2019 Collaborative Protocol Update Summary - EMS Council Collaborative... · Overview •...

CollaborativeProtocol2019ProtocolUpdateSummary

Thisisasummaryofchanges,pleaserevieweachprotocolinitsentiretyandcompletealladditionaltrainingassignedbyyourregionDRAFT7/30/19AdditionalComparisonaddedagainstPDFof2017protocolsUpdated9/11/19

Introduction

• UpdatedtobeconsistentwithBLSProtocols• Bulletsareused,manyprocessesarenotsequentialandshouldbeperformedasmostappropriateforpatientcare• Regionalprotocolsandpoliciesmayaccompanytheseprotocols

• “Ifequippedandtrained”meansthatyouhavebeenregionallyapprovedandtrainedforsaidintervention(reminder)

• BLSinterventionsshouldbecompletedbeforeALSinterventions(reminder)

2

Overview

• ComparisondoneagainstProtocolApp– CategoriesnotincludedonApp

• CFRandallproviderlevelsadded- anytreatmentswithintheCFRscopeofpracticeweremovedtothisnewlevelfromEMTthroughouttheprotocols.

• AEMTtreatmentswithintheirscopeofpracticeadded• Orderandreferencenumberschangedthroughout

– Ainfrontoftheprotocol#indicatesAdult– Pinfrontoftheprotocol#indicatesPediatric– NoAorPinfrontoftheprotocol#indicatesthatitappliestoadultandpediatric

• Recommendhavingacopyofprotocolstoreviewwhilegoingthroughslides

*Appupdatewillbeforthcoming3

Overview

• NolongerneedtodiluteAmiodaronewhengivingasabolusincardiacarrest• NewMedications(RegionalOptions)

– Acetaminophen– Ibuprofen

• IN– Changedtointranasalinmultipleprotocols• Pediatricdefinitionchanged• AEMTleveltreatmentsaddedwithintheirscopeofpractice• Multiplenewprotocols,manyasaresultofstrivingforconsistencybetweenALSandBLSprotocols

4

NewProtocols

P2.1.0CardiacArrest:GeneralApproach- PediatricA2.2ForeignBodyObstructedAirway– AdultP2.2ForeignBodyObstructedAirway– PediatricA2.4RespiratoryArrest/Failure- AdultP2.4RespiratoryArrest/Failure- PediatricP3.1ALTE/BRUE– PediatricAppliestopediatricpatientsunder2yearsofage3.2AlteredMentalStatusP3.4.1BehavioralEmergencies- AgitatedPatientPediatric

5

NewProtocols

• P3.7CardiacRelatedProblem-Pediatric• A3.10.0DifBreathing:Asthma/COPD/Wheezing-Adult(CombinedacuteAsthmaandCOPD)• 3.12Fever-Adult• P3.12Fever-Pediatric• P3.29TechnologyAssistedChildren• 3.30TotalArtificialHeart• 4.10SuspectedSpinalInjuries

6

Index

• TableofcontentschangedtoIndex• Indexupdatedtoincorporatechangedornewresourcesandprotocolsthatareneworcombined

7

Acknowledgements

• Changesinpapercopy,notinapp• AddedacknowledgementforStateEmergencyMedicalServices,StateEmergencymedicalservicesforchildrenandtheBLSprotocolsadvisoryandwritinggroup• Removededitingacknowlegements

8

Introduction

• Changesinpapercopythisisnotinapp– ChangedtointroductionfromRegionalMedicalDirectorstojustintroduction

• Added– TheseprotocolshavebeenupdatedtobeconsistentwiththeStatewideBLSProtocols.Advancedprovidersarealsoresponsiblefor,andmayimplement,thestandingordersindicatedforBLScare.ProtocolsarelistedforeachproviderlevelandSTOPlinesindicatetheendofstandingorders.

– TheseprotocolsdonotsupplantregionallyrequiredequipmentspecificationsortheitemsrequiredunderPublicHealthLawandRegulations.,

– Theseprotocolsshouldnotserveasademonstrationofrequiredequipmentortraining,asregionalandagencyvariationswillexist 9

Introductioncontinued

• Added– Eachlevelnowindicatesstandingorderforthatlevelandthewordingthatthesearealsostandingordersforalllevelsofcredentialedabovethatlevel

– Regionswilldeterminetherequisitetrainingthatprovidersmustreviewpriortoutilizingtheseprotocols

– Definitionfor“ifequippedandtrained”

• Deleted– Thereisatrainingmoduleavailablethatmustbereviewedbyveryadvancedproviderpriortoutilizingtheseprotocols

10

Introductioncontinued

• MovedfromKeypointsconsiderationstotop– BLSinterventionsshouldbecompletedbeforeALSinterventions.Bulletsareusedthroughoutthisdocument.Manyprocessesarenotsequentialandtasksshouldbeperformedasmostappropriateforpatientcare.Regionalprotocolsandpoliciesmayaccompanytheseprotocols.

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PediatricDefinitionandDiscussion

• GeneralGuideline– UseGOODclinicaljudgement– Pediatricprotocolsshouldbeconsideredforpatientwhohavenotyetreachedtheir15th birthday

– PreviousprotocolsfollowedAHAguidanceonsignsofpubertytodifferentiateadult/pediatric

– UtilizeMedicalControlifunsure

• Weightbaseddosingformedication– Per-kilogrambasis– Adultdoseasthepediatricmaximumdose– Stronglyrecommendedtouselengthbasedresuscitationtapesorsimilar• Idealweightshouldbeusedincasesofobesity(reminder)

12

Background

• PreviouslyMedicalControlAgreementinpapercopynotinapp

• TheseprotocolsareintendedtoguideanddirectpatientcarebyEMS.Theyreflectthecurrentevidence-basedpracticeandconsensusofcontentexperts.Theseprotocolsarenotintendedtobeabsolutetreatmentdocuments,rather,asprinciplesanddirectiveswhicharesufficientlyflexibletoaccommodatethecomplexityofpatientmanagement.Noprotocolcanbewrittentocovereverysituationthataprovidermayencounter,norareprotocolsasubstituteforgoodjudgmentandexperience.Providersareexpectedtoutilizetheirbestclinicaljudgmentanddelivercareandproceduresaccordingtowhatisreasonableandprudentforspecificsituations.However,itwillbeexpectedthatanydeviationsfromprotocolshallbedocumentedandreviewed,accordingtoregionalprocedure.

• THESEPROTOCOLSARENOTASUBSTITUTEFORGOODCLINICALJUDGEMENT 13

PatientCareResponsibility

• Movedtoaresourcefrombeginningofpapercopy

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GeneralApproachtotheEMSCall(New)

• Appliestoadultandpediatricpatients• Providesstandardframeworkforapproachingthescene• UsegoodclinicaljudgementandBESAFE!• MirrorsBLSProtocol

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GeneralApproachtothePatient(New)

• Appliestoadultandpediatricpatients• Providesstandardframeworkforapproachingthepatient• UsegoodclinicaljudgementandBESAFE!• MirrorsBLSProtocol

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GeneralApproachtoSafetyRestrainingDevices(New)

• Appliestoadultandpediatricpatients

• Providesstandardframeworkforpatienttransport

• Nolongerpermissibletohaveparentorcaregiverholdachild

• Patientsshouldbesecuredonstretcherandharnessstrapsused

• Childsownsafetyseatcanbeusedwhenavailableandintact– Ifambulancenotequippedwithone,recommendedtopurchaseapprovedchildsafetyseatorrestraint

• Routinelytrainonchildrensafetyseats/restraints– Useinaccordancewithmanufacturersrecommendations

• MirrorsBLSProtocol

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GeneralApproachtoTransportation(New)

• Appliestoadultandpediatricpatients

• Providesstandardframeworkforpatienttransport

• Scenesafetyongoingcontinualsituationalawareness

• ConsiderationforALSinterceptandAirMedicalshouldbedonebasedonpatientneedsandregionalcapabilities

• Transporttotheclosestappropriatereceivinghospitaleventhoseinextremis– Maynotbetheclosestgeographically

• Ensureongoingpatientassessment

• Carefullyconsideruseoflightsandsirens- RiskversusBenefit

• Providepre-arrivalreport

• MirrorsBLSprotocol

• UtilizeMedicalControlifneeded18

A2.1.0CardiacArrest:GeneralApproach(Adult)

• CriteriaRemoved• MovedtoKeyPoints/Considerations- ArtifactfromvibrationsinamovingambulancemaycompromisetheeffectivenessoftheAED• Compressionsinmovingambulancesposeasignificantdangertoproviders,arelesseffective,andshouldbeavoided• MovedtoKeyPoints/Considerations- ConsidermechanicalCPRadjunctswhenavailableforprovidersafetyinmovingambulances(e.g.AutoPulse®,LUCAS®,LifeStat®,Thumper®,orotherFDAapproveddevice)Airwayadjunctschangedtonaso-and/ororopharyngealairway 19

P2.1.0CardiacArrest:GeneralApproach(Pediatric)

• New• OutlinesthecurrentguidelinesforpediatricCPR• IntubationisnotnecessaryifoxygenatingandventilatingpatientwellwithBLSairwaymanagement

20

A2.1.1AsystoleorPulselessElectricalActivity(PEA)– AdultP2.1.1AsystoleorPulselessElectricalActivity(PEA)- Pediatric

• RemovedAirwaymanagementandappropriateoxygentherapyviaBVMasitisincludedingeneralcardiacarrestcareinboththeadultandpediatricprotocol

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A2.1.2VentricularFibrillationorPulselessVentricularTachycardia- Adult

• Amiodarone300mgIV(dilutein20mLofnormalsaline).– Removeddilutein20mLofnormalsaline

• Removedundermedicalcontrolconsiderations- Ifequipmentisavailabletodoso,considerdoublesequentialdefibrillationifventricularfibrillationpersistsaftercompletionof5shocks

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P2.1.2VentricularFibrillationorPulselessVTachycardia- Pediatric

• RemovedasitispartofGeneralCardiacArrestCare– AEDdefibrillation,asindicated(CC/Paramedicmaysubstitutemanualdefibrillationasindicatedbelow)

– AirwaymanagementandappropriateoxygentherapyviaBVM

• Advanced– Defibrillateasappropriateadded

• Paramedic– Diluteamiodaronein20mLofnormalsalineremoved

• KeyPoints/Considerations– IntubationisnotnecessaryifoxygenatingandventilatingpatientwellwithBLSairwaymanagementadded

– TheuseofaparticularmechanicalCPRdevicemaybecontraindicatedinthepediatricpatient;refertomanufacturer’srecommendation–Removedasallequipmentshouldbeutilizedpermanufacturersguidelines(Removed)

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A2.2ForeignBodyObstructedAirway- AdultP2.2ForeignBodyObstructedAirway- Pediatric

• NewProtocolforpatientswithcompleteorpartialairwayobstruction• SeparateprotocolsforAdultandPediatric• FollowscurrentFBAOguidelines

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2.3ObviousDeath(AdultorPediatric)

• Namechangedfrom“DeterminationofObviousDeath”

• RemovedandincludedinAdvanceDirectivesProtocolunderResources– CopiesoftheMOLSTformshouldbehonored– AcopyoftheDNR,MOLST,oreMOLSTformshouldbeattachedtothePCRandretainedbytheagencywheneverpractical

– IfapatientwithaDNR(stand-aloneDNRform,orasdirectedbyaMOLSToreMOLSTform)isaresidentofanursinghomeandexpiresduringtransport,contactthereceivingstafftodetermineiftheyarewillingtoacceptthepatientbacktothatfacility.Ifnot,returnthepatienttothesendingfacility.AcopyoftheDNR,MOLST,oreMOLSTmustbeattachedtothePCRandretainedbytheagencyforalltransportsfromasendingfacilitytoanursinghome

– TheeMOLSTformmaybeprintedandaffixedwithelectronicsignatures.ElectronicsignaturesontheeMOLSTformareconsideredvalidsignatures

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A2.4RespiratoryArrest/Failure- Adult(NEW)

• MirrorsBLSprotocol– Opentheairwayusingthehead-tilt/chin-liftormodifiedjaw-thrustmaneuver

– Removeanyvisibleairwayobstructionbyhand– Cleartheairwayofanyaccumulatedsecretionsorfluidsbysuctioning– Providepositivepressureventilationusingabag-valvemask

• Ifventilationsarenotsuccessful,referimmediatelytothe“Extremis:ForeignBodyObstructedAirway”protocol

– Level-appropriateairwaymanagementwithuseofairwayadjunctsandbag-valvemaskdevice,asindicated,includingsuctionasneeded,ifavailable• Bag-valvemaskshouldbeconnectedtosupplementaloxygen,ifavailable

– Ventilateevery5-6seconds(adultpatient)– Eachbreathisgivenover1secondandshouldcausevisiblechestrise

• AdditionalKeyPoints/Considerations26

P2.4RespiratoryArrest/Failure- Pediatric(NEW)

•MirrorsBLSprotocol– Opentheairwayusingthehead-tilt/chin-liftormodifiedjaw-thrustmaneuver– Removeanyvisibleairwayobstructionbyhand– Cleartheairwayofanyaccumulatedsecretionsorfluidsbysuctioning– Providepositivepressureventilationusingabag-valvemask

• Ifventilationsarenotsuccessful,referimmediatelytothe“Extremis:ForeignBodyObstructedAirway– Pediatric”protocol

– Level-appropriateairwaymanagementwithuseofairwayadjunctsandbagmaskdevice,asindicated,includingsuctionasneeded,ifavailable• Bag-valvemaskshouldbeconnectedtosupplementaloxygen,ifavailable

– Ventilateevery3-5seconds– Eachbreathisgivenover1secondandshouldcausevisiblechestrise– Attachpulseoximeterifavailableandhaveagoalofoxygensaturation≥94%

• Seealso,“Resources:OxygenAdministrationandAirwayManagement”protocol

• AdditionalKeyPoints/Considerations27

A2.5ReturnofSpontaneousCirculation(ROSC)

• AddedunderAdvancedLevel– Ifneeded,administernormalsalinetoatotalof2LtomaintainMAP>65mmHgorSBP>100mmHg,providedthereisnoconcernofpulmonaryedema

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2.6TerminationofResuscitation

• AddedunderKeyPoints/Considerations– ConsidertheEtCO2whendiscussingterminationwithmedicalcontrol

– Wheneverpossible,terminationofresuscitationshouldbedonewhenthepatientisnotinapublicplace

• Removedpointsonadvanceddirectives– seeresource“AdvancedDirectives”

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P3.1ALTE/BRUE– Pediatric(New)Appliestopediatricpatientsunder2yearsofage

• NewProtocol- MirrorsBLSProtocol– ApparentLife-ThreateningEvent(ALTE)/BriefResolvedUnexplainedEvents(BRUE)

– ALTE/BRUEisanepisodeinaninfantorchildlessthan2yearsoldwhichisfrighteningto

– theobserver,hasnowresolvedandischaracterizedbyoneormoreofthefollowing:• Apnea(centralorobstructive)• Skincolorchange:cyanosis,erythema(redness),pallor,plethora(fluidoverload)

• Markedchangeinmuscletone• Chokingorgaggingnotassociatedwithfeedingorawitnessedforeignbodyaspiration

• Seizure-likeactivity

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P3.1ALTE/BRUE– Pediatric(continued)Appliestopediatricpatientsunder2yearsofage

• AlllevelsofCare– Airwaymanagementandappropriateoxygentherapy– Checkpupilsand,ifconstricted,consider“General:Opioid(Narcotic)Overdose”protocol

– Checkbloodglucoselevel,ifequipped• Referto“General:AlteredMentalStatus”protocol,ifnecessary

– Ongoingassessmentoftheeffectivenessofbreathing• Referto“Extremis:RespiratoryArrest/Failure- Pediatric”protocol,ifnecessary

• KeyPoints/Considerations– NOTE:Mostpatientswillappearstableandexhibitanormalphysicalexam.However,thisepisodemaybeasignofunderlyingseriousillnessorinjuryandfurtherevaluationbymedicalstaffisstronglyrecommended.See“Resources:RefusalofMedicalAttention”protocolifthecaregiverwishestorefusetransportation.

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3.2AlteredMentalStatus- New

• MirrorsBLSProtocol– Fortheundifferentiatedpatientwithalteredmentalstatus• Including,butnotlimitedto,BLSmanagementofhypoglycemia

– Seealsothefollowingcollaborativeprotocols,asindicated:• General:ALTE/BRUE– Pediatric• General:BehavioralEmergencies:AgitatedPatient• General:BehavioralEmergencies:ExcitedDelirium• General:Hypoglycemia– Adult• General:Hypoglycemia– Pediatric• General:Opioid(Narcotic)Overdose• General:Poisoning/Overdose:Undifferentiated– Adult• General:Poisoning/Overdose:Undifferentiated– Pediatric 32

3.2AlteredMentalStatus– New(continued)

• Alllevels– Airwaymanagementandappropriateoxygentherapy– Checkpupilsand,ifconstricted,consider“General:Opioid(Narcotic)Overdose”protocol

– Checkbloodglucoselevel,ifequippedandsafetodoso• Ifbloodglucoseisknownorsuspectedtobebelow60mg/dLandpatientcanself-administerandswallowoncommand:– Giveoneunitdose(15-24grams)oforalglucose,oranotheravailablecarbohydratesource(suchasfruitjuiceornon-dietsoda)

• Ifthepatientisunabletoswallowoncommand,ormentalstatusremainsalteredfollowingadministrationoforalglucose:– Donotdelaytransport

– Ongoingassessmentoftheeffectivenessofbreathing• Referto“Extremis:RespiratoryArrest/Failure”or“Extremis:PediatricRespiratoryArrest/Failure,”protocol,ifnecessary 33

3.2AlteredMentalStatus– New(continued)

• Advanced,CC,Paramedic– Seeetiology-specificprotocolscrossreferencedinthe“CRITERIA”sectionabove

• KeyPoints/Considerations– Assessthesceneforsafetyand,ifitisnot,retreattoasafelocationandobtainpoliceassistance

– Considerclosedheadinjuryandnon-accidentaltrauma,especiallyinchildren

– Considerdrugingestion,meningitis/encephalitis

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2-3AdvancedDirectives- New

• EducationalinformationaddedregardingMOLST,eMOLST,DNRforms• Remindertolookforapproveddocument,braceletornecklace• IfpresentedwithHealthCareProxyorLivingwill,orin-hospitalDNRcontactmedicalcontrolifyouneeddirection• FormsshouldbeattachedtoPCR

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A3.3Anaphylaxis- Adult

• PreviouslyAllergicReactionandAnaphylaxis• AddedCriteria

– Anaphylaxisisarapidlyprogressing,lifethreateningallergicreaction;notsimplyarashorhives(previouslythiswasinKeyPoints/Considerations

• GeneralInformationaddedforalllevels– Allowthepatienttomaintainpositionofcomfort– Ongoingassessmentoftheeffectivenessofbreathing

• Refertothe“Extremis:RespiratoryArrest/Failure– Adult”protocol,ifnecessary

– Airwaymanagementandappropriateoxygentherapy

36

A3.3Anaphylaxis– Adult(continued)

– IfSEVERErespiratorydistress,facialororaledema,and/orhypoperfusion:• Administertheepinephrineautoinjector(e.g.EpiPen®),asavailableandastrained– Adultautoinjector0.3mgIM(e.g.EpiPen®)if≥30kg*

– Ifpatienthasahistoryofanaphylaxisandhasanexposuretoanallergendevelopingrespiratorydistressand/orhypoperfusionand/orrash:(nochange)• Administertheepinephrineautoinjector(e.g.EpiPen®),asavailableandastrained– Adultautoinjector0.3mgIM(e.g.EpiPen®)if≥30kg*

– Ifthepatientdoesnotimprovewithin5minutes,youmayrepeatepinephrineonce

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• EMTLevel– Added

• TheSyringeEpinephrineforEMTmaybesubstitutedforanautoinjector

• Ifthepatientiswheezing,albuterol2.5mgin3mL(unitdose),vianebulizer;mayrepeattoatotalofthreedoses

• AdvancedLevel– Epinephrine(1:1,000/1mg/mL)0.3mgIM,ONLYifpatientishypotensiveand/orisdevelopingrespiratorydistressw/airwayswelling,hoarseness,stridor,orwheezing.Mayrepeatevery5minutesifthesesymptomspersist

– AddedNS500mlBolusifSBPis<100(was<90)mmHgorMAP<65(was<60) ;Mayrepeatuptoatotalof2Liflungsoundsremainclear(Removedrechecklungsounds)• GoalSBP>100mmHgandMAP>65mmHg 38


• CCandParamedicLevel– Epinephrinemovedtoadvancedlevel

• MedicalControlConsiderations– Added

• Additionalepinephrineforlevelswithlimitedstandingorders(asavailableandastrained)– Adult0.3mgIM

• KeyPoints/Considerations– Added

• Thoughaprevioushistoryofanaphylaxisisanimportantindicatorfortreatment,providersshouldbeawarethatanaphylaxismaydevelopinpatientswithnopriorhistory

39


• AddedKeyPoints/Considerations(continued)– AnaphylaxismaypresentwithshockassociatedonlywithGIsymptoms.Inthesettingofaknownexposuretoanallergenassociatedwithshock,nausea,vomiting,abdominalpain,and/ordiarrhea,consideranaphylaxisinconsultwithmedicalcontrol.

– *Ifequippedandtrained

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P3.3Anaphylaxis- Pediatric

• ChangesmirrorthosewiththeAdultAnaphylaxisprotocolwiththefollowingexceptions:– Dose:

• Adultautoinjector0.3mgIM(e.g.EpiPen®)if≥30kg*

• Pediatricautoinjector0.15mgIM(e.g.EpiPenJr®)if<30kg*

– MedicalControlConsiderations• Epinephrine(asavailableandastrained)forindicationsotherthanthoseabove

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P3.3Anaphylaxis– Pediatric(continued)

– KeyPoints/Considerations• DonotadministerIVepinephrinewithoutconsultingonlinemedicalcontrol

• Thoughaprevioushistoryofanaphylaxisisanimportantindicatorfortreatment,providersshouldbeawarethatanaphylaxismaydevelopinpatientswithnopriorhistory

• Infantauto-injector(0.1mgIM)maybesubstitutedforpediatricpatients<15kg,ifavailable.

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A3.4.1BehavioralEmergencies- AgitatedPatientAdult

• AllLevels– Added

• Verbalde-escalation(utilizinginterpersonalcommunicationskills)

• Ifverbalde-escalationisnotsuccessfulornotpossible,applysoftrestraints,suchastowels,triangularbandages,orcommerciallyavailablesoftmedicalrestraints,onlyifnecessarytoprotectthepatientandothersfromharm

• Seealso,“General:AlteredMentalStatus”protocolasindicated

• AdditionalKeyPoints/Considerationsadded– Considerhypoxia,hypoperfusion,hypoglycemia,headinjury,intoxication,otherdrugingestion,andothermedical/traumaticcausesofabnormalbehavior

– Considerthepossibilityofabehavioral/developmentaldisordersuchasautismspectrumdisorderormentalhealthproblems

43

P3.4.1BehavioralEmergencies- AgitatedPatientPediatric(NEW)

• Thisprotocolisintendedtobeusedwithpatientswhoaredeemedtoposeadangertothemselvesorothers

• Alllevels– Callforlawenforcement– Airwaymanagement,vitalsigns,andappropriateoxygentherapy,iftolerated

– Verbalde-escalation(utilizinginterpersonalcommunicationskills)

– Ifverbalde-escalationisnotsuccessfulornotpossible,applysoftrestraints,suchastowels,triangularbandages,orcommerciallyavailablesoftmedicalrestraints,onlyifnecessarytoprotectthepatientandothersfromharm

44

P3.4.1BehavioralEmergencies- AgitatedPatientPediatric(NEW)

• EMT,Advanced,CC,ParamedicLevel– Checkbloodglucoselevel,ifequipped,assoonasyouareabletosafelydoso.Ifabnormal,refertothe“General:Hypoglycemia– Pediatric”protocol,asindicated

– Seealso,“General:AlteredMentalStatus”protocolasindicated

• MedicalControlConsiderations– Midazolam(Versed)0.1mg/kgIVorIM– Ketamine*0.5-2mg/kgIVorIM

45

P3.4.1BehavioralEmergencies- AgitatedPatientPediatric(continued)

• KeyPoints/Considerations– Assessthesceneforsafetyand,ifitisnot,retreattoasafelocationandobtainpoliceassistance

– *Ketaminemaybeadministeredbyparamedicsonly– PatientmustNOTbetransportedinaface-downposition

– Considerhypoxia,hypoperfusion,hypoglycemia,headinjury,intoxication,otherdrugingestion,andothermedical/traumaticcausesofabnormalbehavior

– Considerthepossibilityofabehavioral/developmentaldisordersuchasautismspectrumdisorderormentalhealthproblems

46

P3.4.1BehavioralEmergencies- AgitatedPatientPediatric(continued)

• KeyPoints/Considerations(continued)– Ateamapproachshouldbeattemptedforthesafetyofthepatientandtheproviders

– Ifthepatientisinpolicecustodyand/orhashandcuffson,apoliceofficershouldaccompanythepatientintheambulancetothehospital.Theprovidermusthavetheabilitytoimmediatelyremoveanymechanicalrestraintsthathinderpatientcareatalltimes

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A3.4.2BehavioralEmergencies:ExcitedDelirium

• UndercriteriaaddedthewordAdultbeforepatients– Todefineitisforadultsonly

• Alllevelsofcare– Airwaymanagement,vitalsigns,andappropriateoxygentherapy,iftolerated(previouslywordedABC’sandvitalsignsastolerated)

– Verbalde-escalation(utilizinginterpersonalcommunicationskills)

– Ifverbalde-escalationisnotsuccessfulornotpossible,applysoftrestraints,suchastowels,triangularbandages,orcommerciallyavailablesoftmedicalrestraints,onlyifnecessarytoprotectthepatientandothersfromharm

– Seealso,“General:AlteredMentalStatus”protocolasindicated 48

3.5CarbonMonoxideExposure- Suspected

• CFRandalllevels– Added

• Anypatientwithsuspectedcarbonmonoxidepoisoningshouldreceivehighflowoxygenvianon-rebreathermask(NRB)

• EMT,Advanced,CC,Paramedic– Addedandremovedbrandname

• Anobjectivecarbon-monoxideevaluationtoolmaybeusedtoguidetherapy,ifavailable

• Anypregnant(orpotentiallypregnant)womanshouldreceivehighflowoxygenandbetransportedtothehospital

– ChangedthewordingtostronglyencouragefromconsidertransportifCOlevelsarenotdecreasingunderAsymptomaticpatients.

49

3.5CarbonMonoxideExposure- Suspected(continued)

– SymptomaticPatients• Added

– Ifthereisnosootintheairway,considerCPAP*5-10cmH2O(ifthedevicedelivers100%oxygen)» Fortheadultpatient» ForolderpediatricpatientsconsiderCPAP,asequipmentsizeallowsifavailableandtrained

• KeyPoints/Considerations– Wordingchangefromconsiderdirecttransporttohyperbariccentertoconsidercontactingmedicalcontroltodiscussappropriatehospitaldestinationifpatientmeetslistedcriteria

– RemovedBiPAPmaybeusedinplaceofCPAP,astrainingandequipmentallow

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P3.6.1Bradycardia- Pediatric

• AllLevels– Removed

• IfsymptomaticbradycardiapersistsstartCPR

• Paramedic– Removed

• Vascularaccessifneeded- ThisiscoveredunderVascularAccessProtocol

51

• CC,Paramedic– UNSTABLE-Added

• Ifirregularlyirregular,cardioversionmaybeinitiatedat200Joules

52

A3.6.2.1Tachycardia– Widecomplexwithapulse-Adult

A3.7CardiacRelatedProblem/ChestPain

• PreviouslyAcuteCoronarySyndrome– SuspectedCardiacChestPain• Criteria

– Added• Forpatientspresentingwithsuspectedcardiacchestpain;anginaorananginalequivalent

• ForthepatientwithaconfirmedSTEMIsee,“General:STElevationMI(STEMI)”protocolassoonasconfirmed

• CFRandAllLevels– Movedtothislevel

• Airwaymanagementandappropriateoxygentherapy• Aspirin324mg(4x81mgtabs)chewed,onlyifabletochew*

53

A3.7CardiacRelatedProblem/ChestPain(continued)

• EMT– Added

• ForpatientswithaSTEMI,confirmedbymedicalcontrol,begintransporttoafacilitycapableofprimaryangioplastyifestimatedarrivaltothatfacilityiswithin90minutesofpatientcontactorifdirectedbymedicalcontrolorregionalprocedure

– AddedifpatientrequestbeforeassistpatientwithNitroglycerin……

– RemovedadditionalnitroglycerindosesfortheEMTasitiscoveredunderMedicalControlConsiderations

• Advanced– MovedtoAdvancedLevel

• Nitroglycerin0.4mgSLperdose,asneeded,5minutesapart,providedthepatient’ssystolicBPis>120mmHgorMAP>90mmHg

54

A3.7CardiacRelatedProblem/ChestPain(continued)

• MedicalControlConsiderations– Added

• Considermedicalcontrolconsultation,asneeded,fordeterminationofmostappropriatedestinationfacility

• KeyPoints/Considerations• *IfequippedandtrainedforCFRlevel(referringtoASAadministration)• **Ifequipped,trained,andregionallyapproved(referringto12-ECGbyEMT)

55

P3.7CardiacRelatedProblem-Pediatric(New)

• Criteria– Pediatricpatientswhohaveknownheartdiseaseand/orhavebeenoperatedonforcongenitalheartdiseasehavemedicalemergenciesthataredifferentfromadultswithheartdiseasePediatricpatientswithcongenitalheartdiseasemay:• havebaselineoxygensaturationsbetween65and85%ratherthanabove94%(askcareprovideraboutpatient’susualoxygensaturationlevel)

• developsuddenheartrhythmdisturbances• befedbyeitheranasogastrictube(tubeinnose)orbygastrostomy(tubethrough abdominalwall)

• nothaveapulseoraccuratebloodpressureinanextremityafterheartsurgery

• haveapacemaker

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P3.7CardiacRelatedProblem-Pediatric(continued)

• AllLevels– ABCsandvitalsigns,includingbloodpressure– Keeppatientoncontinuouspulseoximetermonitoring,ifavailable(willmonitorbothheartrateandSpO2)

– Askparentsifthepatienthasaheartconditionand/orhasbeenoperatedon(lookforascarinthemiddleorsideofchest);askwhattypeofheartconditionitis

– Keepthechildinasomewhatuprightpositiontoenableoptimalbreathing,orallowchildtobeinpositionofcomfort

– Askparentswhatthechild’susualoxygensaturationisandprovideonlysufficientoxygentobringtheSpO2tohis/herusualbaseline

– Askparentifthepatienthasapacemakerand/orinternaldefibrillator

57


• AllLevels(continued)– Donotgiveanythingbymouth– Ifpatienthasafever,minimizethechild’sclothingandkeeptheambulanceatacomfortabletemperature

• EMT,Advanced,CC,Paramedic– Assessforsignsofpoorperfusion(suchasprolongedcapillaryrefill>2seconds,coolandduskydistalextremities,poorradialanddorsalispedispulses,and/orhypotension)

– Ifpatienthasagastrostomytube,suggesttoparent/caregivertoopenthetubetoairoraspiratestomachcontentstoimprovethechild’sabilitytobreathe

– Obtainvitalsignsincludingbloodpressureevery15minutes

58


• EMT,Advanced,CC,Paramedic(continued)– Ifpatienthasalteredmentalstatus,obtainfingerstickbloodglucoseandrefertothe“General:Hypoglycemia– Pediatric”and/or“General:AlteredMentalStatus”protocol,asindicated

– KeyPoints/Considerations• Chestpaininchildrenisrarelyasignofacardiaccondition(itismorefrequentlyrelatedtoconditionssuchascostochondritisorpleuritis)

• NotifythedestinationhospitalASAPandstatethatthepatienthassignsofcardiacfailureordecompensation

• Infantswithcongenitalheartdiseasemaypresentwithsymptomsverysimilartosepticshock(poorperfusion,poordistalpules,tachypnea,orduskyappearance)

• Pediatricpatientswithacongenitalheartconditionoftenhaveoxygensaturationsinthe65-85%range.Toomuchoxygenmaybedetrimentalandresultinworseningcirculation

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• KeyPoints/Considerations(continued)• Pediatricpatientswithacardiacconditionmayhavesuddenarrhythmiasthatrequiretreatment,includingSVT.FullcardiopulmonarymonitoringshouldbedonebyALS

• Transporttohospitalshouldnotbedelayedinillpediatriccardiacpatients

<1mo<1yr1– 10yr– SystolicHypotension:<60<70(<70+2xageOR<90)

60

A3.8CardiogenicShock-Adult

• CFRandallproviderLevelsadded– MovedtothisLevel

• Airwaymanagementandappropriateoxygentherapy• Aspirin324mg(4x81mgtabs)chewed,onlyifabletochew*

• Advanced– Addedasbulletunderfluidbolus

• GoalSBP>100mmHgandMAP>65mmHg

• KeyPoints/Considerations– RemovedkeypointsregardingAspirin

61

3.9.0Childbirth-Obstetrics

• Criteria– Added

• Childbirthisanaturalphenomenonandthetypeofdeliverycannotberegulatedbyyourlevelofcertification– ifanCFRisfacedwithanythingbutanormaldelivery,pleasefeelcomfortablecallingmedicalcontrolforassistance

• CFRandALLLevels– Added

• Maintainfirmgrasponinfant


• Obtainadditionalhelpformultiplebirths,asneeded62

P3.9.2Childbirth:Newborn/NeonatalResuscitation

• Previouslyneonatalresuscitation• Criteria

– Added• Fortheevaluationandresuscitationofbabiesjustdelivered

• CFRandAllProviderLevels– Changesunderbullet– Iftherespirationsremainabsent……

• Removed–Gentlyinsertoralairway• Added- withavolumejustenoughtoseechestrise• ChangednumberofsecondsbeforeaddingO2to30-60secondsfrom90seconds

63

Cleartheinfant’sairwaybysuctioningthemouthandnosegentlywithabulbsyringe,andthenventilatetheinfantatarateof40–60breaths/minutewithanappropriateBVMassoonaspossible,withavolumejustenoughtoseechestrise.Startwithroomair.Ifnoresponseafter30-60secondsofeffectiveventilationaddoxygen

P3.9.2Childbirth:Newborn/NeonatalResuscitation(continued)


• Hypothermiaandhypoglycemiamaydecreasethelikelihoodofsuccessfulresuscitation

– Removed• Placepulseoximeterprobeonrightwrist/palm

64

A3.10.0DifBreathing:Asthma/COPD/Wheezing-Adult

• CombinedAsthmaandCOPDProtocol• CriteriaAdded

– Patientswitheffectivebutincreasedworkofbreathingwithwheezing• Excludestraumaticcausesofdyspnea• Excludespneumothorax

• CFRandAllLevels– Assessforforeignbodyairwayobstruction– Referimmediatelytothe“Extremis:ForeignBodyObstructedAirway– Adult”protocol,ifindicated

– Ongoingassessmentoftheeffectivenessofbreathing• Refertothe“Extremis:RespiratoryArrest/Failure– Adult”protocol,ifnecessary

– Administersupplementaloxygen;refertothe65

A3.10.0DifBreathing:Asthma/COPD/Wheezing-Adult(continued)

• CFRandAllLevels(continued)– Administersupplementaloxygen;refertothe“Resources:OxygenAdministrationandAirwayManagement”protocol

– Assistpatientwithhisorherownmedications,see“Resources:PrescribedMedicationAssistance”protocol

– Facilitatetransportation,ongoingassessment,andsupportivecare

• EMT– Ifpatientiswheezing:

• Administeralbuterol2.5mgin3mL(unitdose)vianebulizer*– Oxygenpowerednebulizerdevicesforuseinaccordancewithmanufacturerspecifications(typically~6-8LPM)

• Mayrepeattoatotalofthreedosesifsymptomspersist66


• EMT(continued)– ContinuousPositiveAirwayPressure(CPAP)5-10cmH2O,asneeded*

– Ifthepatientisinseveredistress,seemedicalcontrolconsiderationsforuseofepinephrine

• Advanced– Added

• Epinephrine(1:1,000/1mg/mL)dose0.3mgIMforseveredistress– Ifseveredistresspersists,mayrepeatin5minutes

• Albuterol2.5mgin3mL(unitdose),vianebulizerorETtubenebulizer;mayrepeattoatotalofthreedosesforwheezing

67


• MedicalControlConsiderations– Addedracemicepinephrine

• Epinephrine(1:1,000/1mg/mL)3mgvianebulizerorracemicepinephrine(2.25%)0.5mLin3mLofnormalsalinevianebulizer


• Allowthepatienttomaintainpositionofcomfortwhensafetodoso– Donotforcethepatienttoliedown– Donotagitatethepatient

– Wheezingdoesnotalwaysindicateasthma.Considerallergicreaction,airwayobstruction,pulmonaryedema• RemovedCOPDasitisincorporatedinthisprotocol

– Donotdelaytransporttocompletemed.administration

68

A3.10.1DifBreathing:PulmonaryEdema- Adult


• ABCsandvitalsigns• Sitpatientupright,ifpossible• Administersupplementaloxygen;refertothe“OxygenAdministrationandAirwayManagement”protocol

• Facilitatetransportation,ongoingassessment,andsupportivecare

• MedicalControlConsiderations– NitroglycerinoptionforAdvanced

69

P3.10.2DifBreathing:Asthma/Wheezing- Pediatric

• Criteria– Added

• Patientswithincreasedworkofbreathing(retractions,grunting,nasalflaring)andprolongedexpirationand/orpoorairmovement– Excludestraumaticcausesofdyspnea– Excludespneumothorax– Excludesstridor/croup(see“DifficultyBreathing:Stridor–Pediatric”protocol)


• Assessforforeignbodyairwayobstruction– Referimmediatelytothe“Extremis:ForeignBodyObstructedAirway–Pediatric”protocol,ifindicated

70

P3.10.2DifBreathing:Asthma/Wheezing- Pediatric

• CFRandalllevels(continued)– Added

• Ongoingassessmentoftheeffectivenessofbreathing– Refertothe“Extremis:RespiratoryArrest/Failure– Pediatric”protocol,ifnecessary

• Allowpatienttodeterminepositionofcomfort.Ifpatientcannotdoso,havepatientsituprightorelevatetheheadofthestretcher

• Administersupplementaloxygen;refertothe“Resources:OxygenAdministrationandAirwayManagement”protocol

• Assistpatientwithhisorherownasthmamedications(see“Resources:PrescribedMedicationAssistance”protocol),asappropriate


71

P3.10.2DifBreathing:Asthma/Wheezing– Pediatriccontinued

• EMTandAdvanced– AddedLPMandguidancefornebulizers

• Oxygenpowerednebulizerdevicesforuseinaccordancewithmanufacturer specifications(typically~6-8LPM)

• ForolderpediatricpatientsconsiderCPAPforEMT,asequipmentsizeallowsifavailableandtrained

• MedicalControlConsiderations– FortheEMTandAdvanced:

• Additionalalbuterol• Epinephrineforcriticalasthmaattack*(EMTSyringeEpinephrinekitsorautoinjector)

– Addedracemicepinephrine• Epinephrine(1:1,000/1mg/mL)3mgvianebulizerorracemicepinephrine(2.25%)0.5mLin3mLofnormalsalinevianebulizer

72

P3.10.2DifBreathing:Asthma/Wheezing– Pediatriccontinued


• Expiratorywheezingdoesnotalwaysindicateasthma.Considerallergicreaction,airwayobstruction,pulmonaryedema

• Inchildrenunder2yrs.old,bronchiolitisisthemostcommoncauseofwheezing.Bronchiolitismaynotrespondtoalbuterol.Gentlenasalsuctioningistheprimarytreatmentalongwithoxygen,particularlyininfants.

• Allowthepatienttomaintainpositionofcomfortwhensafetodoso– Donotforcethepatienttoliedown– Donotagitatethepatient

• Observeairborneand/ordropletprecautionsinappropriatepatients,suchasthosewithsuspectedpertussis(whoopingcough)

• Donotdelaytransporttocompletemedicationadministration• *Ifequippedandtrained

73

P3.10.3DifBreathing:Stridor– Pediatric

• CFRandAllLevels– Added

• Assessforforeignbodyairwayobstruction(Wordingdifferent)– Referimmediatelytothe“Extremis:ForeignBodyObstructedAirway–Pediatric”protocol,ifindicated

• Assessforanaphylaxis– Referimmediatelytothe“General:Anaphylaxis– Pediatric”protocol,ifindicated

• Ongoingassessmentoftheeffectivenessofbreathing– Refertothe“Extremis:RespiratoryArrest/Failure– Pediatric”protocol,if

necessary

• Administersupplementaloxygen;refertothe“Resources:OxygenAdministrationandAirwayManagement”protocol(Wordingdifferent)

• Considerhighconcentration,humidified,blow-byoxygendeliveredbytubingorfacemaskheldabout3-5inchesfromface(astolerated)

• Facilitatetransportation,ongoingassessment,pulseoximeter,andsupportivecare 74

P3.10.3DifBreathing:Stridor– Pediatriccontinued

• Paramedic– Added

• RacemicEpinephrinedose– IfSEVERErespiratorydistress(severestridorespeciallywithdrooling),epinephrine(1:1,000/1mg/mL)3mgvianebulizerorracemicepinephrine(2.25%)0.5mLin3mLofnormalsalinevianebulizer

• KeyPoints/Considerations– Addedorchangedwording

• Ifthepatienthasstridor(inspiratory),itisoftenanupperairwayproblem(physiologicormechanicalobstruction)

• Viralcroupshouldbeconsideredinchildrenpresentingwithabsentorlowgradefever,barkingcough,stridor,and/orsternalretractions

75

P3.10.3DifBreathing:Stridor– Pediatriccontinued

• KeyPoints/Considerations(continued)• Ifthepatienthasstridor(inspiratory),itisoftenanupperairwayEpiglottitisshouldbeconsideredinchildrenwithahighfever,muffledvoice,tripodposition,and/ordrooling– Avaccinationhistoryshouldbeobtainedbecauseunvaccinatedchildrenareathigherriskofepiglottitis

• Agitatingachildwithcrouporepiglottitiscouldcauseacompleteairwayobstruction

• Limitinterventionsthatmaycauseunnecessaryagitationinachildwithstridorsuchasassessmentofbloodpressureinachildwhocanstillbreathe,cough,cry,orspeak

76

3.11.1Environmental- ColdEmergencies

• CFRandAllLevels– Movedguidanceforlocalcoldinjuryandgeneralizedhypothermiatothislevel

– Undergeneralizedhypothermiaadded• Especiallyforinfantsandyoungpediatricpatients,covertheheadwithacaportoweltodecreaseheatloss

• EMT,Advanced,CC,Paramedic– Changedanticipatedtimeoftransporttothehospitalto60minutesfrom30minutesunderRewarmingextremity


• Pulseoxygenationmeasurementmaybeinaccurateifthepatientishypothermic.Ifthepatientiscyanoticandinapparentrespiratorydistress,administeroxygen

77

3.11.2Environmental- HeatEmergencies

• Advanced,CC,Paramedic– Added“Foradultpatientonly”beforeconsidernormalsaline500ccIVbolus;mayrepeatupto2litersasneeded,iftherearenosignsofpulmonaryedemaandnoconcernforwaterintoxication*

78

3.12Fever-Adult(NEW)

• Criteria– Adultpatientwiththefollowing:

• Temperature>100.4°F(38°C)– OR–• Temperature≥2°F(1°C)overbaseline

– AND–• Suspectedinfection– OR–• Recipientofablood/bloodproducttransfusion

– Patienthasnothadatotaldoseof>650mgofacetaminophen(eitheracetaminophenoranacetaminophencontainingproduct)or>400mgofibuprofenwithinthelast4hours

79

3.12Fever-Adult(continued)

• EMT– ABCsandvitalsigns,toincludeSpO2andtemperature*– Airwaymanagementandappropriateoxygentherapy

• Advanced– Largeborevascularaccess– Normalsaline500mLbolus;mayrepeatonce,iflungsoundsremainclear(noconcernsforpulmonaryedema)

– Ifabletotolerateoralfluidconsideroneofthefollowing:• Acetaminophen650mg/20.3mLPO(2–325mg/10.15mLPOunitdoses)*

• Ibuprofen400mg/20mLPO(4–100mg/5mLPOunitdoses)*80


• CC,Paramedic– Considercardiacmonitor,continuousSpO2

– Considera12-leadECGifappropriate

• MedicalControlConsiderations– Additionalacetaminophen325mg/10.15mLPO(1additional–325mg/10.15mLPOunitdose)

– Additionalibuprofen100mg/5mLPO(1or2additional– 100mg/5mLPOunitdose)

• KeyPoints/Considerations– *Ifequippedandtrained

81


• KeyPoints/Considerations(continued)– *Ifequippedandtrained– Acetaminophencontraindications(unlessmedicalcontrolapproved):• Hxofliverproblems/acuteliverfailure• AcuteliverinflammationduetohepatitisCvirus• Inthesettingofshockoroverdose(especiallyacetaminophenoverdose)

– Ibuprofencontraindications(unlessmedicalcontrolapproved):• Severerenalimpairment(dialysisdependent)• Inthesettingofshockoroverdose• Prescribed‘bloodthinners’(i.e.warfarin/Coumadin)• AllergytoanyNSAID/aspirin• Pregnancy(late)

82


• KeyPoints/Considerations(continued)– AdministeroxygentherapyutilizingtheappropriatedeliverydeviceandtitrationtomaintainSpO2>92%

– Iffeverisduetosuspectedviralorbacterialinfection,refertoprotocol“General:SevereSepsis/SepticShock”protocolandtreatasindicated

– Iffeverisduetosuspectedreactiontoblood/bloodproducttransfusion,immediatelystopthetransfusion,replacealltubing(saveforreceivinghospitalbloodbank)andmaintainIVaccesswithnewbagof0.9%NaCl,contactmedicalcontrol,andtreatperappropriateprotocol• Temperaturemonitoring,takeinitialandevery10minutes• Cardiacmonitor,continuousSpO2andcontinuouspCO2monitoring• Considera12-leadECGifappropriate

83

P3.12Fever-Pediatric(NEW)

• Criteria– Adultpatientwiththefollowing:

• Temperature>100.4°F(38°C)– OR–• Temperature≥2°F(1°C)overbaseline

– AND–• Suspectedinfection– OR–• Recipientofablood/bloodproducttransfusion

– Patienthasnothadadoseofacetaminophen(eitheracetaminophenoranacetaminophencontainingproduct)oribuprofenwithinthelast4hours

84

P3.12Fever-Pediatric(continued)

• EMT– ABCsandvitalsigns,toincludeSpO2andtemperature*– Airwaymanagementandappropriateoxygentherapy– Checkbloodglucoselevel,ifequipped.Ifabnormal,refertothe“General:Hyperglycemia– Pediatric”or“General:Hypoglycemia– Pediatric”protocol,andtreatasindicated

• Advanced– Ifabletotolerateoralfluidconsideroneofthefollowing– Acetaminophen15mg/kgPO*or:(followweightbaseddosingchartinprotocol)

– Ibuprofen10mg/kgPO*or: (followweightbaseddosingchartinprotocol)

85


• CC,Paramedic– Considercardiacmonitor,continuousSpO2– Ifindicationsofhypoperfusion,refertothe“General:Sepsis/Shock/Hypoperfusion–Pediatric”protocolandtreatasindicated

• MedicalControlConsiderations– Acetaminophen10–15mg/kg/doseifgivenIbuprofen– Ibuprofen10mg/kg/doseifgivenAcetaminophen

86


• KeyPoints/Considerations(continued)– *Ifequippedandtrained– Acetaminophencontraindications(unlessmedicalcontrolapproved):• Hxofliverproblems/acuteliverfailure• AcuteliverinflammationduetohepatitisCvirus• Inthesettingofshockoroverdose(especiallyacetaminophenoverdose)

– Ibuprofencontraindications(unlessmedicalcontrolapproved):• Severerenalimpairment(dialysisdependent)• Inthesettingofshockoroverdose• Prescribed‘bloodthinners’(i.e.warfarin/Coumadin)• AllergytoanyNSAID/aspirin• Pregnancy(late)

87


• KeyPoints/Considerations(continued)– AdministeroxygentherapyutilizingtheappropriatedeliverydeviceandtitrationtomaintainSpO2>92%

– Iffeverisduetosuspectedviralorbacterialinfection,refertoprotocol“Sepsis/Shock/Hypoperfusion–Pediatric”andtreatasappropriate

– Diagnosticindicationsforhypoperfusioninclude:cool/clammyormottledskin,inabilitytorecognizeparents,restlessness,listlessness,tachycardia,tachypnea,systolicBP<70mmHg(2yearsandolder),orsystolicBP<60mmHg(lessthan2yearsold)

88


• KeyPoints/Considerations(continued)– Iffeverisduetosuspectedreactiontoblood/bloodproducttransfusion,immediatelystopthetransfusion,replacealltubing(saveforreceivinghospitalbloodbank)andmaintainIVaccesswithnewbagof0.9%NaCl,contactmedicalcontrol,andtreatperappropriateprotocol• Temperaturemonitoring,takeinitialandevery10minutes• Cardiacmonitor,continuousSpO2andcontinuouspCO2

monitoring

89

A3.15Hypoglycemia- Adult

• CriteriaAdded– Forpatientswithknownorsuspectedhypoglycemia– Seealso,“General:AlteredMentalStatus”protocol,asrequired

• CFRandAllLevels– AirwayManagementwordingversusABC’sandVS– Added

• Checkpupilsand,ifconstricted,consider“General:Opioid(Narcotic)Overdose"protocol

• Addedexamplesofcarbohydratestogiveifpatientcanswallow• DonotdelaytransportinplaceofcallingforALSintercept• Ongoingassessmentoftheeffectivenessofbreathing

– Referto“Extremis:RespiratoryArrest/Failure– Adult”protocol,ifnecessary

90

A3.15Hypoglycemia- Adult(continued)


• Assessthesceneforsafetyand,ifitisnot,retreattoasafelocationandobtainpoliceassistance

91

P3.15Hypoglycemia- Pediatric

• CriteriaAdded– Forpediatricpatientswithknownorsuspectedhypoglycemia– Seealso,“General:AlteredMentalStatus”protocol,asrequired

• CFRandAllLevels– AirwayManagementwordingversusABC’sandVS– Added

• Checkpupilsand,ifconstricted,consider“General:Opioid(Narcotic)Overdose"protocol

• DonotdelaytransportinplaceofcallingforALSintercept• Addedexamplesofcarbohydratestogiveifpatientcanswallow• Ongoingassessmentoftheeffectivenessofbreathing

– Referto“Extremis:RespiratoryArrest/Failure– Pediatric”protocol,ifnecessary

92

P3.15Hypoglycemia- Pediatric(continued)

• Advanced– Ifunabletoobtainadequateresultswithoralglucoseconsiderglucagon0.5mgIMif<20kg,otherwise,1mgIM*,ifneeded

93

3.17Opioid(Narcotic)Overdose

• AdultandPediatric– previouslysomeoftheinformationwasinPediatricOD/ToxicExposureprotocol

• CFRandAllLevels– Forsuspectedopioidoverdoseandhypoventilation*orrespiratoryarrest,administernaloxone(Narcan®)2mg**intranasal;1mgpernostril,mayrepeatoncein5minutes,ifnosignificantimprovementoccurs(higher-levelprovidersmaysubstitutetitrationdirectionsandroutesspecifiedbelow)• Inthepediatricpatient,administernaloxone(Narcan®)1mg**intranasal;½mgpernostril,mayrepeatoncein5minutes,ifnosignificantimprovementoccurs

94

3.17Opioid(Narcotic)Overdose(continued)

• Advanced– MovedtoAdvancedlevel

• Titratenaloxone(Narcan)tomax2mgperdoseIV,IM,orintranasal,ONLYifhypoventilationorrespiratoryarrest.(Consideradministeringin≤0.5mgincrements,ifgivingIV)

• KeyPoints/Considerations– **MaysubstitutealternativeFDAandSEMACapproved,commerciallyprepared4mgnasalsprayunitdosedevice• Thisdeviceisapprovedforthefull4mgdoseintheadultorpediatricpatient

• Administer4mgin1nostrilasasinglespray

95

3.18OrganophosphateExposure

• AdultandPediatricProtocolCombined– previouslysomeoftheinformationwasinPediatricOD/ToxicExposureprotocol

• Paramedic– AddedPediatricdoseofAtropineandremovedVerseddoseandputinreferraltoseizureprotocol• Forsymptomaticpatientswithorganophosphatepoisoning:

– Forthepediatricpatient:» Atropine1mgIVevery3-5minutes,untilsecretionsdry

• Forseizures:– Foradultseizuressee,“General:Seizures– Adult”protocol– Forpediatricseizuressee,“General:Seizures– Pediatric”protocol

96

A3.19PainManagement- Adult


• Ifabletotolerateoralfluidconsideroneofthefollowing:– Acetaminophen650mg/20.3mLPO(2–325mg/10.15mLPOunitdoses)*– Ibuprofen400mg/20mLPO(4–100mg/5mLPOunitdoses)*

• CC,Paramedic– MovedKetorolacasachoicewithMorphineandFentanylstandingorderfromMedicalControlConsiderations• MayChooseone***

– Ketorolac**(Toradol)15mgIVor30mgIM

• KeyPointsConsiderations– Removed

• lowerdosingofKetorolacshouldbeconsideredforthoseweighinglessthan50kg

97

A3.19PainManagement– Adult(continued)

• KeyPoints/Considerations(continued)– AddedthewordNon-oral,acetaminophenandIbuprofeninformation• ***ONEnon-oral painmedicationmaybegivenunderstandingorders.Fordosingthatexceedsthestandingordermaximum,ortoswitchtoanotheragent,youmustconsultmedicalcontrol

• Acetaminophencontraindications(unlessmedicalcontrolapproved):– Hxofliverproblems/acuteliverfailure– AcuteliverinflammationduetohepatitisCvirus– Inthesettingofshockoroverdose(especiallyacetaminophenoverdose)

• Ibuprofencontraindications(unlessmedicalcontrolapproved):– Severerenalimpairment(dialysisdependent)– Inthesettingofshockoroverdose– Prescribed‘bloodthinners’(i.e.warfarin/Coumadin)– AllergytoanyNSAID/aspirin– Pregnancy(late)

98

P3.19PainManagement- Pediatric


• Nitrousoxidebyself-administeredinhalation*• Ifabletotolerateoralfluidconsideroneofthefollowing:

– Acetaminophen15mg/kgPO*or:(followweightbaseddosingchartinprotocol)

– Ibuprofen10mg/kgPO*or: (followweightbaseddosingchartinprotocol)

• KeyPoints/Considerations• AddedthewordNon-oral,acetaminophenandIbuprofeninformationmirroringadultPainManagementProtocol

• AddedNitrousinformation– Nitrousoxideisnotarequiredformularyitem– Contraindicationstonitrousoxideinclude:suspectedbowelobstruction,pneumothorax,hypoxia,ortheinabilitytoself-administer

99

3.20Poisoning/Overdoses:Undifferentiated(formerlyunderOverdose/ToxicExposure)

• Criteria– AddedreferraltoAlteredMentalStatusProtocol

• Foralteredmentalstatus,see“General:AlteredMentalStatus”protocol

• CFRandAllLevels– AddedreferraltoTrauma:Burns

• Forcontaminationoftheskinoreyes,refertothe“Trauma:Burns”protocol


• Takeprecautionstoassureprovidersdonotgetexposed• Forinhalationexposures,assurepatientismovedtofreshair

100

P3.20Poisoning/Overdoses:Undifferentiated(formerlyunderOverdose/ToxicExposure)

• CriteriaAdded– Thisprotocolisintendedfortheundifferentiatedtoxicexposureofthepediatricpatient• Forasuspectedcarbonmonoxideexposure,seethe“General:CarbonMonoxideExposure– Suspected”protocol

• Foranopioidoverdose,seethe“General:Opioid(Narcotic)Overdose”protocol

• Foranorganophosphateexposure,see“General:OrganophosphateExposure”protocol

• Forsmokeinhalation,see“General:SmokeInhalation/CyanidePoisoning–Symptomatic”protocol

• Foralteredmentalstatus,see“General:AlteredMentalStatus”protocol

• IfsuspectedWMDnerveagent,refertothe“Resource:NerveAgent–Suspected”protocol

101

P3.20Poisoning/Overdoses:Undifferentiated(formerlyunderOverdose/ToxicExposure)


• Forcontaminationoftheskinoreyes,refertothe“Trauma:Burns”protocol

– Removed• OpioidOverdoseinformation,Narcandosing,andOrganophosphatepoisoningasthisalreadyexistinotherprotocols


• Dystonicreactionisareactiontomedicationresultinginuncontrolledmusclecontractionsoftheface,neck,ortongue.Extrapyramidalsideeffectsmayalsoincludeextremerestlessnessandmaybetreatedasadystonicreaction

• Takeprecautionstoassureprovidersdonotgetexposed• Forinhalationexposures,assurepatientismovedtofreshair

102

3.24Seizures

• CFRandAllLevels– AddedUnderAirwayManagement

• Suctiontheairwayasneeded• Positionthepatientonthesideifvomiting• Donotputanythinginthepatient’smouthwhenthepatientisactivelyseizing– Utilizeanappropriateairwayadjunct,ifneeded,aftertheseizurehasended

– AddedProtectthepatientfromharm• Removehazardsfromthepatient’simmediatearea• Avoidunnecessaryrestraint

– AddedOngoingassessmentoftheeffectivenessofbreathing• Refertothe“Extremis:RespiratoryArrest/Failure– Adult”protocol,ifnecessary

– RemovedABC’sandVS103

3.24Seizures(continued)


• Patientsmaybecomeconfusedandcombativeafteraseizure(inthepostictalstate)– Protectyourselfandthepatient– Obtainlawenforcementassistance,ifneeded

• Statusepilepticus(continuingseizure)isacriticalmedicalemergency.Anticonvulsantmedicationshouldbeadministeredassoonaspossible,preferablystartingnolaterthan5-10minutesaftertheonsetoftheseizure

104

P3.24Seizures– Pediatric

• AllchangesmirrorthechangesmadetotheAdultSeizuresProtocolinpreviousslides

105

A3.25.1Shock:Shock/Hypoperfusion


• Administersupplementaloxygen;refertothe“Resource:OxygenAdministrationandAirwayManagement”protocol


106

A3.25.2Shock:SevereSepsis/SepticShock- Suspected

• CFRandAllLevels– Removed

• IncludingBloodPressureafterABC’sandVS• BloodGlucoseCheck

– Added• (Non-rebreatherastolerated)afterAirwayManagement• Ifthepatienthasalteredmentalstatus,refertothe“General:AlteredMentalStatus”protocol

• Attempttomaintainnormalbodytemperature• Advisethedestinationhospitalthatthepatienthassignsofsepsis/septicshock

• Obtainvitalsigns,includingbloodpressure,frequently

107

A3.25.2Shock:SevereSepsis/SepticShock– Suspected(continued)

• Advanced– Added– AfterNSBolus- ifSBP<100mmHgorMAP<65mmHg;mayrepeatuptoatotalof2Liflungsoundsremainclear

108

P3.25.3Shock:Sepsis/Shock/Hypoperfusion- Pediatric

• Criteriaaddedtoincludesepsis– Forsepsis:

• Pediatricpatientswithsuspectedinfectionwhoareabnormallyhotorcoldtotouch,and/orhaveafeverover100.4° F(38° C),orlessthan96.8° F(36° C)andhighheartrate(agedependent)and/orhighrespiratoryrate(agedependent)with:– Poorperfusion(capillaryrefill>3seconds,decreasedperipheralpulses,distalextremity[hands/feet]coolnessandduskycolor,orage-dependent

– hypotension)and/or– needforoxygen,and/or– alteredmentalstatus(lethargy,irritability)

109

P3.25.3Shock:Sepsis/Shock/Hypoperfusion– Pediatric(continued)


• IncludingbloodpressureafterABC’sandVS• GivehighflowOxygen(Non-rebreatherastolerated)afterairwaymanagement

• Ifthepatienthasalteredmentalstatus,refertothe“General:AlteredMentalStatus”protocol

• Attempttomaintainnormalbodytemperature

• EMTandAdvanced• Added

– Advisethedestinationhospitalforthwiththatthepatienthassignsofsepsis/septicshock

– Obtainvitalsigns,includingbloodpressure,frequently

110

P3.25.3Shock:Sepsis/Shock/Hypoperfusion– Pediatric(continued)


• Sepsis/septicshockisalife-threateningconditioninchildrenandmustberecognizedandtreatedasrapidlyaspossible

• Vitalsigncriteriafordefiningsepsis:

<1mo.<1yr1yr-11yr>11yr– Tachycardia>180>180>140>110– Tachypnea >60 >40 >30 >20– Hypotension*<60<70(<70+2xage) <90

• *Bloodpressuresmaybeverydifficulttoobtainininfants– assuretherespiratoryrateandpulsearemeasuredaccurately

• Communicationwiththedestinationhospitaliscriticalsothattheycanpreparetotreatthechildaggressively

111

3.26SmokeInhalation/Cyanide- Symptomatic

• AddedCyanidetothetitleofprotocol• Appliestoadultandpediatricpatients• CFRandAllproviderlevels

– Movedtothislevel• ABC’sandVS• OxygenviaNRBmaskat15LPM

• EMT– ChangedwordingwithsomeadditionsforCPAP

• Ifthepatientisinrespiratorydistressorralesarepresentandthereisnosootintheairway,considerCPAP*5-10cmH2O(ifthedevicedelivers100%oxygen)– Fortheadultpatient– ForolderpediatricpatientsconsiderCPAP,asequipmentsizeallowsifavailableandtrained

112

A3.27STElevationMI(STEMI)- Confirmed

• CFRandAlllevels– Removed

• ABC’sandVS

• EMT– Addedafteracquireandtransmit12-leadECG**

• ForpatientswithaSTEMI,confirmedbymedicalcontrol,begintransporttoafacilitycapableofprimaryangioplastyifestimatedarrivaltothatfacilityiswithin90minutesofpatientcontactorifdirectedbymedicalcontrolorregionalprocedure

• Ifthepatientrequestsaddedinfrontofassistpatientwithhisorherprescribednitroglycerin…

113

A3.27STElevationMI(STEMI)– Confirmed(continued)

• CC,Paramedic– Added

• GoalSBP>100mmHgandMAP>65mmHgafterconsiderNSBolus

• KeyPoints/Considerations– AddedmaintainingABC’s

• FocusonmaintainingABCs,rapididentification,rapidnotification,andrapidtransporttoanappropriatefacility

114

3.28GeneralStrokeAppliestoadultandpediatricpatients

• CriteriaAdded– Forpatientspresentingwithacutefocalneurologicdeficitsincluding,butnotlimitedto,slurredspeech,facialdroop,and/orunilateral(one-sided)weaknessorparalysis

• EMT– Timechangedto3.5hours,unlessotherwiseregionallydesignated• IftimefromlastknownwellortimeofsymptomonsettoestimatedarrivalintheEDwillbelessthan3.5hours,unlessotherwiseregionallydesignated,transportthepatienttoaNYSDOHDesignatedStrokeCenter,orconsultmedicalcontroltodiscussanappropriatedestinationfacility

– Removed• RequestALS,ifavailable

115

3.28GeneralStroke(continued)Appliestoadultandpediatricpatients


• Makesuretocollectfamilyorwitnesscontactinformationtoassistwithhospitalcare

• MakesuretorecordLastKnownWellandwhoreportedthatinformationaspartofyourverbalreportatthehospitalandinyourwrittendocumentation

• “TimeofSymptomOnset”isalsoakeypieceofinformationifavailablefromwitnesses

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P3.29TechnologyAssistedChildren-New

• Criteria– Childrenwithspecialhealthcareneedsrequiringtechnologicalassistanceforlifesupport:• Tracheostomy

– Breathingtubeinneck• Centralvenouscatheters(tunneledcatheter,Broviaccatheter,Mediport,PICC)– Cathetersthatenteralarge(central)vein

• CSFshunt(e.g.ventriculoperitonealorV-Pshunt)– Internaltubethatdrainsspinalfluidfromthebrainintotheabdomen

• Gastrostomy(PEGtube,MIC-KEY®“button”)orJ-tube– Feedingtubethatgoesthroughtheabdominalwall

• Colostomyorileostomy– Bowelconnectedthroughabdominalwallforcollectionofwasteinabag 117

P3.29TechnologyAssistedChildren–New(continued)

• Criteria(continued)• Ureterostomyornephrostomytube

– Connectionoftheurinarysystemthroughtheabdominalwallorthroughthebackforcollectionofurineinabag

• Foleycatheter– Catheterinurethratocollecturinefromthebladderintoabag

• CFRandalllevels– ABCsandvitalsignsincludingbloodpressure– Basicairwaymanagementifneeded,givehighflowoxygen(non-rebreather)ifneeded

– Supportivemeasures(device-specific):• Tracheostomy

– Ifonventilatorandtherearerespiratoryconcerns,disconnectandattempttoventilateviatracheostomyadapterusingBVM

– Iftracheostomytubeisfullyorpartiallydislodged,removeit,covertracheostomystomawithanocclusivedressing,andventilateviamouthandnoseusingBVM

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• CFRandalllevels(continued)– Supportivemeasures(device-specific):

• Tracheostomy– Ifonventilatorandtherearerespiratoryconcerns,disconnectandattempttoventilateviatracheostomyadapterusingBVM

– Iftracheostomytubeisfullyorpartiallydislodged,removeit,covertracheostomystomawithanocclusivedressing,andventilateviamouthandnoseusingBVM

• Centralvenouscatheters:ifcatheterisbrokenorleaking,clamp(pinchoff)catheterbetweenpatientandsiteofbreakageorleakage

• Gastrostomytubeorbutton,ureterostomyornephrostomytube:iftubeorbuttonisfullydislodged,coverthesitewithanocclusivedressing;ifpartiallydislodged,tapeinplace

• Gastrostomy,colostomy,ileostomy,ornephrostomy:ifstomasiteisbleeding,applygentledirectpressurewithasaline-moistenedgauzesponge

• Foleycatheter:ifcatheterisdislodged,tapeinplace119


• EMT,Advanced,CC,Paramedic– NotifythedestinationhospitalASAPandstatethatthepatienthasspecialhealthcareneedsthatrequirestechnologicalassistance(bespecific)

– Obtainfrequentvitalsigns,includingbloodpressure

• KeyPoints/Considerations– Listentothecaregivers.Theyknowtheirchildbest.Allowthemtoassistwithcare.• Inquireabout:

– PresenceofaPatientCarePlan(PCP)-Whatisdifferenttoday– Syndromes/diseases- Bestwaytomovethechild– Devices/medications– Child’sbaselineabilities– Usualvitalsigns– Symptoms

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• KeyPoints/Considerations(continued)– LookforMedicAlert®jewelry,EmergencyInformationForm(EIF),orPatientCarePlan(PCP),orotherhealthcareforms,ifusualcaregiverisnotavailable

– TakeEmergencyInformationForm(EIF),PatientCarePlan,orotherhealthcareformstothehospitalwiththepatient

– Assessandcommunicatewiththechildbasedondevelopmental,notchronological,age

– Takenecessaryspecializedequipment(e.g.patienttrach/ventilatorpack,G-tubeconnectors,etc.)tothehospitalwiththepatient,ifpossible

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3.30TotalArtificialHeart(TAH)

• Criteria– AnyrequestforservicethatrequiresevaluationandtransportofapatientwithaTotalArtificialHeart.

• CFRandalllevels– Assessairwayandbreathing.Hypertensionorvolumeoverloadcanquicklycausepulmonaryedematodevelop

– DonotuseanAEDorcardiacmonitor.– Assesspulseandartificialheartfunction:

• Ifnopulsepresent:• ConsiderearlyconsultwithTAHcoordinatorormedicalcontrol• CheckforseveredorkinkedTAHdriveline(addressifpossible)• Checkbatterypositionandpowerstatus(replaceifpossible)

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3.30TotalArtificialHeart(TAH)(continued)

• CFRandalllevels(continued)– Assessairwayandbreathing.Hypertensionorvolumeoverloadcanquicklycausepulmonaryedematodevelop

– DonotuseanAEDorcardiacmonitor.– Assesspulseandartificialheartfunction:

• Ifnopulsepresent:• ConsiderearlyconsultwithTAHcoordinatorormedicalcontrol• CheckforseveredorkinkedTAHdriveline(addressifpossible)• Checkbatterypositionandpowerstatus(replaceifpossible)• Usethebackupdriver,orhandpump,ifavailable• DonotperformchestcompressionsorplaceanAED

– Assessbloodpressure:goalbloodpressureis>90mmHgand<150mmHg

– Performasecondaryassessmentandtreatperprotocol123


• CFRandalllevels(continued)– Ifunresponsivewithapulse,evaluatefornoncardiacetiologies

– NotifythereceivinghospitalthatyourpatienthasaTAHwhileonsceneorpromptlyafterinitiationoftransportregardlessofpatient’scomplaint

– Assurethatpatienthasbothdrivers(compressors),handpump,allbatteries,andpowercordsfortransport

– Anytrainedsupportmembershouldremainwithpatient

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• Advanced,CC,Paramedic– Ifbloodpressureis>150mmHgadministersublingualnitroglycerin0.4mg• Repeatsublingualnitroglycerin0.4mgevery5minutesifBP>150mmHg

– Assessforhypovolemia.Ifbloodpressure<90mmHg,orevidenceofdistributiveshock,bloodloss,ordehydration:• IV0.9%NSin250mLboluses;mayberepeatedtoonelitertotalifhypotensionispersistent.Contactmedicalcontrolforadditionalfluidsbeyondoneliter

– Donotapplyacardiacmonitor,orperformpacingordefibrillationanddonotadministervasopressorsorantiarrhythmics

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• MedicalControlConsiderations– Terminationofresuscitation– ConsultationwithaTAHprogramprovider

• KeyPoints/Considerations– TAHpatientshavehadtheirheartremovedandreplacedwitharigiddevicewhichpneumaticallypumpsbloodthroughoutthebody

– Asthesepatientsdonothaveaheart,thereisnoindicationforanECGorcardiacmonitoring.AfunctioningTAHwillnotresultinanymeasurableelectricalactivity

– TAHpatientsareonmulti-agentanticoagulationandmayhavesignificantbleedingwithminorinjuries

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• KeyPoints/Considerations(continued)– TheTAHpatienthasnormalpulseandbloodpressuredetectablebyconventionalmethodsandarehighlypreloadandafterloadsensitive:

– TargetBloodPressureis<150mmHgand>90mmHg– Pulserateissetandregular,between120-135bpm

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3.31VentricularAssistDevice– (VAD)

• CFRandallProviderLevels– ChangedwordingfromABC’sandVS

• Assessairwayandbreathing.Treatairwayobstructionorrespiratorydistressperprotocol.Treatmedicalortraumaticconditionsperprotocol.

– Addedwordchanges• Assessairwayandbreathing.Treatairwayobstructionorrespiratorydistressperprotocol.Treatmedicalortraumaticconditionsperprotocol.

– Added• IncontinuousflowVADpatients(HeartMateII©,Heartware©,oraxialflowdevice),theabsenceofapalpablepulseisnormaleveninthesettingofanormallyfunctioningdevice.Patientsmaynothaveareadilymeasurablebloodpressure

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3.31VentricularAssistDevice– (VAD)

• CFRandallProviderLevels– Added

• InpulsatileflowVADpatientswithaHeartMate3©centrifugaldevice,patientsmayhaveapalpablepulse(pulseisgenerallysetto30BPM)inthesettingofanormallyfunctioningdevice,yetmaynothaveareadilymeasurablebloodpressure

• Performasecondaryassessmentandtreatperappropriateprotocol

– WordingChange• NotifythereceivingfacilitypromptlyandconsiderearlyconsultationwiththeVADcoordinatorormedicalcontrol,regardlessofthepatient’scomplaint

• EMT– Added

• Unlessotherwisedirectedbymedicalcontrol,transportpatienttoafacilitycapableofmanagingVADpatients

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3.31VentricularAssistDevice– (VAD)(continued)

• Advanced,CC,Paramedic– Added

• Applycardiacmonitorandobtain12-leadECG

– Removed• Placepatientinasupinepositionifpossible

– WordingChange– Ifinadequateperfusionoroxygenation,despitethedevicebeingon,treatwithstandardACLSmeasures.ConsiderearlymedicalcontrolconsultationaspatientswithaVADoftenhavedysrhythmias

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• ThemostcommoncomplicationinVADpatientsisinfection.VADpatientsaresusceptibletosystemicillness,sepsis,andsepticshockduetotheirabdominaldrivelineasaconduitofinfection

• PatientswithaVADarehighlypreloaddependentandafterloadsensitive.LowflowalarmsarefrequentlyduetoMAP>90mmHg.Thedevicesaresensitivetoalterationsinvolumestatusandcarefulvolumeresuscitationisoftennecessary

– WordingChange• Onesetoffullychargedbatteriesprovides8-10hoursofpower:

– Ifthebatteryorpowerislow,thebatteriesneedtobereplacedimmediately

– Assistwiththereplacementofbatteriesifdirectedbypatient/caregiver

– NeverdisconnectbothbatteriesatonceasthiscancausecompletelossofVADpower

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• KeyPoints/Considerations(continued)– WordingChange

• Onesetoffullychargedbatteriesprovides8-10hoursofpower:– Ifthebatteryorpowerislow,thebatteriesneedtobereplacedimmediately

– Assistwiththereplacementofbatteriesifdirectedbypatient/caregiver

– NeverdisconnectbothbatteriesatonceasthiscancausecompletelossofVADpower

• VADpatientsareheavilyanticoagulatedandsusceptibletobleedingcomplications

• ControllerDeviceNormalValuesadded- Seechartinprotocol

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4.0TraumaProtocolsAppliestoadultandpediatric

• TourniquetandHemostaticdressingsareapprovedbyuseforCFR,previouslytheCFRlevelwasnotinthecollaborativeanditreadBLS.• ReferraltoTraumaPatientDestination(previouslywordedCDCtraumatriageCriteria)

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4.1Amputation


• ReferraltoTrauma:SuspectedSpinalInjuriesprotocol

– Removed• ReferrallinktoGeneralPainManagement


• Transporttheamputatedpartwiththepatient,ifpossible,butdonotdelaytransporttosearchforamputatedpart

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4.2AvulsedTooth

• KeyPoints/Considerations– Added– Thebesttransportmediumforanavulsedtoothisinthesocket,intheappropriatesituation

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4.3Bleeding/HemorrhageControlAppliestoadultandpediatricpatients

• Criteria– WordingChange

• Removedthewordcompressivedevices• Junctionaltourniquets,woundclosuredevices,andotherhemostaticdevicesmaybeusedinaccordancewithmanufacturerinstructions,ifregionallyapproved

• Tacticalapplicationofthesedevicesbeyondthisprotocolmayberegionallyapproved

• ReferraltoShockprotocolversusHypoperfusionprotocolsforadultandpediatricpatients

• CFRandAllLevels– Removed

• Airwaymanagementandappropriateoxygentherapy(coveredinotherprotocols)

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4.3Bleeding/HemorrhageControl(continued)


• Donotremoveatourniquetthatwasplacedforlifethreateningbleeding– Ifatourniquethadbeenplacedforapparentlynon-lifethreateningbleeding,thetourniquetmaybereleasedwhilemaintainingtheabilitytoimmediatelyreapplyandotherwisecontrolthehemorrhageshouldsignificantbleedingoccur

– Thesestepsarenotintendedtobeusedinsequence;interventionsshouldbetakenusingthebestjudgementoftheEMSprofessional

– Hemodialysisaccesssitesmayresultinlifethreateninghemorrhage.DirectdigitalpressureshouldbeusedfirstfollowedbytourniquetONLYinthesettingoflife-threateninghemorrhagewhenothermeansofhemorrhagecontrolhavebeenunsuccessful.

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4.3Bleeding/HemorrhageControl(continued)

• KeyPoints/Considerations(continued)– Whenextremitybleedingsitescannotberapidlydetermined,tourniquetsmaybeplacedhighandtightinaccordancewithtraining

– Conventionalandpressuresplintsmayalsobeusedtocontrolbleeding

– Hemostaticdressings*shouldbeusedaccordingtomanufacturer’sinstructionsandtrainingandmayrequireremovalofcoagulatedbloodtodirectlyaccessthesourceofbleeding

– *Ifequippedandtrained

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4.4BurnsAppliestoadultandpediatricpatients


• Burnstotheeyerequirecopiousirrigationwithnormalsaline–donotdelayirrigation– Otherneutralfluidmaybeused,ifneeded,suchastapwater

• EMT– WordingChange

• Burnsshouldbecoveredwithdry,steriledressings– Moiststeriledressingsmaybeusedtoaugmentpainmanagementonlyiftheburnis≤10%BSA(bodysurfacearea)

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4.4BurnsAppliestoadultandpediatricpatients

• CC/Paramedic– Added

• Foreyeexposures:– Tetracaine(0.5%)2dropsintheaffectedeyeforpainevery3minutes,asneeded

– Forchemicalexposuretotheeye,youmayuseaMorganLens®forirrigation

• KeyPoints/Considerations– WordingChanges

• Considerotherinjuries…versusbealertforotherinjuries….• Thewholeareaofthepatientshandis~1%BSAversusjustthepalm

– Added• Hypothermiaisasignificantconcernforthesepatients

– Removed• ConsiderationsfordirecttransporttoBurnCenter- HavethatdiscussionwithMedicalControl 140

4.5ChestTraumaAppliestoadultandpediatricpatients

• CFRandAllLevels– Added– Asuckingchestwoundoccurswhenairpassesthroughawoundinthechestwallwhenthepatientbreathesin


• Ifthepatientisincardiacarrest,proceedwithbilateralneedlechestdecompressionandrefertoappropriatearrestprotocol*– ThiswaspreviouslyunderCClevelandisnottaughtunderthenationalAEMTcurriculum,shouldonlybeusedbyTacticaltrainedAEMT’s

*AdvancedEMTsintacticalEMSmaybetrainedandequippedfordecompression,buttheagencymustbe

approvedbytheREMAC141

4.6CrushInjuries- Adult

• KeyPoints/Considerations– Minorwordchange

• Aminimumwasremovedbefore50mLNSinIVbetweencalciumchlorideandsodiumbicarbonate

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4.7EyeInjuriesAppliestobothadultandpediatricpatients

• Exposuresremovedfromtheprotocolname• Careforcontaminatedeyesmovedtoburnprotocol

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4.8MusculoskeletalTrauma


• Referimmediatelytothe“Trauma:Bleeding/HemorrhageControl”protocol,asindicated

• KeyPoints/Considerations– Consideranyopenwoundnearasuspectedboneinjurysitetobetheresultofboneprotrusion

– Physicalexaminationforunstablepelvisfracturesisunreliableandstabilizationofthepelvisisindicatedbasedonthemechanismofinjury

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4.9PatellaDislocationAppliestoadultandpediatricpatients

• EMT,Advanced,CC,Paramedic– WordingChange– Considerpainmanagementversusinitiatepainmanagement

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4.10SuspectedSpinalInjuries(New)Appliestoadultandpediatricpatients

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4.10SuspectedSpinalInjuries(New)(continued)

• KeyPoints/Considerations– Spinalmovementcanbeminimizedbyapplicationofaproperlyfittingrigidcervical collarandsecuringthepatienttotheEMSstretcher

– Theheadofthestretchershouldnotbeelevatedbymorethan30degrees

– Whenspinalmotionrestrictionhasbeeninitiatedandahigherlevelofcarearrives,patientsmaybereassessedforspinalinjury(perthisprotocol)

– Whenpossible,thehighestlevelofcareonscenewilldetermineifspinalmotionrestrictionistobeusedordiscontinued(collarremoved,etc.)

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A4.11TraumaAssociatedShock- Adult

• PreviouslynamedTraumaAssociatedHypoperfusion• Advanced,CC,Paramedic

– Added• UnderdecompensatedshockNSFluidBolus

– IfSBP<100mmHgorMAP<65,mayrepeatuptoatotalof2Liflungsoundremainclear

– Removed• Additionalvascularaccess• 500mLanhourfollow2Lfluidbolus

• KeyPoints/Considerations– ChangesSBPparameterto100insteadof90mmHg– ChangedMAPparametersto65insteadof60mmHg

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4.12TraumaPatientDestinationAppliestoadultandpediatricpatients

• PreviouslynamedTraumaTriage-CDC• Remainsthe2011guidelinesforfieldtriageofinjuredpatientspublishedbytheCDC

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AddedorChangedResources– Pleasereview

• P5.2APGAR• 5.3AutomaticTransportVentilator

– UnderKeyPoints• RemovedATVwillnotbeusedwithCPR,

– ventilatewithBVMduringCPR

• 5.5GlasgowComaScore(GCS)Newinprotocols– Acalculatoronappalreadyexistsundertools

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AddedorChangedResources–Pleasereview

• 5.6IncidentCommand- New(movedfrompatientcareresponsibilities)• 5.7InterfacilityTransports- Movedtoresources• 5.8MedicationFormulary- Addedchartofoptionalmedications– NitrousOxideInhaled– AcetaminophenPO– IbuprofenPO

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AddedorChangedResources- Pleasereview

• 5.10Needlestick/InfectiousExposures– Removedsomekeypointsonfollowupcare– Thesepointsshouldbepartofanagenciesexposurecontrolplan

• 5.11NerveAgent- Suspected– Movedtoresources– GuidanceforDisasterSetting– Alllevelsofcare– YoushouldbefamiliarwithyourlocalChempackProgram.

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• 5.13OxygenAdministrationandAirwayManagement– MovedtoResources– AddedCFRandallproviderlevels– Added-Ongoingassessmentoftheeffectivenessofbreathing• refertothe“Extremis:RespiratoryArrest/Failure– Adult”or“Extremis:RespiratoryArrest/Failure– Pediatric”protocol,ifnecessary

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• 5.13OxygenAdministrationandAirwayManagement(continued)– %Changefrom<92and2informationalpointsadded

• Oxygentherapyvianon-rebreathermask(NRB)10-15LPM,ornasalcannula(NC)2-6LPM,tomaintainoxygensaturationifsaturationis<94%ortoeffectivelymanageothersignsofdyspnea– Somechildrenwithcardiacconditionsmayhavebaselineoxygensaturationsbetween65and85%ratherthanabove94%(askcareprovideraboutpatient’susualoxygensaturationlevel)

– Infantoxygenadministration,ifneeded,shouldbeprovidedat0.5-2LPMviaappropriatelysizednasalcannula

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• 5.13OxygenAdministrationandAirwayManagement(continued)– Added-Anypatientwithsuspectedcarbonmonoxidepoisoningshouldreceivehighflowoxygenvianon-rebreathermask(NRB),seealso“General:CarbonMonoxideExposure– Suspected”protocol

– NPAandOPAchangedtoAppropriateBLSairwayadjuncts

– Oxygenpowerednebulizerdevicesforuseinaccordancewithmanufacturerspecifications(typically~6-8LPM)

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• 5.13OxygenAdministrationandAirwayManagement(continued)– Added- Continuouspositiveairwaypressure(CPAP)5-10cmH2O*• Fortheadultpatient• ForolderpediatricpatientsconsiderCPAPforEMT,asequipmentsizeallowsifavailableandtrained

• 5.14PediatricAssessmentTriangle– Added• 5.15PrescribedMedicationAssistance– MovedtoResources– AddedunderParamedic-Steroids(SoluCortefandothers)viaIMinjection

– MedicalControlConsiderations- wordingchangeto“withinscopeofpractice”from“notlistedabove” 156


• 5.16RefusalofMedicalAttention– New• 5.17ResponsibilitiesofPatientCare- movedtoResources• 5.18TransferofPatientCare– New• 5.19VascularAccess- MovedResources• 5.20VascularDevices– Pre-Existing(nochangeinprotocol,movedtoresources)

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