CHRISTUS EMS CLINICAL PRACTICE GUIDELINES

CHRISTUS EMS CLINICAL PRACTICE

GUIDELINES “Primum nil nocere”

Effective January 1, 2020

__________

Christopher L. Dunnahoo, MD, FAEMS CHRISTUS EMS Chief Medical Officer

Prepared for CHRISTUS EMS 2020.4 Date Version: 07/01/2020 Version 2019.1

Clinical Practice Guidelines Version 2020.4

A Word from Your Medical Director 1 Administration Page

A Word from Your Medical Director

I would like to give credit where credit is due. These CPG’s would not be possible without a concerted effort between Clinical Services, Operations, Administration and Communications. I would specifically like to thank the Clinical Services Department. Their tireless effort in educating both current and new Team Members allows CHRISTUS EMS to have such progressive guidelines. Additionally, I would like to thank our EMT’s and Paramedics; it is their dedication to the patients they serve that allows this company to continually move forward. As always, my intent is to create a set of CPG’s that work for you instead of the other way around. I want CPG’s that you can utilize, along with your judgment and experience, to care for patients. No set of CPG’s can cover all situations. Patients require your judgment and experience in order to receive excellence in care. Through your hard work and our continuing education we will provide that care to our patients. Please remember that first and foremost our job is to care for patients. We see patients on the worst days of their lives. Caring for patients in their time of need is a privilege. We honor that privilege by constantly striving for excellence in every patient interaction that we have. What we do matters. Let me say it one more time: What we do matters. Thank you for allowing me to be your Medical Director. Please be safe out there. Sincerely,

Christopher L. Dunnahoo, MD, FAEMS Chief Medical Officer, CHRISTUS EMS

Version 2020.4 Clinical Practice Guidelines

Acknowledgements 2

Acknowledgements Author Christopher L. Dunnahoo, MD, MS, FAEMS

Co-Authors Michael A. Williams, CCEMT-P Jerri Pendarvis, RN

Editor/Illustrator Michael A. Williams, CCEMT-P

Reviewers Stan Holden, CEO Todd Martin, M.Ed., NRP, LP


Table of Contents 3 Administration Page

Table of Contents A Word from Your Medical Director ---------------------------------------------------------- 1

Acknowledgements ------------------------------------------------------------------------------- 2

Table of Contents ---------------------------------------------------------------------------------- 3

Medical Guidelines Documents -------------------------------------------------------------- 11

Administration Page ------------------------------------------------------------------------------------------- 12

Geographical Area & Duty Status--------------------------------------------------------------------------- 14

Patient Care Guideline Disclaimer -------------------------------------------------------------------------- 15

Introduction and Foundation of Practice ----------------------------------------------------------------- 16

Scope of Practice ------------------------------------------------------------------------------------------------ 17

Scope of Practice Matrix -------------------------------------------------------------------------------------- 18

Allied Health Care Providers Interactions & EMS Student Riders ---------------------------------- 19

Rapid Turnaround Patients/Unscheduled Transfers--------------------------------------------------- 20

Bypass Guidelines ---------------------------------------------------------------------------------------------- 21

Guidelines for Aeromedical Transport -------------------------------------------------------------------- 23

Withholding Resuscitation for the Patient with a DNR ----------------------------------------------- 24

Withholding Resuscitation for the Patient with Obvious Signs of Death------------------------- 25

Termination of Resuscitation (TOR) ----------------------------------------------------------------------- 26

Minimum Patient Care Documentation------------------------------------------------------------------- 27

Documentation of Vital Signs -------------------------------------------------------------------------------- 29

Patient Refusals/No Transport ------------------------------------------------------------------------------ 30

File Transfer of Patient Care Records ---------------------------------------------------------------------- 31

Assessment Standards ---------------------------------------------------------------------------------------- 32

Multiple Casualty Incident Management ----------------------------------------------------------------- 37

Combined START/Jump START Triage Algorithm ------------------------------------------------------- 38

Medication Safety ---------------------------------------------------------------------------------------------- 39

COVID-19 Medical Director Intro Statement ------------------------------------------------------------ 40


Table of Contents 4

Emerging Infectious Disease (COVID-19) Adult and Pediatric --------------------------------------- 41

Blood Draw Request by Texas Magistrate or Law Enforcement Officer -------------------------- 44

Patient Safety Restraint --------------------------------------------------------------------------------------- 45

No CPG Guideline/ Self-Reporting-------------------------------------------------------------------------- 47

Clinical Decision-Making ----------------------------------------------------------------------- 48

Adult General Patient Management ----------------------------------------------------------------------- 49

Airway Management/Oxygenation and Ventilation -------------------------------------------------- 51

Basic and Advanced Airway Management --------------------------------------------------------------- 57

COVID-19 Airway Algorithm --------------------------------------------------------------------------------- 58

DSI Adult & Children (>10 years of Age) Page 1 ------------------------------------------------------ 59

DSI Adult & Children (>10 years of Age) Page 2 --------------------------------------------------------- 60

DSI Children (<10 years of Age) Page 1 -------------------------------------------------------------------- 61

DSI Children (<10 years of Age) Page 2 -------------------------------------------------------------------- 62

Post Intubation Management ------------------------------------------------------------------------------- 64

Mechanical Ventilation --------------------------------------------------------------------------------------- 65

Pain Management ---------------------------------------------------------------------------------------------- 66

Adult Spinal Motion Restriction ---------------------------------------------------------------------------- 68

Hypoperfusion and Shock ------------------------------------------------------------------------------------ 69

Sepsis -------------------------------------------------------------------------------------------------------------- 71

Adult Altered Mental Status --------------------------------------------------------------------------------- 72

Symptom Management --------------------------------------------------------------------------------------- 74

Cardiovascular Disease ------------------------------------------------------------------------- 75

Adult Cardiac Arrest-------------------------------------------------------------------------------------------- 76

Adult Cardiac Care: Bradycardia ---------------------------------------------------------------------------- 78

Adult Cardiac Care: Tachycardia ---------------------------------------------------------------------------- 79

Adult Cardiac Care: Chest Pain/Acute Coronary Syndrome ----------------------------------------- 81

Adult Cardiac Care: Post Resuscitation Care ------------------------------------------------------------- 83

Adult Congestive Heart Failure ------------------------------------------------------------------------------ 84



Medical Problems and Emergencies -------------------------------------------------------- 86

Abdominal Pain (Non-Traumatic) -------------------------------------------------------------------------- 87

Allergic Reaction/Anaphylaxis ------------------------------------------------------------------------------ 88

Agitated/Behavioral/Psychotic Patient ------------------------------------------------------------------- 90

Hyperkalemia ---------------------------------------------------------------------------------------------------- 92

Adult Diabetic Emergencies ---------------------------------------------------------------------------------- 94

Adult Hypertension -------------------------------------------------------------------------------------------- 95

Adult Epistaxis --------------------------------------------------------------------------------------------------- 96

Adult Seizures --------------------------------------------------------------------------------------------------- 97

Adult Stroke/TIA/CVA ----------------------------------------------------------------------------------------- 98

RACE+ (Rapid Arterial Occlusion Evaluation) ----------------------------------------------------------- 101

Obstetrics, Gynecology & Neonatology -------------------------------------------------- 102

Vaginal Bleeding ----------------------------------------------------------------------------------------------- 103

Premature Labor/PROM ------------------------------------------------------------------------------------- 105

Pre-Eclampsia/Eclampsia ------------------------------------------------------------------------------------ 107

Childbirth -------------------------------------------------------------------------------------------------------- 109

Post-Partum Care ---------------------------------------------------------------------------------------------- 111

Neonatal Resuscitation -------------------------------------------------------------------------------------- 113

APGAR Score ---------------------------------------------------------------------------------------------------- 114

Neonatal Stabilization ---------------------------------------------------------------------------------------- 115

Pediatric Clinical Practice Guidelines ----------------------------------------------------- 116

Pediatric Resource Information ---------------------------------------------------------------------------- 117

Pediatric General Patient Management ----------------------------------------------------------------- 118

Pediatric Altered Mental Status --------------------------------------------------------------------------- 120

Pediatric Diabetes Emergencies --------------------------------------------------------------------------- 122

Pediatric Seizures ---------------------------------------------------------------------------------------------- 123

Pediatric Cardiac Care (BLS) --------------------------------------------------------------------------------- 124

Pediatric: Bradycardia ---------------------------------------------------------------------------------------- 125


Table of Contents 6

Pediatric Cardiac Arrest -------------------------------------------------------------------------------------- 127

Pediatric Stable Tachycardia -------------------------------------------------------------------------------- 129

Pediatric Unstable Tachycardia ---------------------------------------------------------------------------- 130

Pediatric: Post Resuscitation Care ------------------------------------------------------------------------- 131

Respiratory Problems and Emergencies ------------------------------------------------- 132

Upper Airway Obstruction ---------------------------------------------------------------------------------- 133

Middle and Lower Airway Obstruction ------------------------------------------------------------------ 135

Trauma, Injury, & Environmental Emergencies ---------------------------------------- 137

Assault & Violence -------------------------------------------------------------------------------------------- 138

Bites and Envenomation’s ----------------------------------------------------------------------------------- 140

Burn Management -------------------------------------------------------------------------------------------- 141

Dental Complaints and Injuries ---------------------------------------------------------------------------- 143

Eye Injury or Complaint -------------------------------------------------------------------------------------- 144

Heat Emergencies --------------------------------------------------------------------------------------------- 145

Hypothermia ---------------------------------------------------------------------------------------------------- 146

Drowning and Near Drowning ------------------------------------------------------------------------------ 147

Toxicological Emergencies and Medication Reactions ----------------------------------------------- 148

Care of Patient in Police Custody -------------------------------------------------------------------------- 151

Isolated Extremity Trauma ---------------------------------------------------------------------------------- 152

Multisystem Trauma ------------------------------------------------------------------------------------------ 153

Traumatic Arrest ----------------------------------------------------------------------------------------------- 155

Head and Face Trauma --------------------------------------------------------------------------------------- 157

Trauma Destination ------------------------------------------------------------------------------------------- 158

National Trauma Triage Protocol -------------------------------------------------------------------------- 159

Trinity Mother Frances Trauma Activation Criteria --------------------------------------------------- 160

Good Shepherd Medical Center Trauma Activation Criteria --------------------------------------- 161

Procedural Application ----------------------------------------------------------------------- 162

Intubation-Orotracheal -------------------------------------------------------------------------------------- 163



Airway Suctioning --------------------------------------------------------------------------------------------- 165

Endotracheal Suctioning ------------------------------------------------------------------------------------- 166

Intubation-Stoma ---------------------------------------------------------------------------------------------- 167

Clear-Guard II Breathing Filter (HEPA) ------------------------------------------------------------------- 168

MDI Spacer using mask -------------------------------------------------------------------------------------- 169

Supraglottic Device (i-gel) ----------------------------------------------------------------------------------- 170

Needle Cricothyrotomy -------------------------------------------------------------------------------------- 171

Surgical Cricothyrotomy ------------------------------------------------------------------------------------- 172

Continuous Positive Pressure Ventilation (CPAP) ----------------------------------------------------- 174

Capnography ---------------------------------------------------------------------------------------------------- 175

Pulse Oximetry ------------------------------------------------------------------------------------------------- 177

Chest Decompression ----------------------------------------------------------------------------------------- 178

Chest Tube Drainage Management & Monitoring ---------------------------------------------------- 180

12 Lead ECG ----------------------------------------------------------------------------------------------------- 181

External Cardiac Pacing -------------------------------------------------------------------------------------- 183

Modified Valsalva Maneuvers ------------------------------------------------------------------------------ 184

Defibrillation – Manual -------------------------------------------------------------------------------------- 185

Double Sequential External Defibrillation (DSED) ----------------------------------------------------- 186

Cardioversion --------------------------------------------------------------------------------------------------- 187

Intravenous Access -------------------------------------------------------------------------------------------- 188

External Jugular Venous Access ---------------------------------------------------------------------------- 190

Vascular Access EZ-IO Access Device --------------------------------------------------------------------- 192

Medication Administration – Continuous IV Infusion ------------------------------------------------ 194

Medication Administration – Intravenous -------------------------------------------------------------- 195

Medication Administration – Intramuscular ------------------------------------------------------------ 196

Intranasal Drug Administration ---------------------------------------------------------------------------- 197

Medication Administration – Endotracheal------------------------------------------------------------- 198

Medication Administration – Sublingual ---------------------------------------------------------------- 199

Medication Administration – Nebulized ----------------------------------------------------------------- 200


Table of Contents 8

Medication Administration – Oral------------------------------------------------------------------------- 201

Blood Product Continuation -------------------------------------------------------------------------------- 202

Naso/Orogastric Tube Insertion --------------------------------------------------------------------------- 204

Helmet Removal ----------------------------------------------------------------------------------------------- 205

Blood Glucose Analysis --------------------------------------------------------------------------------------- 206

Combat Tourniquet ------------------------------------------------------------------------------------------- 207

Medication Reference Guide ---------------------------------------------------------------- 208

Acetaminophen (APAP) -------------------------------------------------------------------------------------- 209

Adenosine ------------------------------------------------------------------------------------------------------- 211

Albuterol (aerosolization) ----------------------------------------------------------------------------------- 213

Albuterol (MDI) ------------------------------------------------------------------------------------------------ 215

Amiodarone ----------------------------------------------------------------------------------------------------- 217

Anectine ---------------------------------------------------------------------------------------------------------- 219

Aspirin ------------------------------------------------------------------------------------------------------------ 221

Atropine Sulfate------------------------------------------------------------------------------------------------ 223

Biorphen (phenylephrine) ----------------------------------------------------------------------------------- 225

Calcium Chloride ----------------------------------------------------------------------------------------------- 227

Calcium Gluconate -------------------------------------------------------------------------------------------- 230

5% Dextrose (D5w) -------------------------------------------------------------------------------------------- 232

10% Dextrose (D10w) ----------------------------------------------------------------------------------------- 233

50% Dextrose in Water (D50w) ---------------------------------------------------------------------------- 234

Dexamethasone (Ozurdex) ---------------------------------------------------------------------------------- 236

Diltiazem --------------------------------------------------------------------------------------------------------- 237

Diphenhydramine --------------------------------------------------------------------------------------------- 239

Epinephrine ----------------------------------------------------------------------------------------------------- 241

Esmolol Hydrochloride --------------------------------------------------------------------------------------- 244

Famotidine ------------------------------------------------------------------------------------------------------ 245

Fentanyl Citrate ------------------------------------------------------------------------------------------------ 247



Glucagon --------------------------------------------------------------------------------------------------------- 249

Ipratropium ----------------------------------------------------------------------------------------------------- 251

Isopropyl alcohol ---------------------------------------------------------------------------------------------- 253

Ketamine --------------------------------------------------------------------------------------------------------- 254

Labetalol --------------------------------------------------------------------------------------------------------- 257

Lidocaine --------------------------------------------------------------------------------------------------------- 259

Magnesium Sulfate -------------------------------------------------------------------------------------------- 262

Methylprednisolone ------------------------------------------------------------------------------------------ 264

Midazolam------------------------------------------------------------------------------------------------------- 266

Naloxone --------------------------------------------------------------------------------------------------------- 268

Nicardipine ------------------------------------------------------------------------------------------------------ 270

Nitroglycerin ---------------------------------------------------------------------------------------------------- 271

Norepinephrine ------------------------------------------------------------------------------------------------ 273

Normal Saline (0.9 Percent Sodium Chloride) ---------------------------------------------------------- 275

Ondansetron ---------------------------------------------------------------------------------------------------- 276

Oral Glucose ---------------------------------------------------------------------------------------------------- 278

Oxygen ----------------------------------------------------------------------------------------------------------- 280

Oxytocin ---------------------------------------------------------------------------------------------------------- 282

Propofol ---------------------------------------------------------------------------------------------------------- 284

Rocuronium Bromide ----------------------------------------------------------------------------------------- 286

Sodium Bicarbonate ------------------------------------------------------------------------------------------ 288

Tetracaine ------------------------------------------------------------------------------------------------------- 290

Thiamine --------------------------------------------------------------------------------------------------------- 292

Tranexamic acid (TXA) ---------------------------------------------------------------------------------------- 294

Toradol ----------------------------------------------------------------------------------------------------------- 296

Miscellaneous Reference Lists -------------------------------------------------------------- 298

Important Lab Values ----------------------------------------------------------------------------------------- 299

IV Infusion Cards ----------------------------------------------------------------------------------------------- 300


Table of Contents 10

Approved Abbreviations ------------------------------------------------------------------------------------- 301

Activase Transport Protocol -------------------------------------------------------------------------------- 303

Medication Inventory CHRISTUS EMS -------------------------------------------------------------------- 304

Minimum Supply List CHRISTUS EMS --------------------------------------------------------------------- 306


Medical Guidelines Documents 11 Administration Page

Medical Guidelines Documents


Medical Guidelines Documents 12

Administration Page The information contained within these guidelines has been prepared specifically for the employees of CHRISTUS Emergency Medical Services (CEMS). This information is designed to provide direction for personnel during patient care situations. All clinicians utilizing these guidelines must be currently certified or licensed as a pre-hospital health care provider by the Texas Department of State Health Services. Additionally, each provider must be authorized to practice as an EMT, AEMT (Intermediate), or Paramedic. All advanced procedures are performed as an extension of the medical control physician and must be authorized prior to the performance. Authorization could be in the form of direct medical contact via phone or radio or via written clinical practice guideline orders. If the pre-hospital clinician is unsure what to do for a patient at any point during care he or she is expected to consult with medical control for guidance. On-Line Medical Control Dr. Dunnahoo serves as the Medical Director for CHRISTUS EMS. They also serve as Off-Line Medical Control for the organization. When questions over direct patient care occur in the field, the Medical Directors have arranged for a predetermined process for online communication with an Emergency Physician. This on-line communication is through Emergency Physicians staffing the CHRISTUS Good Shepherd Health System. When transporting to a CHRISTUS Good Shepherd Health System (GSHS) facility, the facility you are transporting to (i.e. Main, North-Park, Kilgore, or Marshall) will serve as On-Line Medical Control. This will allow the physician who will ultimately be caring for the patient to be involved early inpatient care. When transporting to a non-CHIRSTUS GSHS facility, CHRISTUS GSHS Main will serve as On-Line Medical Control. Please contact Communications to have your call transferred to a CHRISTUS GSHS facility. You will then inform Communications which facility you need to speak with. If you ever have difficulty in reaching a physician at one of the CHRISTUS GSHS sites due to the physician being actively involved in patient care, you can contact one of the other CHRISTUS GSHS facilities. Please remember to contact Communications first to have your call transferred to another CHRISTUS GSHS facility. This will allow the call to be recorded so it can later be reviewed if questions arise. We want all Team Members to feel free to call On-Line Medical Control for any clinical issue, but the Team Member needs to understand the difference between a clinical issue and an operational issue. For example, On-Line Medical Control does not understand all the intricacies of transporting a patient outside of the CEMS service area. These types of issues should be addressed by the Administrator-On-Call (AOC) and not On-Line Medical Control. Transport destination questions should go to the AOC. If any operational/transport issues arise, please contact AOC to discuss the issue. If need be, the AOC can consult the Off-Line Medical Directors for further clarification. On-Line Medical Control should be utilized only to address clinical issues specific to patient care.


Medical Guidelines Documents 13 Administration Page

Each clinical practice guideline is designated as an adult, pediatric, or life span clinical practice guideline. Life Span Clinical Practice Guidelines (CPGs) are applicable to patients of all ages. Adult patients and pediatric patients can be separated by the presence of secondary sex characteristics. If a patient has secondary sex characteristics they will be treated as an adult in this emergency medical services system. Children are defined as those patients without secondary sex characteristics. Each guideline has an icon in the upper corner. Those icons designate the type of clinical practice guideline and mean the following.

Adult CPG Life Span CPG Pediatric CPG

It is imperative that employees are proficiently knowledgeable of this material. Any questions or concerns shall be directed to the Clinical Director for clarification. Approved, this date to be effective Click here to enter a date. January 1, 2020



Geographical Area & Duty Status Geographical Area:

These guidelines may only be utilized in CHRISTUS EMS service areas, mutual aid areas, when responding to disaster request areas, public relations events or when on transfers out of the normal service area. Duty Status:

CHRISTUS EMS personnel shall utilize these clinical practice guidelines only when acting in their official capacity as a clinician of this EMS system.


Medical Guidelines Documents 15 Patient Care Guideline Disclaimer

Patient Care Guideline Disclaimer Clinical Practice Guidelines are systematically developed statements to assist the EMS Crew about appropriate health care for specific clinical circumstances. These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatment from those specified in a given guideline. Guidelines are not entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results. While guidelines can be written that take into account variations in clinical settings, resources, or common patient characteristics, they cannot address the unique needs of each patient. Nor can they account for the combination of resources available to a particular community, health care professional or provider. Deviations from Clinical Practice Guidelines may be justified by individual circumstances. Thus, guidelines must be applied based on individual patient needs using professional judgment.



Introduction and Foundation of Practice Introduction:

This document describes a framework that CHRISTUS EMS pre-hospital clinicians will use to guide our quest to provide high quality pre-hospital patient care. This document incorporates evidence-based guidelines with historically proven practices. It is incumbent on the pre-hospital clinician to understand that these clinical practice guidelines and policies can only provide guidelines for patient care. The very nature of critical and emergency care delivery outside the walls of a hospital demand some level of autonomy and flexibility. Clinician experience and judgment should be utilized to assure the best patient care. While it is impossible to address every variation of disease or traumatic injury, these clinical practice guidelines do provide a foundation for treating the vast majority of patients we encounter. On-line medical control is available and should be utilized for those patient presentations that do not fall within the scope of these guidelines. Pre-hospital providers work with great autonomy but autonomy demands maturity. A key to maturity is recognition of the need for consultation or guidance from on line medical control. Definition of a Patient:

A patient is an individual requesting or potentially needing medical evaluation or treatment. The patient provider relationship can be established via telephone, radio, or personal contact. It is the provider’s responsibility to ensure all potential patients, regardless of the size of the incident, are offered the opportunity for evaluation, treatment, and transport. Rights of a Patient:

Once the pre-hospital clinician begins to collect patient information regarding a patient encounter, it is important to take every precaution to protect patient confidentiality. While clinicians certainly have HIPPA issues to consider, they also have an ethical obligation to protect a patient’s confidential information. This applies to both written and verbal communication. Competent patients retain the right to accept or refuse medical care, even if the consequences of the refusal of care may potentially be harmful for the patient. In the event a patient attempts to refuse medical care, it is important to recall that we should:

Be courteous Offer transport with some (or all) of the recommended treatments if that is what the patient will allow. Clearly advise the patient of the possible complications of their decision. Advise the patient to call back if they subsequently desire treatment and/or transport. Accurately document all components of the patient encounter Provide a witness signature by; police, nursing staff, family, friends, or if no other person is available

EMS team member other than the chart author Finally, the manner in which we carry ourselves is often as important as the care we provide. For many of our less critically ill or injured patients, the human interaction has more of a healing effect than any of our proven practices. Perhaps Dr. Ed Racht, former Austin/Travis County Medical Director states this best: “Being a professional has nothing to do with pay or rank or the level of certification you hold. It is the goal that every member of our practice, from the basic provider to the Medical Director, constantly strives to remain a comprehensive, clinically sophisticated, and compassionate EMS Provider.”


Medical Guidelines Documents 17 Scope of Practice

Scope of Practice General

Under Texas law, all EMS practitioners must work under the authority of a medical director physician. That physician has the right to delegate practice as he or she sees fit. In the CHRISTUS EMS Emergency Medical Services System, providers are delegated to one of three levels of practice. Emergency Medical Technicians may perform basic life support and select pre-hospital medical procedures as listed in the attached “Scope of Practice Matrix.” EMT- Intermediates have additional privileges as listed in the matrix, and paramedics have an even more extensive scope of practice as delineated in the matrix. At all times in this EMS system, the highest designated provider with the patient will retain ultimate authority and responsibility for patient care. In order for a specific pre-hospital provider to function at a specific level that provider must be certified or licensed at the appropriate EMS level by the Texas Department of State Health Services. Additionally, the practitioner must successfully complete the appropriate orientation or internship required by the medical director prior to functioning at a specific EMS provider level. Similarly, the clinician can only maintain a specific level of practice through acceptable performance as judged by continuous performance improvement evaluation, continuing education, and acceptable employee performance. First Responders

Through mutual aid and medical direction agreements, The CHRISTUS EMS Medical Direction System may provide medical direction to first responder agencies that work within the CHRISTUS EMS service area. All first responder agency members covered under this medical direction system will operate at their appropriate level of EMS registration or licensure up to the level of EMT-Basic. First responder agency members that are registered or licensed as an EMT-I, EMT-P, or an LP will only function as an EMT-Basic while operating as a first responder agency member. Interfacility Medication

Throughout these clinical practice guidelines, numerous medications are listed for pre-hospital administration by various members of the transport team. A clinician in the CHRISTUS EMS System may administer or continue to administer any medication during an inter-facility transport that he or she could administer in the pre-hospital environment adhering to the same guidelines he or she would adhere to if involved in pre-hospital patient contact. In the event a paramedic unit is called to an inter-facility transport and arrives to find the patient needs to receive medication in transport above the listed scope of practice for that medication or not specifically detailed in these clinical practice guidelines, the paramedic must make online medical control for permission to transport, inter-facility medication administration orders and parameters, as well as for guidance prior to accepting care of the patient. If at all possible, a critical care team should transport patients that are receiving medications above the paramedic scope of practice or those medications that are not identified in these clinical practice guidelines. Paramedic Attendance

All patients in the CHRISTUS EMS System will be continuously cared for by the highest-level provider prior to and during 911 transports. The only exception is if the paramedic has to temporarily leave the patient to facilitate care (i.e. to retrieve narcotics, MCI). At the paramedic’s sole discretion, EMT’s may function as the team leader for non-emergency (non-911), priority 3 patients. Examples include: patients discharge home from any facility not requiring advanced assessments or interventions. Additionally, the EMT will only function as team leader after completion and certification of the accreditation process provided by the CHRISTUS EMS Education Department



Scope of Practice Matrix EMERGENCY MEDICAL

TECHNICIAN ADVANCED EMERGENCY

MEDICAL TECHNICIAN (INTERMEDIATE)

PARAMEDIC

CPR All EMT Privileges All EMT and AEMT Privileges BVM Ventilations with/without PEEP

Peripheral IV Insertion Venous Blood Sampling

Oral and nasal Airways External Jugular Cannulation Approved Medications by the following route: IV, NG/OG, IN, Rectal, IO, Topical

Bandaging and Splinting IV Fluid Administration ECG Interpretation Blood Glucose Monitoring IO Insertion Defibrillation Pulse Oximetry and O2 administration

SL Nitroglycerin Administration Cardioversion

Supraglottic Airway Placement IM Glucagon Administration TC Pacing Manual and Auto B/P Inhaled Beta Agonist

Administration 12-Lead Interpretation

Oral Glucose Administration Inhaled Ipratropium Administration

Basic Airway Management

ASA administration IV/IM Narcotic Antagonist Administration

Advanced airway management including Oral intubation.

IM Epinephrine Administration IV D-50 Administration Cricothyrotomy Spinal Immobilization IV-Thiamine ETCO2/Capnography Traction Splinting Oral or Nasal Gastric Tube

Placement Mechanical Patient Restraint Needle Decompression Tourniquet Bi-PAP/CPAP/PEEP Cervical Collar Childbirth assistance OG Tube with i-GEL


Medical Guidelines Documents 19 Allied Health Care Providers Interactions & EMS Student Riders

Allied Health Care Providers Interactions & EMS Student Riders Other allied health care providers such as a registered nurse or respiratory therapist who accompany a patient in a CHRISTUS EMS vehicle may assist EMS personnel with patient care. These health care providers may provide specialized patient care according to their level of expertise upon written direct orders of a physician. Despite the presence of an allied health care provider, CEMS personnel will retain ultimate responsibility and control of patient care within CEMS ambulance. The only exceptions to this rule is when a physician is physically present with the patient and assumes responsibility for the patient, and/ or a critical care transport team is physically present and assumes responsibility for the patient.

When CHRISTUS EMS clinicians assume patient care from another health care provider or from a group of providers (i.e. a neighboring EMS agency or hospital staff members) the clinician will obtain an appropriate handoff report. The transfer of care must be clear and the time should be noted in the PCR. The CHRISTUS EMS crew should not perform any invasive procedures such as intubation prior to hand off and receipt of the patient. Crewmembers should perform all advanced procedures necessary after handoff.

Upon arrival at a receiving facility, crewmembers will retain responsibility for patient care until contact has been made with a licensed clinician of the same level or higher and handoff communications have occurred. Any Emergency Medical Services student who is riding in a CHRISTUS EMS vehicle or accompanying a crew for educational purposes under an agreement between an educational institution and CHRISTUS EMS will abide by the policies of CHRISTUS EMS. The EMS crew will maintain control of patient care at all times. The EMS student may practice EMS skills at their level of training but at no time may exceed their level of training. EMS crewmembers and students will work together to maintain an environment that provides quality patient care and quality student learning. EMS students are authorized to attempt endotracheal intubation, Supraglottic insertion at the discretion of the paramedic preceptor. If the airway is predicted to be difficult, the most experienced provider should make the attempt. EMS students are not authorized to attempt Surgical Airway procedures. This skill will only to be performed by a CEMS Paramedic.



Rapid Turnaround Patients/Unscheduled Transfers ● Some patients will require stabilization in an Emergency Department with rapid transport to a facility with a higher

level of care. ● The goal for the treatment of these patients is to resuscitate and stabilize the patient and then rapidly transport

the patient. ● These patients should be quickly identified by both the EMS Crew and the Emergency Department staff. ● In these situations, the EMT Basic should ensure that the unit is promptly cleaned and ready for transport or

another 911 call. ● A 911 call will always take precedence over the transport. ● If a 911 call occurs while at the Hospital with a Rapid Turnaround Patient, it may be necessary for the EMS Crew

to leave the hospital to run the 911. If EMS team member has assumed care for transport, then at no time will the transport be interrupted or delayed.

● CHRISTUS EMS will always attempt to honor the Rapid Turnaround Process. However, a 911 call will need to take precedence in order to ensure care for those patients who have no access to medical providers.

● To ensure continuity of care, the Medic should stay with the patient in the ED and assist, as needed, in caring for the patient (splinting, IV access, etc.). This teamwork model will allow extra hands to help stabilize these critically ill patients.

● Once the patient has been identified as a Rapid Turnaround Patient, the EMS Crew should notify Dispatch that they are staying with the patient at the hospital to assist in the rapid turnaround.

● A Rapid Turnaround Patient should be ready for transport in < 45 minutes. If delays in transport are expected, then the patient does not qualify for Rapid Turnaround. However, the ED staff should be encouraged to notify Dispatch of the potential need for transfer as soon as possible. Once, the pre-transfer process is completed an ambulance can then be requested.

● Aeromedical transport should be considered very early for critically ill patients or patients with a time-sensitive illness. Ideally, a helicopter could be launched to the hospital, by the EMS crew while still in the field. This allows for the patient to be stabilized in the Emergency Department while the helicopter is moving toward the patient.

● A Rapid Turnaround Patient transfer still requires a M.O.T. and administrative approval prior to transfer ● Examples include but are not limited to:

o Unstable STEMI o Unstable Level 1 or Code 88 Trauma Patient

Three levels of unscheduled transfers (see unscheduled transfer policy) Immediate Transfers (Critical response mode)

• Earliest response available with an upper limit of 30 minutes • Critical transfers are time sensitive, life or limb situations

Rapid Transfers (Emergent response mode)

• Response within 1 hour (earlier if resources allow) • Emergent transfers are patients being transferred to a higher level of care but do not have a time sensitive,

life or limb situation • Most long distance transfers will fall under this category. Due to the distance of the transfer and the time that

the unit will be unavailable for 911 coverage, the 1-hour response time may not be met in all cases Routine Transfers (non-emergent response mode)

• Response time within 2 hours (earlier if resources allow) • Non-emergent transfers are stable patients requiring transfer to another facility or back to the nursing home


Medical Guidelines Documents 21 Bypass Guidelines

Bypass Guidelines ● This guideline ensures proper treatment of patients in a timely manner. They were created to serve the best

interest of our patients. To ensure that life-saving treatment be started quickly, some patients will be taken to a closer facility first and then transferred to a facility with a higher level of care once stabilized. By following these guidelines, it ensures that thrombolytic can be started quickly in a Code Stroke patient, antibiotics can be started quickly in a septic patient and an airway can be secured and vasopressors can be started in a critically ill patient. It also ensures that some patients with orthopedic injuries can be treated directly at the local facility and then discharged home with orthopedic follow up. This relieves the burden on the family of having to travel a greater distance to pick up their loved one.

● This guideline should not affect your judgment on when a helicopter should be called. ● Trauma patients should be taken to the appropriate facility based on your judgment and the TRAUMA DESTINATION

CPG. ● Your judgment should always be used on your patients. This guideline cannot cover all potential situations. We

transport too many facilities not listed below. If you have any questions regarding whether or not a patient should be taken to the local facility or bypassed to the facility with higher level of care, contact Medical Control.

● In order to consider bypassing the local facility, all patients must have stable vital signs and an intact airway. If this is not the case, then proceed to the closet facility.

● The list below includes those patients to be considered for bypass. ● CHRISTUS-GSMC Marshall

o Code STEMI ▪ Except for those patients who are unstable (requiring an airway or are hypotensive)

o Pregnant patients > 20 weeks with complaint of pre-term labor, and pain or pelvic pain without signs of imminent delivery

● CHRISTUS-GSMC North-Park o Code STEMI o Level 1 traumas o Field intubated patients o Pregnant patients > 20 weeks with complaint of pre-term labor, and pain or pelvic pain without signs of

imminent delivery o Open fractures

▪ Excluding fingertip injuries o Suspected significant head injury or intracranial hemorrhage

● CHRISTUS-GSMC Kilgore


o Level 1 or Code 88 Traumas ▪ Including Trauma Codes ▪ Except for patients in which an airway cannot be established

o Field intubated patients o Pregnant patients > 20 weeks with complaint of pre-term labor, and pain or pelvic pain without signs of

imminent delivery o Open Fractures

▪ Excluding fingertip injuries



● CHRISTUS-TMF Winnsboro

o Code STEMI ▪ Unstable patients (requiring airway management or hypotensive) should proceed to the closest facility.

DO NOT BYPASS. ▪ Judgment should be used to determine appropriate destination depending on location, weather,

resources, etc. ▪ If a patient has NO contraindications to thrombolytic and there is concern for meeting First Medical

Contact (FMC) to Balloon Time of 90 minutes, transport to the local facility for thrombolytic should be considered. Medical Control can be utilized to assist in determining appropriate destination.

o Open Fractures ▪ Excluding fingertip injuries

● CHRISTUS-TMF Canton


o Level 1 or Code 88 Traumas ▪ Excluding Trauma Codes or patient in which an airway cannot be established

o Field intubated patients o Pregnant patients > 20 weeks with a complaint of pre-term labor, and pain or pelvic pain without signs of

imminent delivery o Open Fractures

▪ Excluding fingertip injuries o Patients experiencing a behavioral health emergency (Acute psychosis, suicidal ideation, homicidal ideation,

etc.)


Medical Guidelines Documents 23 Guidelines for Aeromedical Transport

Guidelines for Aeromedical Transport

Indications:

A helicopter may be utilized when all of the following are present: 1. Patient meets criteria for trauma center evaluation and ground transport would delay arrival at the trauma center. 2. The patient is entrapped and extrication is expected to last greater than 20 minutes. OR Ground transport time

would delay the patient reaching the appropriate facility faster. 3. The patient in cardiac arrest with the following conditions:

- Refractory Ventricular Fibrillation/Tachycardia, Pediatric, Trauma, and Pregnant patient 4. Post Cardiac Arrest ROSC patients

Additionally, EMS providers may request air medical transport via helicopter when any of the following are present and the patient would receive tertiary care faster by aircraft than by ground transport to the appropriate hospital: ● Acute coronary syndromes ● Acute neurological emergencies ● Mass casualty situations. ● Patients with greater than 15% total burn surface area 2nd or 3rd degree burns. ● Patients with 2nd or 3rd degree burns involving hands, feet, genitalia or face. ● Inhalation burns. ● Significant chemical or electrical burns. ● Major trauma ● Obstetrical emergencies (i.e. preterm labor, placental abruption etc.) ● Acute vascular emergencies requiring time sensitive care. ● When time sensitive specialized services are required that local receiving hospitals are not equipped to provide

(critical care services, obstetrics, neonatology, dialysis, etc.). ● The patient requires care available on the aircraft that is not available on a ground ambulance. ● Patient transport by another method is not available. ● Patients with electrolyte disturbances or toxic exposures that require immediate intervention EMS Aircraft Request Procedure:

1. Any public safety provider on scene or enroute to a scene (based on dispatch information) can determine that a helicopter may be needed for a patient. Once the request for an aircraft has been made, it may only be canceled by the senior Paramedic on scene after a patient assessment has been completed.

2. That person will request CHRISTUS EMS Communications to contact the nearest aeromedical provider. 3. Under NO circumstances will transport of a patient be delayed to use a helicopter. 4. If the patient becomes unstable while waiting for the helicopter (requiring advanced airway management,

becomes hypotensive, etc.), the patient should be taken to the closest facility. Flight should then be diverted to the facility for rapid transport after stabilization.

5. If there is ever a question about whether a patient should be flown or taken to the closest facility, contact MEDICAL CONTROL for consultation.

6. When a hospital helipad is being utilized as a LZ, the medic should instruct CHRISTUS EMS Communications to contact that hospital and notify them that their LZ is being utilized for a scene flight.



Withholding Resuscitation for the Patient with a DNR

Indications:

A pulseless, breathless patient who normally would require resuscitation The pre-hospital clinician may withhold resuscitation when the patient is not in a hospital and there is a written record verifying the patient wishes to die without resuscitative care. The document may as listed: ● A properly completed state approved Out-of-Hospital Do-Not-Resuscitate form

Procedure:

1. Assure family consensus with DNR. If there is conflict over the decision to resuscitate, contact medical control. 2. Verify that the patient is the person named in the DNR order or form. 3. Cease all resuscitation efforts. 4. Notify law enforcement and/or justice of the peace of the patient’s death. 5. Attach original DNR form or photocopy of the patient's DNR order to the completed PCR. 6. If unsure of validity of a do not resuscitate order, begin CPR and contact online medical control. 7. If physician has signed order in a skilled nursing facility’s chart, and no Out-of-Hospital DNR exist then CEMS

crew will need to make contact with medical control


Medical Guidelines Documents 25 Withholding Resuscitation for the Patient with Obvious Signs of Death

Withholding Resuscitation for the Patient with Obvious Signs of Death

Indications:

One or more of the following are present: ● Rigor mortis. ● Dependent lividity. ● Decapitation and/or hemicorporectomy (transection of the torso) ● Incineration with no signs of life present “See below”. ● Decomposition. ● The patient is tagged as a black patient under START triage criteria in a disaster. ● Blunt or Penetrating traumatic cardiac arrest with no signs of life present and asystolic. Procedure:

1. Do not resuscitate any patient who meets the above criteria. 2. If resuscitation efforts are in progress, consider discontinuing the resuscitation efforts. 3. Notify law enforcement and/or justice of the peace of the patient’s death. IF YOU ARE UNSURE WHETHER THE PATIENT MEETS THE ABOVE CRITERIA, RESUSCITATE! With the exception of blunt or penetrating traumatic arrest, an ECG strip is not required for any patient that meets any of the above criteria. Witnessed cardiac arrest does not qualify for withholding of resuscitative efforts. Patients should be managed per the ADULT PULSELESS ARREST or PEDIATRIC CARDIAC ARREST CPGs. Signs of life include:

● Any spontaneous movement ● Any sign of respiratory effort (including agonal respirations) ● Any peripheral pulses (radial, etc.), central pulses (carotid, femoral), or any auscultated heart sounds. If any signs of life are present, resuscitate!



Termination of Resuscitation (TOR) Discontinuation of cardiopulmonary resuscitation and other advanced lifesaving interventions may be considered when ALL OF THE FOLLOWING CRITERIA HAVE BEEN MET: ● Adequate CPR has been administered ● Endotracheal intubation or Supraglottic placement has been achieved. ● IV/IO access has been achieved. ● Rhythm appropriate medications have been administered according to the correct CPG or the Traumatic Arrest

CPG has been completed fully. ● Persistent Asystole or an Agonal rhythm is present in two leads and no reversible causes are identified. ● The patient exhibits all of the following after 20 minutes of ALS resuscitation by the CEMS crew.

o No spontaneous circulation (palpable pulse). o No neurological activity (spontaneous respiration, eye opening motor response). o ETCO2 readings of less than 10 mmHg.

● Patient is 18 years old or older. ● Patient is not in a public venue (public facility, parking lot, cemetery, sports arena, mass gathering, etc.). ● There is no presence of hypothermia (exposure, cold water drowning). ● All medical personnel on scene agree with the decision to cease efforts. ● Termination can be completed in a manner that poses no risk to EMS providers, the deceased body, or evidence

on the scene. ● There has not been a defibrillation performed by first responders or EMS.

If the patient has a ROSC at any point in the resuscitation, transport will be initiated immediately.

If the resuscitation is terminated, all disposable invasive devices will be left in place, and the patient will remain where they are at the time the resuscitation is terminated. Law enforcement and/or Justice of the Peace should be contacted and the crew should remain on scene until law enforcement arrives. Medical Control should be contacted to cease efforts on any patient that has been defibrillated but has remained in Asystole or an Agonal rhythm >20 minutes. If transport is selected for an arrest patient, it should be done priority 2, and to the closest hospital. Agonal Rhythm – Often the last ordered semblance of organized activity in the heart prior to death. Typically the heart rate is <20 bpm, without “P” waves and wide bizarre appearing QRS

***If the patient has been moved inside a CEMS unit, resuscitation efforts should continue & the patient should be transported to the nearest appropriate facility***


Medical Guidelines Documents 27 Minimum Patient Care Documentation

Minimum Patient Care Documentation For every patient contact, the following must be documented at a minimum:

1. A clear history of the present illness including: chief complaint, time of onset, associated complaints, pertinent

negatives, mechanism of injury, etc. This should be included in the subjective/typed portion of the PCR. The section should be thorough enough to re-create the clinical situation after it has faded from memory.

2. Each chart should be documented so that assessment, intervention, and reassessment follow a chronological order. Each note must be time stamped so that clinician thoughts, events that occur during the call, medication and procedural interventions, and patient vital signs could be recreated by a third party into an objective time line.

3. Each Clinical Decision making CPG has a list of minimum points of documentation. Each point must be addressed in the PCR.

4. An appropriate physical assessment that may include: pupil assessment, breath sounds, motor function, abdominal exam, chest exam, head exam, extremity exam, etc. When appropriate, this information should be included in the procedures section of the PCR.

5. Each time vital signs are documented they must include a pulse, respirations, blood pressure, (with the first blood pressure being auscultated) Glasgow Coma Scale, a pain scale and pulse oximetry readings. Vital signs should be repeated and documented after every drug administration, prior to patient transfer, and as needed during transport and upon final destination. A minimum two sets of vitals to be provided in the ePCR documentation not excluding other requirements. (See below #8)

6. Additionally, vital signs will include ETCO2 (when applicable) for any patient that meets the following criteria; a. Any patient oxygenated with a BVM. b. Intubated. c. Mechanically ventilated. d. Any respiratory complaint. e. Any acute altered mental status f. Patients receiving narcotics must be on Etco2 waveform

7. A patient temperature will be documented during care for the following patients; a. Pediatric patients b. Obstetrical patients c. Heat or cold related illnesses d. Critically ill or critically injured patients e. Patients with signs or symptoms of infection

8. Vitals signs will be documented a minimum of every fifteen minutes for stable patient, and five minutes for unstable

9. All critically ill or critically injured patients, as well as any patient receiving narcotics, sedatives, or hemodynamically active drugs will have vital signs documented every five minutes.

10. Only CEMS approved abbreviations will be used. 11. For drug administration, you must document the dosage of the drug, route of administration, time of

administration, and response to drug. After administration of analgesics, pain must be reassessed and documented.

12. A complete listing of treatments performed in chronological order and any response to these treatments. 13. For patients with an extremity injury, pulse, movement, and sensation must be noted before and after

immobilization and repeated every fifteen minutes. 14. For patients with spinal immobilization, pulse, movement, and sensation must be documented before and after

spinal immobilization and repeated every fifteen minutes. 15. For IV administration, the size and location of the IV catheter, the number of IV attempts, the type of fluid

administered, and the flow rate must be documented.



16. The cardiac monitor upload of “Code Summary” is required for all patient care activities. The additional high acuity transports i.e. field advanced airway management cardiac arrest require “ALL DATA” to be uploaded to the Code Stat System and ePCR. Any significant rhythm changes will be documented in the vitals reassessment section under rhythm interpretation. Monitors will be applied to all patients with any cardiac history, this includes interfacility transfers. Code Summary reports require the medic to push the event button to record the rhythm change

17. 12 lead ECGs, when performed, should also be included in the report/transmission with patient’s name. Any

adult patient with cardiac or respiratory distress will have a 12 lead ECG on scene, during transport and before arrival at the hospital. a. Interfacility transport of patients with possible cardiac event will require a minimum of two12-lead ECG’s

performed during transport. b. Additional, any change in patient’s condition will require an additional 12-lead ECG c. Interfacility transfers for patients with an identified STEMI & Cath Lab activation at receiving facility require a

12-lead ECG to be performed by the CEMS crew.

18. For patients who receive intubation, the PCR should reflect the size of the ET tube, the centimeter mark at the teeth, the number of intubation attempts (and by whom) and a minimum of four methods used to confirm placement. a. Direct visualization b. Click and Lock

i. Tactile stimulation of the bougie on the tracheal rings (click) ii. Prevention of advancement of the device (lock)

c. No epigastric sounds with equal bilateral breath sounds d. Continuous ETCo2 monitoring

i. Only true confirmation ii. Must be done on every patient, every time

19. During intubation attempts the EMS crew must strive to keep the SPO2 greater than >94%. If pulse oximetry drops below <94%, crewmembers must document interventions to correct hypoxia.

20. Capnography tracings will be provided through the ePCR upload reflecting the time of pre-oxygenation, immediately after intubation, and at the time of patient hand off in the receiving unit... (ALL DATA UPLOAD)

21. Any requested physician orders, whether approved or denied, should be documented clearly, and recorded through CEMS communications.

22. Any wasted narcotics will include the quantity, name of crewmember wasting, where wasted, and name of person who witnessed the waste. Hospital personnel should be utilized, if available.

23. All crewmembers will review the content of the PCR for accuracy. 24. Upon arrival at the receiving facility, the crewmember will document the patient condition with a handoff note in

the PCR. 25. After giving report to the receiving facility staff, a receiving facility staff member signature will be obtained

verifying receipt of the patient. 26. Once the PCR is completed, patient care information may not be modified for any reason. Corrections or

additions should be in the form of an addendum. Any corrections to the PCR will delete the signatures. 27. The PCR shall be completed prior to leaving the hospital (no more than 15 minutes) unless the unit is being

assigned to a pending emergency. The ePCR should be made available to the receiving facility within 2 hours unless call volume will not allow it. In this case the report must be complete before leaving shift or contact AOC if there is some reason it cannot be completed.

28. A CHRISTUS EMS Short Form will be left at the hospital in the event that an electronic ePCR cannot be completed within the 15 minutes transfer of care. This form must be signed, copied and attached to the ePCR.


Medical Guidelines Documents 29 Documentation of Vital Signs

Documentation of Vital Signs Vital signs are a key component in the evaluation of any patient and a complete set of vital signs is to be documented for any patient who receives some assessment component. To Insure:

● Evaluation of every patient’s volume and cardiovascular status. ● Documentation of a complete set of vital signs. Procedure:

1. An initial complete set of manual vital signs includes: a. Pulse rate b. Respiratory rate c. Systolic and diastolic blood pressure d. Level of consciousness (GCS) e. Pain severity (when appropriate to patient complaint) f. Pulse oximetry

2. When no ALS treatment is provided, palpated blood pressures are acceptable for repeat vital signs. 3. Based on patient condition and complaint, vital signs may also include:

a. Temperature b. ETCO2

4. If the patient refuses this evaluation, the patient’s mental status and the reason for the refusal of evaluation must be documented.

5. In situations that preclude the evaluation of a complete set of vital signs the reasons should be clearly documented.

6. Vital signs will be assessed every 15 minutes on stable patients and every 5 minutes on unstable patients. A minimum of two sets vitals are required if transports time is less than 15 minutes for stable patient.

7. For stable long distance interfacility transfers, vital signs can be assessed every 30 minutes if the patient is noted to be stable on the first two sets.

Note: Any change in patient’s condition requires an additional set of vitals to be recorded in the vitals section to support patient’s reassessment



Patient Refusals/No Transport Competent patients maintain the right to refuse care and/or transport. If unsure, Administrator-on-call (AOC)/Regional Manager should be contacted. When a CHRISTUS EMS unit arrives on scene the CEMS Professional, under medical direction, is the only person that will assess need for transport, and/or no transport after assessing the patient. Who may consent / Refuse care?

• Legal as the authorized decision maker: >18 years of age, Pregnant minors, and Emancipated minors • Mental capacity with sufficient understanding and memory to comprehend the situation

All patients refusing service will: ● Be informed of the availability of service and offered treatment and transport in a non-confrontational and polite

manner a minimum of 3 times. ● Be advised to call 9-1-1 for the return of symptoms or if they change their mind about transport to the hospital. ● Be advised that they accept full responsibility for their actions. Contact AOC/Regional Manager if treatment has been started, a treatment beyond what the patient could do for themselves, i.e., D50 medication administered or significant evaluation (including C-spine clearance or ECG assessment) has occurred, and the patient declines transport. If the AOC/Regional Manager is unable to convince the patient to be transported, and advanced medical care has been provided Medical Control should be contacted & allow for a 3-way-communication between field paramedic, AOC/Regional Manager & Medical Control ● Give the Medical Control Physician an explanation of the situation and request permission to discontinue

treatment. ● The name of the physician who provided on-line medical control must be documented in the PCR. ● When making contact with the physician, the contact should be done via a recorded line through the dispatch

center. Calling the hospital direct will not record the call. Documentation:

1. In the report narrative, describe: a. The patient encounter b. Vital signs c. Advice is given d. That the patient is alert and oriented to person, place, and time and has the capacity to make this choice. e. That the patient understands the instructions given to him/her and not under the influence of ETOH, drugs or

medications. 2. If possible, have the patient sign the refusal form and a third party witness (family, law enforcement, fire

department personnel) with signature. 3. At no time will EMS professionals mention cost of transport, patient’s insurance status, hospital billing or

insurance practices, the status of system/unit availability, or any other non-clinical subject in an attempt to influence a patient’s decision to accept or decline transport.

4. The Patient Refusal Checklist and No Transport form must be completed in the interventions section of the electronic PCR. A No Transport Form will be given to the patient prior to leaving the scene.

***If the AOC/RM is unable to convince the patient to be transported, medical control should be contacted &

allow for a 3-way communication between crew, AOC/RM & medical Control. ***


Medical Guidelines Documents 31 File Transfer of Patient Care Records

File Transfer of Patient Care Records A Patient Care Record (PCR) shall be accurately completed for each response to a call for service. The PCR should contain all available requested information regarding call demographics, patient assessment, care rendered and patient response to care. This includes non-emergency responses with or without patient transport and all transfers whether scheduled or non-scheduled. Completed PCR’s may not be altered or changed unless done by the individual that completed the form, except to add or change billing information or add a name and other pertinent demographic information if it was unknown at the time of the call. Completed PCR’s are confidential patient medical records and access is limited to responding personnel, Texas Department of State Health Services as part of an administrative, investigative process, authorized medical facilities that received the transport, members of the CHRISTUS EMS Continuous Quality Improvement Program, and ambulance provider service payer sources. Copies of completed PCR’s may be provided to other sources only as legally permitted. The records may also be provided to the patient or patient’s responsible party by valid medical record release. PCR completion

1. Documentation of patient assessment and treatment information contained on the PCR is the responsibility of personnel providing patient care.

2. Completed PCR’s may not be altered or changed except by the individual that completed the form, except as previously noted. If a paper PCR is utilized, any documentation error shall be lined through, and the correction shall have the patient attendant’s initials beside it. Any changes made to an automated PCR shall have documentation of those changes noted and attached as an addendum.

3. Each PCR shall be accurately completed with all available and relevant information as described in the documentation standards. Use of CEMS approved abbreviations are permitted in the narrative section of the record or as defined in automated PCR prepopulated pick lists.

4. Each PCR shall be accurately completed as soon as possible after the response, or patient transport is completed, and copies should be provided to the receiving facility in a customary manner.

5. Wait and return transfers receive two incident numbers (one incident number to transport the patient to the destination and the second to return the patient to the original location). Therefore, the two reports should be written.



Assessment Standards Our immediate patient assessment consists of the evaluation and, if needed, management of the following components: ● Life-threatening bleeding ● Cervical Spine ● Airway ● Breathing ● Circulation ● Level of consciousness The following is an outline for the assessment and management of these components. The initial assessment includes (in order) 1. Tourniquet life-threatening bleeding 2. Obtain manual control of the cervical spine, if indicated 3. Evaluate airway and establish a patent airway, if needed 4. Evaluate breathing, initiate ventilation or ventilatory assistance, if needed, assess for open chest wounds and

occlude, if found 5. Check for presence and adequacy of circulation and initiate chest compressions, if needed 6. Quickly establish a level of consciousness (AVPU) Cervical Spine

If there is any possibility of a spinal injury, the provider should assume that one exists and approach the patient accordingly. The provider’s first step for any patient with the possibility of a spinal injury is to obtain control of the c-spine manually. This manual c-spine stabilization should be maintained until: 1. Further assessment clearly and absolutely rules out any possibility of spinal injury 2. The spine is adequately immobilized with adjuncts (C-Collar) which relieve the need for manual stabilization OR 3. The patient refuses further treatment or transport

According to PHTLS, the following are indicators from the mechanism of injury that a potential spinal injury exists and that these patients should be immobilized: ● Blunt trauma above the clavicles ● Diving accident ● Motor vehicle collision or bicycle accident ● Fall ● Stabbing or impalement anywhere near the spinal column ● Shooting or blast injury with forces that could act on the spinal column or cord. Patients who are found unconscious on the floor are considered to have a cervical spinal injury unless a bystander or family member can give an accurate account of how the patient got to the floor. Proper cervical spine protection includes manual stabilization, C-collar application, and patient placement; following the spinal motion restriction pathway.


Medical Guidelines Documents 33 Assessment Standards

Airway

The patient’s airway should next be evaluated for patency. If there is any indication of a compromise in the patient’s airway or any threat that such a compromise will develop, the provider should immediately intervene to secure the airway. Indications of compromise may be as overt as apnea or a visible obstruction or may be indicated by a less obvious sign such as airway noises (stridor, snoring, gurgling, etc.). The airway should be secured first with positioning, using a jaw-thrust if the spinal injury cannot be ruled out or a head-tilt/chin-lift if a spinal injury is not a concern. If material must be physically removed from the airway, this should be done using abdominal or chest thrusts, a finger sweep and/or oral suctioning as appropriate. If a patient’s level of consciousness is diminished, an airway adjunct should be placed. An oral airway should be used; if tolerated, otherwise a nasal trumpet should be used. Manual positioning should be maintained concurrently with the use of such an adjunct. If possible, the airway should next be definitively secured with ET intubation. Even in the patient whose airway is initially patent, the provider should continuously reassess and be prepared to intervene against any airway compromise. Breathing

The next component to be assessed is the patient’s respiratory status. If the patient is not breathing spontaneously, ventilation with supplemental oxygen should be initiated immediately. If the patient is breathing spontaneously, the adequacy of the patient’s respiratory effort should be evaluated. If the patient’s rate or tidal volume is inadequate, assisted ventilation with supplemental oxygen should be provided immediately. The patient’s chest should also be rapidly assessed for open wounds, which would compromise respiration. If an open chest wound is found, it should be immediately occluded, initially with the provider’s gloved hand and then with an occlusive dressing. The bag-valve-mask device with oxygen at 10-15 LPM and a reservoir bag is the preferred method of providing ventilation. When indicated, the airway should be secured with ET intubation/Etco2. As with the airway, the provider should continuously reassess the ventilatory status of even the most stable patient and be prepared to intervene if respiratory compromise develops rapidly. Circulation

The patient shall be assessed for: 1. Adequate circulation AND 2. For the presence of major external hemorrhage. If the patient is awake or at least responsive to verbal or physical stimulus, the provider shall assume that circulation is adequate for the moment and move on. If the patient is unresponsive, the provider should assess for the presence and adequacy of a palpable carotid pulse. If the patient does not have a palpable carotid pulse, (or a heart rate less than <60 bpm in an infant or <100 bpm in a neonate), the provider should initiate chest compressions. A more accurate evaluation of the patient’s perfusion status should be done during the secondary survey. Next, rapidly assess the patient for external bleeding. If major bleeding is found, it should be immediately controlled with a tourniquet. After the airway and breathing are secured, the provider can return to the bleeding and attempt to control it with direct pressure or tourniquet. Level of Consciousness

The level of consciousness should be briefly assessed using the “AVPU” scale (Alert, Verbal, Painful, Unresponsive). Further assessment of the level of consciousness can be deferred until the secondary survey. All patient contact will



complete triage assessments based upon (RED, YELLOW, GREEN or BLACK) and radio this information to the Communications Officer upon patient contact Focused and Detailed Assessment

The focused assessment is pertinent to the patient’s complaint. The detailed physical exam is a systematic, whole body assessment that evaluates physical findings and significant history. It is performed after the initial assessment has determined that there is not a life threat, or the interventions have been made to lessen that threat. The amount of time expended or even the necessity of these exams is directly dependent on the patient’s condition. All remarkable findings, associated symptoms, and pertinent negatives (ASPN) should be documented. This is also the time that an interview is conducted for history. This information is to be included in the patient report to the health care provider who receives this patient as well as in the patient care report. The SAMPLE mnemonic is easily remembered as: S – Signs and Symptoms A – Allergies M – Medications (prescribed, over the counter or elicit) P – Pertinent past medical history L – Last oral intake E – Events that led up to calling EMS R – Risk Factors

O – Onset of symptoms A – Associated P – Provocation S – Symptoms Q – Quality of Pain P – Pertinent R – Radiation of Pain N – Negatives S – Severity T – Time

Trauma Survey

A helpful mnemonic to assess trauma patients Head, Neck, Chest, Abdomen, and Extremities can be systematically checked using DCAP-BLS-TIC. D – Deformity B – Burns C – Contusions L – Lacerations A – Abrasions S – Stability P – Puncture, Penetration or Paradoxical Movement T – Tenderness I – Instability C – Crepitus

Trauma Head-To-Toe Survey

Head, Face, Eyes • Deformities • Depressions • Contusions • Hematomas or Battle signs

• Lacerations • Pupil size, equality, reaction to light • Extraocular motions • Raccoon eyes • Blink reflex


Medical Guidelines Documents 35 Assessment Standards

• Foreign bodies • Penetrations • Burns • Facial symmetry • Fractures • Discharge from ears and nose • Loose teeth or dentures • Oral secretions, vomitus or bleeding • Contacts or glasses Neck • Point tenderness • Alignment • Neck veins: flat or distended • Trachea: midline or deviated Chest • Paradoxical motion • Breath and Heart Sounds • Sternal inspection • Crepitus • Retractions with respirations

• Contusions, abrasions, hematomas • Sucking chest wound Pelvis and Extremities • Deformities • Pain on palpation • Contusions, abrasions, hematomas • Ecchymosis • Genitalia trauma • Distal circulation • Range of motion • Motor and sensory response • Abnormalities and deformities • Skin color and turgor Back • Pain • Deformities • Contusions, abrasions, hematomas

Medical/Cardiac Head-To-Toe Survey

Head, Face, Eyes • Pupil size, equality, reaction to light • Extraocular motions • Conjunctiva color • Blink reflex • Contacts or glasses • Facial symmetry • Skin color and quality • Discharge from ears and nose • Mouth odors • Loose teeth or dentures • Mucous membrane color Neck • Carotid artery bruits • Neck veins: flat or distended • Trachea: midline or deviated • Nuchal rigidity Abdomen • Localized tenderness

• Rebound tenderness or referred pain • Pulsating mass • Distention • Rigidity • Bowel sounds • Ecchymosis Extremities • Distal circulation • Range of motion • Motor and sensory response • Abnormalities and deformities • Skin color and turgor • Cyanosis, clubbing, edema



Occasionally, EMS personnel will encounter a patient whose injury can only be treated definitively with surgery. When confronted with such a patient, the attending EMS personnel shall institute the basic interventions noted here and begin transport to an appropriate facility AS SOON AS POSSIBLE. Rapid transport includes utilizing the helicopter to transport the patient when doing so expedites the transport of the patient to the most appropriate facility. See the “GUIDELINES FOR AEROMEDICAL TRANSPORT” regarding this issue. ONLY THE FOLLOWING INTERVENTIONS ARE TO BE DONE PRIOR TO INITIATING TRANSPORT OF A CRITICALLY ILL TRAUMA PATIENT. ● Spinal Motion Restriction

Spinal Motion restriction procedures may need to be modified and abbreviated to achieve rapid transport in some situations. Such deviations should be well documented and should still ensure that the patient is adequately and appropriately secured. The KED should not be used to immobilize sitting patients in a rapid transport situation.

● If rigid extrication device is used to move the patient to stretcher the removal of such a device should follow the Adult Spinal Motion Restriction algorithm

● BLS airway and ventilation procedures (Oxygen administration, OPA, BVM, etc.) ● Intubation IF it can be accomplished rapidly with no more than three attempts ● Surgical or needle airway ● Occlusion of open chest wounds ● Decompression of a tension pneumothorax ● Vital signs (may use peripheral pulses to estimate a blood pressure) ONLY TRAUMA PATIENTS ● Freeing patient from entrapment

All other interventions are to be done en-route to the hospital. If entrapment delays transport, other interventions may be instituted on-scene while awaiting the patient to be freed (e.g., Bandaging or splinting, IV initiation, cardiac monitoring, etc.)


Medical Guidelines Documents 37 Multiple Casualty Incident Management

Multiple Casualty Incident Management

General

Occasionally pre-hospital providers are called to multiple patient incidents where patients’ need exceed the capabilities of EMS providers on the scene. When responding to Multiple Casualty Incidents (MCIs), providers must shift their focus away from the needs of a single patient and instead focus on utilizing available resources to meet the need of the most salvageable patients. An MCI occurs when the number of patients is greater than a unit can effectively manage.

Procedure

1. Upon recognition of a multiple casualty incidents the primary unit on the scene must immediately notify dispatch that they have a multiple casualty incident.

2. The primary unit must establish command of the scene via radio. 3. The primary paramedic will assume the role of a (Triage Officer) patient care provider. 4. The secondary clinician will assume the role of Incident Medical Commander. 5. Patients will be triaged utilizing the combined START/Jump START triage algorithm.



Combined START/Jump START Triage Algorithm

6. If the incident involves six or more patients, each patient will be identified with a triage tag. 7. The incident commander will frequently update dispatch and maintain an accurate patient count and

their destination. 8. As additional units arrive on the scene they will be routed to the most critical patients. 9. The first unit on the scene will be the last unit to leave the scene after all patients have been

accounted for and dispositioned appropriately. 10. Documentation will at a minimum, provide names and DOB’s for every person triaged. For any

person receiving any interventions or care, a full ePCR must be completed.

Able to Walk?

Breathing

Respiratory Rate

Perfusion

Mental Status

Position Upper Airway

5 Rescue Breaths

No

Yes

<30 Adult15-45 Pedi

Obeys Commands (Adult)“A”, “V”, or “P” (Appropriate) (Pediatric)

Does not obey commands (Adult)“P”(Inappropriate), Posturing or “U” (Pediatric)

Yes

CR > 2 sec (Adult)No Palpable Pulse (Pedi)

Yes

No Breathing

Breathing

Minor

Immediate

Immediate

Delayed

Adult/Pedi

Apneic

DeceasedAdult

PulsePedi

No Pulse

Pulse

Apneic

> 30 Adult<15 or >45 Pedi

Secondary Triage

Using the JS algorithm, evaluate first all children who did not walk under their own power.


Medical Guidelines Documents 39 Medication Safety

Medication Safety

General

Pre-hospital clinicians administer numerous medications under circumstances that are often hectic and less than optimal. Therefore, it is imperative that all medication administration be completed in a manner that assures patient safety.

Procedure

1. No medication will be administered to a patient before asking the patient about previous allergies or medication reactions (assuming the patient can answer such questions).

2. No medication will be administered to a patient by a pre-hospital clinician unless it is a medication ordered by a physician either through online medical control or as standing order in these clinical practice guidelines.

3. All medications administered will be visually verified by the senior paramedic on the call to assure the right patient, right medication, right dose, right route, and right concentration prior to administration.

4. All medications that are withdrawn into an unlabeled container, like a syringe, will be individually labeled by the same person who withdrew them, prior to drawing additional medications.

5. Under no circumstances will pre-hospital clinicians ever administer a drug that is outside their scope of practice.

6. The paramedic may continue to administer a medication that has been ordered by a transferring physician on an inter-facility transport if the medication is within the level of practice applicable to the paramedic.

7. If an inter-facility transport patient is on a medication that is not within the CHRISTUS EMS scope of practice for a paramedic, a critical care team must transport the patient, or the sending facility must send a registered nurse and written physician orders with the patient unless there is preauthorization from online medical control.

8. All narcotic patches will be removed upon discovery if there is concern that the patch led to, or is the cause of the patients’ condition. If the patient requires pain control, treat pain per the PAIN MANAGEMENT CPG.

9. If the paramedic mixes a medication for infusion, the bag will be marked with the type of medication, the amount added and the date and time infused.



COVID-19 Medical Director Intro Statement During our response to the current global pandemic of Coronavirus (COVID-19), CHRISTUS EMS will make changes in how we respond and provide care for patients based on current evidence and recommendations from local and national organizations. We recognize that this is a dynamic situation that may require changes on a routine bases. During this time we have created a special section within our Standard Delegated Orders titled COVID-19 Specific Adjustments. These guidelines will contain information that will be utilized for the duration of our response to the current pandemic. These guidelines, titled COVID-19, will supersede any guidelines that may be contracting within this document. These guidelines will remain in effect until the CHRISTUS EMS Medical Director has deemed that these guidelines are no longer needed. Christopher L. Dunnahoo, MD, MS, FAEMS Medical Director


Medical Guidelines Documents 41 Emerging Infectious Disease (COVID-19) Adult and Pediatric

Communication Center Screening( Note 1)

Communication indicates patient positive screening for COVID-19

Apply PPE( Note 3 & 4 )

Place surgical mask on patient

General Patient Management CPG

Move to appropriate CPG based on symptoms( Note 5 & 6 )

Emerging Infectious Disease (COVID-19) Adult and Pediatric

Notes 2-6 Next page

(1)Screening for General Illness or Flu-like Illness (FLI) a. Fever (measured >100.4 or subjective) b. Cough c. Difficulty Breathing or Shortness of Breath d. Other FLI (runny nose, sore throat)

or (2) Is currently under investigation/isolation for COVID-

19 by public health (3) Has been in close contact with someone known to be sick with, or under public health investigation/isolation for COVID-19 If patient meets at least 1 criterion from 1 or 1 criterion

from 2-3 then the Communication Center will: e. Instruct the individual to isolate themselves, if

able, from close contact with others until EMS arrival

f. Notify responding EMS crew that patient meets pre-arrival screening criteria for COVID-19 and isolation/PPE measure should be taken prior to contact

g. Follow agency policies to limit multi-unit response or to limit the number of first responders that are exposed to the patient if possible

Note 1

Scope of Practice Age Scope Paramedic

Intermediate EMT-Basic Med Control



Note 2 • Do not rely solely on EMD personnel to identify potential exposure patient

Note 3 • Full PPE is required and includes a N95 mask, gown, eye protection and gloves

Note 4 • Limit patient contact to only one provider, if at all possible • All providers should attempt to maintain a distance of 6 feet or more, when feasible, and does

not interfere with patient care Note 5

Great care should be used with procedures that create aerosolization of infectious particles. These Include: • CPR • Intubation • Nebulization • Oropharyngeal and Nasopharyngeal Suctioning • CPAP • Bag Valve Mask Use • Oxygen Use at >6 L/min (nasal cannula and non-rebreathers) with open exhalation ports

If one of these procedures is being performed, all caregivers should be in full PPE In order to reduce aerosolization, these measures are to be taken:

• Intubation should be supraglottic airway device (iGel). Direct laryngoscopy should be used if the (iGel) fails

• Nebulization is high risk and should not be used for patients with confirmed or suspected COVID-19. Ask the patient if they have a home albuterol inhaler. If so, bring and utilize the patient’s home albuterol inhaler. If a home albuterol inhaler is not available, utilize the albuterol inhaler provided by CEMS. This inhaler should be left with the patient at receiving facility to allow for further treatments. If no albuterol inhaler is available, provide oxygen at no greater than 6 L/min. A NRB with ports covered with ECG electrodes can be used at 15 L/min Move to early CPAP in patients in severe respiratory distress. Epinephrine can then be used to treat bronchospasm.

• CPAP should be discontinued before entering the facility. Failure to do so potentially puts the entire ED staff at risk for exposure.

• Suctioning should only be performed if secretions are preventing adequate oxygenation and ventilation.

• HEPA filters should be used on BVM’s to decrease particle aerosolization (See HEPA Filter procedure).

• A maximum of 6L/min should be used for oxygen flow for nasal cannula and non-rebreathers. A NRB with ports covered with ECG electrodes can be used at 15 L/min. Higher rates aerosolize contaminates into the air. A nasal cannula or non-rebreather can be used. A surgical mask should be placed over the nasal cannula or non-rebreather. Passive oxygenation can still be used during intubation but with a maximum rate of 6 L/min.


Medical Guidelines Documents 43 Emerging Infectious Disease (COVID-19) Adult and Pediatric

Note 6 • Any suspected or confirmed COVID-19 patient requires full PPE. You must notify the ED

charge nurse by phone or radio of your concerns prior to arrival. You are to remain in the ambulance in the ambulance bay and wait for the staff to come out and meet you before the off-loading of the patient



Blood Draw Request by Texas Magistrate or Law Enforcement Officer General

● HB 434 of the State of Texas relating to the persons authorized to take a blood specimen from a

vehicle operator to test for alcohol concentration or other intoxicating substances. ● Section 724.017 amended the subsections adding the following licensed or certified emergency

technician Intermediate/Paramedic authorized to take a blood specimen ● Blood specimen must be taken in a sanitary place; this is noted as a controlled environment example:

patient compartment of the ambulance but not limited only to EMS vehicles, i.e. CHRISTUS EMS station.

● The CHRISTUS EMS Unit will not delay or deviate from the primary mission of patient care to obtain a blood draw on scene

● If for any reason, the paramedic feels uncomfortable performing this procedure, he/she should contact a supervisor immediately. If a supervisor is unavailable, ask communications to contact the administrator on call.

Procedure

Blood draws should be under the supervision of the requesting Justice of the Peace or Law

Enforcement Officer Use the blood draw kit as supplied by Law Enforcement Don appropriate personal protective equipment. Cleanse the venipuncture site using the povidone-iodine prep pad from the kit. Do not use

alcohol preps, as this could alter the accuracy of the test results. Make the venipuncture with an 18 or 20 gauge catheter. Withdraw the blood into the provided blood tubes using the needleless vacutainer equipment. Slowly invert the tubes at least 5 times to assure proper mixing of the blood and the

anticoagulant powder. The paramedic should write his/her initials, date and time on the tubes before handing the tubes to the Law Enforcement Officer

The Paramedic who drew the blood tubes should sign any required forms or labels and observe the blood tubes being sealed by the officer.

Accurate and thorough documentation of the circumstances and events should be recorded including the name of JP or Law Enforcement Officer requesting procedure, the site of the blood draw, the time performed and the time the blood sample was released to the JP or Law Enforcement.

Have the JP or Law Enforcement individual sign as having received the blood sample. Include documentation of site preparation as well as the use of betadine or iodine solutions. This documentation is important in the event the procedure and/or outcome of the test results are challenged in a court of law.


Medical Guidelines Documents 45 Patient Safety Restraint

Patient Safety Restraint General

This policy shall attempt to establish guidelines to ensure the safety of EMS personnel as well as patient safety in situations when the patient may be extremely agitated, and the potential for harm to self and/or others may exist.

Pre-hospital Patient Restraints (PPR) should be considered whenever a patient requiring immediate medical treatment becomes a threat to himself or other emergency personnel. This should be accomplished with the least amount of force necessary to protect the patient and emergency personnel. Law Enforcement Officers should be requested for assistance on any patient who requires physical restraints. A blood glucose level should be obtained as soon as it is safe to do so. Whenever possible, the communications officer should advise responding to personnel of potentially unstable or known unstable scenes and/or situations and locations when a request for EMS assistance is received. Additionally, responding personnel are to the staging for Law Enforcement personnel and should not enter the location until Law Enforcement Officers have assessed scene safety. A detailed evaluation of the patient’s mental status is required prior to initiating patient safety restraint. Full documentation of all events and the patient’s condition should appear on the Patient Care Report (PCR) whenever patient safety restraint is utilized.

Agitation or acute behavioral disorders may manifest differently. Always suspect an organic cause first. Life-threatening organic conditions that may be present with behavioral agitation could include pathologies like a subdural hematoma, intracerebral hemorrhage, meningitis, hypertensive crisis, hypoglycemia and pharmacological effects (especially atropine, stimulants, hallucinogens, and cyclic antidepressants). ● This procedure applies to patients being treated under implied consent and is not to be used on

patients specifically refusing transport that are of sound judgment to make that decision. ● If EMS personnel have entered a location that becomes unstable and physical injury is threatened

verbally and/or the patient, or other parties threaten physical harm, EMS personnel should physically remove themselves from the scene and move to a location of safety until Law Enforcement officials arrive. If necessary EMS personnel should leave medical equipment to accomplish this task. The safety of EMS personnel comes first.

● In all events, attempts should be made to “talk the patient down” before restraint is considered. The conversation should be honest and straightforward. EMS personnel should attempt to have equally open escape routes for both the EMS providers and the patient.

● DO NOT endanger yourself or other EMS personnel. At all times the safety of the medical personnel will remain first priority.

● Assess the patient’s mental status. Determine if the patient has suicidal or homicidal ideation. ● Use the minimum PPR needed to accomplish necessary patient care and ensure safe transportation

and crew safety. Employees will never use hard restraints (e.g., handcuffs, plastic ties, or leathers) to restrain patients. Patients may be restrained in handcuffs only if the police officer will remain with the patient in the ambulance during transport.

● If the patient is restrained with plastic restraints, the Law Enforcement officer may follow behind the ambulance during transport.



● Upon arrival at the facility, if an officer is no longer available, the plastic restraints must be removed. ● Acceptable restraints for EMS personnel include kerlix, sheets, wristlets, and chest posey. (If

Available) ● Additional manpower should be requested prior to attempting this procedure. A minimum of five (5)

people should be present to apply PPR safely. Four-Point restraints (restraining both arms and both legs) are preferred.

● In addition to securing both arms and legs, it may be helpful to tether the hips, thighs, and chest. Tethering the thighs just above the knees prevents kicking more effectively than restraining the ankles.

● Nothing should be placed over the patient's face, head, or neck. A non-rebreather mask with appropriate oxygen flow may be placed over the patient’s mouth to prevent spitting on emergency personnel.

● A c-collar may be applied to limit the mobility of the patient’s neck, decrease the patient’s range of motion to protect from biting as well as preventing injuries to the patient.

● Restraints WILL NEVER be placed in such a way that prevents the evaluation of the patient’s mental status or interfere with necessary patient care activities.

● Patients in the care of EMS personnel will never be placed in a prone position. ● Patients in the care of EMS personnel will never be sandwiched between two long spinal

boards. ● Patients in the care of EMS personnel will never be transported with hands and feet tied

behind their backs (i.e. in a prone maximal restraint position or hog-tied). ● EMS personnel should monitor circulation and pulses to ensure proper circulation and prevent further

injury to the patient. ● Full documentation of all events and patient’s condition are required on the Patient Care Report

(PCR) whenever Patient Safety Restraints are utilized. ● Continuous ECG, ETCO2, pulse oximetry and blood pressure monitoring (every 5 min) are

mandatory while being cared for by EMS personnel. ● All patients restrained by EMS personnel should receive chemical safety sedation to prevent

further excessive agitation and struggling against patient safety devices. Continued struggling against safety devices can lead to hyperkalemia, rhabdomyolysis and cardiac arrest.

● Patients will never be transported in a manner that compromises the safety of the crew or the ambulance. If in doubt about safety, or continued/resumed agitation, the pre-hospital clinician should consult with Medical Control regarding intubation and sedation.

● In the event that safety to a crew member or the patient arises during transport, the vehicle should be stopped as soon as safely possible, and law enforcement should be contacted to assist in safely restraining the patient.


Medical Guidelines Documents 47 No CPG Guideline/ Self-Reporting

No CPG Guideline/ Self-Reporting It is understood that no set of protocols/guidelines could ever be all-inclusive. With that understanding, occasionally, EMS providers will be in a patient care situation where no applicable protocol/guideline exists. In these circumstances, the paramedic on scene may consider all allowable treatment options within the CHRISTUS EMS CPG’s and discuss appropriate management options with ONLINE MEDICAL CONTROL. If he/she believes such interventions are necessary, the paramedic must inform Medical Control that no protocol/guideline exists to cover that particular situation. Additionally, the Clinical QA/QI Coordinator should be notified after the completion of the call so that the chart may be reviewed and changes of the CPG considered. Self-reporting is a term used when the EMS provider finds the patient to be of a High Acuity/High-Risk classification based upon the patient’s condition, and or treatments provided by the EMS provider. These scenarios much like the no CPG guidelines statement require the Clinical QA/QI Coordinator to review the reports and if necessary meet with the EMS provider to provide loop closure and training as needed. Examples include but not limited to:

• Unsuccessful field intubation • Cricothyrotomy by EMS personnel or Flight crew in the CHRISTUS EMS Unit • Multisystem Trauma Patients • Chest Decompression • Delivery of a newborn infant, and/or resuscitation of Newborn Infant • Use of the Agitated/Behavioral/Psychotic algorithm to including the use of restraints • Delay in patient care or transfer of patient care to another EMS provider • Failure in both equipment and/or ambulance during patient care • All resuscitation measures to include DOS

The self-reporting should be completed by email on the same shift of the failure and reported to the Clinical QA/QI Coordinator. Details should be provided to support an understanding of what took place. This will include the ePCR number.


Clinical Decision-Making 48

Clinical Decision-Making


Clinical Decision-Making 49 Adult General Patient Management

Adult General Patient Management



Note 1 Signs of hypoperfusion can include altered mental status, pale/cool skin, decreased capillary refill, tachycardia, hypotension, decreased urine output.

Note 2 Any patient with an altered level of consciousness should be assumed to have increased intracranial pressure. Adults with increased intracranial pressure should be managed so that the Mean Arterial Pressure is maintained greater than 80. Mean Arterial Pressure may be calculated as: 𝑀𝑀𝑀𝑀𝑀𝑀 = 𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆 𝐵𝐵𝐵𝐵+(2×𝐷𝐷𝑆𝑆𝐷𝐷𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆 𝐵𝐵𝐵𝐵)

3

Note 3 Bleeding from a dialysis graft or fistula is different. Most are a pinpoint area of bleeding from the needle insertion. Direct pressure with a finger handles the majority of bleeds

Scene Secure• Contact Law Enforcement• Do not expose self or co-workers to the

scene until it has been secured

Don PPE and bring all necessary equipment to the patient

Yes

No

• Tourniquet life threatening bleeding (Note 3)• C-Spine: manage per Spinal Motion Restriction CPG• Airway: manage per Basic & Advanced Airway Management CPGs• Breathing: manage per Oxygenation and Ventilation CPG• Circulation: manage hypoperfusion per Shock CPG (Note 1)• Disability: manage per Altered Mental Status CPG (Note 2)• Expose: undress and assess the patient as applicable

• Vital Signs• Chief Complaint• HPI• SAMPLE History• Reassessment

• Keep patient NPO• SpO2• Temperature (keep patient normothermic)• Large bore IV’s in critically ill patients• ECG/ETCO2 monitoring

• Apply appropriate CPG based on assessment• Treat symptoms per Symptom CPG

Contact medical control if:• Required by a specific CPG• If the patient does not fit a CPG• If you need consultation• If a complication arises

MC Transport ASAP



Documentation

• Respiratory and hemodynamic status • Applicable assessment • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if the patient is unstable • ECG/Temp/SpO2/ETCO2 as applicable • Abnormal neurologic findings • Glasgow Coma Scale

• The specific time of symptom onset • SAMPLE History • Symptom assessment (PQRST) • Treatment prior to your arrival • Treatment you provide • Response to treatment • Communication with medical control

CPG Links Medication Links Intervention Links

BASIC AND ADVANCED AIRWAY MANAGEMENT

ADULT ALTERED MENTAL STATUS AIRWAY MANAGEMENT/OXYGENATION AND VENTILATION

HYPOPERFUSION AND SHOCK ADULT SPINAL MOTION RESTRICTION ISOLATED EXTREMITY TRAUMA


Clinical Decision-Making 51 Airway Management/Oxygenation and Ventilation

Airway Management/Oxygenation and Ventilation No skill defines the pre-hospital clinician more than airway management. There is nothing more crucial in emergency medicine than the ability to assess and manage the patient’s airway. Airway management and decision-making should follow a progression from less to more invasive based on the needs of each patient. While we take it for granted, every human being must have multiple facets in place to maintain their own airway every day. The patient must have an adequate level of consciousness to detect an obstruction, the neurological and muscular ability to move the muscles and tissues of their airway to maintain patency, and the ability to move air in and out of their lungs. Any patient who does not have the level of consciousness, neurological function, and muscular control to maintain airway patency and minute volume faces a life and death emergency that the clinician must fix.

Indications for Airway Protection and or Management

Airway Protection

● Any patient with altered mental status who is not able to protect the airway from aspiration requires definitive airway management. Presence of gag reflex is not an acceptable rationale not to intubate. The ability to swallow secretions better confers some assurance of the patient’s ability to maintain their own airway at the time of evaluation.

● If the airway is threatened by pathological obstruction (examples: gunshot wound to the neck; severe mid-face fractures; inhalational injury), early definitive airway management is essential

● Any patient who requires interventions to establish patency of the airway also requires control of that airway unless the underlying etiology causing airway compromise can be corrected immediately (e.g., hypoglycemia, which should respond to intravenous dextrose administration or suspected opioid overdose which should respond to naloxone administration or a seizure patient that is postictal).

Respiratory Failure - Clinical evidence of Failure of Ventilation or Oxygenation

● Respiratory failure can be defined as hypoxia (SpO2 <94% despite high flow oxygen and efforts to manage the underlying problem, except for patients with known lung disease who have a baseline Sp02 value of 85-94%) and/or hypercapnia. If the patient is chronically hypercapnic and is not in imminent respiratory failure, monitor the patient closely and treat underlying causes. If the patient is not chronically hypercapnic, oxygenate and progress with airway management.

● The decision to intervene with airway and ventilatory support should be based on clinical assessment. Patients with a new onset of ETCO2 >45 or acute respiratory distress should be placed on CPAP and have their underlying problems corrected.

● For those patients in whom tracheal intubation and mechanical ventilation are known to dramatically increase the risk of morbidity and mortality (e.g., severe asthma), wherever possible an aggressive trial of medical therapy should be attempted before definitive airway management is initiated. For patients with acute respiratory failure who may specifically benefit from a trial of non-invasive positive pressure ventilation (cardiogenic pulmonary edema, some patients with Chronic Obstructive Pulmonary Disease exacerbation), CPAP or BiPAP may be tried before intubation. If the patient does not improve rapidly or worsens, the clinician should move to intubation.

Anticipated Clinical Course

● If the patient has a significant probability of losing their airway or becoming unstable en route (examples: a patient with high cervical spine injury with diaphragmatic respirations), it is prudent to control the airway



preemptively rather than to wait until the patient becomes unstable and requires emergent intubation in the extremes.

● Patients with known or probable traumatic brain injury, a GCS <11 and a deteriorating mental status, should be intubated earlier rather than later.

Contraindications

● Valid out-of-hospital DNR ● Rapidly reversible disease process (e.g., hypoglycemia) ● Patients with a predicted very difficult airway (e.g. laryngotracheal injury or pathology) who are maintaining

oxygenation and ventilating effectively, in whom deferring invasive airway intervention to allow airway control by a specialist (e.g. anesthesia in an accessible facility with difficult airway expertise and resources such as flexible fiber optics and surgical backup) seems to confer more benefit than risk. In these unusual cases, a “disaster plan” and preparation for en-route deterioration are essential.

Procedure

1. Intervene to establish airway patency and protection as needed. 2. Positioning:

a. To open the airway: i. Jaw thrust with manual in-line neck stabilization if there is a risk of cervical spine injury ii. Jaw thrust or head tilt/chin lift if there is no risk of cervical spine injury.

b. For mask ventilation and intubation i. If spinal motion restriction not indicated: Independent of age or habitus, optimal positioning for

laryngoscopy can be achieved by aligning the external auditory meatus with the level of the sternal angle or just above the anterior shoulder 1. Neonates and infants often require a shoulder roll 2. Adults typically require ≈ 10 cm of padding behind the occiput 3. Obese patients require extensive padding under the head, neck, and shoulder to “ramp” them into

a good position 4. Such positioning may not be possible in patients

ii. If spinal motion restriction is indicated, maintain manual in-line neck stabilization and loosen or remove an anterior portion of a cervical collar for laryngoscopy.

3. Suction secretions as needed from the mouth, nose, and trachea as needed 4. Airway adjuncts – insert as indicated:

a. Nasopharyngeal airway b. Oropharyngeal airway

5. Provide high-concentration oxygen to all patients during active airway management. Support respirations with bag-mask ventilation as needed. Consider non-invasive positive pressure ventilation per appropriate guideline for patients with acute pulmonary edema or chronic obstructive pulmonary disease exacerbation.

6. For foreign body airway obstruction, follow American Heart Association guidelines. 7. If definitive airway management is indicated, determine the appropriate pathway for airway control based on

the Basic and Advanced Airway Management algorithm. 8. Evaluate patients for predictors of a potentially difficult airway, recognizing that preparedness for an

unanticipated difficult airway is essential even in the absence of any warning signs of potential difficult intubation. When screening patients for evidence of a potential difficult airway, consider multiple dimensions of difficulty: a. Difficult Bag-Mask Ventilation b. Difficult Laryngoscopy and Tracheal Intubation



c. Difficult Extraglottic Device (e.g., i-GEL) Placement d. Difficult Cricothyrotomy

9. Patient safety considerations during advanced airway management a. Oxygenation is always the priority of airway management. b. If at any point during advanced airway management, the patient develops hypoxemia (SpO2 < 94%)

during an intubation attempt, abandon that attempt immediately and revert immediately to bag-mask ventilation.

10. Preparation for Intubation a. Ample preparation is essential to ensure safe and effective airway management. Clinicians, as standard

practice, always bring airway management equipment, including a standard pack with bag-valve-mask and airway adjuncts, intubation equipment, rescue ventilation devices, and other critical items to every patient’s side for initial evaluation.

b. Adequate preparation and availability of backup equipment are essential for all patients requiring emergency airway management, whether or not a difficult airway is predicted.

c. The mnemonic STOP-IC-BARS should be used for training and in practice to define the equipment needed. While this specifically applies to DSI, this also defines the supplies that should be prepared for every emergency airway encounter

S Suction Working suction available with the Yankauer tip placed under the

patient’s right shoulder. T Tubes Tubes of appropriate size for the patient should be prepared.

• Pediatric patients: Use HANDTEVY Tape or Reference Card • Adult Female: 7.0-8.0 mm tube • Adult Males: 7.0-9.0 mm tube

O Oxygen Adequate oxygen supply with resuscitation bag/mask with PEEP valve

P Pharmacology All needed medications, including post intubation sedation and analgesic, should be prepared in syringes and labeled.

I Intravenous Line Clinicians must confirm patency and adequacy of vascular access. C Connect Monitors ECG, SpO2, NiBP, and ETCO2 monitoring should be connected. Place

NiBP monitor on stat mode during airway manipulation. B Blades, Bougie Appropriate size laryngoscope blade checked for function.

A bougie should be at arm’s reach for every intubation and utilized per guidelines.

• Pediatric Bougie (10F) for ET tubes 3.5-5.5 mm • Adult Bougie (15F) for ET tubes 6.0-9.0 mm

A Alternative An alternative airway is a non-direct laryngoscopy approach to tracheal intubation, such as an intubating laryngeal airway. A rescue airway is a supraglottic airway used for failed oxygenation and/or failed intubation.

R Rescue Airway

S Surgical Airway Cricothyrotomy equipment is immediately available.

11. Direct Laryngoscopy

a. The duration of laryngoscopy should be tailored to the rate of desaturation. When a patient’s pulse ox reaches <94%, the provider must terminate the laryngoscopy and ventilate the patient.

b. Do not initiate a laryngoscopy effort if the patient is already hypoxemic without first achieving effective bag-mask ventilation.



c. If hypoxia occurs (SpO2 falls to < 94%) during any laryngoscopy effort, abandon the attempt and initiatebag-mask ventilation.

d. Grade each laryngoscopy using Cormack and Lehane Classification System. If an effort improves thelaryngeal view, note both the initial view and ultimate view achieved and what intervention produced thatimproved laryngoscopic exposure.

i. In any view other than a grade I view, attempt to improve laryngeal view using the approachdescribed below.

ii. Do not blindly pass ETT when a grade 4 view is encountered

Grade I Grade II Grade III Grade IV

Full view of glottic aperture including a good view of the true vocal cords.

Partial view of the posterior aspect of the glottis, including at least the interarytenoid notch.

Epiglottis-only view No discernible periglottic anatomy can be identified during laryngoscopy

e. Employ a planned strategy for first pass success. If laryngoscopic exposure is not adequate initially,utilize the following during the first attempt:

i. Consider lessening or releasing cricoid pressure, if used.ii. Utilize external laryngeal manipulation (ELM). ELM is counter pressure on the thyroid cartilage

initiated by the laryngoscopic and maintained by an assistant.iii. If not contraindicated, additional head elevation may be helpful.iv. If these efforts are not successful, abandon the attempt and move to an extraglottic device.

f. Utilize the tracheal tube introducer (Bougie) for all intubation attempts unless the appropriate sizeBougie is not available.

Sequential Management of the Patient utilizing Medication Assisted Intubation: • Key elements of Medication Assisted Intubation for the DSI Airway patient can be divided into eight steps

Time Frame Component Zero – 10 minutes Preparation and Pre-treatment Zero – 5 minutes Pre-oxygenation with Passive Oxygenation Zero - 3 minutes Protection and positioning

Zero Induction with possible paralysis Zero + 45 sec Placement with Confirmation

Zero + 1 minute Post Intubation Management



Important considerations:

Preparation

Focus on assuring that the patient and equipment are ready to proceed with induction and sedation. The preparation phase is critical as this is the phase where the clinician should assess the airway for anticipated difficulty with intubation, ventilation, or rescue. Assessing difficulty with intubation using the acronym LEMON, the ability to bag with the acronym MOANS, the ability to place an extraglottic device with the acronym RODS, and the ability to perform a surgical Airway utilizing the acronym SHORT, can assist in decision-making. LEMON ● Look- Does the patient look like they will be difficult to intubate, ventilate, or complete surgical airway

(cricothyrotomy)? ● Evaluate the 3-3-2 Rule- Can the patient fit 3 fingers in the mouth and between the chin and hyoid? Can the

fit two fingers between the hyoid and thyroid? ● Mallampati- What is the patient’s Mallampati score?

Class I Class II Class III Class IV

● Obstructions- Do you see any obstructions to intubation or ventilation? ● Neck mobility- Can the patient’s head be moved into a sniffing position?

Obstructions to BVM Ventilation (MOANS) ● Mask Seal ● Obesity ● Age > 55 ● No Teeth ● Stiff Lungs

Obstructions to Extraglottic Device Placement (RODS) ● Restricted mouth opening ● Obstruction at or below the level of the larynx ● Disrupted or Distorted Airway ● Stiff Lungs (Asthma, Pulmonary Edema, COPD, C-spine injury with limited neck mobility) Obstructions to a Surgical Airway (SHORT) ● Surgery ● Hematomas ● Obesity ● Radiation ● Tumor

Pretreatment

● Fluid loading with Normal Saline, 10-20 ml/kg IV should be administered rapidly, particularly when patients are hypovolemic, have labile vital signs, or have dynamic hyperinflation (e.g., asthma and COPD exacerbation) that may result in deterioration with the initiation of positive-pressure ventilation.



Preoxygenation

● Pre-oxygenation is achieved by providing high FiO2 (0.85-1.0) for 3 minutes (normal tidal volumes) or 8 vital capacity breaths.

● CPAP or BiPAP, with FiO2 1.0, are appropriate when already employed on a patient. ● If the patient’s spontaneous ventilatory effort is inadequate or the patient’s oxygen saturation does not

improve with passive oxygen delivery, then gentle bag-mask assisted ventilation is indicated. ● In patients in whom ability to establish FRC is compromised (morbid obesity or advanced pregnancy) or in

whom oxygen consumption is increased (children at baseline, critically ill patients) will have more rapid desaturation than patients with normal lungs and oxygen consumption.

Passive Oxygenation

Studies have shown that patients can continue to oxygenate even if they are not actively breathing. A technique known as passive oxygenation allows for patients to continue maintaining their oxygen saturation throughout the entire DSI procedure. A nasal cannula is placed on the patient at 15 liters per minute. Conscious patients will not tolerate this high flow rate. However, patients who have been sedated and paralyzed will tolerate the high flow rate quite well. The continuous flow of oxygen will allow O2 to diffuse across the alveoli into the bloodstream.

Protection

Protection of the cervical spine and positioning for optimal laryngoscopy are undertaken while the patient is becoming unconscious. ● If spinal motion restriction is in place, manual in-line neck stabilization is maintained, and the anterior portion

of the cervical collar is removed. ● Positioning is key for optimal laryngoscopy. The external auditory meatus should be in line with the sternal

notch. This positions the airway for optimal visualization during laryngoscopy.

Induction with possible paralysis

• The DSI protocol calls for induction with ketamine 2 mg/kg to provide rapid sedation • The DSI protocol is then followed and a paralytic, Rocuronium or succinylcholine 1 mg/kg, is only given if

all 3 hear stops (hypoxia, hypotension, & a grossly contaminated airway) have been addressed and corrected.

Placement with Confirmation

● Follow the DSI protocol to guide you in choosing the correct type of airway (extraglottic vs endotracheal tube) and any therapies to treat hypoxia, hypotension and grossly contaminated airway.

● Abandon attempt if SpO2 falls below <94% or falls precipitously, and bag the patient.

Confirmation

1) Direct visualization 2) Click and Lock

a) Tactile stimulation of the bougie on the tracheal rings (click) b) Prevention of advancement of the device (lock)

3) No epigastric sounds with equal bilateral breath sounds 4) Continuous ETCO2 monitoring

a) Only true confirmation b) Must be done on every patient, every time

Post-Intubation Management

• See POST INTUBATION MANAGEMENT CPG. Insertion of an OG TUBE and placement of a cervical collar


Clinical Decision-Making 57 Basic and Advanced Airway Management

Basic and Advanced Airway Management

Criteria for Airway Management • Inability to swallow • Oxygenation or ventilation failure despite noninvasive ventilation inhaled O2 and/or medication • Reasonable expectation of a rapidly decreasing clinical course during your care



Document • Airway assessment (EMT-P) • Airway algorithm utilized (DSI) • Medication names, times, and doses utilized during

medication-assisted intubation • ELM or cric pressure • Airway placement start time/end time • Total number of intubation attempts by each provider • Method of airway placement (i.e., oral, nasal, etc.)

• Complications with ventilation and methods to correct ventilation

• Lowest SpO2 during airway placement • Airway confirmation by at least 3 methods • Print and attach ETCO2 immediately after

airway placement and immediately before patient handoff

• Chart ETCO2 and SpO2 with each set of vitals

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT POST INTUBATION MANAGEMENT

Airway Management

Indicated?

Monitor ECG, ETCO2, SpO2


Monitor patient for patency of airway

• Reposition the head• Open airway with jaw thrust• Consider nasal and/or oral airway

Can patient control their own airway

Yes

No Yes

No

PIntubate utilizing DSI Algorithm



HypoxiaDyspnea

Respiratory Failure

Agitation, Apnea, Altered(AAA)

Ketamine for

Induction

Pre-Oxygenation (VIA)BVM, NIV with(HEPA) Filter

DSI with

SGA/ETT

NC up to 6 LSurgical Mask

NRB/CoverVents/Surgical

Mask

TransportP

I

P

Yes No

Patient becomesAAA

Move to Ketamine

If Patient Stabilized

Non-Invasive Ventilation using (HEPA) filter

COVID-19 Airway Algorithm



Note 1 • Tolerate Hypoxia – Treat Patient not oxygen saturation • Paralytic Hard Stops Still Apply – SBP <90 or Oxygen saturation <94% • Cover all open ports of exhalation using (HEPA) filter or ECG electrodes on mask


Clinical Decision-Making 59 DSI Adult & Children (>10 years of Age) Page 1


Pre-Oxygenate-Apneic – NC 15 LPM, BVM 15 LPM, PEEP 5-15 cmH2O-Spontaneous Breathing – NC 15 LPM, NRB 15 LPM or NIV

Ketamine 2mg/kg IV/IO(Note 2)

Spo2 >94% for 3 consecutive minutes

(Note 3)

Make adjustments-Positioning-Oral, nasal airways-PEEP

HypotensiveSBP <90

GrossContamination

OfAirway

AttemptIntubation Successful

2 attempts Or

Spo2 <94%

Position Patient-HOB 15 degrees Ear to Sternal notchReverse Trendelenburg for spinal trauma

Spo2 >94% for 3 minutes

Rocuronium1 mg/kg IV/IO

Place SGA Device

Push Dose Biorphen0.5-1.0 ml

Q 2 minutes untilSBP >90 ( note 4)

SBP>90 Place SGA Device

Manage per Hypotensive &

Shock CPG

See next Page

Prepare for“SALAD”

Park Maneuver

Rocuronium1 mg/kg IV/IO

Perform for“SALAD”

Park Maneuver

Place SGA Device

P

P

P

I

I

P

I

P

Yes

Yes

No Yes Yes

No

No

No

No

Yes

Yes

Yes

See next Page

No

See next Page

DSI Adult & Children (>10 years of Age) Page 1



COVID-19 Specific Adjustments - No Ketamine should be used for pain management during the COVID-19 pandemic. - This is in attempt to manage possible airway management medication shortages. -During COVID-19 pandemic all Rocuronium will be used as multiple-dose vial. Procedure as follows: *Date vial on first usage (use up to 60 days) *Place into proper cold storage and use appropriately until gone



DSI Adult & Children (>10 years of Age) Page 2 Place SGA Device I

Clinical Improvement? -Improvement in cyanosis

-Improving Spo2(Note 5)

Chest Rise & Fall(Note 6 )

Perform Surgical Cricothyrotomy

Procedure Successful ?

-Recheck your procedure-Rapidly transport to nearest facility -Alert facility early of a failed airway

No

No

Yes

Yes

Yes

P

Post Intubation

Management

-Add PEEP 5-15 cmH2o-HOB to 45 degree RT for Patient with spinal trauma

No

Note 1 -There are 4 ways people die during intubation: -Failure to oxygenate -Failure to ventilate -Aspiration -Worsening Perfusion ***DSI allows for a hard stop to treat these 4 issues before giving the paralytic***

Note 2 -Even Ketamine can cause hypotension in patients in shock -Shock is a known anesthetic, therefore patients may not need the full dose of ketamine to obtain adequate Sedation -Patients who are already hypotensive or have a high shock index (HR/SBP) >0.9 consider starting with 0.5 mg/kg of Ketamine and adding in 0.5 mg/kg dose up to 2 mg/kg in order to obtain adequate sedation - IV Fluids should be started pre-intubation & push dose Biorphen (phenylephrine) should be ready for these patients Note 3 Note 4 -The EMT is responsible for following the Spo2 levels reporting to the paramedic -If the Spo2 level drops <94% make adjustments & restart the 3 minute clock

Note 5 -Some patients, due to poor perfusion, may have difficult to obtain Sp02. If patients seem to be improving clinically and have good EtCO2 readings, proceed as if your Sp02 is improving. -Even after ETI, some patients remain hypoxic. This is not a failure of the intubation, but a sign of underlying lung pathology

Note 6 -True failure to oxygenate and failure to ventilate are the indicators for moving forward with Cricothyrotomy -If there is adequate chest rise & fall with good EtCo2 (adequate ventilation) & all means of providing adequate oxygenation (100% 02 maximize PEEP, HOB to 45 degrees) have been provided the medic should then move to post-intubation management.

-Max Total dose of Biorphen is 200 mcg


Clinical Decision-Making 61 DSI Children (<10 years of Age) Page 1

DSI Children (<10 years of Age) Page 1 (Note 1 & 2)


Pre-Oxygenate-Apneic – NC 15 LPM, BVM 15 LPM, PEEP 5-15 cmH2O-Spontaneous Breathing – NC 15 LPM, NRB 15 LPM or NIV

Ketamine 2mg/kg IV/IO(Note 3)

Spo2 >94% for 3 consecutive minutes

(Note 4)

Make adjustments-Positioning-Oral, nasal airways-PEEP

HypotensiveBelow minimum SBP

70 mmhg + (2 x years in Age)

GrossContamination

OfAirway

AttemptIntubation Successful

Two Attempts at Intubation

unsuccessful And/or

Spo2 drops <94%

Position Patient-HOB 15 degrees Ear to Sternal Notch -Reverse Trendelenburg for spinal trauma

Spo2 >94% for 3 minutes Place SGA Device

Push Dose Biorphen

Q 2 minutes untilBP> 70 mmhg +

(2 x years in Age) (note 5)

SBP>90 Place SGA

Manage per Hypotensive & Shock

CPG

See Next Page

Perform for“SALAD”

Park Maneuver

Place SGA Device

P

PI

I

I

P

Yes

Yes

No Yes Yes

No

No

No

No

Yes

NO

Yes

Yes

See next page

See next Page





DSI Children (<10 years of Age) Page 2

Place SGA Device I

Clinical Improvement-Improvement in cyanosis

-Improving Spo2( Note 4 )

Chest Rise & Fall( Note 5 )

Perform Needle Cricothyrotomy

Procedure Successful ?

-Recheck your procedure-Rapidly transport to nearest facility -Alert facility early of a failed airway

No

No

Yes

Yes

Yes

P

Post Intubation

Management

-Add PEEP 5-15 cmH20-HOB to 45 degree RT for Patient with spinal trauma

No

See next page


Clinical Decision-Making 63 DSI Children (<10 years of Age) Page 2

Note 5 Pediatric Biorphen (phenylephrine) dosing

• Age <1 years – Contraindicated • Age 1-5 years – 0.25 ml (25 mcg) Q2 until BP > 70 + (age x 2 in years) Max total dose 100 mcg • Age 6-10 years – 0.5 ml (50mcg) Q2 until BP >70 + (age x 2 in years) Max total dose 200 mcg

Note 6 • Some patients, due to poor perfusion, may have difficult to obtain Sp02. If patients seem to be

improving clinically and have good Etco2 readings, proceed as if your Sp02 is improving • Even after ETI, some patients remain hypoxic. This is not a failure of the intubation but a sign of

underlying lung pathology

Note 7 • True failure to oxygenate and failure to ventilate are the indications for moving forward with

Cricothyrotomy • If there is adequate chest rise & fall with good EtCO2 (adequate ventilations) & all means of proving

adequate oxygenation (100% O2 maximize PEEP, HOB to 45 degrees) have been provided, the medic should then move to post-intubation management.

Note 1 Note 2 There are 4 ways people die during intubation -Failure to oxygenate -Failure to ventilate -Aspiration -Wavering Perfusion

** DSI allows for a hard stop to treat these 4 issues before giving the paralytic**

Differences in a Pediatric airway -Large Tongue -Small airway diameter (Airway obstruction can occur within a small airway with swelling) - Short Trachea (Makes accidental extubation easy) -Anterior Trachea (Making visualization very difficult) -Pediatric airway (Approaches the size of an adult by 8-9 years of age -Infants are obligate nose breathers until the age of 6 months

Note 3 Note 4 -Utilize the HandTevy App for tube size & drug dosing -The Pediatric Resource information page (link) can also be used

-The EMT is responsible for following the Sp02 levels reporting to the medic -If the Sp02 level drops <94% make adjustments & restart the 3 minute clock

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT KETAMINE OG TUBE INSERTION HYPOPERFUSION AND SHOCK Biorphen (phenylephrine) PEEP/ETCO2

COVID-19 Specific Adjustments - No Ketamine should be used for pain management during the COVID-19 pandemic. - This is in attempt to manage possible airway management medication shortages. -During COVID-19 pandemic all Rocuronium will be used as multiple-dose vial. Procedure as follows: *Date vial on first usage (use up to 60 days) *Place into proper cold storage and use appropriately until gone



Post Intubation Management (Note 1)



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT KETAMINE OG TUBE INSERTION HYPOPERFUSION AND SHOCK FENTANYL PEEP/ETCO2 ROCURONIUM

Note 1 When you have applied a C-Collar on a patient to ensure proper stabilization of the ET-Tube, and there is no concern for C-Spine injury, relay that information to the receiving staff.

Note 2 Methods for improving oxygenation post-intubation include -Adding PEEP 5-15 cmH2o -Raising the HOB to 45 degrees or reverse trendelenburg for patients with concern for spinal trauma


See Hypoperfusion and Shock CPG

Continue monitoring and medicating as needed

• Insert an OG tube and decompress the stomach

• Apply a C-Collar• Apply PEEP and ETCO2 (Note 2)

Adult Systolic BP >90?PEDS 70 mmg + (2x age in

years)?No

Yes

Sedation achieved? No

Fentanyl 1-2 mcg/kg SIVP

Repeat every 10 minutes as needed.

Yes

Systolic BP >90?

No

Ketamine 2 mg/kg IVP/IO

May repeat either every 5 minutes as needed (no max dose if intubated)

Yes

ConsiderRocuronium 1 mg/kg IVP

Immediately repeat sedation

Difficulty Ventilating Patient despite

Adequate Sedation?

Yes

No


Clinical Decision-Making 65 Mechanical Ventilation

Mechanical Ventilation



Note 1 “Advanced airway” includes ET Tubes, Extraglottic Airways, and Tracheotomies.

Note 2 For Inter-facility transfers with values that are not within appropriate ranges for the patient’s history, contact Med Control and discuss treatment options.

Note 3 Set your volume/kg on the higher side if the

patient has “healthy lungs” and on the lower volume side for those patients with “restrictive lungs” such as Asthma or COPD.

Ideal Body Weight formula: Male 5’ = 50kg every inch above add 2.3 kg Female 5’= 45kg every inch above add 2.3kg

Note 4 • To increase O2 saturation: Increase the

amount of PEEP (Assure adequate tidal volume)

• CO2 levels >45: Increase ventilation rate (recheck tidal volume)

• CO2 levels <35: Decrease ventilation rate (recheck tidal volume)

• Patients with a baseline elevation of ETCO2 (COPD patients) should be kept at a higher level of CO2 to simulate their baseline.

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT OG TUBE INSERTION POST INTUBATION MANAGEMENT

Continuous monitoring of ETCO2 and Waveform progression is MANDATORY! This is required on every intubated patient, every time, no exceptions

Autovent 2000 is not to be used on patients <40kg. Autovent 3000 is not to be used on patients <20kg.


Manually ventilate with a BVM

Post Intubation Management CPG

• Advanced Airway in place and secured?

• Does patient have a pulse?

Note 1

No

No

Maintain • ETCO2 between 35-45 mmHG• SpO2 >95%

Note 4

Yes

Adequate Chest Rise and Fall?

No

• Transport time >30 minutes?• EtCO2 between 35-45?• SpO2 >95%

Note 2

Yes

Set Tidal Volume at 5-8 mL/kgIdeal Body Weight

Note 3

Yes

Set BPMAdult: 10-12 BPMChild: 14-20 BPM Elevate the patient’s head

to 45 degrees unless contraindicated.

Keep oral secretions cleared with suction,

insert an OG tube if the patient is tracheal

intubated



Pain Management


Contact Medical Control


No

Ketorolac (Toradol)-Adult: 30 mg IVP

-Pedi: 0.5 mg/kg IVP (max of 30 mg)

Note 1

Is the pain acute?

Yes

Level of Pain

Age 1-60?

Yes

Age 8-70?

Mild to Moderate Moderate to Severe

Fentanyl 1mcg/kg slow IV/IO

Fast IN(Max single dose of 100mcg)

-May repeat the dose after 15 minutes @ 1mcg/kg Slow

IV/IO. (Max single dose of (100mcg)

-A smaller dose may be given based on clinical judgment.

-Additional dosing will require Medical Direction approval.

Note 2 & 4, 5

No

Yes

Ketamine-Adult 18-70 years old

10 mg in 50 or 100 ml NS wide open

Infuse over 2-5 minutes or

10 mg IN Fast

-Pediatric 8-17 year old0.2mg/kg in 50 or 100 ml/NS (wo)

(to infuse over 2-5 min)Max 10 mgs

-May repeat the dose 15 minutes after 1st dose completion of

Ketamine (Same dose) Note 3 & 4, 5

Yes

Able to take PO Medications

Acetaminophen Adult 500- 1000 mg po

Pedi 15 mg/kg po Max dose 1gm

No

Yes



COVID-19 Specific Adjustments - No Ketamine should be used for pain management during the COVID-19 pandemic. - This is in attempt to manage possible airway management medication shortages.


Clinical Decision-Making 67 Pain Management

Note 1 • To be used for relief of mild to moderate pain in an acute event; not a chronic condition. • Ketorolac should be utilized in combination with Fentanyl for patients with moderate to severe pain as long

as a contraindication does not exist. • Do not use Toradol in patients with any trauma and or Head Injury • Do not use for patients who are actively bleeding or at risk for bleeding • Especially helpful in renal colic

Note 2 • To be used for the relief of a moderate to severe pain in an acute event; not a chronic condition. • Any patient receiving Fentanyl must have a pain score documented prior to each analgesia and 5-10

minutes after each dose of the medication. • For stable patients with traumatic injuries, a single dose of Fentanyl may be given (IN) prior to moving the

patient onto the stretcher if IV access cannot be established initially.

• Note 3

• Do not give for cardiac-related Chest Pain. Fentanyl should be used for all ischemic pain • Ideal agent for patients with traumatic pain and/or hypotensive patient • Treat nausea & vomiting with Zofran and Emergence Reaction with Midazolam

• Note 4

• When treating moderate to severe pain, a total of 2 doses of pain medication (fentanyl or ketamine) is permitted (ex. Fentanyl dosing x 2 ketamine dosing x 2, fentanyl followed by ketamine or ketamine followed by fentanyl)

• Any further doses will require approval by medical control (MC) • Note 5

• Shock is a known analgesic. Many hypotensive patients do not require pain control. Even through Fentanyl & Ketamine are considered hemodynamically stable medications, they can cause hypotension during the shock phased of a patient’s condition. Lower doses of a quarter to half dose, should be considered.

• These medications should be avoided in the hypotensive patients (SBP <90 adult or SBP <70 + (2xage in years) for Pediatric patients.

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT FENTANYL KETOROLAC (TORADOL) KETAMINE



Adult Spinal Motion Restriction



Distracting Injuries ● Burns or Abrasions >1%

BSA ● Multi-system trauma ● Chest or Abdominal Pain ● Crush injuries or

amputations ● Deformity or obvious

fractures ● Any injury requiring

treatment with opiates. While En Route

If a patient was originally cleared at the scene but develops neck pain en route, a C-collar should be placed immediately.


Mechanism of injury that could cause spinal column injury ?

Do you suspect ETOH or sedating/anlgesic medications being taken?

Age <18 or >65

Distracting Injury

Any laps of consciousness during or following the event

Multi-system trauma

Neck Pain on Palpation Neck pain when moving head up, down, left, or right

EMS Clinician can refrain from placing patient in spinal motion restriction devices

Transport in position of comfort

Place C-Collar

Is patient Ambulatory on scene

Assist to Stretcher

Can Patient safelySelf-extricate

-Use rigid extrication device to move the patient to the stretcher-Remove rigid extrication device

using log roll techniques once patient is on stretcher if possible

Transport with spinal restrictions utilizing a flat stretcher and

C-collar in place

No

Yes

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

NoYes

Yes

No

No


Clinical Decision-Making 69 Hypoperfusion and Shock

Hypoperfusion and Shock

Note 1

-Push Dose Biorphen (phenylephrine) can be considered as a temporary measure in a peri-arrest patient * Adult Age >10 years of Age 0.5-1.0 ml IVP * Peds Age < 1 year of age contraindication * Peds age 1-5 years of age 0.25 ml (25 mcg) IVP * Peds age 6-10 years of age 0.5 ml (50 mcg) IVP ** Levophed or Epinephrine infusion should be started due to the brief duration of action of Biorphen**




EtiologyNote 1

Frequent CausesBleeding

DehydrationThird Spacing

Diuresis

Frequent CausesArrhythmias

Tension PneumothoraxCardiac TamponadeCardiogenic Shock

Fluid Problem

Frequent CausesSepsis

(See Sepsis Pathway)Neurogenic Shock

Anaphylaxis(See Anaphylaxis

Pathway)

Pump Problem

Frequent CausesHeat StrokeMalignant

HyperthermiaThyroid Storm

Pipe ProblemHigh Metabolism

Stop ongoing fluid or blood loss

Uncontrolled Bleeding?

Coexistent Closed Head

Injury

Titrate fluids to maintain MAP >80-100 in adults

Keep systolic BP >(2 x age) + 70 in children

I

Fluid bolus 10 mL/kgTreat reversible causes I

Yes

Yes

No

No

Control metabolic demand by cooling patient

Manage fluid and pump problems as described left

Initiate pressors to maintain BP:Levophed

Adult: 2-30 mcg/minPedi: 0.05-0.1 mcg/kg/min

P

Yes

Patient remains hypoperfused?

Initiate Large bore IVs of NS andbegin fluid resuscitation I

Administer medications as appropriate and available

FeverTylenol 500-100 mg PO

Pedi: 10 mg/kg PO

P

Titrate fluids to maintain perfusion goals:

• Strong distal pulses• Warm, pink, and dry skin• Age Appropriate HR,

Respirations, and BP

I

Titrate fluids to maintain radial pulses and

consciousnessI

Consider an inotropic drug to improve

contractility such as Levophed

Adult 2-30 mcg/minPedi 0.05-2 mcg/kg/min

P

Fluid bolus 20 mL/kg up to 3x I

Maximize O2 Delivery

Initiate IV Access x2 IMonitor ECG, NIBP, SpO2, ETCO2 P

No



COVID-19 Specific Adjustments - Avoid aggressive fluid resuscitation in confirmed or suspected COVID-19 patient - Hypotension should be treated with a fluid challenge of 1 liter - Consider early advancement to a vasopressor (Levophed) if fluids does not correct hypotension

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT


Clinical Decision-Making 71 Sepsis

Sepsis

General Patient ManagementCPG

Etco2, Cardiac & Spo2 Monitoring

Gain IV Access

Suspected Infection

2 or more SIRS Criteria

Note 1-Initiate Fluid Resuscitation

Up to 1 L (NS) bolus

-Monitor for Fluid overload

Etco2 <25 mmHg

Notify Hospital of Code Sepsis Initiate Fluid Resuscitation

Up to 30 ml/kg (NS)Until SBP >90 mmHg

Monitor for Fluid Overload

SBP remains <90 mmHg despiteFluid Resuscitation Levophed Infusion @ 2-30 mcg/min

Monitor Patient&

Transport

Yes

No

Yes

Yes

Yes

No

No

No

Note 1 • SIRS Criteria • Temp >100.4, <96. • RR >20 • HR >90

COVID-19 Specific Adjustments - Avoid aggressive fluid resuscitation in confirmed or suspected COVID-19 patient - Hypotension should be treated with a fluid challenge of 1 liter - Consider early advancement to a vasopressor (Levophed) if fluids does not correct hypotension



Document • Respiratory and hemodynamic status • Suspected type of shock • Vital signs q 5 minutes if infusing vasoactive medications or if the patient is unstable • Fluid intake and output • Treatment • Response to treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT LEVOPHED TYLENOL



Adult Altered Mental Status


Detailed AssessmentNotes 2 and 3

Maintain MAP >80 mmHg I

Malnourished?Alcoholism?

On Diuretics?Thiamin 100 mg IVP or IM I

Blood Glucose >60 mg/dL No

Yes

No

If unable to start IV, administer Glucagon 1mg IM I

Narcan 2-4 mg IM, IN, IV, or IONote 5 I

Increased LOC?

Increased LOC?

Consider Intubation P

• Maintain airway• Support respiratory effort• Keep patient warm

Yes

No

Yes

No Yes

May repeat Narcan every 10 min as needed I

Administer Dextrose 25g IVNote 4 I

Initiate large bore IV accessNote 1 I



Note 1 If signs of dehydration exist, administer a fluid challenge of NS 20 mL/kg. (Less for CHF or renal failure patients, 250-500 mL)

Note 2 Detailed assessment: Document Glasgow Coma Scale. Check for odor on breath. Look for medical alert tags, needle tracks, and evidence of trauma.

Note 3 Observe environment closely for signs of potential overdose

Note 4 Dextrose: Recheck blood glucose 5 min following dextrose. If the blood glucose remains <60 mg/dL, repeat.

Note 5 If the patient is a known chronic user of narcotics, and depression in consciousness is believed to be the result of narcotic use, consider titration Narcan 0.2-4 mg SIVP.

Possible Causes U Units of Insulin

(Hypoglycemia) N Narcotics/Drugs C Convulsions O Oxygen (Hypoxia) N Nonorganic (Psychogenic) S Stroke C Cocktails (alcohol) I Increased ICP O Organisms (Infection) U Urea (Renal or Liver

Failure) S Shock


Clinical Decision-Making 73 Adult Altered Mental Status

Glasgow Coma Scale Eye Opening Spontaneous 4

To Voice 3 To Pain 2 None 1

Best Verbal Response Oriented 5 Confused 4 Inappropriate Words 3 Incomprehensible Sounds 2 None 1

Best Motor Response Obeys Commands 6 Localizes Pain 5 Withdraws (Pain) 4 Flexion 3 Extension 2 None 1

Document

• Airway Patency • Respiratory and hemodynamic status • Pupils • Glasgow Coma Scale • Blood glucose • SAMPLE History • Cardiac Rhythm • Nature of Pain (PQRST) • Vital Signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications • Fluid intake and output • Temp, SpO2, & ETCO2 • Treatment • Response to treatment


GENERAL PATIENT MANAGEMENT THIAMINE INTUBATION DEXTROSE GLUCAGON NARCAN




Manage patient condition per appropriate CPG

Nausea or Vomiting

Note 1Pain Agitation

Adult• Isopropyl Alcohol

(inhalation) by nose• Adult Zofran 4 mg SIVP or* Adult Zofran ODT 4 mg SLPEDS* Oral >6 month – 7 years Zofran ODT 2 mg SL (½ tab)*Oral >8 years Zofran 4 mg SL• Pedi dose: 0.1 mg/kg up to

4 mg• May repeat q 20 min

See Pain Management CPG

Is the patient Intubated?No

Yes

See Post Intubation Management

See Agitated/Behavioral/Psychotic Patient

Management

Symptom Management



Note 1 Consider for patients at high risk for vomiting, aspiration, or motion sickness.

General Note Isopropyl Alcohol soaked pads are used for the treatment of mild to moderate nausea and vomiting. Have patient inhale deeply as frequently as required to achieve nausea relief held 1 to 2 cm below the nares

Documentation • Assessment of symptom severity before and after each dose of medication • Vital signs • ETCO2 • SpO2 • Treatment • Any abnormal or unexpected reaction

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT Isopropyl alcohol ZOFRAN


Cardiovascular Disease 75 Symptom Management

Cardiovascular Disease


Cardiovascular Disease 76

Adult Cardiac Arrest



COVID-19 Specific Adjustments - CPR & Intubation is an aerosolization generated procedure (AGP) - Full PPE should be applied


• CPR for 2 minutes• Insert Supraglottic Device• ETCO2

V-Fib/V-Tach

See Post Cardiac Arrest Care CPG

Apply monitor and identify rhythm

Asystole

Shock 200JImmediately resume

CPR for 2 minutes

CPR for 2 minutes

IV/IO access

Epi 1 mg (1:10,000) IV/IORepeat every 3-5 minutes.

Continue CPR for 2 minutes

IV/IO accessNote 4

Check RhythmCheck Pulse



If the rhythm is shockable repeat defibrillation every 2

minutes, 300-360jResume CPR after each

defibrillation

Amiodarone 300 mg IVPRepeat in 5 min 150 mg IVP ROSC?

ROSC?

Yes

NoCPR for 2 minutes

Yes

Yes

No RVF PresentNote 3 Yes

No

DSED Possible? Yes

Perform DSED

PEA

CPR for 2 minutes

IV/IO accessNote 4



QRS WideOr Narrow?

Note 5

IVF Wide Open1-2 liters

-CaCl 1 gm IVP-NaHCO3 1 meq/kg

ROSC?

See Post Cardiac Arrest Care CPG

Narrow Wide

No

YES

Continue ACLS Guidelines

No

Esmolol0.5mg/kg IVP/IO

Continue ACLS Guidelines

No


Cardiovascular Disease 77 Adult Cardiac Arrest

Note 5

• Studies have shown that during a cardiac arrest, recall of the 5H’s & 5T’s is difficult • By dividing the QRS into Wide & Narrow, the clinician can place the reversible causes of PEA into 2

category’s • Narrow QRS is due to a mechanical (RV) problem. Cardiac tamponade, tension pneumothorax,

mechanical lung hyperinflation, pulmonary embolism. • Wide QRS is due to a metabolic (LV) problem. Severe hyperkalemia, sodium-channel blocker toxicity

Note 6

• Refractory V-Fib (RVF) is persistent VF following at least 3 unsuccessful single defibrillations along with epinephrine & administration & dosing of an antiarrhythmic

Note 1

• Auto Pulse is an option for the QRV medic • Indications: Adult >18 & weight <300 lbs

Note 2 • Respiratory rate with advanced airway is 1 breath every 6-8 seconds

Note 3

• Refractory V-Fib Definition (RVF) • RVF is persistent VF following at least 3 unsuccessful single shocks with Epinephrine administration &

a dose of antiarrhythmic

Note 4

• A single attempt at IV access should be made & if unsuccessful, IO access should be obtained immediately

• Evidence for epinephrine, like most drugs in cardiac arrest, is lacking. Current science suggests that epinephrine is most beneficial when given as early as possible.

Note 2

• Respiratory rate with advanced airway is 1 breath every 6-8 seconds

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT CALCIUM CHLORIDE CHEST DECOMPRESSION POST CARDIAC ARREST MAGNESIUM SULFATE DSED SODIUM BICARBONATE ESMOLOL



Adult Cardiac Care: Bradycardia



Note 1 Symptomatic Includes: • Chest Pain • Shortness of Breath • Signs of poor perfusion • Altered Mental Status • Hypotension

Note 2 • Once capture is obtained,

consider sedation and analgesia per the SYMPTOM MANAGEMENT and PAIN MANAGEMENT CPG.

• Titrate rate to maintain blood pressure

• Titrate milliamps to maintain capture

• You may utilize EPINEPHRINE in conjunction with PACING

Note 3 In the event that the patient has a

2nd or 3rd-degree heart block, do not administer ATROPINE; go directly to pacing for treatment.

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT ATROPINE TRANSCUTANEOUS PACING PAIN MANAGEMENT SYMPTOM MANAGEMENT EPINEPHRINE

Epinephrine Drip Take 1 mg of 1:10,000 Epi and mix in 1,000 mL of NS. This concentration is 1mcg/mL. 2 mcg/min = 120 mL/hr 3 mcg/min = 180 mL/hr 4 mcg/min = 240 mL/hr


Symptomatic?Note 1

Observe and Monitor

IV Present?

No

Yes

Improvement?

Contact Medical Control for Epi Drip @ 2-10 mcg/min MC

No

Yes

No

Improvement?

No

Yes

Yes

Rapid administration of Atropine 0.5 mg IVP.

May repeat q 5 min to max dose of 3 mgNote 3

P

Transcutaneous PacingNote 2 P


Cardiovascular Disease 79 Adult Cardiac Care: Tachycardia

Adult Cardiac Care: Tachycardia



Note 1 Rates that are less than 150 bpm usually respond to fluid administration. See HYPOPERFUSION AND SHOCK CPG

Note 2 Unstable tachycardia includes patients with hypotension, sever dyspnea, chest pain and altered mental status

Note 3 Administer VERSED for sedation unless it will greatly delay CARDIOVERSION

General Patient Management CPGNote 1

Improvement?

Unknown?

Unstable?Immediate

CardioversionNote 2

Yes

ConsiderModified Valsava

Maneuversbefore

Adenosine 12 mgRapid IVP

SVTRegular QRS

≤ 120 ms

V-TachRegular QRS

>120 ms

A-Fib with RVRIrregular QRS

Variable Width

No

No

No

Amiodarone 150 mg IVP over 10 min

Bolus of NS 10 mL/kgRepeat 1x unless

respiratory compromise presents.

Professional Consultation MC Unknown?

SVTRegular QRS

≤ 120 ms

V-TachRegular QRS

>120 ms

A-Fib with RVRIrregular QRS

Variable Width

No

No

NoNo

Yes

Yes

Yes

50-100 J200 J300 J360 J

100 J200 J300 J360 J

120-200 J300 J360 J

200 J300 J360 J

Yes

Yes

Yes

No

• Monitor• Maintenance Medications as needed• Treat per symptom and pain management CPG

Yes

12-Lead without delaying therapy



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT ADENOSINE CARDIOVERSION PAIN MANAGEMENT AMIODARONE SYMPTOM MANAGEMENT VERSED HYPOPERFUSION AND SHOCK


Cardiovascular Disease 81 Adult Cardiac Care: Chest Pain/Acute Coronary Syndrome

Adult Cardiac Care: Chest Pain/Acute Coronary Syndrome



Note 1 In patients with an ECG Non-diagnostic for STEMI but the concern for ACS is high, a minimum of 3 ECGs should be obtained (one on the scene, one during transport, and one within 10 minutes before arrival). If a STEMI is found in any of the subsequent ECGs, the ED should be notified and the patient was taken to a facility with cardiac interventional

capabilities. If a patient has NO contraindications to thrombolytics and there is a concern for meeting First Medical Contact (FMC) to Balloon Time of 90 minutes, transport to the local facility for

thrombolytics should be considered

Note 2 Avoid Nitrates in any patient who has used Viagra or Levitra in the past 24 hours or Cialis in the past 36 hours due to the potential for severe hypotension.

Note 3 Notify ED of Code STEMI <10 minutes • When a STEMI is suspected, and when patient condition allows, Pulsara is the preferred method to notify the ED, via either

Paramedic’s personal device CEMS computer/tablet

• If patients condition and resources do not allow for the use of Pulsara, remember patient care always take precedence over the use of Pulsara, in this case, the Paramedic will pre-alert STEMI activation by radio through the communications center


STEMI in II, III, aVF

No

ASA 324 mg POTransport to a facility with

Interventional Cardiac Capabilities

Yes

Not RVI

• IV Access• Complete rainbow blood draw I

ST Elevation MI

ST Depression or Dynamic T-Wave

Inversion (Non-STEMI)

Normal EKG or Non-Diagnostic ST/T wave

changes (Angina)

Non ischemic type chest pain

Obtain right side EKG.If patient has an RVI, do not give nitrates; Follow Shock CPG

P

Activate Code STEMIPre-Alert / Pulsara

Limit Scene time to < 10 MinNote 3

P

Place Defib pads on patientPlace patient in hospital gown

Fentanyl per Pain Management CPG P

• ECG and SpO2 Monitoring• 12-Lead within 5 minutes of contact• Initial Assessment and ECG Review

Note 1

P

ASA 324 mg PONitroglycerine 0.4 mg SL q 5 min up to 3x

Note 2

P

Nitroglycerine 0.4 mg SL thenNitroglycerine 10 mcg/min IV. Can titrate up to 200 mcg/min

Maintain • Systolic BP >110• Diastolic >60

Note 2

P

Fentanyl per Pain Management CPG P



Document • The specific time of symptom onset • SAMPLE history • Nature of pain (PQRST) • Right side 12-lead if inferior MI • Each rhythm change • Respiratory and hemodynamic status • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if the patient is unstable • Pain scale with each set of vitals • Fluid intake and output • Medic interpretation of 12-lead • Associated symptoms • SAMPLE history • Temp/ETCO2/SpO2 • Treatment • Response to Treatment

Major Contraindications Against the Use of Thrombolytic Therapy

• Any previous history of hemorrhagic stroke • History of Stroke, dementia, or central nervous system damage within 1 year • Head Trauma or Brain surgery within 6 months • Known intracranial neoplasm • Suspected aortic dissection • Internal bleeding within 6 weeks • Active bleeding or known bleeding disorder • Major surgery, trauma, or bleeding within 6 weeks • Traumatic cardiopulmonary resuscitation within 3 weeks


GENERAL PATIENT MANAGEMENT ASPIRIN PAIN MANAGEMENT FENTANYL SYMPTOM MANAGEMENT NITROGLYCERINE

• It is important to note the transmission of an ECG to the receiving ED is not a requirement for Code STEMI activation. If a medical facility refuses or fails to activate Code STEMI for any reason you are required to notify the CEMS Clinical QA/QI Coordinator

COVID-19 Specific Adjustments - During the COVID-19 pandemic some cardiologists are moving away from PCI to thrombolytics - The change in hospital practice will not affect the pre-hospital care or procedures to activate STEMI criteria


Cardiovascular Disease 83 Adult Cardiac Care: Post Resuscitation Care

Adult Cardiac Care: Post Resuscitation Care



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT HYPOPERFUSION AND SHOCK ADULT BRADYCARDIA ADULT TACHYCARDIA

Document • Down time • Bystander CPR • Each rhythm change • Respiratory and hemodynamic status • Vital signs q 5 minutes if infusing vasoactive medications or if patient is unstable • Fluid intake and output • 12-lead ECG if ROSC • Candidacy for therapeutic hypothermia if ROSC • Vital Signs • Temp/ETCO2/SpO2 • Treatment • Response to treatment

General Patient Management CPGReturn of Spontaneous Pulse after cardiac arrest

Shock/Hypoperfusion Known or suspected reason for arrest Bradycardia Unstable

Tachydysrhythmia

If patient has acute coronary syndrome, transport to a hospital capable of reperfusion

Reassess ABCs, ETCO2, SpO2, BP, ECG

Treat per Hypoperfusion & Shock CPG Treat per appropriate CPG Treat per Bradycardia CPG Treat per Tachycardia CPG

Obtain 12-Lead EKG P

Transport and follow General Patient Management CPG



Adult Congestive Heart Failure

Document ● The specific time of symptom onset • SAMPLE History • Compliance with medications • Presence of chest pain • Nature of pain (PQRST) • Cardiac rhythm • 12-Lead ECG q 15 minutes



Note 1 Consider early use of CPAP to increase mean airway pressure.


Is the patient hypoxic or

hypercapnic?Note 1

No

Treat respiratory distress per Oxygenation and Ventilation CPG

Is the patient in shock?

No

Treat per Hypoperfusion/Shock CPG

Nitro SL 3xHR increase <15 bpm

Systolic BP >100Diastolic BP >60

Yes

Yes

May repeat Nitro q 5 minutes up to 3 x as long as:• HR does not increase by more than 15 BPM• Systolic BP > 100• Diastolic BP >60

P

Decrease preload and afterload utilizingNitroglycerine 0.4 mg SL P

Nitroglycerine drip starting at 20 mcg/min

Titrate up q 5 minutes to max of 200 mcg/min if• HR increase <15 bpm• Systolic BP >100• Diastolic BP >60

P


Cardiovascular Disease 85 Adult Congestive Heart Failure

• Medic interpretation of 12 lead • Right side 12-lead if inferior MI • Each ECG rhythm change • Respiratory and hemodynamic status • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if the patient is unstable • Pain scale with each set of vitals • Fluid intake and output • Associated symptoms • Temp/ETCO2/SpO2 • Treatment • Response to treatment • Code STEMI activation time if applicable.


GENERAL PATIENT MANAGEMENT NITROGLYCERINE CPAP HYPOPERFUSION AND SHOCK OXYGEN AND VENTILATION


Medical Problems and Emergencies 86

Medical Problems and Emergencies


Medical Problems and Emergencies 87 Abdominal Pain (Non-Traumatic)

Abdominal Pain (Non-Traumatic)



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT HYPOPERFUSION AND SHOCK PAIN MANAGEMENT SYMPTOM MANAGEMENT

Exam Notes • Note Pain (nature, duration,

intensity on 0-10 scale, radiation)

• Auscultate prior to palpation • Observe for palpable mass;

avoid palpation if you suspect an abdominal mass.

• Note associated signs and symptoms: Nausea/vomiting, bowel tones, guarding, rebound tenderness, distention

• History: previous episodes, last meal, current medications

Document • Abdominal signs/symptoms • Absence or presence of chest

pain • Cardiac rhythm • Nature of pain (PQRST) • Changes in pulses or BP in

different extremities • Vital signs q 15 minutes • Vital signs q 5 minutes if

infusing vasoactive medications • Pain scale with each set of vitals • Fluid intake and output • SpO2 and ECG • Treatment • Response to treatment


Hypoperfusion?

No


Rapid TransportYes

Large bore IV access I

Manage symptoms per Pain Management and Symptom CPGs P

Frequent vital signs

Transport



Allergic Reaction/Anaphylaxis



Note 1 Minor symptoms include: • Itching • Hives • Swelling • Rash

Note 2 Moderate symptoms include respiratory distress with: • Bronchospasm • Tachycardia • Weakness

Note 3 Severe symptoms include: • Airway swelling • Stridor • Hypotension Pediatric hypotension is <(70+2x age in years)

Note 4 Epi should be used with extreme caution in elderly patients and patients with a history of Coronary Artery Disease. Evaluate benefit vs. risk

Note 5 For a patient that is near death, hypotensive, or have imminent respiratory failure.

Epinephrine Drip Mix 1 mg of 1:10,000 in 250 mL of saline. This is a 4 mcg/mL concentration. Infusion rate is: 1 mcg = 15 mL/hr 2 mcg = 30 mL/hr 3 mcg = 45 mL/hr


Near death, hypotensive,

imminent respiratory

failure

No

Yes

SeverityModerate/Severe

SymptomsNote 2 and 3

Minor SymptomsNote 1

Initiate IV access I Epinephrine 1:1,000 • Adult Dose: 0.3-0.5 mg IM• Pedi Dose: 0.01 mg/kg IM

(max of 0.3 mg)Note 4


DiphenhydramineAdult: 25-50 mg IV

Pedi: 1 mg/kg IVP

SolumedrolAdult: 125 mg IVPedi: 2 mg/kg IV

P

FamotidineAdult: 20 mg IV

Pedi: 0.25 mg/kg IVP

Epinephrine DripAdult: 1-3 mcg/min

Pedi: 0.1-2 mcg/kg/minNote 5

P

Consider inhaled bronchodilatorAlbuterol 2.5 mg in 3 cc NS I

Initiate IV accessBolus NS 20 mL/kg (may repeat 1x) I


Medical Problems and Emergencies 89 Allergic Reaction/Anaphylaxis


GENERAL PATIENT MANAGEMENT EPINEPHRINE HYPOPERFUSION AND SHOCK DIPHENHYDRAMINE SOLUMEDROL FAMOTIDINE ALBUTEROL

Documentation • Respiratory and hemodynamic status • Difficulty breathing • Rash, hives, or swelling • Abnormal lung sounds • Probable allergen • Absence or presence of chest pain • Cardiac rhythm • Nature of pain (PQRST) • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications • Pain scale with each set of vitals • Fluid intake and output • SpO2 and ECG • Treatment • Response to treatment



Agitated/Behavioral/Psychotic Patient

Is the patient intubated?

Does the patient have an altered level of

consciousness?

Is the patient refusing care or

showing aggressive behavior?

Is patient in police custody?

Does patient have capacity to refuse care

Note:3

-Remove patient from stressful environment-Use verbal calming techniques (reassurance)-Involve family/friends-Involve Law Enforcement

Has treatment been given?

Have patient sign patient refusal of

form


Still agitated?Note: 5

Continue supportive care

Can medications be given safely

Versed: 2.5mg IV/IO/IN repeat q5 minutes prn max dose 10 mg

OrVersed: 5mg IM q5 minutes prn max

dose 10 mg totalNote: 6 & 7

-Elicit Law Enforcement or nursing home help to restrain patient-See patient safety restraint guidelines

Still agitated?Note:5

No Yes

No Yes

Yes

No

No

Yes

No Yes

Yes

Yes

No No

Yes

YesNo

Yes

See Post IntubationManagement

See Adult Altered MentalStatus

Excited Delirium Syndrome Present?

Note 5

No -Elicit Law

Enforcement for help to restrain the

patient

Yes

Ketamine 2mg/kg IVOr

4 mg/kg IM

Once Medication has taken effect immediately

-obtain IV access (If not already done)-Place patient on Cardiac Monitor, SPo2,

Etco2 and oxygen-Transport

Note 7


Treat Suspected Medical or Trauma problems appropriate



Note 1 & Note 2 All notes on next page


Medical Problems and Emergencies 91 Agitated/Behavioral/Psychotic Patient

Note 1 Note 2 Note 3 -Scene safety is paramount -Law enforcement should be used for any concern over an unsafe situation. -If handcuffs are applied, Law Enforcement must be with the patient at all times -If plastics (zip ties) are applied the Law Enforcement may follow behind the ambulance

-Paralysis & Intubation are never indicated for the sole purpose of restraining violent behavior -Patients with co-existing medical conditions, i.e. severe head injury; overdose with loss of airway control may require intubation for clinical reasons

-A&Ox4 is not capacity. A patient must understand the ramifications of not obtaining care -Additionally, the patient must not be suicidal or under the influence of drugs or alcohol -Psychiatric & OD patients should not cross state lines and if possible transported to facility in same county.

Note: 4 Note: 5 Note: 6 Agitation to the point that patient care is compromised and/or patient crew safety is compromised, or the patient continues to struggle against physical restraints -Make sure that all of these patients have; -Cardiac monitor, Spo2, Etco2 to monitor patients respiratory system

Excited Delirium Syndrome is characterized by Aggressive behavior with altered sensorium, hyperthermia, superhuman strength, diaphoresis & lack of willingness to yield to overwhelming force - Patients with EDS are at high risk for sudden death if they continue to struggle against restraints

Medications should be administered cautiously in frail, older, and/or debilitated patients; lower doses should be considered

Note 7

-Airway management is critical for any patient given versed or ketamine -While intubation should not be performed as the sole purpose of restraining violent patients, these medications could result in respiratory depression resulting in the need for airway control

CPG Links Medication Links Intervention Links POST INTUBATION MANAGEMENT VERSED GENERAL PATIENT MANAGEMENT KETAMINE Bypass Guidelines



Hyperkalemia



General PatientManagement CPG

• Apply ECG and Spo2 monitoring• Etco2 monitoring

Gain IV Access

P

HPI & PESuper T Hyper K?

Note 1 & 2

ECG FindingsHyperkalemia

PersistentNote 3

Monitor patient&

Transport

• Calcium gluconate 1 gm IV/IO over 10 minutes• Sodium Bicarbonate 50 mEq IV/IO slow • Albuterol 2.5 mg nebulized continuously with max

dose 15mg

I

YES NO

Yes

NO

Note 1

-Historical Findings History of Renal Failure or Dialysis Sever hyperglycemia / DKA Excited Delirium Crush Syndrome -Physical Findings Generalized weakness Nausea / Vomiting Altered Mental Status

Note 2

-Crush Syndrome occurs when an extremity becomes entrapped (>4 hours) leading to hypoperfusion of the entrapped body part -CS patients are at high risk for hyperkalemia once the entrapped body part is released -Therefore treatment should be started before extrication when possible -IV access should be obtained for pretreatment prior to extrication -Treatment - 1 L (NS) bolus - 1 gm Calcium gluconate IV/IO over 10 minutes -50 mEq Sodium Bicarbonate slow IV/IO push

Note 3


Medical Problems and Emergencies 93 Hyperkalemia

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT Sodium Bicarbonate HYPOPERFUSION AND SHOCK Calcium Gluconate ALBUTEROL



Adult Diabetic Emergencies

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT DEXTROSE

GLUCAGON THIAMINE

Note Due to Nationwide shortage the 25g can be given by D50w or infused by D10 250 ml to meet required glucose

** Oral Glucose can be given to patients without airway compromise that are able to swallow an oral preparation

Scope of Practice Age Scope Paramedic Intermediate EMT-Basic Med Control

Document • Level of consciousness• The specific time of symptom

onset• SAMPLE history• Compliance with medications• Respiratory and hemodynamic

status• Capillary glucose• Signs or symptoms of

dehydration• Vital signs and temperature q

15 minutes• Vital signs q 5 minutes if

infusing vasoactive medicationsor if the patient is unstable

• Fluid intake and output• Temp, ETCO2, SpO2, ECG• Treatment• Response to treatment


Blood Glucose

• Alcoholic• Malnourished• On Diuretics

Thiamine 100 mg IV/IM

Recheck glucose in 10 minutesRepeat 25 g IV if necessary

Treat per appropriate CPG

Yes

60-300 mg/dL

No

>300 mg/dL ≤60 mg/dL

Treat dehydration of 10 mL/kg fluid bolus I

If unable to start IV, Glucagon 1 mg IM I

Administer Dextrose25 g IV I


Medical Problems and Emergencies 95 Adult Hypertension

Adult Hypertension

Document • Respiratory and hemodynamic

status• The specific time of symptom

onset• SAMPLE history• Pupils• Neurological assessment• Compliance with medications• Presence of chest pain• Nature of symptoms (PQRST)• 12-Lead ECG q 15 min• Changes in pulses or BP in

different extremities• Signs or symptoms of

dehydration• Vital signs and temperature q

15 minutes• Vital signs q 5 minutes if

infusing vasoactive medicationsor if the patient is unstable

• Fluid intake and output• Temp, ETCO2, SpO2• Treatment• Response to treatment

The most common organs affected by severe hypertension are the neurological, cardiac, and renal systems. Signs of the crisis include severe hypertension and one or more of the following symptoms: Altered LOC, Chest Pain, Epistaxis, Pupillary Changes, Retinal Hemorrhages, ECG changes, Respiratory Distress, and Spilling Blood in Urine. The reduction of elevated blood pressure in the field with antihypertensive medications is not advised.

Scope of Practice Age Scope Paramedic Intermediate EMT-Basic Med Control

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT NITROGLYCERIN PIH/PRE-ECLAMPSIA/ECLAMPSIA CHEST PAIN/ACS CVA SYMPTOM MANAGEMENT


Blood pressure >200/110

Yes

Yes

No

No Probably not Hypertensive Crisis.Treat patient per appropriate CPG.

Is patient in 2nd or 3rd trimester of

pregnancy?

See PIH, Pre-Eclampsia and Eclampsia CPG

Symptoms consistent with ischemic cardiac

chest pain

Symptoms consistent with

CVA or subarachnoid

bleed

Yes

Yes

See Chest Pain/ACS CPG


No

Treat physiological causes of hypertension such as pain or agitation per Symptoms CPG

P

No

Monitor patient and transport



Adult Epistaxis

Adult General Patient Management

Epistaxis controlledWith pressure applied

• Gain IV access• Provide fluid bolus if hypotensive per shock

CPG If bleeding controlled treat patient per appropriate CPG


Have Patient blow Nose

• Tranexamic Acid (TXA) ( 1ml)(100mg) IN to each nostril P

I

Apply Nasal ClampDo Not Remove Clamp Prior to ED Arrival B

NO YES


Document • Airway Patency • Respiratory and

hemodynamic status • New onset or chronic

Epistaxis • Mean duration of symptoms

prior to EMS • Use of antiplatelet

medications (aspirin, clopidigrel, etc.)

• Use of anticoagulant medications (Warfarin, Heparins, NOAC’s)

• Site of bleeding (unilateral, bilateral)

• Efficacy of bleeding control on ED arrival (worse, unchanged, improved, completely stopped)

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT Tranexamic acid (TXA) Hypoperfusion and Shock




Medical Problems and Emergencies 97 Adult Seizures

Adult Seizures



Document • Airway Patency • Respiratory and hemodynamic

status • New onset or chronic seizures • Length of seizure activity • Type of seizure activity • History or recent illness • Compliance with medications • Pupils • Glasgow Coma Scale • Blood glucose • SAMPLE history • Vital signs and temperature q 15

minutes • Vital signs q 5 minutes if infusing

vasoactive medications or if the patient is unstable

• Fluid intake and output • Temp, ETCO2, SpO2 • Treatment • Response to treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT VERSED PIH/PRE-ECLAMPSIA/ECLAMPSIA THIAMINE DEXTROSE

Note 1 Recheck blood glucose 10 minutes following dextrose. If blood glucose remains <60 mg/dL, repeat.

Note 2 After administering Versed, monitor and assist in ventilations for approximately 2 minutes for the therapeutic effects of the medication. Maintain a MAP above 80 in adult patients.


Blood Glucose

Yes

No

≤60 mg/dL

Alcoholism?Malnourished?On Diuretics?

No

Yes

Monitor patient and transport to a facility with CT capabilities

Protect patient from injury

Cool patient if febrile

Thiamine 100 mg IV/IM I

If unable to start IV,Glucagon 1 mg IM I

Refractory Seizures

>60 mg/dL

IV Access?

Yes

No


Versed 2.5 mg IN or 5 mg IMRepeat as needed Q 5 Min. Max total dose: 10 mg

Note 2P

Versed 2.5 mg IV/IORepeat as needed Q 5 Min. Max total dose: 10

mgNote 2

P

Dextrose 25 g IV/IONote 1 I

Is patient in the 3rd trimester of pregency through 2 weeks post-

partum

See Pre-Eclampsia CPG

Yes

No



Adult Stroke/TIA/CVA


Keep patient’s head midline and elevated 30 degrees

Initiate Rapid Transport to a Primary Stroke Center

• Initiate IV access x 2 (at least one 18 ga to AC if possible)• Complete rainbow blood draw• Obtain a 12-lead ECG

P

Recognize: Using RACE+ assessment toolRule Out: BGL, Sepsis, ToxinsRank: RACE +Report: Stroke Activation <10 minutes on scene

LVOPositive(Note 1)

Notify receiving ED of Stroke Alert if within 4.5 hrs (LKW)

<24 hrs(LKW)

Is Comprehensive Stroke Center

available without extending

transport time more than 15

minutes?

Transport to ComprehensiveStroke CenterYes

YesYes

No

NoNo

Yes

See Next Page



Note 1 • A RACE+ score of >5 is considered positive for an large vessel occlusion (LVO) Stroke • Cortical signs (+signs) are specific for LVO’s but not necessary for a LVO to be present


Medical Problems and Emergencies 99 Adult Stroke/TIA/CVA

Code Stroke Activation Criteria Inclusion Criteria Exclusion Criteria

• Age > 18 • The patient will be at the medical facility within 4.5

hours of symptom onset • Clinical diagnosis/suspicion of an ischemic stroke

causing the neurologic deficit

• Major trauma or surgery within 15 days of symptom onset

• Head trauma • Pregnancy • Eliquis, Pradaxa, Xarelto, Savaysa

(note to ask last time taken)

Document • Specific symptom onset time • Airway Patency • Respiratory and hemodynamic status • RACE Assessment (EMT-P) • Nature of symptoms (PQRST) • Pupils • Glasgow Coma Scale • Blood glucose • 12-lead ECG • SAMPLE history • Vital signs q 5 minutes if infusing vasoactive • Vital signs and temperature q 15 minutes • Medications or if the patient is unstable • Fluid intake and output • Temp, ETCO2, SpO2 • Treatment • Response to treatment • Code Stroke activation time if applicable



Comprehensive Stroke Centers CHRISTUS Trinity Mother Frances-Tyler UT-Tyler Designated Stroke Centers CHRISTUS Good Shepherd Medical Center-Longview CHRISTUS Good Shepherd Medical Center-Marshall CHRISTUS Trinity Mother Frances-Winnsboro CHRISTUS Trinity Mother Frances-Sulphur Springs CHRISTUS St. Michael’s Atlanta Titus Regional Medical Center- Mt. Pleasant UT-Henderson UT-Pittsburg UT-Quitman UT-Athens

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT LABETALOL CGSMC ACTIVASE TRANSPORT

PROTOCOL


Medical Problems and Emergencies 101 RACE+ (Rapid Arterial Occlusion Evaluation)

RACE+ (Rapid Arterial Occlusion Evaluation)


Obstetrics, Gynecology & Neonatology 102

Obstetrics, Gynecology & Neonatology


Obstetrics, Gynecology & Neonatology 103 Vaginal Bleeding

Vaginal Bleeding

Document • Respiratory and hemodynamic status • Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if the patient is unstable • Abdominal Signs and Symptoms • Gravida and Para Status • Last menstrual period start date • Sexual activity/chance of pregnancy • SAMPLE history • Nature of symptoms (PQRST) • Pain scale with each set of vitals • Temp, ETCO2, SpO2 • Fluid intake and output • Treatment • Response to treatment



Definitions Gravida # of pregnancies Para # of births after 20 weeks

• Stillbirths are included • Twins/triplets/etc. count as one

Abortus # of pregnancies lost for any reason (Induced abortion or spontaneous/miscarriage)


NPO: Nothing by mouthObtain pad count

Ask about potential for pregnancy

Yes

Manage symptoms per Symptom CPG P


Hypoperfusion?

No

Transport

See Shock CPG



Do not perform a digital exam.

Interfacility Transport Considerations ● Active Labor can be defined as:

o Regular Contractions < 5 minutes apart o Cervical Dilatation > 5 cm o Cervical Effacement > 50% o Evidence of imminent birth

▪ Crowning ▪ Bloody show

● For patients in active labor, the benefit of transfer to a facility with OB/GYN and Neonatal ICU services may outweigh the risk of transfer. For these patients, the crew must assess the patient and then ensure that a 3-way telephone consult with the transferring physician, medical control and the accepting physician occurs prior to an agreement to transfer the patient

● Assistance through another unit or ED nursing staff should be requested when deemed appropriate

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT OXYTOCIN SHOCK MANAGEMENT SYMPTOM MANAGEMENT


Obstetrics, Gynecology & Neonatology 105 Premature Labor/PROM

Premature Labor/PROM Note 1 & 2



Note 1 “Preterm labor” denotes regular rhythmic contractions producing cervical changes in a patient who is less than 37 weeks gestation. “Premature rupture of membranes” denotes rupture of the membranes prior to the onset of labor.

Note 2 Consider common causes of preterm labor (i.e. infection, dehydration, etc.). Treat causes as appropriate.

Note 3 Do not perform a digital exam.

General Note If Magnesium Sulfate has been started by transferring facility it should be continued at the same rate. Monitor closely for signs of Magnesium toxicity

Interfacility Transport Considerations • Active Labor can be defined as:


Crowning Bloody show

• For patients in active labor, the benefit of transfer to a facility with OB/GYN and Neonatal ICU services may outweigh the risk of transfer. For these patients, the crew must assess the patient and then ensure that a 3-way telephone consult with the transferring physician, medical control and the accepting physician occurs prior to an agreement to transfer the patient

• Assistance through another unit or ED nursing staff should be requested when deemed appropriate • The transferring facility may start medications to stop or slow pre-term labor. These medications should be

continued per the transferring facility directions. • When in doubt contact medical control


YesCrowning?Note 3

No

Transport to nearby facility with Obstetrical capabilities

See Childbirth CPG

• Place patient left lateral recumbent• Administer high flow O2• Obtain IV access

Start IV Fluid Bolus 10-20 ml/kg

Limit Scene time



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT CALCIUM CHLORIDE SYMPTOM MANAGEMENT CALCIUM GLUCONATE SHOCK MANAGEMENT MAGNESIUM SULFATE

Document • Specific time of symptom onset • SAMPLE history • Gravida and Para Status • Last menstrual period start date and Due Date • Prenatal Care • Contraction onset, frequency, and duration • Transport position • Presence and nature of pain (PQRST) • Pain scale with each set of vitals

• Respiratory and hemodynamic status • Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if patient is unstable • Deep tendon reflexes q 15 min if on Magnesium • Fluid intake and output • Associated symptoms • Temp, ETCO2, SpO2 • Treatment and Response to treatment


Obstetrics, Gynecology & Neonatology 107 Pre-Eclampsia/Eclampsia

Pre-Eclampsia/Eclampsia

Note 1



Note 1 PIH denotes “Pregnancy Induced Hypertension”. The diagnosis of PIH can be made by a new onset BP > 140 Systolic or 110 Diastolic beginning after onset of pregnancy. The diagnosis of Pre-Eclampsia can be made if the patient has PIH and protein in her urine. Other signs include hyperreflexia, photophobia, and headache. This occurs in the third trimester of pregnancy through 2 weeks post-partum

Note 2 Signs of Magnesium toxicity include decreasing deep tendon reflexes, decreasing level of consciousness, and hypoventilation. Treat by turning off the Magnesium and if hypoventilation occurs, treat with 1.5-3 g of Calcium Gluconate or 0.5-1g of Calcium Chloride over 10 minutes.




• For patients in active labor, the benefit of transfer to a facility with OB/GYN and Neonatal ICU services may outweigh the risk of transfer. For these patients, the crew must assess the patient and then ensure that a 3-way telephone consult with the transferring physician, medical control and the accepting physician occurs prior to an agreement to transfer the patient

• Assistance through another unit or ED nursing staff should be requested when deemed appropriate


YesActive Seizures orWitness prior to

arrival

Transport to nearby facility with Obstetrical capabilities

• Place patient left lateral recumbent• Administer high flow O2• IV access

Loading Dose of 50% Magnesium Sulfate 4-6 g over 30 min

ThenInfuse at 2-4 g/hr

P

• Monitor for Magnesium toxicity• Assess deep tendon reflexes q 15 min

Note 2

IV Access? Yes

Versed 2.5 mg IV/IO repeat Q 5 Min as needed. Max total dose: 10 mg PNo

Versed 2.5 mg IN or 5 mg IM repeat Q 5 Min as needed. Max total dose: 10 mg P

No

Monitor closely for Seizure Activity

BP >140/110 3rd trimester through 2

week post partum

Monitor closely for Seizure Activity

No

Yes



Document • The specific time of symptom onset • SAMPLE history • Gravida and Para Status • Last menstrual period start date and Due Date • Prenatal Care • Contraction onset, frequency, and duration • Transport position • Presence and nature of pain (PQRST) • Pain scale with each set of vitals


medications or if the patient is unstable • Deep tendon reflexes q 15 min if on Magnesium • Fluid intake and output • Associated symptoms • Temp, ETCO2, SpO2 • Treatment and Response to treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT MAGNESIUM VERSED


Obstetrics, Gynecology & Neonatology 109 Childbirth

Childbirth Scope of Practice Age Scope Paramedic



NoActive Labor?

Yes

History and examNote 1

3rd trimester bleeding or

pain?

Manage per Vaginal Bleeding CPG

Position left lateral recumbant

Transport to a facility with Obstetrical capbilities.

Yes

Crowning? <36 weeks gestation?

No

No No

Prepare for delivery

Yes

Abnormal Presentation? Contact Medical Control

Control DeliverySupport head with rotation

No

Yes

See Premature Labor/PROM CPG

Yes

Hand, cord, face?

• Elevate hips• Prevent cord compression

with gloved hand; • saline to cord

Emergently transport to hospital with emergency C-Section capability

Yes

Cord around neck?

• Slip cord over head and shoulder OR

• Place clamps 2" apart and cut cord

Footling Breach

Frank Breach

Support legs and trunk

No

Lower body to help head pass

As hairline appears, rotate baby around pubis by placing arm under baby and rotating up toward mom’s abdomen.

The head should deliver.Bulb suction mouth, then nose

Guide head upward to deliver lower shoulder, then downward to deliver upper shoulder

Control delivery of trunk and legs

Clamp cord 8" from navel with 2 ties 2" apart and cut between ties

• Manage mother per Post Partum CPG• Manage neonate per Neonatal Resuscitation CPG

Delay and attempts to

breath?

• Do not pull on baby.• Form a V with 2 fingers

to hold vaginal wall from baby’s face.

Head delivers

Bulb suction mouth, then nose

Yes

No

No

Yes



Note 1

Pertinent History • Previous births • Prenatal Care • Edema • Multiple Births • Previous c-sections • Medical history • Vital signs • Frequency of contractions • Fetal heart rate

Document • The specific time of symptom onset • SAMPLE history • Gravida and Para Status • Last menstrual period start date and Due Date • Prenatal Care • Contraction onset, frequency, and duration • Fetal heart tones • Transport position • Presence and nature of pain (PQRST) • Pain scale with each set of vitals


medications or if the patient is unstable • Deep tendon reflexes q 15 min if on Magnesium • Fluid intake and output • Associated symptoms • Temp, ETCO2, SpO2 • Treatment and Response to treatment




• For patients in active labor, the benefit of transfer to a facility with OB/GYN and Neonatal ICU services may outweigh the risk of transfer. For these patients, the crew must assess the patient and then ensure that a 3-way telephone consult with the transferring physician, medical control and the accepting physician occurs prior to an agreement to transfer the patient • Assistance through another unit or ED nursing staff should be requested when deemed appropriate

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT VAGINAL BLEEDING PREMATURE LABOR/PROM POST-PARTUM CARE NEONATAL RESUSCITATION


Obstetrics, Gynecology & Neonatology 111 Post-Partum Care

Post-Partum Care

Note 1 If the uterus inverts after the placenta delivers, discontinue Pitocin and contact Medical Control.



Document • Time of birth • Time of placental delivery • The color of amniotic fluid • Estimated fluid and blood loss • Complications if any • SAMPLE history


YesPlacenta delivered

Note 1

No

Manage per Hypoperfusion and Shock CPG

Manage neonate per Neonatal Resuscitation CPG

Place baby to breast to promote placental delivery

Manage per Hypoperfusion and Shock CPG.Administer Oxytocin 10 units in 1 L of NS at 125 mL/hrPerform Fundal Massage

Bleeding >250 cc?

Uterine Inversion?

Transport to a facility with emergent OB surgical intervention.

Manage per Hypoperfusion and Shock CPGPerform Fundal Massage

If bleeding does not slow or stop in 10 minutes, double the dose of Oxytocin to 250 mL/hr

No

No

Yes

Yes



• Gravida and Para Status • Last menstrual period start date

and Due Date • Prenatal Care • Presence and nature of pain

(PQRST) • Pain scale with each set of

vitals • Respiratory and hemodynamic

status • Vital signs and temperature q

15 minutes • Vital signs q 5 minutes if

infusing vasoactive medications or if the patient is unstable

• Fluid intake and output • Temp, ETCO2, SpO2 • Treatment and Response to

treatment CPG Links Medication Links Intervention Links

GENERAL PATIENT MANAGEMENT OXYTOCIN HYPOPERFUSION AND SHOCK NEONATAL RESUSCITATION


Obstetrics, Gynecology & Neonatology 113 Neonatal Resuscitation

Neonatal Resuscitation

Term gestation?Breathing or crying?

Good tone?

Check chest movementVentilation corrective steps

if neededETT or laryngeal mask if

needed

Intubate if not already done.Chest compressionsCoordinate with PPV

100% 02ECG Monitoring

HR below 60 bpm?

LaboredBreathing or

PersistentCyanosis?

PPV @Room airSPo2 monitoring

Consider ECG monitoring

Antenatal counselingTeam briefing and equipment check

HR below 60 bpm?

Warm and maintain normal temperature, position airway, clear secretions if needed, dry stimulate

HR below 100Bpm?

Post-resuscitation careTeam debriefing

Apnea, gasping, or HR below 100 bpm?

IV Epinephrine

If HR persistently below 60 bpmConsider hypovolemia

Consider pneumothorax

Stay with mother for routine care:Warm and maintain normal

Temperature, position airway,Clear secretions if needed, dry

Ongoing evaluation

Position and clear airwaySPO2 monitor

Supplemental 02 as needed

Birth

Pre-ductal SP02 Target

1 min 60%-65%2 min 65%-70%3 min 70%-75%4 min 75%-80%5 min 80%-85%10 min 85%-95%

No

1Minute

Yes

No

Yes

No

No

Yes

Yes

Yes



Note 1 Intubation may be considered at numerous points in resuscitation PPV should receive 5 cm PEEP pressure

Note 2 Epinephrine dose is 0.1 mL/kg IV/IO (1:10,000). May repeat 3-5 min as necessary

Note 3 If infusing volume, use 10 mL/kg. May repeat after reassessment.

Target SpO2 after birth

1 min 60-65% 2 min 65-70% 3 min 70-75% 4 min 75-80% 5 min 80-85% 10 min 85-95%



APGAR Score

Sign 0 1 2 Heart Rate Absent <100 >100 Respiratory Effort Absent Slow Good/Crying Muscle Tone Limp Some flexion Active Reflex Irritability No Response Grimace Cough/Sneeze Color Blue/Pale Body Pink Completely Pink

Document • Time of Birth • APGAR Score at 1 and 5 minutes • The color of amniotic fluid • Complications if any • Due Date/Gestational Age • Respiratory and hemodynamic status

• Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if the patient is unstable • Glucose • Fluid intake and output • Temp, ETCO2, SpO2 • Treatment and Response to treatment

CPG Links Medication Links Intervention Links NEONATAL STABILIZATION EPINEPHRINE INTUBATION


Obstetrics, Gynecology & Neonatology 115 Neonatal Stabilization

Neonatal Stabilization

Document • Time of Birth • APGAR Score at 1 and 5 minutes • The color of amniotic fluid • Complications if any • Due Date/Gestational Age • Respiratory and hemodynamic status • Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if the patient is unstable • Glucose • Fluid intake and output • Temp, EtCO2, SpO2 • Treatment and Response to treatment


NEONATAL RESUSCITATION DEXTROSE APGAR SCORE



Dextrose 0-28 do 5 mL/kg D10 29 do to 8 yo 2 mL/kg D25 >8 yo 1 mL/kg D50 max of 25 g To make D10, mix 25 g of D50 in 250 mL of NS To make D25, waste 12.5 g (25 mL) of D50 and refill syringe with NS (50 mL total)

Neonatal Resuscitation CPG

Yes

No

• Apply ECG and SpO2 monitoring• Keep patient warm• Maintain SpO2>92%• Transport to the closest facility

• Keep patient in warm environment.• Remove cold or wet linens.• Keep temp >97.7oF

Reassess Airway and Oxygenation

Mean Arterial Pressure ≥ gestation

age in weeks

Contact receiving neonatologist or medical control if patient continues to do poorly or if

you need treatment guidance.

Administer O2 or ventilation as necessary to maintain SpO2>92%

No Distress

No

Distress

Yes

Heel blood glucose <40 mg/

dL

• Initiate IV access• Administer D10 2mL/kg

over 5 min.P

D10 maintenance drip:4 mL/kg/hr P

Evaluate need for fluid or pressors.Fluid: 10 mL/kg of NSPressor: Norepinephrine 0.05-2 mcg/kg/min

P


Pediatric Clinical Practice Guidelines 116

Pediatric Clinical Practice Guidelines


Pediatric Clinical Practice Guidelines 117 Pediatric Resource Information

Pediatric Resource Information

Age Weight (kg) Heart Rate Resp Rate Systolic BP Diastolic BP Premature 1 145 <40 32-52 13-29 Premature 2-3 135 <40 40-60 20-36 New Born 2-3 125 <40 40-60 29-45 1 Month 4 120 24-35 64-96 30-62 6 Month 7 120 24-35 60-118 50-70 1 Year 10 120 20-30 66-126 41-91 2-3 Year 12-14 115 20-30 90 + 2x age 45-85 4-5 Year 16-18 100 20-30 90 + 2x age 45-85 6-9 Year 20-26 100 12-25 90 + 2x age 45-85 10-12 Year 32-42 75 12-25 90 + 2x age 53-83

ET Tube Size 𝑀𝑀𝐴𝐴𝐴𝐴

4+ 4

ET Tube Depth ET Tube Diameter x 3

Hypotension Systolic Blood Pressure 70 + 2 x age

Normal Systolic Blood Pressure 90 + 2 x age



Pediatric General Patient Management



Note 1 Signs of hypoperfusion can include: Altered mental status Pale/cool skin Decreased capillary refill Tachycardia Hypotension Decreased urine output Normal Systolic BP: 90+2x Age Hypotensive Systolic BP: < 70 + 2x Age

Note 2 Any patient with an altered level of consciousness should be assumed to have increased intracranial pressure. Pediatric patients with potential increased intracranial pressure should be managed to maintain Systolic BP at least 90+2x age


• Vital Signs• Chief Complaint• HPI• SAMPLE History• Reassessment

• Apply appropriate CPG based on assessment• Treat symptoms per Symptom CPG

Scene Secure• Contact law enforcement• Do not expose self or co-workers to

the scene until it has been secured

Yes

No

• Tourniquet life threatening bleeding • C-Spine: Immobilized the spine if there is evidence of potential injury• Airway: Manage per Basic and Advanced Airway Management CPG• Breathing: Manage per Oxygenation and Ventilation CPG• Circulation: Manage hypoperfusion per Shock CPG (Note 1)• Disability: Manage per Pediatric Altered Mental Status CPG (Note 2)• Expose: Undress and assess the patient as applicable

Contact Medical Control If:• Required by a specific CPG• Patient does not fit a CPG• You need consultation• Complications arise

MC

• Keep patient NPO• Temperature (Keep patient normothermic)

• SpO2• Initiate large bore Ivs in all critically ill patients• Initiate maintenance fluids if patient is NPO

I

• Cardiac Rhythm• ETCO2 P


Pediatric Clinical Practice Guidelines 119 Pediatric General Patient Management

Document • Respiratory and hemodynamic status • Applicable assessment • Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if the patient is unstable • ECG/Temp/SpO2/ETCO2 as applicable • Abnormal neurologic findings • Glasgow Coma Scale • The specific time of symptom onset • SAMPLE History • Symptom Assessment (PQRST) • Treatment Prior to Arrival • The treatment you provide and response to treatment • Communication with medical control

CPG Links Medication Links Intervention Links PEDIATRIC RESOURCE INFORMATION BASIC AND ADVANCED AIRWAY MANAGEMENT

OXYGENATION AND VENTILATION SHOCK PEDIATRIC ALTERED MENTAL STATUS SYMPTOM MANAGEMENT ISOLATED EXTREMITY TRAUMA



Pediatric Altered Mental Status



Note 1 If signs of dehydration exist, administer an IV fluid challenge NS 10-20 mL/kg.

Note 2 Detailed assessment: Airway Patency (including positional obstruction/restriction), Work of Breathing, Air Movement, Lung Sounds, Pulse Oximetry, Capillary Refill, Skin Color/Temperature, Blood Pressure

Note 3 Observe the environment closely for signs of potential overdose.

Note 4 Recheck blood glucose 5 min following dextrose. If blood glucose < 80 mg/dL, repeat.

Note 5 If the patient is a known user of narcotics and depression is consciousness is believed to be the result of narcotic use, consider titrating the dose of Narcan to respiratory improvement.

Possible Causes U Units of Insulin (Hypoglycemia) N Narcotics/Drugs C Convulsions O Oxygen (Hypoxia) N Nonorganic (Psychogenic) S Stroke C Cocktails (alcohol) I Increased ICP O Organisms (Infection) U Urea (Renal or Liver Failure S Shock

Blood Glucose >80 mg/dL

Yes

No

Pediatric General Patient Managment

Detailed AssessmentNote 2 and 3

Maintain Systolic BP >(70 + 2x Age) I

Increased LOC?

Consider Intubation P

• Maintain airway• Support respiratory effort• Keep patient warm

Increased LOC?

If unable to start IV, consider Glucagon>20kg: 1 mg IM

<20 kg: 0.5 mg IMI

No

YesYes

No

Repeat Narcan as needed I

Initiate IV AccessNote 1 I

Narcan 0.1 mg/kg IV/IOmax of 2 mg

Note 5I

Administer Dextrose IVNote 4 I


Pediatric Clinical Practice Guidelines 121 Pediatric Altered Mental Status

Dextrose 0-28 do 5 mL/kg D10 28 do - 8 yo 2 mL/kg D25 >8 yo 1 mL/kg D50 max of 25 g To make D10, mix 25 g of D50 in 250 mL of NS To make D25, waste 12.5 g (25 mL) of D50 and refill syringe with NS (50 mL total)

Glasgow Coma Scale

Eye Opening Spontaneous 4 To Voice 3 To Pain 2 None 1

Best Verbal Response Oriented 5 Confused 4 Inappropriate Words 3 Incomprehensible Sounds 2 None 1

Best Motor Response Obeys Commands 6 Localizes Pain 5 Withdraws (Pain) 4 Flexion 3 Extension 2 None 1

Document

• Airway Patency • Respiratory and hemodynamic status • Pupils • Glasgow Coma Scale • Blood Glucose • SAMPLE History • Cardiac Rhythm

• Nature of Symptoms (PQRST) • Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if the patient is unstable • Fluid intake and output • Temp/SpO2/ETCO2 as applicable • Treatment and response to treatment


PEDI GENERAL PATIENT MANAGEMENT

DEXTROSE INTUBATION

GLUCAGON NARCAN



Pediatric Diabetes Emergencies

Note 1 Signs of dehydration to treat in these patients • Skin tenting • Dry mucosa • Hypotension • Sunken Fontanels Do not assume that tachycardia is due to the patient being dehydrated. An elevation in blood sugar will create tachycardia. Administer NS @ 10 mL/kg and reassess.

Dextrose 0 - 28 do 5 mL/kg D10 29 do – 8 yo 2 mL/kg D25 >8 yo 1 mL/kg D50 max of 25 g To make D10, mix 25 g of D50 in 250 mL of NS To make D25, waste 12.5 g (25 mL) of D50 and refill syringe with NS (50 mL total)

Document

• Level of consciousness • The specific time of symptom onset • SAMPLE History • Compliance with medications • Respiratory and hemodynamic status • Blood Glucose • Signs or symptoms of dehydration

• Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if the patient is unstable • Fluid intake and output • Temp/SpO2/ETCO2 as applicable • Treatment and response to treatment



DEXTROSE

GLUCAGON



Blood Glucose? ≤80 mg/dL

Pediatric General Patient Managment

If unable to start IV, consider Glucagon>20kg: 1 mg IM

<20 kg: 0.5 mg IMI

Administer Dextrose IV I

IV Access and Transport.Withhold fluids unless obvious

signs of dehydration.Note 1

I


80-300 mg/dL

>300 mg/dL

Recheck glucose in 10 minutes and repeat if necessary. I


Pediatric Clinical Practice Guidelines 123 Pediatric Seizures

Pediatric Seizures

CPG Links Medication Links Intervention Links PEDI GENERAL PATIENT MANAGEMENT DEXTROSE GLUCAGON VERSED



Note 1 If signs of dehydration exist, administer an IV fluid challenge NS 10-20 mL/kg

Note 2 Recheck blood glucose 10 min following dextrose. If blood glucose remains <80 mg/dL, repeat.

Document • Airway Patency • Respiratory and hemodynamic status • New onset or chronic seizures • Length of seizure activity • Type of seizure activity • History or recent illness • Compliance with medications • Pupils • Glasgow Coma Scale • Blood glucose • SAMPLE history • Vital signs and temperature q 15 minutes • Vital signs q 5 minutes if infusing

vasoactive medications or if the patient is unstable

• Fluid intake and output • Temp, ETCO2, SpO2 • Treatment and response to treatment

Dextrose 0 – 28 do 5 mL/kg D10 29 do – 8 yo 2 mL/kg D25 >8 yo 1 mL/kg D50 max of

25 g To make D10, mix 25 g of D50 in 250 mL of NS To make D25, waste 12.5 g (25 mL) of D50 and refill syringe with NS (50 mL total)


Blood Glucose>80 mg/dL

Yes

No

No

Yes


Protect patient from injury

Cool patient if febrile

Refractory Seizures

Administer DextroseNote 2 I

If unable to start IV consider Glucagon IM,

< 20 kg: 0.5 mg≥ 20 kg: 1 mg

I

IV Access?

Yes

No

Attempt to terminate seizures with:Versed 0.1 mg/kg IV/IO (max single dose: 2 mg)

May repeat 1 x in 5 minutesP

Attempt to terminate seizures with:Versed 0.2 mg/kg IN/IM

May repeat 1 x in 5 minutesP

Maintain Systolic BP > 70 + 2 x ageNote 1 I




Open Airway

Give 2 breaths to make the chest rise.

Is Patient Breathing?

NoYes

Is there a response?

CPR1 Rescuer: 30:22 Rescuer: 15:2

Is there a pulse >60 bpm

• Apply O2• Assist ventilations if needed• Ensure pulse >60 with good perfusion

Go to appropriate CPG

No

Yes

Yes

No

Pediatric Cardiac Care (BLS)



Document

• Down time • Bystander CPR • Care prior to arrival • Respiratory and

hemodynamic status • Vital signs q 5 minutes if

infusing vasoactive medications or if the patient is unstable

• Potential causes for arrest • Vital signs • AED directions and times • Fluid intake and output • SpO2 • Treatment and response to

treatment





Pediatric Clinical Practice Guidelines 125 Pediatric: Bradycardia

Pediatric: Bradycardia

Note 1 Cardiopulmonary compromise? -Hypotension -Acutely altered mental status -Signs of shock

Document

• Assessment • ECG Rhythm • Each rhythm change • Respiratory and hemodynamic status • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if the patient is unstable • Verification of mechanical and electrical capture if paced • Fluid intake and output • Associated symptoms • SAMPLE history • Temp/ETCO2/SpO2 • Treatment and response to treatment




Support ABCs as neededGive Oxygen

Attach monitor/defibrillator

Perform CPR

HR <60 with Poor perfusion despite 02 & Ventilation

YesNo

Persistent symptomatic bradycardia

EpinephrineIV/IO 0.1 mL/kg (1:10,000)

Repeat 3-5 min

• Support ABCs• Give oxygen as needed• Observe• Consider expert consultation

Go to Pulseless Arrest Algorithm if needed

No

Yes

Bradycardia with a pulse causing cardiorespiratory

compromise(Note 1)

If increased vagal tone or AV block is present, give Atropine 0.02 mg/kg.

Min 0.1 mg to Max 0.5 mgRepeat x1

Consider Pacing



Reminders During CPR push hard and fast (100/min) Ensure full chest recoil Minimize interruptions in chest compressions Support ABCs Secure airway if needed; confirm placement

Contributing Factors • Hypovolemia • Hypoxia or ventilation problems • Hydrogen ions (acidosis) • Hypo/hyperkalemia • Hypoglycemia • Hypothermia

• Toxins • Tamponade (Cardiac) • Tension pneumothorax • Thrombosis (coronary or pulmonary) • Trauma (hypovolemia, increased ICP)

CPG Links Medication Links Intervention Links PEDI GENERAL PATIENT MANAGEMENT ATROPINE PACING PEDI PULSELESS ARREST EPINEPHRINE


Pediatric Clinical Practice Guidelines 127 Pediatric Cardiac Arrest


Airway management without interrupting chest compressions

using Supraglottic device .Apply EtCO2 monitoring

Shockable Rhythm

NoYes

Pediatric Post Resuscitation Care

Yes

2 minutes CPR uninterruptedNote 1 & 2

VF/Pulseless VT Aystole/PEA

Defibrillate 2 J/kgCPR for 2 min

Note 3P

Insert an IV/IO Note 4 I

Epi 0.1 mL/kg IV/IO (1:10,000)Repeat 3-5 min P

Defibrillate 4 J/kgCPR for 2 min P

Amiodarone 5mg/kg IVP2 cycles of CPR May repeat 1x

P

Insert an IV/IONote 4 I

Epi 0.1 mL/kg IV/IO (1:10,000)Repeat 3-5 min P

Return of pulses?

If TorsadesMag Sulfate 25-50 mg/kg

Max dose: 2 gP Reassess and repeat per

current PALS GuidelinesNo

IVF 20 ml/kg I

Pediatric Cardiac Arrest



Contributing Factors • Hypovolemia • Hypoxia or ventilation

problems • Hydrogen ions

(acidosis) • Hypo/hyperkalemia • Hypoglycemia • Hypothermia • Toxins • Tamponade (Cardiac) • Tension pneumothorax • Thrombosis (coronary

or pulmonary) • Trauma (hypovolemia,

increased ICP)




Note 1 -High-quality CPR is one of the few interventions with proven benefit in cardiac arrest -Push hard (at least 2 inches in depth or ≥1/3 AP diameter of the chest) -Push fast but not too fast (100-120 per minute) utilize the metronome on the LifePak -Allow for complete chest recoil -We should approach Pediatric Cardiac Arrest the same as adult cardiac arrest (i.e., bring care to the patient, High-quality CPR, early defibrillation) by remaining on the scene while we perform these interventions

Note 2 -Respiratory rate with advanced airway is (1) breath every 6-8 seconds -Utilize the metronome on the LifePak -Do not over ventilate the patient

Note 3 -Early defibrillation has the best evidence for benefit in cardiac arrest -For every minute delay in defibrillation, the chance of survival decreases by 10% -Every effort should be made to minimize pauses in CPR. Pauses occur during partner switches, defibrillation & rhythm checks. Pauses should be no more than 10 seconds in length. -Charge defibrillator while performing CPR to lessen the hands off time to defibrillation -If rhythm is shockable, then shock. If rhythm is not shockable then dump the charge and continue CPR

Note 4 -IV access is difficult in critically ill pediatric patients -IV access should be the preferred option -Evidence for epinephrine, like most drugs in cardiac arrest, is lacking. Current science suggest that epinephrine is most beneficial when given as early as possible

CPG Links Medication Links Intervention Links PEDI GENERAL PATIENT MANAGEMENT AMIODARONE PEDIATRIC POST RESUSCITATION CARE

EPINEPHRINE

MAGNESIUM SULFATE


Pediatric Clinical Practice Guidelines 129 Pediatric Stable Tachycardia

Pediatric Stable Tachycardia

CPG Links Medication Links Intervention Links PEDI GENERAL PATIENT MANAGEMENT ADENOSINE


Intermediate EMT-Basic Med Control Pediatric General Patient Management

QRS > 0.09 sec (90 ms)

No

Sinus Tach Probable SVT Possible SVT with aberrancy Probable V-Tach

• P-waves present/normal• Variable R to R with constant

PR interval• Infant rates usually <220/min• Child rates usually < 180/min

• Regular R to R interval• Uniform QRS morphology• Infant rates usually >220/min• Child rates usually >180/min

• P-waves absent/abnormal• Rate not variable with activity• Infant rates usually >220/min• Child rates usually >180/min

Consider Modified Valsalva maneuvers

Consider Adenosine 0.1 mg/kg(6 mg is max first dose)May give second dose of 0.2 mg/kg(12 mg is max second dose)Give as Rapid Bolus

Search for and treat causes

Yes

Expert consultation is strongly recommended.

Search for and treat reversible causes.

Obtain 12-lead

MC



Pediatric Unstable Tachycardia

Note Sedate if needed but do not delay cardioversion


PEDI GENERAL PATIENT MANAGEMENT ADENOSINE CARDIOVERSION




QRS > 0.09 sec (90 ms)

No

Sinus Tach Probable SVT Possible SVT with aberrancy Probable V-Tach

• P-waves present/normal• Variable R to R with constant

PR interval• Infant rates usually <220/min• Child rates usually < 180/min

• Regular R to R interval• Uniform QRS morphology• Infant rates usually >220/min• Child rates usually >180/min

• P-waves absent/abnormal• Rate not variable with activity• Infant rates usually >220/min• Child rates usually >180/min

Consider vagal maneuvers but do not delay cardioversion

If IV/IO is not available or Adenosine is ineffective, Synchronized CardioversionInitial Dose: 0.5-1 J/kgSubsequent Doses: 2 J/kg

Note 1

Search for and treat causes

Yes

Expert consultation is strongly recommended.

Search for and treat reversible causes.

Obtain 12-lead

MC

If an IV/IO is present, give Adenosine 0.1 mg/kg (max of 6 mg)

Immediate Synchronized CardioversionInitial Dose: 0.5-1.0 j/kgSubsequent Doses: 2 j/kg

Note 1


Pediatric Clinical Practice Guidelines 131 Pediatric: Post Resuscitation Care

Pediatric: Post Resuscitation Care

Note 1

Post-ROSC patients have better neurologic outcomes when hypotension is avoided -Therefore norepinephrine drips should be available immediately if patients become hypotensive -For every 10 minutes of hypotension, the mortality increases -Utilize the Pediatric Resource Information to determine hypotension

CPG Links Medication Links Intervention Links PEDI GENERAL PATIENT MANAGEMENT HYPOPERFUSION & SHOCK PEDIATRIC BRADYCARDIA PEDIATRIC UNSTABLE TACHYCARDIA

NOREPINEPHRINE



General Patient Management CPGReturn of Spontaneous Pulse after cardiac arrest

Shock/Hypoperfusion Known or suspected reason for arrest Bradycardia Unstable

Tachydysrhythmia

Reassess ABCs, ETCO2, SpO2, BP, ECGNote 1

Treat per Hypoperfusion & Shock CPG Treat per appropriate CPG Pediatric

Treat per Bradycardia CPGPediatric

Treat per Tachycardia CPG

Transport to closet appropriate Medical Facility


Respiratory Problems and Emergencies 132

Respiratory Problems and Emergencies


Respiratory Problems and Emergencies 133 Upper Airway Obstruction

Upper Airway Obstruction


Intermediate EMT-Basic Med Control General Patient Management

Able to talk, cry, or cough?

Swelling Airway

No

Foreign Body Obstruction

<1 Years5 back slaps/5 chest thrusts

>1 YearsAbdominal Thrusts

Epinephrine Nebulized 0.5 mg/kg (1:1,000) in 3 mL NSMax dose: 5 mg

Manage per appropriate CPG

Yes

Maintain position of comfort.Limit stimuli to the patient.

Give humidified oxygen.

Anaphylactic Reaction?

Stridor present while at rest?

Go to Allergic Reaction/Anaphylaxis CPGYes

No

No

Yes

Improvement?


Airway Clear?

<1 Years5 back slaps/5 chest thrusts

>1 YearsAbdominal Thrusts

AdultsChest Compressions

Attempt direct laryngoscopy

Yes

No/Still Responsive

No/Unresponsive

Airway Clear?Cricothyrotomy or

Needle Cric for Pediatrics

Yes

No

NoYes



Croup Usually children under 5 Usually a history of upper respiratory infections “Seal like” cough Stridor present Improves with cold air exposure

Epiglottitis Very sudden onset Often painful to swallow, may drool Can occur in any age Rare event


GENERAL PATIENT MANAGEMENT EPINEPHRINE NEEDLE CRICOTHYROTOMY PEDI GENERAL PATIENT MANAGEMENT SURGICAL CRICOTHYROTOMY ALLERGIC REACTION/ANAPHYLAXIS


Respiratory Problems and Emergencies 135 Middle and Lower Airway Obstruction

Middle and Lower Airway Obstruction Asthma, COPD, Reactive Airway Disease, Toxic Inhalation

General Patient Management

Compensated Peri-arrestNote 1

Compensation

Treat hypoxia and hypercapnia per Oxygenation and Ventilation CPG Treat hypoxia and hypercapnia per

Oxygenation and Ventilation CPG

Manage symptoms per Symptom CPG

IV fluid bolus 20 mL/kg unless patient is in CHF I

For refractory bronchospasm consider Magnesium Sulfate

Adult: 2 g over 10 minPedi: 50 mg/kg up to 2 g diluted in 2 mL/kg NS over 10 minutes

P

Solumedrol IV/IM/IOAdult: 125 mg P

Assemble MDI MaskAdults eight (8) “puffs” of Albuterol i f MDI is available

May repeat once in 5 minutesPediatric <10 yrs. of age requires

Four (4) “puffs” of Albuterol i f MDI is available

May repeat once in 5 minutesAS Needed

Adult 0.3 mg Epinephrine (1:1,000) in thigh. Reduce to 0.15 mg if pat ient i s over 50 years old, heart rate is greater than 130 bpm,

or history of coronary artery diseasePediatric 0.01 mg/kg with max dose 0.3 mg IM

Repeat in 10 minutes if needed

Administer Epinephrine by most rapidly accessible route.

Epinephrine (1:1,000)• Adult: 0.3-0.5 mg IM• Pedi: 0.01 mg/kg (max of 0.3

mg)Epinephrine Drip

• Adult: 2-10 mcg/min• Pedi: 0.1-2 mcg/kg/min

Titrate for blood pressure and respiratory/vascular status

Notes 1

P

DexamethasonePedi only

0.6 mg/kg po/IV (max 10 mg)P

P



Epi Drip Take 1 mg of 1:10,000 Epi and mix in 250 mL of NS. This is 4 mcg/mL 1 mcg/min = 15 mL/hr 2 mcg/min = 30 mL/hr 3mcg/min = 45 mL/hr

Note 1 Signs of instability and near arrest include: • Rapidly falling level of

consciousness • Falling respiratory rate and

depth • Bradycardia • Absent or diminishing lung

sounds Administration of Epi is for patients that are truly near death. Do not administer if patient is adequately compensating.

Intubation Patients with asthma or COPD have a problem breathing out not in. Intubation does not fix this. Intubation should only be considered as a last resort when the patient’s minute volume is so small they are suffocating.

COVID-19 Specific Adjustments -Steroids should be avoided in suspected or confirmed COVID-19 patient -Position of comfort in a prone position has been shown to decrease work of breathing, but careful monitoring of the patient’s condition should be followed with ETCO2. Prone positing is acceptable for patient comfort and work of breathing during COVID-19. Patient can be transported in the prone position with the stretcher flat and built-in restraints in place



Document • Respiratory and hemodynamic status • Assessment of respiratory distress and lung sounds • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if patient is unstable • SAMPLE History • Presence of chest pain • Nature of symptoms (PQRST) • 12-lead ECG if over 40 years old • Fluid intake and output • Temp/ETCO2/SpO2 • Treatment and response to treatment


GENERAL PATIENT MANAGEMENT ALBUTEROL NEEDLE CRICOTHYROTOMY PEDI GENERAL PATIENT MANAGEMENT EPINEPHRINE SURGICAL CRICOTHYROTOMY OXYGENATION AND VENTILATION IPRATROPIUM BROMIDE SYMPTOM MANAGEMENT SOLUMEDROL Dexamethasone


Trauma, Injury, & Environmental Emergencies 137 Middle and Lower Airway Obstruction

Trauma, Injury, & Environmental Emergencies


Trauma, Injury, & Environmental Emergencies 138

Assault & Violence

Note 1 If unsure if the closest facility has a SANE nurse, contact the facility prior to transport. Good Shepherd Medical Center and Trinity Mother Frances Medical Center both have active SANE programs.

Document

• Respiratory and hemodynamic status • Location and nature of injuries • Any observed evidence • Methods to preserve evidence and chain of custody • Specific statements from patient about event or suspect information • Nature of symptoms (PQRST) • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if patient is unstable • Pain scale with each set of vitals • Fluid intake and output • SpO2 • Treatment and response to treatment



Transport to an appropriate facility

Yes

No

Adult/Pedi General Patient Management

Sexual Assault

Physical injury or illness>


• Protect patient privacy and coordinate care in conjunction with law enforcement personnel

• Discourage the patient from washing or bathing.• Protect any potential evidence and document a

chain of custody.

Transport to a facility with a Sexual Assault Nurse Examiner

Note 1

Yes

No


Trauma, Injury, & Environmental Emergencies 139 Assault & Violence

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT PEDI GENERAL PATIENT MANAGEMENT



Bites and Envenomation’s



Document • Respiratory and

hemodynamic status • Absence or presence

of pain • Location and nature of

injuries • Suspected animal type

responsible for bite • Signs of

envenomation • Estimated time of bite • Nature of symptoms

(PQRST) • Vital signs q 15

minutes • Vital signs q 5 minutes

if infusing vasoactive medications or if patient is unstable

• Pain scale with each set of vitals

• Fluid intake and output • ECG/SpO2 • Treatment and

response to treatment • Tourniquet use is

contraindicated

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT PEDI GENERAL PATIENT MANAGEMENT ALLERGIC REACTION/ANAPHYLAXIS SYMPTOM MANAGEMENT


Allergic Reaction?

No

Assure animal control has been notified if a domestic animal

• Control bleeding as necessary• Immobilize extremity if applicable

Treat allergic reaction per Anaphylaxis/Allergic Reaction CPG

Control symptoms per Symptom CPG P

Black Widow spider bite?

Snake Bite

Yes

No

Assure animal control has been notified if a domestic animal

Yes

No

• Immobilize the limb• Keep the extremity in a neutral

position.• Remove jewelry from the involved

extremity.

Yes

Consider Versed for muscle spasmAdult dose: 2.5 mg IV/IM/IN

Pedi dose: 0.1 mg/kg IV/IM/IN

May repeat 1x in 10 minutes

P


Trauma, Injury, & Environmental Emergencies 141 Burn Management

Burn Management



Note 1: Minor Burn Definition

Type: • 1st Degree <30% BSA

OR • 2nd/3rd Degree <5% Excludes any of the following involvement: • Face • Hands • Feet • Peritoneum

Note 2: Parkland Burn Formula

𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝐴𝐴 =2 × %𝐵𝐵𝐵𝐵𝑀𝑀 × 𝑊𝑊𝐴𝐴𝑊𝑊𝐴𝐴ℎ𝑡𝑡 (𝐾𝐾𝐾𝐾) Infuse volume over 8 hours from the time of burn. Repeat infusion over 16 hours.

Note 3 The diagnosis of Rhabdomyolysis should be made in any patient with massive muscle damage and darkening urine. If Rhabdomyolysis is present, administer 20 mL/kg NS bolus then begin the Parkland Burn Formula.

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT PEDI GENERAL PATIENT MANAGEMENT HYPOPERFUSION/SHOCK MANAGEMENT

SYMPTOM MANAGEMENT

Adult or Pediatric General Patient Management

Type of Burn

• Stop burning process• Remove constrictive clothing or jewelry

No

Yes

Thermal Burn Chemical Burn

• Calculate area of burn using Rule of Nines• Cover with dry sterile dressing

• Remove clothing and any visible dry chemicals or powder

• Flush area with normal saline for 15 minutes

Severe burn?Note 1

Consider intubation for airway burns P

Consider direct air transport to nearest burn center


Transport to closest appropriate facility

HypoperfusionManage per Shock CPG


Yes

No



Manage per Parkland Burn FormulaNote 2 and 3 I



Document • Respiratory and hemodynamic status • Body surface areas burned • Mechanism of the burn • Presence of smoke inhalation • Estimation of total surface area burned • Parkland Burn Formula calculation • Coexistent trauma • Nature of symptoms (PQRST) • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if patient is unstable • Pain scale with each set of vitals • Fluid intake and output • ECG/SpO2/ETCO2 • Treatment and response to treatment


Trauma, Injury, & Environmental Emergencies 143 Dental Complaints and Injuries

Dental Complaints and Injuries



Note 1 Avoid rinsing or scrubbing the tooth. Handle as little as possible

Document • Respiratory and hemodynamic status • Location and nature of injuries • Nature of symptoms (PQRST) • SAMPLE History • If an avulsed tooth, method utilized to preserve tooth. • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if patient is unstable • Fluid intake and output • SpO2 • Treatment and response to treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT PEDI GENERAL PATIENT MANAGEMENT SYMPTOM MANAGEMENT


Secondary tooth avulsion?

Note 1No

Control bleeding with pressure

Reassess and monitor

Yes


Awake & Oriented, Maintaining Airway

Sitting Upright

Place tooth under patient’s tongue

Place tooth in milk or NS

No

Yes



Eye Injury or Complaint

Document • Respiratory and hemodynamic status • Specific time of symptom onset • SAMPLE History • Length of exposure • Care prior to arrival • Nature of symptoms (PQRST) • Ability for patient to see out of injured eye

• Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if patient is unstable • Pain scale with each set of vitals • Fluid intake and output • Associated Symptoms • SpO2 • Treatment and response to treatment


GENERAL PATIENT MANAGEMENT TETRACAINE PEDI GENERAL PATIENT MANAGEMENT SYMPTOM MANAGEMENT




NaturePain/Visual Disturbance

• Assess visual acuity• Evaluate Pupils• Complete Neuro exam• Screen for chemical or agent

exposure

Injury Isolated to eys(s)?

Cover with saline moist gauze

No

Yes

Cover both eyes

Manage symptoms per Symptom CPG P

Eye in socket?

Go to appropriate CPG

No

Mechanism

Yes

Irrigate with NS Assess orbital stabilityAssess visual acuity

when feasible

PhysicalTrauma

Burn/Chemical

Cover the unaffected eye

Irrigate with NS P

Tetracaine 2 gtt P


Trauma, Injury, & Environmental Emergencies 145 Heat Emergencies

Heat Emergencies

Document • Respiratory and hemodynamic status • Patient temp • Ambient temp • Length of exposure • Nature of symptoms (PQRST) • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if patient is unstable • Pain scale with each set of vitals • Fluid intake and output • ECG/SpO2/ETCO2 • Treatment and response to treatment



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT PEDI GENERAL PATIENT MANAGEMENT


Decreased LOC?Core Temp > 107F?

Not Sweating?

• Remove patient from source of heat

• Obtain baseline temperature• Begin external cooling with

tepid water and fanning• Titrate IV fluids to hydration

status (20 mL/kg bolus)

No

Yes

Assume heat stroke

Probably heat exhaustion/heat cramps.

Continue care and transport

Consider intubation and sedation/paralysis to prevent shivering or in

patients that are not protecting their airway

P



Hypothermia

Note 1 As a general rule, patients in hypothermic cardiac arrest should be resuscitated and transported to a hospital.

Document

• Respiratory and hemodynamic status • Patient temp • Ambient temp • Length of exposure • Down time if in arrest

• Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive medications or if

patient is unstable • Fluid intake and output • ECG/SpO2/ETCO2 • Treatment and response to treatment



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT ADULT PULSELESS ARREST PEDI GENERAL PATIENT MANAGEMENT PEDIATRIC CARDIAC ARREST


Cardiac Arrest?

• Remove wet clothing and stop ongoing heat loss• Move patient gently• Monitor temp q 15 minutes

No Yes

Passive and/or active internal rewarming

• CPR• Defibrillate VF/VT (120-200 J

Biphasic) one time• Resume CPR• IV and bolus with warm fluids• Secure airway and ventilate with

100% O2

Core Temp ≥ 86° F

• Continue CPR• Withhold medication• Limit defibrillation to one time

• Defibrillate recurrent VF/VT as indicated

• Give IV medication as indicated but extended dosing intervals to max of 10 minutes.

YesNo

Core Temp

• Passive and active external rewarming of truncal areas

• May use hot packs, warm IV fluids bags against body, vehicle heater

Active internal rewarming utilizing warm IV fluids, warm gas if avaible

Continue rewarming until core temperature is > 95 F or resuscitation measures cease

Note 1

93.2-96.8°F

86-93.2°F

<86°F


Trauma, Injury, & Environmental Emergencies 147 Drowning and Near Drowning

Drowning and Near Drowning



Document • Specific time of submersion • Estimated duration of submersion • Approximate temperature of water • Type of water (clean, dirty, fresh, salt, etc) • Loss of consciousness • Need or lack of need for spinal

immobilization • SAMPLE History • Cardiac rhythm • Respiratory and hemodynamic status • Lung sounds • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing

vasoactive medications or if patient is unstable

• Pain scale with each set of vitals • Fluid intake and output • Associated symptoms • Temp/ECG/SpO2/ETCO2 • Treatment and response to treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT ALBUTEROL PEDI GENERAL PATIENT MANAGEMENT HYPOTHERMIA OXYGENATION & VENTILATION CPG


• Remove patient from water• Maintain c-spine precautions if there is

any potential for neck trauma.• Quickly begin drying and warming patient

• Perform appropriate airway measures• Manage life threatening arrhythmias per

appropriate CPG• Treat hypothermia per Hypothermia CPG

If bronchospastic consider nebulized Albuterol 2.5 mg in 3 cc NS I

Transport to a facility with Trauma and Neurological services



Toxicological Emergencies and Medication Reactions

Document • Respiratory and hemodynamic status • Ability to maintain airway • Suspected toxin, amount, and time of exposure • ECG/ETCO2/SpCO2 • 12-Lead if any cardiotoxin involved • Treatment • Any abnormal or unexpected reaction


Intermediate EMT-Basic Med Control Adult or Pediatric General Patient Management

Contact Medical Control if you need assistance

• Treat airway issues per Basic and Advanced Airway Management CPG• Treat hypoxia and hypercapnea per Oxygenation and Ventilation CPG• Treat hypoperfusion and shock per Hypoperfusion and Shock CPG• Treat altered mental status per Altered Mental Status CPG

Select from matrix and treat appropriately

Yes Known Toxin? Rapid TransportNo


Trauma, Injury, & Environmental Emergencies 149 Toxicological Emergencies and Medication Reactions

Alcohol Benzodiazepine Beta Blockers Treat per SYMPTOM CPG Protect airway and ventilate as

appropriate Treat per BRADYCARDIA CPG

Assure patent and clear airway GLUCAGON • Adult Dose: 1-5 mg q 10 min • Pedi Dose: 0.1 mg/kg IV Titrate to heart rate

Calcium Channel Blockers Carbon Monoxide Cocaine Treat per BRADYCARDIA CPG Treat with 100% O2 via BVM

Consider transport to a facility with hyperbaric capability

Treat hyperthermia per HYPERTHERMIA CPG If symptomatic: CALCIUM GLUCONATE or

CALCIUM CHLORIDE Titrate to heart rate Medicate with Benzodiazepines per SYMPTOM CPG

Digitalis Extrapyramidal Reaction Hallucinogens Contact Medical Control for any arrhythmias.

BENADRYL • Adult Dose: 50 mg IVP • Pedi Dose: 1 mg/kg (max of

50 mg)

Consider sedation per SYMPTOM CPG

Organophosphates Tricyclic Antidepressant Unknown ATROPINE: • Adult Dose: 2-5 mg q 5 min • Pedi Dose: 0.03 mg/kg q 10 min Titrate to bronchospasm and secretions up to 3 times

If QRS>120 ms and symptomatic: SODIUM BICARBONATE Adult/Pedi Dose: 1 mEq/kg IV over 10 min


Or 2.1 mg ATROPINE/600 MG PRALIDOXIME AUTO INJECTOR IM



CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT ATROPINE PEDI GENERAL PATIENT MANAGEMENT BENADRYL ALTERED MENTAL STATUS CALCIUM CHLORIDE PEDI ALTERED MENTAL STATUS CALCIUM GLUCONATE BASIC AND ADVANCED AIRWAY MANAGEMENT

GLUCAGON

BRADYCARDIA-ADULT SODIUM BICARBONATE BRADYCARDIA-PEDIATRIC HYPOPERFUSION AND SHOCK CPG HYPERTHERMIA OXYGENATION & VENTILATION CPG SYMPTOM MANAGEMENT


Trauma, Injury, & Environmental Emergencies 151 Care of Patient in Police Custody

Care of Patient in Police Custody

Document • Respiratory and hemodynamic status • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if patient is unstable • Fluid intake and output • Level of consciousness

• Abnormal actions requiring treatment or restraint • Blood sugar • Name of Law Enforcement Officer involved • Law Enforcement Officer Willingness to take

patient into custody. • Treatment and response to treatment



General Note If handcuffs are applied Law Enforcement must be with patient at all times. If plastics (zip ties) are used Law enforcement may follow behind ambulance

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT TETRACAINE MIDDLE & LOWER AIRWAY OBSTRUCTION

SYMPTOM MANAGEMENT


Irrigate face/eyes with waterRemove contaminated clothing

Treat per appropriate CPG Yes Evidence of injury or illness

No

Device Used?PepperSpray

Remove impaled probes(s) and clean

wound(s)Do not remove if in eye

Taser

Tetracaine 2 gtt in each eye P

Wheezing? History of Asthma?

Observe 20 minutes.

Wheezes?

No

Yes

Treat per Middle & Lower Airway Obstruction CPG

Yes

Yes

Agitated Delirium

Significant injury from taser, fall

post taser, struggle with

police

Consider sedation per Symptom CPG

Treat per appropriate CPG and transport

Coordinate disposition with patient and law enforcement officers

Cardiac History, Pacemaker, chest pain, palpitations

No

Yes

No

Yes

Yes

NoNo

No

No



Isolated Extremity Trauma



Note 1 Definition of Isolated

A Single site injury that does not include the head, neck or torso. Any complaint of pain or any obvious injury to 2 or more areas of the body is multi-system. See MULTI-SYSTEM TRAUMA.

Document • Specific time of injury • SAMPLE History • Respiratory and hemodynamic

status • Estimated blood loss • Location and nature of injuries • Glasgow coma scale • Distal pulses and neurological

assessment pre and post immobilization and q 15 minutes.

• Vital signs q 15 minutes • Vital signs q 5 minutes if

infusing vasoactive medications or if patient is unstable

• Pain scale with each set of vitals • Fluid intake and output • Associated symptoms • Temp/ECG/SpO2/ETCO2 • Treatment and response to

treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT MULTI-SYSTEM TRAUMA SYMPTOM MANAGEMENT



Yes

Isolated extremity injury

Note 1No

Crush or amputation of finger or toe?

• Control bleeding and dress wounds as appropriate• Apply tourniquet if hemorrhage is life threatening• Immobilize above and below injury.• Apply cold as appropriate to decrease swelling and pain

Yes

Limb amputation

Transport to nearest “appropriate Level Trauma Center”

No

Yes

Yes

No

Treat symptoms per Symptom CPG P

• Clean amputated part with NS• Wrap in sterile NS soaked dressing• Place in zip lock bag• Place bag on ice

Consider air transport to reattachment capable facility

Clean “guillotine” type

injury?

Transport to appropriate hospital

No


Trauma, Injury, & Environmental Emergencies 153 Multisystem Trauma

Multisystem Trauma

Life Threatening

Chest Trauma

SuspectedOpen book

PelvicInjuryNote 4

Hemorrhagic Shock Present

SBP <90

Perform Needle Decompression

Apply pelvic Binder

Age >18 years Tranexamic acid (TXA)1 gm over 10 minutes

Monitor & Stabilize • Keep patient NPO• Keep patient normal thermic • ETCO2/Spo2• Large bore IV’s of NS

Detailed Exam• Vital signs q 5 min if unstable• Head to toe assessment • HPI• SAMPLE History

Pain Control: See pain Management CPG

Note 6

Transport to nearest “appropriate Level” Trauma Center unless unable to maintain

pulses or establish an airwayNote 4

Scene Secure?


Initial Assessment• Tourniquet life threatening bleeding• C-spine: Place multisystem trauma patients in SMR (Note 1)• Airway: Manage per Basic and Advanced Airway Management CPG• Breathing: Manage per Oxygenation and Ventilation CPG• Circulation: Manage hypoperfusion per Shock CPG (Note 2)• Disability: Manage per Altered Mental Status CPG (Note 3)• Expose: Undress and assess the patient

Yes

Yes

Yes

No

NO

No

See Next Page for Notes 5 & 6



Note 1 Spinal Motion Restriction is not required for patient on interfacility transport if: • C-spine has been cleared by

CT by a radiologist AND • Patient meets clearance

criteria per ADULT SPINAL MOTION RESTRICTION CPG

Note 2 Signs of hypoperfusion include • Altered Mental Status • Pale/cool skin • Decreased capillary refill • Tachycardia • Hypotension • Decreased urine output

Note 3 Any patient with altered LOC should be assumed to have increased intracranial pressure. • Maintain adult Mean Arterial

Pressure >80 • Maintain pediatric Systolic

BP > 70 + 2x age 𝑀𝑀𝑀𝑀𝑀𝑀 =𝐵𝐵𝑆𝑆𝑆𝑆𝑡𝑡𝑉𝑉𝑉𝑉𝑊𝑊𝑆𝑆 𝐵𝐵𝑀𝑀 + (2 × 𝐷𝐷𝑊𝑊𝐷𝐷𝑆𝑆𝑡𝑡𝑉𝑉𝑉𝑉𝑊𝑊𝑆𝑆 𝐵𝐵𝑀𝑀)

3

Note 4 Open book pelvic fractures should be suspected in the presence of bilateral femur fractures, sever lower extremity trauma. Shock without evidence of external bleeding and/or pelvic instability palpated with posterior or lateral compression



Note 5

Contraindications for TXA use: -Less than 18 years old -Injury >3 hours -Isolated Head Injury -Any known thromboembolic disease history including DVT, PE or ACS

Note 6 Shock is a known analgesic. Many hypotensive trauma patients do not require pain control. Even through Fentanyl is considered a hemodynamically stable medication it can cause hypotension in trauma patients. Lower doses, 25-50 mcg, should be considered. It should be avoided in hypotensive patients (SBP<90)

Document

• Specific time of injury • SAMPLE History • Respiratory and hemodynamic status • Estimated blood loss • Location and nature of injuries • Glasgow Coma Scale • Pulse, movement, and sensation in all extremities • Pupils • Blood Glucose

• Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if patient is unstable • Pain scale with each set of vitals • Fluid intake and output • Associated symptoms • ECG/Temp/ETCO2/SpO2 • Treatment prior to arrival • Treatment and response to treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT TXA NEEDLE THORACOSTOMY ADULT SPINAL MOTION RESTRICTION PELVIC BINDER ALTERED MENTAL STATUS BASIC AND ADVANCED AIRWAY MANAGEMENT

OXYGENATION AND VENTILATION SHOCK AND HYPOPERFUSION


Trauma, Injury, & Environmental Emergencies 155 Traumatic Arrest

Traumatic Arrest



Note 1 -Do not rush to move/transport patient. The goal of clinical management would be to achieve ROSC & then initiate transport to the trauma center -If ROSC is not obtained within 20 minutes

consider Termination of Resuscitation (TOR)

- If the patient has been loaded in the ambulance, CPR should be continued and the patient should be transported, priority 2, to the closest hospital.

- If by your clinical judgement, you suspect the patient had a medical cardiac arrest followed by an insignificant trauma, then treat the patient per the Adult Pulseless Arrest or Pediatric Cardiac Arrest CPG’s

-If extenuating circumstances, including but not limited to weather, lighting, physical safety and/or large bystander gathering, exist that would prevent the completion of the Traumatic Arrest CPG, then the patient should be moved to the ambulance. The CPG should be followed without termination of resuscitation. CPR should then be continued and the patient should be transported, Priority 2, to the closest, appropriate hospital.

- Chest decompression should not be delayed for any other medical procedure to be accomplished, including CPR

- In general, CPR by itself is not helpful in traumatic arrest. It is however, useful to briefly allow for rapid correction of underlying causes of traumatic arrest. There is no evidence that prolonged attempts at resuscitation, as done for medical patients, is helpful in trauma.


Injuries incompatible with Life?

Withhold resuscitationSee withholding resuscitation for the patient with

obvious Signs of Death

Bilateral Needle Decompression

NO YES

High QualityCPR

Advanced Airway using i-Gel Device

OrEndotracheal Intubation

If Supraglottic device failure

Control Exsanguinating Hemorrhage-Direct Pressure

-Tourniquets as necessary -Pelvic binding for unstable pelvis

IV Access2-Large bore IV’s or Single IO in uninjured extremity

Fluid Resuscitation2 – Liters of Normal Saline on pressure bag

Reduce long bone fracturesTo splint in anatomical position

ROSC after 20 minutes of resuscitation

Transport to Trauma Center

Contact Medical ControlFor

Termination of Resuscitation (TOR)MCNO

YES



CPG Links Intervention Links GENERAL PATIENT MANAGEMENT CHEST DECOMPRESSION MULTI-SYSTEM TRAUMA Supraglottic Device (i-gel) WITHHOLDING RESUSCITATION WITH OBVIOUS SIGNS OF DEATH

VASCULAR ACCESS EZ-IO DEVICE


Trauma, Injury, & Environmental Emergencies 157 Head and Face Trauma

Continuously monitor and treat as appropriate

Yes

No

Adult/Pedi General Patient Management

• Maintain head in a midline position• Elevate patient’s head 30 degrees• Do not allow SpO2 to drop below <94%

Titrate fluids to maintain Adults: MAP 80-100

Pedi: Systolic BP> 70 + 2x AgeI

Patient combative or

GCS<8?

Intubate, sedate and paralyzeAssure adequate hydration P

Clear signs of cerebral herniation?

Note 1

Hyperventilate to a CO2 of 30-35 mmHg P

No

Transport to a facility with neurosurgical coverage

Yes

Head and Face Trauma



Note 1 Signs of Cerebral Herniation

• Decreasing LOC • Pupillary changes • Posturing • Cushing’s Reflex

o Hypertension o Bradycardia o Changing respiratory patterns

Document • Specific time of injury • SAMPLE History • Respiratory and hemodynamic status • Estimated blood loss • Location and nature of injuries • Glasgow Coma Scale • Pulse, movement, and sensation in all extremities • Signs of cerebral herniation • Pupils • Blood Glucose

• Airway patency • Vital signs q 15 minutes • Vital signs q 5 minutes if infusing vasoactive

medications or if patient is unstable • Pain scale with each set of vitals • Fluid intake and output • Associated symptoms • ECG/Temp/ETCO2/SpO2 • Treatment and response to treatment

CPG Links Medication Links Intervention Links GENERAL PATIENT MANAGEMENT DSI



Trauma Destination The following Trauma Destination CPG is designed to aid you in transporting the appropriate patient to the appropriate Medical Facility/Trauma Center. Though this CPG cannot replace your clinical observations while with the patient, it should help you make the destination decisions. The destination of a critically ill trauma patient is simple. They belong at a facility with the capabilities to perform the necessary surgical intervention to correct internal hemorrhages. These would be a Level I or II Trauma Center. There are trauma cases that a Level III or IV facility can manage without difficulty and those hospitals are appropriate destinations. The following CPG is complex but the theory is simple. Take the right patient to the right facility. Your knowledge of the area hospitals capabilities will be the best tool for you to decide a patient’s destination. However, do not allow your emotion of preference to skew your judgment of appropriate destinations. Remember these things:

1. Trauma is priority over a burn. a. If your patient is a trauma patient and also has a burn, the traumatic injury of that patient takes

precedence over the burn. Take them to a Trauma Center. 2. Burn patients that are not trauma patients should be cared for at a Burn Center unless there are

uncorrected respiratory issues or the patient is hypotensive. 3. An inadequate airway must be fixed first.

a. A patient without a secured airway will die. Regardless of the trauma findings, if your patient does not have adequate chest rise and fall with oxygenation, take them to the closest hospital if you are unable to quickly secure the airway.

4. Do your care while transporting to the hospital! It is a detriment to the trauma patient to stay on scene and do interventions such as IV access, splinting and bandaging. Perform your care, in the back, moving toward the hospital. If you must perform advanced airway procedures, get help, and transport.

5. If you are unsure, contact Medical Control to discuss most appropriate care for the patient.


Trauma, Injury, & Environmental Emergencies 159 National Trauma Triage Protocol

National Trauma Triage Protocol

Measure vital signs and level of consciousness

Assess Anatomy of Injury

Assess Mechanism of Injury and evidence of high-energy impact

Assess special patient or system considerations

• Glasgow Coma Scale <14 OR• Systolic blood pressure < 90 OR• Respiratory Rate <10 or >29 (<20 if <1 year old)

• All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee• Flail chest• Two or more proximal long bone fractures• Crushed, degloved, or mangled extremity• Amputation proximal to wrist or ankle• Pelvic fractures• Open or depressed skull fracture• Paralysis

Falls• Adults: >20 ft (one story = 10 ft)• Children: >10 ft or 2-3 times height of the child

High Risk Auto Crash• Intrusion: >12 in. occupant site or >18 in any site• Ejection (partial or complete) from automobile• Death in same passenger compartment• Vehicle telemetry data consistent with high risk of injury

Auto vs. Pedestrian/Bicyclist• Thrown• Run Over• Significant (>20 MPH) impact

Motorcycle Crash• >20 MPH

Age• Adults: Risk of injury or death increases after age 55• Children: Should be triaged preferentially to pediatric-capable trauma centers

• Anticoagulation and Bleeding Disorders

Burns• Without other trauma mechanism: triage to burn facility• With trauma mechanism: triage to trauma center

• Time Sensitive Extremity Injury• End-Stage Renal Disease Requiring Dialysis• Pregnancy >20 Weeks• EMS Provider Judgment

No

No

No

Take to Trauma CenterSteps 1 and 2 attempt to identify the most seriously

injured patients. These patients should be transported preferentially to the highest level of care

within the trauma system.

Transport to closest appropriate trauma center.Depending on the trauma system, need not be the

highest level trauma center

Contact medical control and consider transport to a trauma center or a specific resource hospital.

Transport according to protocolNo

Yes

Yes

Yes

Yes



Trinity Mother Frances Trauma Activation Criteria

Code 88 • All penetrating wounds (GSW, stabbing, etc.) to torso, face, neck, head • All penetrating wounds to extremities without a pulse • Pulseless extremity • Auto pedestrian age <10 or > 55 • Flail chest • Burns 30% body surface 2nd or 3rd degree or greater • Amputations proximal to the wrist or ankle • Patient has airway problems or unable to intubate • Patient is intubated • Systolic BP < 90 (Includes all patients with transient hypotension from trauma and blood products given

enroute to the hospital) • Pulse < 60 or > 120 • Respiratory rate <10 or >30 • GCS <11 • Patient appears to be paralyzed • Open skull fracture If unsure- activate the trauma team, We would rather over triage than under triage a patient.

Code 55

• Utilized for stable patients BP >90 or <170 and pulse >60 or <120 • All open fractures • Falls greater than 20 feet • All known long bone or pelvic fractures • Stable patient with significant (death in same vehicle, major intrusion, high-speed) mechanism of injury

(i.e. MVC rollover, unrestrained, etc.) • Stable auto pedestrian

Other mechanisms for Trauma Surgeon Notification: Venomous snakebites, strangulation, severe child abuse, severe animal bites, and bicycle accidents without a helmet


Trauma, Injury, & Environmental Emergencies 161 Good Shepherd Medical Center Trauma Activation Criteria

Good Shepherd Medical Center Trauma Activation Criteria

• Traumatic arrest • Glasgow Coma Score ≤ 8 • Systolic Blood Pressure < 90 (<70 + 2x age of child in

years if <14) • Respiratory Rate < 10 or > 29 • Airway distress, compromise or intubation • Major penetrating trauma to the head, neck, torso and

extremities proximal to the elbow or knee • Amputation proximal to elbow or knee • Any patient receiving blood products to maintain vital signs • Pulseless extremity • Suspected spinal cord injury or limb paralysis • Open depressed skull fracture • ED Physician discretion

• Auto-pedestrian/auto-bicycle > 20mph • MVC with extrication > 20 min, ejection from vehicle,

death in same vehicle, or major intrusion • MCC/ATV > 20 MPH or with rider separation • All open extremity fractures • Two or more long bone fractures (humerus/femur) • Unstable pelvic fracture • All degloving/crush injuries • Pregnancy ≥ 20 weeks gestation • Burns partial/full thickness > 10% TBSA and/or

inhalation injury • Falls:

o Adults > 20 ft o Pediatrics > 10ft or 3 x child’s height o Elderly (≥ 65 years) any height on

anticoagulant/antiplatelet therapy • ED Physician discretion

• Any patient with traumatic injury not otherwise specified above

• Transfer from another facility unless meets any criteria specified above

• ED Physician discretion


Procedural Application 162

Procedural Application


Procedural Application 163 Intubation-Orotracheal

Intubation-Orotracheal

Indications • Any patient unable to maintain the patency of their airway, requiring mechanical ventilation and/or PEEP

• Patients with possible increasing ICP Contraindications • Ability to maintain airway less invasively Complications • Hypoxia

• Bradycardia • Airway injury • Esophageal intubation

Equipment • Endotracheal tube(s) of appropriate size • Stylet for ET tubes smaller than 3.5 • Laryngoscope handle and batteries • Laryngoscope blades of the appropriate sizes and

desired type • Bag valve mask, complete • KY Jelly or other lubricant • Securing device • Syringe 10 ml • Suction apparatus • Stethoscope • End-tidal CO2 detector, or other approved device • Oxygen • Pulse oximeter • Gum Elastic Bougie

Procedure

1. Perform a time out to assure the correct patient, correct procedure, and correct location. 2. Don personal protective equipment (gloves, eye protection, etc.). 3. Attach pulse oximetry. 4. Manually establish or secure the airway and oxygenate the patient. 5. Consider placing an oral and/or nasal airway(s) to improve BVM ventilation. 6. Chose proper ET tube and “preload” it on a gum elastic bougie. 7. Position patient’s head as appropriate (neutral if c-spine injury suspected, otherwise “sniffing” position). 8. Remove mask and oral airway (if in place). 9. Insert the laryngoscope blade. 10. Visualize tube glottis, intra-arachnoid notch or vocal cords. 11. Advance the gum elastic bougie through the glottis. 12. Note the presence of tracheal click and tracheal lock. 13. Advance the tube over the bougie through glottic opening. 14. Advance tube until the cuff is just past the cords then STOP advancing. 15. Remove the bougie. 16. Check for presence of breath sounds in left and right chest, and absence of breath sounds in abdomen. 17. If you are unsure of placement, remove tube and ventilate patient with bag-valve mask. 18. Once proper placement is verified, inflate the cuff with 5 to 10 ml of air and insert an oropharyngeal airway or

other bite block. 19. Secure the tube to the patient’s head with a COMMERCIAL restraint.

Scope of Practice Paramedic Intermediate EMT-Basic Med Control



20. Apply end-tidal CO2 detector and monitor expired CO2. 21. Reassess airway and breath sounds each time after moving the patent. 22. Intubated patients should have their head immobilized in a c-collar to minimize the risk of inadvertent

extubation. 23. Reconfirm tube placement often. This is especially important after moving the patient or manipulating ET

tube. 24. An ETCO2 strip must be recorded and placed with the permanent chart upon receiving the patient (or

immediately after intubation). A second strip, taken at the receiving hospital at turn over, must also be obtained and attached to the permanent chart to verify correct placement.


Procedural Application 165 Airway Suctioning

Airway Suctioning

Indications • Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient who cannot maintain or keep the airway clear.

Contraindications • None Complications • Airway trauma

• Hypoxia • Gag reflex stimulation

Equipment • Suction and an appropriate catheter Procedure:

Ensure suction device is in proper working order with suction tip in place. Pre-oxygenate the patient as is possible. Explain the procedure to the patient if they are coherent. Examine the oropharynx and remove any potential foreign bodies or material that may occlude the

airway if dislodged by the suction device. If applicable, remove ventilation devices from the airway. Use the suction device to remove any secretions, blood, or other substance. The alert patient may assist with this procedure. Reattach ventilation device (e.g., bag-valve mask) and ventilate or assist the patient. Record the time and result of the suctioning in the patient care report (PCR).




Endotracheal Suctioning

Indications • Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient currently being assisted by an airway adjunct such as a naso-tracheal tube, endotracheal tube, tracheotomy tube, or a Cricothyrotomy tube.

Contraindications • Inability to suction in a sterile manner Complications • Hypoxia

• Bradycardia • Increased ICP • Stimulation of the cough reflex

Equipment • Sterile suction catheter and suction Procedure:

Ensure suction device is in proper working order. Pre-oxygenate the patient. Attach suction catheter to suction device, keeping sterile plastic covering over catheter. For all devices, the suprasternal notch and the end of the airway into the catheter will be placed as

guides, measure the depth desire for the catheter. (Judgment must be used regarding the depth of suctioning with Cricothyrotomy and tracheostomy tubes).

If applicable, remove ventilation devices from the airway. With the thumb port of the catheter uncovered, insert the catheter through the airway device. Once the desired depth (measured in #4 above) has been reached, occlude the thumb port and

remove the suction catheter slowly. Reattach ventilation device (e.g., bag-valve mask) and ventilate the patient Document time and result in the patient care report (PCR).



Procedural Application 167 Intubation-Stoma

Intubation-Stoma

Indications • Pre-existing tracheotomy with any of the following o Respiratory Arrest o Hypoventilation

Contraindications • None when used in the emergency setting Complications • Injury to the Stoma Equipment • Endotracheal tube

• KY Jelly • Securing device • Syringe 10 ml • Suction Apparatus • Bag valve mask with oxygen source • Stethoscope • End-tidal CO2 detector or other approved device.

Procedure:

1. Perform a time out to assure the correct patient, correct procedure, and correct location 2. Assemble the equipment while continuing ventilation with BVM 3. Chose the tube size. (Note: if the stoma is constricted to may need to use a smaller size tube; 6mm or

7mm) 4. Position patient 5. Insert the tube through the stoma 6. Advance the tube until the cuff is just inside the stoma. Insert air into the cuff to prevent and air leak. 7. Check for presence of breath sounds in left and right chest, and absence of breath sounds in abdomen.

If you are unsure of placement, remove tube and hyperventilate the patient with BVM device and supplemental oxygen.

8. Once proper placement has been verified inflate cuff with 5 to 10 ml of air. 9. Secure the tube to the patient’s neck. 10. Apply end-tidal CO2 detector and monitor expired CO2. 11. Reassess airway and breath sounds each time after moving the patient. 12. An ETCO2 strip must be recorded and placed with the permanent chart upon receiving the patient (or

immediately after intubation). A second strip, taken at the receiving hospital at turn over, must also be obtained and attached to the permanent chart to verify correct placement.




Clear-Guard II Breathing Filter (HEPA)

Indications • HEPA filters are used in applications that require contamination control, such as the use of advance airway devices i.e., BVM, iGEL, ETT, Ventilators

Contraindications • None when used in the emergency setting Complications • Low volume application less <200 mm hh Equipment • HEPA filter

• Airway adjunct; BVM, iGEL, ETT, Ventilator •

Procedure

1. Insert (HEPA) filter on device closest to the source to prevent dead air space issues. 2. (HEPA) filter should be place proximal to any sensor when using ventilator 3. (HEPA) filter is for one time use per patient to be discarded through proper disposal process Proper Application of (HEPA) to BVM device Proper Application of (HEPA) Circuit to ETT

Do Not Use this method Proper Application of (HEPA) to ETT



Procedural Application 169 MDI Spacer using mask

MDI Spacer using mask

Indications • MDI Albuterol is to be use for Middle and Lower Airway Obstructions, (Wheezing, COPD and asthma)

Contraindications • None when used in the emergency setting Complications • None in the emergency settings Equipment • Kit assembled by Logistics to include: (Simple face

mask, corrugated tubing) Or

* Non-rebreathing mask and corrugated tubing from nebulizer kit

Procedure

1. Assemble MDI Mask using the following kit or equipment listed 2. Attach NR-mask or Simple-Face-Mask to corrugated tubing and cover exhalation ports on each side of mask using ECG electrodes 3. Insert the MDI device to corrugated tubing as seen in picture




Supraglottic Device (i-gel)

Indications • Patient is apneic and without a gag reflex

Contraindications • An intact gag reflex • Cases of known or suspected caustic poisoning • Known esophageal disease, or esophageal trauma

Complications • Oral or esophageal trauma Equipment • i-gel Device

• BVM • Securing device

Procedure

Perform a time out to assure the correct patient, correct procedure, and correct location Ventilate patient with a bag valve mask with high flow oxygen. If appropriate (i.e. respiratory arrest) ventilate 30-60 seconds prior to Supraglottic device attempt. Continue ventilations while preparing the (i-gel) Airway. Place small bolus of a water-based lubricant

into the middle of the smooth surface of the protective cradle. Lubricate the back and both sides with a thin layer of the water based product.

Place the head in a “sniffing the morning air position” with head extended and neck flexed unless there is concern for c-spine injury. The chin should be gently pressed down before proceeding. Introduce the leading soft tip into the mouth towards the hard palate

Glide the device downwards and backwards along the hard palate with continues but gentle push until a definitive resistance is felt.

The tip of the airway should be located into the upper esophageal opening and the cuff should be located against the laryngeal framework

The incisors should be resting on the integral bite block with the device taped down from “maxilla to maxilla”

Attach a bag-valve-mask to device and begin ventilations. Using a stethoscope, listen for breath sounds in both lateral lung fields to confirm placement. Secure Airway in place. Periodically check for appropriate placement of the (i-gel) Airway and adequate ventilations.

If unsuccessful after the second attempt to insert the supraglottic device discontinue the procedure and continue ventilations via a bag-valve-mask.

Continues ETCO2 must be recorded throughout patient care and placed with the permanent chart upon receiving the patient (or immediately after intubation). A second ETCO2 strip, taken at the receiving hospital at patient hand off, must also be obtained and attached to the permanent chart to verify correct placement.



Procedural Application 171 Needle Cricothyrotomy

Needle Cricothyrotomy

Indications • Inability to secure an airway by a less invasive means in the pediatric patient who has anatomy that is too small for surgical cricothyrotomy

Contraindications • Ability to maintain an airway less invasively • Inability to recognize the necessary landmarks

Complications • Bleeding • Damage to thyroid or hypothyroid • False passage into the subcutaneous tissue

Equipment • 14 gauge x 1 ¼ inch angiocath • Skin antiseptic solution or prep • 3.5 mm ET tube hub • Securing device • ETCO2 • Pulse Oximeter • Bag valve mask

Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location Ensure suction device is in proper working order. Identify the procedure site

Prep the site with antiseptic solution Insert the angiocath at a 45 degree angle pointing toward the lungs Aspirate from the angiocath to assure free flow of air verifying tracheal placement Attach a 3.5 ETT connector to the angiocath hub and ventilate the patient with the BVM Verify correct placement with capnography, auscultation, and visualization of chest rise An ETCO2 strip must be recorded and placed with the permanent chart upon receiving the patient (or immediately after intubation). A second strip, taken at the receiving hospital at turn over, must also be obtained and attached to the permanent chart to verify correct placement.




Surgical Cricothyrotomy

Indications • Inability to secure an airway by a less invasive means

Contraindications • Ability to maintain an airway less invasively • Inability to recognize the necessary landmarks

Complications • Bleeding • Tracheal transection • Esophageal intubation • Damage to thyroid or hypothyroid • False passage into the subcutaneous tissue

Equipment • #11 Scalpel • ETT Tube • Bougie • Skin antiseptic solution or prep • Tracheal hook • Securing device • ETCO2 • Pulse Oximeter • Bag valve mask

Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location. Ensure suction device is in proper working order. Identify the procedure site. Prep the site with antiseptic solution.



Procedural Application 173 Surgical Cricothyrotomy

While stabilizing the larynx with one hand, use the opposite hand to make a 3-4 cm vertical (long ways) incision through the skin in the midline over the cricoid membrane.

After identification of the cricoid membrane, use the hemostat to make a puncture through the

membrane.

Enlarge the hole with blunt dissection but do not remove the hemostats. Advance a bougie and confirm tracheal placement with tracheal click and tracheal lock. Advance the ETT over the bougie.

Place the ET tube into the airway, and inflate the balloon. Remove the bougie. Verify correct placement with capnography, auscultation, and visualization of chest rise. An ETCO2 strip must be recorded and placed with the permanent chart upon receiving the patient (or immediately after intubation). A second strip, taken at the receiving hospital at turn over, must also be obtained and attached to the permanent chart to verify correct placement.



Continuous Positive Pressure Ventilation (CPAP)

Indications • Any patient with increased work of breathing related to the respiratory system

Contraindications • Apneic patients • Inability to maintain open airway • Uncontrolled nausea • Decreased level of consciousness • Inability to understand directions • Inadequate respiratory effort • Excessive secretions • Tracheotomy • Patients at risk for aspiration (nausea/vomiting,

foreign body airway obstruction • Facial trauma that would interfere with proper fit of

mask Complications Equipment • Oxygen

• CPAP device Pre-CPAP Patient Assessment

• Assess patient, record vital signs and pulse oximetry at room air • Apply Capno-Mask to evaluate Capnography waveform • Administer 02 by non-rebreather mask while preparing equipment Procedure

Select the appropriate size face mask for your patient: Medium Adult Mask (Size 5) Large Adult Mask (Size 6)

Place the mask on the patients face Set Oxygen flow to deliver CPAP in cmH2O of water pressure:

15 liters = 5cmH2O 20 liters = 7.5 cmH2O 25 liters = 10 cmH2O

Reassess patient and encourage patient If patient is in distress and they do not improve after 5 minutes of CPAP move to mechanical

ventilation via intubation Monitor ETCO2 and attach a strip to the patient care record



Procedural Application 175 Capnography

Capnography

Indications • Capnography shall be used when available with all endotracheal, and Supraglottic devices (i-gel, etc.).

• Capnography shall also be used on all patients treated with CPAP, Magnesium and/or any induction agents, or paralytics.

Contraindications • None Complications • None Equipment • Capnography monitor

• Sample device Procedure:

Attach Capnography sensor to Supraglottic device, endotracheal tube, nebulizer, or oxygen delivery device.

Note CO2 level and waveform changes. These will be documented on each respiratory failure, cardiac arrest, or respiratory distress patient.

Capnometer shall remain in place with the airway and be monitored throughout care and transport. Any loss of CO2 detection or waveform indicates an airway problem and should be documented. The capnogram should be monitored as procedures are performed to verify or correct the airway

problem. Document the procedure and results on/with the patient care report (PCR).

Waveform Components

Normal Waveform

Bronchospasm

Hypoventilation waveform

Bradypneic ventilation




Hyperventilation


Procedural Application 177 Pulse Oximetry

Pulse Oximetry

Indications • Patients with known or potential hypoxemia. • Should be checked in all patients, should be

continuously assessed in all critically ill patients Contraindications • None Failure to understand that SPO2 only

confirms one type of hypoxia. Patients with Stagnant, Hypemic, or Hystotoxic Hypoxia can be profoundly hypoxic despite a normal SPO2.

Complications • None Equipment • Pulse oximeter

Procedure:

1. Apply probe to patient’s finger or any other digit as recommended by the device manufacturer. 2. Allow machine to register saturation level. 3. Record time and initial saturation percent on room air if possible on/with the patient care report (PCR). 4. Verify pulse rate on machine with actual pulse of the patient. 5. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor

patients for a few minutes as oxygen saturation can vary. 6. Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to

correct hypoxemia. 7. In general, normal saturation is 97.99%. If the reading is below 94%, suspect respiratory compromise. 8. Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data provided by the

device. 9. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or

when it is the standard of care to apply oxygen despite good pulse oximeter readings, such as chest pain. 10. Factors which may reduce the reliability of the pulse oximeter reading include:

a. Poor peripheral circulation (blood volume, hypotension, hypothermia) b. Excessive pulse oximeter sensor motion c. Fingernail polish d. Carbon monoxide bound to hemoglobin e. Irregular heart rhythms (atrial fibrillation, SVT, etc.) f. Jaundice g. Placement of BP cuff on same extremity as pulse ox probe




Chest Decompression

Indications • Patients with hypotension (SBP <90), clinical signs of shock, and at least one of the following signs:

o Jugular vein distention o Tracheal deviation away from the side of

the injury (often a late sign) o Absent or decreased breath sounds on

the affected side o Hyper resonance to percussion on the

affected side o Increased resistance when ventilating a

patient • Patients in traumatic arrest with chest or abdominal

trauma for whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above

• Patients with a strong clinical concern for pneumothorax who have a declining clinical picture but have not yet developed a tension pneumothorax

Contraindications • Simple pneumothorax Complications • Creation of a pneumothorax

• Injury to chest vasculature • Injury to mediastinum structures • Injury to infraclavicular vessels or nerves • Infection

Equipment • Large bore angiocath or a cook catheter • Skin antiseptic solution or prep

Procedure:

Don personal protective equipment (gloves, eye protection, etc.). Administer high flow oxygen. Identify and prep the site:

a. Primary location 2nd intercostal space in the mid-clavicular line on the same side as the pneumothorax.

b. Secondary location (Adults only) 4th or 5th intercostal space at the mid-axillary line (Should be considered in obese patients) (Primary Site) (Secondary Site) Adults only

c. Prepare the site with skin antiseptic.


Secondary Site 4th or 5th intercostal


Procedural Application 179 Chest Decompression

Primary site insert the catheter into the skin over the 3rd rib and direct it just over the top of the rib (superior border) into the pleura. Secondary site (Adults only) 4th or 5th intercostal space mid-axillary line. Secondary site considered in obese patients

Advance the catheter through the parietal pleura until a “pop” is felt and air or blood exits under pressure through the catheter, then advance the catheter only to chest wall.

Remove the needle, leaving the plastic catheter in place. Secure the catheter hub to the chest wall with dressings and tape. Consider placing a finger cut from an exam glove over the catheter hub. Cut a small hole in the end of

the finger to make a flutter valve. Secure the glove finger with tape or a rubber band a. NOTE: Don’t waste much preparing the flutter valve; if necessary, control the air flow

through the catheter hub with your gloved thumb.



Chest Tube Drainage Management & Monitoring

Indications • To maintain a water seal for a chest tube • To provide specific titration of suction through a

chest tube Contraindications • None Complications • Infection Equipment • Chest drainage unit

• Suction source • Connection tubing • Tape • 1 liter bottle of sterile water

Procedure:

Fill the chest drainage system with sterile water through the water fill line unless the system is waterless.

Fill the suction control chamber to the prescribed level of suction (typically 20 cm of H2O) unless the system is waterless.

Set the drainage system below the patient and assure it can’t be knocked over. Attach the drainage system to the patient’s chest tube Turn on suction to a level that produces gentle constant bubbling Tape all connection points Monitor the patient for signs of increasing thoracic pressure Monitor drainage output Reassess the patient and notify medical control if any of the following occur

a. More than 1500 mL out in the first hour b. More than 200 mL out an hour for 2 or more hours c. Steady drainage suddenly stops



Procedural Application 181 12 Lead ECG

12 Lead ECG

Indications • Suspected cardiac patient • Shortness of breath patient • Suspected tricyclic overdose • Electrical injuries • Syncope • CHF

Contraindications • None Complications • None Equipment • 12 lead ECG

Procedure:

Assess the patient and monitor cardiac status. If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after treatment,

perform a 12 Lead ECG. Prepare ECG monitor and connect patient cable with electrodes. Expose chest and prep as necessary. Modesty of the patient should be respected. Apply chest leads and extremity leads using the following landmarks:

RA Right arm or as directed by manufacturer LA Left arm or as directed by manufacturer RL Right leg LL Left leg V1 4th intercostals space at right sternal border V2 4th intercostals space at left sternal border V3 Directly between V2 and V4 V4 5th intercostals space at midclavicular line V5 Level with V4 at left anterior axillary line V6 Level with V5 at left midaxillary line Instruct the patient to remain still. Press the appropriate button to acquire the 12 Lead ECG. Print data as per guidelines and attach a copy of the 12 Lead to the PCR. Place the name and age of

the patient on the paper copy of the ECG. If STEMI is suspected, perform a right sided 12 lead.

V4 5th intercostal space at the midclacicular line on the right side of the chest. Press the appropriate button to acquire the 12 lead ECG. Circle the V4 lead and label V4R. Transmit the left sided ECG to interventional cardiology facility. Document the procedure, time, and results on/with the PCR. An EMT may perform a 12 Lead ECG; a Paramedic, however, should review it before implementing any treatment modalities.




I-Lateral aVR V1-Septal V4-Anterior

II-Inferior aVL-Lateral V2-Septal V5-Lateral

III-Inferior aVF-Inferior V3-Anterior V6-Lateral

Initial Placement V4R Placement

The 15-lead ECG should be completed after the first 12-lead ECG when the medic believes the patient to have ACS. By simply moving V4, V5 and V6 to the new positions as listed. Run a second ECG as a 15 lead with documentation to support the additional placement in the intervention section.

http://www.google.com/imgres?um=1&hl=en&biw=1024&bih=540&tbm=isch&tbnid=CihVR9D6bkfg0M:&imgrefurl=http://ems12lead.com/tag/right-sided-chest-leads/&docid=a8EKwT72bBcy4M&imgurl=http://1.bp.blogspot.com/_2MjIeQJj8UM/STqH4_dFy6I/AAAAAAAAAaY/WdmdthgOBJw/s320/precordial_V4R.jpg&w=320&h=240&ei=xhBZT8_sI_SCsAL50L3LDQ&zoom=1


Procedural Application 183 External Cardiac Pacing

External Cardiac Pacing

Indications • Symptomatic bradycardia or relative bradycardia with one or more of the following sign or symptoms o Chest pain o Hypotension o Pulmonary edema o AMS, disorientation, confusion, etc. o Ventricular ectopy

• Asystole, pacing must be done early to be effective. • PEA, where the underlying rhythm is bradycardic

Contraindications • A valid DNR refusing resuscitation Complications • Pain

• Over sensing • Under sensing • Failure to capture

Equipment • Pacer Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location. Attach standard four-lead monitor. Apply defibrillation/pacing pads to chest and back:

a. One pad to left mid chest next to the sternum, one pad to mid left posterior chest next to the spine.

Rotate selector switch to pacing option. Adjust heart rate to 70 BPM for an adult and 100 BPM for a child. Note pacer spikes on ECG screen. Slowly increase output until capture of electrical rhythm on the monitor.

a. Verify electrical capture by the presence of a QRS complex and a T wave after each spike. If there is not a T wave then a wide complex after a pacer spike is not a QRS

If unable to capture while at maximum current output, stop pacing immediately. If capture observed on monitor, check for corresponding pulse and assess vital signs.

Consider the use of sedation or analgesia if patient is uncomfortable. Document the dysrhythmia and the response to external pacing with ECG strips in the PCR.




Modified Valsalva Maneuvers

Indications • Narrow Complex Tachycardia Contraindications • None in the setting of SVT Complications • Bradycardia

• Syncope • Hypotension

Equipment • Endotracheal tube • Personal protective equipment • ECG monitor • Vascular access established • Oxygen • Emergency medications and equipment will be

immediately available. Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location Ensure that patient is on oxygen, has a patent vascular access, and is on a cardiac monitor. Record the ECG rhythm continuously while performing all vagal maneuvers.

Modified Valsalva Maneuver: a. Position the patient in the semi-recumbent position (45 degree) b. Open a 10 ml syringe and break the initial vacuum seal. All air should then be pushed out of

the syringe c. Position the small end of the syringe into the patients mouth d. Instruct the patient to blow into the small end of the syringe with enough force to move the

plunger. The duration of this step in 15 seconds e. Immediately after these 15 seconds, the head of the bed should be lowered to a flat or

supine position and your partner should rise both of the patient’s legs to a 45 degree for an additional 15 seconds. The patients legs should be returned to the stretcher and the patient back in the semi-recumbent position (45 degree)

f. Allow 45 seconds before re-assessment of the cardiac rhythm g. If no conversion & patient remains stable, repeat the procedure for up to two total attempts.



Procedural Application 185 Defibrillation – Manual

Defibrillation – Manual

Indications • Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia.

Contraindications • Any rhythm with a palpable pulse Complications • None Equipment • ECG/Defibrillator

Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location. Ensure chest compressions are adequate and interrupted only when necessary. Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation. Apply hands free pads to the patient’s chest in the proper position (Anterior-Posterior position). Set the appropriate energy level. Charge the defibrillator to the selected energy level. Continue chest compressions while the

defibrillator is charging. Hold compressions, assertively state “CLEAR,” and visualize that no one, including you, is in contact

with the patient. Deliver the counter shock by depressing the shock button for hands free operation. Immediately resume chest compressions and ventilate for 2 minutes. After 2 minutes of CPR, analyze

rhythm and check for a pulse only if appropriate for rhythm. Repeat the procedure every two minutes as indicated by patient response and ECG rhythm. Keep the interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation.

Pediatric Information for proper pad placement

≤ 8 years old or ≤ 25 kg (55 lbs.) use pediatric pads




Double Sequential External Defibrillation (DSED)

Patient remains in refractory Ventricular Fibrillation despite multiple attempts at defibrillation (at least 3 attempts) and use of Epinephrine & Amiodarone without conversion move to double sequential external defibrillation (DSED)

i. Call for additional unit requesting defibrillator if available ii. Place defibrillation pads side by side iii. Set maximum energy 360j on both defibrillators iv. Use Sequential defibrillation of both monitors to maximize the effect. (Do not use Syn-

mode for (DSED)

Methods of Pads Placement


Procedural Application 187 Cardioversion

Cardioversion

Indications • Unstable tachycardia Contraindications • Digitalis toxicity (relative, avoid if possible) Complications • Potential to create a terminal rhythm Equipment • ECG/Defibrillator

Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location. Apply hands free pads to the patient’s chest in the proper position (Anterior-Posterior position). Turn on the sync button and assure the monitor is identifying QRS complexes Set the appropriate energy level.

a. For Ventricular Tachycardia or atrial fibrillation start at 100J b. For SVT or atrial flutter start at 50J

Charge the defibrillator to the selected energy level. Assertively state “CLEAR,” and visualize that no one, including you, is in contact with the patient. Deliver the counter shock by depressing the shock button for hands free operation. Hold the button

until the shock is delivered, when syncing the monitor may take a few seconds to deliver its charge Repeat the procedure if the rhythm does not convert using escalating energy levels (100-200-300-

360J)




Intravenous Access

Indications • Intravenous access shall be obtained when the clinical assessment indicates the necessity of medication administration, fluid replacement and/or resuscitation.

Contraindications • Prolonged attempts at intravenous access in a critically ill patient. If an IV cannot be accomplished within 3 attempts or 90 seconds for any critically ill patient proceed to intraosseous insertion

Complications • Infections • Air embolism • Catheter shear • Hematoma • Arterial Puncture

Equipment • Appropriate size and type IV/IO catheter • Appropriate administration set • Skin antiseptic solution or prep • 5-10 ml syringe • IV start kit • Dressing and tape or commercial securing device

(“Venigard”, “Opsite”) • Blood draw set up

General Standards

• Vascular access can be accomplished by a saline lock (see appropriate procedure) or peripheral venous infusion.

• In all pediatric patients receiving intravenous fluid, a buretrol administration set should be used and delivery of fluids should be monitored.

• Insert large bore IV’s in trauma patients or those that are hemodynamically unstable

• All critically patients regardless of age should have two points of intravenous access

Procedure for Peripheral Cannulation:

Don appropriate personal protective equipment Explain the need for IV administration and describe what will be done Check the IV solution for expiration date, cloudiness, etc. Spike the bag with the appropriate IV tubing Remove air from IV tubing Place the tourniquet on the extremity Select the site (Preferred IV site for patients in cardiac arrest is the antecubital fossa) Cleanse the skin with Skin antiseptic solution or prep Make puncture while maintaining vein stability

Watch for flashback. If you have no blood return and you are in the vein, remove the needle hub and attach your syringe to assist in aspirating blood. Once you have a blood return, advance the catheter as per normal IV technique and attach the IV tubing.

Remove the tourniquet Begin IV fluid therapy. Observe the site for redness, edema or other indications of infiltration. Secure catheter and IV tubing (remember Not to restrict other vascular structures by applying dressing too tight)



Procedural Application 189 Intravenous Access

Considerations:

Do not place IVs on the side of an injured area or in the chest Avoid using lower extremities unless last resort Do not place IVs on the side of a previous mastectomy Do not place IVs on the side of paralysis. Hickman catheters or other indwelling IV access ports should be used only if instable patient

condition necessitates and IV, and no other access is available. DO NOT USE RENAL SHUNTS



External Jugular Venous Access

Indications • For infusion of fluid or administration of medications in any urgent/critical patient in whom vascular access cannot be obtained in 3 attempts at other peripheral sites.

• EJV cannulation may be considered as first-line vascular access in cardiac arrest or sever hypovolemic / hypotensive crisis.

Contraindications • Ability to obtain IV access by less invasive means Complications • Air embolism

• Pnuemothroax • Infection • Catheter shear • Hematoma • Arterial puncture

Equipment • Appropriate size and type IV/IO catheter • Appropriate administration set • Skin antiseptic solution or prep • 5-10 ml syringe • IV start kit • Dressing and tape or commercial securing device

(“Venigard”, “Opsite”) • Blood draw set up

General Standards

• Vascular access can be accomplished by a saline lock (see appropriate procedure) or peripheral venous infusion.

• In all pediatric patients receiving intravenous fluid, a buretrol administration set should be used and delivery of fluids should be monitored.

• Insert large bore IV’s in trauma patients or those that are hemodynamically unstable

• All critically patients regardless of age should have two points of intravenous access

Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location. Don appropriate personal protection gear Select and prepare equipment. Attach 10 ml syringe to hub of catheter/needle to assist in

identification of placement in patients with low or no cardiac output. Clear air from tubing Place the patient in a supine, trendelenburg position. Identify external jugular vein.



Procedural Application 191 External Jugular Venous Access

Prepare the site with a skin antiseptic. Place finger above the clavicle to facilitate filling the vein. (This should also assist with stabilization of

site) Make your puncture midway between the angle of the jaw and the middle of the clavicle while

maintaining vein stability with you finger. Watch for flashback. If you have no blood return and you are in the vein, remove the needle hub and attach you syringe to assist in aspirating blood. Once you have a blood return, advance the catheter as per normal IV technique and attach the IV solution.

DO NOT ALLOW AIR TO ENTER THE CATHETER ONCE IT HAS BEEN INSERTED. Remember to cover the catheter with a gloved finger while preparing to attach the IV tubing.

Initiate IV fluid therapy. Observe site for redness, edema or other indications of infiltration. Secure IV catheter and tubing. A cervical collar may be useful to prevent mobility and ensure that the catheter does not dislodge.

Two attempts are allowed on one side. NEVER attempt cannulation on both external jugular veins. Consider IO if all other attempts are unsuccessful.



Vascular Access EZ-IO Access Device

Indications Any for whom you are unable to obtain peripheral vascular access after three attempts or 90 seconds and that has one or more of the following: • Hemodynamic instability • Respiratory compromise • Patients requiring EMERGENCY medicinal therapy

or volume replacement Contraindications • Any patient that may receive fibrinolytic thrombolytic

therapy; specific to Active MI and/or Stroke. • Suspected fracture of the associated tibia or femur • Previous orthopedic procedures: i.e., knee

replacement • Extremity that is compromised by pre-existing

medical condition. i.e. tumor or PVD • Overlying skin infection/trauma at placement site • Inability to locate the 3 anatomical landmarks for

insertion, which are the patella, tibial tuberosity, and 1 finger width medial of the tibial tuberosity.

• Excessive tissue over the insertion site. • Osteomyolitis

Complications • Infections • Air embolism • Catheter shear • Hematoma • Arterial Puncture

Equipment • EZ-IO Driver • EZ-IO Needle (25mm AD to support 3kg and up )

(45mm LD to support XL patients) • Skin antiseptic solution or prep • IV setup and/or optional extension tubing • 10 ml or 20 ml Syringe • Roller gauze • 2% Lidocaine

Procedure:

Perform a time out to assure the correct patient, correct procedure, and correct location. Don PPE Determine if EZ-IO is indicated and no contraindications are present. Locate proximal tibia or proximal humerus site for EZ-IO insertion.

a. Proximal Tibia Site i. Feel the front surface of the leg and locate the patella. ii. Locate the tibial tuberosity inferior to the patella. iii. Place 1 finger medial of the tibial tuberosity. Insertion location is 1 finger width

medial of the tibial tuberosity b. Proximal humerus site

i. Expose shoulder and adduct humerus (place the patient’s arm against the patient’s body) resting the elbow on the stretcher or ground.

ii. Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect or humeral head. As you near the shoulder you will note a protrusion. This is the base of the greater tubercle insertion site.



Procedural Application 193 Vascular Access EZ-IO Access Device

iii. With the opposite hand you may consider “pinching” the anterior and inferior aspects of the humeral head while confirming the identification of the greater tubercle. This will ensure that you have identified the midline of the humerus itself

Cleanse the insertion site with skin antiseptic using accepted aseptic technique. Remember to work from the inside to the outside in concentric circles.

If patient is conscious, inform patient of the EMERGENT need to perform procedure and that they might feel some discomfort until lidocaine is administered. Obtain consent from patient; recall that the patient has the right to refuse.

Pre-medicate the insertion site with 2-3 mL of 2% Lidocaine subcutaneous. Prepare the EZ-IO Driver and Needle Set.

a. Open the cartridge and attach the needle set to the driver b. Remove needle set from the cartridge c. Remove the cap from the needle set

Begin insertion of the EZ-IO a. Hold EZ-IO driver in one hand and stabilize the leg near the insertion site with opposite hand b. Position the driver at the insertion site at a 90° angle to the bone surface. c. Power the driver through the skin at the insertion site until it makes contact with the bone.

Power the EZ-IO Driver and continue insertion until the flange (base) of the EZ-IO needle set touches the skin OR a sudden lack of resistance is felt, indicating entry into the marrow cavity.

Remove driver from the needle Remove the stylet from the catheter. DO NOT REPLACE or ATTEMPT to recap the needle set. Confirm proper EZ-IO catheter tip position by checking for at least 1 of the following:

a. IMMEDIATELY SYRINGE FLUSH with at least 10mL of fluid b. IO catheter standing at 90° and firmly seated in tibia c. Blood on the stylet d. A free-flow of fluid through the needle with no evidence of extravasation. DO NOT

ASPIRATE Connect IV tubing and begin infusion. An extension set is recommended but not required. If site does not flow, consider pressure infusion, re-flush and/or rotate needle 180°. Consider a combination of these procedures and repeat as necessary.

Dress site with roller gauze to prevent accidental dislodgement If patient is conscious for procedure, administer bolus 2-3 mL (20-30 mg)of Lidocaine 2% slow push for local analgesia. This will probably provide pain relief for up to 1 hour.

Tibia Insertion Humeral Head Insertion



Medication Administration – Continuous IV Infusion General • Any medication that should be administered via IV

infusion as indicated by manufacturer and/or protocol. Indications Prior to any pre-hospital medications being administered

all of the following should be present: • Appropriate patient assessment has determined the

need for a medication. • Patient is interviewed for known allergies and

medication history to identify risk of drug interaction of potentiation.

Equipment • All equipment as noted for intravenous access. • Medication and IV fluid for infusion (as specified in

protocol or Drug Reference) • 18g syringe needle or needless adapter. • 60 gtts/ml IV drip chamber and tubing (inter-facility

transport) or IV pump tubing Procedure: Continuous Drip

Verify patient identification with two identifiers Explain the procedure to the patient, the medication to be utilized, and inquire about medication

allergies. Don appropriate personal protective equipment Utilize pre-mixed intravenous medications if available. If a premixed medication is unavailable,

appropriate dose of medication may be added to an intravenous fluid bag. Affix a label to the fluid container identifying the medication, dose, concentration, and time of initiation. Shake the bag to distribute medication.

Flush air from tubing and attach a connector needle to the end of tubing. Insert pump tubing into IV pump.

Attach the tubing to IV site. Begin medication infusion. Check for patency (indicated by good flow and absence or infiltration). Once patency is established, set infusion rate on the IV pump. All continuous intravenous medications will be administered with an IV pump utilizing the drug

calculation mode if available. Monitor patient and pump during transport for consistency and patency of IV medication line.



Procedural Application 195 Medication Administration – Intravenous

Medication Administration – Intravenous

General • Any patient requiring medications via the intravenous route. Indications Prior to any pre-hospital medications being administered all of the

following should be present: • Appropriate patient assessment has determined the need for

a medication. • Patient is interviewed for known allergies and medication

history to identify risk of drug interaction of potentiation. Equipment • All equipment as noted for intravenous access.

• Syringe(s) of appropriate size(s) for medication dose • 18g syringe needle or needless adapter. • Medication to be administered • Alcohol preps

Procedure:


allergies. Don personal protective equipment Establish vascular access Draw up the medication into a syringe Label the medication Clear air from the syringe Cleanse the site and attach the syringe to IV tubing Verify the IV is patent

Clamp the tubing or alternatively do not clamp the IV, but rather push medication slow enough to maintain flow in the drip chamber

Administer the medication as per manufacturer recommendations Monitor IV the catheter site for signs of infiltration. Dispose of the syringe in appropriate container.




Medication Administration – Intramuscular

General • Medications requiring Intramuscular administration Indications • Appropriate size syringe

• Medication • 18 GA syringe needle (to draw medication) • 20 – 22 GA syringe needle (for medication administration) • Alcohol preps • Band-Aid

Equipment • All equipment as noted for intravenous access. • Medication and IV fluid for infusion (as specified in protocol or

Drug Reference) • 18g syringe needle or needless adapter. • 60 gtts/ml IV drip chamber and tubing (inter-facility transport)

or IV pump tubing Procedure:


allergies. Don personal protective equipment Prepare the medication with a 5 ml syringe with a needle 18 – 22 GA, 1 ½ - 2 inches. Label the medication Select a site and cleanse it with alcohol (deltoid, dorsal gluteal, ventro-gluteal). Spread skin taut, insert the needle at 90-degree angle, and aspirate. If no blood appears in syringe, inject medication slowly. Withdraw the needle and massage the site with alcohol prep or 4x4.

Dispose of syringe in sharps container. Place a Band-Aid over the injection site.



Procedural Application 197 Intranasal Drug Administration

Intranasal Drug Administration

General • Medications requiring intranasal administration Indications • Appropriate size syringe with needle

• Medication • MAD Atomizing Device

Equipment • All equipment as noted for intravenous access. • Medication and IV fluid for infusion (as specified in

protocol or Drug Reference) • 18g syringe needle or needless adapter. • 60 gtts/ml IV drip chamber and tubing (inter-facility

transport) or IV pump tubing Procedure:


allergies. Don personal protective equipment Draw the medication with a 5 ml syringe with a needle Label the medication Remove the needle and attach the MAD device Verify the nostril is not occluded Administer the medication Dispose of syringe in sharps container.




Medication Administration – Endotracheal

Indications • ET medication administration should never substitute intravenous medication administration.

Equipment • All equipment as noted in the endotracheal intubation procedure.

• Medications, appropriate syringes, and syringe needles.

• If medication is not diluted, use 10 ml of NS for dilution Procedure:

Note: All medications administered via the ETT are to be doubled except pediatric epinephrine which should be given at 10 times the IV dose.


allergies. Don personal protective equipment Endotracheal intubation with confirmation of tube placement. Draw up medication or prepare pre-filled syringe for use. Reconfirm tube placement by auscultation and CO2 detector. Hyperventilate the patient for 30 seconds Rapidly inject the medication down the tube in a bolus that is diluted or followed by NS to flush the

tube. The total fluid that should be administered in one bolus is 10 ml maximum. Hyperventilate the patient for at least 30 seconds following medication administration.



Procedural Application 199 Medication Administration – Sublingual

Medication Administration – Sublingual

Indications • Administration of medications typically given by a sublingual route

Equipment • Medication in a sublingual form Procedure:

• Verify patient identification with two identifiers • Explain the procedure to the patient, the medication to be utilized, and inquire about medication allergies. • Don personal protective equipment • Place medication under the patient’s tongue. • Advise the patient not to chew or swallow but to allow the medication to absorb • Monitor for medication effects or complications




Medication Administration – Nebulized

Indications • Dyspnea with evidence of bronchospasm (wheezes, silence), due to asthma, or COPD, or upper airway swelling.

Equipment • Medication • Oxygen driven nebulizer • Oxygen

Procedure:


allergies. The patient may self-administer a metered dose inhaler (MDI) or hand-held nebulizer If the patient has inadequate minute volume to inhale the mist, medications may be nebulized with a

positive-pressure breathing device such as a bag-valve-mask or with an in-line device attached to the ETT.

Medication should be measured and introduced into nebulizer. The medication should be nebulized with 8-10 liters of oxygen.

The patient should be instructed to breathe normally and to hold a deep inspiration every 4-5 breaths. Treatment is continued until all medication is gone or is discontinued due to complication in patient

condition such as a. ECG ectopy b. A heart rate increases by more than 20 bpm



Procedural Application 201 Medication Administration – Oral

Medication Administration – Oral

General • Need for oral medications administration Contraindications • Decreased and/or altered mental status Equipment • Medication

Procedure:


allergies. Don appropriate personal protective equipment Prepare medication for administration. Prior to administration check for:

a. Expiration date b. Name of medication being administered to ensure medication chosen is correct.

Obtain permission from patient to administer medication. Advise the patient what to expect after medication has been administered. (e.g., Nitro may cause headache but should relieve chest pain, etc.).

Provide medications to patient with direction on the administration (i.e.: to be chewed, swallowed, held under tongue)




Blood Product Continuation

Indications • Packed Red Blood Cells (PRBCs)- Replacement of red blood cells in the patient with anemia and objective evidence of tissue hypoxia (increased lactate, metabolic acidosis, ongoing blood loss with signs of shock, etc)

• Fresh Frozen Plasma (FFP)- Replenishment of coagulation factors in the patient with active bleeding or high risk for bleeding. Reversal of Coumadin.

• Platelets- Replacement of a platelet deficiency in the patient with a platelet count less than 20K, (or 50K is actively bleeding)

• Cryoprecipitate- Control of bleeding as a result of a fibrinogen deficiency, factor VIII deficiency, treatment of von Willebrand’s disease

Contraindications • Incompatible typed or cross matched blood Complications • Fluid overload

• Transfusion related acute lung injury • DIC • Hemolytic reaction • Febrile reaction • Anaphylaxis*

o If the patient presents with a mild allergic reaction with none to .5 degree temperature increase, follow the appropriate CPG during the infusion. If the patient has a severe reaction and elevation in temp, stop the infusion, bolus with saline and treat accordingly.

Equipment • Blood product • Blood administration set • Normal saline • IV tubing connector

Procedure:

Verify patient identification with two identifiers Explain the procedure to the patient, the product to be utilized, and inquire about medication allergies. Don personal protective equipment Verify physician prescription for blood product Validate the type and screen have been completed unless giving un-typed blood in an emergency BOTH crewmembers must identify the following

a. Patient’s full first and last name b. The type of blood product c. The ABO type and Rh factor of the patient and the donor blood d. Unit number e. Expiration date f. Appearance of blood

Obtain a pre-transfusion set of vital signs including heart rate, blood pressure, respiratory rate and temperature.

Prime the blood tubing with normal saline and then add the blood product. Begin infusion slowly if possible and monitor for signs of a reaction.

a. It is normal to have a mild reaction to blood administration. Treat with Benadryl per Allergic Reaction CPG.



Procedural Application 203 Blood Product Continuation

b. It is normal to have a slightly elevated temp. If it is above 101.0, stop infusion contact medical control and Teat per appropriate CPG

Obtain a complete set of vitals five minutes after transfusion initiation and every fifteen minutes there after (or more frequently if the patient is unstable).

If infusing multiple units of blood, the blood tubing should be changed after each four units. If the patient has any kind of abnormal reaction immediately stop the blood, bolus the patient with NS, and notify Medical Control. Deliver the unused blood to the receiving hospital with the patient.

Patient Blood Type Compatible Red Cell Donors

A A/O B B/O AB AB/A/B/O O O

Transport Considerations

• If patient becomes hypotensive: treat per Shock CPG • Mild Reaction

o Treat per Allergic Reaction CPG • Severe Reaction

o Stop the infusion o Flush with saline o Treat per Allergic Reaction CPG o Contact Medical Control



Naso/Orogastric Tube Insertion

Indications • Gastric emptying or gastric decompression when oral insertion is not optimal.

Contraindications • Basilar skull fracture • Mid face trauma • Coagulopathy • Nasal obstruction

Complications • Nasal Bleeding • Gagging • Airway obstruction • Placement in the trachea

Equipment • NG/OG tube • 60 mL syringe • Lubricating jelly • Stethoscope • Securing device • MAD device with Lidocaine

Procedure:

Estimate insertion length by superimposing the tube over the body from the nose to the stomach. Flex the neck (if not contraindicated) to facilitate esophageal passage. MAD 1ml of Lidocaine in the selected nare. Liberally lubricate the distal end of the tube and pass through the patient’s nostril along the floor of

the nasal passage. Do not orient the tip upward into the turbinate. This increases the difficulty of the insertions and may cause bleeding.

In the setting of an unconscious, intubated patient or a patient with facial trauma, oral insertion of the tube may be considered or preferred.

Continue to advance the tube gently until the appropriate distance is reached. Confirm placement by injecting 20ml of air and listen for the swish or bubbling of the air over the

stomach. If any doubt about placement, do not administer medications. Secure the tube. Decompress the stomach of air and food either by connecting the tube to suction or manually

aspirating with the large catheter tip syringe. Document the procedure, time, and result (success) on/with the patient care report (PCR).



Procedural Application 205 Helmet Removal

Helmet Removal

Indications • Helmet removal to facilitate managing the airway. Contraindications • Inability to remove the helmet without aggravating

potential spinal injury unless the helmet compromises airway management.

Complications • Aggravation of cervical injury Equipment • Medication

Procedure:

The decision whether the remove a helmet or not to remove a helmet should be based on the following criteria: Tight-Fitting Helmets

If the patient is awake and able to protect his/her own airway, it is generally preferable to leave the helmet in place using the helmet to assist with immobilization.

If the airway cannot be controlled for any reason with the helmet in place, the helmet should immediately be removed while maintaining in-line immobilization.

If the patient has an altered level of consciousness and/or is unable to protect his/her airway. The face shield cannot easily be removed; the helmet should be removed while maintaining in-line immobilization.

Loose-Fitting Helmets If the patient is wearing a loose helmet that does not conform closely to his/her head, the helmet

should be removed using in-line immobilization prior to completing spinal immobilization on the patient.

The void behind the Occipital skull created by the helmet and any other protective sports equipment should be filled during the spinal immobilization procedure.

Considerations:

• When immobilizing patients with the helmet in place, the backboard portion of most immobilization devices may cause the neck to flex forward when the patients head is placed on it. For that reason, head immobilization devices should generally not be used in these patients. The helmet should rest directly on the backboard with towel rolls used to provide lateral support to the helmet.

• EMS crews should work closely with team trainers and physicians for organized team sports.




Blood Glucose Analysis

Indications • Patients with potential hypoglycemia (diabetic emergencies, change in mental status, bizarre behavior, etc.)

Contraindications • None Complications • Infection Equipment • Glucometer

• Glucometer strips • Lancet • Alcohol preps

Procedure:

Gather and prepare equipment. Blood samples for performing glucose analysis should be obtained simultaneously with intravenous

access when possible. Place correct amount of blood on reagent strip or site on the glucometer per the manufacturer’s

instructions. Time the analysis as instructed by the manufacturer. Document the glucometer reading and treat the patient as indicated by the analysis and protocol. Repeat glucose analysis as indicated for reassessment after treatment and as per protocol. Perform Quality Assurance on glucometers at least once every 7 days, if any clinically suspicious

readings, and/or as recommended by the manufacturer and document in log.



Procedural Application 207 Combat Tourniquet

Combat Tourniquet


Medication Reference Guide 208

Medication Reference Guide


Medication Reference Guide 209 Acetaminophen (APAP)

Acetaminophen (APAP) Trade Names Tylenol

Acquisition This medication is carried on CHRISTUS EMS units.

Scope of Practice

Paramedic Intermediate Basic First Responder

Indications • Reduce fever • Temporarily relieve mild to moderate pain

Absolute Contraindications

• Known hypersensitivity to acetaminophen or phenacetin • QT prolongation.

Relative Contraindications

• Avoid repeated administration to patients with anemia or hepatic disease.

Precautions • Arthritic or rheumatoid conditions affecting children under 12 yr • Alcoholism • Malnutrition • Thrombocytopenia

Adult Dose

Indication: All

Route: PO

Seq Dose Rate Max Single Dose Next Dose 1 500-1000 mg N/A 1000 mg One time Dose

Pediatric Dose

Indication: All

Route: PO

Seq Dose Rate Max Single Dose Next Dose 1 15 mg/kg N/A 1 gm One time Dose

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class

Rapid 3-4 hours 1-3 hours C



Drug Details

Action

It is a clinically proven analgesic/antipyretic. Acetaminophen produces analgesia by elevation of the pain threshold and antipyresis through action on the hypothalamic heat-regulating center. Acetaminophen is equivalent to aspirin in analgesic and antipyretic effectiveness. Unlike aspirin, acetaminophen has little effect on platelet function, does not affect bleeding time, and generally produces no gastric bleeding. It is unlikely to produce many of the side effects associated with aspirin and aspirin-containing products.

Interactions

• Increased potential for chronic hepatotoxicity if chronically co-administered with: o Barbiturates o Carbamazepine o Phenytoin o Rifampin

• Chronic, excessive ingestion of alcohol will increase risk of hepatotoxicity

Side Effects

Acute Toxicity • Dizziness • Lethargy

Cardiovascular

Dermatological/Skin

GI/Renal Nausea, vomiting, Epigastric/abdominal pain, diarrhea, acute renal failure (rare)

Metabolic/Endocrine Hepatic toxicity, hepatic coma, elevation of serum transaminases (ALT, AST) and bilirubin, hypoglycemia

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal

Psychological/Behavioral Anorexia

Pulmonary

General/Other


Medication Reference Guide 211 Adenosine

Adenosine Trade Names Adenocard


Scope of Practice Paramedic Intermediate Basic First Responder

Indications • PSVT refractory to vagal maneuvers


• Known hypersensitivity • Pre-existing 2nd/3rd degree AV blocks • Bradycardia


Precautions • Use with caution in patients with asthma • Brief post administration dysrhythmias include: PVCs, PACs, sinus bradycardia, sinus

tachycardia, various degrees of AV block, Asystole

Adult Dose

Indication: All

Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 12 mg Rapid Push N/A End Dosing Administer via rapid Single syringe push including both medication and saline using a

20ml syringe.

Pediatric Dose

Indication: All

Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 0.1 mg/kg Rapid Push 6 mg Seq 2 in 1-2 min 2 0.2 mg/kg Rapid Push 12 mg End Dosing

Administer via rapid push including both medication and saline in 10ml saline flush.

Pharmacokinetics


20-30 Seconds 30 Seconds 10 seconds C



Drug Details

Action Slows conduction through the AV node, can interrupt reentry pathways through AV and SA nodes, and can restore normal sinus rhythm in patients with PSVT (including PSVT associated with WPW).

Interactions • Methylxanthines decrease its effectiveness. • Dipyridamole potentiates its effects.

Side Effects

Acute Toxicity

Cardiovascular Atrial fibrillation/flutter, chest pain, hypotension, chest pressure, palpitations

Dermatological/Skin Facial flushing, sweating

GI/Renal Nausea

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular Blurred vision

Pregnancy/Neonatal

Psychological/Behavioral

Pulmonary Dyspnea, hyperventilation

General/Other Lightheadedness, dizziness, tingling or heaviness in the arms, numbness, apprehension, neck/back pain, metallic taste, tightness in throat, pressure in groin

Technique: 12 mgs rapid push over 1-3 seconds followed by a 20 ml NS bolus. Adenosine should be given in a large bore IV

in the antecubital fossa or higher.


Medication Reference Guide 213 Albuterol (aerosolization)

Albuterol (aerosolization) Temporarily Suspended for Suspected (COVID-19) patients

Trade Names Ventolin


Scope of Practice (Bronchospasm) Paramedic Intermediate Basic First Responder

Scope of Practice (Potassium Shift) Paramedic Intermediate Basic First Responder

Indications

• Bronchospasm in patients with: o Asthma o Chronic bronchitis o Emphysema o Acute onset

• Hyperkalemia requiring intracellular potassium shift


• Known hypersensitivity


Precautions • Monoamine oxidase inhibitors (MAOI) or tricyclic antidepressants may potentiate effects on vascular system

Adult Dose

Indication: Bronchospasm

Route: Nebulized

Seq Dose Rate Max Dose Next Dose 1 2.5 mg in 3 mL N/A N/A Repeat as needed

Indication: Hyperkalemia

Route: Nebulized

Seq Dose Rate Max Dose Next Dose 1 5 mg in 6 mL N/A N/A Repeat as needed

Pediatric Dose See Adult Dose

Pharmacokinetics


5-15 Minutes 3-6 hours <3 hours C



Drug Details

Action

• It is a relatively selective beta 2 adrenergic. • The prime action of beta-adrenergic drugs is to stimulate adenyl cyclase, the

enzyme that catalyzes the formation of cyclic-3´, 5´-adenosine monophosphate (cyclic AMP) from adenosine triphosphate (ATP). The cyclic AMP causes relaxation of the smooth muscles of the bronchial tree, decreasing airway resistance, facilitating mucus drainage, and increasing vital capacity.

• It exerts minimal effects on beta 1 (heart) or alpha (peripheral vasculature) receptors.

• In therapeutic doses, albuterol, by inhibiting histamine release from mast cells, also reduces the mucus secretion, capillary leaking, and mucosal edema caused by an allergic response in the lungs

Interactions

• Other sympathomimetic aerosol bronchodilators or epinephrine should not be used concomitantly with albuterol.

• Beta receptor blocking agents and albuterol inhibit the effects of each other. • Since albuterol may lower serum potassium, care should be taken in patients

also using other drugs that lower serum potassium as the effects may be additive.

Side Effects

Acute Toxicity

Cardiovascular Palpitations, tachycardia, hypertension,

Dermatological/Skin Rash

GI/Renal Nausea, dyspepsia, pharyngitis,

Metabolic/Endocrine

Muscular/Skeletal Tremors

Neurological Seizures

Ocular

Pregnancy/Neonatal

Psychological/Behavioral Anxiety

Pulmonary Nasal congestion, cough

General/Other Dizziness, headache, insomnia


Medication Reference Guide 215 Albuterol (MDI)

Albuterol (MDI)

Trade Names Ventolin


Scope of Practice (Bronchospasm) Paramedic Intermediate Basic First Responder

Indications

• Bronchospasm in patients with: o Asthma o Chronic bronchitis o Emphysema o Acute onset


• Known hypersensitivity


Precautions • Monoamine oxidase inhibitors (MAOI) or tricyclic antidepressants may potentiate effects on vascular system

Adult Dose

Indication: Bronchospasm

Route: MDI

Seq Dose Rate Max Dose Next Dose 1 8 puffs = N/A N/A Repeat in 5 minutes as needed

one time

Pediatric Dose Indication: Bronchospasm Route: MDI

Seq Dose Rate Max Dose Next Dose

1 4 puffs = N/A N/A Repeated in 5 minutes as needed one time

Pharmacokinetics Onset Duration Half-Life Pregnancy Class

5-15 min 3-6 hrs <3 hrs C



Action

• It is a relatively selective beta 2 adrenergic. • The prime action of beta-adrenergic drugs is to stimulate adenyl cyclase, the

enzyme that catalyzes the formation of cyclic-3´, 5´-adenosine monophosphate (cyclic AMP) from adenosine triphosphate (ATP). The cyclic AMP causes relaxation of the smooth muscles of the bronchial tree, decreasing airway resistance, facilitating mucus drainage, and increasing vital capacity.

• It exerts minimal effects on beta 1 (heart) or alpha (peripheral vasculature) receptors.

• In therapeutic doses, albuterol, by inhibiting histamine release from mast cells, also reduces the mucus secretion, capillary leaking, and mucosal edema caused by an allergic response in the lungs

Interactions

• Other sympathomimetic aerosol bronchodilators or epinephrine should not be used concomitantly with albuterol.

• Beta receptor blocking agents and albuterol inhibit the effects of each other. • Since albuterol may lower serum potassium, care should be taken in patients

also using other drugs that lower serum potassium as the effects may be additive.

Side Effects

Acute Toxicity

Cardiovascular Palpitations, tachycardia, hypertension,


GI/Renal Nausea, dyspepsia, pharyngitis,

Metabolic/Endocrine


Neurological Seizures

Ocular

Pregnancy/Neonatal


Pulmonary Nasal congestion, cough

General/Other Dizziness, headache, insomnia


Medication Reference Guide 217 Amiodarone

Amiodarone Trade Names Cordarone, Pacerone



Indications

Life-threatening cardiac dysrhythmias such as • ventricular tachycardia • ventricular fibrillation • atrial fibrillation


• Known hypersensitivity to the drug. • QT prolongation.


Due to decrease in automaticity, conductivity, and contractility do not use in the presence of the following without a pacemaker available • Cardiogenic Shock • Severe Sinus Bradycardia • Advanced AV Block

Precautions • Patients with latent or manifest heart failure because failure may be worsened. • Patients with severe liver disease (drug is metabolized in the liver. • Prolongs the QT interval.

Adult Dose

Ventricular Tachycardia with a Pulse Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 150 mg 10 min 2 g/day Repeat as needed

Ventricular Fibrillation/Pulseless Ventricular Tachycardia Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 300 mg Bolus N/A Seq 2 in 3-5 min 2 150 mg Bolus N/A End Dosing

Maintenance Infusion Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1 mg/mi Infusion 2 g/day Seq 2 in 6 hours 2 0.5 mg/min Infusion 2 g/day End Dosing

Mix 500 mg in 250 mL D5W to create a 2 mg/mL concentration.

Pediatric Dose

Ventricular Tachycardia with a Pulse Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 5 mg/kg 20-60 min 300 mg Repeat to daily max 15 mg/kg

Ventricular Fibrillation/Pulseless Ventricular Tachycardia Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 5 mg/kg Bolus 300 mg Repeat to daily max 15 mg/kg




Pharmacokinetics

30-45 min Varies 40-55 days D

Drug Details

Action

A class 3 antiarrhythmic. • It is thought to prolong the duration of the action potential and refractory period

without significantly affecting the resting membrane potential. • The IV formulation relaxes vascular smooth muscle, decreases peripheral

vascular resistance, and increases coronary blood flow. • Amiodarone also blocks effects of sympathetic stimulation.

Interactions

• Significantly increases digoxin levels and enhances pharmacologic effects and toxicities of disopyramide, procainamide, quinidine, flecainide, and lidocaine.

• It also enhances the anticoagulant effects of oral anticoagulants. • Calcium channel blockers and beta-blockers may potentiate sinus bradycardia,

sinus arrest, or AV block. • Amiodarone may increase phenytoin levels 2- to 3-fold. • Ritonavir may increase cardiotoxicity. • Additional interactions include fentanyl, cyclosporine, cholestyramine, and

cimetidine.

Side Effects

Acute Toxicity

Cardiovascular bradycardia, hypotension (IV), sinus arrest, cardiogenic shock, CHF, dysrhythmias; AV block

Dermatological/Skin slate-blue pigmentation, rash; (with chronic use): angioedema,

GI/Renal Nausea, Vomiting, Constipation

Metabolic/Endocrine hyperthyroidism or hypothyroidism, hepatotoxicity

Muscular/Skeletal Peripheral neuropathy (muscle weakness, wasting numbness, tingling), fatigue, abnormal gait, dyskinesia

Neurological Paresthesia

Ocular corneal microdeposits, optic neuritis, optic neuropathy, blurred vision, permanent blindness, corneal degeneration, macular degeneration, photosensitivity;

Pregnancy/Neonatal May cause neonatal hypo- or hyperthyroidism if taken during pregnancy.


Pulmonary Respiratory (pulmonary toxicity): Alveolitis, pneumonitis (fever, dry cough, dyspnea), interstitial pulmonary fibrosis;

General/Other Headache, Dizziness


Medication Reference Guide 219 Anectine

Anectine Trade Names Succinylcholine



Indications • Delayed Sequence Intubation (DSI) • Ultra-short acting depolarizing skeletal muscle relaxant


• Known hypersensitivity to the drug. • Malignant Hyperthermia with (personal or family history) • Extensive denervation of skeletal muscle, or upper motor neuron injury (ALS) • Kyperkalemia • Major Burns & Crush Injuries with concerns for (rhabdomyolysis) >8 hours


• Multiple Trauma • Intraocular pressure (Acute angle-closure glaucoma)

Precautions • Ventricular dysrhythmias

Adult Dose

Indication: DSI Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1 mg/kg Bolus Repeat as needed

Pediatric Dose


Seq Dose Rate Max Dose Next Dose 1 2 mg/kg Bolus

Increase risk in bradycardia with repeated dosing

Pharmacokinetic Onset Duration Half-Life Pregnancy Class

1 minute 4-6 minutes unknown C

Action

Succinylcholine is a depolarizing skeletal muscle relaxant. As does acetylcholine, it combines with the cholinergic receptors of the motor end plate to produce depolarization. This depolarization may be observed as fasciculation’s. Subsequent neuromuscular transmission is inhibited so long as adequate concentration of succinylcholine remains at the receptor site. Onset of flaccid paralysis is rapid (less than 1 minute after IV administration), and with single administration lasts approximately 4 to 6 minutes.



Succinylcholine is rapidly hydrolyzed by plasma cholinesterase to succinylmonocholine (which possesses clinically insignificant depolarizing muscle relaxant properties) and then more slowly to succinic acid and choline. About 10% of the drug is excreted unchanged in the urine. The paralysis following administration of succinylcholine is progressive, with differing sensitivities of different muscles. This initially involves consecutively the levator muscles of the face, muscles of the glottis, and finally, the intercostal and the diaphragm and all other skeletal muscles.

Interactions

• Drugs which may enhance the neuromuscular blocking action of succinylcholine include: promazine, oxytocin, aprotinin, certain non-penicillin antibiotics, quinidine, β-adrenergic blockers, procainamide, lidocaine, trimethaphan, lithium carbonate, magnesium salts, quinine, chloroquine, diethylether, isoflurane, desflurane, metoclopramide, and terbutaline. The neuromuscular blocking effect of succinylcholine may be enhanced by drugs that reduce plasma cholinesterase activity (e.g., chronically administered oral contraceptives, glucocorticoids, or certain monoamine oxidase inhibitors) or by drugs that irreversibly inhibit plasma cholinesterase

Side Effects


Cardiovascular Lower Blood Pressure, Lower Heart Rate,

Dermatological/Skin Urticaria, rash, with possible allergic reactions

GI/Renal Acute renal failure

Metabolic/Endocrine About 10% of the drug is excreted unchanged in the urine.

Muscular/Skeletal

Neurological

Ocular Increased pressure

Pregnancy/Neonatal Can be used with caution


Pulmonary

General/Other

https://www.rxlist.com/script/main/art.asp?articlekey=5915




Medication Reference Guide 221 Aspirin

Aspirin Trade Names



Scope of Practice EMT Basic/Intermediate/Paramedic

Indications • Chest pain suggestive of an acute myocardial infarction


• Known hypersensitivity to salicylates including methyl salicylate (oil of wintergreen) • Active ulcer disease • Active Bleeding, GI, GU, Pulmonary, Trauma, etc. • Asthma • Children/Teenagers (due to possible links to Reye’s Syndrome)


Precautions • Allergies to other NSAIDs • Bleeding disorders

Adult Dose

Indication: All Route: PO (Chewed)

Seq

Dose Rate Max Dose Next Dose

1 324 mg N/A N/A End Dosing

Pediatric Dose None


5-30 Minutes 1-4 Hours 15-20 Minutes C



Drug Details

Action

Aspirin is an anti-inflammatory agent and an inhibitor of platelet function. The major actions of aspirin appear to be associated primarily with inhibiting the formation of prostaglandins involved in the production of inflammation, pain, and fever. These anti-inflammatory actions also contribute to analgesic effects. As an analgesic, it relieves mild to moderate pain by acting on the peripheral nervous system with limited action in the central nervous system (hypothalamus). In addition to inhibiting prostaglandin synthesis, aspirin lowers body temperature in fever by indirectly causing centrally mediated peripheral vasodilation and sweating. As an antiplatelet agent, aspirin (but not other salicylates) powerfully inhibits platelet aggregation by blocking the formation of thromboxane A2, which causes platelets to aggregate and arteries to constrict. This action results in an overall reduction in mortality associated with myocardial infarction. It also reduces the rate of nonfatal reinfarction and nonfatal stroke.

Interactions • Anticoagulants increase risk of bleeding • Oral hypoglycemic agents increase hypoglycemic activity with aspirin doses

greater than 2 grams per day

Side Effects


Cardiovascular Hemolytic anemia, prolonged bleeding, thrombocytopenia

Dermatological/Skin Urticaria, rash, petechia, easy bruising

GI/Renal Nausea, vomiting, diarrhea, heart burn, stomach pain, ulceration, occult bleeding, GI bleeding, impaired renal function

Metabolic/Endocrine Hepatic toxicity, hepatic coma, elevation of serum transaminases (ALT, AST) and bilirubin, hypoglycemia

Muscular/Skeletal

Neurological Confusion, drowsiness

Ocular

Pregnancy/Neonatal Prolonged pregnancy and labor with increased bleeding


Pulmonary Bronchospasm, laryngeal edema

General/Other Dizziness, tinnitus, hearing loss, anaphylactic shock


Medication Reference Guide 223 Atropine Sulfate

Atropine Sulfate Trade Names Acquisition This medication is carried on CHRISTUS EMS units. Scope of Practice Paramedic Intermediate Basic First Responder

Indications • Stable Symptomatic Bradycardia • Pediatric Induction Agent • Organophosphate Poisoning


• Bradycardia in post heart transplant patients • Bradycardia in the setting of 2nd/3rd degree AV blocks


Precautions • May worsen bradycardia associated with 2nd Degree Type II (Mobitz II) and 3rd

degree AV blocks. • Use with caution with signs of myocardial ischemia/infarction • Glaucoma due to increased intraocular pressure

Adult Dose

Stable Symptomatic Bradycardia Route: IV/IO

Seq


1 0.5 mg Bolus 0.04 mg/kg or 3 mg

Repeat as needed Q 3-5 minutes

Organophosphate Poisoning Route: IV/IO

Seq


1 2-5 mg Bolus N/A Repeat as needed Q 5 minutes

Pediatric Dose

Stable Symptomatic Bradycardia Route: IV/IO

Seq

Dose Min Dose Max Dose Next Dose

1 0.02 mg/kg 0.1 mg 1 mg End Dosing

Organophosphate Poisoning Route: IV/IO

Seq


1 0.03 mg/kg Bolus N/A Repeat as needed


Immediate 4 hours 2-3 hours C



Drug Details

Action

Atropine exerts its effects on the autonomic nervous system. It is a competitive antagonist that selectively blocks all muscarinic responses to acetylcholine (ACh). By blocking vagal (parasympathetic) impulses to the heart it increases SA node discharge, enhances conduction through the AV junction, and increases cardiac output. Its antisecretory action suppresses sweating, lacrimation, salivation, and secretions from the upper and lower respiratory tract. Atropine is a potent bronchodilator when bronchoconstriction has been induced by parasympathomimetics. It plays an important role as an antidote of organophosphate poisoning.

Interactions Few in the prehospital setting.

Side Effects

Acute Toxicity

Cardiovascular Hypertension, hypotension, ventricular tachycardia, palpitations, paradoxical bradycardia, AV dissociation, atria or ventricular fibrillation

Dermatological/Skin Flushed/dry skin, rash, urticaria, contact dermatitis,

GI/Renal Nausea, vomiting, constipation, delayed gastric emptying, urinary hesitancy/retention, dysuria, anhidrosis

Metabolic/Endocrine

Muscular/Skeletal Ataxia

Neurological Excitement, irritability, convulsions, drowsiness, confusion, disorientation, hallucinations,

Ocular Mydriasis, blurred vision, photophobia, increased intraocular pressure, cycloplegia, eye dryness, local redness, allergic conjunctivitis

Pregnancy/Neonatal

Psychological/Behavioral Mental depression

Pulmonary

General/Other Headache, dizziness, fatigue, weakness, dry mouth/thirst, dysphagia, loss of taste, impotence


Medication Reference Guide 225 Biorphen (phenylephrine)

Biorphen (phenylephrine)

Trade Names Acquisition This medication is carried on CHRISTUS EMS units. Scope of Practice Paramedic Intermediate Basic First Responder Indications • Treatment of clinically important hypotension Absolute Contraindications

• None in the present of unstable hypotension • Age <1 year


Bradycardia with Biorphen can cause sever bradycardia and decreased cardiac output

Precautions • Angina • Heart Failure • Pulmonary Arterial Hypertension

Adult Dose

Peri-Arrest patient with hypotension Route: IV/IO PUSH

Seq Dose Rate Max Dose Next Dose 1 0.5-1.0 ml Push Not to exceed

a total dosage 200 mcg

Repeat as needed Q 2 minutes until SBP >90

Pediatric Dose Age <1 year Contraindication Age 1-5 years Age 6-10 years

Peri-Arrest patient with hypotension Route: IV/IO PUSH

Seq Dose: <1 yr

age Min Dose Max Dose Next Dose

1 0.0 mg/kg none o none

Seq Dose Rate Max

Dose Next Dose

1 0.25 ml (25mcg) Push Total 100 mcg

Repeat as needed Q2 minutes until SBP above (70 +(2 x age)

Seq Dose Rate Max Dose Next Dose 1 0.5 ml (50 mcg) Push Total 200

mcg Repeat as needed Q 2 minutes until SBP above (70 +(2 x age)


Immediate 5 minutes C



Drug Details

Action

Phenylephrine is a alpha-1 adrenergic receptor agonist. This medication MUST NOT BE DILUTED before administration as an intravenous bolus. The chemical name of phenylephrine hydrochloride is (-) –m-hydroxy-x- (methyylamino) methyl] benzyl alcohol hydrochloride, its molecular formula is C9 H13 NO2 Interaction of phenylephrine with α-1 adrenergic receptors on vascular smooth muscle cells causes activation of the cells and results in vasoconstriction. Following phenylephrine hydrochloride intravenous administration, increases in systolic and diastolic blood pressures, mean arterial blood pressure, and total peripheral vascular resistance are observed. The onset of blood pressure increase following an intravenous bolus phenylephrine hydrochloride administration is rapid, typically within minutes. As blood pressure increases following intravenous administration, vagal activity also increases, resulting in reflex bradycardia. Phenylephrine has activity on most vascular beds, including renal, pulmonary, and splanchnic arteries.

Interactions Phosphodiesterase Type 5 inhibitors, Calcium channel blockers, Ace inhibitors, Monoamine oxidase inhibitors (MAOI)

Side Effects

Acute Toxicity

Cardiovascular Reflex bradycardia, lowered cardiac output, ischemia, hypertension, arrhythmias

Dermatological/Skin Pruritis

GI/Renal Nausea, vomiting, Epigastric pain (ESRD), dose response indicate increased responsiveness to phenylephrine

Metabolic/Endocrine

Muscular/Skeletal

Neurological Headache, blurred vision, neck pain, tremors

Ocular

Pregnancy/Neonatal


Pulmonary Dyspnea

General/Other Store Biorphen at (68*F to 77*F) the 5 ml ampule is for single use only


Medication Reference Guide 227 Calcium Chloride

Calcium Chloride Trade Names



Indications • Cardiac toxicity of hyperkalemia • Magnesium sulfate toxicity • Calcium channel blocker overdose


• Ventricular Fibrillation


Precautions • Digitalized patients • Renal or cardiac insufficiency • Immobilized patients

Adult Dose

Indications: Cardiac Arrest with concern for Hyperkalemia Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1000mg(1amp) IVP 3 g/day Repeat as needed Q 10 minutes

10% solution

Indications: Hyperkalemia (non-arrest), Magnesium Toxicity, Calcium Channel Blocker Overdose

Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 500-1000 mg 10 min 3 g/day Repeat as needed Q 20 minutes

Pediatric Dose


Seq Dose Rate Max Dose Next Dose 1 20 mg/kg IVP 1 g Seq 2 in 10 minutes if needed 2 20 mg/kg IVP 1 g End Dosing

Indications: Hyperkalemia (Non-arrest), Magnesium Toxicity, Calcium Channel Blocker Overdose

Route: IV/IO Seq Dose Rate Max Dose Next Dose 1 20 mg/kg 10 min 1 g Seq 2 in 20 min if needed 2 20 mg/kg 10 min 1 g End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Immediate

C


Medication Reference Guide 229 Calcium Chloride

Drug Details

Action

It provides elemental calcium in the form of the cation Ca++. Calcium is necessary for many physiologic activities. It is an essential element for regulating the excitation threshold of nerves and muscles, for blood clotting mechanisms, maintenance of renal function, and for the development of skeletal bones and teeth. Calcium causes a significant increase in myocardial contractility and in ventricular automaticity. It also plays a role in regulating the storage and release of neurotransmitters and hormones; regulating amino acid uptake and absorption of vitamin B12; controlling gastrin secretion; and in maintaining structural and functional integrity of cell membranes and capillaries. Calcium chloride acts like digitalis on the heart, increasing cardiac muscle tone and force of systolic contractions (positive inotropic effect) making it especially useful for patients with sympathetic blockade. Calcium chloride is 3 times as strong as Calcium Gluconate.

Interactions • Will interact with sodium bicarbonate and form a precipitate. • It may enhance inotropic and toxic effects of digoxin. • Antagonize the effects of verapamil and possibly other calcium channel blockers.

Side Effects


Cardiovascular Hypotension, bradycardia, other dysrhythmias, syncope, cardiac arrest

Dermatological/Skin Tissue irritation/burning, cellulitis, soft tissue calcification, necrosis/sloughing (if extravasation)

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other Tingling sensations



Calcium Gluconate Trade Names Kalcinate



Indications • Cardiac toxicity of hyperkalemia • Magnesium sulfate toxicity • Calcium channel blocker overdose


• Ventricular Fibrillation


Precautions • Digitalized patients • Renal or cardiac insufficiency • Immobilized patients

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 500-1000 mg IVP 3 gm Repeat as needed Q 10 minutes


Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 500-1000mg 10 min 3 gm Repeat as needed Q 20 minutes

Pediatric Dose


Seq Dose Rate Max Dose Next Dose 1 60 mg/kg IVP 3 g Seq 2 in 10 min if needed 2 60 mg/kg IVP 3 g End Dosing


Route: IV/IO Seq Dose Rate Max Dose Next Dose 1 60 mg/kg 10 min 3 g Seq 2 in 20 min if needed 2 60 mg/kg 10 min 3 g End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Immediate

C


Medication Reference Guide 231 Calcium Gluconate

Drug Details

Action

It provides elemental calcium in the form of the cation Ca++. Calcium is necessary for many physiologic activities. It is an essential element for regulating the excitation threshold of nerves and muscles, for blood clotting mechanisms, maintenance of renal function, and for the development of skeletal bones and teeth. Calcium causes a significant increase in myocardial contractility and in ventricular automaticity. It also plays a role in regulating the storage and release of neurotransmitters and hormones; regulating amino acid uptake and absorption of vitamin B12; controlling gastrin secretion; and in maintaining structural and functional integrity of cell membranes and capillaries. Calcium Gluconate acts like digitalis on the heart, increasing cardiac muscle tone and force of systolic contractions (positive inotropic effect) making it especially useful for patients with sympathetic blockade. Calcium chloride is 3 times as strong as Calcium Gluconate.

Interactions • Will interact with sodium bicarbonate and form a precipitate. • It may enhance inotropic and toxic effects of digoxin. • Antagonize the effects of verapamil and possibly other calcium channel blockers.

Side Effects


Cardiovascular Hypotension, bradycardia, other dysrhythmias, syncope, cardiac arrest

Dermatological/Skin Tissue irritation/burning, cellulitis, soft tissue calcification, necrosis/sloughing (if extravasation)

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other Tingling sensations



5% Dextrose (D5w) Trade Names



Indications Mix for medication administration via continuous infusion


• None in the emergency setting


Precautions • Monitor to prevent fluid overload. • Since it contains only glucose, it is possible for other important physiological

electrolytes to become depleted when large amounts are administered. • Can cause hyponatremia and cerebral edema in large doses.

Adult Dose N/A

Pediatric Dose N/A

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class <1 minute Dependent on

degree of hypoglycemia

Dependent on degree of hypoglycemia

C

Drug Details

Action Hypotonic crystalloid solution IV fluid containing 5% glucose

Interactions Few in the emergency setting.

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other


Medication Reference Guide 233 10% Dextrose (D10w)

10% Dextrose (D10w)

Trade Names



Indications • Adult blood glucose level < 60 mg/dL • Child blood glucose level < 80 mg/dL • Neonate blood glucose level < 40 mg/dL




Precautions • Patients with increasing intracranial pressure as glucose may worsen cerebral edema • Use with 100 mg Thiamine if suspected Thiamine deficiency

Adult Dose

Indications: All Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 25 g Bolus N/A End Dosing

Pediatric Dose

Age: 0 – 28 days old Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 5-10 mL/kg 20 min N/A Seq 2

Age: 29 days old to 8 years old

Route IV/IO Concentration D10 Seq Dose Rate Max Dose Next Dose 1 5 mL/kg Bolus N/A End Dosing

Age: >8 years Route IV/IO Concentration D10

Seq Dose Rate Max Dose Next Dose 1 250 mL Bolus N/A End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class < 1 Minute Dependent on



C



50% Dextrose in Water (D50w) Trade Names



Indications • Adult blood glucose level < 60 mg/dL • Child blood glucose level < 80 mg/dL • Neonate blood glucose level < 40 mg/dL




Precautions • Patients with increasing intracranial pressure as glucose may worsen cerebral edema • Use with 100 mg Thiamine if suspected Thiamine deficiency

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 25 g Bolus N/A End Dosing

Pediatric Dose

Age: 0 – 28 days old Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 5 mL/kg 20 min N/A Seq 2

Dilute 25 g of D50 in 250 mL of NS to make D10.

Age: 29 days old to 8 years old

Route IV/IO Concentration D25 Seq Dose Rate Max Dose Next Dose 1 2 mL/kg Bolus N/A End Dosing

Mix D50 with equal volume of NS to get D25 (i.e. 25 mL D50 [12.5 g] with 25 mL NS to get 12.5 g of D25) Mix resulting volume with equal volume of D5W and administer.

Age: >8 years Route IV/IO Concentration D50

Seq Dose Rate Max Dose Next Dose 1 1 mL/kg Bolus N/A End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class < 1 Minute Dependent on



C


Medication Reference Guide 235 50% Dextrose in Water (D50w)

Drug Details

Action

Dextrose is the principal form of glucose (sugar) used by the body to create energy. Since serious brain injury can occur in prolonged hypoglycemia, the rapid administration of glucose is essential. Dextrose 50% IV is the treatment of choice for hypoglycemic patients with an altered mental status or no gag reflex.

Interactions None in the emergency setting.

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin Warmth/pain/burning at injection site Necrosis, phlebitis, sclerosis, thrombosis at injection site.

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological Wernicke’s encephalopathy or Korsakoff ’s psychosis if patient is thiamine deficient

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other



Dexamethasone (Ozurdex)

Trade Names Dexamethasone



Indications • Reactive Airway Disease for Pedi patient only


• Uncontrolled infections • Known hypersensitivity to medication • Cerebral malaria • Concurrent treatment with live virus vaccines


• Psychoses, infectious diseases, Herpes Simplex, Keratitis

Precautions • May cause: Headache, dizziness, nausea, vomiting, upset stomach

Pediatric Dose Indications: Middle and lower Airway Obstruction

Route: PO / IV

Pediatric Dose

Seq Dose Rate Max Dose Next Dose 1 0.6 mg/kg PO / IV 10 mg End Dosing

Pharmacokinetic Immediate Duration Half-Life Pregnancy Class

1-2 hrs 8 hrs 3.2 hours C


Medication Reference Guide 237 Diltiazem

Diltiazem Trade Names Cardizem

Acquisition Not carried on CHRISTUS EMS units. May be maintained during an inter-facility transfer.


Indications • Supraventricular tachydysrhythmias at rates >150 bpm including:

o Atrial fibrillation o Atrial flutter o PSVT refractory to adenosine


• Known hypersensitivity • Sick sinus syndrome (unless pacemaker is in place and functioning • 2nd/3rd degree AV block • Severe hypotension (Systolic <90 mmHg or Diastolic <60 mmHg) • Wide complex tachycardia (ventricular tachycardia) • Wolf-Parkinson-White syndrome • Tachycardia secondary to physiological compensation (treat the underlying

problem) including: o Heart failure o Hypovolemia o Pain


Precautions

Conduction abnormalities renal or hepatic impairment The elderly Nursing mothers Monitor the blood pressure constantly as Cardizem can cause systemic hypotension. Calcium chloride can be used to prevent the hypotensive effects of calcium channel blockers and in the management of calcium channel blocker overdose. Medication should be kept refrigerated but can be kept at room temperature for one month then discarded.

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 0.25 mg/kg 2 min N/A Seq 2 in 15 minutes if needed

otherwise Seq 3 2 0.35 mg/kg 5 min N/A Seq 3 3 10-15 mg/hr Infusion N/A End Dosing

Infusion mix: 125 mg(25 mL) in 100 mL of NS or D5W to make 1 mg/mL

Pediatric Dose None

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 3 Minutes 1-3 Hours 2 Hours C



Drug Details

Action

It inhibits calcium ion influx through slow channels into cell of myocardial and arterial smooth muscle (both coronary and peripheral blood vessels). As a result, intracellular calcium remains at subthreshold levels insufficient to stimulate cell excitation and contraction. Diltiazem slows SA and AV node conduction (antidysrhythmic effect) without affecting normal arterial action potential or intraventricular conduction. By vasodilation of peripheral arterioles it decreases total peripheral vascular resistance and reduces arterial BP at rest.

Interactions

• Diltiazem should not be used with IV beta blockers because of the increased risk of congestive heart failure, bradycardia, and asystole.

• Diltiazem may increase digoxin or quinidine levels • Cimetidine may increase diltiazem levels, thus increasing its effects. • Diltiazem may increase cyclosporine levels.

Side Effects

Acute Toxicity

Cardiovascular Dysrhythmias, angina, 2nd/3rd degree AV block, bradycardia, CHF, flushing, hypotension, palpitations

Dermatological/Skin Edema, rash

GI/Renal Nausea, vomiting, diarrhea, constipation impaired taste

Metabolic/Endocrine

Muscular/Skeletal Tremors, gait abnormality

Neurological Confusion, syncope

Ocular

Pregnancy/Neonatal

Psychological/Behavioral Nervousness, anorexia

Pulmonary

General/Other Headache, fatigue, dizziness, drowsiness, weight increase


Medication Reference Guide 239 Diphenhydramine

Diphenhydramine Trade Names Benadryl



Indications

• Anaphylaxis, allergic reactions, • Dystonic reactions due to phenothiazine’s, • Irritant cough, • Nausea, vomiting, • Vertigo associated with motion sickness, • Mild cases of Parkinson’s disease, • Drug induces extrapyramidal symptoms.


• Asthma, • COPD, • Glaucoma • Pregnancy • Nursing mothers


Precautions • Hypotension

Adult Dose

Indications: Allergic Reaction Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 25-50 mg 2 min N/A End Dosing

Pediatric Dose

Indications: Allergic Reaction Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1 mg/kg Bolus N/A End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Immediate 4-6 Hours 1-4 Hours B



Drug Details

Action Blocks histamine receptors. Histamine causes bronchoconstrictioon and vasodilation. Blocking the receptors will not reverse these effects, but will prevent further incidence.

Interactions • Additive effects with alcohol and other CNS depressants (hypnotics, sedatives,

tranquilizers, etc). • MAO inhibitors prolong and intensify the anticholinergic (drying) effects of the

drug

Side Effects

Acute Toxicity

Cardiovascular Palpitations, tachycardia

Dermatological/Skin

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological Sedation


Pregnancy/Neonatal


Pulmonary Dries bronchial secretions, wheezing

General/Other Headache, dry mouth


Medication Reference Guide 241 Epinephrine

Epinephrine Trade Names Adrenalin Acquisition This medication is carried on CHRISTUS EMS units.

Scope of Practice (Anaphylaxis)


Scope of Practice (All Other)


Indications • Cardiac Arrest • Allergic Reactions

• Reactive Airway Disease • Vasopressor Support


• None in the setting of Cardiac Arrest • Known hypersensitivity to the

sympathomimetic amines • Hemorrhagic, traumatic, Cardiac

dilatation

• Cerebral arteriosclerosis • Coronary insufficiency • Dysrhythmias • Organic heart or brain disease • During second stage of labor


• Narrow angle glaucoma (Moderate Allergic Reaction/Bronchospasm or Vasopressor if other interventions are available)

• Cardiogenic Shock (unless Bradycardia and refractory to Pacing and Atropine)

Precautions

• Elderly or debilitated patients • Hypertension; • Diabetes mellitus; • Hyperthyroidism; • Parkinson’s disease

• Tuberculosis • Patients with long-standing asthma and

emphysema • Degenerative heart disease • Children less than 6 yr of age • Protect from light

Adult Dose

Indication: Cardiac Arrest Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1 mg (1:10,000) Bolus N/A Repeat Q 3-5 min

Indication: Vasopressor Support or Severe Allergic Reaction Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 2-10 mcg/kg/min Bolus N/A Continuous Infusion

Mix 1 mg (1:10,000) in 250ml of NS. This is 4 mcg/mL

Indication: Moderate Allergic Reaction or Bronchospasm Route: IM

Seq Dose Rate Max Dose Next Dose 1 0.3-0.5 mg

N/A N/A Seq 2 in 10 minutes if needed

2 0.3-0.5 mg Seq 3 in 10 minutes if needed 3 0.3-0.5 mg End Dosing

Indication: Severe Allergic Reaction or Bronchospasm Route: Nebulized



Seq Dose Rate Max Dose Next Dose 1 0.5 mg/kg in 3 mL NS N/A 5 mg End Dosing

1:1,000 concentration

Pediatric Dose

Indication: Cardiac Arrest or Bradycardia with Cardiorespiratory Compromise Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 0.01 mg/kg (1:10,000) Bolus N/A Repeat Q 3-5 min

Indication: Cardiac Arrest or Bradycardia with Cardiorespiratory Compromise Route: ET

Seq Dose Rate Max Dose Next Dose 1 0.1 mg/kg (1:1,000) Bolus N/A Repeat Q 3-5 min

Indication: Moderate Allergic Reaction or Bronchospasm Route: IM

Seq Dose Rate Max Dose Next Dose 1 0.01 mg/kg

N/A 0.3 mg Seq 2 in 10 minutes if needed

2 0.01 mg/kg Seq 3 in 10 minutes if needed 3 0.01 mg/kg End Dosing

1:1,000 concentration Indication: Severe Allergic Reaction or Bronchospasm

Route: Nebulized Seq Dose Rate Max Dose Next Dose 1 0.5 ml/kg in 3 mL NS N/A 5 ml End Dosing

1:1,000 concentration (See Handtevy dosing of Preemie & Newborn)

Indication: Sever Allergic Reaction or Airway Obstruction (This pathway are for patients truly near death)

Route: Infusion (Drip) Seq Dose Rate Max Dose Next Dose 1 0.1- 2 mcg/kg/min n/a 2 mcg/kg/min Continuous Infusion

Take 1 mg of 1:10,000 Epi and mix in 1,000 mL of NS. This gives 1 mcg/mL

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class <2 min (IV/IO/ET) 3-10 min (IM)

5-10 Min (IV/IO/ET) 20-30 Min (IM)

5 Min (IV/IO/ET) C


Medication Reference Guide 243 Epinephrine

Drug Details

Action

It is a naturally occurring catecholamine that has potent alpha and beta adrenergic stimulant properties. It imitates actions of the sympathetic nervous system. Beta 1 effects: strengthen myocardial contraction; increases systolic but may decrease diastolic blood pressure; and increases cardiac rate and cardiac output. Beta 2 effects: dilate bronchiole vasculature smooth muscle resulting in bronchodilation and vasodilation. Alpha effects: constrict bronchial arterioles and inhibit histamine release. Also constrict arterioles but dilates skeletal muscle blood vessels.

Interactions

• Can be deactivated when administered with highly alkaline solutions such as bicarbonate.

• May increase hypotension in circulatory collapse or hypotension caused by phenothiazines.

• It has additive toxicities with other sympathomimetics. • Alpha- and beta adrenergic blocking agents antagonize the effects of

epinephrine.

Side Effects

Acute Toxicity

Cardiovascular Precordial pain, palpitations, hypertension, MI, tachydysrhythmias including ventricular fibrillation

Dermatological/Skin Pallor, sweating, tissue necrosis with repeated injections

GI/Renal Nausea, vomiting

Metabolic/Endocrine


Neurological CVA,

Ocular

Pregnancy/Neonatal

Psychological/Behavioral Nervousness, restlessness, sleeplessness, fear, anxiety

Pulmonary

General/Other Severe headache, weakness, dizziness, syncope



Esmolol Hydrochloride

Trade Names Brevibloc, (Beta blocker)



Indications • Refractory Ventricular Fibrillation after unsuccessful conversion with at least 3 defibrillations and administration of antiarrhythmic


• Known hypersensitivity to the drug • Sever Sinus Bradycardia • Heart Block


• -Beta blockers may cause decreased placenta perfusion, fetal and neonatal bradycardia and hypoglycemia

Precautions • Hypotension • Nausea • Dizziness

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 0.5 mg/kg IVP/IO IVP/IOP N/A One time dose

Pediatric Dose


Seq Dose Rate Max Dose Next Dose 0 0 N/A N/A N/A

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Very Rapid 1-2 Minutes 2-9 Minutes C

Drug Details

Action Esmolol is used to control rapid heartbeats or abnormal heart rhythms by a selective beta 1 blocker with a rapid onset, a very short duration of action, and no significant intrinsic sympathomimetic. Class II antiarrhythmic

Interactions Never piggy back with other drugs or fluids

Side Effects

Acute Toxicity

Cardiovascular Class II antiarrhythmic

Dermatological/Skin None

GI/Renal N/A

Metabolic/Endocrine

Muscular/Skeletal


Medication Reference Guide 245 Famotidine

Famotidine Trade Names Pepcid



Indications • Allergic reactions (Histamine blocking adjunct for Gastrointestinal system) Absolute Contraindications

• Known hypersensitivity to other H2 antagonists


Precautions • Renal impairment

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 20 mg Bolus N/A End Dosing

Pediatric Dose

Age 1-16 years Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 0.25 mg/kg 2 Min N/A End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 60 Minutes 0.5-3.5 Hours B



Drug Details

Action Competitively blocks histamine at H 2 receptors, particularly those in gastric parietal cells, leading to inhibition of gastric acid secretion

Interactions None

Side Effects

Acute Toxicity

Cardiovascular Arrhythmia, AV block, palpitation agranulocytosis (rare)

Dermatological/Skin Orbital or facial edema

GI/Renal Constipation, nausea, vomiting, abdominal discomfort

Metabolic/Endocrine Cholestatic jaundice, liver enzyme abnormalities

Muscular/Skeletal Asthenia, Musculoskeletal pain including muscle cramps

Neurological Grand mal seizures

Ocular Conjunctival injection

Pregnancy/Neonatal

Psychological/Behavioral Psychic disturbance

Pulmonary

General/Other Headache, dizziness

Other Notes This medication is good for 7 days out of the cooler at room temperature. Once it is removed from the cooler, date the medication.


Medication Reference Guide 247 Fentanyl Citrate

Fentanyl Citrate Trade Names Sublimaze



Indications • Moderate to Severe pain • Maintenance Analgesia


• Known hypersensitivity • MAO inhibitors use within 14 days • Myasthenia gravis • Severe hemorrhage • Hypotension Adult SBP <90 Pedi SBP <70 + (2x Age in Yeas)



Precautions

• Head Injuries/Increased Intracranial Pressure • Reduce dose for very young, elderly, and poor risk patients • COPD/Other Respiratory Problems • Liver/Kidney dysfunction • Brady-dysrhythmias • Reverse with Narcan

Adult Dose Age 18-70

Indication: Pain Route: IV/IO

Infusion Mix (Med Control Only): Mix 250 mcg in 250 mL D5W. This is 1 mcg/mL. REFERENCE PAIN MANAGEMENT CPG

Seq Dose Rate Max Dose Next Dose 1 1 mcg/kg Fast Push 100 mcg One time Dose

Seq Dose Rate Max Dose Next Dose 1 1 mcg/kg 1-3 Min 100mcg Seq 2 in 15 Minutes if needed 2 1 mcg/kg 1-3 Min 100mcg End Dosing

Indication: Pre-Intubation Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 3 mcg/kg Bolus N/A One time Dose

REFERENCE RSI CPG

Pediatric Dose Age 8-17 See Adult Dose


Indication: Pain Management Route: IN Fast Push



Pharmacokinetics

Immediate 30-60 Min 6-8 Hours C

Action

It is a potent synthetic narcotic agonist analgesic with pharmacologic actions qualitatively similar to those of morphine and meperidine, but whose action is more prompt and less prolonged. Its principal actions are analgesia and sedation. Drug-induced alterations in respiratory rate and alveolar ventilation may persist beyond the analgesic effect. The emetic effect is less than with either morphine or meperidine.

Interactions • Alcohol and other CNS depressants potentiate its effects • MAO inhibitors may precipitate hypertensive crisis.

Side Effects

Acute Toxicity

Cardiovascular Hypotension, bradycardia, circulatory depression, cardiac arrest


GI/Renal Nausea, vomiting, constipation, ileus, urinary retention

Metabolic/Endocrine

Muscular/Skeletal Muscle rigidity (especially respiratory muscles after rapid IV infusion)

Neurological Sedation, euphoria, delirium, convulsions with high doses

Ocular Miosis, blurred vision

Pregnancy/Neonatal


Pulmonary Laryngospasm, bronchoconstriction, respiratory depression or arrest

General/Other Dizziness, diaphoresis

Other Notes Store at 15-30 oC (59-86 oF) unless otherwise directed. Protect drug from light.


Medication Reference Guide 249 Glucagon

Glucagon Trade Names Glucagen


Scope of Practice (Hypoglycemia)


Scope of Practice (All Other)


Indications • Hypoglycemia without IV access • Beta blocker overdose


• Known hypersensitivity to glucagon or protein compounds.


Precautions • Patients with cardiovascular or renal disease • Only effective if there are glycogen stores in the liver

Adult Dose

Indication: Hypoglycemia Route: IM

Seq Dose Rate Max Dose Next Dose 1 1 mg N/A N/A End Dosing

Indication: Beta Blocker Overdose Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1-5 mg/kg 1 Min N/A Seq 2 in 10 Min if needed 2 1-5 mg/kg 1 Min N/A End Dosing

Pediatric Dose

Indication: Hypoglycemia <10 kg Route: IM/SC/IV/IO

Seq Dose Rate Max Dose Next Dose 1 0.1 mg/kg N/A 1 mg Seq 2 in 20-30 min if needed 2 0.1 mg/kg N/A 1 mg End Dosing

Indication: Hypoglycemia >10 kg Route: IM/SC/IV/IO

Seq Dose Rate Max Dose Next Dose 1 1.0 mg N/A N/A Seq 2 in 20-30 min if needed 2 1.0 mg N/A N/A End Dosing

Indication: Beta Blocker Overdose Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 0.1 mg/kg 1 Min N/A End Dosing



Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 5-20 Minutes 1-1.5 Hours 3-10 Minutes B

Drug Details

Action

Glucagon is a natural polypeptide hormone produced by alpha cells of the Islets of Langerhans in the pancreas. When released it causes a breakdown of stored glycogen to glucose and inhibits the synthesis of glycogen from glucose. Both actions increase the blood levels of glucose. Given via the intramuscular route, it is a useful drug in hypoglycemia when IV access is unsuccessful. Glucagon also increases heart rate and myocardial contractility, and improves AV conduction in a manner similar to that produced by catecholamines. Its actions are independent of beta blockade.

Interactions None in the emergency setting

Side Effects

Acute Toxicity

Cardiovascular Hypotension

Dermatological/Skin


Metabolic/Endocrine Hyperglycemia, hypokalemia

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other Dizziness, headache, hypersensitivity reactions


Medication Reference Guide 251 Ipratropium

Ipratropium Trade Names Atrovent



Indications

• Relieve bronchospasm associated with o Asthma o Chronic bronchitis o Emphysema o Allergic Reactions o Acute onset


• Known hypersensitivity to Ipratropium, atropine or its derivatives • QT prolongation.



Precautions

• Should not be primary treatment for acute bronchospasm requiring rapid intervention • Use with caution in the following settings:

o Elderly o Pregnant/nursing mothers o Cardiovascular disease o Hypertension

Adult Dose

Indications: All Route: Nebulized

Seq Dose Rate Max Dose Next Dose 1 0.5 mg in 2.5 mL NS 5-15 Min N/A End Dosing

Pediatric Dose See Adult Dose

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Varies 4-6 Hours 1.5-2 Hours B



Drug Details

Action

Ipratroprium is an anticholinergic agent, chemically related to atropine. Given in a nebulized form, it acts directly on the smooth muscle of the bronchial tree by inhibiting acetylcholine at receptor sites. By blocking parasympathetic action, it dilates the bronchial smooth muscle and decreases secretions. It also abolishes the vagally mediated reflex bronchospasm caused by inhaled irritants such as smoke, dust, cold air, and by a range of inflammatory mediators (e.g. histamine).

Interactions Few in the prehospital setting.

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin Rash, hives,

GI/Renal Nausea, constipation, urinary retention

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular Blurred vision (especially if sprayed into eye), acute eye pain, worsening of narrow angle glaucoma

Pregnancy/Neonatal


Pulmonary Cough, hoarseness, exacerbation of symptoms, drying of bronchial secretions, mucosal ulcers, nasal dryness

General/Other Bitter taste, dry oropharyngeal membranes, headache


Medication Reference Guide 253 Isopropyl alcohol

Isopropyl alcohol

Trade Names Isopropyl alcohol



Indications • Acute onset of nausea and vomiting before giving Zofran

Absolute Contraindications None

Relative Contraindications • Large amounts inhaled may cause irritation to the mucous membranes

Precautions o Not to come into direct contact of skin. Wave 2-3 cm under nares

Adult Dose

Indications: Nausea / Vomiting Route: Inhaled

Seq Dose Rate Max Dose Next Dose 1 Medicated pad 2-3 minutes N/A End Dosing

Pediatric Dose Not for Pediatric use


10 minutes 4-6 Hours N/A B



Ketamine Trade Names Ketalar



Indications • Induction agent for DSI (Asthmatic, Septic Shock, Hypotensive) any cause • Agitated/Behavioral/Psychotic Patient with Excited Delirium Syndrome • Pain Control


• In patients with significant elevation of blood pressure • Patients with known or suspected elevated intracranial pressure (intracranial mass or

hemorrhage) who have a measured blood pressure in the normal to high range

Relative Contraindication

Precautions • Patients with known or suspected ischemic heart disease who have a measured blood pressure in the normal to high range

Adult Dose Age 18-70

Indications: RSI, Excited Delirium Route: IV/IO (IM for Agitated pathway only)

Seq Dose Rate Max Dose Next Dose 1 10 mg in 50-100

ml NS 2-5 minutes 10 mg In 15 minutes if needed

Seq Dose Rate Max Dose Next Dose 2 10 mg in 50-100

ml NS 2-5 minutes 10 mg End Dosing

Seq Dose Rate Max Dose Next Dose 1 10 mg Fast One time dose

Seq Dose Rate Max Dose Next Dose 1 2 mg/kg (IV/IO) 15-30 sec One time dose Seq Dose Rate Max Dose Next Dose 1 4 mg/kg (IM) 15-30 sec One time dose

Indications: Pain Route: IV/IO infusion

Indications: Pain Route: IN Fast


Medication Reference Guide 255 Ketamine

Pediatric Dose Age 8-17

Indications: RSI, Excited Delirium Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 2 mg/kg (IV/IO) 15-30 sec One time dose

Seq Dose Rate Max Dose

Next Dose

1 0.2 mg/kg in 50-100 ml NS

2-5 minutes 10mg Seq 2 in 15 minutes if needed

2 0.2 mg/kg in 50-100 ml NS

2-5 minutes 10 mg Ending Dose

Seq Dose Rate Max Dose Next Dose 1 0.2 mg/kg (IN) Fast Push 10mg One time dose


30 Seconds 5-10 Min 2-3 hours B

Updated Clinical Practices: Ketamine -Effective 4/01/2020 No longer use Ketamine for pain management

Indication: Pain management Route: IN Fast Push

Indication: Pain management Route: IV/IO



Drug Details

Action NMDA receptor antagonist

Interactions Prolonged recovery time may occur if barbiturates and/or narcotics used concurrently with Ketamine

Side Effects

Acute Toxicity

Cardiovascular Blood pressure and pulse rates are frequently elevated following administration

Dermatological/Skin Injection site rash have been reported

GI/Renal Anorexia, nausea and vomiting have been observed. Treat with Zofran

Metabolic/Endocrine

Muscular/Skeletal

Neurological Muscle tone may be manifested by tonic and clonic movement sometimes resembling seizures

Ocular Diplopia and nystagmus have been noted following Ketamine administration. Slight elevation in intraocular pressure

Pregnancy/Neonatal

Psychological/Behavioral Emergence Reaction: psychomotor agitation occurs during a sub-dissociative state as ketamine is being metabolized by the body. Treat with Midazolam

Pulmonary Apnea may occur following rapid intravenous administration

General/Other Class III controlled substance


Medication Reference Guide 257 Labetalol

Labetalol Trade Names Trandate, Normodyne (Class Beta Blocker)



Indications • Hypertension management during tPA interfacility transport only Absolute Contraindications

• Patients with bronchial asthma, uncontrolled cardiac failure, heart block (greater than first degree), cardiogenic shock, and sever bradycardia


•

Precautions • Patients with non-allergic bronchospastic disease (COPD), well-compensated

patients with history of heart failure; pheochromocytoma; impaired hepatic function, jaundice; diabetes mellitus; peripheral vascular disease

Adult Dose

Indications: Post tPA hypertension Route: IV

Seq Dose Rate Max Dose Next Dose 1 20mg Slow push 300mg Every 10 minutes as needed

Pediatric Dose

Indications: Route:

Seq Dose Rate Max Dose Next Dose 1

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 2-5 minutes 2-4 Hours 3-8 hours C

Action

Labetalol is an adrenergic-receptor blocking agent that combines selective alpha activity and nonselective beta-adrenergic blocking actions. Both activities contribute to reduce blood pressure. Alpha blockade results in vasodilation, decreased peripheral resistance, and orthostatic hypotension and only slightly affects cardiac output and coronary artery blood flow. Beta-blocking effects on sinus node, AV node, and ventricular muscle lead to bradycardia, delay in AV conduction, and depression of cardiac contractility.

Interactions Cimetidine may increase the effects of labetalol; beta agonists antagonize effects of labetalol. Other antihypertensive agents may potentiate the effects of labetalol. Do not use with IV calcium channel blockers.

Side Effects

Acute Toxicity

Cardiovascular Postural hypotension, angina pectoris. Palpitation, Bradycardia, syncope, pedal or peripheral edema, pulmonary edema, CHF

Dermatological/Skin Rashes of various types, increased sweating, pruritus



GI/Renal Nausea, vomiting, dyspepsia, constipation, diarrhea

Metabolic/Endocrine • Metabolized in Liver

Muscular/Skeletal Difficulty speaking, breathing, swallowing, twitching/tremors

Neurological Restlessness, confusion, disorientation, irritability, convulsion (high doses)

Ocular Blurred/double vision, impaired color perception

Pregnancy/Neonatal

Psychological/Behavioral Apprehension, euphoria, wild excitement, psychosis, anorexia, tinnitus, decreased hearing

Pulmonary Respiratory dyspnea, bronchospasm

General/Other

Other Notes


Medication Reference Guide 259 Lidocaine

Lidocaine Trade Names Xylocaine



Indications

• Ventricular tachycardia with and without a pulse • Ventricular fibrillation only when Amiodarone is unavailable • Analgesic for airway procedures • Analgesic for IO insertion • Suspected head injuries (CVAs or Increased ICP) • Rapid Sequence Intubation


• Known hypersensitivity to amide type local anesthetics • Supraventricular dysrhythmias • Stokes-Adams Syndrome • Untreated sinus bradycardia • Severe degrees of SA, AV, and intraventricular heart block


Precautions • Liver/Renal disease • CHF • Myasthenia gravis • Hypovolemia/Shock

• Marked hypoxia or respiratory depression • Debilitated patients/Elderly • Family history of malignant hyperthermia

(fulminate hypermetabolism)

Adult Dose

Indication: Post-IO placement analgesia Route: IO

Seq Dose Rate Max Dose Next Dose 1 20-40 mg Slow Push N/A End Dosing

Indication: Airway analgesia Route: Nebulized

Seq Dose Rate Max Dose Next Dose 1 10-20 mg N/A N/A End Dosing

Indication: Head Injury/CVA/Increased ICP Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1.5 mg/kg 30-60 Sec N/A End Dosing

Indication: V-Fib/Pulseless V-Tach Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1.5 mg/kg Bolus 3 mg/kg

(total combined dose)

Seq 2 in 5-10 min as needed 2 0.5-0.75 mg/kg Bolus Seq 3 in 5-10 min as needed 3 0.5-0.75 mg/kg Bolus Seq 4 in 5-10 Min as needed 4 0.5-0.75 mg/kg Bolus End Dosing



Adult Dose

Indication: V-Fib/Pulseless V-Tach Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1-1.5 mg/kg Bolus N/A Seq 2 if converted 2 1-4 mg/min Infusion N/A Continuous Infusion

Pediatric Dose

Indication: Post-IO Placement Analgesia Route: IO

Seq Dose Rate Max Dose Next Dose 1 0.5 mg/kg Slow Push N/A End Dosing

Indication: Airway Analgesia Route: Nebulized

Seq Dose Rate Max Dose Next Dose 1 10-20 mg N/A N/A End Dosing

Indication: V-Fib/Pulseless V-Tach/V-Tach with Pulse Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1 mg/kg Bolus N/A Seq 2 2 20-50 mcg/kg/min Infusion N/A Continuous Infusion

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 30-45 min Varies 40-55 days B


Medication Reference Guide 261 Lidocaine

Drug Details

Action

It exerts antidysrhythmic action (class Ib) by suppressing automaticity in the His-Purkinje system and by elevating electrical stimulation threshold of ventricle during diastole. It is used to raise the threshold for ventricular dysrhythmias and to lower the threshold for defibrillation and cardioversion. Progressive depression of CNS occurs with increasing blood concentration; produces anticonvulsant, sedative, and analgesic effects.

Interactions

• Barbiturates decrease lidocaine activity. • Cimetidine, beta blockers, and quinidine increase the pharmacologic effects of

lidocaine. • Phenytoin increases its cardiac depressant effects; • Procainamide compounds neurologic and cardiac effects.

Side Effects

Acute Toxicity

Cardiovascular Hypotension, bradycardia, conduction disorders, heart block, cardiovascular collapse, cardiac arrest

Dermatological/Skin Numbness of lips or tongue, paresthesia sensations (heat, cold), excess perspiration, soreness at IM site, local thrombophlebitis (with prolonged IV infusion)


Metabolic/Endocrine

Muscular/Skeletal Difficulty speaking, breathing, swallowing, twitching/tremors

Neurological Restlessness, confusion, disorientation, irritability, convulsion (high doses)

Ocular Blurred/double vision, impaired color perception

Pregnancy/Neonatal

Psychological/Behavioral Apprehension, euphoria, wild excitement, psychosis, anorexia, tinnitus, decreased hearing

Pulmonary Respiratory depression/arrest (high doses)

General/Other Drowsiness, dizziness, light-headedness

Other Notes Infusion mix: 1 g in 250 mL of D5W or NS



Magnesium Sulfate Trade Names



Indications • Torsades de Pointes • Refractory ventricular fibrillation or pulseless ventricular tachycardia • Bronchospasm refractory to Albuterol and Ipratropium Bromide • Eclampsia/Pre-Eclampsia


• Shock • Hypocalcemia • Heart Block


Precautions • Impaired renal function • Digitalized patients • Concomitant use with CNS depressants or neuromuscular blocking agents

Adult Dose

Indication: Torsades de Points/Refractory V-Fib/Refractory Pulseless V-Tach Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 1-2 g Bolus N/A End Dosing

Indication: Pre-Eclampsia/Eclampsia Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 4-6 g 30 Min N/A Seq 2 (if Critical Care) 2 2-4 g/hr Infusion N/A End Dosing

Indication: Respiratory Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 2 g 10 Min N/A End Dosing

Pediatric Dose

Indication: Torsades de Pointes/Refractory V-Fib/Refractory Pulseless V-Tach Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 25-50 mg/kg Bolus 2 g End Dosing

Indication: Respiratory Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 50 mg/kg in 2 mL/kg NS 10 Min 2 g End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Immediate 1 Hour A


Medication Reference Guide 263 Magnesium Sulfate

Action

An essential element in many biochemical processes that occur within the body. It acts as a physiologic calcium channel blocker and blocks neuromuscular transmission. Hypomagnesaemia (decreased magnesium levels) can cause cardiac dysrhythmias, including refractory ventricular fibrillation. It also can result in symptoms of cardiac insufficiency and sudden cardiac death. When given parenterally, it acts as a CNS depressant and also a depressant of smooth, skeletal, and cardiac muscle function. It has anticonvulsant properties thought to be produced by CNS depression, principally by decreasing the amount of acetylcholine liberated from motor nerve terminals, thus producing peripheral neuromuscular blockade.

Interactions • Neuromuscular blocking agents add to respiratory depression and apnea. • If administered in conjunction with digitalis, cardiac conduction abnormalities can

occur.

Side Effects

Acute Toxicity

Cardiovascular Hypotension, depressed cardiac function, complete heart block, circulatory collapse

Dermatological/Skin Flushing, sweating

GI/Renal

Metabolic/Endocrine Hypocalcaemia

Muscular/Skeletal Muscle weakness

Neurological Sedation, confusion, depressed or absent reflexes, flaccid paralysis

Ocular

Pregnancy/Neonatal


Pulmonary Respiratory paralysis

General/Other Extreme thirst, hypothermia



Methylprednisolone Trade Names Solu-Medrol, A-Metharpred



Indications • Severe Anaphylaxis • Asthma/COPD


• None in the anaphylactic setting


Precautions • Limit to a single dose in the prehospital setting

Adult Dose

Indication: Anaphylaxis/Asthma/COPD Route: IV/IO/IM

Seq Dose Rate Max Dose Next Dose 1 125 mg Bolus 125 mg End Dosing

Pediatric Dose

Indication: Anaphylaxis/Asthma/COPD Route: IV/IO/IM

Seq Dose Rate Max Dose Next Dose 1 2 mg/kg Bolus 125 mg End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Varies 1-5 Weeks IM 3.5 Hours C


Medication Reference Guide 265 Methylprednisolone

Drug Details

Action

It is an intermediate-acting synthetic adrenal corticosteroid with similar glucocorticoid activity but considerably fewer sodium and water retention effects than hydrocortisone. Like the other steroids, its pharmacologic actions are vast and complex and, in medicine, have a wide range of uses. Effective as an anti-inflammatory agent, it is used in management of allergic reactions and occasionally as an adjunctive agent in the management of shock.

Interactions • Furosemide and thiazide diuretics may increase potassium loss. • Phenytoin, phenobarbital, isoniazid, and rifampin may decrease the

effectiveness of methylprednisolone and increase the metabolism of steroids.

Side Effects

Acute Toxicity

Cardiovascular CHF, hypertension, leukocytosis

Dermatological/Skin Edema

GI/Renal Nausea, vomiting, peptic ulcer, abdominal distention, fluid retention

Metabolic/Endocrine Carbohydrate intolerance, hyperglycemia, hypokalemia, Cushingoid features

Muscular/Skeletal Muscle weakness, delayed wound healing, muscle wasting, osteoporosis, aseptic necrosis of bone, spontaneous fractures

Neurological Confusion

Ocular Cataracts

Pregnancy/Neonatal

Psychological/Behavioral Euphoria, insomnia, psychosis

Pulmonary

General/Other Headache, vertigo, growth suppression in children, malaise, hiccups



Midazolam Trade Names Versed



Indications • Sedation • Seizures • Facilitation of intubation/mechanical ventilation • Muscle spasms secondary to envenomation


• Intolerance to benzodiazepines • Acute narrow angle glaucoma • Shock • Coma • Acute alcohol intoxication


Precautions • COPD • CHF • Chronic renal failure • Elderly

Adult Dose

Indication: Seizures Route: IV/IO/IN

Seq Dose Rate Max Dose Next Dose 1 2.5 mg Bolus 10 mg Repeat in 5 minutes as needed

Indication: Seizures Route: IM

Seq Dose Rate Max Dose Next Dose 1 5 mg Bolus N/A Seq 2 in 5 minutes if needed 2 5 mg Bolus N/A End Dosing

Indication: Sedation or muscle spasm secondary to envenomation Route: IV/IO/IM/IN

Seq Dose Rate Max Dose Next Dose 1 2.5 mg Bolus N/A Seq 2 in 10 minutes if needed 2 2.5 mg Bolus N/A End Dosing

Pediatric Dose

Indication: Seizures or muscle spasms secondary to envenomation Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 0.1 mg/kg Bolus 2 mg Seq 2 in 5 Minutes as needed 2 0.1 mg/kg Bolus 2 mg End Dosing


Medication Reference Guide 267 Midazolam

Indication: Seizures Route: IM/IN

Seq Dose Rate Max Dose Next Dose 1 0.2 mg/kg Bolus 2 mg Seq 2 in 5 Minutes as needed 2 0.2 mg/kg Bolus 2 mg End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 3-5 Minutes <2 Hours 1-4 Hours D

Drug Details

Action

Midazolam is a short-acting parenteral benzodiazepine with CNS depressant, muscle relaxant, anticonvulsant, and anterograde amnestic effects. Its exact mechanism of action is unclear. Intensifies activity of gamma-aminobenzoic acid (GABA), a major inhibitory neurotransmitter of the brain, by interfering with its reuptake and promoting its accumulation at neuronal synapses. This calms the patient, relaxes skeletal muscles, and in high doses produces sleep. Like the other benzodiazepines, it has no effect on pain.

Interactions

• Alcohol, CNS depressants, and anticonvulsants potentiate CNS depression. • Cimetidine increases midazolam plasma levels, increasing its toxicity. • Midazolam may decrease the antiparkinsonism effects of levodopa. • It also may increase phenytoin levels. • Smoking decreases its sedative and antianxiety effects.

Side Effects

Acute Toxicity

Cardiovascular Hypotension, tachypnea

Dermatological/Skin Hives, swelling, burning, pain at injection site


Metabolic/Endocrine

Muscular/Skeletal Weakness

Neurological Retrograde amnesia, drowsiness, excessive sedation, confusion

Ocular Blurred vision, diplopia, nystagmus, pinpoint pupils

Pregnancy/Neonatal

Psychological/Behavioral Euphoria

Pulmonary Coughing, laryngospasm (rare), respiratory arrest

General/Other Headache, chills, hiccups



Naloxone Trade Names Narcan



Indications

• Respiratory depression secondary to narcotic overdose • Morphine • Heroin • Methadone • Codeine • Paregoric

• Meperidine (Demerol) • Hydromorphone (Dilaudid) • Fentanyl (Sublimaze) • Hydrocodone (Percodan)

• Nalbuphine (Nubain) • Propoxyphene (Darvon) • Pentazocine (Talwin) • Butorphanol (Stadol)


• Known hypersensitivity to the Naloxone.


Precautions • Known or suspected narcotic addicts due to possible abrupt and complete reversal of

narcotic effects resulting in withdrawal. • Newborn infants of mothers with known or suspected narcotic dependence.

Adult Dose

Indication: All Route: IV/IO/IN

Seq Dose Rate Max Dose Next Dose 1 2 mg Slow Push N/A Repeat Q 2-3 Minutes as

needed Seq Dose Rate Max Dose Next Dose Chronic User Note 5

0.2-4mg Titrating Slow Push

N/A Repeat Q 2-3 Minutes as needed

Pediatric Dose

Indication: All Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 0.1 mg/kg Slow Push N/A Repeat Q 2-3 Minutes as needed

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class <2 Minutes 20-120 Minutes 60-90

Minutes C


Medication Reference Guide 269 Naloxone

Drug Details

Action

Naloxone, an analog of oxymorphone, is a pure narcotic antagonist, essentially free of agonistic (morphine-like) properties. Thus it produces no significant analgesia, respiratory depression, psychotomimetic effects, or miosis when administered in the absence of narcotics and possesses more potent narcotic antagonist action. Naloxone competes for and displaces narcotic molecules from opiate receptors in the brain.

Interactions Naloxone may cause withdrawal symptoms in narcotic addicts avoid use if the patient is a known chronic narcotic user

Side Effects

Acute Toxicity

Cardiovascular Increased BP, elevated partial thromboplastin time Excessive Reversal: (tachycardia)

Dermatological/Skin Excessive Reversal: (sweating)

GI/Renal Excessive Reversal: (Nausea, vomiting)

Metabolic/Endocrine


Neurological Slight drowsiness

Ocular

Pregnancy/Neonatal


Pulmonary Hyperventilation

General/Other Reversal of analgesia (from narcotics)



Nicardipine Trade Names Nicardipine (Cardene)

Acquisition This medication is not carried on CHRISTUS EMS units.

Scope of Practice (Flush Fluid) Paramedic

Indications • Hypertension during EMS transport of post “tPA” patients only


• Hypersensitivity to Nicardipine or other calcium-channel blockers • Advanced aortic stenosis


May cause symptomatic hypotension or tachycardia; titrate slowly to avoid systemic hypotension and possible negative inotropic effects with CHF patients

Precautions • Metabolized in liver (first pass)

Adult Dose IV: 5 mg/hr by slow infusion (50 ml/hr) initially; may be increased by 2.5 mg/hr every 15 minutes; not to exceed 15 mg/hr

Pediatric Dose Not approved by FDA; limited data available (0.5-3 mcg/min IV)


10-20 minutes Immediate release 2-4 hr Category C

Action

Calcium-channel blocker (dihydropyridine); inhibits transmembrane influx of extracellular calcium ions across membranes of myocardial cells and vascular smooth muscle cells without changing serum calcium concentrations; this inhibits cardiac and vascular smooth muscle contraction, thereby dilating main coronary and systemic arteries

Interactions • IV Lactated Ringer solution, sodium bicarbonate 5%

Side Effects

Acute Toxicity

Cardiovascular Exacerbation of angina 6%; Syncope 1%

Dermatological/Skin Flushing 10%; Rash 1%

GI/Renal Use with caution in hepatic or renal impairment

Metabolic/Endocrine

Muscular/Skeletal

Neurological Headache (IV; 15%)

Ocular

Pregnancy/Neonatal Unknown whether drug is excreted in breast milk; avoid use


Pulmonary


Medication Reference Guide 271 Nitroglycerin

Nitroglycerin Trade Names Nitrostat, Tridil



Indications • Chest pain associated with angina pectoris • Chest pain associated with acute myocardial infarction • Acute pulmonary edema


• Known hypersensitivity • Hypotensive <100 Systolic • Shock • Idiosyncracy • Intolerance to nitrates • Taking Sildenafil • Severe anemia • Head trauma • Increased ICP • Glaucoma


Precautions

• Patient may develop tolerance • Protect from light; drug rapidly deteriorates after being opened. • Monitor blood pressure/vital signs • Tridil may produce more profound hypotension • Titrate to stable blood pressure. If sudden hypotension occurs, turn off drip and give

fluid bolus and/or Levophed

Adult Dose

Indication: All Route: SL

Seq Dose Rate Max Dose Next Dose 1 0.4 mg N/A N/A Seq 2 2 0.4 mg N/A N/A Seq 3 3 0.4 mg N/A N/A End Dosing

Indication: All Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 10-200 mcg/min Titrate to effect N/A Continuous Infusion

Mix 25 mg in 250 mL of D5W or NS to create 100 mcg/mL

Pediatric Dose N/A

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 1-3 Minutes 20-30 Minutes 1-4 Minutes C



Drug Details

Action

Nitroglycerin is an organic nitrate and potent vasodilator with antianginal, antiischemic, and antihypertensive effects. It relaxes vascular smooth muscle by unknown mechanism, resulting in dose related dilation of both venous and arterial blood vessels. It also promotes peripheral pooling of blood, reduction of peripheral resistance, and decreased venous return to the heart. Both left ventricular preload and afterload are reduced and myocardial oxygen consumption or demand is decreased. Therapeutic doses may reduce systolic, diastolic, and mean BP; heart rate is usually slightly increased.

Interactions • Alcohol and antihypertensive agents may compound the hypotensive effects. • It may cause orthostatic hypotension when used in conjunction with beta

blockers. • Patients taking sildenafil are at risk for severe cardiac event.

Side Effects

Acute Toxicity

Cardiovascular Postural hypotension, palpitations, tachycardia (sometimes with paradoxical bradycardia), increase in angina, circulatory collapse

Dermatological/Skin

Cutaneous vasodilation with flushing, rash, exfoliative dermatitis, contact dermatitis with transdermal patch, topical allergic reactions with ointment. Pruritic eczematous eruptions, anaphylactoid reaction (oral, mucosal, conjunctival edema), pallor, cold sweat, SL local sensation

GI/Renal Nausea, vomiting, incontinence, abdominal pain, dry mouth

Metabolic/Endocrine

Muscular/Skeletal Weakness, muscle twitching

Neurological Syncope


Pregnancy/Neonatal

Psychological/Behavioral Apprehension

Pulmonary

General/Other Headache, vertigo, dizziness, faintness


Medication Reference Guide 273 Norepinephrine

Norepinephrine Trade Names Levarterenol, Levophed, Noradrenaline



Indications • Increase systemic vascular resistance • Increase blood pressure in the setting of distributive shock


• Known hypersensitivity to the drug.


• Do not use a sole therapy in hypovolemic states except as a temporary emergency measure due to constriction of renal and mesenteric blood vessels.

Precautions

• Hypertension • Hyperthyroidism • Severe heart disease • Within 14 days of MAO inhibitor therapy • Tricyclic antidepressant use • Elderly

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 2-30 mcg/min Titrate to BP N/A Continuous Infusion

Seq Dose Rate Max Dose Next Dose 1 0.5-1.0 ml slow N/A Repeat in 2 minutes until >90 SBP

Pediatric Dose


Seq Dose Rate Max Dose Next Dose 1 0.05 - 2 mcg/kg/min N/A N/A Continuous Infusion

Seq Dose Rate Max Dose Next Dose 1 0.25 – 0.5 ml Push N/A Repeat in 2 minutes unit

SBP > (70+ 2x age)

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Very Rapid 1-2 Minutes 3 Minutes C

Indications: DSI Push-Dose IVP

Indications: DSI Push-Dose IVP



Drug Details

Action

It is a direct-acting sympathomimetic amine identical to body catecholamine norepinephrine. It acts directly and predominantly on alpha-adrenergic receptors; little action on beta receptors except in heart (beta1 receptors). Its main therapeutic effects are vasoconstriction and very slight cardiac stimulation. It has powerful vasoconstrictor action on resistance and capacitance blood vessels. Peripheral vasoconstriction and moderate inotropic stimulation of heart result in increased systolic and diastolic blood pressure, myocardial oxygenation, coronary artery blood flow, and work of heart. Cardiac output varies reflexively with systemic BP

Interactions • Alpha and beta blockers antagonize its pressor effects. • Tricyclic antidepressants may potentiate its pressor effects

Side Effects

Acute Toxicity

Cardiovascular Palpitation, hypertension, reflex bradycardia, fata dysrhythmias (large doses), plasma volume depletion, retrosternal, cerebral hemorrhage

Dermatological/Skin Pallor, tissue necrosis at injection site (with extravasation), edema, hemorrhage, diaphoresis, vomiting

GI/Renal Pharyngeal pain

Metabolic/Endocrine Hyperglycemia

Muscular/Skeletal Tremors, weakness

Neurological Convulsions

Ocular Blurred vision, photophobia

Pregnancy/Neonatal


Pulmonary Respiratory difficulty

General/Other Headache, restlessness, dizziness, insomnia, intestinal/hepatic/renal necrosis


Medication Reference Guide 275 Normal Saline (0.9 Percent Sodium Chloride)

Normal Saline (0.9 Percent Sodium Chloride) Trade Names


Scope of Practice (Flush Fluid) Paramedic Intermediate Basic First Responder

Scope of Practice (IV Infusion) Paramedic Intermediate Basic First Responder

Indications • Isotonic IV fluid administration • Flush fluid for contamination of eyes or wounds

Absolute Contraindications • None in the emergency setting


Precautions • Monitor for circulatory overload • Other electrolytes may become depleted when large volumes are administered

Adult Dose Varies

Pediatric Dose Varies


Drug Details

Action Isotonic crystalloid solution IV fluid containing water and electrolytes (sodium and chloride).

Interactions • Few in the emergency setting.

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other Rare in therapeutic dosages



Ondansetron Trade Names Zofran



Indications • Nausea • Prophylactically in spinally immobilized patients


• Known hypersensitivity to the drug or serotonin blockers.


Precautions • Heart Failure • Bradycardia • QT prolongation/Family history of QT

prolongation

• Hepatic disease • Family history of sudden cardiac

death Pregnant/breast feeding patients

• Children <12 years

Adult Dose

Indications: All Route: IV/IO/IM/SL

Seq Dose Rate Max Dose Next Dose 1 4 mg 30 Seconds N/A Seq 2 if needed 2 4 mg 30 Seconds N/A End Dosing

Pediatric Dose

Indications: All Route: IV/IO/IM

Seq Dose Rate Max Dose Next Dose 1 0.1 mg/kg 30 Seconds 4 mg End Dosing

Seq Dose Rate Max Dose Next Dose >6 mo to 7 yrs 2 mg 30 Seconds N/A End Dosing >8 yrs to 17 yrs 4 mg 30 seconds N/A End Dosing

• 2 mg (1/2 of 4 mg tab)

Indications: ALL Route: SL

PEDS: Dosage >6 months to 7 years & PEDS: Dosage >8 years – 17 years

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Rapid (IV/IO/SL) 30 Minutes (IM)

4-8 Hours 3-7 Hours B


Medication Reference Guide 277 Ondansetron

Drug Details

Action • Reduces the activity of the vagus nerve. • This activates the vomiting center in the medulla oblongata and also blocks

serotonin receptors in the chemoreceptor trigger zone. • May cause QT prolongation.

Interactions Can be potentiated by dexamethasone..

Side Effects

Acute Toxicity

Cardiovascular Chest pain, hypotension

Dermatological/Skin Rash, pain at injection site, Anaphylaxis

GI/Renal Constipation, diarrhea, abdominal pain, dry mouth, urinary retention

Metabolic/Endocrine Fever

Muscular/Skeletal Shivering

Neurological

Ocular

Pregnancy/Neonatal

Psychological/Behavioral Dizziness, headache, lightheadedness, malaise, drowsiness, fatigue, weakness

Pulmonary

General/Other



Oral Glucose Trade Names Glutose, Instant glucose



Indications • Hypoglycemia in conscious patient with intact gag reflex Absolute Contraindications

• None in the emergency setting.


Precautions • Altered LOC/verify ability to swallow without compromising airway.

Adult Dose

Indications: All Route: PO

Seq Dose Rate Max Dose Next Dose 1 12.5-25 g N/A N/A Repeat as needed

Pediatric Dose

Indications: All Route: PO

Seq Dose Rate Max Dose Next Dose 1 12.5 g N/A N/A Repeat as needed

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 10 Minutes Varies Varies A


Medication Reference Guide 279 Oral Glucose

Drug Details

Action After absorption from GI tract, glucose is distributed in the tissues and provides a prompt increase in circulating blood sugar.

Interactions None

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin

GI/Renal Nausea, Vomiting

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other



Oxygen Trade Names



Indications

• Suspected or possible hypoxia in any patient • Chest pain possibly due to cardiac ischemia • Respiratory difficulty • During labor and delivery • Any critical patient

Absolute Contraindications • None in the pre-hospital setting.


Precautions • COPD patients are regulated by blood oxygen levels (hypoxic drive) instead of

carbon dioxide. High oxygen concentrations may result in respiratory depression. • Prolonged neonatal administration can cause eye damage. • Humidify prolonged administration to prevent drying of mucosa.

Adult Dose Titrate to pulse oximetry, patient condition and underlying problem

Pediatric Dose Titrate to pulse oximetry, patient condition and underlying problem


Immediate A


Medication Reference Guide 281 Oxygen

Drug Details

Action

Enters body through the respiratory system and transported to cells by hemoglobin in red blood cells. It is required for the efficient breakdown of glucose into usable energy. Its administration increases oxygen concentration in the alveoli, which increases the oxygen saturation of available hemoglobin. It is an odorless, tasteless, colorless gas necessary for life.

Interactions May increase the toxicity of certain herbicides (i.e. paraquat and diaquat)..

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary Drying of mucous membranes/irritation/nosebleeds if nonhumidified for prolonged periods.

General/Other



Oxytocin Trade Names Pitocin, Syntocinon



Indications • Postpartum hemorrhage after placenta delivery Absolute Contraindications

• Known hypersensitivity to Oxytocin. • Prehospital prior to delivery of baby


Precautions • Rule out multiple fetuses prior to administration

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 125 mL/hr N/A N/A Seq 2 if significant bleeding 2 250 mL/hr N/A N/A End Dosing

Mix 10 U in 1L of NS

Pediatric Dose N/A

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Immediate 1 Hour 2-5 Minutes C


Medication Reference Guide 283 Oxytocin

Drug Details

Action

It is a synthetic, water-soluble polypeptide identical pharmacologically to the oxytocin secreted by the posterior pituitary. By direct action on myofibrils, it produces phasic contractions characteristic of normal delivery. Oxytocin also promotes milk ejection (letdown) reflex in nursing mother, thereby increasing flow (not volume) of milk, and facilitates flow of milk during period of breast engorgement. Uterine sensitivity to oxytocin increases during gestation period and peaks sharply before parturition. It is used to induce labor in selected cases

Interactions Vasoconstrictors can cause severe hypertension

Side Effects

Acute Toxicity

Cardiovascular Severe hypertension

Dermatological/Skin

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other



Propofol Trade Names Diprivan

Acquisition Not carried on CHRISTUS EMS units. May be maintained during an inter-facility transfer.


Indications • Maintain sedation for interfacility transfers. Absolute Contraindications

• Known hypersensitivity to the drug, eggs, or soy products.


Precautions

• Have resuscitation equipment available due to risk of apnea, hypoventilation, and hypotension

• If patient becomes agitated, increase dose by 10 mcg/kg/min. Monitor closely for hypotension.

• If increasing the dose does not achieve sedation, contact Medical Control • If patient become hypotensive, reduce dose by 10 mcg/kg/min and contact Medical

Control

Adult Dose

Indication: Sedation for Ventilation Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 5-50 mcg/kg/min N/A N/A Seq 2 in 10 Minutes if needed

otherwise continuous infusion 2 Increase by 10

mcg/kg/min N/A 100

mcg/kg/min Repeat seq 2 as needed Q 10 minutes until max infusion rate

Pediatric Dose

Indication: Sedation for Ventilation Route: IV/IO

Seq Dose Rate Max Dose Next Dose 1 50 mcg/kg/min N/A N/A Seq 2 in 10 minutes as needed

otherwise continuous infusion 2 Increase by 10

mcg/kg/min N/A 200

mcg/kg/min Repeat Seq 2 as needed Q 10 minutes until max infusion rate

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 30 Seconds 3-10 Minutes 40 Minutes B


Medication Reference Guide 285 Propofol

Drug Details

Action General Anesthetic


Side Effects

Acute Toxicity

Cardiovascular Hypotension

Dermatological/Skin Burning at injection site

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary Hypoventilation

General/Other

Other Notes Supplied in 10 mg/mL in 20, 50, and 100 mL containers.



Rocuronium Bromide Trade Names Zemuron



Indications • DSI • Skeletal muscle relaxation during mechanical ventilation


• Known hypersensitivity to the drug.


Precautions • Have resuscitation equipment ready. This drug will cause apnea

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 1 mg/kg Bolus N/A Repeat as needed

Pediatric Dose Same as adult dose

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 30-60 Seconds 30-60 Minutes 14-18 Minutes C

Updated Clinical Practices: Rocuronium

-Effective 4/01/2020 save leftover Rocuronium if accessed by clean needle Procedure Write date of first administration on medication label (Use opened vials of Rocuronium within 30 days)


Medication Reference Guide 287 Rocuronium Bromide

Drug Details

Action Acts by binding competitively to cholinergic receptors at the motor end plate to antagonize the action of acetylcholine, an effect that is reversible in the presence of acetylcholinesterase inhibitors, such as neostigmine and edrophonium.

Interactions

• Intensity and duration of paralysis may be prolonged by: o Lidocaine o Quinidine o Procainamide o Beta-adrenergic blocking agents o Potassium-losing diuretics o Magnesium

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin

GI/Renal

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other

Other Notes Medication is good for 60 days out of the cooler at room temperature. Date the vial upon removal from cooler.



Sodium Bicarbonate Trade Names



Indications

• Metabolic acidosis secondary to bicarbonate deficiency or increased exogenous acids

• Known or suspected hyperkalemia • Severe acidosis refractory to hyperventilation • Tricyclic antidepressant overdose


• Lactic acidosis


Precautions • May cause metabolic alkalosis in large quantities. • Always calculate dose based on weight

Adult Dose


Seq Dose Rate Max Dose Next Dose 1 1 mEq/kg Bolus N/A Seq 2 in 10 minutes if needed 2 0.5 mEq/kg Bolus N/A Repeat Q 10 minutes if needed

Pediatric Dose


Seq Dose Rate Max Dose Next Dose 1 1 mEq/kg Bolus N/A Seq 2 in 10 minutes if needed 2 0.5 mEq/kg Bolus N/A Repeat Q 10 minutes if needed

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class <15 Min 1-2 Hours C


Medication Reference Guide 289 Sodium Bicarbonate

Drug Details

Action

It is a short-acting, potent buffer. Given IV, it immediately raises the pH of blood plasma by buffering excess hydrogen ions (acidosis). In a short time, the plasma alkali reserve is increased and excess sodium and bicarbonate ions are excreted in urine, thus rendering the urine less acidic. This effect plays an important role in treating certain drug overdoses, particularly tricyclic antidepressants and barbiturates, by speeding excretion of the drug from the body. The role of sodium bicarbonate is limited in cardiac arrest. Because ventilation is an effective tool in managing respiratory acidosis, sodium bicarbonate should only be considered in a prolonged cardiac arrest after adequate airway and ventilation have been accomplished. It is considered acceptable if the arrested patient has a pre-existing hyperkalemia, a pre-existing bicarbonate-responsive acidosis, or a tricyclic antidepressant overdose.

Interactions • Deactivates most catecholamines and vasopressors (dopamine, epinephrine). • May form a precipitate with calcium chloride that will clog the IV line.

Side Effects

Acute Toxicity

Cardiovascular Inhibit oxygen release secondary to a left shift in the oxyhemoglobin dissociation curve, malignant arrhythmias

Dermatological/Skin Sever tissue damage if extravagated

GI/Renal

Metabolic/Endocrine

Paradoxical acidosis that can depress cerebral and cardiac function. Extracellular alkalosis. Reduced concentration of ionized calcium, decreased plasma potassium

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other



Tetracaine Trade Names Altacaine, Opticaine, Amethocaine



Indications • Anesthetic for pain during eye procedures Absolute Contraindications

• Known hypersensitivity to the drug. • Do not use if cloudy, discolored, or contains particles.


Precautions • Allergies (especially drug allergies) • Heart disease • Liver Disease • Hyperthyroid problems

Adult Dose

Indications: All Route: Eye Drops

Seq Dose Rate Max Dose Next Dose 1 1-2 drops/eye N/A N/A End Dosing

Pediatric Dose Same as adult dose

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class 25-30seconds >15 minutes C


Medication Reference Guide 291 Tetracaine

Drug Details

Action Anesthetic that works by blocking nerve impulses, which results in loss of feeling.

Interactions None

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin Itching

GI/Renal

Metabolic/Endocrine


Neurological

Ocular Stinging, tearing, swelling, sensitivity to light, blurred vision, pupil dilation. Cornea erosion (prolonged use)

Pregnancy/Neonatal

Psychological/Behavioral Anxiety, confusion

Pulmonary Dyspnea

General/Other Dizziness, drowsiness



Thiamine Trade Names Betamin, Biamine



Indications

• Administer with D50 if the following are suspected: o Alcoholism o Malnutrition o Chemotherapy o Delirium Tremens


None in the emergency setting


Precautions None in the emergency setting

Adult Dose

Indication: All Route: IV/IO/IM

Seq Dose Rate Max Dose Next Dose 1 100 mg Slow Push N/A End Dosing

Pediatric Dose N/A

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Rapid Varies N/A A


Medication Reference Guide 293 Thiamine

Drug Details

Action

Thiamine is a water-soluble vitamin and member of the B-complex group. It functions as an essential coenzyme in carbohydrate metabolism. Thiamine is not produced by the body but must be obtained through the diet. It is required for the conversion of pyruvic acid to acetyl-coenzyme-A. Without thiamine, a significant amount of the energy available in glucose cannot be obtained. The brain, particularly, is extremely sensitive to thiamine deficiency. Chronic alcoholic intake interferes with the absorption, intake, and use of thiamine, thus a significant number of alcoholics have thiamine deficiency. Two serious neurologic conditions, Wernicke’s syndrome and Korsakoff ’s psychosis, can result from thiamine deficiency.


Side Effects

Acute Toxicity

Cardiovascular Cardiovascular collapse, slight decrease in BP if given rapidly

Dermatological/Skin Urticaria, diaphoresis, anaphylaxis

GI/Renal Nausea, tightness of throat cyanosis, GI hemorrhage

Metabolic/Endocrine

Muscular/Skeletal Weakness

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary Pulmonary edema

General/Other Restlessness, feeling of warmth



Tranexamic acid (TXA)

Trade Names Tranexamic acid (TXA) Adult only


Scope of Practice Paramedic Basic First Responder

Indications • Hemorrhagic shock, systolic <90 mmHg, with traumatic mechanism • Uncontrolled Epistaxis


• Pediatrics • Injury >3 hours prior • Isolated head injury • Use with caution in patients with hx of thrombotic events or potentially embolism


Precautions To avoid hypotension administer at a rate not to exceed 100 mg per minute (1gm over 10 minutes)

Adult Dose

Indication: Hemorrhagic Shock Route: IVP

Seq Dose Rate Max Dose Next Dose 1 1ml (100mg)

each nostril Fast 200 mg

total dose End Dosing

Seq Dose Rate Max Dose Next Dose 1 1gm Slow Push

over 10 minutes

End Dosing

Indication: Epistaxis Uncontrolled

Route: IN

Pediatric Dose N/A

Pharmacokinetics Onset Duration Half-Life Pregnancy Class Rapid Varies N/A A


Medication Reference Guide 295 Tranexamic acid (TXA)

Drug Details

Action

Tranexamic acid is a synthetic derivative of the amino acid lysine and binds the 5 lysine binding sites on plasminogen. This inhibits plasmin formation and displaces plasminogen from the fibrin surface. It may also directly inhibit plasmin and partially inhibit fibrinogenolysis at higher concentrations. This medication serves as an antifibrinolytic agent used to prevent, stop or reduce unwanted bleeding.

Interactions

Some medications may interact with this drug include: “blood thinners” (anticoagulants such as warfarin, heparin), drugs that prevent bleeding (include factor IX complex, anti-inhibitor coagulant concentrates), tretinon, estrogens, hormonal birth control (such as pills, patch, ring).

Side Effects

Acute Toxicity

Cardiovascular May cause serious blood clot problems

Dermatological/Skin

GI/Renal Nausea, vomiting, diarrhea

Metabolic/Endocrine

Muscular/Skeletal Muscle pain may occur

Neurological

Ocular

Pregnancy/Neonatal This drug passes into breast milk


Pulmonary Trouble breathing with overdose

General/Other Allergic reaction to this drug is rare



Toradol Trade Names Ketorolac



Indications • Acute Pain


• Allergies to aspirin or other NSAIDs • Renal insufficiency • Pregnancy • Acute Coronary Syndrome • Any Trauma • Head Injury


Precautions • Asthma • Anemia

Adult Dose

Indications: All Route: IV/IM

Seq Dose Rate Max Dose Next Dose 1 30 mg Bolus N/A End Dosing

Pediatric Dose

Indications: All Route: IV/IO/IM

Seq Dose Rate Max Dose Next Dose 1 0.5 mg/kg Bolus 30 mg End Dosing

Pharmacokinetics

Onset Duration Half-Life Pregnancy Class Rapid Varies N/A C


Medication Reference Guide 297 Toradol

Drug Details

Action Toradol is a NSAID medication, used for the short-term relief of mild to moderately severe pain that is acute.

Interactions • None in the emergency setting

Side Effects

Acute Toxicity

Cardiovascular

Dermatological/Skin Sweating

GI/Renal Nausea, vomiting, diarrhea, constipation, gas

Metabolic/Endocrine

Muscular/Skeletal

Neurological

Ocular

Pregnancy/Neonatal


Pulmonary

General/Other Headache, dizziness, drowsiness


Miscellaneous Reference Lists 298

Miscellaneous Reference Lists


Miscellaneous Reference Lists 299 Important Lab Values

Important Lab Values

Normal Adult Electrolyte Parameters Sodium (Na+) 135-145 mEq/L Blood Urea

Nitrogen BUN 6-23 mg/dL

Potassium (K+) 3.5-5.5 mEq/L Creatinine 0.6-1.4 mg/dL Calcium (Ca++) 8.8-10.4 mg/dL Glucose 70-110 mg/dL Magnesium (Mg+) 1.5-2.5 mEq/L Serum Osmolality 285-295 mOsm/kg

water Chloride (CL-) 95-105 mEq/L Carbon Dioxide

(CO2) 24-30 mEq/L

Phosphorus 3.0-4.5 mg/dL Anion Gap 12 +/- 4 Bicarbonate (HCO3) 21-28 mEq/L

Normal CBC Lab Values

Hemoglobin 12-18 g/dL Hematocrit 36-52% Platelets 140-400 x 109/L WBCs 4,500-10,500 cells/mm3 Bands 0-3%

Normal Coagulation Lab Values

PT 11-13 Seconds INR 1 APTT 21-35 Seconds Fibrinogen 200-400mg/dL Fibrin Split Products

< 10mg/L

D-Dimer <250mcg/L

Normal Cardiac Labs BNP <100pg/mL Troponin I <0.5 ng/mL CK Total 0-120 ng/mL CK MB 0-3 ng/mL Lactate <2.0mEq/L

Calculations

Anion Gap = Na – CL – HCO3 Osmolar Gap = (2 x Na) + (BUN/2.8) + (Glucose/18) Delta Gap = Na – CL – 39



IV Infusion Cards

TRIDIL DRIP

10-200mcg/min infusion To Give: Rate:

(Titrate to blood pressure 10mcg/min 6ml/hr and pain control) 15mcg/min 9ml/hr 100mcg/ml concentration. For every 5mcg/min increase, add 3ml/hr to rate.

LEVOPHED

Dose is 2-30mcg/min

To Give: Rate:

Mix 4mg into 250ml of 2mcg/min 7.5ml/hr

D5W. This is a 16mcg/ml 4mcg/min 15ml/hr concentration. 8mcg/min 30ml/hr 10mcg/min 37.5ml/hr

EPINEPHRINE DRIP

Adult: 2-10mcg/min

To Give: Rate: Pedi: 0mg-2mcg/kg/min

1mcg/min 15 ml/hr Mix 1mg of 1:10,000 epi 2mcg/min 30 ml/hr into 250ml on NS. 3mcg/min 45 ml/hr

DOPAMINE DRIP

2-20mcg/kg/min 5mcg/kg/min: Fast rate,

1600mcg/ml weight in lbs, drop the Concentration either last #. Subtract 2 from 400mcg in 250ml or the remaining. This is the 800mg in 500ml. ml/hr. Double for 10mcg.

MAG SULFATE

Respiratory Emergencies

Adult: 2 grams over 10 minutes

Pedi: 50mg/kg in 2ml/kg of D5W. Rate=600ml/hr

VTBI=100ml Mix 5 grams in 250ml of D5W. Rate=ml x 6 Mix 50mg/kg (max 2g) in 2ml/kg of D5W. VTBI= Total of ml


Miscellaneous Reference Lists 301 Approved Abbreviations

Approved Abbreviations A&O x4 Person, place, time ,event ABC’s Airway, breathing, circulation Abd Abdomen AC Antecubital AKA Above knee amputation ALOC Altered level of consciousness ALS Advanced life support AMA Against medical advice AOS Arrived on scene ASA Aspirin ASAP As soon as possible BBB Bundle branch block Bid Twice a day Bilat Bilateral BKA Below knee amputation BLS Basic life support BM Bowel movement B/P Blood pressure Bpm Beats per minute BS Breath Sounds BSA Body surface area/burn surface area BVM Bag valve mask C/C Chief complaint CA Cancer CAD Coronary Artery Disease CCU Cardiac Care Unit CHF Congestive Heart Failure Cm Centimeter CNS Central nervous system c/o Complains of COPD Chronic obstructive pulmonary disease CP Chest pain CPR Cardiopulmonary resuscitation CSF Cerebrospinal fluid C-Spine Cervical Spine CVA Cerebrovascular accident D/C Discontinue D-Fib Defibrillation DNR Do not resuscitate DOS Dead on scene DTR Deep tendon reflexes DX Diagnosis ECG Electrocardiogram ED Emergency Department ENT Ear nose throat Epi Epinephrine EST Estimated ETT Endotracheal tube ETA Estimated time of arrival ETOH Ethyl alcohol F/B Foreign body

F/R Fire rescue or first responder FX Fracture f/u Follow up GCS Glasgow Coma Score Gm Gram GYN Gynecological GSW Gunshot wound Gtts Drops = micro drops HA Headache HazMat Hazardous Materials HEENT Head eyes ears nose throat HX History IC Incident command ICU Intensive Care Unit IM Intramuscular IO Intraossous cannulation IVP Intravenous push J Joules JVD Jugular vein distention K+ Potassium Kg Kilogram KVO Keep vein open L Left or liter Lac Laceration Lido Lidocaine LLQ Left lower quadrant LMP Last menstrual period LOC Level of consciousness +LOC Positive loss of consciousness -LOC Negative loss of consciousness LSB Long spine board LUQ Left upper quadrant Mcg Microgram mEq Milliequivalent Mg Milligram MI Myocardial infarction Min Minute MS Morphine sulfate MVC Motor vehicle crash N/C Nasal cannula N/G Nasogastric NKDA No known drug allergies NPA Nasopharyngeal airway NPO Nothing by mouth NRB Non-rebreather mask NS Normal saline NSTEMI Non-ST elevated myocardial infarction NTG Nitroglycerin N/V Nausea vomiting O2 Oxygen OB Obstetrics



OD Overdose O/G Orogastic Palp Palpation Per Through by way of PCN Penicillin ePCR Electronic patient care record PEA Pulseless electrical activity PERRL Pupils equal round and reactive to light PMD Private medical doctor PMHX Past medical history PMS Pulse motor and sensation PO By mouth POC Position of comfort POV Privately owned vehicle PR Per rectum Prn As needed PSVT Paroxysmal supraventricular

tachycardia Pt Patient PT Prothrombin time PTT Partial thromboplastin time Pta Prior to arrival PVC Premature ventricular contraction Q Each every Qh Every hour q.i.d. Four times a day q.o.d. Every other day R Right RLQ Right lower quadrant R/O Rule out ROM Range of motion ROSC Return of spontaneous circulation RUQ Right upper quadrant RX Prescription

s/s Signs and symptoms SaO2 Oxygen saturation SBP Systolic blood pressure SL Sublingual s/o Sudden onset SO Sheriff’s officer SOB Shortness of breath SOP Standard operating procedures SQ Subcutaneous SR Sinus rhythm ST Sinus tachycardia START Simple triage and rapid treatment STEMI ST elevation myocardial infarction SVT Supraventricular tachycardia T Temperature TIA Transient ischemic attack Tid Three times a day TKO To keep open TxF Transfer T-Spine Thoracic spine TX Treatment Uncon Unconscious UTI Urinary tract infection VF Ventricular fibrillation VS Vital signs VTach Ventricular tachycardia WMD Weapons of mass destruction WNL Within normal limits W/O Wide open Y/O Year old


Miscellaneous Reference Lists 303 Activase Transport Protocol

Activase Transport Protocol MANAGEMENT OF BLOOD PRESSURE: 1. Monitor BP:

Every 15 minutes for 2 hours from the start of tPA therapy Then every 30 minutes for 6 hours; and Then every hour for 16 hours

2. If SBP is >180 mm HG or DBP is 105 mm HG during tPA administration - FOLLOW THE ALGORITHM BELOW: TREATMENT OF ANGIOEDEMA FROM tPA INFUSION STEP 1: ASSESS SYMPTOMS: May include - Swelling of the mouth, tongue or lips Difficulty breathing that can progress rapidly STEP 2: STOP tPA INFUSION STEP 3: ADMINISTER: BENADRYL 50MG IV X 1 DOSE _________Time/Initials__________ FAMOTIDINE 20MG IV X 1 DOSE _________Time/Initials__________ SOLUMEDROL 125MG IV X 1 DOSE _________Time/Initials__________ ALBUTEROL NEB UNIT DOSE X 3 _________Time/Initials__________ _________Time/Initials__________ _________Time/Initials__________ STEP 4: IF THERE IS FURTHER INCREASE IN ANGIOEDEMA ADMINISTER: 0.1% EPINEPHRINE 0.3 MG (O.3ML) IM X 1 DOSE ________Time/Initials__________ __________________________________________________ ____________________________ Physician Signature Date / Time __________________________________________________ ___________________________ RN Signature / Paramedic Date / Time

*Keep SBP between 165 – 180mmHG *Keep DBP between 90 – 105mmHG

**Keep patient lying flat as much as possible

VITAL SIGN DOCUMENTATION BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______ BP:_______ HR:________RR:______TIME:______

• IF HR > 60 AND BP > 180/105 FOLLOW ALGORITHM •

STEP 1: IF HR is >60 bpm and BP is >180/105, administer Labetalol 10mg IV over 1 -2 minutes RECHECK BLOOD PRESSURE IN 10 MINUTES – THEN STEP 2: IF HR >60 AND BP REMAINS >180/105, administer Labetalol 20mg IV over 1- 2 minutes RECHECK BLOOD PRESSURE IN 10 MINUTES – THEN

• STEP 3: IF HR >60 AND BP REMAINS >180/105, administer Labetalol 20mg IV over 1- 2 minutes RECHECK BLOOD PRESSURE IN 10 MINUTES



Medication Inventory CHRISTUS EMS

Par Item 650 mg Acetaminophen elixir 1 gram Acetaminophen tablet 28 mg Adenosine 7.5 mg Albuterol 450 mg Amiodarone 324 mg Aspirin

1 mg Atropine Sulfate 20 mg Atropine Sulfate MDV

500 mcg Biorphen (phenylephrine) 1 gram Calcium Gluconate or Calcium Chloride 250 ml D5W Add Bag

25 grams D50 or D10 in 250 ml 10 mg Dexamethasone 50 mg Diphenhydramine 5 mg Epinephrine 1:1,000 6 mg Epinephrine 1:10,000

100 mg Esmolol Hydrochloride 20 mg Famotidine

300 mcg Fentanyl 1 mg Glucagon 1 pad Isopropyl Alcohol 1.5 mg Ipratropium 500 mg Ketamine 100mg Labetalol 300 mg Lidocaine 5 grams Magnesium Sulfate 125 mg Methylprednisolone 10 mg Midazolam 2 mg Naloxone

1.2 mg Nitroglycerin 4 mg Norepinephrine

2000 ml Normal Saline 8 mg Ondansetron

15 gram Oral Glucose 10 units Oxytocin 100 mg

Rocuronium (due to nationwide shortage if

needed replace with) 200 mg’s Succinylcholine

100 mEq Sodium Bicarbonate 1 gm Tranexamic Acid 1 bttl Tetracaine

100 mg Thiamine 30 mg Toradol 25 mg Tridil

Concentrations may vary per pharmacy availability.


Miscellaneous Reference Lists 305 Medication Inventory CHRISTUS EMS

Approved by CHRISTUS EMS Chief Medical Officer January 01, 2020

Christopher L. Dunnahoo, MD, MS, FAEMS



Minimum Supply List CHRISTUS EMS

Par Item 3 Reflective vests

1ea Mobile UHF & VHF radio 1 Liability insurance card 1 Valid inspection sticker

1ea No smoking sign Front / Back 1 Portable radios 1 Flashlight 1 DOT HAZ MAT Response guide 1 Flexall Splint 1 Traction splint for Adult and Pedi 1 KED

1ea Stair chair and Stretcher 1 Fire extinguisher 1 Trauma bag 1 Backboards w/ straps 1 Adult c-collars & immobilizer blocks 1 Pedi c-collars & immobilizer blocks 1 Main oxygen tank 1 Oxygen wrench 1 Set of 3 roadway reflectors 1 Laptop computer 1 Cardiac monitor / defibrillator 1 Airway / drug bag 1 Container of Sani-wipes

1ea Oxygen flow meters w/trees / 1 w/25 psi

1 Unit suction 1 Current Champion CPGs 1 Trash can 1 Mounted sharps container

1ea Gloves sm, med, lg, XL 1 Glucometer 1 Pen light 1 DSHS license 1 Med cooler 1 Portable suction 2 Bio hazard bags 1 Dial-a-flow 3 N 95 masks 3 Surgical mask w/ splash guard 20 4x4 2 Kerlix rolls 2 Cravats 2 ABD pads

1ea B/P cuff, Lg Adult, Adult, Child, Infant 1 MCI bag 1 Pillow and pillow case 1 Blanket 2 Sheets 2 Towels

Par Item 1 Adult BVM 1 Child BVM with Infant mask 1 CPAP system 1 Suction canister w/ lid 1 Urinal 1 Bed pan 1 Silver swaddler 1 OB kit 2 Burn sheets 1 Nose Clamp 1 Scissors 2 Arm boards 6” 1 Roll ECG paper 1 Thermometer

2ea AA & C-cell batteries 1 Spare monitor battery 1 Adult NRB 1 Pedi NRB 1 Adult cannula 1 Pedi cannula

1ea Adult & Pedi stylet 1ea ET tube 2.5 – 5.0, 6,7,8,9 1 Meconium aspirator 1 14 ga 3” Cath

1ea IO drill w/ 1ea= 45mm 15ga needle 1ea= 25mm 15ga needle

1ea IV cath 14, 16, 18, 20, 22, 24 2ea DuCanto Catheter and suction tubing’s 1ea Adult / Pedi tube tamers 1ea NPA 26, 28, 30, 32 1 Spare O2 with regulator 1 PEEP Valve 2 10 drop IV tubing 2 60 drop IV tubing 2 IV start kits

1set OPA’s 1 Humidified oxygen kit 1 Nebulizer

1ea i-gel tubes 1, 1.5, 2.0, 2.5, 3, 4, 5 1ea Mac laryngoscope blades 1-4 1ea Miller laryngoscope blades 0-4 1 Laryngoscope handle

1ea Large & small McGill Forceps 1 Stethoscope

1ea Rolls tape 1”, 2” 2 Occlusive dressings 2 Multi trauma dressing

2ea 1cc, 3cc, 10cc, 60cc luer-lock syringes 2 Lancets


Miscellaneous Reference Lists 307 Minimum Supply List CHRISTUS EMS

Par Item 2 21 gauge needle 10 Isopropyl Alcohol prep pads 1 Portable ventilator 1 60cc syringe catheter Tip

1ea Nasogastric tube 10 FR,18 FR 1 Handtevy Length-Based Tape 1 CAT Tourniquet 1 Adult and Pedi Bougie 1 MAD device 2 Large Paper Bags 2 Large Zip lock bags

Par Item 1set Rainbow blood tubes

1 Cric Kit 1 Pulse Oximeter Cable

1ea Adult and Pedi multi-function pads 1ea 4 and 12 lead cables 1 Inline EtCO2 detector 1 EtCO2 Cannula

1ea BP cuff, large adult, adult, child, infant 1ea IV pump and tubing 1 Dial-a-flow

Approved by CHRISTUS EMS Chief Medical Officer January 01, 2020

Christopher L. Dunnahoo, MD, MS, FAEMS

CHRISTUS EMS CLINICAL PRACTICE GUIDELINES

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