10. BITES AND STINGS............................................................................................. page 41 11. BRADYCARDIA.................................................................................................... page 47 12. CARDIAC ARREST.............................................................................................. page 51 13. CHEST PAIN – STEMI......................................................................................... page 63 14. CO-CN EXPOSURE............................................................................................. page 71 15. DEATH IN FIELD.................................................................................................. page 75 16. ENVIRONMENTAL EMERGENCIES.................................................................... page 79 17. EPISTAXIS........................................................................................................... page 86 18. FIREFIGHTER REHABILITATION........................................................................ page 87 19. HYPERTENSIVE EMERGENCIES....................................................................... page 91 20. IMPAIRED OR ALTERED CONSCIOUSNESS.................................................... page 95 21. OB / CHILD BIRTH EMERGENCIES.................................................................. page 101 22. PAIN AND NAUSEA – VOMITING MANAGEMENT........................................... page 115 23. PEPPER SPRAY EXPOSURES......................................................................... page 119 Page 1 of 2 3 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT MEDICAL MENU 24. POISONING / DRUG OVERDOSE..................................................................... page 121 25. POST RESUSCITATION.................................................................................... page 127 26. PSYCHIATRIC EMERGENCIES........................................................................ page 129 27. RAPE MANAGEMENT....................................................................................... page 131 28. RESPIRATORY EMERGENCIES....................................................................... page 133 29. SEIZURES.......................................................................................................... page 139 30. SHOCK – HYPOTENSION................................................................................. page 141 31. SICKLE CELL PATIENTS................................................................................... page 145 32. STROKE............................................................................................................. page 147 33. SYNCOPE.......................................................................................................... page 149 34. TACHYCARDIA.................................................................................................. page 151 35. TASER EXPOSURES......................................................................................... page 159 36. THERAPEUTIC HYPOTHERMIA....................................................................... page 161 37. UNIVERSAL INITIAL ADULT PATIENT ASSESSMENT CARE......................... page 163 38. VENTRICULAR ASSIST DEVICE (VAD)............................................................ page 171 39. WATER RELATED EMERGENCIES.................................................................. page 177 Page 2 of 2 4 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ABDOMINAL PAIN Introduction There are many causes of abdominal pain. However, diagnosing the causes of abdominal pain in the pre-hospital environment is usually not indicated, but having an understanding of the possible reasons for a patient’s abdominal pains can assist in the management of these patients. In the pre-hospital environment, the management of a patient with abdominal pain is determined by the presence of any associated signs or symptoms. These include: 1. Hypotension a. Vascular emergencies such as ruptured abdominal aortic aneurysms b. Ruptured ectopic pregnancies c. Bowel obstructions causing fluids to build up within the gut d. Traumatic damage to a solid organ; spleen, kidney, liver e. Gastrointestinal Bleeding 2. Nausea and/or vomiting 3. Bleeding from the mouth or rectum Important points to remember when evaluating patients with abdominal pain: 1. Upper abdominal pain (everything above the umbilicus): a. Any male 35 years or older needs a 12-lead ECG. b. Any female 45 years or older needs a 12-lead ECG. 2. Lower abdominal pain (everything below the umbilicus): a. Females of childbearing years should be treated as a possible ectopic pregnancy until proven otherwise. The past medical/surgical history is frequently helpful in determining the cause of the patient’s current episode of abdominal pain. Determination of current medication use can also assist in understanding reasons for the patient’s abdominal pains. Location of the pain is the most helpful piece of information when trying to determine the cause of the pain. 1. Renal colic (kidney stones) starts in the posterior flank and radiates around to the lower abdomen on the side of the pain and never crosses the midline. 2. Right upper quadrant pain: a. Gallbladder pain starts in the right upper quadrant but may move around the upper abdomen into the mid back. Page 1 of 4 5 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ABDOMINAL PAIN 3. Right lower quadrant pain: a. Kidney stones b. Ectopic pregnancy c. Classic appendicitis pain starts in the mid-upper abdomen or around the umbilicus and later moves to the right lower quadrant. 4. Left upper quadrant pain: a. Pancreatitis – look for a history of pancreatitis, alcohol abuse, or gallbladder stones. 5. Left lower quadrant pain: a. Diverticulitis b. Ectopic pregnancy c. Kidney stones Abdominal pain may be associated with nausea and/or vomiting, diarrhea or constipation, urinary symptoms, difficulty breathing, cough, fever. Patients who have had gastric bypass surgery are at increased risk for having complications. These complications can occur shortly after surgery to many years following the surgical procedure. All of these patients who are now complaining of abdominal pain should be transported to a hospital for further evaluation. Questions to Ask: 1. Onset sudden or gradual? 2. Since onset, is the pain constant or intermittent? 3. Has the pain moved since it started? 4. Have you had this type of pain before? 5. Is there anything that makes the pain worse, or better? 6. Are there any other associated symptoms or clinical findings, for example, nausea, vomiting, diarrhea, urinary symptoms, and/or shortness of breath? 7. On a scale of 1 to 10 with 10 being the worst pain, how bad is the pain now? 8. Have you taken any medications to make yourself feel better? If so, did it make any difference? 6. When appropriate, timing of last menses. Page 2 of 4 6 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ABDOMINAL PAIN Page 3 of 4 7 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ABDOMINAL PAIN TREATMENT 1. Universal Initial Adult Patient Assessment / Care. 2. Hypotension a. Administer normal saline, 500 mL IV bolus. May repeat once if needed. b. Advise receiving hospital of patient’s status. 3. Nausea/Vomiting a. Administer ondansetron (Zofran) ODT, 8 mg PO. b. Many patients with abdominal pain will have associated nausea and frequently treating the abdominal pain will also relieve the patient’s nausea. 4. Consider Pain Management 5. Vomiting Blood or Bleeding Large Amounts Per Rectum a. Start a saline lock. Only administer normal saline if patient also has hypotension or tachycardia. Page 4 of 4 8 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ABUSE REPORTING & COMMUNITY SERVICES Reporting to Community Services Whenever a Fire-Rescue employee encounters a person, as a patient or under other circumstances, whom he/she believes would benefit from the assistance provided through the Elder-Links Project or other Community Services, the Fire Rescue employee shall: 1. Complete the Elder-Helpline Referral Form. 2. Deliver or fax the completed form to the Rescue Division. 3. If the person is a patient, document the referral in the narrative section of the Patient Care Record. 4. Elder Links Information: Florida Department of Elder Affairs, Alliance for Aging Inc. (Elder Links) Phone: 305-670-HELP (4357) or 1-800-96ELDER (1-800-963-5337) Fax: 305-670-6516 or 305-671-7229 Reporting ABUSE, NEGLECT, or EXPLOITATION of Children or Vulnerable Adults As defined by Florida Statute 415, any Fire-Rescue employee who knows or has reasonable cause to suspect abuse, neglect, or exploitation of a child or vulnerable adult will immediately report such knowledge or suspicion to the Florida Abuse Hotline. 1. Notify Police 2. Notify the Rescue Division Supervisor prior to the end of your shift. 3. These incidents should be reported by calling the Florida Abuse Hotline 1-800-96ABUSE (1-800-962-2873). 4. Obtain the following information: a. The victim's name b. The full address (including zip code, apartment, building, or lot number) c. Telephone number Page 1 of 2 9 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ABUSE REPORTING & COMMUNITY SERVICES d. Date of birth, age, race, and sex e. Social Security Number f. Brief description of physical, mental, or behavioral indications demonstrating that the person is infirm or disabled g. Signs or indications of harm or injury, including a physical description if possible h. A brief history including medical conditions and the situation found in the home i. Incident number and police case number if applicable 5. Complete the Florida Abuse Hotline Fax Transmittal Form, and if contact was made with the FL Abuse Hotline, document the counselor’s name and identification number above the Incident Number on the form. 6. Deliver or Fax the completed form to the Rescue Division for follow up with the local office of the Florida Department of Children and Family Services. NOTE: DO NOT fax forms to the Florida Abuse Hotline, as there is no guaranteed process to confirm that the forms have been received. 7. Document the referral and method of referral in the narrative section of the Patient Care Record. Additional Information Response by a police agency to the incident scene or transportation of the neglected or exploited person to a hospital, does not release the Unit from the responsibility of reporting the incident to the Florida Abuse Hotline. Page 2 of 2 10 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS THE AGITATED PATIENT / EXCITED DELIRIUM SYNDROME Fire Rescue may be called to the scene to manage patients that are agitated and presenting with verbally and/or physically threatening behavior. These patients are agitated, restless, sometimes crying, sometimes confused, and they appear to be out of control. Their agitated condition may be related to mental illness and/or drug use (particularly stimulants such as cocaine). Alcohol withdrawal and head trauma may contribute to the condition. Excited Delirium Syndrome Agitated patients may be experiencing an excited delirium syndrome, and when managing the care of these patients it is important to evaluate the agitated patient for possible excited delirium syndrome. Patients with the Excited Delirium Syndrome may demonstrate some or all of these finds: Extremely aggressive or violent behavior Constant physical activity, restless Not responsive to police/fire presence Attracted to bright lights, loud sounds, their own reflections in glass or mirrors May be naked or near naked Rapid breathing Profuse sweating Little response to pain Superhuman strength Hot to the touch Law enforcement agencies may utilize a TASER, as a non-lethal method to temporarily incapacitate individuals who exhibit threatening behavior. Thus, it is important when approaching a patient who has been TASERed, to evaluate the patient for possible excited delirium syndrome. Patients with excited delirium syndrome typically continue to be agitated again after being TASERed. TREATMENT 1. Have enough personnel on the scene to handle the situation, and if necessary, to physically manage the patient. 2. Secure the scene and use universal precautions. 3. Attempt to calm the patient down. Speak softly and non-threateningly. Avoid loud noises and sudden movements. Page 1 of 3 11 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS THE AGITATED PATIENT / EXCITED DELIRIUM SYNDROME 4. Use the least restrictive method of restraint. Providers should ensure their own safety. If possible, allow the patient to correct inappropriate behavior. Use restraints if unable to calm the patient down, and the patient remains a threat to himself/herself or others. If restraint is necessary, DO NOT put the patient prone (face down). Use a supine or recovery position. Use as many providers/police present to safely restrain the patient. 5. If chemical restraint is indicated and available, administer ketamine, 4 mg/kg IM (maximum dose 400 mg). Ketamine may be given in the mid shaft anteriolateral aspect of the thigh OR the lateral deltoid muscle of the shoulder. It may be given through clothing. 6. If the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off, OR IF KETAMINE IS NOT AVAILABLE. a. If vascular access is available: 1) Administer lorazepam (Ativan), 2 mg IV slowly over 1 minute OR 2) Administer midazolam (Versed), 5 mg IV. b. If vascular access is NOT available: 1) Administer lorazepam (Ativan), 2 mg IM OR 2) Administer midazolam (Versed), 10 mg IM / IntraNasal. c. Both medications may each be repeated in 3-5 minutes if indicated. 7. Universal Initial Adult Patient Assessment / Care. 8. Ensure a maintainable airway. 9. Obtain a blood glucose level and treat with dextrose 50% (D50W), if indicated. 10. Monitor cardiac rhythm, ETCO2 and SpO2. Give supplemental O2, if indicated. 11. Treat any medical complaint per the appropriate protocol(s). 12. If the patient is exhibiting disrhytmias indicative of metabolic acidosis, such as a wide QRS and/or loss of P waves, consider giving sodium bicarbonate, 1 mEq/kg IV/IO. Page 2 of 3 12 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS THE AGITATED PATIENT / EXCITED DELIRIUM SYNDROME 13. IF THE AGITATED PATIENT IS EXHIBITING SIGNS OF EXCITED DELIRIUM AND THE PATIENT IS FEBRILE OR HOT TO THE TOUCH (temperature reading of 104°F (40°C) or higher OR if unable to obtain a temperature and the patient feels hot to the touch) attempt to cool the patient down. a. Remove as much clothing as possible. b. If possible, move patient to a cooler environment and/or fan blowing on patient. c. If available, apply ice packs to the neck, axillae, and groin areas. d. If available, take and document a baseline temperature before administering cold normal saline. Also take and document a temperature at the time of patient transfer in the ED. e. Establish vascular access and bolus cold (34°F) normal saline, 30 mL/kg IV/IO (maximum 2 Liters). f. If Ativan or Versed have not already been given, AND the patient is shivering, administer midazolam (Versed), 5 mg IV/IO or 10 mg IM / IntraNasal. g. If the patient is agitated and/or in pain after midazolam (Versed) and the systolic BP remains at 90 mmHg or greater, administer morphine sulfate, 5 mg IV/IO/IM. If the patient continues with agitation and/or pain, the morphine may be repeated every 5 minutes as needed. The total amount of morphine given should not exceed 20mg. Page 3 of 3 13 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne 14 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AICD (AUTOMATIC IMPLANTABLE CARDIOVERTER/DEFIBRILLATOR) Introduction An Automatic Implantable Cardioverter/Defibrillator (AICD) is a device usually implanted in the soft tissues of the patient’s chest wall. It consists of: A lead system that senses cardiac electrical activity, Computer circuitry to analyze ECG rhythms, A power supply for the unit functions and generation of voltage, and A capacitor that stores and delivers shocks to the heart when indicated. TREATMENT AICD Discharges 1. Universal Initial Adult Patient Assessment/Care. 2. Airway Management 3. Monitor the ECG and SpO2. Maintain SpO2 at 94% or greater. 4. Establish vascular access. 5. Treat dysrhythmias per appropriate protocol(s). 6. Transport ALS to the closest appropriate hospital. AICD Confirmed by ECG to be Discharging Inappropriately 1. Monitor ECG, verify rhythm, AND any inappropriate defibrillator discharge(s). 2. For repetitive discharges, consider Pain Management in the conscious patient. Notes: Identification information of the AICD type is usually given to the patient as a wallet card. This information should accompany the patient to the hospital. CPR may be performed over an actively firing internal defibrillator without risk to the paramedic. If external defibrillation is required, avoid placing the defibrillator patches over the implanted device. Page 1 of 1 15 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne 16 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT Assessment of a patient’s respiratory status is divided into two categories, evaluation of the upper airway and evaluation of the lower airway. The upper airway is defined as everything at or above the vocal cords, i.e., tongue, soft palate, throat, oropharynx, and vocal cords. The lower airway is defined as everything in the respiratory tree below the vocal cords including the trachea, bronchi and lungs. Evaluation of the upper airway is an assessment of the openness or patency of the upper airway. Is the patient able to get air into their lungs? The patency of the upper airway may be compromised by an obstruction, either a foreign body, vomitus, or swelling of the tissues of the upper airway, e.g., allergic reactions, medication reactions, or infections. The upper airway may also be compromised in patients with an altered mental status, especially in those patients with a diminished or absent gag reflex. These patients are at risk for airway obstruction from the tongue falling back against the back of the throat or from aspirating their own vomitus. Evaluation of the lower airway is an assessment of two elements: 1. Is the patient able to ventilate, i.e., to move air in and out of their lungs? 2. Is the patient able to oxygenate, i.e., is the blood moving through the lungs able to be perfused with oxygen so that the patient has adequate levels of oxygen in their blood? Assessment of the upper airway is easier in the alert patient. An alert patient that is able to speak clearly and has no complaints regarding speaking, breathing or swallowing has a clear upper airway. The presence of gurgling, gasping, snoring, stridor, or an otherwise noisy airway/breathing suggests an upper airway obstruction. Application of a CO2 monitor, if available, will allow assessment of a patient’s ventilatory status and is particularly helpful in evaluating patients with altered levels of consciousness to determine whether their airway is in need of management. A clinical assessment of the lower airway can be helpful, but the patient’s recent and past medical history, as well as the medications that the patient is currently taking, may be more helpful in assessing the cause of any respiratory difficulties being experienced by the patient. The clinical assessment of the lower airway has several elements: 1. Assessment of the patient’s mental status - (alert, confused, responsive to verbal stimuli, responsive to painful stimuli, or unresponsive). 2. Assessment of the patient’s skin - warm/dry, pink, ashen or cyanotic (cyanosis can be central involving only the lips, or peripheral involving only the fingers). 3. Assessment of the chest wall and the ribs and muscles used to assist in moving air in and out of the chest – are there retractions or accessory muscles being used to assist in breathing? Is there abdominal breathing? Page 1 of 8 17 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT 4. Listening for lung sounds - wheezing, a musical sound heard in either or both inspiration and expiration; rhonchi, a deeper coarse almost gargling sound; rales, a fine crackling sound similar to listening with an ear close to a glass of a carbonated beverage; and finally the absence of breath sounds on either one or both sides. 5. There is a continuum of options available to the healthcare provider in the management of a patient in apparent respiratory distress. These include the following listed from the least invasive to the most invasive: a. Nasal Cannula Least invasive b. Simple Face Mask c. NRB mask d. BVM with reservoir e. CPAP f. Invasive Advanced Airways 1) Supraglottic devices 2) Oral ETT 3) Cricothyrotomy Most invasive When initiating oxygen treatment of a patient, start with one of the choices from the above list that seems most reasonable. These questions can help you choose a starting point: 1. Is the patient conscious? 2. If the patient is conscious, are they able to speak, and are they able to cooperate with their treatment? Regardless of which one you choose as your starting point, the key in managing these patients is repeated re-evaluations to determine whether the initial management chosen for a particular patient is the correct choice. Invasive Airways are usually reserved for patients with severe respiratory distress with depressed levels of consciousness. After you have started oxygen treatment, the patient should be monitored by following their level of consciousness, their SpO2 levels, and their capnography waveforms. The level of consciousness is a good measure of whether the target organs are receiving enough oxygen. The SpO2 levels are a measure of whether there is sufficient oxygen in the blood to feed the cells of the body. The capnography waveforms monitor the patient’s ventilations or the ability to move oxygen in and out of the lungs. Page 2 of 8 18 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT The approach to managing a patient in apparent respiratory distress is to understand that whatever tool for administering oxygen is chosen as a starting point; if the patient is not oxygenating well, not ventilating well, or their level of consciousness falls, move on to another, more invasive level of oxygen administration. Consider oxygen treatment as administering a drug. You must reevaluate the patient periodically to determine whether the treatment provided to the patient is solving the patient’s problem regarding oxygenation and ventilation. Intubation of the patient accomplishes in a controlled manner oxygenation, ventilation, and protection of the airway in patients without a gag reflex. Respiratory Adjuncts Consider the options available to stabilize the patient when treating patients in respiratory distress. The presentation of a patient exhibiting signs of respiratory distress will change from minute to minute and requires an on-going evaluation of the patient and their response to your treatment. Oxygen at levels greater than what is present in the air is a medication. Below are the available choices when starting oxygen and some recommendations on which delivery system may be the appropriate starting point in a particular patient. If the patient does not respond to one choice, then go to the next level. When in doubt, it is always better to make a choice of the higher level of oxygen delivery. The SpO2 goal should be 94% or greater, except in patients with severe COPD or emphysema where the goal SpO2 should be 88-92%. 1. Nasal Cannula: used with mild respiratory distress and with a pulse oximeter reading of less than 94%. Oxygen is not indicated for patients with ischemic chest pain who have a normal SpO2 reading of 94% or greater. 2. Non-Rebreather Mask (NRBM): used with moderate respiratory distress, with normal respiratory rate and volume, and a pulse oximeter reading of less than 94%. 3. Nebulizer Mask: used with ipratropium/albuterol (DuoNeb) for acute bronchospasm (wheezes) as with asthma or allergic reaction, or with normal saline for control of upper airway edema (patient has stridor) as in children with croup. 4. Positive Pressure Ventilation (PPV): used for severe respiratory distress or when respirations are too slow or too shallow. Three adjuncts are available for PPV: a. CPAP: Best for Acute Pulmonary Edema. Patient must be awake and able to follow directions. CPAP may also be used for respiratory distress (COPD and Acute Bronchospasm) that does not respond to medication. CPAP may be applied to any patient with acute respiratory distress and a low SpO2 even if the lung sounds are clear. Page 3 of 8 19 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT b. Automatic Ventilator: is used for PPV (positive pressure ventilation) in either the demand mode (assist patient with breathing that is too shallow) or manual mode (assist patient with breathing that is too shallow and/or too slow) or automatic mode (used with an advanced airway in apneic patients). c. BVM: Used when CPAP or Automatic Ventilator is indicated, but not available. It may be used (without the mask) in conjunction with the use of advanced airways. Use enough BVM compression to visualize chest rise. If more volume is needed, use the Automatic Ventilator. If available, the manometer should be set at 10. 5. Advanced Airway: When the patient is in respiratory arrest, or prolonged PPV is required with a BVM or Automatic Ventilator, an advanced airway should be properly placed. There is a choice of a Supraglottic Airway or an oral Endotracheal Tube. In preparation for an advanced airway the patient should be given 100% oxygen while preparing for the procedure. a. Supraglottic Airway: is placed in the initial set of compressions in cardiac arrest. It can also be used in respiratory arrest and respiratory distress when there is no gag reflex. Supraglottic Airways are contraindicated when there is damaged tissue in the supraglottic area or there is a high risk of aspiration. I-gel is an example of a supraglottic airway. b. Endotracheal Tube (ETT): is no longer the primary airway in cardiac arrest. It is the airway of choice when there is a high risk of aspiration. It is also usually indicated when Supraglottic Airways are contraindicated. c. Bougie: if available, can be used to place an ETT. The bougie is placed through the vocal cords and the ETT is passed over the bougie into the trachea. A bougie can also be used to change the airway from an I-gel to an ETT. With an I-gel already properly placed, insert the bougie into the I-gel and through the vocal cords until you feel resistance. Holding the bougie in place, remove the I-gel and introduce the ETT with the 20 mm marker at the lips. Listen for bilateral breath sounds, and confirm placement with waveform capnography. d. If an advanced airway is established: 1) Secure the advanced airway device. 2) Maintain the patient’s head and neck in the neutral position. Flexion and/or hyperextension may dislodge the device. 3) If the patient’s condition deteriorates and/or the SpO2 drops to less than 94%, consider the following possibilities (DOPE): Displacement of the device. Check for neutral head/neck position Obstruction of the device. Pneumothorax. Check for bilateral breath sounds. Equipment failure. Check pop-off valve Page 4 of 8 20 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT TREATMENT All patients should have Universal Initial Adult Patient Assessment / Care Spontaneous Breathing Present but Impaired (based on patient complaint or EMS findings): 1. Ensure a patent airway, and maintain proper head positioning (head- tilt/chin-lift), observing cervical spine precautions if indicated (modified jaw-thrust maneuver). 2. Evaluate/manage any suspected obstructions. 3. Suction as necessary. 4. Monitor pulse oximetry. Maintain a pulse oximeter reading equal to or greater than 94% (except in known COPD patients, maintain at 88%- 92%). 5. Administer supplemental oxygen, if indicated. 6. Listen to breath/lung sounds. If abnormal, refer to the appropriate protocol. 7. Has the patient’s breathing improved? Is the SpO2 equal to or greater than 94%? a. If yes, then continue with current airway management and transport. b. If not, consider more invasive airway management. 8. When appropriate and if available, assess non-intubated ETCO2 and treat appropriately (Normal range is 35 to 45 mmHg). Spontaneous Breathing Absent or Severely Compromised: 1. Ensure a patent airway, and maintain proper head positioning (head- tilt/chin lift), observing cervical spine precautions if indicated (jaw-thrust maneuver). 2. Evaluate/manage any suspected obstructions. 3. Suction as necessary. 4. Ventilate with 100% O2. Use an Automatic Ventilator or a BVM with a reservoir @ 15 LPM. Consider CPAP if the patient is awake with severely compromised breathing. Page 5 of 8 21 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT 5. If unable to see chest rise, reposition the head, and try again. If still unable to see chest rise, consider an airway obstruction, and manage appropriately. a. In respiratory/cardiac arrest, deliver 1 breath every 6 seconds (10-12 breaths per minute). 6. Has the patient's breathing improved? Is the SpO2 equal to or greater than 94%? a. If YES, then continue with current airway management and transport. b. If NOT, insert a Supraglottic Airway device, or intubate the patient with an appropriate sized ETT, if indicated, and confirm and monitor proper placement with capnography. 7. If the patient has a difficult airway to open (such as trismus – clenched jaw muscles) and/or has an active gag reflex: a. If you are ABLE to establish vascular access, intubate using amidate (Etomidate), 0.3 mg/kg IV/IO slowly over 15-60 seconds – OR if amidate (Etomidate) is NOT available, administer midazolam (Versed), 10 mg IV/IO. b. If you are UNABLE to establish vascular access, or amidate (Etomidate) is not available, administer midazolam (Versed), 10 mg IM / IntraNasal. 8. Confirm correct tube placement, and secure properly. Intubation should only be attempted 2 times. Use Supraglottic Airway if ETT intubation attempts are not successful. 9. If patient becomes combative following a successful placement of an Advanced Airway: a. Reconfirm proper Advance Airway placement with ETCO2 and SpO2 measurements. b. Consider sedation with midazolam (Versed), 5 mg IV/IO. May repeat once in 5 minutes as needed. c. If there is no vascular access, administer midazolam (Versed), 10 mg IM / IntraNasal or Buccal (part the patient’s lips and without opening the jaws, place the medication laterally between the teeth and cheek with half of the dose on each side of the mouth). 10. In cardiac arrest, ventilate once every 6 seconds (10-12 breaths per minute), attach a CO2 sensor, if available, and monitor waveform capnography. Page 6 of 8 22 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT 11. Consider insertion of an Oral Gastric Tube in situations where abdominal distention persists after successful endotracheal intubation. 12. Monitor and record ETCO2 after successful placement of an Advanced Airway and again upon every patient transfer. Continuously monitor ETCO2 in all patients with an Advanced Airway (Supraglottic or ETT). 13. If unable to place an advanced airway or deliver effective BVM breaths: a. Re-attempt BVM ventilation by inserting 2 NPAs (one in each nostril) and 1 OPA (if possible) b. Also, use additional EMS personnel: 1) One medic uses both hands to maintain a good mask seal with a jaw thrust maneuver. 2) Another medic uses both hands to deliver forceful BVM breaths. 3) If needed, a third medic can assist with positioning the head and jaw thrust. 14. If unable to ventilate patient by any means, perform a cricothyrotomy if clinically warranted. Partial Airway Obstruction (Patient is able to speak, “I have something in my throat,” but patient is in obvious respiratory distress.) 1. Allow patient to assume a position of comfort. 2. If patient will allow it, apply a NRBM with high flow oxygen. 3. Transport and monitor. Complete Airway Obstruction in CONSCIOUS patients: (Includes children 1 year and older according to AHA.) 1. Administer abdominal thrusts (use chest thrusts for obese or pregnant patients). 2. Repeat until cleared or the patient becomes unconscious. Page 7 of 8 23 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS AIRWAY MANAGEMENT Complete Airway Obstruction in UNCONSCIOUS patients with a pulse: (Includes children 1 year and older according to AHA.) 1. Open the airway. 2. Attempt to ventilate. If unable to ventilate, reposition the head and try again. If still unable to ventilate, perform 5 cycles of 30:2 CPR. 3. Check the mouth, and if an object is visible, attempt to manually remove it or use suction. DO NOT perform blind sweeps on any patients Adult, Child, or Infant. 4. Attempt to ventilate. If still unsuccessful, repeat steps 2 & 3 above. 5. If the airway remains obstructed, use a laryngoscope to visualize the obstruction and attempt to remove the obstruction using the Magill forceps. 6. If still unable to remove the obstruction and unable to place an advanced airway or deliver effective BVM breaths: a. Re-attempt BVM ventilation by inserting 2 NPAs (one in each nostril) and 1 OPA (if possible) Also, use additional EMS personnel: One medic uses both hands to maintain a good mask seal with a jaw thrust maneuver. Another medic uses both hands to deliver forceful BVM breaths. If needed, a third medic can assist with positioning the head and jaw thrust. b. If there is no success with the above procedure, perform an emergency cricothyrotomy if clinically warranted. OR, as a last resort: c. Intubate the trachea, and force the obstruction into one of the main stem bronchi with the ETT. d. Another option is to get an ETT and cut off the Murphy eye at the tip. Attach the ETT to suction with a Meconium Aspirator. Intubate until you meet resistance apply suction and attempt to remove the obstruction by withdrawing the ETT while maintaining suction. Page 8 of 8 24 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ALCOHOL INTOXICATION Introduction Alcohol is a CNS depressant, and Acute Alcohol Intoxication should be suspected in patients with an altered mental status and/or the patient exhibits any of the signs and symptoms listed below during the physical exam. Signs & Symptoms Respiratory depression Malnourished Delirium tremens Red (bloodshot) eyes Slurred speech Smell of alcohol on the patient's breath Assessment 1. Universal Initial Adult Patient Assessment and Care 2. Adults with no history of or clinical evidence on examination of recent head trauma AND who are believed to be under the influence of drugs and/or alcohol can be placed into one of three categories: a. Green: All of these must be present 1) Alert and able to respond to questions 2) Can state name (if on a university or high school campus ask for student ID# and campus address) 3) Able to stand and walk under own power b. Yellow: If one or more of these behaviors are exhibited 1) Unable to walk and stand under own power 2) Vomiting 3) Difficulty speaking or identifying self (if on a university or high school campus, patient doesn’t know name, student ID# or campus address) 4) Violent or threatening behavior c. Red: If one or more of these behaviors are exhibited 1) Person is passed out, unconscious, or unresponsive. 2) Breathing seems slow and irregular; difficulty breathing 3) Vomiting blood 4) An injury requiring medical attention is present. Page 1 of 3 25 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ALCOHOL INTOXICATION 3. Police may be called to evaluate situations of apparently intoxicated individuals and may subsequently call for a dispatch of fire department units. a. Typically fire department units will not be dispatched on Green category patients but if dispatched will respond accordingly. b. All Yellow category patients should be transported. c. All Red category patients shall be transported. 4. Transportation guidelines: a. Green category patients can be transported BLS when appropriate. The patient can sign AMA (against medical advice) if the patient refuses transportation and is of legal age. b. Yellow category patients should be transported via an ALS unit to the closest appropriate facility, unless patient can be left under care of responsible adult. c. Red Category patients shall be transported via an ALS unit to the closest appropriate facility. TREATMENT 1. Green: Walking and talking a. Establish baseline vitals, level of consciousness, glucose testing, rule out possible drug ingestion/overdose. Try and talk the patient into going to an appropriate hospital. Any refusals shall be signed and witnessed. b. If the patient refuses and police will not employ the Marchman Act (FS397.6811), fire department crews will have patient sign AMA when of legal age. 2. Yellow: Slurred speech, trouble walking straight line, increased reaction times. Disoriented to Person/Place/Time/Event. a. Establish baseline vitals, level of consciousness, glucose testing, rule out possible drug ingestion/overdose. b. Establish vascular access. c. Treat with dextrose 50% (D50W) if indicated. d. This patient SHOULD be transported to the closest appropriate facility. Page 2 of 3 26 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ALCOHOL INTOXICATION e. Once the decision has been made by the OIC that the patient needs to be seen by a physician, and if the patient refuses, police will utilize the Marchman Act (FS397.6811), and fire department crews will transport to the closest appropriate facility. 3. Red: Unconscious / Death a. Airway Management b. Check for pulse, monitor for arrhythmias, and treat if indicated. c. Supplemental Oxygen, BVM/supraglottic/intubate, as indicated. d. Check blood glucose, treat with dextrose 50% (D50W) if indicated. e. Establish IV / IO. f. CPR / AutoPulse if indicated. g. Transport to closest appropriate facility. Delirium tremens (DTs), a sign of Alcohol Withdrawal, may present as anything from fine tremors to tonic-clonic seizures. Delirium Tremens usually begins 6-24 hours after a decrease in the patient’s usual intake of alcohol. If the patient is agitated and/or combative treat per the Agitated Patient protocol. If the patient is uncooperative and a threat to themselves or to others, they can be held and treated under the Marchman Act (FS397.6811). Consider concurrent drug overdose. Drugs and alcohol can be a deadly combination. Individuals that have consumed highly caffeinated alcoholic drinks may not demonstrate the true level of their alcohol intoxication. Appropriate management of these individuals might include transport to the closest appropriate facility for further observation. Page 3 of 3 27 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne 28 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ALLERGIC / SYSTEMIC REACTIONS Mild Allergic Reaction Treatment is aimed at making the patient comfortable and continually assessing for the development of respiratory distress and/or anaphylaxis. Mild reactions include: Local/systemic redness (flushing) Itching and/or urticaria (hives) Periorbital edema Conjunctivitis (red, bloodshot eyes) Rhinitis (runny nose) Mild bronchospasm (wheezing) TREATMENT 1. Universal Initial Adult Patient Assessment / Care 2. Administer diphenhydramine (Benadryl), 50 mg slow IVP or IM. 3. If bronchospasm, administer ipratropium/albuterol (DuoNeb), 0.5 mg/3 mg of premixed single unit dose via nebulizer at 6 LPM. May repeat once if needed. Anaphylaxis (Severe Allergic Reaction) Anaphylaxis is a condition resulting from a severe allergic reaction. The patient will present in circulatory shock and/or acute respiratory distress as a result of angioedema and/or acute bronchospasm. EVALUATION OF LUNG SOUNDS AT THIS TIME IS CRITICAL in determining severity of the allergic reaction. Severe reactions include: Angioedema (localized swelling, particularly mouth, tongue, or throat) Laryngeal edema (voice changes, difficulty speaking) Hypotension Respiratory failure (low SpO2 or high CO2) Shock TREATMENT 1. Universal Initial Adult Patient Assessment / Care 2. If available, administer one injection from the Epi-Pen into the lateral thigh or upper arm for a moderate to severe anaphylactic reaction OR administer epinephrine 1:1,000, 0.3 mg IM (0.3 mL) for asthma or allergic reactions. Page 1 of 4 29 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ALLERGIC / SYSTEMIC REACTIONS 3. In addition to epinephrine in the hypotensive patient, administer normal saline, 500 mL IV fluid bolus. May repeat once if needed. 4. If patient remains hypotensive (BP less than 90 mmHg systolic OR with no radial pulse), OR they develop acute upper airway obstruction within 3-5 minutes after the IM epinephrine and normal saline fluid bolus, administer epinephrine 1:10,000, 0.1 mg (1 mL) IV/IO. May repeat every 3 to 5 minutes as needed to a maximum dose of 0.5 mg (5 mL). 5. Administer diphenhydramine (Benadryl), 50 mg slow IVP or IM. Benadryl is slower in onset, but longer in duration than epinephrine and should take effect just as epinephrine is losing effectiveness. 6. If the hypotension persists, administer premix dopamine, 400 mg in 250 mL D5W (1,600 mcg/mL), start at 30 drops per minute and titrate until BP is equal to or greater than 90 mmHg systolic. 7. If bronchospasm is not relieved by the administration of the first dose of epinephrine, administer ipratropium/albuterol (DuoNeb), 0.5 mg/3 mg of premixed single unit dose via nebulizer at 6 LPM. May repeat once if needed. Dystonic Reaction Dystonia or extrapyramidal symptoms (EPS) are the result of side effects related to a number of anti-psychotic and anti-emetic drugs. Signs and symptoms include: Protrusion of the tongue Sustained upward deviation of the eyes Jaw/teeth clenching Extreme arching of the back Facial grimacing Or rarely, laryngospasm Deviation of the head to one side Suspect possible dystonia in the patient exhibiting these signs and who has taken any of the following medications: Haloperidol (Haldol) Fluphenazine HCL (Prolixin) Perphenazine (Trilafon) Prochlorperazine (Compazine) Thiothixene (Navane) Trifluoperazine (Stelazine) Trimethobenzamide HCL (Tigan) Metoclopramide (Reglan) NOTE: The individuals taking any of these medications may have been prescribed benztropine mesylate (Cogentin) to combat these above untoward effects. Page 2 of 4 30 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ALLERGIC / SYSTEMIC REACTIONS TREATMENT 1. Universal Initial Adult Patient Assessment / Care 2. Administer diphenhydramine (Benadryl), 50 mg slow IVP or IM. Angioedema Localized edema-swelling usually of the lips, tongue, and/or throat. Patients taking blood pressure medications of the class called angiotensin-converting enzyme inhibitors (ACE-inhibitors) e.g.: Captopril (Capoten) Enalapril (Vasotec, Renitec) Zofenopril (Bifril, Zofenil, Zofepril, Zopranalol) Ramipril (Altace, Tritace, Ramace, Ramiwin) Quinapril (Accupril) Perindopril (Coversyl, Aceon) Lisinopril (Listril, Lopril, Novatec, Prinivil, Zestril) Benazepril (Lotensin) Fosinopril (Monopril) can present with localized angioedema particularly of the lips, tongue, and throat; and partial upper airway obstruction with stridor, rather than bronchospasm with wheezing. During transport, these patients should be observed for any developing or increasing respiratory difficulty and/or changes in their voices that may represent swelling involving the pharynx/vocal cords. This condition can occur in patients who are taking these medications for a short period of time and in those patients who have been taking these medications for many years. The swelling can be severe enough to block the upper airway. TREATMENT 1. Universal Initial Adult Patient Assessment / Care 2. This is NOT an allergic reaction; however, some patients may benefit from treatment with epinephrine and Benadryl. a. Administer epinephrine 1:1,000, 0.3 mg (0.3 mL) IM. Page 3 of 4 31 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS ALLERGIC / SYSTEMIC REACTIONS b. Administer diphenhydramine (Benadryl), 50 mg slow IVP or IM. Benadryl is slower in onset, but longer in duration than epinephrine and should take effect just as epinephrine is losing effectiveness. 3. Changes in the tone of voice or a muffled speech may be the first sign of upper airway obstruction in these patients. 4. These patients require careful monitoring and protection of the upper airway. On occasion these patients will require endotracheal intubation. Unless the need for airway intervention is emergent, any airway intervention should be under a controlled environment at the hospital. 5. All of these patients should be transported to the nearest appropriate hospital. 6. Monitor ETCO2 and SpO2 during transport. Page 4 of 4 32 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BACK PAIN Understanding the medical problem that a patient with back pain is experiencing is made easier by the anatomical location of the back pain. Upper back pain or thoracic spine pain is more often the result of some internal condition. Lower back pain or lumbar pain is most often the result of trauma and is muscular or skeletal in origin. Pain located in the posterior flanks is usually related to the kidneys that lie just below the soft tissues in that area. A good history taken from the patient will provide much more insight than most clinical exams. Questions to Ask: 1. Is there a history of similar pain? a. Patients with chronic lower back pain will experience frequent exacerbations of their back pain. Understanding what medications the patient is taking will help in understanding the chronic nature of a complaint. b. Even patients with chronic lower back pain can have acute events. It is important to ask about any new motor weakness or sensory changes in the lower extremities. Is the patient having bowel or bladder incontinence or unable to urinate? 2. Is there a history of recent trauma? a. Was there a significant mechanism of injury? b. Are there other associated injuries? 3. When did the pain begin? Sudden or gradual onset? 4. Has the pain moved? Into the abdomen, chest, or down the legs? 5. Is there anything that the patient does that makes the pain worse, for example, movement or breathing? 6. Are there other associated new symptoms that began with the back pain, for example, fever, cough, difficult or painful urination, SOB, nausea or vomiting? Lower Back Pain 1. Musculoskeletal pain 2. Sciatica (pinched nerve) Page 1 of 4 33 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BACK PAIN Flank Pain 1. Kidney infection - usually one-sided and associated with fever, nausea, vomiting and urinary difficulties. 2. Kidney stones - usually one-sided, may radiate into the lower abdomen and associated with nausea and vomiting, may have blood in the urine. Upper Back Pain 1. Dissecting aortic aneurysm - classically associated with chest pain that penetrates through to the back and is tearing in nature. 2. Acute Coronary Syndrome (ACS) - can present with chest and left shoulder pain that radiates into the left scapular area. 3. Acute cholecystitis - (gallbladder stones/disease) may radiate from the RUQ of the abdomen, under the right ribs in front, around into the mid- back on one side or both sides. 4. Pulmonary embolus - blood clots in the lung that can present with a sudden onset of upper back pain associated with SOB. TREATMENT 1. Universal Initial Adult Patient Assessment/Care. 2. Monitor vital signs. 3. If the patient is hemodynamically unstable (has a low blood pressure), administer normal saline, 500 mL IV bolus. Re-evaluate the vital signs after the patient has received the fluids. May repeat once if needed. 4. Consider Pain Management as indicated. 5. With acute upper back pain: a. Any male 35 years or older needs a 12-lead ECG. b. Any female 45 years or older needs a 12-lead ECG. 6. With acute lower back pain, perform a neurological exam evaluating motor and sensory function in the lower extremities. 7. If the back pain is a result of a traumatic injury, follow the appropriate trauma protocol. Page 2 of 4 34 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BACK PAIN 8. If there is associated shortness of breath or a low SpO2, follow the appropriate airway management protocol. 9. If there is associated nausea, administer ondansetron (Zofran) ODT, 8 mg PO. UPPER BACK THORACIC SPINE POSTERIOR FLANK LUMBAR SPINE SACRUM Page 3 of 4 35 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BACK PAIN Ischemic Cardiac Aortic Dissection Kidney Infection Kidney Stone Mechanical Sciatica These locations are rough guides. Page 4 of 4 36 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BAKER ACT / MARCHMAN ACT Per FS 401.445, Fire Rescue personnel may examine, treat, and/or transport a patient without their informed (verbal) consent under certain conditions where the patient is incapacitated. Refer to Consent and Refusal. Baker Act Involuntary Examination, Florida Mental Health Act (“The Baker Act", FS 394.463) 1. A person may be taken to a receiving facility for involuntary examination if there is reason to believe that the person has a mental illness and because of his or her mental illness: a. The person has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination; or b. The person is unable to determine for himself or herself whether examination is necessary; and c. Without care or treatment, the person is likely to suffer from neglect or refuse to care for himself or herself; such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services; or d. There is a substantial likelihood that without care or treatment the person will cause serious bodily harm to himself or herself or others in the near future, as evidenced by recent behavior. 2. The Baker Act can only be imposed by the following individuals: a. A Judge b. A sworn law enforcement officer c. A physician, clinical psychologist, or psychiatric nurse, mental health counselor, marriage and family therapist, or clinical social worker. 3. For the purposes of patient exam, treatment, or transportation, the Baker Act will not be considered unless it is clearly understood by all parties that the patient has met the required criteria above (1.a–d). 4. Reasonable force (restraint) may be applied. If restraint is necessary, DO NOT place the patient in a prone (face down) position. Use a supine or recovery position. 5. Careful documentation on the Patient Care Record, including the name and agency of the person imposing the Baker Act will be required. Page 1 of 3 37 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BAKER ACT / MARCHMAN ACT 6. The Baker Act preserves the rights of individuals, including informed consent, the right to refuse treatment, privacy, confidentiality, communications, and/or abuse reporting. 7. The Baker Act is NOT: a. To be used to enforce medical procedures. b. A substitute for the Marchman Act (substance involved). c. To be used for punitive purposes or as a method of arbitrary control. 8. Patients under the Baker Act have the right to refuse any testing, taking of vital signs, blood draws, IV fluids, medications, and other treatments. a. However, clinical judgment must be used when the patient’s wellbeing is at risk. When a patient’s immediate health is at risk for life or limb and the patient is refusing any health care interventions, for example, as above, the healthcare provider should take the appropriate steps to manage the situation so that care may be rendered to the patient. b. This should include attempting to convince the patient, family, or friends of the need for healthcare interventions. c. If there is no success in verbally persuading the patient, controlled, appropriate steps including restraints may be employed to administer testing and treatment to these patients. d. All of the above should be documented in the patient’s medical record. Marchman Act 1. The Marchman Alcohol and Other Drug Services Act may be implemented when a patient has threatened or inflicted physical harm toward themselves or others while under the influence of drugs or alcohol. 2. Additionally, the implementation of the Marchman Act may be considered if it appears that the individual’s judgment is so impaired by alcohol or drugs that while in this state they cannot make appropriate judgments as relates to their health and well-being. Page 2 of 3 38 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BAKER ACT / MARCHMAN ACT 3. The Florida State Statute is cited below. e. 397.675 Criteria for involuntary admissions, including protective custody, emergency admission, and other involuntary assessment, involuntary treatment, and alternative involuntary assessment for minors, for purposes of assessment and stabilization, and for involuntary treatment.—A person meets the criteria for involuntary admission if there is good faith reason to believe the person is substance abuse impaired and, because of such impairment: 1) Has lost the power of self-control with respect to substance use; AND/EITHER 2) Has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on himself or herself or another; OR 3) Is in need of substance abuse services and, by reason of substance abuse impairment, his or her judgment has been so impaired that the person is incapable of appreciating his or her need for such services and of making a rational decision in regard thereto; 4) However, mere refusal to receive such services does not constitute evidence of lack of judgment with respect to his or her need for such services. Page 3 of 3 39 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne 40 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BITES & STINGS For any reptile or spider bite whether known or unknown if venomous, request the Miami-Dade County Venom 1 Unit. GENERAL TREATMENT 1. Universal Initial Adult Patient Assessment / Care. 2. Monitor ECG and SpO2. 3. Attempt to identify the insect, reptile, or animal that caused the injury if it is safe to do so. If unknown or it is a known venomous reptile bite or spider bite, have dispatch contact Miami-Dade Fire Rescue Venom 1. If Venom 1 is providing anti-venom, they respond to the receiving facility, not to the scene. Ensure Venom 1 knows your transport destination. 4. Be alert for the development of any anaphylactic reaction and treat according to the Systemic Reactions Protocol. 5. Immobilize the affected area. Keep the patient calm. 6. Remove and secure in a safe location any rings, bracelets, jewelry, etc. that may be on the injured area before swelling prevents easy removal of these items. 7. Do not apply tourniquets or cold packs. Do not make incisions around the area, or attempt to suction the area. 8. Contact the Poison Control Center, 1-800-222-1222, for assistance in managing specific envenomations. 9. Maintain SpO2 of 94% or greater. 10. Establish vascular access with a saline lock on the unaffected extremity. North American Pit Vipers (Includes rattlesnakes, copperheads, and cottonmouths/moccasins) 1. For any known or suspected bite, alert Venom 1. Page 1 of 6 41 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BITES & STINGS 2. Evaluate for specific signs/symptoms: Distinct "fang marks" or puncture wounds. Swelling and pain at the site. Weakness, nausea, and vomiting. Muscle twitching. Numbness and tingling around the face and head. Metallic taste, change in taste sensation. Hypotension and shock. Allergic reactions. 3. Mark the end point of the initial swelling and the time directly on the skin. This should be repeated every 15 minutes if applicable. The time of the bite should also be recorded on the Patient Care Record. 4. If possible, keep the injured area low, and splint to minimize movement. 5. Provide rapid transport, and alert the receiving facility of the specific snake. Coral Snake Bites Patients who have been bitten by a Coral Snake may not have any symptoms for a few hours. If there is a reliable history of a possible Coral Snake bite, the patient should be transported to the hospital for further observation and evaluation. Coral snakes do not have fangs but have small milk teeth. The typical story is that a patient is bitten on the finger or toe and the patient has to shake the snake off. “Red next to yellow can kill a fellow” “Red next to black is a friend of Jack” (Coral Snake) (King Snake, non-poisonous) 1. For any known or suspected bite, alert Venom 1. 2. Evaluate for specific signs/symptoms: Most signs and/or symptoms may be delayed up to 12 hours and are related to the type of venom, which is a neurotoxin; therefore, CNS disturbances may be observed. Stroke-like signs and/or symptoms. Page 2 of 6 42 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BITES & STINGS 3. Respiratory paralysis may develop. Be prepared to manage respiratory distress and provide ventilation assistance. 4. Wrap an ace bandage snugly around the affected limb starting at the site of the bite and working towards the heart (proximal), wrapping the entire extremity. Wrap the ace bandage as snug as you would for a sprained ankle. Monitor distal circulation by capillary refill and/or pulse to ensure the wrap does not become a tourniquet. 5. If possible, keep the injured area low and splint to minimize movement. 6. Provide rapid transport and alert the receiving facility of the specific snake. Exotic Snakes (Includes cobras, vipers, mambas, etc.) In the case of an exotic bite, it is imperative to identify the snake’s scientific name or at least its common name. Signs and symptoms will vary greatly among different species. Have Dispatch contact Venom 1 immediately. Brown Recluse Spider Bites 1. Evaluate for specific signs/symptoms: Small bleb (blister) surrounded by a white ring. Localized pain, redness and swelling. Localized tissue necrosis. Most patients are unaware that they were bitten until the area becomes ischemic and ulcerates. 2. There is no specific pre-hospital treatment. Page 3 of 6 43 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BITES & STINGS Black Widow Spider Bites 1. For any known or suspected bite, alert Venom 1. 2. Evaluate for specific signs/symptoms: Immediate localized pain. Progressive muscle spasms (usually beginning in the back and abdomen). Rigid abdomen. Seizures. Paralysis. 3. To reduce severe muscle spasms, if indicated, administer midazolam (Versed), 5 mg slow IV or 10 mg IM / IntraNasal. 4. If patient still has severe muscle spasms after Versed, and the systolic BP remains at 90 mmHg or greater, administer morphine sulfate, 5 mg IV/IO/IM. If patient continues to complain of severe muscle spasms, the morphine may be repeated every 5 minutes as indicated. Do not exceed at total dose of 20 mg morphine. 5. Consider Pain Management in the conscious patient. 6. Provide rapid transport. The patient may require specific Antivenin injections. Scorpion Stings 1. Evaluate for specific signs/symptoms: Mild to sharp pain which often progresses to numbness. Salivation. Slurred speech. Muscle twitching. Allergic reaction. 2. Consider Pain Management in the conscious patient. 3. Provide rapid transport if symptomatic. Page 4 of 6 44 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BITES & STINGS Marine Animal Envenomations (Includes Stingrays, Scorpion fish, Catfish, Lionfish, Starfish, and Sea Urchins) 1. Immerse the puncture(s) in non-scalding hot water as warm as tolerable (110- 113°F) to achieve pain relief. Transport should not be delayed. Immersion in non-scalding hot water may be continued during transport, as it may take 30-90 minutes for total relief. 2. If the spine is still embedded, do not attempt removal in the field. 3. Consider Pain Management in the conscious patient. Marine Animal Stings (Includes stings from Jellyfish, Man-O-War, Sea Lice, Hydroids and Fire Coral) 1. Evaluate ABCs for evidence of an allergic reaction, severe inflammation and swelling that might compromise airway and breathing. 2. Attempt to remove any visible tentacles using 4x4s with a double-gloved hand. Avoid contact with unprotected skin as the stinging cells are activated on contact, even after the animal has been out of the water for hours. 3. If available, apply a vinegar (acetic acid) soaked gauze (if available) to the affected areas for 30 minutes. 4. Consider Pain Management in the conscious patient. 5. After there has been pain relief, attempt to remove any remaining tentacles by using shaving cream and gentle scraping action with a wooden tongue depressor (if not available use something with a rigid edge like a credit card/driver’s license). Page 5 of 6 45 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BITES & STINGS Bees/Wasps/Hornets/Yellow Jackets/Ant Stings Most patients will have significant pain with these bites. Some patients may develop localized allergic reactions to these bites and/or some may develop anaphylactic reactions from the stings of these insects. 1. Apply local ice packs. 2. Consider Pain Management in the conscious patient. 3. If the patient develops an allergic reaction and/or an anaphylactic reaction refer to the appropriate protocol. Page 6 of 6 46 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BRADYCARDIA Bradycardia is a heart rate less than 60 beats per minute (bpm). The patient’s presenting signs and symptoms may or may not be related to their low heart rate. Further assessment, including patient history and medications, is needed. Symptomatic bradycardia means that the patient’s signs and symptoms are related to the bradycardia. Symptomatic bradycardia patients are categorized as either STABLE (monitor and transport) or UNSTABLE (requires immediate treatment). STABLE bradycardia patients have adequate perfusion on exam. Signs and symptoms may include: Generalized Weakness / Dizziness Nausea Mild anxiety UNSTABLE bradycardia includes at least 2 of the following: New onset of Altered Mental Status Syncope Respiratory distress / CHF Chest pain Low blood pressure Signs / Symptoms of Shock STEMI TREATMENT OF UNSTABLE BRADYCARDIAS 1. Universal Initial Adult Patient Assessment / Care. 2. As with all patients, use a team approach in the management of patients with an unstable bradycardia. One paramedic should start an IV while another paramedic applies the external pacemaker. Begin external pacing as soon as possible. Do not delay pacing while waiting for vascular access or for atropine to take effect. 3. Ensure adequate ventilations. Check rate and depth. Remember that hypoxia/ inadequate ventilations are a common cause of bradycardia. 4. Administer atropine sulfate, 0.5 mg IVP/IO. This may be repeated every 2-3 minutes until a maximum dose of 0.04 mg/kg (3 mg for the average adult) is reached; however, atropine in unlikely to be effective for bradycardias with wide QRS complex 2nd Degree Mobitz II and 3rd Degree AV Blocks. Page 1 of 3 47 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BRADYCARDIA 5. If the patient is conscious and not tolerating the pain from pacing, consider pain management. 6. If the above treatments are successful in raising the patient’s heart rate above 60 bpm, but the BP remains less than 90 mmHg: a. Administer a fluid bolus of normal saline, 500 mL IV/IO. May repeat once as needed. b. If the BP still remains less than 90 mmHg after fluid administration, administer premix dopamine, 400 mg in 250 mL D5W (1,600mcg/mL) IV/IO, start at 30 drops per minute and titrate until BP is equal to or greater than 90 mmHg systolic. c. Consider other causes of shock, but do not delay transport. SPECIAL CIRCUMSTANCES 1. If the bradycardia is the result of a Beta Blocker or Calcium Channel Blocker excess / OD: a. Administer atropine sulfate, 1 mg IV every 2-3 minutes to a maximum of 3 mg. b. If the patient remains hypotensive, administer normal saline, 500 mL IV bolus. May repeat once if patient remains hypotensive. 2. If the bradycardia is the result of an Organophosphates Overdose: a. Administer atropine sulfate, 2 mg IVP every 5 minutes until drying of the secretions (atropinization) occurs, or 2 mg IM with an Atropen Auto Injector if available. 4. In a patient with an acute inferior wall myocardial infarction and a bradycardia due to a high-grade Mobitz II or a Third Degree Heart Block (complete heart block) with a wide QRS complex, external pacing is preferred as the first treatment. Dopamine may be used to increase the heart rate while applying the transcutaneous pacer. 5. If the patient has a heart rate of 40 bpm or less but is otherwise stable, apply the external pacemaker pads without turning the pacer on and observe for any signs/symptoms suggesting that the patient is unstable. Page 2 of 3 48 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS BRADYCARDIA 6. Patients with bradycardia will frequently demonstrate ventricular ectopy. This ventricular ectopy (rate dependent PVC) is an escape beat that the heart uses to attempt to maintain adequate blood flow. These patients should NOT be given lidocaine or amiodarone for these ventricular ectopic beats but should be given atropine or external pacing to raise the heart rate. Frequently, raising the heart rate will cause the ventricular ectopies to disappear. 7. Patients with heart transplants and bradycardia will not respond to atropine and need external pacing and/or dopamine to correct the heart rate. 8. Dialysis patients may develop high levels of serum potassium (hyperkalemia). These patients present with a wide complex QRS and bradycardia. These patients are usually hemodynamically stable and do not require external pacing. This wide complex bradycardia, most often due to hyperkalemia, is treated as follows: a. Administer sodium bicarbonate,1 mEq/kg IV/IO. May repeat with 0.5 mEq/kg in 10 minutes. b. If no response, flush the IV access line with at least 20 mL of normal saline and then administer calcium chloride, 1 gram IV/IO slowly over 1 minute. Page 3 of 3 49 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne 50 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS CARDIAC ARREST INITIAL PATIENT ASSESSMENT 1. Check for responsiveness, breathing, and pulse. 2. If the patient is unresponsive, determine presence or absence of a pulse. 3. Start chest compressions and continue uninterrupted until the monitor or AED is ready to assess the rhythm. Primary attention is paid to immediate continuous chest compressions and assessment of the patient’s cardiac rhythm. 4. Defibrillator pads should be applied without interrupting compressions. 5. Quickly determine whether the patient has a shockable rhythm, and if so, immediately DEFIBRILLATE. 6. If defibrillated, resume compressions immediately after, and manage according to the appropriate protocol(s). 7. If patient does not have a shockable rhythm, resume compressions and manage according to the appropriate protocol(s). 8. If a pulse returns (Return Of Spontaneous Circulation – ROSC), Initiate Post Resuscitation Care. 9. If no ROSC, refer to Death in the Field Protocol. CHEST COMPRESSIONS (use a manual Active Compression / Decompression Device if available) 1. In cardiac arrest, the emphasis is on continuous chest compressions with adequate rate and depth, rather than on ventilations. 2. PUSH HARD. PUSH FAST. ALLOW FULL CHEST RECOIL. MINIMIZE INTERRUPTION OF COMPRESSIONS. a. Compress at a rate of 100-120 compressions per minute (or per active compression/decompression procedure, if available). b. One adult cycle is 2 minutes of compressions. c. Perform 2 minutes of CPR between each rhythm check. DO NOT CHECK FOR A PULSE UNLESS THERE IS AN ORGANIZED RHYTHM ON THE MONITOR AND THERE HAS BEEN AN INCREASE IN THE ETCO 2 LEVEL OF 20 MM OR MORE. Page 1 of 11 51 Common EMS Protocols - Coral Gables, Hialeah, Miami, Miami Beach, and Key Biscayne COMMON EMS PROTOCOLS ADULT PROTOCOLS CARDIAC ARREST d. Change the compressor (with manual compressions) after every 2 minutes of CPR. e. Compressions must be delivered on a HARD SURFACE. f. Minimize interruptions of chest compressions to less than 10 seconds. g. DO NOT INTERRUPT COMPRESSI

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