Protocols.pdf

The Maryland Medical Protocols for Emergency Medical Services Maryland Institute for Emergency Medical Services Systems Effective July 1, 2023  General Patient Care (GPC) 2.1 The General Patient Care section shall ap...

The Maryland Medical Protocols for Emergency Medical Services Maryland Institute for Emergency Medical Services Systems Effective July 1, 2023  General Patient Care (GPC) 2.1 The General Patient Care section shall apply to all patient encounters unless otherwise noted in any specific treatment protocol. A. RESPONSE Review the dispatch information and select appropriate response. B. SCENE ARRIVAL AND SIZE-UP 1. Consider Body Substance Isolation (BSI). 2. Consider Personal Protective Equipment (PPE). 3. Evaluate the scene safety. 4. Determine the number of patients. 5. Consider the need for additional resources. C. PATIENT APPROACH 1. Determine the Mechanism of Injury (MOI)/Nature of Illness (NOI). 2. If appropriate, begin triage and initiate Mass Casualty Incident (MCI) procedures. D. INITIAL ASSESSMENT Rapidly develop a general impression of the patient on first contact: 1. Identify the critically unstable patient – any patient in extremis or with imminent risk for General Patient Care 2.1 deterioration to arrest: a) New onset of altered mental status (AVPU not alert) b) Airway compromise c) Acute respiratory distress d) Signs of poor perfusion e) A  ny other patient judged by the clinician to be in extremis or at risk for deterioration to cardiac arrest 2. If you have identified a critically unstable patient: a) STOP ALL MOVEMENT OF PATIENT b) DO NOT INITIATE TRANSPORT c) PROCEED TO CRITICALLY UNSTABLE PATIENT PROTOCOL IMMEDIATELY For pediatric patients, use the Pediatric Assessment Triangle. Appearance Work of Breathing Circulation to Skin www.miemss.org 15 Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) 3. Assess mental status a) Alert b) Responds to Verbal stimuli c) Responds to Painful stimuli d) Unresponsive 4. Airway a) Stabilize cervical spine when appropriate b) Open and establish airway using appropriate adjunct. c) Place patient in appropriate position. d) Suction airway as needed, including tracheostomy tubes. e) If a patent airway cannot be established, the patient must be transported to the closest appropriate hospital-based emergency department or designated free- standing emergency medical facility. EMS clinicians should remain available to assist with patient transfer, if the hospital determines such a transfer is appropriate. f)  In infants and young children, inspiratory stridor is an indication of upper airway foreign body or partial airway obstruction. Request ALS rendezvous. Transport the patient rapidly and with caution. Have foreign body airway removal equipment ready for immediate use in case the patient’s airway becomes obstructed. General Patient Care 2.1 5. Breathing a) Determine if breathing is adequate and assess oxygen saturation (SpO2) with pulse oxim- eter. (1) If patient’s ventilations are not adequate, provide assistance with 100% oxygen using Bag-Valve-Mask (BVM). (i)  For patients 13 years of age and older, deliver 1 breath every 6 seconds (10 breaths per minute). (ii)  For neonates and patients less than 13 years of age, deliver 1 breath every 3 seconds (20 breaths per minute). (iii)  For newly born patients (first hour after delivery), refer to Newly Born Protocols 5.2 and 5.3. (2) The decision to oxygenate will be based on the patient’s clinical condition. (i)If the patient has SpO2 less than 94%, administer supplemental oxygen, titrated to SpO2 level of 94%. (ii) Supplemental oxygen is not needed if SpO2 greater than or equal to 94% unless the patient is in respiratory distress, acutely dyspneic, or suffering from suspected CO poisoning. Patients in severe respiratory distress may benefit from high-flow oxygen from a nonrebreather (NRB). (iii) Unless in respiratory distress, avoid administration of high-flow oxygen to patients presenting with the following conditions: (a) STEMI / angina (b) CVA / stroke (c) Post-arrest (iv) CO exposure: Apply 100% oxygen via NRB mask. Maintain SpO2 at 100%. Release Date July 1, 2023 16 www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 (3) Utilize continuous ETCO2 waveform monitoring in all intubated patients. (4) Measure carbon monoxide level with a co-oximeter, if appropriate and available. Percent O2 Saturation Ranges General Patient Care 94–100% Normal Give oxygen as necessary 91–93% Mild Hypoxia Give oxygen as necessary 86–90% Moderate Give 100% oxygen Hypoxia Assisting Ventilations if necessary less than Severe Hypoxia Give 100% oxygen or equal to Assist Ventilations 85% If indicated, Intubate INACCURATE OR MISLEADING SpO2 READINGS MAY OCCUR IN THE FOLLOWING PATIENTS: HYPOTHERMIC, HYPOPERFUSION (SHOCK), CO POISONING, HEMOGLOBIN ABNORMALITY, ANEMIA, AND VASOCONSTRICTION. b) Hyperventilate the head-injured patient only if signs/symptoms of herniation are present, General Patient Care 2.1 including posturing, loss of pupillary light response, dilation of one or both pupils, vomit- ing, hypertension, bradycardia, and/or irregular respirations. (1) If hyperventilating, use the following rates: (i) Adult (including adolescent 13 years of age or older): 20 breaths per minute (ii) Child (1-12 years of age): 30 breaths per minute (iii) Infant (less than 1 year of age): 35 breaths per minute (2) Use ETCO2 monitoring. (i)  Maintain ETCO2 between 35-40 mmHg for any patient with significant head injury (ii) For patients with significant head injury and signs of herniation, adjust ventila- tions to achieve ETCO2 of 30-35 mmHg. 6. Circulation a) Assess pulse. (1) Patients within the first hour after delivery, refer to Newly Born protocol. (2) Patients from one hour after birth up to those who have not reached their 13th birthday, refer to the Universal Algorithm for Pediatric Emergency Cardiac Care for BLS. (3) P atients 13 years of age or greater, refer to the Universal Algorithm for Adult Emergency Cardiac Care for BLS. (4) If pulseless, stay on scene and immediately initiate high-quality continuous HPCPR. (i) Ensure frequent clinician rotations and minimal interruptions (less than 10 seconds). (ii) Mechanical CPR devices may be used, if available, for patients 13 years of age and older only. (iii) Perform CPR while preparing for rhythm analysis and defibrillation. www.miemss.org 17 Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) HPCPR Reference Chart for All Ages Component Adults and Adolescents Children (Age 1 Year to Puberty) Infants (Age Less Than 1 Year, Excluding Newborns) Compression- 1 rescuer ventilation ratio 30:2 without advanced Continuous compressions at 2 or more rescuers airway a rate of 100-120/min. Give 1 15:2 breath every 6 seconds Compression- Continuous compressions at a rate of 100-120/min. (10 breaths/min). ventilation ratio Give 1 breath every 3 seconds (20 breaths/min). WITH advanced airway Compression rate 100-120/min Compression depth At least 2 inches (5 cm). Com- At least one-third At least one-third pression depth should be no anterior-posterior diameter of anterior-posterior diameter of more than 2.4 inches (6 cm). chest. About 2 inches (5 cm). chest. About 1½ inches (5 cm). Hand placement 2 hands on the lower half of the 2 hands or 1 hand (optional for 1 rescuer breastbone (sternum). very small child) on the lower half 2 fingers in the center of the of the breastbone (sternum). chest, just below the nipple line. 2 or more rescuers 2 thumb-encircling hands in the center of the chest, just below the nipple line. General Patient Care 2.1 b) Assess for and manage profuse bleeding, using a method appropriate for the patient’s injuries: (1) Direct pressure (2) Wound packing (3) Hemostatic gauze (4) Tourniquet or junctional tourniquet (with jurisdictional training) c) Assess skin color, temperature, and capillary refill. d) Initiate cardiac monitoring as appropriate. 7. Disability a) Assess for pulse, motor and sensory function in all extremities b) Assess GCS for trauma patients c) Determine the need for Spinal Motion Restriction. (1) Patients who have a blunt trauma with a high-energy mechanism of injury that has potential to cause spinal cord injury or vertebral instability and one or more the fol- lowing should receive spinal motion restriction. - Midline spinal pain, tenderness, or deformity - Signs and symptoms of new paraplegia or quadriplegia - Focal neurological deficit - Altered mental status or disorientation - Distracting injury: Any injury (e.g., fracture, chest, or abdominal trauma) associated with significant discomfort that could potentially distract from a patient’s ability to accurately discern or define spinal column pain or tenderness. (2) In addition to the above indicators for adults, the below apply to children who have not yet reached their 15th birthday. Release Date July 1, 2023 18 www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 - Neck pain or torticollis - High-impact diving incident or high-risk motor vehicle crash (head on col- lision, rollover, ejected from the vehicle, death in the same crash, or speed greater than 55 mph) - Substantial torso injury - Conditions predisposing to spine injury d) If NO to all of the above, transport as appropriate. e) Infant or child car seats may not be used as a spinal immobilization device for the pediatric patient. f) If patient is unable to communicate or appropriately respond to the above questions, apply Spinal Motion Restriction protocol. 8. Exposure To assess patient’s injuries, remove clothing as necessary, considering condition and environment. 9. Assign Clinical Priority a) Priority 1 — Critically ill or injured person requiring immediate attention; unstable patients with life-threatening injury or illness. b) Priority 2 — Less serious condition yet potentially life-threatening injury or illness, requir- General Patient Care 2.1 ing emergency medical attention but not immediately endangering the patient’s life. c) Priority 3 — Non-emergent condition, requiring medical attention but not on an emergency basis. d) Priority 4 — Does not require medical attention. e) In the event of a multiple casualty incident, the Simple Triage and Rapid Treatment (START and/or JumpSTART) technique will be instituted for rapid tagging and sorting of patients into priority categories for both treatment and transport. 10. Normal Vital Signs Chart AGE ESTIMATED HEART RESPIRATORY SYSTOLIC WEIGHT RATE RATE B/P Premature Less than 3 kg 160 Greater than 40 60 Newborn 3.5 kg 130 40 70 3 mo. 6 kg 130 30 90 6 mo. 8 kg 130 30 90 1 yr. 10 kg 120 26 90 2 yrs. 12 kg 115 26 90 3 yrs. 15 kg 110 24 90 4 yrs. 17 kg 100 24 90 6 yrs. 20 kg 100 20 95 8 yrs. 25 kg 90 20 95 10 yrs. 35 kg 85 20 100 12 yrs. 40 kg 85 20 100 14 yrs. 50 kg 80 18 110 ADULT Greater than 50 kg 80 18 120 www.miemss.org 19 Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) E. HISTORY AND PHYSICAL EXAMINATION/ASSESSMENT 1. Conduct a Focused Examination/Detailed Examination/Ongoing Assessment. 2. Collect and transport documentation related to patient’s history (example: Emergency In- formation Form, Medic Alert, EMS DNR/MOLST, or jurisdictional form). 3. Clinicians should obtain and document a contact telephone number for one or more in- dividuals who have details about the patient’s medical history so that the physician may obtain and validate additional patient information. 4. Obtain an EKG when appropriate. ALL HEALTH CARE CLINICIANS ARE OBLIGATED BY LAW TO REPORT CASES OF SUS- PECTED CHILD OR VULNERABLE ADULT ABUSE AND/OR NEGLECT TO EITHER THE LOCAL POLICE OR ADULT/CHILD PROTECTIVE SERVICE AGENCIES. DO NOT INITIATE REPORT IN FRONT OF THE PATIENT, PARENT, OR CAREGIVER (MD CODE, FAMILY LAW, § 5-704). UNDER MARYLAND LAW, EMS CLINICIANS ARE PROTECTED FROM General Patient Care 2.1 LIABILITY IF THEY MAKE A REPORT OF CHILD/VULNERABLE ADULT ABUSE AND NE- GLECT IN GOOD FAITH (COURTS AND JUDICIAL PROCEEDINGS ARTICLE § 5-620). F. TREATMENT PROTOCOLS 1. Refer to ALL appropriate protocols. 2. Patients who have had an impaled conducted electrical weapon used on them will be transported to the nearest appropriate facility without dart removal (exception: Tactical EMS). ANY conducted electrical weapon dart impalement to the head, neck, hands, feet, or genitalia must be stabilized in place and evaluated by a physician. 3. Clinicians may assist the patient or primary caregiver in administering the patient’s pre- scribed rescue medication. a) BLS clinicians may assist with the administration of the patient’s fast-acting bronchodi- lator MDI and sublingual nitroglycerin. b) ALS clinicians may administer the patient’s prescribed benzodiazepine for seizures, Factor VIII or IX for Hemophilia A or B, or reestablish IV access for continuation of an existing vasoactive medication. c) Clinicians should obtain on-line medical direction to administer other prescribed rescue medications not specifically mentioned in The Maryland Medical Protocols for Emergency Medical Services (e.g., hydrocortisone (Solucortef) for adrenal insufficiency). The rescue medication must be provided by the patient or caregiver and the label must have the pa- tient’s name and the amount of medication to be given. 4. For patients with fever documented by EMS as greater than 100.4 F (38 C), clinicians may treat with acetaminophen.  O NOT ADMINISTER ORAL MEDICATIONS (EXCEPT ORAL GLUCOSE) TO PATIENTS WITH AN ALTERED D MENTAL STATUS. Release Date July 1, 2023 20 www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 5. For pediatric patients a) Pediatric section of the treatment protocol will be used for children who have not reached their 15th birthday (trauma) or their 18th birthday (medical), except as otherwise stated in the treatment protocol. b) Medication dosing (1) Pediatric doses apply to patients weighing less than 50 kg. (2) For pediatric patients equal to or greater than 50 kg, utilize adult dosing. c) The developmental age of the infant/child must be considered in the communication and evaluation for treatment. Destination consideration:  For those patients who are 18 years of age or older who receive specialized care at a pediatric facility, consider medical consultation with a Pediatric Base Sta- tion for patient destination. d) Infants and children must be properly restrained prior to and during transport. e) A parent/guardian/care taker may remain with a pediatric patient during transport, but must be secured in a separate vehicle restraint system at all times during transport. f) For patients with fever documented by EMS as greater than 100.4 F (38 C), clinicians may treat with acetaminophen. General Patient Care 2.1 G. COMMUNICATIONS 1. Hospital Notification: A brief communication to the ED for notification of an inbound patient. a) All Priority 1, Priority 2, and Specialty Alert patients require hospital notification via EMRC. (Note: All communications via EMRC/SYSCOM are recorded.) b) For Priority 3 patients, notification may be made via EMRC or EOC/EMS communica- tion system in accordance with the standard operating procedures of the local jurisdic- tion. 2. Medical Consultation: a bi-directional communication via EMRC between an authorized hospital-based physician (or EMSOP medical director) and prehospital EMS clinician for the purpose of incorporating the physician’s knowledge and experience into ongoing patient care. Medical consultation: a) Shall be obtained when required by a specific protocol b) Should be obtained when a clinician has reached the end of their therapeutic or diag- nostic capabilities without adequate effect from their treatments c) Is available at any time for any patient for any reason 3. If medical consultation is genuinely unavailable, or if the time necessary to initiate consul- tation significantly compromises patient care, the clinician shall proceed with additional protocol-directed care, so long as transport will not be significantly delayed. “Exceptional Call” must be indicated on the Patient Care Report (PCR). www.miemss.org 21 Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) 4. Suggested elements for notifications and medical consults: a) Assigned patient priority (1 to 4) b) Age c) Chief complaint d) Clinician impression e) Pertinent patient signs and symptoms f) HR, RR, BP, Pulse Ox (do not use “within normal limits” or “stable” in description) g) Pertinent physical findings h) ETA In addition, for specialty center patients: Trauma a) Number of victims, if more than one b) GCS, including motor GCS score c) Patient Trauma Decision Tree Category (Alpha, Bravo, Charlie, Delta) General Patient Care 2.1 Stroke d) Last known well time e) Specific neurological findings (sensory, motor, cognitive) f) Upon positive assessment using the Cincinnati Stroke Scale, a STROKE alert shall be made and the LAMS score will be included in the consult. STEMI g) 12-lead interpretation h) Duration of symptoms 5. Mass Casualty Incident (MCI) Communications a) When a local jurisdiction declares an MCI, it is extremely important to maximize patient care resources and reserve EMS communications for emergent situations. Except for extraordinary care interventions, EMS clinicians may perform all skills and administer medications within protocol during a declared MCI. When the MCI condition is institut- ed, the “Exceptional Call” box must be checked on the PCR. b) During an MCI, the EMS Officer-in-Charge (OIC) shall designate an EMS Communicator, who shall establish appropriate communications. c) Reference the Multiple Casualty Incident/Unusual Event Protocol. H. REASSESSMENT 1. Reassess unstable patients frequently (recommended every 5 minutes). 2. Reassess stable patients at a minimum of every 15 minutes. 3. Reassess patients being discharged to home or long-term care at the beginning and end of the transport or more frequently, at the clinician’s discretion. Release Date July 1, 2023 22 www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 I. DISPOSITION 1. Destination a) Priority 1 patients shall be triaged according to Maryland Medical Protocols to the clos- est appropriate hospital-based emergency department, designated trauma, or desig- nated specialty referral center. Critically unstable patients in need of immediate life-sav- ing interventions that cannot be provided in the field shall, with the approval of EMS system medical consultation, be diverted to the closest facility (including freestanding emergency medical facility) capable of immediately providing those interventions. b) Priority 2 patients shall be triaged according to the Maryland Medical Protocols to the closest appropriate hospital-based emergency department, designated trauma or desig- nated specialty referral center unless otherwise directed by EMS system medical con- sultation. Stable Priority 2 patients may be referred to a freestanding emergency medical facility. c) Stable Priority 3 or 4 patients who do not need a time-critical intervention may be trans- ported to the local emergency department or freestanding emergency medical facility. d) Patients Under Investigation (PUI) for an Emerging Infectious Disease (EID) at a residence should be transported directly to an Assessment Hospital unless total transport time is no longer than 45 minutes greater than transport to the nearest Frontline Hospital ED. If transport time is longer than 45 minutes greater than transport to the nearest Frontline General Patient Care 2.1 Hospital ED, the patient must be transported to the closest appropriate Frontline hospi- tal. Priority 1 and Priority 2 patients with unresolved symptoms that cannot be managed outside the hospital should be taken to the closest Frontline Hospital. Receiving hospital notification of all suspected PUI patients should be done as early as possible to allow for hospital staff to prepare. Helicopter transport is NOT indicated for the PUI patient. e) For Priority 2 and Priority 3 patients not meeting a specialty center destination care protocol, the EMS clinician should ask if the patient has had a hospital admission (in- patient service) within the last 30 days. If the answer is yes, the EMS clinician should transport (repatriate) the patient to that hospital as long as that hospital is not more than 15 additional minutes further than nearest hospital (or greater if allowed for by the EMS Operational Program). 2. Mode of transport (air, land, water) a) Medevac patients with indications for specialty referral center should be flown to the appropriate type of specialty center if not more than 10–15 minutes further than the closest trauma center. (Patients with an airway, breathing, or circulatory status who would be jeopardized by going an additional 10–15 minutes should go to the closest trauma center.) b) Consider utilization of a helicopter when the patient’s condition warrants transport to a trauma or specialty referral center and the use of a helicopter would result in a clinically significant reduction in time compared with driving to a trauma/specialty center.  LL REQUESTS FOR SCENE HELICOPTER TRANSPORTS SHALL BE MADE THROUGH SYSCOM. FOR A TRAUMA DECISION TREE CATEGORY CHARLIE OR DELTA, RECEIVING TRAUMA CENTER MEDICAL CONSULTATION IS REQUIRED WHEN CONSIDERING WHETHER HELICOPTER TRANSPORT IS OF CLINICAL BENEFIT. www.miemss.org 23 Release Date July 1, 2023 Back to Contents  General Patient Care (GPC) 2.1 (continued) c) If the time of arrival at the trauma or specialty referral center via ground unit is less than 30 minutes, there will generally be no benefit in using the helicopter, especially for Trauma Decision Tree categories Charlie and Delta. d) Refer to the Trauma Decision Tree when considering use of aeromedical transport. Provide SYSCOM with the patient’s category (Alpha, Bravo, Charlie, or Delta). e) On-line medical direction should be obtained from the local trauma center and the specialty referral center when transport to the specialty center would require more than 10–15 min- utes additional transport time. (1) Pediatric Trauma Patients: Indications as per the pediatric section of the Trauma protocols. (2) Spinal Trauma Patients: Indications as per Spinal Motion Restriction protocol. (3) Burn Patients: Indications as per Burn protocol. Special note: Isolated burn patients without airway injury or other associated trauma should normally be flown to a burn center, regardless of the location of the closest trauma center. (4) Hand Injury Patients: Indications as per Hand Trauma protocol. Special note: Medevac patients with appropriate indications for hand center referral should normally be flown to the hand center, regardless of the location of the clos- est trauma center. General Patient Care 2.1 3. Status Evaluate the need for emergent versus non-emergent transportation.  O NOT WAIT ON-SCENE FOR ADVANCED LIFE SUPPORT. ATTEMPT TO RENDEZVOUS D EN ROUTE TO THE HOSPITAL. J. TRANSFER OF CARE/RENDEZVOUS AND TRANSITION OF PATIENT CARE ALS TO BLS The ALS clinician-patient relationship is established when the ALS clinician initiates patient assessment and 4. ALS medication(s)* is/are administered or 5. ALS procedure(s)* is/are performed or 6. Upon ALS clinician assessment of the patient there is potential risk of deterioration. * Based on the medication or procedure as listed in protocol 9.2: Procedures, Medical Devices, and Medications for EMS and Commercial Services. ALS clinicians may only terminate their EMS clinician-patient relationship when they are as- sured that the patient will continue to receive care at the same or greater levels, or when they have documented with on-line medical direction that the patient’s condition has improved and that patient care may be transferred safely to an EMS clinician with a lower scope of practice. BLS clinicians have the right to decline the transition of patient care. When consensus between the clinicians cannot be gained, ALS shall get on-line medical direction. Clinicians will relay assessment findings and treatment provided to the individual(s) assuming Release Date July 1, 2023 24 www.miemss.org Back to Contents  General Patient Care (GPC) (continued) 2.1 responsibility for the patient(s). Should an ALS clinician perform an EKG (of any type), it shall be imported into the patient care report and a copy shall be sent with the BLS unit to the re- ceiving facility. K. DOCUMENTATION A Patient Care Report (PCR) will be completed and delivered to the receiving facility as soon as pos- sible, ideally upon transfer of care. If this is not immediately possible, clinicians must provide docu- mentation of the patient’s prehospital care on a template and in a format provided or approved by MIEMSS for inclusion in the patient care record before leaving the receiving facility, then deliver the completed PCR within 24 hours after dispatch, in compliance with COMAR 30.03.04.04. Only the unit that pronounces death will select the “Dead on Scene” option in the PCR (eMEDS®) and thus all other units will report “Operational Support Only.” If no interventions are performed, the highest level EMS clinician on scene will pronounce death and document “Dead on Scene.” If BLS care was rendered by a BLS unit and then termination of resuscitation and pronouncement of death occurred, the BLS unit will select “Dead at Scene with BLS Intervention” option on the eMEDS® PCR. If ALS care was rendered by an ALS unit and then termination of resuscitation and pronounce- ment of death occurred, the ALS unit will select “Dead at Scene with ALS Intervention” option on the eMEDS® PCR. General Patient Care 2.1 L. CONFIDENTIALITY Patient confidentiality must be maintained at all times. M. PROFESSIONAL CONDUCT All patients should be treated with dignity and respect in a calm and reassuring manner. www.miemss.org 25 Release Date July 1, 2023 Back to Contents  2.2 General Patient Care (GPC) – HISTORY AND PHYSICAL EXAMINATION General Patient Care: History and Physical Examination 2.2 Release Date July 1, 2023 26 www.miemss.org Back to Contents  General Patient Care (GPC) – DETAILED AND ONGOING ASSESSMENTS 2.2 General Patient Care: Detailed and Ongoing Assessments 2.2 www.miemss.org 27 Release Date July 1, 2023 Back to Contents  2.3 General Patient Care (GPC) – START TRIAGE ALGORITHM General Patient Care: START Triage Algorithm 2.3 Source: U.S. National Library of Medicine Release Date July 1, 2023 28 www.miemss.org Back to Contents  General Patient Care (GPC) – JumpSTART TRIAGE ALGORITHM 2.3 General Patient Care: JumpSTART Triage Algorithm 2.3 Source: U.S. National Library of Medicine ©Lou Romig MD, 2002 www.miemss.org 29 Release Date July 1, 2023 Back to Contents  2.4 General Patient Care (GPC) – CRITICALLY UNSTABLE PATIENT a) INDICATIONS Adult patients (18 years of age or older) who are identified to be in extremis or are at risk for deterioration to cardiac arrest at any point during their care. These patients can include, but are not limited to, patients with: (1) New onset altered mental status (AVPU – not alert) (2) Airway compromise (3) Acute respiratory distress (4) Signs of poor perfusion (5) Any other patient judged by the clinician to be in extremis or at risk for deterioration to cardiac arrest b) BLS (1) Cease all efforts at patient movement until treatments in this protocol are General Patient Care: Critically Unstable Patient 2.4 complete. (2) Obtain a complete patient assessment, including pulse oximetry. (3) Consider the need for more resources, if available, including multiple ALS clinicians. (4) Control life-threatening external hemorrhage. (5) Manage the patient’s airway and ventilation (e.g., BVM with or without OPA/NPA) as indicated and tolerated. (6) Treat hypoxia and respiratory distress aggressively. c) ALS (1) Initiate ETCO2 monitoring. (2) Obtain 12-lead EKG, if appropriate for patient condition. (3) Obtain vascular access and support perfusion with IV fluids and vasopressors as indicated. (4) Address any other life threats noted on physical exam. (5) Continue General Patient Care, including transport. Release Date July 1, 2023 30 www.miemss.org Back to Contents  Treatment Protocols Treatment Protocols Treatment Protocols www.miemss.org 31 Release Date July 1, 2023 Back to Contents  3.1-A Adult Emergency Cardiac Care for BLS – Algorithm BLS Cardiac: Adult Emergency Cardiac Care for BLS – Algorithm 3.1-A Release Date July 1, 2023 32 www.miemss.org Back to Contents  Adult Emergency Cardiac Care for ALS – Algorithm 3.1-A ALS Cardiac: Adult Emergency Cardiac Care for ALS – Algorithm 3.1-A GO TO VT/VF ALGORITHM Pulmonary Edema/CHF See Protocol Chest Pain GO TO ASYSTOLE GO TO PEA See Protocol ALGORITHM ALGORITHM GO TO GO TO BRADYCARDIA TACHYCARDIA ALGORITHM ALGORITHM www.miemss.org 33 Release Date July 1, 2023 Back to Contents  3.1-P Pediatric Emergency Cardiac Care for BLS – Algorithm BLS UNIVERSAL ALGORITHM FOR PEDIATRIC EMERGENCY CARDIAC CARE FOR BLS Greater than 1 hour old and less than 13 years of age If less than 1 hour old, refer to Newly Born Protocol Cardiac: Pediatric Emergency Cardiac Care for BLS – Algorithm 3.1-P Stay on Scene Oxygen as needed Begin HPCPR VENTILATE as needed Attach AED with pediatric capability Target ventilations rate to 20 bpm 100-120 compressions/minute Vital Signs 100% oxygen History & Physical Detailed Assessment Defibrillate 1 time Resume HPCPR Resume HPCPR immediately immediately for 2 minutes for 2 minutes Release Date July 1, 2023 34 www.miemss.org Back to Contents  Pediatric Emergency Cardiac Care for ALS – Algorithm 3.1-P ALS UNIVERSAL ALGORITHM FOR PEDIATRIC EMERGENCY CARDIAC CARE FOR ALS Greater than 1 hour old and less than 13 years of age If less than 1 hour old, refer to Newly Born Protocol Cardiac: Pediatric Emergency Cardiac Care for ALS – Algorithm 3.1-P Oxygen as needed Stay on Scene VENTILATE as needed Begin HPCPR Target ventilations rate to 20 bpm Attach AED with pediatric capability Cardiac monitor 100-120 compressions/minute Vital Signs IV with LR History & Physical 100% oxygen Detailed Assessment GO TO PEDIATRIC CARDIAC ARREST ALGORITHM Altered Mental Status: See Protocol Respiratory Distress Allergic Reaction or Anaphylaxis: See Protocol, as appropriate Asthma/COPD: See Protocol Pulmonary Edema/CHF: See Protocol GO TO PEDIATRIC GO TO PEDIATRIC BRADYCARDIA TACHYCARDIA ALGORITHM ALGORITHM www.miemss.org 35 Release Date July 1, 2023 Back to Contents  3.2-A Adult Bradycardia Algorithm Indications l Slow heart rate, less than 60 bpm l Bradycardic patients may also present with serious signs and symptoms including: n Chest pain or shortness of breath n Altered/decreased level of consciousness n Hypotension or hypoperfusion n Congestive heart failure or pulmonary congestion n Acute myocardial infarction BLS l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. ALS Heart rate less than 60 bpm Cardiac: Adult Bradycardia Algorithm 3.2-A Serious signs or symptoms? YES NO Transcutaneous Pacemaker (a) Second-degree Atropine 0.5-1 mg IVP if TCP is unavailable or Type II AV Block ineffective (b, c) or Third-degree AV Block (d) Epinephrine 1 mL/min using approved epi infusion. (2-10 mcg/min on IV infusion pump) (e) YES NO Prepare for Transcutaneous Observe pacing. Start pacing if the patient develops serious signs and symptoms related to the slow heart rate. (a) Do not delay TCP while awaiting IV or atropine to take effect if the patient is symptomatic. (b) Denervated transplanted hearts will not respond to atropine. (c) Atropine should be repeated every 3-5 minutes, if appropriate, to max dose of 0.04 mg/kg. (d) Do not treat third-degree AV block or ventricular escape beats with amiodarone. MC (e)  Additional dosing above 1 mL/min (1 drop/second using 60 drop set and approved epinephrine infusion) requires medical consultation. Adults: titrate to systolic BP 90 mmHg. (f)  If patient develops discomfort with TCP, administer opioid or ketamine per Pain Management protocol OR administer midazolam 0.1 mg/kg SLOW IVP over 1-2 minutes, in 2 mg increments. Max single dose of 5 mg. Reduce dose by 50% for patients 69 and older. Release Date July 1, 2023 36 www.miemss.org Back to Contents  Pediatric Bradycardia Algorithm (If less than 1 hour old, refer to Newly Born Protocol) 3.2-P Indications l Slow heart rate (refer to Normal Vital Signs Chart) BLS l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. l Begin CPR if HR less than 60 with signs of poor perfusion despite oxygenation and ventilation ALS Cardiac: Pediatric Bradycardia Algorithm 3.2-P Epinephrine (b) IV/IO 0.01 mg/kg (0.1 mg/mL) ET 0.1 mg/kg (1 mg/mL), Dilute in 5 mL; Repeat every 3–5 minutes If pulseless arrest develops go to Pediatric Cardiac Arrest Algorithm (a) Hemodynamically unstable is defined as a systolic blood pressure less than 60 in neonates (patients less than 28 days old), less than 70 in infants (patients less than 1 year of age), and less than [70 + (2 x years) = systolic BP] for patients greater than 1 year of age. (b) Neonates (0 to 28 days), epinephrine ET 0.03 mg/kg (0.1 mg/mL) dilute with 1 mL. (c) Volume infusion for neonates and volume-sensitive children, 10 mL/kg; for infant and child 20 mL/kg. (d) Calcium chloride, 20 mg/kg (0.2 mL/kg) SLOW IVP/IO (50 mg/min). Max dose 1 gram. MC (e) Sodium bicarbonate, 1 mEq/kg with medical consultation. (f)  If patient develops discomfort with TCP, administer opioid or ketamine per Pain Management protocol OR administer midazolam 0.1 mg/kg SLOW IVP over 1-2 minutes, in 2 mg increments. Max single dose of 5 mg. www.miemss.org 37 Release Date July 1, 2023 Back to Contents  3.3-A Adult Tachycardia Algorithm – Irregular Rhythm BLS l Place patient in position of comfort. l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. ALS Cardiac: Adult Tachycardia Algorithm – Irregular Rhythm 3.3-A Treat underlying non-cardiac causes, if present Irregular rhythm with HR greater than 130 and SBP greater than 100 (a) S  igns and symptoms related to tachycardia: hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort/AMI, or acute heart failure. (b) Consider pre-procedural sedation or analgesia (midazolam, ketamine OR opioid). However, over- all patient status, including BP, may affect ability to administer sedative/analgesia. (c) Consider calcium chloride 500 mg IVP for hypotension induced by diltiazem. (d) If rate does not slow in 15 minutes, administer a second dose of diltiazem (0.35 mg/kg over 2 minutes, max dose of 25 mg). For patients older than 50 years of age, SBP 100–120, known renal failure or CHF, consider initial 5–10 mg SLOW IV bolus over 2 minutes. (e) T  hese rhythms include Wolff-Parkinson White (WPW) syndrome, Lown-Ganong-Levine syndrome (LGL), and Mahaim type. Release Date July 1, 2023 38 www.miemss.org Back to Contents  Adult Tachycardia Algorithm – Regular Rhythm 3.3-A BLS l Place patient in position of comfort. l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. ALS Cardiac: Adult Tachycardia Algorithm – Regular Rhythm 3.3-A (a) S  igns and symptoms related to tachycardia: hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort/AMI, or acute heart failure. (b) Consider pre-procedural sedation or analgesia (midazolam, ketamine OR opioid). However, over- all patient status, including BP, may affect ability to administer sedative/analgesia. (c) Be prepared for up to 40 seconds of asystole. (d) T  hese rhythms include Wolff-Parkinson White (WPW) syndrome, Lown-Ganong-Levine syndrome (LGL), and Mahaim type. www.miemss.org 39 Release Date July 1, 2023 Back to Contents  Pediatric Tachycardia Algorithm 3.3-P (If less than 1 hour old, refer to Newly Born Protocol) BLS l Assess and treat for shock, if indicated. l Continuously monitor airway and reassess vital signs every 5 minutes. ALS Identify and treat underlying causes Evaluate QRS duration Narrow Wide regular (less than or equal to 0.09 seconds) (greater than 0.09 seconds) Cardiac: Pediatric Tachycardia Algorithm 3.3-P Possible VT (g) Probable sinus Probable tachycardia supraventricular Hemodynamically unstable? tachycardia (a) (b) Identify and treat underlying Consider vagal cause maneuvers YES NO Consider Cardiovert Consider adenosine (e) adenosine (e) 0.5 J/kg (c) (d) Amiodarone (f) Consider (c) (d) Cardiovert cardioversion 1 J/kg Cardiovert (a) - V entricular Heart Rates in excess of: Infant 220 bpm 2 J/kg or Pediatric 180 bpm (b) - Hemodynamically unstable is defined as a systolic blood pressure less than 60 in neonates (patients IV/IO access from birth to 28 days old), less than 70 in infants (patients less than 1 year of age), less than [70 + (2 x years) = systolic BP] for patients greater than 1 year of age, altered mental status with hypoperfusion Amiodarone (f) evidenced by delayed capillary refill, pallor, or peripheral cyanosis. (c) - If calculated joules setting is lower than cardioversion device is able to deliver, use the lowest joules setting possible or obtain medical consultation. (d) - Consider pre-procedural sedation or analgesia (midazolam, ketamine OR opioid with medical consultation). However, overall patient status, including BP, may affect ability to administer sedative/analgesia. (e) - Adenosine: 0.1 mg/kg rapid IV/IO, maximum 6 mg. Second and third doses 0.2 mg/kg rapid IV/IO, maximum single dose 12 mg. Be prepared for up to 40 seconds of asystole. (Contraindicated in polymorphic or irregular wide complex tachycardia) (f) -  Amiodarone: 5 mg/kg IV/IO over 20 minutes (mixed in 50 - 100 mL of approved diluent). Obtain 12-lead EKG prior to administration of amiodarone. (g) If torsades de pointes, administer magnesium sulfate (25 mg/kg IV/IO to a maximum of 2 grams over 2 minutes). Release Date July 1, 2023 40 www.miemss.org Back to Contents  3.4-A Cardiac Arrest – Adult Indications l Adult patients (medical arrest: 13 years of age and older; trauma arrest: 15 years of age and older) who are unconscious, apneic, and pulseless BLS l  erform high-quality uninterrupted chest compressions (manual or mechanical) as soon P as possible and until defibrillator available. l Apply AED as soon as available. l Follow machine prompts regarding rhythm analyses and shocks. l Limit breaks in compressions to 10 seconds or less for rhythm analysis periods and during shocks; perform compressions while defibrillator is charging. l On-scene resuscitation: Patients who are found in arrest or who arrest prior to transport and are attended to by BLS clinicians must only be resuscitated in place (with minimal movement, no attempts at patient loading, and no attempts at transport) until the follow- ing have been accomplished: n Medical etiology: the patient has received a minimum of five two-minute cycles of chest compressions and rhythm interpretation n Traumatic etiology: patient has received treatments for reversible causes per Trauma Protocol: Trauma Arrest protocol l Exemptions from on-scene resuscitation: Cardiac: Cardiac Arrest – Adult 3.4-A n Physical barriers prevent resuscitation n Clinicians are in danger n Pregnant patients n Patients in cardiac arrest thought to be secondary to hypothermia or submersion l Following the initial on-scene resuscitation above, clinicians may continue on-scene re- suscitation until termination of resuscitation or transport the patient at any time. Clinicians should ensure that a mechanical CPR device is in place (if available) prior to transport. l Pregnancy: For pregnant patients greater than 20 weeks gestation in cardiac arrest, provide constant left lateral uterine displacement. ALS l Assess for shockable rhythm at next appropriate interval and treat appropriately. l On-scene resuscitation: Patients who are found in arrest or who arrest prior to transport and are attended to by ALS clinicians must remain in place (with minimal movement, no attempts at patient loading, and no attempts at transport) until the following have been accomplished: n Medical etiology: the patient has received three doses of epinephrine, regardless of algorithm being followed n Traumatic etiology: the patient has received treatments for reversible causes per Trauma Arrest protocol l Following the initial on-scene resuscitation above, clinicians may choose to continue the on-scene resuscitation until termination of resuscitation or to transport the patient at any time. Clinicians should ensure the following prior to transport: n Mechanical CPR (mCPR) in place (if available) n Placement of an airway that facilitates ventilation during transport by a restrained clinician l If ROSC, refer to ROSC protocol. l Consider Termination of Resuscitation when appropriate. MC l Not applicable. Release Date July 1, 2023 42 www.miemss.org Back to Contents  Adult Pulseless Electrical Activity (PEA)/Asystole Algorithm 3.4-A ALS High-Performance CPR Adequate Oxygenation and Ventilation IV/IO with Lactated Ringer’s Give Epinephrine early: Epinephrine (0.1 mg/mL) 1 mg every 4 minutes up to a max of 4 doses for the initial arrest. If re-arrest occurs after ROSC, an additional 2 doses may be Cardiac: Adult Pulseless Electrical Activity (PEA)/Asystole Algorithm 3.4-A administered. Assess ECG Rhythm Pulseless Electrical Activity Asystole (a) QRS Narrow (less than 0.12ms) QRS Wide (greater than 0.12ms) Consider hypoxic cause. Consider severe hypotension or Consider toxicologic/metabolic Ensure adequate airway and obstructive cause. cause. ventilation. Wide-open fluids (b), high-perfor- Wide-open fluids (b), high-perfor- Wide-open fluids (b), high-perfor- mance CPR, Epinephrine (c) mance CPR, Epinephrine (c) mance CPR, Epinephrine (c) If tension pneumo - needle If tension pneumo - needle decompress. decompress. NA channel blocker (including tricyclic antidepressants and Hyperkalemia phenobarbital) overdose Severe metabolic acidosis Calcium Chloride 1 gram IVP/IO and Sodium bicarbonate 1 mEq/kg Sodium bicarbonate 1 mEq/kg IV/IO IV/IO (a) Confirm asystole in more than one lead. (b) Volume infusion is Lactated Ringer’s 20 mL/kg. (c) Epinephrine is not indicated in adult traumatic cardiac arrest. All hypothermic patients in cardiac arrest shall be rewarmed; see exclusions to Termination of Resuscitation (3.6-A). When the patient’s condition changes, indicating transition to a new treatment algorithm, the new treatment shall take into account prior therapy (e.g., previously administered medications). www.miemss.org 43 Release Date July 1, 2023 Back to Contents  Ventricular Fibrillation and 3.4-A Pulseless Ventricular Tachycardia Algorithm ALS High-Performance CPR Adequate Oxygenation & Ventilation VF/VT present on monitor Defibrillate 1 time Resume CPR immediatelyfor 2 minutes Confirm Rhythm Cardiac: Ventricular Fibrillation and Pulseless Ventricular Tachycardia Algorithm 3.4-A Persistent or Return of Spontaneous Recurrent PEA Asystole Circulation GO TO PEA GO TO ASYSTOLE VF/VT GO TO ROSC ALGORITHM ALGORITHM PROTOCOL Defibrillate 1 time Resume CPR immediately for 2 minutes IV/IO with LR Epinephrine (0.1 mg/mL) 1 mg IV/IO every 4 minutes up to a max of 4 doses for the initial arrest. If arrest occurs after ROSC, an additional 2 doses may be administered. Defibrillate 1 time Resume CPR immediately for 2 minutes Amiodarone 300 mg IV/IO push May repeat once 150 mg IV/IO push (a) (b) (c) Defibrillate 1 time Resume CPR immediately for 2 minutes. Repeat CPR and defibrillation for shockable rhythms until ROSC or TOR. For refractory VF/VT after amiodarone, administer magnesium sulfate 1-2 grams IV/IO over 2 minutes (a) - Sodium bicarbonate 1 mEq/kg IV/IO, only in cases for which the suspected cause of cardiac arrest is acidosis, NA channel blocker (tricyclic antidepressant and phenobarbital) overdose. (b) - If torsades de pointes is present, give magnesium sulfate 1–2 grams IV/IO over 2 minutes before amiodarone. When the patient’s condition changes, indicating the transition to a new treatment algorithm, the new treat- ment shall take into account prior therapy (e.g., previously administered medications). Release Date July 1, 2023 44 www.miemss.org Back to Contents  Cardiac Arrest – Pediatric 3.4-P Indications l Pediatric patients (medical arrest: less than 13 years of age; trauma arrest: less than 15 years of age) who are unconscious, apneic, and pulseless BLS l  erform high-quality uninterrupted chest compressions (manual or mechanical) as soon P as possible and until defibrillator available. l Apply AED as soon as available. l Follow machine prompts regarding rhythm analyses and shocks. l Limit breaks in compressions to 10 seconds or less for rhythm analysis periods and during shocks; perform compressions while defibrillator is charging. l On-scene resuscitation: Patients who are found in arrest or who arrest prior to transport and are attended to by BLS clinicians must only be resuscitated in place (with minimal movement, no attempts at patient loading, and no attempts at transport) until the follow- ing have been accomplished: n Medical etiology: the patient has received a minimum of fifteen two-minute cycles of chest compressions and rhythm interpretation n Traumatic etiology: patient has received treatments for reversible causes per Trauma Protocol: Trauma Arrest protocol l Exemptions from on-scene resuscitation: Cardiac: Cardiac Arrest – Pediatric 3.4-P n Physical barriers prevent resuscitation n Clinicians are in danger n Pregnant patients n Patients in cardiac arrest thought to be secondary to hypothermia or submersion l Following the initial on-scene resuscitation above, clinicians may continue on-scene resuscitation until termination of resuscitation or transport the patient at any time. Clini- cians should ensure that a mechanical CPR device is in place (if available) for patients 13 years of age and older prior to transport. l Pregnancy: For pregnant patients greater than 20 weeks gestation in cardiac arrest, provide constant left lateral uterine displacement. ALS l Assess for shockable rhythm at next appropriate interval and treat appropriately. l Only in a pediatric or neonatal arrest situation, epinephrine can be administered via the ET route. Medications administered for pediatric patients via the endotracheal tube route shall be 2–2.5 times the IV dose for naloxone and atropine sulfate, and 10 times the IV dose for epinephrine (1 mg/mL). All ET medications shall be diluted in 5 mL of Lactated Ringer’s for pediatric patients. l On-scene resuscitation: See BLS section above. l Following initial on-scene resuscitation, clinicians may choose to continue the on-scene resuscitation until termination of resuscitation or to transport the patient at any time. Cli- nicians should ensure the following prior to transport: n Mechanical CPR (mCPR) in place for patients 13 years of age and older (if available) n Placement of an airway that facilitates ventilation during transport by a restrained clinician l If ROSC, perform 12-lead EKG and transport the patient to Children’s National Medical Center or Johns Hopkins Children’s Center by ground or medevac. If arrival time is greater than 30 minutes to either of these destinations, transport to the closest appropriate facility. l If no ROSC, transport to the closest appropriate facility or consider Termination of Resuscitation protocol, as appropriate. MC l Not applicable. www.miemss.org 45 Release Date July 1, 2023 Back to Contents  3.4-P Pediatric Cardiac Arrest Algorithm (BLS) BLS PEDIATRIC HIGH PERFORMANCE CPR (HPCPR) Assess Patient (less than 10 seconds) Remain on Scene Begin HPCPR Unresponsive Not Breathing No pulse Clinician # 1 Start Chest Compressions (100-120/min) Cardiac: Pediatric Cardiac Arrest Algorithm (BLS) 3.4-P Ventilations 2 Breaths: 30 Compressions Call for AED/Defibrillator Clinician #2 2 minute Attach AED/Defibrillator cycles Assume Ventilation Role - 2 Breaths: 15 compressions Place Airway Adjunct Suction Continue HPCPR for 2-minute Clinician #3 or More cycle – less than10 second pause BLS – HPCPR Coach for coordinated activities BLS – Family Support Check pulse ALS – Establish IO Check rhythm (AED) ALS – Administer medication Shock if indicated ALS – Establish ALS airway Change compressors Pediatric HPCPR Team Member Initial Roles Essentials of High Performance CPR for When 2 or More Clinicians Are Present Pediatrics Clinician #1: 1. Ensure proper chest compression rate Chest compressions at 100-120 per minute 100-120/min Call for AED 2. Ensure proper compression depth Less than 1 year – 1 ½ inches (4 cm) Clinician #2: Greater than or equal to 1 year – Ventilate at 2 breaths:15 compressions 2 inches (5 cm) Attach AED 3. Minimize interruptions (less than 10 second pause) Clinician #3 or MORE: 4. Ensure full chest recoil Assume timekeeper role 5. Coordinate 2 minute cycles Assume AED role 6. Rotate Compressor IO Access Medications *Once an advanced airway is in place: Establish ALS Airway L  ess than 13 years of age: 1 ventilation every Family Support 3 seconds interposed asynchronously 13 years and older: 1 ventilation every 3 secon