Whitehall-EMS Protocol.pdf

Whitehall EMS Protocol UPDATED 02/01/2023 2023 ® www.responsoft.com Preface Signature Page Preface December 4, 2018 The purpose of this protocol is to establish guidelines between EMS administration, the EMS provider and medical direction for the management, treatment and transport of specif...

Whitehall EMS Protocol UPDATED 02/01/2023 2023 ® www.responsoft.com Preface Signature Page Preface December 4, 2018 The purpose of this protocol is to establish guidelines between EMS administration, the EMS provider and medical direction for the management, treatment and transport of specific emergencies. The goal of these protocols is to help us a achieve excellent, consistent prehospital care for our patients. These protocols may not cover every circumstance that arises. These protocols are not designed or intended to limit the EMS provider in the exercise of good judgement or initiative in taking reasonable action in extraordinary circumstances. It is the responsibility of each provider to know and understand the material covered in these protocols. Conditions not specifically addressed in these protocols will be treated using the emergency medical responders’ scope of practice approved by the Ohio State Board of Emergency Medical, Fire and Transportation Services Division of EMS that is in effect at the time of the care event. Our objective is to not only serve the people in our service area but to give them the highest quality service possible. We will continue to achieve the high standard required of emergency medical services by working together and maintaining a high degree of professionalism. This protocol is effective January 1, 2019 and shall remain in effect until either it is replaced by an updated protocol or discontinued by the medical director. Specific focused protocol changes without a complete protocol revision may be periodically required as dictated by changes in medication availability, advances in practice or regulatory requirements. Any such protocol changes will be added as written amendment to this protocol Finally, I welcome any input you may have to make these protocols better in the future. Protocol Approved: Ashley Larrimore, MD, FAEMS Medical Director [email protected]/508‐269‐3892 Responsoft EMS Protocols Page 2 10/13/2020 Comments for Future Protocol Changes (Sticky Notes) Responsoft EMS Protocols Page 3 10/13/2020 Legend General Information Medication from Pharmacology Section Procedure (some procedures i.e. 12 Lead ECG, are not listed in procedures section but, are procedure) Black or Heavy Lined Boxes contain important information All Drugs color coded in Dark Green. Example: Atropine Calculated Drugs are Blue. Example: 125 mg DS = Drug Shortage. This is found in Pharmacology Section drugs that may not be available and will link you to the Drug Shortage page for alternative drug(s) to be used. Use Dextrose 50% in place of Dextrose 10% during shortages Found in Pharmacology Section, listed drug is used only when there is a drug shortage General Information boxes Important Note: Pharmacology Section: Indications. This links where particular medication will be found in the protocol. Example; Albuterol Indications. Toxic Exposure. Not specifically used for Toxic Exposure, but is referenced being used if Smoke Inhalation/Co Poisoning and patient is wheezing, not used for other exposures typically. Responsoft EMS Protocols Page 4 10/13/2020 Table of Contents Table of Contents, Page 1 Cover Preface Signature Page Future Protocol Changes Legend Adult Section Cardiovascular Cardiovascular Asystole/PEA Bradycardia Chest Pain/MI Dialysis Patients in Cardiac Arrest Narrow Complex Tachycardia (PSVT) Post Resuscitation V-Fib/Pulseless V-Tach Wide Complex Tachycardia (V-Tach w/Pulse) Environmental Environmental Bites/Envenomations Drowning/Near Drowning Hyperthermia/Heat Exposure Hypothermia General General Behavioral Chemical Restraint Part A Chemical Restraint Part B Epistaxis-Nosebleed Hyperglycemia/Hypoglycemia Non-Traumatic Shock/Dehydration Pain Control Sepsis Unconscious/Unknown Universal Patient Assessment Neurological Neurological CVA/Unconscious CVA/Unconscious-continued Seizure OB/GYN OB/GYN Abnormal Deliveries Table of Contents 1 Preface Preface Preface 2 3 4 Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular 12 13 14 15 16 17 18 19 20 Environmental Environmental Environmental Environmental Environmental 21 22 23 24 25 General General General General General General General General General General General 26 27 28 29 30 31 32 33 34 35 36 Neurological Neurological Neurological Neurological 37 38 39 40 OB/GYN OB/GYN 41 42 Table of Contents Table of Contents, Page 2 Childbirth/Labor Obstetric Emergencies-Eclampsia Obstetric Emergencies-Vaginal Bleeding Sexual Assault Respiratory Respiratory Adult Airway Difficult Airway Allergic Reaction/Anaphylactic Shock Esophageal Foreign Body Hyperventilation Pulmonary Edema/CHF Rapid Sequence Intubation (RSI) Delayed Sequence Intubation (DSI) Respiratory Distress Toxicology Toxicology Carbon Monoxide Poisoning Overdose Toxic Exposure Trauma Trauma Abdominal Trauma Burns Chest Trauma Crush Syndrome Spinal Injury Assessment Dental Injuries Extremity Trauma Multiple Trauma Neurological Trauma (Head) Ocular Trauma Trauma in Pregnancy Pediatric Section Pediatric Cardiovascular Pediatric Cardiovascular Pediatric Bradycardia Pediatric Pulseless Arrest Pediatric Tachycardia w/Pulse Pediatric General Pediatric General Pediatric Brief Resolved Unexplained Event (BRUE) Table of Contents OB/GYN OB/GYN OB/GYN OB/GYN 43 44 45 46 Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory 47 48 49 50 51 52 53 54 55 56 Toxicology Toxicology Toxicology Toxicology 57 58 59 60 Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma 61 62 63 64 65 66 67 68 69 70 71 72 Pediatric Cardiovascular Pediatric Cardiovascular Pediatric Cardiovascular Pediatric Cardiovascular 74 75 76 77 Pediatric General Pediatric General 78 79 Table of Contents Table of Contents, Page 3 Pediatric Behavioral Emergencies Pediatric Fever Pediatric Hypovolemic Shock Pediatric Pain Control Pediatric Unconscious/Hypoglycemic Universal Pediatric Assessment Pediatric Neonatal Pediatric Neonatal Care Pediatric Neurological Pediatric Neurological Pediatric Seizures Pediatric Respiratory Pediatric Respiratory Pediatric Airway Pediatric Allergic Reaction Pediatric Respiratory Distress (Lower Airway) Pediatric Respiratory Distress (Upper Airway) Pediatric Toxicology Pediatric Toxicology Pediatric Toxic Overdose Pediatric Trauma Pediatric Trauma Pediatric Burns Pediatric Chest Trauma Pediatric Head Trauma Pediatric Multiple Trauma Pharmacology Adenosine (Adenocard) Afrin (Oxymetazoline) Albuterol (Proventil Ventolin) Amiodarone (Cordarone) Aspirin Atropine Calcium Chloride Dexamethasone (Decadron) Dextrose (D10) Dextrose (50) Diazepam (Valium) Diphenhydramine (Benadryl) Epinephrine 1:1,000 Epinephrine 1:10,000 Epinephrine Push Dose Table of Contents Pediatric General Pediatric General Pediatric General Pediatric General Pediatric General Pediatric General Pediatric Neonatal Pediatric Neonatal 80 81 82 83 84 85 86 87 Pediatric Neurological Pediatric Neurological 88 89 Pediatric Respiratory Pediatric Respiratory Pediatric Respiratory Pediatric Respiratory Pediatric Respiratory 90 91 92 93 94 Pediatric Toxicology Pediatric Toxicology 95 96 Pediatric Trauma Pediatric Trauma Pediatric Trauma Pediatric Trauma Pediatric Trauma 97 98 99 100 101 Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 Table of Contents Table of Contents, Page 4 Etomidate (Amidate) Fentanyl (Sublimaze) Glucagon Haloperidol (Haldol) Ibuprofen (Motrin, Advil) Ipratropium (Atrovent) Ketamine (Ketalar) Ketorolac (Toradol) Lidocaine (Xylocaine) Magnesium Sulfate Methylprednisolone (Solu-Medrol) Midazolam (Versed) Morphine Naloxone (Narcan) Nitroglycerin Normal Saline Ondansetron (Zofran) Oral Glucose (Glutose 15 Insta-Glucose) Oxygen Pralidoxime (2-PAM) Promethazine (Phenergan) Racemic Epinephrine 2.25% Rocuronium (Zemuron) Sodium Bicarbonate Succinylcholine (Anectine) Tetracaine Tranexamic Acid (TXA) Drug Substitutions (DS) Drug Substitutions (DS)-continued Clinical Standards Adult Primary Assessment Patient Assessment-Medical Patient Assessment-Trauma Pediatric Primary Assessment Pediatric Assessment-Medical Pediatric Assessment-Trauma Consent, Refusal or Treatment/Transport Part A Consent, Refusal of Treatment/Transport Part B Controlling Protocol and In-Charge Paramedic COTS Exceptions to Trauma Transport and Caveats Criteria for Death or Withholding Resuscitation DNR-Advanced Directive Part A Table of Contents Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology Pharmacology 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 Patient Assessment Patient Assessment Patient Assessment Patient Assessment Patient Assessment Patient Assessment Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards 149 150 151 152 153 154 155 156 157 158 159 160 Table of Contents Table of Contents, Page 5 DNR-Advanced Directive Part B DNR-Advanced Directive Part C DNR-Advanced Directive Part D EMS Blood Collection of Blood Sample High Performance/Priority Based CPR Part A High Performance/Priority Based CPR Part B Interfacility Transfers Interfacility Transport Part A Interfacility Transport Part B IV/IO Ohio Prehospital Trauma Triage Decision Tree - 2019 Update Pain Control Standard Patient Restraint Patient Transport Part A Patient Transport Part B Patient Transport Part C Patient Transport Part D Patient Transport Part E Physician on Scene Physician on Scene-continued Pre-Existing Medical Devices/Drug Administrations Part A Pre-Existing Medical Devices/Drug Administrations Part B Safe Discharge of Diabetic Patients Special Needs Patients Surgical Emergency Response Team (SERT) Termination of Resuscitation Part A Termination of Resuscitation Part B Termination of Resuscitation-Checklist Transport of Patient with Pre Existing Condition Procedures Capnography Childbirth CPAP O2-RESQ CPR Cricothyrotomy-Needle Cricothyrotomy-Surgical Cricothyrotomy-Surgical Images External Transcutaneous Pacing-Zoll Helmet Removal: Non-Football Helmet Removal-Football Intraosseous Infusion EZ-IO (Humerus) Intraosseous Infusion EZ-IO (Distal Tibia) Table of Contents Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards Clinical Standards 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures 191 192 193 194 195 196 197 198 199 200 201 202 Table of Contents Table of Contents, Page 6 Intraosseous EZ-IO (Proximal Tibia) Intubation-Oral Intubation-Pediatric Oral LifeVest Part A LifeVest Part B Morgan Eye Lens Mucosal Atomizer Device (MAD) ResQPOD SAM Pelvic Sling Splinting Suctioning of ET Tubes & Tracheostomy Tubes Taser Removal Tourniquet Application Valsalva Maneuver Ventricular Assist Device (VAD) Part A Ventricular Assist Device (VAD) Part B Ventricular Assist Device (VAD) Part C Reference Protocol Changes-Part A Protocol Changes-Part B Protocol Changes-Part C Protocol Changes-Part D Protocol Changes-Part E Protocol Changes-Part F Capnography-Basics Capnography-Information Capnography-Information/Waveforms Pediatric Lower Airway Disorders Pediatric Vital Signs Phone Numbers Phone Numbers-continued RSI Assessment Tips FLACC-Revised Scale Table of Contents Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures Procedures 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 Adult Section Responsoft EMS Protocols Adult Section Page 11 Adult Section 10/13/2020 Cardiovascular Responsoft EMS Protocols Cardiovascular Page 12 Cardiovascular 10/13/2020 Asystole/PEA Cardiovascular Administer Oxygen Oxygen Rhythm Shockable? CPR Quality ■ Avoid excessive ventilation. Deliver ventilations during chest compressions recoil ■ Quantitative waveform capnography - If PETCO2 < 10 mmHg, attempt to improve CPR quality Start CPR Attach monitor/defibrillator No Asystole/PEA Yes Yes Go to: VF/VT CPR 2 minutes (PETCO2 partial pressure of end-tidal carbon dioxide) Treat reversible causes Consider for prolonged resuscitation with effective ventilation; on return of spontaneous circulation. Preexisting hyperkalemia Or if cardiac arrest due to tricyclic OD, Cocaine, ASA or Diphenhydramine Sodium Bicarbonate mEq/kg IVP, IO 1 1mEq/kg Cardiovascular IV/IO access IV/IO Reversible Causes - Hypovolemia - Hypoxia - Hydrogen ion (acidosis) - Hypoglycemia - Hypo-/hyperkalemia - Hypothermia - Tension pneumothorax - Tamponade, cardiac - Toxins - Thrombosis, pulmonary - Thrombosis, Coronary - Trauma Epinephrine 1:10,000 1 mg IV, IO Repeat every 3-5 minutes Consider advanced airway, capnography After Advanced Airway attach End Tidal. ■ If no signs of return of spontaneous circulation (ROSC), go to CPR & Epinephrine or CPR every 2 minutes. Also start considering: Termination of Resuscitation Part A ■ If ROSC, go to Post Resuscitation Responsoft EMS Protocols Page 13 10/13/2020 Bradycardia Cardiovascular Intervention by ems for bradycardia rhythm may not be necessary unless patient is symptomatic. Signs and symptoms such as hypotensive, altered mental status with inadequate perfusion, chest pain. Universal Patient Assessment Cardiac Monitor / 12 Lead ECG Cardiovascular Bradycardia can be caused by: Hypoxia, MI, Sick sinus syndrome, Heart blocks, and other ectopy not producing a pulse. The palpable rate will be < 50. Remember, a slow heart rate can be normal in some patients if cardiovascular condition is in superb state. Transmit 12 Lead ECG IV/IO IV/IO Symptomatic Watch for 2nd or 3rd Degree Block Hypotension BP < 90 mm/Hg PVC’s, Altered Mental Status Symptoms-chest pain, dyspnea Ischemia or Infarction No Yes Monitor Atropine 0.5 mg IVP, IO Maximum 3 mg If patient with symptomatic bradycardia and acute change in mental status and/or profound hypotesion and unable to easily obtain IV access transcutaneous pacing may be initiated before epinephrine or atropine is administered Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes For sedation Midazolam (Versed) 2 mg IVP, IO May repeat in 5 minutes x 1 or 5 mg IN (2.5 mg per nostril) May be repeated x 1 in 5 minutes Responsoft EMS Protocols External Transcutaneous Pacing-Zoll Zoll: Set Rate 70 bpm Set Current Conscious start at: 30 mA and increase by 10 mA Unconscious start at: 30 mA and increase by 10 mA Page 14 10/13/2020 Chest Pain/MI Cardiovascular Unless extenuating circumstances, scene time should be 15 minutes or less. Cardiovascular Universal Patient Assessment Cardiac Monitor / 12 Lead ECG Transmit 12 Lead ECG Oxygen should be administered Oxygen to maintain SpO2 >94% Aspirin 324 mg (baby Aspirin) IV/IO If necessary, Normal Saline Bolus 300 - 500 ml May consider Nitro Nitro Paste Paste 1" 1" if unable to administer oral Nitroglycerin Nitroglycerin Spray/Tablet 0.4 mg SL May repeat x 2 If BP > 90 Systolic and IV established. (3 doses total) Persistent chest pain and blood pressure >90 mmHg? Consider Fentanyl Fentanyl No Hypotension / Dysrhythmias, Treat per Protocols 11 mcg/kg mcg/kg IVP, IO every 3 - 5 minutes for pain 100 mcg maximum per dose Maximum 200 mcg In a patient with suspected MI and PVC's present, if the heart rate is 60 or above, and no 2nd or 3rd degree block is present, institute the following: Amiodarone Mix 150 mg in 100 ml of 0.9 NS over 10 minutes, 15 mg/min. IV Infusion Responsoft EMS Protocols Page 15 10/13/2020 Cardiovascular Dialysis Patients in Cardiac Arrest Hyperkalemia may be the cause of cardiac arrest in dialysis patients. Universal Universal Patient Patient Assessment Assessment CPR Calcium Chloride 1 gm IVP, IO Cardiovascular Some causes of Renal Patients Coronary Heart Disease:  Hypertension following erythropoietin (hormone that controls red blood cell production) in chronic kidney disease.  Hypertension in dialysis patients  Inflammation in renal insufficiency  Myocardial dysfunction in end-stage renal disease  Pericarditis in renal failure  Serum cardiac enzymes in patients with renal failure Flush with 50 – 100 ml Normal Saline CPR Sodium Bicarbonate 100 mEq IVP, IO CPR Go to appropriate protocol: V-Fib/Pulseless V-Tach Asystole/PEA Responsoft EMS Protocols Page 16 10/13/2020 Cardiovascular Narrow Complex Tachycardia (PSVT) Universal Patient Assessment SVT can originate from the Sinus node (responds to adenosine) or from the atria does not respond to adenosine). Among these concerns, the SVT may be symptomatic: chest pain, hypotension, altered mental status or may be asymptomatic. Cardiovascular Unstable Signs: Altered mental status, chest pain, hypotension, or other signs of shock. Rate-related symptoms uncommon if heart rate <150/min. Cardiac Monitor Narrow Complex Tachycardia (PSVT) Heart Rate 150 BPM or Greater IV/IO IV/IO Stable Unstable For sedation Midazolam (Versed) 2 mg IVP, IO Cardiac Monitor / 12 Lead ECG or 5 mg IN (2.5 mg per nostril) Transmit 12 Lead ECG Synchronized Cardioversion May attempt Zoll Valsalva Maneuver 70, 120, 150, 200 joules initially and after each drug administration if indicated Perform continuous cardiac monitoring and print strip If Atrial Fibrillation, Synchronized Cardioversion Zoll Administer 120, 150, 200 joules Adenocard 6 mg rapid IVP over Adenosine (Adenocard) 1 – 3 seconds and flush immediately with 20 ml 0.9% NS If no response after 1 – 2 minutes repeat Adenosine 12 mg rapid IVP over 1–3 seconds and flush If rhythm changes Go to Appropriate Protocol immediately with 20 ml 0.9% NS Monitor blood pressure closely after each dose If during Adenosine administration patient develops hypotension (systolic BP < 90), chest pain, shortness of breath, decreased level of consciousness, proceed with direct synchronized Cardioversion of PSVT rhythm Responsoft EMS Protocols Page 17 10/13/2020 Cardiovascular After ROSC, optimize hemodynamic, respiratory, and neurologic support. Identify and treat reversible causes of arrest. Post Resuscitation Repeat Primary Assessment Continue ventilatory support to adjust FiO2 as needed, to maintain O2 saturation or 94% Cardiovascular Continuous reassessment. Ventilatory support as needed must continue. Consider semi-Trendelenburg position and fluid bolus. IV/IO IV/IO Cardiac Monitor Obtain 12 Lead ECG & Transmit to ED Obtain vital signs every 3 - 5 minutes Pulse Oximetry / Capnography Capnography Hypotension Consider NS Fluid Bolus 300 – 500 ml If Ventricular Ectopy or returning out of V-Fib / Pulseless V-Tach and Amiodarone NOT administered Bradycardia Treat per Bradycardia Protocol Amiodarone Consider Epinephrine Push Dose Mix 150 mg in 100 ml of 0.9 NS over 10 minutes, 15 mg/min. IV Infusion 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes If arrest reoccurs, revert to appropriate protocol and / or initial successful treatment Responsoft EMS Protocols Page 18 10/13/2020 Cardiovascular V-Fib/Pulseless V-Tach CPR x 2 minutes (CPR should be continued for 2 minutes after every defibrillation) Once an advanced airway is in place, 2 rescuers no longer deliver “cycles” of CPR. Instead, the compressing rescuer should give continuous chest compressions without pauses for ventilations. Zoll Defibrillation Settings 120, 150, 200 Joules Cardiovascular Cardiac Monitor Defibrillate 120 joules Continuous compressions of at Least 100 per minute (80 per minute with Autopulse) AT ANY TIME Return of Spontaneous Circulation 8 - 10 breaths per minute. IV/IO Adult Airway Protocols Go to Post Post Resuscitation Resuscitation Protocol Epinephrine 1:10,000 1 mg IVP, IO Repeat every 3-5 minutes Defibrillate Zoll 150 joules Amiodarone Amiodarone May use Lidocaine instead of Amiodarone Lidocaine (Xylocaine) 300 mg IVP, IO - 1.5 mg/kg 1 –11.5 mg/kg For refractory VF, after 3 shocks, switch to Anterior-Posterior pads Consider Sodium Bicarbonate May repeat 0.5 0.5–- 0.75 0.75 mg/kg Defibrillate Zoll 200 joules If torsades de pointes suspected Amiodarone MagnesiumSulfate Sulfate Magnesium 150 mg IVP, IO mEq/kg IVP, IO 1 mEq/kg 2 grams IVP, IO Defibrillate Zoll 200 joules See: Criteria for Discontinuation? Yes No Termination of Resuscitation Part A Guideline CPR Medications, Continue CPR, Defibrillation Responsoft EMS Protocols Zoll 200 joules and Transport Page 19 10/13/2020 Cardiovascular Wide Complex Tachycardia (V-Tach w/Pulse) VT is usually associated with ischemia or heart disease. Some causes are: CHF, drug toxicity, cocaine, hypokalemia and electrolyte imbalance. Unstable Signs: Altered mental status, chest pain, hypotension, or other signs of shock. Rate-related symptoms uncommon if heart rate < 150 min. Universal Patient Assessment Cardiac Monitor V-Fib/Pulseless V-Tach Protocol No Cardiovascular Palpable pulse? Yes IV/IO IV/IO Stable Unstable For sedation Cardiac Monitor / 12-Lead ECG Midazolam (Versed) 2 mg IVP, IO Transmit 12 Lead ECG or 5 mg IN (2.5 mg per nostril) Synchronized If regular and monomorphic administer: Adenocard 6 mg rapid IVP over Adenosine (Adenocard) Cardioversion 70, 120, 150, 200 joules 1 – 3 seconds and flush immediately with 20 ml 0.9% NS If no response after 1 – 2 minutes repeat Adenosine 12 mg rapid IVP over 1–3 seconds and flush Amiodarone immediately with 20 ml 0.9% NS Mix 150 mg in 100 ml of 0.9 NS over Monitor blood pressure closely after each dose 10 minutes, 15 mg/min. IV Infusion If during Adenosine administration patient develops hypotension (systolic BP < 90), chest pain, shortness of breath, decreased level of consciousness, proceed with direct synchronized Cardioversion of PSVT rhythm Amiodarone Mix 150 mg in 100 ml of 0.9 NS over 10 minutes, 15 mg/min. IV Infusion Responsoft EMS Protocols Page 20 10/13/2020 Environmental Responsoft EMS Protocols Environmental Page 21 Environmental 10/13/2020 Environmental Rash, skin break, pain, soft tissue swelling, redness and/or blood oozing from the bite wound shortness of breath, wheezing, hives, itching, shock, hypotension Bites/Envenomations Universal Patient Assessment IV/IO IV/IO Cardiac Monitor Consider the safety of the rescuer. Calm the patient. Dog / Human Bite Consider the safety of the rescuer. Treat as a soft tissue injury. All bites are considered to be infectious. Treatment by a physician is recommended and necessary. Notify local animal control and law enforcement. Provide transportation as necessary. Assessment as per protocol. *be prepared for patient to state “Hymenoptera” as their allergy, this is an allergy to the bites/stings of winged insects. Obtain a complete history about the animal, insect or reptile (includes size, color, markings, shape of the head, location of the event, time of event, how it happened and if the predator was captured and available for transport to facility) Treat patient utilizing appropriate medical protocol and transport to medical facility. Stings If stinger present, attempt to remove stinger by brushing it with the edge of a credit card or equivalent device. Clean the area once the stinger is removed; apply sting eze™ if available and patient not allergic (contains Iodine) to it. A. If possible, place the site below the level of the patient’s heart. Cold packs may be applied, but not directly to the skin. B. During transport, be prepared for vomiting. Monitor vital signs. If bronchospasm, refer to Allergic Allergic Reaction/Anaphylactic Reaction/Anaphylactic Shock Shock Contact receiving facility, as soon as practical, as they can prepare for patient arrival. Responsoft EMS Protocols Environmental Page 22 Snake Bites Consider the safety of the rescuer. Calm the patient. Remove jewelry, apply constricting bands (above and below), and immobilize extremity. Be prepared for site swelling. Notify local animal control and law enforcement. The snake is needed for ID purposes only. Treat for shock, treat the soft tissue injury and manage other medical problems appropriately as per protocol. Provide transportation as necessary. 10/13/2020 Environmental Drowning/Near Drowning There are multiple considerations with Drowning / Near Drowning. Water temperature being primary. All cold water drowning should be worked. Trauma and C-Spine should be considered and managed. As with all environmental exposures, time and duration will also need to be noted. Environmental Universal Patient Assessment Spinal Injury Assessment Cardiac Monitor Adult Airway Protocol Follow the appropriate protocol for the cardiac rhythm present: Asystole/PEA V-Fib/Pulseless V-Tach regardless of hypothermia IV/IO Monitor and reassess If victim and/or water is extremely cold, limit ACLS/defibrillation attempts to one trial, continue resuscitation until rewarmed at medical facility. Near Drowning Insist on transportation to medical facility for evaluation. May have pulmonary complications. Responsoft EMS Protocols Page 23 10/13/2020 Environmental Hyperthermia/Heat Exposure Some causes of hyperthermia are: High temperatures in the environment or excessive exercise in moderate to extremely high temperatures. Also, Older or ill incapacitated patient, a failing of temperature regulating center. Universal Patient Assessment Document patient temperature Move to cooler environment, remove all outer clothing. Allow minimal modesty. Apply room temperature water to skin and increase air flow around patient Consider Cold packs to major artery sites Environmental Signs & Symptoms Heat Cramps Severe muscle cramps Heat Exhaustion Altered mental status, dizziness, nausea & vomiting, headache, elevated core body temperature Heat Stroke Extremely elevate core body temperature, the absence of sweating, with hot red or flushed dry skin, rapid pulse, difficulty breathing, strange behavior, hallucinations, confusion, agitation, disorientation seizure, coma Be prepared for seizures. Direct fan on patient if available. DON'T GIVE FLUIDS ORALLY. IV/IO Maintain systolic B/P greater than 90 mmHg. Monitor and reassess Appropriate Protocol based on patient symptoms Responsoft EMS Protocols Page 24 10/13/2020 Hypothermia Environmental A core body temperature of 95°F (35°C) can lead to decrease in heat production and increase in heat loss. Universal Patient Assessment Remove patient from cold environment, and remove wet clothing. Avoid rough movement. Cardiac Monitor Environmental Medical considerations include time and duration of exposure. Level of patient distress indicated by clinical presentation such as presence of shivering, level of consciousness, core temperature reading. Auxiliary and oral measurements are poor measures of core temperature. Rectal temperatures are closer to estimate the core temperature. Passive rewarming. Attempt rectal temperature if possible IV/IO IV/IO (warmed) Severe Hypothermia < 88°F (< 31°C) Moderate Hypothermia 88-92°F (31-34°C) Withhold intubation unless the respiratory rate is less than 6/min and no gag reflex is present, or, the patient is in cardiac arrest Use appropriate protocol for rhythm, but decrease all cardiac medications by one-half Mild Hypothermia < 92-96o F (34-36o C) Appropriate Protocol based on patient symptoms Limit resuscitation to one round of ACLS medications. (see appropriate rhythm) Limit Defibrillation to 1 countershock @ 200 joules Transport as soon as possible. Attempt further defibrillation only when core temperature rises Responsoft EMS Protocols Page 25 10/13/2020 General Responsoft EMS Protocols General Page 26 General 10/13/2020 General Chemical restraint is preferred over physical restraint. Behavioral General Scene Safety Treat suspected medical or trauma problems per appropriate protocol If patient is sedated, use Capnography Universal Patient Assessment Hyperglycemia/Hypoglycemia Unconscious/Unknown Overdose Neurological Trauma (Head) Causes of Excited Delirium Drug related, Stimulant drugs: Cocaine Amphetamines Club Drugs Hallucinogens, Adverse Drug Reaction, Drug Withdrawal, Hypoglycemia, Head Trauma, Hypoxia, Hypoventilation, Shock, Psychiatric, New drug, Off Drugs, Other Medical Delirium, Infection, Dementia Attempt to remove patient from stressful environment Verbal techniques (reassurance, calm, establish rapport) Explain all movements and procedures. Look for a possible cause. For patients who are agitated and/or combative consider Physical and Chemical restraint as needed per the Chemical Restraint Protocol An alternative to Ketamine is: Midazolam. Midazolam should be used in patients in which Ketamine is contraindicated or ineffective or if there is suspicion that the agitation may be related to underlying seizure activity. Responsoft EMS Protocols Page 27 10/13/2020 Chemical Restraint Part A General General Clinical Indications 1. Therapeutic: to control the patient’s ventilation, intracranial pressure, or heat production. Additional benefits are to decrease anxiety and minimize discomfort of invasive or uncomfortable procedures. 2. Safety: to insure that the combative patient is not a threat to himself or crew members and that necessary treatments or procedures are not compromised. The sedated patient experiences both physiologic consequences of the medication and loss of important physical clues. 1. Whenever possible, establish baseline vitals. 2. Determine the Sedation Assessment score Sedation Assessment Tool (SAT)1 Score Responsiveness Speech +3 Combative, Violent, Out of control Continual loud outbursts +2 Very anxious and agitated Loud outbursts +1 Anxious/restless Normal -> talkative 0 Awake and calm/cooperative Speaks normally -1 Asleep but rouses if name is called Slurring or prominent slowing -2 Responds to physical stimulation Few recognizable words -3 No response to stimulation Nil Responsoft EMS Protocols Page 28 10/13/2020 General Chemical Restraint Part B 3. Determine correct medication, dose and route SAT +2: Consider SAT +1:: Consider Midazolam (Versed) Midazolam (Versed) 5 mg IVP 2 mg IVP Midazolam (Versed) Midazolam (Versed) 10 mg IN, IM 5 mg IN, IM OR General Ketamine - If vial is 100 mg / mL, dilute to 50 mg / mL for IV use Ketamine (Ketalar) (50 mg/mL) mg/kg IVP 11 mg/kg Ketamine (Ketalar) (50 mg/mL) mg/kg IM 22 mg/kg Ketamine (Ketalar) (100 mg/mL) 22 mg/kg mg/kg IM SAT +3: Consider dispatching an EMS Officer on any run with a SAT score of +3 Ketamine - If vial is 100 mg / mL, dilute to 50 mg / mL for IV use Ketamine (Ketalar) (50 mg/mL) mg/kg IVP 22 mg/kg Ketamine (Ketalar) (50 mg/mL) 44 mg/kg mg/kg IM Ketamine (Ketalar) (100 mg/mL) 4 4 mg/kg mg/kg IM 4. Obtain and document vital signs  Pulse Oximetry  BP  EtCO2  Continuous Cardiac Monitor 5. Repeat and document vitals every 5 minutes 6. Monitor patient throughout transport In considering whether patient meets criteria for Ketamine- is there immediate danger to self or others In most cases, the target level of sedation to aim for post-sedation is: SAT 0 to -1. The most common exception requiring deeper sedation will be for medical assisted intubation ( 1 Calver, L.A., Stokes, B. & Isbister, G.K. (2011). ‘Sedation assessment tool to score acute behavioral disturbance in the emergency department’. Emergency Medicine Australasia, vol. 23, pp. 732-740). NOTE: This is a consensus protocol on the care and management of acute behavioral emergencies from the following central Ohio EMS medical directors: Robert Lowe, MD (Columbus Division of Fire), Ashley Larrimore, MD & Michael Dick, MD (Ohio State University Center for EMS), Eric Cortez, MD (OhioHealth EMS), Frank Orth, DO and Paul Zeeb, MD (MEC EMS). Protocol approved November 1, 2021 for implementation with next affiliated agency's(ies') protocol update Responsoft EMS Protocols Page 29 10/13/2020 General Epistaxis-Nosebleed Epistaxis can be a symptom of hypertension. Be thorough in your evaluation while treating this minor problem. Universal Patient Assessment Place patient in either a standing or upright seated position. If patient is recumbent in bed and unable to sit up, have patient turn head to the side. General Controlling significant bleeding or hemodynamic instability should take precedence over obtaining a lengthy history. Note the duration, severity of the hemorrhage, and the side of initial bleeding. Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, family history, easy bruising, or prolonged bleeding after minor surgical procedures. Recurrent episodes of epistaxis, even if self-limited, should raise suspicion for significant nasal pathology. www.emedicine.medscape.com Have the patient tilt their head forward (chin to chest) and have the patient hold firm pressure on the nares. The patient should hold pressure for ten (10) minutes. Afrin (Oxymetazoline) 0.05% - 2 - 3 puffs/nares on side of bleeding. Responsoft EMS Protocols Page 30 10/13/2020 Hyperglycemia/Hypoglycemia General In DKA patients, Kussmaul respiration helps correct acidosis. Patients with an EtCO2 of less than 29 were found to be in acidosis 95% of the time, whereas no patients with EtCO2 of 36 or higher were in acidosis. General Universal Patient Assessment Spinal Injury Assessment IV/IO IV/IO Cardiac Monitor Blood Glucose No Glucose < 60 mg/dl Dextrose Dextrose10% 10% 100 ml boluses IVP, IO Until patient awake &/or follow up blood sugar > 60 mg/dl Glucose 60 - 240 mg/dl Glucose > 240 mg/dl signs of dehydration Normal Normal Saline Saline bolus 500 ml Bolus See: Unconscious/Unknown May be repeated x 2 with no signs of CHF, Pulmonary Edema Glucagon 1 mg IM, IN (if no IV access) If patient conscious consider Oral Glucose 15 gm PO Return to baseline? Yes Reassess glucose and monitor If Patient refuses transport See: Diabeticof Safe Discharge Safe Discharge Diabetic Patients No Repeat Dextrose may be given up to a total dose of 100 ml per bolus Offer transportation to hospital. Responsoft EMS Protocols Page 31 10/13/2020 General Non-Traumatic Shock/Dehydration Dehydration is an abnormal decrease in the total body water. It is accompanied by a disturbance in the balance of essential electrolytes. Universal Patient Assessment General Dehydration may follow prolonged fever, diarrhea, vomiting, acidosis, and any condition which there is rapid depletion of body fluids. For heart rate less than 60 and BP less than 90 mmHg systolic with patient symptomatic, follow Bradycardia Protocol ? IV/IO IV/IO Auscultate lungs frequently for rales. If rales or dyspnea increase, terminate fluid bolus. In any patient without rales or dyspnea who has a systolic BP less than 90 mmHg or less than 90 mmHg with signs of shock 0.9 NS Fluid Bolus 20 ml/kg 20 ml/kg May repeat x 2 Titrate to effect Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes Responsoft EMS Protocols Page 32 10/13/2020 Pain Control General General Universal Universal Patient Patient Assessment Assessment Information to Record 1. Time of arrival 2. Heart Rate and Blood Pressure and Respiratory Rate 3. Glasgow Coma Scale 4. Time of each dose of analgesia 5. Dosage of each administration of analgesia 6. Time and results of pain assessments 1-10 scale Assess Pain Severity: 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain. Document description of pain, examples: sharp, dull, stabbing, constant, intermittent, alleviating factors. Patient care according to Protocol based on Specific Complaint Indication for Medication IV/IO IV/IO Monitor and reassess No Indications for Use: Chest pain, especially in acute M.I., pain associated with trauma, burns, known history of kidney stones, and abdominal pain, Acute (not chronic) musculoskeletal pain, etc. Yes Fentanyl Continuous Pulse Oximetry 1 mcg/kg IVP, IO Maximum single dose 100 mcg Maximum total 200 mcg Patient may have additional Fentanyl in 100 mcg mcg/kg IN 1.5 mcg/kg doses to total additional Maximum of 200 mcg. May repeat original dose every 3 – 5 minutes Maximum 200 mcg Patient must be transported to hospital if Fentanyl administered. In case of major trauma, major thermal injuries and intubated patients, Maximum cumulative total dose of fentanyl permitted is 400 mcg. 100 mcg per bolus dose for all cases except first dose for RSI. Additional pain medication option: Ketorolac (Toradol) 15 mg IVP (or 30 mg IM) ONCE only Contraindicated if: cardiac cause of chest pain suspected, allergy to NSAID, advanced Renal disease, failure, or kidney transplant or confirmed or suspected active bleeding (trauma, GI bleeding, etc.) For severe / excruciating / painful discomfort caused from a fracture / dislocation / subluxation Consider, if Fentanyl is not sufficient or ineffective: Monitor and reassess Anticipate use for major burns and major trauma. Ketamine Responsoft EMS Protocols Page 33 0.2 mg/kg mg/kg IVP, IO Maximum 40 mg 10/13/2020 Sepsis General Are there signs and symptoms of acute infection/sepsis? Suspect sepsis if any of the following are present. Sepsis > Age 16 1. Pneumonia 2. Urinary Tract Infection 3. Abdominal pain or distension 4. Meningitis 5. Indwelling medical device or intravenous line 6. Cellulitis, septic arthritis, infected wound 7. Recent chemotherapy 8. Organ transplant (kidney, heart, lung etc) 9. Age > 65 years General Universal Universal Patient Patient Assessment Assessment Oxygen Oxygen should be administered to maintain SpO2 >94% Modified Trendelenburg Position (feet up), if tolerated. Initiate treatment for sepsis if all 3 criteria met: 1. Infection suspected 2. Two or more of the following: a. Temperature > 100.4 F (38 C) or < 96.8 F (36 C) b. Heart rate > 90 bpm c. Respiratory rate > 20 3. ETCO2 < 25 mmHg If not in Acute Pulmonary Edema/CHF Initiate 30 30 ml/kg ml/kg Normal Saline rapid IV bolus Auscultate the lungs frequently for rales. If rales appear or dyspnea increases at any time, terminate the fluid bolus. Request receiving facility initiate a “Sepsis Alert” as part of radio report. If the systolic blood pressure remains < 90 mmHg after Normal Saline bolus Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes Responsoft EMS Protocols Page 34 10/13/2020 General Fainting, "blacking out," or syncope is the temporary or transient loss of consciousness followed by the return to full recovery, but may encounter a short period of confusion. This loss of consciousness is accompanied by loss of muscle tone that can result in falling or slumping over. Unconscious/Unknown Universal Patient Patient Assessment Assessment Universal Spinal Injury Assessment (If necessary) General Possible causes of syncope include: Hypoglycemia, Toxicity (alcohol, drugs, medications) CVA, underlying cardiac dysrhythmias, history of head trauma and seizure. IV/IO IV/IO Cardiac Monitor Blood Glucose Glucose 60 - 240 mg/dl Consider Naloxone if signs and symptoms of opiate overdose (decreased/absent respirations, pinpoint pupils) Glucose < 60 mg/dl See: Hyperglycemia/Hypoglycemia Naloxone (Narcan) 0.4 - 2 mg IVP, IO, IN May repeat every 5 minutes as needed Administer in lowest dose as needed to maintain adequate respirations Consider other causes: Head injury, Overdose Stroke, Hypoxia Responsoft EMS Protocols Page 35 10/13/2020 General Universal Patient Assessment General The Universal Patient Care Protocol should be used as primary guide to all patient assessment. Scene Safety & BSI (body substance isolation) Adult Adult Primary Primary Assessment Assessment Patient Assessment-Medical Patient Assessment-Trauma Documentation of Vitals Signs per guideline (Temperature if appropriate) Adult Airway Airway Protocol Adult Consider Pulse Oximetry & Capnography Consider: Carbon Monoxide Poisoning Nausea & Vomiting Nausea & Vomiting Ondansetron (Zofran) Ondansetron (Zofran) 4 mg IVP, IO 8 mg PO (2 Tablets) Pain PainControl Control Protocol Cardiac Monitor / 12 Lead ECG Transmit 12 Lead ECG If monitor capable of transmitting EKG, transmit all EKGs to receiving hospital. Repeat 12 Lead ECG for any significant change in cardiac rhythm (SVT, VF, VT) Appropriate Protocol Responsoft EMS Protocols Page 36 10/13/2020 Neurological Responsoft EMS Protocols Neurological Page 37 Neurological 10/13/2020 Neurological CVA/Unconscious Neurological Stroke can present with dysrhythmias, aphasia, vertigo, dizziness, headaches, weakness, paralysis, Head trauma, and tumors. There are 3 types of CVA, (Hemorrhagic, thrombosis, and embolus) Assess for time of onset and progression of symptoms. Hypertension can also be present with CVA. Universal Patient Assessment Spinal Injury Assessment (If necessary) Cardiac Monitor IV/IO IV/IO Blood Glucose Examine patient closely for signs of trauma In patients with decreased level of consciousness of unknown etiology Glucose < 60 mg/dl Glucose > 60 mg/dl Naloxone 0.4 - 2 mg IVP, IO, IN May repeat 5 to 10 minutes if partial response is noted Dextrose 10% 100 ml boluses until patient awake &/or follow up blood sugar > 60 mg/dl if unable to obtain IV Glucagon Prehospital Stroke Screen Obtain medical history and medications if possible. Any use of anti-coagulants is important. Hyperventilate patient to achieve an end-tidal CO2 reading of 35 mmHg if vital signs are deteriorating or if there are signs of impending herniation as evidenced by unilateral dilated pupil, sudden change in level of consciousness, decorticate or decerebrate posturing LAMS Score ALL patients with positive stroke screen, should be transported emergently. Attempt to bring primary historian to hospital with patient. Consider other protocols as indicated 1 mg IM, IN Important Points to Consider 1. When was patient last normal? This may take some detective work when talking with family or witnesses. 2. Is the patient on anticoagulants? 3. If intubation is required, hyperventilate as necessary to attain end-tidal CO2 of 35 mmHg. Avoid going below 35. 4. Patients with LAMS of 1-3 should go to closest stroke center. LAMS of 4-5 should go to closest interventional stroke center. Seizure Go to: CVA/Unconscious-continued Responsoft EMS Protocols Page 38 10/13/2020 Neurological CVA/Unconscious-continued Neurological Stroke Screen Evaluate the patient using the Los Angles Motor Scale (LAMS) EMS stroke triage tool below: History Last time patient without neurological symptoms Date: Time: LA Motor Scale Facial Droop Absent = 0 Present = 1 Arm Drift Absent = 0 Drift = 1 Falls Rapidly = 2 Grip Strength Absent = 0 Weak = 1 No Grip = 2 Total Yes No Stroke Scale Deficits? Age > 18 years of age? Symptom duration 5 hours? Blood Glucose 60 - 400 mg/dl? Head Trauma Ruled Out? If “yes” to all five questions above, then pre-hospital screening criteria is met. Declare “Stroke Alert” and follow appropriate treatment and transportation steps. Patients with LAMS Scores of 1 - 3 points should be transported to the closest hospital as listed below: •Grant Medical Center •OSU East Hospital •Mt. Carmel East Hospital •OSU Wexner Medical Center •Mt. Carmel West Hospital •Riverside Methodist Hospital •Mt. Carmel St. Ann’s Hospital Patients with LAMS of 4 - 5 points should be transported to the closest Comprehensive Stroke Center unless bypassing a primary stroke center results in an incremental increase in transportation time greater than 15 minutes. Comprehensive stroke centers are: •Mt. Carmel East Hospital •OSU Wexner Medical Center •Riverside Methodist Hospital Responsoft EMS Protocols Page 39 10/13/2020 Seizure Neurological Some causes of seizures are: Head injury, overdose, stroke, hypoxia, infection, hypoglycemia, hyperglycemia, brain tumor, eclampsia, alcohol. Neurological Universal Patient Assessment Spinal Injury Assessment If patient is having active seizure on EMS arrival Midazolam (Versed) (Versed) Midazolam MAD (Preferred) IN dose see: MAD Transport all patients experiencing first time seizure activity. Transport patients with known seizure disorders if seizure different than normal or continues longer than 3 - 5 minutes. Cardiac Monitor Place in Rescue position (patient’s side) 10 mg IN (5 mg per nostril) Blood Glucose Glucose < 60 mg/dl Dextrose 10% 100 ml boluses until patient awake &/or follow up blood sugar > 60 mg/dl if unable to obtain IV Glucagon 1 mg IM, IN Status epilepticus Postictal Any patient with seizure activity upon arrival of EMS should be intubated if appropriate Adult AdultAirway Airway Protocol Focused history / Physical exam IV/IO IV/IO IV/IO Blood Glucose > 60 mg/dl Status / Seizure recurs? Status / Seizure recurs? Midazolam (Versed) Midazolam (Versed) (Preferred) IN dose see: MAD (Preferred) IN dose see: MAD 10 mg IN (5 mg per nostril) 10 mg IN (5 mg per nostril) 5 mg IVP, IO 2 mg IVP, IO May repeat IVP, IO every 5 minutes x 2 May repeat IVP, IO every 5 minutes x 2 IN is preferred unless IV/IO access has already been obtained. If IV/IO in place then preferred route is IV/IO. IN is preferred unless IV/IO access has already been obtained. If IV/IO in place then preferred route is IV/IO. Responsoft EMS Protocols Page 40 10/13/2020 OB/GYN Responsoft EMS Protocols OB/GYN Page 41 OB/GYN 10/13/2020 Abnormal Deliveries OB/GYN Universal Patient Assessment Oxygen 10 - 15 LPM NRB Mask Childbirth Procedure OB/GYN Prolapsed Cord: An umbilical cord that comes out of the uterus ahead of the fetus. Breech Delivery: A delivery presenting the feet or the buttocks. Multiple Births: More than one fetus. Meconium Delivery: The first fetal stools in the amniotic fluid. Prolapsed Cord Breech Delivery Meconium Delivery Call for ALS upon recognition. Place mother in head down position with hips elevated Position mother with head down and buttocks elevated. Immediate and rapid transport, notify receiving facility ASAP Insert one gloved hand into the vagina, following the cord as far as possible and gently push baby’s presenting part off of the cord. Make sure to explain this procedure to patient. IV/IO IV/IO If delivery progressing, support legs and buttocks, then assist with delivery of the head If head does not deliver in 4-6 minutes, insert gloved hand into vagina and create an airway for the infant Transport while maintaining this position. Call for ALS upon recognition Do not stimulate before suctioning mouth. Suction mouth then nose with bulb syringe. Maintain airway, Transport as soon as possible. IV/IO Multiple Births: Make sure you have adequate manpower available. Be prepared for more than one (1) resuscitation. Consideration of one (1) ALS unit per infant. Follow appropriate delivery algorithm, based upon scenario. Responsoft EMS Protocols **Amniotic fluid any color other than clear may indicate fetal distress** Page 42 Signs/Notes: Thick = pea soup Common in late birth deliveries More common in low birth weight deliveries 10/13/2020 Childbirth/Labor OB/GYN Three stages of labor: First Stage: Onset of contractions with progressive changes in cervix. Second Stage: Labor begins and fully dilated. Ends with birth. Third Stage: Separation and delivery of placenta. Obstetrical EmergenciesVaginal Bleeding Universal Patient Assessment Have mother lie in preferred birthing position. Yes OB/GYN How far along in the pregnancy is the patient? Time contractions. Was there prenatal care? Has the patient’s water broken? Is there any blood? Has crowning began yet? Is there any other presentation of the fetus? Note: Up to 500 ml blood loss during delivery is normal and well tolerated by the mother. Abnormal vaginal bleeding? No Yes Inspect perineum (No digital vaginal exam) No crowning Crowning Priority symptoms Crowning, patient needs to push. See Abnormal Deliveries Monitor and reassess Document frequency and duration of contractions IV/IO IV/IO Rapid Transport Childbirth Childbirth Procedure Vaginal Bleeding after Delivery Oxygen should be administered to maintain SpO2 >94% If brisk bleeding continues, massage “knead” the uterus over the lower abdomen above the pubis with firm pressure. PREGNANT PEDIATRIC PATIENTS All pediatric patients that are obviously pregnant, or, who have verified their pregnancy will be transported to the nearest hospital with an Obstetrical Unit. If traumatic injuries are involved, then transport to a Trauma Center is indicated. SM Nationwide Children’s Hospital is not equipped to deliver babies. Responsoft EMS Protocols Page 43 If bleeding continues, evaluate massage technique, position for shock. Cardiac Monitor if hemodynamically unstable 10/13/2020 OB/GYN Obstetric Emergencies-Eclampsia Eclampsia: New onset of grand Mal seizure or unexplained coma during pregnancy. Universal Patient Assessment IV/IO IV/IO Cardiac Monitor Vaginal bleeding / Abdominal pain? Seizure (Eclampsia/Toxemia) Assessment and history of pregnancy OB/GYN ECLAMPSIA/TOXEMIA Definition: Toxemia: is the presence of any combination of the following after the 20th week of pregnancy. Can occur for up to 2 weeks post delivery. A. Total body edema B. Hypertension: BP systolic > 140 mmHg, BP diastolic > 90 mmHg or a change in the diastolic pressure > 15 mmHg from antenatal pressure. C. Seizures after the 6th month of pregnancy Eclampsia: is the presence of toxemia plus seizures. Protect patient from seizure activity Suction secretions as needed, transport in left lateral decubitus position Adult Airway Protocol Midazolam (Versed) Versed 2 mg IVP, IO 5 mg IN This dose may be repeated in 5 minutes, if hypotension does not occur and Magnesium Sulfate Sulfate Magnesium 4 gm in 100 ml IV Infusion 0.9% NS, Infuse over 20 - 30 minutes (200 ml/hr) If unable to obtain IV or IO access in a patient with eclampsia you may give Magnesium 10 g IM in two divided 5 g injections with a 3” 20 gauge needle in each buttock. This should only be done if no other access available Stop infusion if hypotension develops, difficulty breathing, decreased deep tendon reflexes or paralysis. Responsoft EMS Protocols Page 44 10/13/2020 OB/GYN Obstetric Emergencies-Vaginal Bleeding Pregnancy complications can occur for several reasons, including; trauma, and preexisting health problems, ex. diabetes, hypertension, and heart disease to name a few. Universal Patient Assessment IV/IO IV/IO Large bore IV Titrate to keep BP > 90 systolic Cardiac Monitor if hemodynamically unstable Oxygen 10 - 15 LPM via NRB Mask Obtain history of pregnancy and estimate amount of bleeding Consider performing orthostatic vital signs Miscarriage < 20 weeks OB/GYN Vaginal Bleeding during Pregnancy: < 20 Weeks (Miscarriage) Miscarriage – Termination of pregnancy before fetus is viable. > 20 Weeks (abruption or Placenta Previa) AbruptionPremature separation of the placenta from the wall of the uterus Placenta Previa- Attachment of the placenta very low in the uterus that completely or part covers the internal cervical opening. Abruption or Placenta Previa > 20 weeks Control bleeding Do not insert packing into vagina Apply external vaginal pads Elevate hips of patient Bring any fetal tissues to hospital. Do not remove anything from the vaginal area. Transport immediately to OB hospital Transport to appropriate facility, on left side. Consider second IV enroute if patient unstable Responsoft EMS Protocols Page 45 10/13/2020 Sexual Assault OB/GYN Sexual assault is sexual contact without the consent of the person assaulted. Unless victim has life threatening injuries, verbally obtain permission to treat before you begin. ALL alleged or suspected sexual assaults must be reported to police. OB/GYN The victim of a sexual assault may display many different emotions. Approach the victim calmly. Universal Patient Assessment ABC’s, assess and treat injuries as usual Protect crime scene. Remove only clothing necessary to assess and treat injuries; then give to law enforcement. Examine genitalia only if profusely bleeding Discourage patient from bathing, douching, changing clothes, voiding, combing hair or cleaning nails. Clean only wounds that are necessary. Transport to a hospital designated as a Rape Crisis Center if possible. Responsoft EMS Protocols Page 46 10/13/2020 Respiratory Responsoft EMS Protocols Respiratory Page 47 Respiratory 10/13/2020 Adult Airway Respiratory Important skills to master for the adult airway are: ■ Best method for airway management ■ Managing the airway relevant to patients condition ■ Rapid assessment for intubation ■ Realizing when planned interventions have failed and the need for an alternative technique is required Assess ABC’s, respiratory rate, effort, adequacy Respiratory Breath Sounds: Listen for absent, diminished, unequal, wheezing, Rhonchi, Crackles, Stridor. Inadequate Adequate Pulse Oximetry & Capnography Pulse Oximetry Oxygen If necessary Suction Supplemental Oxygen Oxygen Basic airway maneuvers: Manual, nasal or oral airway. Consider Spinal Injury Assessment if necessary. Ventilate with bag mask device Pulseless & Apneic Objective criteria for evaluation of the Respiratory Distress patient includes: • Accessory muscle use / retractions • O2 saturation < 94% • Respiratory rate > 24 • Unable to speak full sentences • Abdominal / paradoxic breathing • Altered mentation (GCS 11-14) Obstruction Foreign Body Airway Obstruction Intubation-Oral Apneic Direct laryngoscopy and remove using Magill forceps if possible. Intubation-Oral Establish airway and re attempt to ventilate. Cricothyrotomy-Surgical Responsoft EMS Protocols Page 48 10/13/2020 Respiratory Difficult Airway Respiratory Unsuccessful attempt at intubation by most experienced person on scene --> Spo2 >94% with BVM & 100% O2 --> YES Continue BVM, consider placement of supraglottic airway NO Able to ventilate and oxygenate with BVM ---> yes---> continue BVM NO If unable to oxygenate or ventilate with other means proceed to Cricothyrotomy-Surgical Responsoft EMS Protocols Page 49 10/13/2020 Respiratory Allergic Reaction/Anaphylactic Shock Allergic reaction: Exposure to allergen and signs and symptoms of any of the following – respiratory difficulty, wheezing/stridor, tightness in chest or throat, nausea, vomiting, flushing, hives, itching swelling of face/ lips/tongue Anaphylaxis = serious, rapid onset (minutes-hours) reaction to suspected trigger AND two or more body systems involved (eg skin/mucosa, cardiovascular, respiratory, GI) OR hemodynamic instability OR respiratory compromise Universal Patient Assessment IV/IO IV/IO Respiratory An allergic reaction may include one or several symptoms. Most allergic reactions occur within minutes of the exposure, but some reactions may occur several hours later. Cardiac Monitor Albuterol / Ipratropium (Atrovent) 2.5 mg & 0.5 mg / 5.5 ml saline Nebulized If evidence of bronchospasm, the aerosol should be discontinued if significant PVC’s appear. Diphenhydramine 50 mg IVP, IO, IM, PO Over 1 – 2 minutes, watch for hypotension Dexamethasone 10 mg IVP, IO, PO (for moderate Dexamethasone The aerosol should be discontinued if significant PVC’s appear. to severe distress) If signs of anaphylaxis (2 or more body systems OR hemodynamic instability OR significant respiratory distress) immediately give Epinephrine IM Epinephrine should be the initial treatment in patients exhibiting signs of anaphylaxis Epinephrine 1:1,000 0.3 - 0.5 mg IM May repeat every 20 minutes If wheezing Shock or Circulatory Collapse NS Fluid Bolus If none of the above are present, then treat symptomatically. In asymptomatic patients with known history of anaphylactic reaction (as opposed to local reaction), administer Epinephrine 1:1,000 1:1,000 0.3 ml IM Epinephrine ml/kg to maintain 20 ml/kg BP > 90 mmHg systolic Place patient in shock position, if tolerated. Epinephrine Epinephrine1:10,000 1:10,000 0.5 mg (5 ml) IVP, IO Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes Responsoft EMS Protocols Page 50 Extrapyramidal Symptoms (EPS) is not an allergic reaction, but Benadryl can also be used for EPS. Common symptoms: Pseudoparkinsonism-tremor, masklike facies, drooling, rigidity Akathisia-motor restlessness, aniexty to inability to lie or sit quietly Dystonias- involuntary, irregular, clonic contortions of the muscles of the trunk and limbs Tardive-Having symptoms that develop slowly or that appear long after inception. Dyskinesia- impairment in the ability to control movements, characterized by spasmodic or repetitive motions or lack of coordination. 10/13/2020 Respiratory Esophageal Foreign Body A foreign body in the esophagus is most likely the result of a food bolus impaction. Although most foreign bodies pass readily, occasionally they are the result of some underlying medical condition. Esophageal foreign bodies can occur more frequently in mentally impaired individuals or the elderly. Signs of a esophageal foreign body may include the following: 1. Dysphagia (difficulty swallowing) 2. Pain or tenderness in the neck 3. Inability to swallow oral secretions (indication total obstruction) 4. Other symptoms such as retro-sternal fullness, regurgitation of undigested food, and painful swallowing Respiratory Universal Patient Assessment Adult AdultAirway Airway Protocol Establish patient airway. Administer Oxygen therapy as needed Intubate if necessary. IV/IO Glucagon 1 mg IVP for relaxation of esophageal smooth muscle, which may promote passage of the foreign body Ondansetron (Zofran) 4 mg IVP, IO For nausea or vomiting as warranted Patients with suspected esophageal foreign body should be transported to the closest Emergency Department. Responsoft EMS Protocols Page 51 10/13/2020 Hyperventilation Respiratory When a patient is hyperventilating, the patient is breathing rapidly, which results in exce