EMS Emergency Treatment Protocols PDF

Acute ABDOMINAL | FLANK PAIN 1. IMC special considerations: Inspect, auscultate, palpate abdomen in all quadrants Compare pulses in upper vs. lower extremities Note/record nature & amount of vomiting/diarrhea, vaginal/urethral/rectal lesions/discha...

Acute ABDOMINAL | FLANK PAIN 1. IMC special considerations: Inspect, auscultate, palpate abdomen in all quadrants Compare pulses in upper vs. lower extremities Note/record nature & amount of vomiting/diarrhea, vaginal/urethral/rectal lesions/discharge; jaundice Vomiting precautions Adjust IV rate to maintain hemodynamic stability Document OPQRST of pain; menstrual history in females of childbearing age; last BM; orthostatic VS; travel history Rx per PAIN Mgt. SOP LOWER ACUITY: NONE to MILD cardiorespiratory compromise Alert, SBP ≥ 90 (MAP ≥ 65), no evidence of tissue hypoperfusion or shock 2. Transport in position of comfort EMERGENT to CRITICAL: Moderate to Severe cardiorespiratory compromise Time Altered sensorium, signs of hypoperfusion. sensitive pt 2. IMC special considerations: Consider need for NS IVF challenges if pt severely dehydrated/hypovolemic: (Ex: appendicitis, cholecystitis, pancreatitis, hepatitis, cirrhosis, upper/lower GI bleed, bowel obstruction, sepsis) 3. If suspected abdominal aortic aneurysm (AAA): Do not give IV fluid challenges unless SBP < 80 (MAP 12% abnormal, ( 93.2° F): Cover with blankets; protect head from heat loss Active external rewarming (T 82°- 93.2° F): Passive + surface warming devices (wrapped hot packs to axillae, groin, neck, & thorax; warming mattress if available) | Passive rewarming alone inadequate for these pts 3. Warm NS IVF challenges in 200 mL increments (Peds: 10 mL/kg) to maintain hemodynamic stability SEVERE Hypothermia (CRITICAL): Core temp < 30°C (86° F), coma, muscle rigidity, Time cardiac dysrhythmias: bradycardia, VF (cardiac arrest/absent pulse); hypotension, slowed RR to apnea, sensitive pupils fixed & dilated, no shivering pt 2. ITC special considerations: Core rewarming (generally not available in field). Rewarm trunk only with hot packs; avoid rewarming extremities Consider need for ADV airway: If indicated; use gentle technique to prevent vagal stimulus and VF O2 12-15 L/NRM or BVM (warm O2 to 42˚ C / 107.6° F if possible); do NOT hyperventilate - chest will be stiff Vascular access: Warm NS 200 mL (peds 10 mL/kg) IVP/IO fluid challenges up to 1 L May require large volume replacement due to leaky capillaries, fluid shift, and vasodilation as rewarming occurs 3. If unresponsive with apnea or no normal breathing (only gasping) check for a pulse. Pulse not definitely felt in 30 seconds: Start CPR - TRIPLE ZERO CANNOT BE CONFIRMED until rewarmed unless obviously dead (rigor mortis or non-survivable injury) | Treat per CARDIAC ARREST SOP + rewarming 4. ROSC: Support CV status per CARDIAC ARREST SOP | Look for & treat causes of severe hypothermia If induced hypothermia (TTM) indicated: Continue to warm to goal temp of 34° C / 93.2° F If hypothermia contraindicated (trauma patient); continue rewarming to normal temp 5. Transport very gently to avoid precipitating VF NWC EMSS 2022 SOP 31 Rev. 3-11-24  Environmental: SUBMERSION/DROWNING (Adult & Peds) Notes: All victims of submersion who require any form of resuscitation (including rescue breathing alone) should be transported to the hospital for evaluation and monitoring, even if they appear to be alert and demonstrate effective cardiorespiratory function at the scene (Class I, LOE C). All persons submerged ≤ 1 hour should be resuscitated unless signs of obvious death. 1. ITC special considerations: Rescue and removal: Ensure EMS safety during the rescue process; only rescuers with BLS appropriate training and equipment should enter moving or deep water to attempt rescue - Wear protective garments if water temp is < 70˚ F | Attach a safety line to the rescue swimmer - In-water ventilations may be considered by trained rescuers, preferably with a flotation device | chest compressions should not be attempted in the water - Keep pt. in a horizontal position if possible. Cold-induced hypovolemia, cold myocardium, and impaired reflexes may cause significant hypotension. - If hypothermic: Appropriate rewarming indicated concurrent with resuscitation SMR only if circumstances/clinical S&S suggest a spine injury SpO2 may be unreliable, particularly after cold water immersion, but can increase FiO2 to meet ITC targets EMERGENT: Awake with good respiratory effort, yet congested and increased work of breathing: 2. O2 /C-PAP to deliver 5-10 cm PEEP | Use 15 L/NRM if CPAP unavailable or contraindicated If SBP < 90 (MAP < 65) or hypotensive for age: Titrate PEEP down to 5 cm; remove C-PAP if MAP < 60 CRITICAL: If unresponsive and ineffective ventilations with a pulse: 2. Suction prn; PPV using BLS airways and BVM | Abdominal thrusts contraindicated Pts usually respond after PPV; consider ADV Airway if pt. unresponsive to PPV CRITICAL: If unresponsive, apneic, and pulseless: 2. CPR using traditional A-B-C approach as soon as removed from water | Rx per Cardiac Arrest SOP Suction prn: Vomiting is common in those who require compressions & ventilations Remove wet clothing / dry pt. ASAP – especially the chest before applying pads and defibrillating If pt is cold: refer to HYPOTHERMIA SOP 3. Evaluate for ↑ ICP: (↑ SBP, widened PP; ↓ pulse, abnormal respiratory pattern, gaze palsies, HA, vomiting) If present; Rx per Head Trauma SOP 4. Enroute: Complete ITC: IV NS TKO [ALS] SCUBA | Diving-related emergencies: Consider decompression illness if any of these S&S present even if an apparently safe dive according to the tables or computer Serious Neurological: Dysfunction involving bladder, bowel, gait, or coordination (ataxia), reflexes, mental status (dysphasia, mood, memory, orientation, personality), vision, hearing (tinnitus), consciousness, strength, vertigo Cardiopulmonary: Cough, hemoptysis, dyspnea, voice change Mild Neurological: Paresthesia, numbness, tingling, altered sensation Pain: Ache, cramps, discomfort, joint pain, pressure, spasm, stiffness Lymphatic or Skin: Edema, itching, rash, burning sensation, marbling Constitutional/Nonspecific: Dizziness, fatigue, HA, N /V, chills, diaphoresis, malaise, restlessness. ITC special considerations: Position supine or in recovery position Consider transport to a hyperbaric chamber: See Carbon Monoxide Poisoning SOP for chamber locations. If assistance is needed: Divers Alert Network (DAN) (919) 684-9111 High Altitude Travel and Altitude Illness: See https://wwwnc.cdc.gov/travel/yellowbook/2020/noninfectious-health- risks/high-altitude-travel-and-altitude-illness NWC EMSS 2022 SOP 32 Rev. 3-11-24  Environmental: HEAT EMERGENCIES (Adult & Peds) HEAT CRAMPS OR TETANY (Lower acuity) 1. IMC: IV may not be necessary; if cramps severe/vomiting and/or oral electrolyte replacement unavailable; IV NS 2. Move patient to a cool environment | Remove excess clothing | Do NOT massage cramped muscles HEAT EXHAUSTION (EMERGENT to CRITICAL): Heavy sweating; weakness; cool, pale, Time moist skin; fast, weak pulse; N / V, syncope (If AMS, see Heat Stroke below) sensitive pt 1. IMC special considerations: NS IVF in consecutive 200 mL increments (peds 10 mL/kg) to maintain SBP ≥ 90 (MAP ≥ 65) or normal for age Vomiting precautions; ready suction; consider need for ONDANSETRON (standard dosing per IMC SOP) Monitor ECG Monitor and record mental status; seizure precautions 2. Move patient to a cool environment | Remove as much clothing as possible HEAT STROKE (CRITICAL): High body temperature (above 103°F); hot, red, dry or moist skin; Time rapid pulse; AMS, possible unconsciousness sensitive pt 1. IMC special considerations: Anticipate ↑ ICP; check bG for hypoglycemia If SBP 110 / normal for age / or above: IV NS TKO (may use cold NS); elevate head of stretcher 10˚-15˚ If signs of hypoperfusion: - Place supine with feet elevated (do NOT place in Trendelenburg position) - NS IVF challenges in 200 mL increments (peds 10 mL/kg) up to 1 L to maintain SBP ≥ 90 (MAP ≥ 65) or normal for age unless contraindicated | Caution: Patient at risk for pulmonary and cerebral edema Monitor ECG 2. Move to a cool environment | Initiate rapid cooling (avoid shivering): Remove as much clothing as possible Chemical cold packs (CCP) to cheeks, palms, soles of feet If additional CCP available, apply to neck, lateral chest, groin, axillae, temples, and/or behind knees Sponge or mist with cool water and fan 3. If generalized tonic/clonic seizure activity: MIDAZOLAM standard dose for seizures (adult and peds) Medications/substances that predispose to heat emergencies: Anticholinergics (atropine), antihistamines (diphenhydramine) Beta blockers, antihypertensives, cardiovascular drugs Tranquilizers, antidepressants, antipsychotics, phenothiazines (Thorazine), MAO inhibitors ETOH, LSD, PCP, amphetamines, cocaine Diuretics NWC EMSS 2022 SOP 33 Rev. 3-11-24  GLUCOSE | DIABETIC Emergencies 1. IMC special considerations: PMH; type of diabetes; presence of automated insulin delivery (AID) systems; glucose monitoring devices Determine general compliance; time and last doses of medications prescribed for DM mgt and last oral intake Obtain/record blood glucose (bG) level on all pts with S&S of hypo or hyperglycemia, AMS or neuro deficits Reference ranges: Neonates > 3 days to adults: Fasting: 70-99 mg/dL Non-fasting: 70-139 mg/dL S&S Hypoglycemia Pallor; diaphoresis; shakiness; weakness, fatigue; hunger, anxiety, nervousness, irritability, difficulty Mild: concentrating; HA; dizziness; numbness, tingling around mouth and lips; nausea, rapid HR, palpitations Irritability, agitation, confusion; ataxia; motor weakness; difficulty speaking or slurred speech; elderly patients Moderate may present with S&S of a stroke Severe Lethargy, confusion to coma; seizures; inability to swallow; cold limbs / hypothermia Blood glucose ≤ 70 or S & S of hypoglycemia Hypoglycemic patients with AMS are considered nondecisional. When hypoglycemia is corrected and confirmed by a repeat bG reading, they can be re-assessed for ability to refuse care. 2. If GCS 14-15 and able to swallow safely (+ gag reflex): up to 15 g of a rapidly-absorbed oral carbohydrate if available [BLS] | May repeat in 15 minutes. Options include (not limited to) any one of the following: Glucose tablets (5 g per tablet) | Glucose gel (15 g per tube) Sweetened fruit juice: 12 g carbs / 4 oz (120 mL) | Regular soda (not diet): 18 g carbs / per 6 oz (180 mL) Honey: 17 g carbs / 1 T (15 mL) | Granulated sugar: 12.5 g sugar / 1 T 3. IF AMS & cannot swallow safely | bG borderline 60-70: DEXTROSE 10% (25 g/250 mL) IVPB rapidly (wide open) – infuse up to 12.5 g (125 mL or ½ IV bag) If bG < 60 (no S&S pulmonary edema – if lungs congested see cautions in appendix): DEXTROSE 10% (25 g/250 mL) IVPB rapidly (wide open) – infuse up to 25 grams (entire 250 mL) If S&S of hypoglycemia fully reverse and pt becomes decisional after a partial dose, reassess bG If > 70; close clamp to D10% and open NS TKO Approved alternative if D10% unavailable: D50% (25 g/50 mL): See drug appendix 4. Assess patient response 5 minutes after dextrose administration: Mental status (GCS) and bG level If ≥ 70: Ongoing assessment If < 70: Repeat D10% in 5 g (50 mL) increments at 5 -10 min intervals Reassess bG and mental status every 5 min after each increment 5. If no IV/IO: GLUCAGON 1 mg IN/IM [BLS] 6. If decisional pt refuses transport after bG normalized: Advise pt to eat & call PCP before EMS leaves scene Time DIABETIC KETOACIDOSIS (DKA) or HHNS (CRITICAL) sensitive pt Pts may be hyperglycemic and NOT be in DKA or HHNS. They must present with at least dehydration + hyperglycemia Dehydration: Tachycardia, hypotension, ↓ skin turgor, warm, dry, flushed skin, N/V, abdominal pain Acidosis: AMS, Kussmaul ventilations, seizures, peaked T waves, and ketosis (fruity odor to breath) Hyperglycemia: Elevated blood sugar; most commonly 240 or above Diabetic ketoacidosis (DKA) presents with all 3: More common in pts with T1D Hyperosmolar hyperglycemic nonketotic syndrome (HHNS): More common with T2D | Very high bG levels + severe dehydration, but NO acidosis or ketosis 2. IMC special considerations: EMS shall not assist any patient in administering insulin Monitor ECG for dysrhythmias and changes to T waves Vascular access: NS wide open up to 1 L unless contraindicated (HF, bilateral crackles) Assess lung sounds & respiratory effort after each 200 mL in elderly or those w/ Hx CVD or CKD Attempt to maintain SBP ≥ 90 (MAP ≥ 65); monitor for development of cerebral and pulmonary edema NWC EMSS 2022 SOP 34 Rev. 3-11-24  HYPERTENSION Hypertensive emergencies include a spectrum of presentations in which uncontrolled high BPs lead to progressive or impending end-organ dysfunction. Hypertensive urgencies and emergencies both have BP elevations (SBP > 160) | Only hypertensive emergencies have life-threatening end-organ damage that requires rapid antihypertensive medications S&S: Hypertensive urgency: Headache, epistaxis, faintness, and psychomotor agitation Hypertensive emergency: Above + Causes and S&S suggesting end-organ dysfunction - Neurologic damage due to hypertensive encephalopathy, stroke, SAH or intracranial hemorrhage Assess for headache, visual disturbances, seizures, AMS, weakness/paralysis - Cardiovascular damage due to myocardial ischemia/infarction; LV dysfunction, acute pulmonary edema; or aortic dissection: Assess for chest pain, dyspnea, JVD; back pain; pulse deficits between limbs - Other organ system dysfunction may lead to acute renal failure, retinopathy, or eclampsia - Assess for seizures, peaked T waves, and hematuria - Ask about drug use (cocaine/methamphetamine); assess for S&S of delirium w/ extreme agitation 1. IMC special considerations: Rx the patient, not the number | Use correct BP cuff size & technique Assess BP in supine and sitting positions unless contraindicated ( for volume depletion) Assess BP in both arms: a significant difference may suggest aortic dissection Maintain head and neck in neutral alignment; do not flex neck or knees Assess and record baseline 12 L ECG; GCS, and neuro signs; repeat q. 15 min or if changes occur Assess for Hx of trauma, HTN, CVD, ACS, aortic aneurysm, CKD, DM, pregnancy, or adrenal tumor HYPERTENSIVE URGENCY No evidence of end organ damage or focal neurologic deficits 2. Transport without drug therapy to reduce BP 3. If severe headache: Adult: FENTANYL or ACETAMINOPHEN standard dose per PAIN Mgt SOP HYPERTENSIVE EMERGENCY (SBP > 160) plus Time Non-traumatic origin; evidence suggesting end-organ dysfunction present sensitive pt DO NOT use drug therapy solely to rapidly lower BP in chronically hypertensive pts: Needs IV BP control at hospital 2. IMC special considerations: Assess stroke scale. If positive for stroke Stroke SOP Keep patient as quiet as possible; reduce environmental stimuli If GCS ≤ 8: Assess need for ADV airway Elevate head of stretcher 10˚-15˚ Seizure/vomiting precautions; suction only as needed Repeat VS before and after each intervention 3. If chest pain or pulmonary edema: NITROGLYCERIN 0.4 mg per ACS SOP [BLS] | Contact OLMC for repeat dose 4. If generalized tonic/clonic seizure activity: Not pregnant: MIDAZOLAM standard dose for seizures Pregnant: MAGNESIUM SULFATE per Eclampsia SOP 5. Continue treating per appropriate SOP based on etiology and clinical S&S NWC EMSS 2022 SOP 35 Rev. 3-11-24  PSYCHIATRIC | Behavioral Health Emergencies (BHE): May be critical Decisional capacity | Risk assessment | Care (Adult & Peds) SCENE SAFETY: If safety in jeopardy, request law enforcement protection; withdraw until scene is safe for EMS. Assess for imminent risk of harm to self or others: verbal; non-verbal, or written threats/threatening behavior (shaking fists, intentionally slamming doors, punching walls, destroying property, vandalism, sabotage, theft, or throwing objects), self-injurious behaviors, disordered eating, physical attacks (hitting, shoving, biting, pushing or kicking). Extremes include rape, arson, and use of lethal force). Inspect environment for clues suggesting substance use; suicide notes, plans to harm others General pt appearance; hygiene, grooming, odors | Inspect for Medic alert jewelry; impairment; trauma Collateral information from informants: History (if known) and recent mood, behavior, or thought changes Consider use of the Richmond Agitation Sedation Scale (RASS) – See bottom of 3rd page BHE SOP DECISIONAL CAPACITY / RISK ASSESSMENT Ability to understand and appreciate the nature and consequences of a decision re: medical Rx or foregoing life-sustaining treatment and the ability to reach and communicate an informed decision (755 ILCS 40/10 , as amended by P.A. 90-246). Capacity can be influenced by medications, pain, time of day, mood, medical or mental illness. If any S&S below are abnormal/impaired the pt may lack capacity Attempt to assess if changes are new (acute) or features of chronic dx and how grossly abnormal EMS interprets the exam findings to be. Has pt been declared an emancipated minor? Yes No Has pt been declared legally incompetent? Yes No Alertness (Abn. GCS 13 or less): E (3 or 4 OK): V (5): M (6) Total: Orientation X 4: Answers accurately person, place, time, and situation (Abn. X 3 or less / 4) Speech: Speaks with normal rate, volume, articulation, content | (Disorganized, repetitive utterances?) Affect: Mood/emotional response (sad, depressed, flat, anxious, irritable, angry, elated, inappropriate, and incongruent with speech content) Behavior: Posture, gestures, abnormal movements, repetitive behaviors; is pt. quiet, restless, inattentive, hyperactive, agitated, violent? Is pt cooperative and able to remain in control? Cognition: Intellectual ability/thought processes - Note if linear, confused, disorganized, obsessive thoughts, not making sense; evidence of delusions, delirium, dementia, hallucinations, phobias, suicidal or homicidal ideations. Memory: Immediate, recent, remote (amnesia/dementia?) Insight: Can pt articulate lucid and logical implications of the situation and consequences to their choices? Do they understand relevant information? Can they draw reasonable conclusions based on facts and communicate a safe and rational alternative choice to recommended care? Assess for and Rx causes of AMS per symptom-specific SOP (Consider baseline/normal ranges for pt) BALANCE/Coordination – Ataxia (upper or lower extremities); tremors | EYES: Nystagmus - Denies PMH or unable to obtain PMH - A: Alcohol/drugs/toxins (substance use); ACS/HF, arrhythmias, anticoagulation, anemia Look for medical causes - E: Endocrine/exocrine, particularly thyroid/liver/renal/adrenal dx; electrolyte/fluid imbalances; ECG: dysrhythmias/prolonged QT - I: Insulin disorders: glucose for hypo or hyperglycemia (DKA/HHNS) - O: O2 deficit (hypoxia – SpO2), opioids/OD, occult blood loss (GI/GU) - U: Uremia; other renal causes including hypertensive problems HPI/ PMH - T: (recent) Trauma, temperature changes (hypo-hyperthermia) - I: Infections, neurologic and systemic (sepsis) - P: Psychological*; poisoning; perfusion deficits; massive pulmonary embolism - S: Space occupying lesions (epi or subdural, SAH, tumors); stroke, shock (hypotension), seizures Neuro: Delirium, dementia (Alzheimer’s dx), developmental impairment, autism, Parkinson’s dx; migraine/other HA Metabolic: Acidosis ( EtCO2), vitamin/dietary deficiencies; disordered eating / malignancies *Psych/behavioral: Anxiety or mood disorders; PTS, mental health crisis; personality and bipolar disorders; delusions, psychosis; hallucinations (auditory, visual, tactile) Determine decisional capacity + mental health safety risk □ Low risk: Flat affect; low suicide risk; thoughts disordered (confused) with insight, cooperative Risk □ Medium risk: Intoxicated, disinhibited, no insight, unpredictable, cooperative □ High risk: Violent; agitated; aggressive, uncooperative; no insight | high risk to self/others IMC special considerations | MEDICAL care = MEDICAL decision | Work collaboratively w/ mental health / LEO personnel C A 1. Priority: PT & PERSONNEL SAFETY | Recognize warning signs | Use least risk/force possible to protect all R from injury; facilitate assessment | Rx life-threats; and/or safely transport. E Do not antagonize | Maintain dignity to extent possible | Maintain safe distance unless urgent interventions indicated Inform pt of intent to touch them for an assessment or safety hold | PPE/source control | consider early O2 NWC EMSS 2022 SOP 36 Rev. 3-11-24  May be PSYCH | BHE Care cont.| Sedation | Restraint | Suicide screen critical 2. Provide low stimulus & calm environment; limit responders to minimum safe levels, isolate from bystanders prn 3. Empathetic communication | Use concise, simple words | Set boundaries and clear limits (mutual respect) 4. If pt lacks decisional capacity | poses medium-high risk to self or others: DO NOT LEAVE ALONE Provide continuous visual observation and ability to intervene immediately | Rx per implied consent 5. If S&S of anxiety | verbal aggression and confrontation | Cooperative | Low-medium safety risk: - Verbally redirect and de-escalate when possible with coaching & reassurance - Unsuccessful: If BP (MAP) normal for pt/age: MIDAZOLAM (anxiety/sedation dose) If suspect use of alcohol, opioids, or CNS depressants: reduce MIDAZOLAM total dose to 0.1 mg/kg 5. If physical aggression/violent | severe agitation | UNcooperative | High safety risk to self or others: C Inform pt that violence or abuse cannot be tolerated | Take all threats seriously A Verbal de-escalation | Use barriers for protection | Self-defense when appropriate R If unsuccessful & unsafe: KETAMINE (Sedation dose): Estimate pt wt carefully | Caution if active psychosis E RESTRAINT (Physical hold/mechanical restraints per protocol): Humane, judicious & safe - Indications: Pt poses imminent risk of harm to self, others, or environment - Must not be punitive | Position to maximize airway/ventilations & minimize aspiration risk - Ensure peripheral perfusion distal to restraint | Allow for rapid removal if ABCs compromised - Avoid injury | Never use prone, hogtie (hobble) positioning nor place under backboard or mattress - Cardiac arrest can happen quickly | Watch for sudden giving up, quiet compliance, collapse - In an emergency: apply restraints; then confirm necessity with OLMC | Document thoroughly - If applicable: Describe how restraint was applied by others and EMS assessment of pt safety Cont. monitoring/frequently reassess: GCS, RASS, airway, VS; SpO2; EtCO2; WOB; ECG; at least q. 5 min Document untoward events after sedation or restraint | Watch for complications of delirium w/ severe agitation 6. Provide pre-arrival notification & report ASAP Suicide Screen: Explore risk of suicide/harm to others (current, recent, or lifetime SI attempts); warning signs/behavior changes; mitigating/protective factors/support systems. Bring suicide notes to hospital. Possible RISK FACTORS for suicide Mental health or illness disorders (esp. depression and bipolar disorder) Previous suicide attempts or self-inflicted injury | Access to lethal means coupled with suicidal thoughts Hx of trauma, loss, marginalizing experiences (adverse childhood experiences; family history of suicide, bereavement, or economic loss); discrimination based on socioeconomic factors, race/ethnicity or gender/sexual identity Serious illness, or physical or chronic pain or impairment; substance use Social isolation; barriers to healthcare; pattern/history of aggressive or antisocial behavior; family or peer conflict Discharge from inpatient psychiatric care, particularly within first weeks and months after discharge Always ask questions #1 & #2 In past month 1. Wish to be dead: Have you wished you were dead or wished you could go to sleep and not wake up? 2. Suicidal thoughts: Have you actually had any thoughts about killing yourself? If YES to #2, answer questions 3, 4, 5 & 6 If NO to #2, go directly to question 6 3. Suicidal thoughts w/ method (no plan or intent to act): Have you thought about how you might do this? 4. Suicidal intent, no specific plan: Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them? 5. Suicidal intent with plan: Have you started to work out or have worked out the details of how to kill yourself? Do you intend to carry out this plan? ALWAYS ASK QUESTION #6 In past 3 mos. 6. Have you done anything, started to do anything, or prepared to do anything to end your life? Ex: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, held a gun but changed your mind, cut yourself, tried to hang yourself, etc. Any YES must be taken seriously. If YES to #4, #5 or #6, immediately transport to appropriate HC facility. Check pts and bystanders for items that could be used to make a suicide attempt or harm others. Observe for hanging anchor points and minimize use of items that can be used for self-injury: bandages, sheets, plastic bags, IV & O2 tubing. National Suicide Prevention Lifeline: Call 988 | Veterans: 1-800-273-8255; press 1 for live chat or text 838255 NWC EMSS 2022 SOP 37 Rev. 3-11-24  PSYCH | BHE cont.: Documentation | Contested collaborative care decisions May be critical Transport without consent | Agitation scoring tool Documentation in addition to usual history and exam (ImageTrend worksheet) Who called EMS? What happened? ▪ Types of threat alleged or observed: verbal or physical (nature) Where/when did event happen? ▪ Witnesses; others involved; account of situation/statements by pt Preceding factors (prior events) ▪ Verify injuries sustained: emotional/physical Decisional capacity/risk assessment findings ▪ Evidence to support risk assessment (notes/social media posts) Suicide screen (if applicable) ▪ Scene factors/observations to support risk concerns Interventions (type and nature)/responses ▪ Pt’s stated preferences regarding Rx if different from EMS Any challenges encountered during the call ▪ LEO/mental healthcare worker presence/engagement Pt’s access to lethal means of harm ▪ Patient disposition BHE pts may not dissent to care/transport if: EMS has access to the pt + they lack legal or decisional capacity; and/or Pt poses an imminent risk to self (suicide/self-injurious behaviors), others, or meets self-neglect emergency criteria (see SOP Introduction); and/or Remains acutely & severely hemodynamically unstable/ in physiologic distress with AMS after care. If any of the above are present - transport under implied consent Caveats on contested collaborative care decisions/EMS safety issues - Non-medical persons cannot compel EMS practitioners to provide or withhold any EMS care. - EMS personnel have no duty to place themselves at risk of bodily harm in the absence of law enforcement assistance and protection. - OLMC cannot compel EMS to act in a way that subjects them to risk of harm – which may mean leaving a high-risk patient at the scene when EMS access has been denied, LEOs decline to assist, and/or there is reason to believe the pt may have access to lethal weapons. EMS shall not seek OLMC approval of a refusal if the above applies. Rather, they shall report the following: We are on scene with a person who has denied us access to provide a reasonable assessment and law enforcement has declined to intervene. [OR] We have determined that this person has legal and decisional capacity and they appear to pose no imminent risk to self or others and decline to be transported at the present time. They have been informed of the benefits of Rx/transport, given disclosure of the risks of dissenting, alternatives for care, and they demonstrate appropriate insight. They persist in declining our assistance. We are therefore leaving them in their current environment. Disposition □ Treat/transport w/ express consent Treat/transport w/ implied consent Decisional pt refused care/transport No care d/t EMS safety concerns Modified Richmond Agitation Sedation Scale (RASS) Used for Behavioral Health Emergency patients prior to / during / after sedation Score Responsiveness Speech +4 Combative, violent, out of control Continual loud outbursts or growling +3 Very anxious and agitated Loud outbursts +2 Agitated, overstimulated but self-controlled Fast speech; flight of ideas +1 Anxious or restless Normal, talkative 0 Awake, alert, calm, cooperative Normal -1 Drowsy, asleep, rouses to voice Slurring or slowing -2 Light sedation; rouses to physical stimulation Marked slowing; few recognizable words -3 Moderate sedation; responds to pressure stimulus Words or no speech -4 Deep sedation; no response to stimulus – hold further med No speech Complications of delirium w/ severe agitation: Stroke, STEMI, hypoglycemia, hyperthermia, rhabdomyolysis, trauma NWC EMSS 2022 SOP 38 Rev. 3-11-24  Time STROKE | TRANSIENT ISCHEMIC ATTACK sensitive pt 1. IMC special considerations: History of present illness/PMH | Complete BEFAST STROKE SCREEN + LVO assessments – See next page Attempt to determine baseline status: dementia, pre-existing limitations/deficits, unable to care for self? Support ABCs as needed; O2 if SpO2 < 94% or O2 sat unknown; avoid hypoxia and hyperoxia Seizure/vomiting precautions; suction prn Maintain head/neck in neutral alignment; do not use pillows. If SBP > 100: Elevate head of bed 10° - 15° Monitor ECG; acquire 12 L if possible IV: 18 g AC. (Max 2 attempts); avoid excess fluid loading Repeat VS frequently & after each intervention. Anticipate HTN & bradycardia due to ↑ ICP. Do NOT Rx HTN or give atropine for bradycardia if SBP > 90 (MAP > 65) Provide comfort and reassurance; establish means of communicating with aphasic patients Limit activity; do not allow pt to walk; protect limbs from injury 2. If generalized tonic/clonic seizure activity: Observe and record seizure activity per Seizure SOP MIDAZOLAM standard dose for seizures 3. If AMS, seizure activity, or neurologic deficit: Assess blood glucose If ≤ 70 or S & S of hypoglycemia: Treat per Glucose Emergencies SOP 4. Minimize scene time 24 hrs Time: T Time of S&S discovery: Earliest time pt known to have new S&S Time: Level of consciousness: AMS? GCS: E V M Total GCS: Orientation: Answers accurately: Name, age, month of year; location, situation X (1-4) Responds to commands: open/close eyes Y N Gross hearing – Note new onset unilateral hearing deficit; sound sensitivity R L Say “Ah”, palate rises, uvula midline; Stick out tongue: remains midline (note abnormalities) R L Agnosia: Inability to recognize an object (part of body) or person Other R L Neglect: One sided extinction (visual, auditory, sensory) Motor: Lift leg. Normal | Abnormal: drift to no effort against gravity R L Sensory: Focal changes/deficits (face, arms, legs); paresthesias, numbness R L ANS: Sweating only one side R L Neck stiffness (cannot touch chin to chest; vomiting Y N Blood glucose level - List reading: Y N None A-Fib/Flutter AVM, tumor, aneurysm Bleeding disorders CAD/Prior MI/Heart/vascular dx Carotid stenosis Pregnant (or up to 6 wks. post- partum) Depression Diabetes Drug/Alcohol Abuse PMH Dyslipidemia Family Hx stroke HF Hormone RT HTN Migraine Obesity Previous stroke Previous TIA: Previous intracranial surgery/bleed Serious head trauma *Prosthetic valve PVD Renal failure Sleep apnea Smoker/tobacco use Anticoagulant use in 48 hrs: warfarin/Coumadin/Jantoven apixaban/Eliquis argatroban dabigatran/Pradaxa desirudin/Privask edoxaban/Savaysa enoxaparin/Lovenox fondaparinux/Arixtra LMW heparin lepirudin/Refludan rivaroxaban/Xarelto MEDS Platelet inhibitors: ASA clopidogrel/Plavix dipyridamole/Aggrenox prasugel/Effient ticagrelor/Brilinta ticlodipine/Ticlid Cocaine/other vasoconstrictors (amphetamines: PCP) Destination options if primary impression is stroke: □ Nearest hospital: Patient unstable □ Nearest SC (Primary or Comp.) BEFAST +/ LVO not suspected OR LKN > 24 hours | Transport time to CSC > 30 min □ Nearest Comprehensive SC LVO cortical signs | SAH/ICH suspected + LKN ≤ 24 hours + Transport time ≤ 30 min Stroke alert called to (OLMC hospital) Time: Receiving hospital Comprehensive SCs (Thrombectomy up to 24 hrs after onset S&S) ABMC LGH NCH CDH/MSU NWC EMSS 2022 SOP 40 Rev. 3-11-24  SEIZURES History: History /frequency / type of seizures Prescribed meds and patient compliance; amount and time of last dose Recent or past head trauma; fall, predisposing illness/disease; recent fever, headache, or stiff neck History of ingestion/drug or alcohol SUD; time last used Consider possible etiologies: Anoxia/hypoxia Anticonvulsant withdrawal/noncompliance Cerebral palsy or other disabilities Infection (fever, meningitis, encephalitis) Eclampsia Metabolic (glucose, electrolyte disorders, acidosis) Stroke/cerebral hemorrhage Toxins/intoxication/SUD; OD | Withdrawal; DTs Trauma/Abuse Tumor | ↑ ICP Secondary assessment Observe and record the following Presence of an aura Focus of origin: one limb or whole body Simple or complex (conscious or loss of consciousness) Partial/generalized Progression and duration of seizure activity Eye deviation prior to or during seizure Abnormal behaviors (lip smacking) Incontinence or oral trauma Duration and degree of postictal coma, confusion 1. IMC special considerations: No bite block. Vomiting/aspiration precautions; suction prn Protect patient from injury; do not restrain during tonic/clonic movements Position on side during postictal phase unless contraindicated 2. If generalized tonic/clonic seizure activity: Benzodiazepine administration takes precedence over bG determination in pts who are actively seizing MIDAZOLAM 2 mg increments slow IVP q. 30-60 sec (0.2 mg/kg IN) up to 10 mg IVP/IN titrated to stop seizure If IV/IO unable/IN contraindicated: 5-10 mg (0.1-0.2 mg/kg) IM (single dose) All routes: May repeat to a max total dose of 20 mg prn if SBP ≥ 90 (MAP ≥ 65) unless contraindicated If hypovolemic, elderly, debilitated, chronic Dx (HF/COPD); on opioids/CNS depressants: ↓ total dose to 0.1 mg/kg If pregnant with possible eclampsia: Rx with MAGNESIUM SULFATE per Eclampsia SOP 3. Identify and attempt to correct reversible precipitating causes (see above) Assess/record blood glucose l If ≤ 70 or S&S of hypoglycemia: Treat per Glucose Emergencies SOP NWC EMSS 2022 SOP 41 Rev. 3-11-24  Time SEPSIS and SEPTIC SHOCK sensitive pt 1. IMC special considerations: Rapidly assess for risk factors | S&S suggesting infection* | Infectious source - IF YES SpO2: Use central sensor if pt has poor peripheral perfusion (cold hands) Assess EtCO2 - Correlations EtCO2 ≤ 31 = Lactate 2 | Suggests hyperventilation; poor perfusion; and/or metabolic acidosis EtCO2 < 25 = Lactate ≥ 4 (metabolic distress) Assess qSOFA: Quick Sequential [Sepsis-related] Organ Failure Assessment criteria - AMS (GCS < 15); assess for disorientation/agitation and/or GCS 1 or more points below patient’s baseline - RR ≥ 22 (adult) SBP ≤ 100 (adult) (note if ≥ 2 criteria are present) Trend pulse pressures (PP) (normal 30-50) + MAP (normal 70-110) q. 5 min Can crash rapidly | Elderly & those with HTN cannot tolerate hypotension for even a short time Assess S&S of fluid depletion: Orthostatic VS changes if not hypotensive; poor skin turgor, dry mucosa Vascular access: 18 g AC preferred if inopressor needed | IVF- See below Assess blood glucose: Anticipate hyperglycemia and electrolyte abnormalities (6-24 hrs): RR; hyperdynamic phase with high cardiac output; SBP 25% < normal; fever, Warm stage vasodilation, skin: hot, dry, flushed Cold Stage (ominous/late): AMS; T< 96.8° F; skin cold; mottling; HR & RR; profound hypotension *Indicators suggesting infection: Fever; warm skin Fatigue, altered mental status Cough, dyspnea Sore throat, ear ache Diarrhea Dysuria, foul smelling/cloudy urine Local redness, warmth, swelling, unhealed wounds etc. If infection, no sepsis: Cardio-resp. support | Rx specific conditions per appropriate SOP or OLMC SEPSIS: Suspect infection + EtCO2 ≤ 31 + ≥ 2 qSOFA criteria: (SBP 90-100 | MAP > 65) 2. Call OLMC with a Sepsis alert per local policy/procedure 3. NS 200 mL boluses to achieve SBP ≥ 100 mmHg (max 1 L) SEPTIC SHOCK: Sepsis + SBP < 90 (MAP < 65) or hypotensive for pt (40 mmHg < baseline); or EtCO2 ≤ 25 2. Call OLMC with a Sepsis alert per local policy/procedure. 3. IV/IO NS 200 mL boluses in rapid succession (max: 20 mL/kg) to SBP ≥ 90 (MAP ≥ 65) Reassess VS / skin signs / EtCO2 after each bolus to assess for fluid responsiveness and S&S of volume overload 4. If hypotension persists after 500 mL IVF – add inopressor while continuing IVF (2nd IV line needed) NOREPINEPHRINE drip IV (lg. vein) / IO: Conc: 4 mg in 1,000 mL NS (4 mcg/mL) | Use of IV pump preferred Initial dose: 8 mcg/min (2 mL/min) titrated to SBP ≥ 90 (MAP ≥ 65) Higher doses (10 mcg/min) RARELY needed – contact OLMC. Assess BP (MAP) q. 2 min until target BP reached (don’t overshoot) | Then reduce dose (drip rate) incrementally just to maintain at BP targets Maintenance: 2 to 4 mcg/min (0.5 mL to 1 mL/min) or less | Continue to reassess BP q. 5 min. At risk populations: ≥ 65 or < 1 yr, or weakened immune systems (cancer, HIV/AIDS); indwelling devices; chronic steroid use; sickle cell disease, splenectomy; bedridden or immobile); recent trauma, surgery, or dental work; breached skin integrity (wounds, burns); IV drug use; females - recent birth, miscarriage, abortion; PID, post-organ transplant; chronic disease: DM, cirrhosis, autoimmune, renal Results in a systemic immune/inflammatory response leading to massive vasodilation and capillary leak that causes hypoperfusion | Other concerns: Hypercoagulability (petechiae); mottling May be sicker than they look – Consider shock index; tissue hypoxia and acidosis begin BEFORE ↓ BP NWC EMSS 2022 SOP 42 Rev. 3-11-24