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Saskatchewan Air Ambulance – CLINICAL PROTOCOLS

INDEX April 2019

CLINICAL PROTOCOL INDEX

Cardiovascular x Acute Coronary Syndrome C1 x Cardiogenic Shock C2 x Temporary Tranvenous Pacing C3

Gastrointestinal x Gastrointestinal Bleed GI1

General x Cabin Altitude Restrictions G1 x Combative Patient G2 x Intra-aortic Balloon Pump Counterpulsation G3 x Oxygen Endurance Chart G4 x Sepsis / Severe Sepsis / Septic Shock G5 x Intra-Osseous Needle Insertion G6

Medications

x Anti-emetics M1 x Pain Management M2 x Sedation Management M3

Metabolic

x Diabetic Emergencies – Hyperglycemia MET1 x Diabetic Emergencies – Hypoglycemia MET2

Neurological x Seizures N1 x Hemorrhagic Stroke N2 x Ischemic Stroke N3

CLINICAL PROTOCOL INDEX

INDEX April 2019

Obstetrical

x Breech Presentation Delivery OB1 x Cord Prolapse OB2 x Emergency Childbirth OB3 x Hypertension in Pregnancy OB4 x Obstetrical Hemorrhage – Post-Partum Hemorrhage OB5 x Obstetrical Hemorrhage - Third Trimester OB6 x Shoulder Dystocia OB7 x Women in Labor OB8

Poisoning – Toxicities x Beta Blocker Toxicity P1 x Calcium Channel Blocker Toxicity P2 x Cholinesterase Toxicity P3 x Cocaine Toxicity P4 x Acute Digoxin Toxicity P5 x Hyperkalemia P6 x Opioid Toxicity P7 x Toxic Alcohol Poisoning P8 x Tricyclic Antidepressant Overdose P9

Respiratory x Airway Management R1 x Anaphylactic Shock R2 x Drug Assisted Intubation R3 x Mechanical Ventilation R4 x Non-Invasive Positive Pressure Ventilation R5 x Respiratory Emergencies - Asthma R6

Trauma x Burns T1 x Cardiac Tamponade – Emergency Pericardiocentesis T2 x Decompression Sickness T3 x Life-Threatening Hemorrhage T4 x Ophthalmic Emergency – Globe Rupture T5 x Pneumothorax / Chest Tubes / Pleural Drains T6 x Severe Head Injury T7 x Spinal Injury and Neurogenic Shock T8 x Tension Pneumothorax – Emergency Needle Decompression T9


SECTION: CARDIOVASCULAR Reviewed April 2019 Page C1-1

CARDIOVASCULAR PROTOCOL C1 ACUTE CORONARY SYNDROME

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP) is required for ongoing care once stabilization has occurred.

DEFINITION

Acute coronary syndrome (ACS) is a spectrum of clinical conditions: low/intermediate-risk ACS, high risk non-ST-elevation ACS (NSTE-ACS), and ST-elevation MI (STEMI). All describe varying stages of coronary atherosclerosis.

INDICATIONS

Patients that present with chest discomfort or atypical chest pain, unexplained sudden shortness of breath, epigastric pain, or back pain should be screened for life-threatening causes. Other immediate life-threatening causes of chest pain include: aortic dissection, pulmonary embolism, pericardial effusion with acute tamponade, and tension pneumothorax.

x 12 lead ECG: x STEMI:

x Men ≥ 40 years of age: ST elevation in 2 or more contiguous leads (J-point elevation of 2mm in leads V2 and V3 and 1 mm in all other leads) or presumed new LBBB

x Men ≤ 40 years of age: ST elevation 2.5 mm in leads V2 and V3 and 1mm in all other leads x Women: ST elevation of 1.5 mm in leads V2 and V3 and 1 mm in all other leads

x High risk NSTE-ACS: x ST-segment depression (J-point depression of -0.5 mm in leads V2, V3 and -1 mm in all

other leads), or dynamic T-wave inversion with pain or discomfort x Transient ST-segment elevation for less than 20 minutes

x Low/intermediate risk ACS: x Normal or non-diagnostic changes in ST segment or T wave that are inconclusive

x Biomarkers: x High risk NSTE-ACS: elevated troponin

MANAGEMENT

1. Primary management of suspected high risk NSTE-ACS and STEMI is the rapid transport of patient to a tertiary care centre capable of primary coronary intervention (PCI).

2. Reduce sympathetic stimulation – manage pain and anxiety keeping SBP > 100 mmHg: x nitroGLYCERIN: 1-2 sprays SL up to 3 doses 5 minutes apart x morphine: 2 mg IV prn

x If pain unrelieved, under direction of TP/Cardiologist initiate:

o nitroGLYCERIN: infusion 5- 200 mcg/min titrating to reduce chest pain o LORazepam: 0.5 mg- 1 mg SL prn

Or midazolam: 1-2 mg IV

ACUTE CORONARY SYNDROME


x Consider under direction of TP/Cardiologist: o metoprolol: 50 mg po or 5 mg IV

3. Monitor ECG for changes:

x 12 lead ECG, repeat 12 lead ECG during transport with evolving symptoms or post fibrinolytic x If patient has inferior wall MI or is bradycardic, perform right sided leads

4. Hypoxia:

x Administer oxygen and titrate to keep Sp02 90-94% x If NPPV required, see Clinical Protocol R5 – Non-Invasive Positive Pressure Ventilation x If mechanical ventilation required, see Clinical Protocol R4 – Mechanical Ventilation

5. Antiplatelet agents, with the guidance of the TP/Cardiologist administer:

x ASA: 160-325 mg po x If PCI is planned, administer ticagrelor: 180 mg po x If fibrinolytic has been given, administer clopidogrel: 300 mg po or if > 75 years of age, 75 mg po Patient’s that are suspected of 3 vessel disease and requiring urgent surgical intervention for complications of MI should not receive clopidogrel or ticagrelor

6. Anticoagulate, with the guidance of the TP/Cardiologist: x unfractionated heparin: as per low intensity heparin nomogram order set

o 60 units/kg IV (maximum 5000 units), followed by 12 units/kg/h (maximum 1000 units/h)

7. In patient meets criteria for fibrinolysis, with the guidance of the TP/Cardiologist, administer: x tenecteplase (TNK) as per STEMI fibrinolytic standardized orders

OTHER CONSIDERATIONS

1. Nitrates are contraindicated with recent phosphodiesterase inhibitor use (sildenafil or vardenafil within the previous 24 hours, or tadalafil within 48 hours).

2. Prior to the initiation of fibrinolytic therapy draw necessary blood work and ensure the patient has 2 large bore IV’s.

REFERENCES

AHS Critical Care MCPs (v2.0)/Cardiac

https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4956/view/40948/Algorithm

American Heart and Stroke Association (2017) ACLS for Experienced Providers manual and Resource Text.

Saskatchewan Health Authority. Saskatoon Health Region Emergency department Confirmed STEMI for PCI order set. Retrieved January 2019

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/103831.pdf#search=stemi

Saskatchewan Health Authority. Saskatoon Health Region Emergency Department Confirmed ACS order set.

Retrieved January 2019.

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/103832.pdf#search=acs%20order%20set


http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/103831.pdf#search=stemi

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/103832.pdf#search=acs%20order%20set

ACUTE CORONARY SYNDROME


Saskatchewan Health Authority, Saskatoon Health Region Cardiovascular low dose heparin nomogram.

Retrieved January 2019

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/100749.pdf#search=100749

Saskatchewan Health Authority, Saskatoon Health Region STEMI Fibrinolytic orders. Retrieved January 2019,

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/101577.pdf#search=STEMI%20fibrinolytic%20

%20

Saskatchewan Health Authority. Retrieved January 2019.

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/metoprolol.pdf

Saskatchewan Health Authority. Retrieved January 2019.

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/nitroGLYCERIN%20IV.pdf

Approval: Effective Date: April 23, 2019 Medical Director:

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/100749.pdf#search=100749

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/101577.pdf#search=STEMI%20fibrinolytic%20%20

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/101577.pdf#search=STEMI%20fibrinolytic%20%20

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/metoprolol.pdf




CARDIOVASCULAR PROTOCOL C2 CARDIOGENIC SHOCK


DEFINITION

Cardiogenic shock is a state of crucial end-organ hypoperfusion due to reduced cardiac output (CO).

INDICATIONS

Symptoms of cardiogenic shock include: high central venous pressure (CVP)/pulmonary capillary wedge pressure (PCWP), low CO, high systemic vascular resistance (SVR).

x Systolic BP < 90 mmHg or MAP less than 65 mmHg or vasopressors to achieve systolic pressure > 90 mmHg

x Pulmonary congestion or elevated left ventricular filling pressure x Signs of impaired organ perfusion:

o Altered mental status o Cold, clammy skin o Oliguria o Increased serum lactate

Suspect cardiogenic shock in the following patients:

x Cardiomyopathy x MI with left or right ventricular failure x Papillary muscle rupture x Septal defects x Sustained cardiac arrhythmia x Valvular disorders x Pericardial tamponade x Ventricular rupture x Pulmonary embolus

MANAGEMENT

1. Primary management of suspected cardiogenic shock is identification and treatment of the cause.

2. Hypotension:

Target MAP 65 mmHg:

x Administer NS or RL fluid challenge 250-500ml x If patient is unresponsive to fluid bolus, or if signs of pulmonary edema develop, administer:

x norepinephrine: 0.03-1.5 mcg/kg/min

CARDIOGENIC SHOCK


x If patient is unresponsive to vasopressor and inotropic therapy is required, with the direction of the TP, consider:

x DOBUTamine: 2-15 mcg/kg/min

(doses in hemodynamically stable heart failure range 0.5-7.5 mcg/kg/min)

Or x EPINEPHrine: 0.01-0.3 mcg/kg/min

(doses 0.04-0.1 mcg/kg/min stimulate beta-receptors increasing HR, CO and stroke volume; doses > 0.2 mcg/kg/min stimulate alpha receptors producing increased SVR)

3. Management of pulmonary edema: x If SBP > 90 mmHg, with the direction of the TP, administer:

x nitroGLYCERIN: SL or 5-100 mc/min IV x furosemide: 0.5-1 mg/kg IV. If no response, a 2 mg/kg dose may be given in 1hour.

Single maximum dose: 160 mg IV x morphine: 2-4 mg IV

4. Optimize oxygenation target Sp02 90-94%:

x NIPPV, see Clinical Protocol R5 – Non Invasive Positive Pressure Ventilation x Mechanical ventilation, see Clinical Protocol R4 – Mechanical Ventilation

REFERENCES

AHS Critical Care MCPs (v2.0)/shock https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4971/view/40997/Algorithm

American Heart and Stroke Association (2017) ACLS for Experienced Providers Manual and Resource Text.

Levy et al (2015). Experts’ recommendations for the management of adult patients with cardiogenic shock. In

Annals of Intensive Care, retrieved from http://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-015-0052-1.

Saskatchewan Health Authority. Retrieved January 2019

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/EPINEPHrine.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/norepinephrine.pdf

Saskatchewan Health Authority, Retrieved January 2019

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/DOBUTamine.pdf

Saskatchewan Health Authority, retrieved January 2019




http://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-015-0052-1

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/EPINEPHrine.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/DOBUTamine.pdf



SECTION: CARDIAC Reviewed April 2019 Page C3-1

CARDIOVASCULAR PROTOCOL C3 TEMPORARY TRANSVENOUS PACING

The Flight Nurse/Paramedic may manage temporary pacemakers. Consultation with the Transport Physician (TP) is required for ongoing care once stabilization has occurred.

DEFINITION

A temporary pacemaker generator is an electronic device which senses the heart’s intrinsic electrical activity and, dependent on the settings, determines if it is necessary to stimulate the heart. Transvenous pacemaker wires can be placed by a physician in the internal jugular, subclavian, or femoral vein via a percutaneous sheath. They can be placed under fluoroscopy or blindly, utilizing a temporary pacing wire with a balloon.

INDICATIONS

Indications for temporary pacing:

x Unstable bradycardia associated with acute myocardial infarction x Unstable bradycardia not associated with myocardial infarction x Overdrive suppression of unstable tachycardia

MANAGEMENT

1. Initial set up of a pulse generator: x Attach leads to pulse generator. Distal lead into negative electrode. Proximal lead into positive

electrode x Adjust pacemaker settings to minimum output, maximum sensitivity and a rate below patient’s

intrinsic rate x Turn generator on and adjust pacemaker settings:

x Rate: Set rate 10 bpm above patient’s rate x Increase output (mA) until capture occurs. Set the mA at 2-3 increments above the

threshold value x Leave pacing sensitivity at maximum unless pacemaker is sensing artifact as patient

beats. Adjust sensitivity as required increasing mV if the pacemaker is over-sensing, and decreasing mV if pacemaker is under-sensing

x Ensure every paced beat is accompanied by mechanical capture x Assess rhythm strip to ensure pacemaker is sensing and capturing. Document settings and

rhythm strip


1. Troubleshooting failure to fire: x Check for loose connections x Ensure pacemaker has battery power x Reduce sensitivity (mV) if over-sensing

TEMPORARY TRANSVENOUS PACING

SECTION: CARDIAC Reviewed April 2019 Page C3-2

2. Troubleshooting failure to capture: x Check for loose connections x Ensure pacemaker has battery power x Turn the patient to the position they were in when the pacemaker last worked or position on right

side x Check for causes of increased threshold:

x Acid/base imbalance x Electrolyte disturbance x Hypoxia x Ischemia x Medications

x Increase output (mA)

3. Troubleshooting failure to sense (under-sensing): x Lower mV to increase sensitivity x Turn the patient to the position they were in when the pacemaker last worked or position on right

side x Check for loose connections x Ensure pacemaker has battery power

4. Troubleshooting over-sensing:

x Increase mV to decrease sensitivity

REFERENCES

Medtronic 5438 single Chamber Temporary Pacemaker Technical Manual.

http://manuals.medtronic.com/wcm/groups/mdtcom_sg/@emanuals/@era/@crdm/documents/documents/198137001_cont_20080311.pdf?bcsi_scan_2F83426B613409AB=1

Pollak, A. (2018). Critical Care Transport 2nd ed. Jones and Bartlett, Burlington.

Saskatoon Health Region Department of Nursing Practice and Education (2005). Temporary pacemakers learning package, pp. 11-12.





SECTION: GASTROINTESTINAL Reviewed April 2019 Page GI1-1

GASTROINTESTINAL PROTOCOL GI1 GASTROINTESTINAL BLEED


DEFINITION

Gastrointestinal (GI) bleeding can be categorized as an upper GI bleed which is proximal to the ligament of Treitz, or a lower GI bleed which is distal to the ligament of Treitz. Causes of upper GI bleeding include: gastric ulcer, gastritis, esophageal varices, Mallory-Weiss tear, esophagitis, dueodenitis, and aorto-enteric fistulas. Causes of lower GI bleeding include: diverticulosis, angiodysplasia, cancer, hemorrhoids, inflammatory bowel disease, infectious or ischemic colitis, and anal fissures.

INDICATIONS

Symptoms of bleeding include:

x Coffee ground emesis or bloody emesis x Melena stools x Bright red blood per rectum x Occult bleeding may present as weakness, malaise, or pre-syncope

GI bleeding can lead to significant hypovolemic shock. See Clinical Protocol T4 Life-Threatening Hemorrhage.

MANAGEMENT

1. Airway management if required (refer to Clinical Protocol R1). x Consider placement of OG or NG tube in upper GI bleeding unless contraindicated

2. Fluid resuscitation:

x Target a MAP 65 mm Hg or SBP of 90 mm Hg to maintain end-organ perfusion: x Palpable radial pulse x Level of consciousness x Target urine output 0.5 ml/kg/h

x Administer warmed Ringers Lactate 500-1000 ml, up to a maximum of 20 ml/kg x If patient is unresponsive to fluid bolus, under the direction of the TP, administer:

x Crossmatched or uncrossmatched PRBC x Concurrently initiate the following:


3. Upper GI bleed: under direction of TP administer: x octreotide: 50 mcg IV followed by 50 mcg/h x pantoprazole: 80 mg IV followed by 8 mg/h x Consider cefTRIAXone: 1 g IV

4. Lower GI bleed consider possible upper GI source.

GASTROINTESTINAL BLEED


5. Consider cause of bleed and, under direction of transport physician, some of the following may be

ordered: x Fresh frozen plasma, platelets, cryoprecipitate x Prothrombin complex concentrate x Vitamin K: 1-10mg in 50 ml NS IV over 30 min x TXA: 1 g over 10 minutes IV q 6-8h x Balloon tamponade placed by physician


1. Balloon tamponade is associated with potentially lethal complications such as aspiration, migration and subsequent occlusion of airway, and necrosis/perforation of the esophagus. Care of patients during transport include:

x Patients transported with balloon in place must be intubated and mechanically ventilated, sedated to a RASS -4 with or without paralytic agent

x The tube has 4 ports: x Esophageal balloon x Esophageal aspiration port x Gastric aspiration port x Gastric balloon

x Post insertion the gastric balloon is filled with 50 ml of air. An x-ray is done to confirm placement. The physician will further inflate the balloon with up to a total of 500 ml of air.

x Gently pull back to seat against the gastro esophageal junction. Secure the tube in place at the patient’s mouth or nose and mark and document the depth of the tube. Tie one end of a twill tape around Minnesota tube and the other end to a 1 litre bag of IV fluid. Apply gentle traction by allowing the bag to hang over the transport arch freely.

x A 60 ml catheter tip syringe must be taped to the head of the sled at all times in the event the balloons need to be deflated immediately.

REFERENCES

AHS Critical Care MCPs (v2.0)/Gastrointestinal https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4961/view/40951/Algorithm

Guadalupe, G. (2007). ACG Clinical Guideline: Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis. The American Journal of Gastroenterology. Retrieved January 2019 https://gi.org/guideline/prevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis/

Laine, L and Jensen, D. (2012). ACG Clinical Guideline: Management of Patients with Ulcer Bleeding. The American Journal of Gastroenterology. Retrieved January 2019. https://gi.org/guideline/management-of-patients-with-ulcer-bleeding/

Strate, L, and Gralnek, I. (2016). ACG Clinical Guideline: Management of Patients with Acute Lower gastrointestinal Bleeding. The American Journal of Gastroenterology. Retrieved January 2019 https://gi.org/physician-resources/podcasts/the-american-journal-of-gastroenterology-author-podcasts/strate/


https://gi.org/guideline/prevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis/

https://gi.org/guideline/prevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis/

https://gi.org/guideline/management-of-patients-with-ulcer-bleeding/

https://gi.org/guideline/management-of-patients-with-ulcer-bleeding/

https://gi.org/physician-resources/podcasts/the-american-journal-of-gastroenterology-author-podcasts/strate/

GASTROINTESTINAL BLEED


Saskatchewan Health Authority. Retrieved January 2019 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/octreotide.pdf

Saskatchewan Health Authority. Retrieved January 2019. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/pantoprazole.pdf

Saskatoon Health region. Esophageal Tamponade Tube (Minnesota tube) – assisting with insertion, care of a patient, assisting with removal. Policy 1097. Revised March 2017. Retrieved January 2019. https://www.saskatoonhealthregion.ca/about/NursingManual/1097.pdf

Tomaseli, G. (2017). ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. Retrieved January 2019. https://reader.elsevier.com/reader/sd/pii/S0735109717409387?token=E4ECCB64A3CCA51B4D779FEF1A0A8ABDBFA865846F1A2B99959976CD02EDC767ED042F84939CAA3EAD2731FDB27BB8F2

Approval: Effective Date: April 2019 Medical Director:

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/octreotide.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/pantoprazole.pdf

https://www.saskatoonhealthregion.ca/about/NursingManual/1097.pdf

https://reader.elsevier.com/reader/sd/pii/S0735109717409387?token=E4ECCB64A3CCA51B4D779FEF1A0A8ABDBFA865846F1A2B99959976CD02EDC767ED042F84939CAA3EAD2731FDB27BB8F2

https://reader.elsevier.com/reader/sd/pii/S0735109717409387?token=E4ECCB64A3CCA51B4D779FEF1A0A8ABDBFA865846F1A2B99959976CD02EDC767ED042F84939CAA3EAD2731FDB27BB8F2


SECTION: GENERAL Reviewed April 2019 Page G1-1

GENERAL PROTOCOL G1 CABIN ALTITUDE RESTRICTIONS

BODY SYSTEMS AND PATIENT CARE CONSIDERATIONS

Body

System

Aviation Factors Affecting Condition

Specific Condition

Effect of Flight

Patient Care Considerations For Transport

Eyes, Ears, Nose and Throat

x Reduced partial pressure of oxygen (hypoxemia)

x Reduced atmospheric pressure (gas expansion)

x Decreased presence of water vapor (dehydration)

x Gravitational forces

x Motion sickness

x Vibration

Eye Trauma x Retinal hypoxia

x Gas expansion in globe causes vascular or optic nerve compression, and possible extrusion of contents

x Corneal drying

x Tension on optic nerve

x Vomiting increases intra-ocular pressure

x Altitude restriction (2,000 ft. ASL)

x Administer 02 to maintain 02 sats 96% or more

x Keep eye covered. Do not instill drops if open eye injury

x Antiemetic to reduce vomiting

x Load patient with head to nose of aircraft

x Elevate head 30q

CABIN ALTITUDE RESTRICTIONS



Body

System


Specific Condition

Effect of Flight


Dental Disease x Increased pain x Avoid flying within forty eight hours after dental work

Epiglottitis x Swelling of epiglottis increases

x Consider intubation prior to flight

x Altitude restriction (2,000 ft. ASL)

Upper Respiratory Infection or Congestion

x Increased pain x Slow descent

x Cabin altitude restriction

x Awaken sleeping patients prior to descent

x Encourage maneuvers to equalize middle ear and sinus pressures with atmosphere

x Decongestants

x Treat infection (i.e. antibiotics) Unconsciousness x Corneal drying x Artificial tears

x Keep eyes closed CNS x Reduced partial

pressure of oxygen (hypoxemia)

Head Trauma x Increase hypoxemia

x 02 supplement to maintain 02 sats of 96% or more




Body

System


Specific Condition

Effect of Flight


x Reduced atmosphere pressure (gas expansion)


x Motion sickness

Stroke

x Gas expansion and swelling leading to ICP

x Vomiting and potential airway compromise

x Airway control and protection, as needed

x Hyperventilation (controlled)

x Altitude restriction of 2,000 ft. ASL

x Spinal immobilization in trauma patient

x Elevate head 30q, if C-spine and airway are intact

x Anticonvulsants, as necessary

x Administer medications to reduce ICP

Epilepsy x “Flicker vertigo”

x Hypoxemia

x Protect patient

x Anticonvulsants




Body

System


Specific Condition

Effect of Flight


x Anxiety x Supplement 02 to maintain 02 sats of 96% or more

x Keep cabin dim

CVS x Reduced partial pressure of oxygen (hypoxemia)



x Gravitational

Hypotension x Redistribution of blood flow

x Increased hypoxemia


x 02 supplementation to maintain 02 sats of 96%

x Load patient head to tail of the aircraft if hypovolemia; head to nose if CHF

x Stabilize blood pressure with volume and/or medication

Anemia x Hypoxemia x Supplement 02 to maintain 02 sats of 96% or more

x Administer PRBC’s to augment hemoglobin, if extremely low





Body

System


Specific Condition

Effect of Flight


Sickle Cell Anemia x Sickling may occur at altitudes as low as 4,000 ft


x Provide adequate hydration

x 02 supplement

Open Wounds x Increased bleeding may occur at high altitudes

x Apply pressure dressing


Angina or MI x Hypoxia may aggravate existing ischemia

x Gravitational forces may cause hypotension and tachycardia

x Vomiting may result in vagal response

x Anxiety may increase tachycardia

x Resuscitation would be

difficult in aircraft due to space restrictions

x Supplement 02 to maintain 02 sat 96% or more

x Position head to nose if possible

x Administer antiemetic preflight x Be prepared for arrest

x Altitude restriction of 2,000 ft. ASL if pain is present

x Treat ischemia/MI appropriately, with emphasis on prevention of complications




Body

System


Specific Condition

Effect of Flight


Respiratory x Reduced partial pressure of oxygen (hypoxemia)


x Decreased presence of water vapor


Respiratory Insufficiency

x Increased hypoxemia

x Gas expansion, possibly resulting in spontaneous pneumothorax

x Dehydration

x Vomiting, with potential for aspiration


x Administer supplemental 02 to maintain 02 sats of 96% or more

x Monitor for evidence of pneumothorax

x Prevent vomiting through use of antiemetic

x Load patient with head to nose of the aircraft

x Put sterile water in ETT cuff

Pneumothorax x Increased hypoxemia

x Gas expansion enlarging pneumothorax

x Potential for tension

x Supplemental 02 to maintain 02 sats of 96%


x Decompress pneumothorax by




Body

System


Specific Condition

Effect of Flight


pneumothorax inserting chest tube with one way flutter valve. Tape connections securely

x Observe for tension pneumothorax

x See protocol T6 for instructions for transport following removal.

x Use disposable underwater seal chest tube drainage systems, such as “pleurivac”

COPD x Increased hypoxemia

x Spontaneous pneumothorax

x Altitude restriction of 2,000 to 4,000 ft. ASL

x Careful 02 supplementation to maintain 02 sats from 90 to 93%


x Observe for spontaneous pneumothorax and be prepared to treat as needed




Body

System


Specific Condition

Effect of Flight


GI System x Reduced atmospheric pressure (gas expansion)

x Turbulence


x Reduced water vapor

Bowel Obstruction or Paralytic Ileus

x Gas expansion resulting in increased distention, pain and vomiting

x Altitude restriction of 2,000 to 4,000 ft. ASL

x Decompress stomach using NG to straight drainage or suction. Do not clamp during flights

x Load head to nose of aircraft


x Administer antiemetics as needed

Nausea and Vomiting

x Increased motion sickness associated with flight

x Consider preflight antiemetic, such as dimenhyDRINATE

x Encourage patient to gain sense of position (i.e. look out window)

x Reproduction

System x Reduced partial


x Reduced atmospheric pressure (gas

Pregnancy x Maternal and fetal hypoxemia

x Expansion of breast or uterine tissue may result in increased oxytocin hormone


x 02 supplement to maintain 02 sats of 96%




Body

System


Specific Condition

Effect of Flight


expansion)



release, thereby enhancing labor

x Gravitational forces may enhance labor

x Position patient in lateral position facing care team

x Load patient head to tail of the aircraft

x Monitor maternal-fetal well-being Musculo-skeletal





Fractures x Increased pain

x Increased swelling


x Casts must be bi-valved if < 72 hours old, or if significant swelling is expected. Avoid air splints

x All fractures must be immobilized and splinted

x Analgesia should be considered

x No free hanging traction splints

x Frequent assessment of CWSM Massive Soft Tissue

Injuries x Increased pain



x Immobilize affected limb




Body

System


Specific Condition

Effect of Flight


x Increased fluid loss


x Analgesia should be considered Integument


pressure of oxygen



Burns x Increased fluid loss


x Temperature loss


x Airway control if evidence of facial or airway burns

x Maintain warm cabin and monitor temperature

x Prepare burn dressings preflight

x Perform escharotomy if evidence of neurovascular impairment

x Provide adequate volume replacement (Parkland formula) in order to maintain urine output

x Maintain clean environment to reduce risk of infection




Body

System


Specific Condition

Effect of Flight


Psychiatric x Fear and anxiety Anxiety Psychosis x Increased anxiety and fear

x Violent or combative behavior

x Chemical and physical restraints

x Reassurance

All Systems x Reduced atmospheric pressure (gas expansion)

Patients with IV’s x Variable flow rate

x IV pulled out

x Careful securement of all IV’s, particularly during loading and off- loading procedures

x Maintain IV fluid bag as high as possible above IV insertion site

x Use infusion pumps to control IV rates in children and for the administration of medications by continuous infusion in all patients

x Monitor IV infusion during all phases of flight, but particularly ascent and descent

x Have at least two IV sites in all seriously ill patients



REFERENCES

CAMATA. (2016). Canadian Aerospace Medicine and Aeromedical Transportation Association air Medical Training Program Level One 2nd ed.




GENERAL PROTOCOL G2 COMBATIVE PATIENT

The Flight nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP) is required for ongoing care once stabilization has occurred.

INDICATIONS

The Richmond Agitation Sedation Score (RASS) can be used to objectively describe a combative patient. A RASS of +3 to +4 poses a risk to self or staff during transport.

Some Potential causes of combative behaviour are:

x Acute psychosis x Head injuries x Space-occupying intracranial lesions x hypoxia x Toxins x Metabolic imbalances x Pain

Initial assessment and effective management of combative emergencies is crucial to air transport safety.

MANAGEMENT

1. Stabilization: x Reassure patients: give brief, honest answers and firm, calm direction x Pharmacologic restraint should be considered prior to physical restraint

COMBATIVE PATIENT


x Keep environment as quiet as possible

2. Pharmacological Restraint: x Initiate only after underlying causes of the combative behaviour have been addressed.

x Administer midazolam: 0.1 mg/kg (5 mg maximum) slow IV push or IM, depending on patient response, may repeat q5-10 min., maximum dose of 20 mg. Airway management and/or mechanical ventilation may be required

x As an alternative to midazolam or for a longer duration of action administer LORazepam: 1–4 mg IV or IM

3. Physical Restraint:

x Indications for physical restraint prior to transport: o Measures to alleviate precipitating cause of combativeness are unsuccessful o Patients who have a history of combative/violent behaviour o Pharmacological restraint is ineffective o Any patient whose physical activity will hinder delivery of care or cause further injury

x Utilize the SHR supplied disposable limb holders. Restrained limbs require circulation checks with documentation q15 minutes

UNCONTROLLABLE COMBATIVE PATIENT IN-FLIGHT

1. If an unrestrained patient becomes combative after addressing potential causes of combative behaviour:

x Administer ketamine: 0.5–1 mg/kg (maximum dose 200 mg) IV or 5 mg/kg IM. Airway management and/or mechanical ventilation may be required

and

x Administer midazolam: 2-10 mg IV or IM

x If necessary, direct the pilot to land at the nearest suitable airport as soon as possible

x Contact PACC to facilitate the necessary ground support required upon landing, e.g. road ambulance, local authorities, etc.

x All patients who have required pharmacologic restraint for violent combative behaviour must have physical restraints applied


1. Ketamine is relatively contraindicated in patients with concurrent cardiovascular disease, withdrawal syndromes, and patients with stimulant overdose due to its effect on the central nervous system outflow and inhibition of catecholamine reuptake.

2. Complications that may be anticipated include: hypersalivation, nausea, vomiting, laryngospasm, and airway compromise, hypotension if sepsis or cardiovascular disease is present. Ketamine can have a paradoxical effect including increasing tone. The jaw may become clenched making intubation difficult or impossible.

3. Benzodiazepines should be administered concurrently to prevent the occurrence or decrease the severity of emergence reaction that includes hallucinations and agitation.

COMBATIVE PATIENT


REFERENCES

AHS Critical Care MCPs (v2.0)/Analgesia/Sedation https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4955/view/40939/Notes

Cole, J. et.al. (2017). A prospective study of ketamine as primary therapy for prehospital profound agitation. American Journal of Emergency Medicine 36, pp 789-796.

Linder, L, et.al. (2018). Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy: the Journal of Human Pharmacology and Drug therapy. Vol 38(1).

Saskatchewan Health Authority. Retrieved February 2019. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/ketamine.pdf


https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4955/view/40939/Notes



GENERAL PROTOCOL G3 INTRA-AORTIC BALLOON PUMP COUNTERPULSATION


INDICATIONS

The goal of Intra-Aortic Balloon Pump Counterpulsation (IABP) is to improve cardiac output and reduce afterload by:

x Increasing coronary artery perfusion x Increasing myocardial oxygen supply x Decreasing myocardial oxygen demand x Resting a diseased heart x Maintaining adequate end organ perfusion

Absolute contraindications for use include:

x Severe aortic valve insufficiency x Abdominal/aortic aneurysm x Severe calcific aortic-iliac disease or peripheral vascular disease

MANAGEMENT

1. Care of IAB catheter and pressure line: x Assess and ensure balloon is securely dressed and taped at site x Level transducer to patient’s phlebostatic axis x Zero pressure transducer at ground, and at altitude x Heparinized saline flush solution is a 2:1 concentration (1000u/500ml Normal Saline) x Prolonged flushing of IAB catheter should be avoided x Blood sampling from the IAB catheter is not recommended

2. Care of the patient:

x Blood pressure readings should be taken from the IABP console. The IAB catheter reading represents the most accurate pressure as compared to those from a distal arterial site

x Titrate vasopressors to values obtained from IAB catheter x Patient is on bedrest with HOB flat. Leg must not be flexed x Check and document pulses, color, temperature, and capillary refill of distal limb q1h x Assess and document condition of insertion site hourly x Tape ECG leads from IABP console to patient using waterproof tape

3. Loading and unloading procedure:

x The procedure will be done in a slow and controlled manner to minimize risk to the patient x Pilot in command is the leader during loading and unloading. All team members: Flight

Nurse/Paramedic, and Perfusionist have specific roles:

INTRA-AORTIC BALLOON PUMP COUNTERPULSATION


x Perfusionist: remains outside the aircraft and Is responsible for watching the line and console

x Flight Nurse/Paramedic: remains inside the aircraft and loads/Unloads the patient on the sled and the IABP console on the cargo sled

x First Officer: remains outside the aircraft and loads/unloads the patient on the sled and the IABP console on the cargo sled

x All team members may halt the loading/unloading process if an unsafe situation is apparent

x Confirm with destination airport that additional resources are sufficient for during loading and unloading patient


1. Equipment required to transport a patient with IABP therapy: cargo sled and 2 cargo straps with brownline attachments.

2. Equipment weights: x Cardiosave Weight and dimensions

o Weight: (with one battery and 1 AC adaptor, cables) 54.6 lbs o Dimensions: 1’x2’x16” (width, height, depth) o Extra supplies the Perfusionist will bring:

� 2 extra batteries 14 lbs � 1 bag heparinized saline 2.2 lbs

REFERENCES

Saskatchewan Health Authority (Saskatoon Health Region) Intra-aortic Balloon Pump therapy RN learning package revised December 2017. Retrieved January 2019. http://infonet.sktnhr.ca/nursingaffairs/Documents/Intra-Aortic%20Balloon%20Pump.pdf#search=iabp


http://infonet.sktnhr.ca/nursingaffairs/Documents/Intra-Aortic%20Balloon%20Pump.pdf#search=iabp



GENERAL PROTOCOL G4 OXYGEN ENDURANCE CHART

OXYGEN ENDURANCE CHART

Cylinder Size D E G Q M H/K

Capacity (litres) 300 600 1,000 2,000 3,450 6,500

Flow Rate (litres per min.)

2 2:30 5:00 8:20 16:40 28:45 54:00

4 1:15 2:30 4:10 8:20 14:20 27:00

6 0:50 1:40 2:45 5:30 9:35 18:00

8 0:35 1:10 2:05 4:10 7:10 13:30

10 0:30 1:00 1:40 3:20 5:45 11:00

15 0:20 0:40 1:05 2:10 3:50 7:15

20 0:15 0:30 0:50 1:40 2:50 5:30

25 0:12 0:24 0:40 1:20 2:20 4:20

NOTES

x Endurance times in hours and minutes are approximations based on full bottle pressure at start of flow rate.

x Oxygen regulators are calibrated for accuracy at sea level. Therefore, at altitude, oxygen will flow faster than the setting on the flow meter.

x As altitude increases, oxygen requirements increase.

x As altitude decreases, oxygen requirements decrease.

x Always estimate flight time plus two hours, to ensure adequate oxygen supply.

x Saskatchewan Air Ambulance carries 2 M tanks.

OXYGEN ENDURANCE CHART


REFERENCES

CAMATA. (2016). Canadian aerospace medicine and Aeromedical Transportation Association Air Medical Training program Level one 2nd ed.




GENERAL PROTOCOL G5 SEPSIS, SEVERE SEPSIS AND SEPTIC SHOCK

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP) is required for antibiotic administration and ongoing care once stabilization has occurred.

DEFINITION Sepsis is a systemic manifestation of infection. Severe sepsis is sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Septic shock is severe sepsis with arterial hypotension. INDICATIONS 1. Sepsis:

Any of the two following symptoms: x Temperature > 38 C x HR > 90 bpm x RR > 20 bpm x WBC > 12 x 109/L or less than 4 x 109/L AND x Proven or suspected infection x Recent major surgery/trauma/burn x Primary liver cirrhosis x Age > 70 years x Prolonged or recent hospitalization x Immunosuppression x Invasive procedures/devices

2. Severe Sepsis: Symptoms of sepsis plus:

x SBP < 90 mmHg or MAP < 65 mmHg x SBP decrease greater than 40 mmHg from baseline x Venous lactate > 4 mmol/L

3. Septic Shock:

Symptoms of severe sepsis plus: x Hypotension unresponsive to fluid challenge

MANAGEMENT (1 Hour bundle)

1. When possible, request sending facility collect cultures of the blood, sputum, wound and urine to transport with patient to receiving centre.

SEPSIS, SEVERE SEPSIS AND SEPTIC SHOCK


2. Under physician direction, initiate antibiotic therapy:

x Targets: x Sepsis: first-dose antibiotic target: within 3 hours from time sepsis identified x Severe Sepsis: first-dose antibiotic target: within 1 hour from the time severe sepsis identified x Septic shock: first-dose antibiotic target: within1 hour from the time severe sepsis identified

x Antibiotics available: x cefTRIAXone: 2 grams IV over 5 minutes x ciprofloxacin: 400 mg IV over 30 minutes x moxifloxacin: 400 mg IV over 60 minutes x piperacillin/tazobactam: 3.375 grams IV over 30 minutes x vancomycin: 25mg/kg IV over 60 – 90 minutes (maximum 3.5 gram loading dose)

2. IV Fluid therapy:

x Ensure adequate large bore IV access x NS or RL 500ml bolus q 10 minutes until MAP > 65 mmHg, maximum 3 L then review x Maintain urine output 0.5 ml/kg/h

3. Vasopressors to keep MAP > 65 mmHg:

x norepinephrine: 0.03-1.5 mcg/kg/min x DOPamine: 5-20 mc/kg/min x vasopressin: 0.01-0.03 units/min, under physician direction

REFERENCES

Levi, M. (2018). The Surviving Sepsis Campaign Bundle: 2018 Update. The Society of Critical Care Medicine and the European Society of Intensive medicine. Retrieved November 2018. http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018.pdf

Saskatoon Health Region (2016). Sepsis screening tool. Retrieved October 2018. http://infonet.sktnhr.ca/SaferEveryDay/Pages/Sepsis%20Package.pdf#search=SEPSIS

Saskatoon Health Region (2015). Adult severe sepsis/septic shock management order set. Retrieved October 2018. http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/102864.pdf.

Saskatchewan Health Authority. Retrieved October 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/piperacillin%20tazobactam.pdf


http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018.pdf

http://infonet.sktnhr.ca/SaferEveryDay/Pages/Sepsis%20Package.pdf#search=SEPSIS

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/102864.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/piperacillin%20tazobactam.pdf


SECTION: GENERAL Review April 2019 Page G6-1

GENERAL PROTOCOL G6 INTRA-OSSEOUS NEEDLE INSERTION

DEFINITION

Intra-osseous (IO) access is a catheter placed in the epiphyses of long bones providing access to central circulation through a vast system of blood vessels in the medullary space.

INDICATION

The Flight Nurse/Paramedic may insert intraosseous needle when unable to obtain IV access in urgent or medically-necessary cases.

PROCEDURE

1. Clean hands, prepare equipment and don personal protective equipment.

x Chlorhexadine antiseptic solution/swabs (alcohol for infants < 2 months of age) x 0.9% saline-10 ml syringe with luer lock x 3-way stopcock x Microbore extension tubing or IO-specific IV adaptor flushed with 0.9% saline x IV solution as ordered x IV pump, pressure bags, and 60 ml luer lock syringes as required x Preservative-free Lidocaine 2%

2. Select appropriate sized needle: if the EZ-IO Gun is being used, calculations for needle size are weight-based. In addition, clinical judgement should be used to determine appropriate needle set selection based on patient anatomy and tissue depth.

Between 3 – 39 Kg: use the pediatric #15 gauge 15 mm needle

Over 40 Kg: use the adult #15 gauge 25 mm needle

Bariatric patients: use the #15 g 45 mm needle (defined by manufacturer as “excess tissue”)

3. Select puncture site. Considerations when selecting puncture site include: age, easy identification of

proper anatomical landmarks, bone fractures, ability to secure and access during transport.

x Proximal humerus: preferred site for adults when landmarks can be clearly identified.

INTRA-OSSEOUS NEEDLE INSERTION


Adduct elbow at 90 degrees by placing patient’s hand over the abdomen. Place your palm on the patient’s shoulder anteriorly, the “ball” under your palm is the general target area.

Place the ulnar aspect of your hand vertically over the axilla. Place the ulnar aspect of your other hand along the midline of the upper arm laterally.

Place your thumbs together over the arm. This identifies the vertical line of insertion on the proximal humerus.

Palpate deeply up the humerus to the surgical neck. It may feel like a golf ball on a tee – the spot where the ball meets the tee is the surgical neck. The insertion site is 1 to 2 cm above the surgical neck, on the most prominent aspect of the greater tubercle.

Point the needle set tip at a 45 degree angle to the anterior plane and posteromedial.



Graphics from: EZ-IO Teleflex https://www.teleflex.com/usa/clinical-resources/ez-io/index?language_id=11

If puncture unsuccessful at this site, attempt at the same location on the other shoulder.

x Anteromedial tibia: (preferred site for children)

Graphics from: EZ-IO Learning Disc – Vidacaire (2007)

If puncture unsuccessful at this site, attempt at the same location on the other leg.

x Distal tibia:

Graphics from: EZ-IO Learning Disc – Vidacaire (2007)

If puncture is unsuccessful at this site, attempt at the same location on the other ankle. Do not use this site on same limb that attempted an antero-medial tibial IO. 4. Cleanse site with chlorhexidine. Clean skin at center of desired puncture site and make increasingly

larger circular motions on the skin until an area approximately six centimetres is covered.

5. Insert IO needle: x Use a clean, ”no touch” technique

Less than 12 years of age: locate tibial tuberosity, and move medial and 1 to 3 cm (approximately one fingerbreadth) below the tibial tuberosity, away from joint and epiphyseal plates. Pinch the tibia between your fingers to identify the medial and lateral borders, and insert in the center of the bone.

Over 12 years of age and adults: extend the leg. The insertion site is approximately 2cm medial to the tibial tuberosity, or approximately 2 cm medial, along the flat aspect of the tibia.

In adults, adolescents, and older children the insertion site is located approximately 3cm proximal to the most prominent aspect of the medial malleolus. Palpate the anterior and posterior borders of the tibia to ensure that your insertion site is in the flat center of the bone and perpendicular to the surface of the bone. For infants and children the insertion site is located approximately 1-2 cm proximal to the most prominent aspect of the medial malleolus. Palpate the anterior and posterior borders of the tibia to ensure that your insertion site is in the flat center of the bone and perpendicular to the surface of the bone.

https://www.teleflex.com/usa/clinical-resources/ez-io/index?language_id=11



x Attach a drill to compatible needle of an appropriate size. Line up needle with site at a 90 degree angle to the bone

x Gently press needle through the skin until the tip touches the bone. The 5mm black mark on the needle set MUST be visible above the skin prior to insertion

x If the 5 mm marking is visible, continue with insertion. If the 5 mm marking is not visible, do not continue with the procedure as the needle may not reach the IO space. Procedure may be restarted with a longer needle

x Press the trigger and apply gentle steady pressure on the drill. In adult patients, advance the needle set approximately 1-2 cm after entry into the medullary space which is felt as a change in resistance. In the humeral site for most adults, the needle set should be advanced 2cm or until hub is flush against the skin. In pediatric patients, stop the insertion when a change in pressure or resistance is felt, indicating entry into the medullary space

x Hold the hub and gently pull the driver straight off. While continuing to hold the hub twist the stylette from inner cannula, leaving cannula in place

7. Place the stabilizer dressing over the hub.

8. Attach an extension set to the catheter hub.

9. Confirm placement: x Catheter feels firmly seated in the bone x Aspiration for blood/bone marrow. Inability to aspirate from the catheter hub does not mean

the insertion was unsuccessful

10. Gently flush with 5-10 ml of NS in adult patients, 2-5 ml of NS in pediatric patients to clear the marrow and fibrin from the medullary space and allow for effective infusion rates. If the patient has pain, stop flushing and proceed to the next step.

11. Assess the patient’s response to pain. In the conscious patient, administer 2% Lidocaine via the IO. Slowly infuse the lidocaine IO over 2 minutes. Allow a 60 sec dwell time then flush with NS. Duration of anesthetic may vary among patients. Repeat doses of lidocaine may be necessary administered over 60 seconds.

x Adult- Lidocaine 2%: 20 to 40 mg x Pediatric -Lidocaine 2%: 0.5 mg/kg mg/kg to max of 40 mg

MANAGEMENT

1. Restrain the limb to prevent movement and the inadvertent dislodgement of the intraosseous needle. For proximal humerus insertions, apply a sling.

2. Flush the line with at least 5 ml of fluid after all boluses of drugs to ensure that the medication enters the central circulation as quickly as possible.

3. Monitor site q 30 min for complications of the IO insertion. Extravasation is the most common complication. If this occurs, discontinue the IO infusion immediately and remove the needle.

4. Removal: Using a sterile luer-lock syringe as a handle, attach to the hub of the catheter. Maintain alignment and rotate clockwise while pulling straight up. Avoid rocking the catheter on removal.



5. Intraosseous lines have higher resistance than intravenous lines and, therefore, may require higher infusion pressures. Utilize syringes, pumps and pressure bags to administer fluid.


1. Any drug that can be administered IV can be given via the intraosseous route.

2. Contraindications to IO insertion: x Fracture in target bone x Overlying skin or soft tissue infection x Excessive tissue (severe obesity) and/or absence of adequate anatomical landmarks x Infection at area of insertion site x Previous, significant orthopedic procedure at the site, prosthetic limb or joint x IO access (or attempted access) in targeted bone within past 48 hours x If the drill slows during insertion it indicates too much pressure is being exerted by the user. Apply

gentle steady pressure

3. In the event of driver failure, disconnect the power driver, grasp the needle set hub by hand and advance into the medullary space while twisting.

4. IO insertion sites can be used and maintained for up to 24 hours until more definitive vascular access can be obtained.

REFERENCES

Heart and Stroke Foundation. (2015). Pediatric Advanced Life Support Provider Manual. American Heart Association.

Saskatoon Health Region (2015). Initiation of intraosseous infusion, RN learning package.

Teleflex Arrow EZ-IO intraosseous clinical resources. https://www.teleflex.com/usa/clinical-resources/ez-io/index?language_id=11

Teleflex (2016) Arrow EZ-IO Intraosseous Vascular Access System Pocket Guide. https://www.teleflex.com/usa/product-areas/vascular-access/emergency-trauma-products/intraosseous-access/EZ-IO%20Pocket%20Guide%20ipad%20MC-000280%20Rev%2003.pdf

Teleflex (2017) The Science and Fundamentals of Intraosseous Vascular Access Third Edition. https://www.teleflex.com/global/clinical-resources/ez-io/EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf




https://www.teleflex.com/usa/product-areas/vascular-access/emergency-trauma-products/intraosseous-access/EZ-IO%20Pocket%20Guide%20ipad%20MC-000280%20Rev%2003.pdf

https://www.teleflex.com/usa/product-areas/vascular-access/emergency-trauma-products/intraosseous-access/EZ-IO%20Pocket%20Guide%20ipad%20MC-000280%20Rev%2003.pdf

https://www.teleflex.com/global/clinical-resources/ez-io/EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf


SECTION: MEDICATION Reviewed April 2019 Page M1-1

MEDICATION PROTOCOL M1 ANTI-EMETICS

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications.

DEFINITION

Gas expansion, hypoxia, spacial disorientation, fatigue, heat, anxiety, turbulence and medications are common causes of nausea and vomiting in patients being transported by air. Risks that occur as a result of nausea and vomiting include: aspiration, increased intracranial pressure, increased ocular pressure and parasympathetic stimulation.

MANAGEMENT

1. Non pharmaceutical measures include: x Administration of oxygen x Fixation of vision on stationary object x Decompression of GI tract with OG/NG tube

2. Administer:

x dimenhyDRINATE: 25-50 mg IV q4h

or

x ondansetron: 4–8 mg IV over 2-3 minutes q8h


1. dimenhyDRINATE may potentiate the sedative effects of opiates, ethanol or other sedatives. It also may potentiate the anticholinergic effects of tricyclic antidepressants. Use with caution in patients with asthma, cardiovascular disease, narrow angle glaucoma, prostatic hypertrophy, and in the elderly.

2. ondansetron is not as effective in preventing motion-induced nausea. It may cause QT prolongation in the elderly, patients with congenital long QT syndrome, hypokalemia, hypomagnesemia, heart failure, and bradyarrhythmias. Use with caution in patients receiving drugs that prolong QT intervals (amiodarone, macrolides, fluoroquinolones, haloperidol, risperidone) or Torsade de pointes may result.

REFERENCES

CAMATA. (2004). Canadian Aerospace Medicine and Aeromedical Transport Association air Medical Training Program Level one 2nd Ed.

Saskatchewan Health Authority. Retrieved January 2019 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/ondansetron.pdf

ANTI-EMETICS

SECTION: POISONING Reviewed April 2019 Page M1-2

Saskatchewan Health Authority. Retrieved January 2019 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/dimenhyDRINATE.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/dimenhyDRINATE.pdf



MEDICATION PROTOCOL M2 PAIN MANAGEMENT


DEFINITION

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The reference standard measure of pain is a patient’s self-report, but the inability of a patient to self-report does not negate the patient’s pain experience. Severe pain negatively affects the patient status (cardiac instability, respiratory compromise, and immunosuppression) in critically ill patients.

INDICATIONS

Critical Care Pain Observation Tool (CPOT) score > 2 indicates pain.

PAIN MANAGEMENT


MANAGEMENT

1. Opioid: x fentanyl: 20-50 mcg IV over 1 minute. Repeat q5 min titrating to patient response. If maximum

dose of 300 mcg is reached, consult transport physician x morphine: 2-5 mg IV over 1 minute. Repeat q15 min titrating to patient response. If maximum

dose of 20 mg is reached, consult transport physician x Under direction of the TP: consider fentanyl infusion: 25-100 mcg/h

2. If opioid alone is ineffective, under the guidance of the TP, stop opioid infusion and start:

x ketamine: 0.125-0.25 mg/kg IV. May be repeated q10 min. No more than 5 doses x Consider, in addition to intermittent opioids, ketamine infusion: 0.4 mg/kg/h


1. Rapid administration of fentanyl may cause chest wall rigidity and difficulty ventilating.

REFERENCES

AACN. (2014) AACN Practice Alert: Assessing Pain in the Critically Ill Adult. Retrieved January 2019. http://ccn.aacnjournals.org/content/34/1/81.full

American Critical Care Society. (2018). Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Critical Care Medicine.

Saskatchewan Health Authority. Retrieved January 2019 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/fentaNYL%20IV.pdf

Saskatchewan Health Authority. Retrieved January 2019 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/morphine%20IV.pdf

Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/ketamine.pdf


http://ccn.aacnjournals.org/content/34/1/81.full

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/fentaNYL%20IV.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/morphine%20IV.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/ketamine.pdf



MEDICATION PROTOCOL M3 SEDATION MANAGEMENT


DEFINITION

Sedation is administered to relieve anxiety, reduce the stress of being mechanically ventilated, and prevent agitation-related harm. If sedation is required the patient’s current sedation status must be assessed and frequently reassessed using a valid and reliable scale.

INDICATIONS

Sedation requirements are individual and require individual dosing regimens. The Richmond Agitation Sedation

Scale (RASS) is an objective tool used to measure a patient’s level of awareness. Patients who are critically

injured (particularly patients with traumatic brain injury) may benefit from a deeper state of sedation to help

blunt the stimulus from the stressors of transport/flight.

Richmond Agitation Sedation Scale (RASS)

SEDATION MANAGEMENT


MANAGEMENT

1. Determine a target RASS typically -1 to -2 in an intubated mechanically ventilated patient, and +1 to -1 in an awake patient.

2. Consider the source of the agitation: pain, toxin, hypoxia, hypo-perfusion, head injury, psychosis and treat cause.

3. If treatment of cause alone is ineffective, consider the source of the agitation and add an appropriate dose of benzodiazepine:

x midazolam: 1-3 mg IV. May repeat q 5-15 minutes to a maximum of 15 mg. Titrate dose intervals to target RASS

x < 55 years old initial dose no more than 2-2.5 mg IV over 3-5 minutes x > 55 years old, or in debilitated patients, initial dose no more than 1-1.5 mg IV over 3-5 minutes

OR

x LORazepam: 0.5-1 mg SL or 1-4 mg may repeat once x Caution: use lower doses in elderly or debilitated patients, patients with renal, heart or liver

failure

4. If inadequately sedated (above target RASS), under direction of the TP, consider one of the following: x midazolam: infusion 0.02-0.1 mg/kg/h x ketamine: infusion 0.3-1.2 mg/kg/h x propofol: infusion 5-80 mcg/kg/min

REFERENCES

American Critical Care Society. (2018). Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Critical Care

Medicine.




https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/LORazepam.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/midazolam.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/propofol.pdf



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/LORazepam.pdf




SECTION: METABOLIC Reviewed April 2019 Page MET1-1

METABOLIC PROTOCOL MET1 DIABETIC EMERGENCIES: HYPERGLYCEMIA

The Flight Nurse/Paramedic may implement the following protocol for stated indications, after consultation with the Transport Physician (TP).

DEFINITION

Hyperglycemia: a blood glucose 15 mmol/L or greater. This includes diabetic ketoacidosis (DKA), or hyperglycemic, hyperosmolar state (HHS).

INDICATIONS

Symptoms for both syndromes include:

x Hyperosmolality x Osmotic diuresis x Fluid and electrolyte loss x Volume depletion

Mild DKA Moderate DKA Severe DKA Hyperosmolar

Nonketotic Hyperglycemia

Plasma glucose (mmol/L) 14 or greater 14 or greater 14 or greater 33 or greater

Arterial pH 7.25 to 7.30 7.00 to 7.24 Less than 7.00 Greater than 7.30 Serum bicarbonate

(mEq/L) 15 to 18 10 to less than 15 Less than 10 18 or greater

Urine ketones Positive Positive Positive Small Serum ketones Positive Positive Positive Small/Negative

Effective serum osmolality (mOsm/kg)

Variable Variable Variable 320 or greater

Anion gap 10 or greater 12 or greater 12 or greater Variable

Alteration in sensorial or

mental obtundation Alert Alert / drowsy Stupor / coma Stupor / co

Copied from: https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4962/view/40955/Notes


DIABETIC EMERGENCIES: HYPERGLYCEMIA


MANAGEMENT

1. Volume replacement: x RL or NS 20 ml/kg bolus followed by an additional 1-2 L in the first hour (consider patient

tolerance in the presence of cardiac dysfunction) x Maintenance rate of .45 NS at 150-300 ml/h x Target urine output 1ml/kg/h (indwelling catheter required) x If target urine output has not been reached by the second hour, repeat fluid bolus x Add dextrose-containing fluids (D5.45NS) when blood glucose is < 16.7 mmol/L. Maintain blood

glucose > 8.3 mmol/L

2. Measure serum potassium: x If serum potassium is < 3.3 mmol/L hold insulin and administer potassium 40mmol/h as potassium

chloride until potassium is > 3.3 mmol/L x If serum potassium is 3.3-5.0 mmol/L and urine output is adequate, administer potassium 20 mmol

in each litre of fluid to maintain potassium at 4.0-5.0 mmol/L x If serum potassium is > 5.0 do not administer potassium in IV fluid

3. Insulin:

Hold insulin if serum potassium is < 3.3 mmol/L until potassium is replaced.

x Loading dose: 0.1 units/kg x Infusion 0.1 units/kg/h x In DKA decrease rate of infusion to 0.05 units/kg/h when blood glucose reaches 13.9 mmol/L

Or

x Initiate insulin infusion at 0.14 units/kg/h x Target reduction rate 2.8-4.2 mmol/L/h x Decrease infusion to 0.20-0.05 units/kg/h

4. Measure serum glucose q15 min. Titrate insulin to maintain blood glucose 8.3-11.1 mmol/L.

5. Correct ketoacidosis:

x Administration of sodium bicarbonate is not recommended. Exceptions: i. Hyperkalemia-producing ECG changes ii. Severe acidosis: pH < 7.0-7.1 iii. Bicarbonate < 5 mmol/L iv. Acidosis-induced cardiac or pulmonary dysfunction

6. Monitor for signs and symptoms of cerebral edema:

x Headache x Altered mental status x Pupil changes


1. Volume replacement with normal saline and initiation of an insulin infusion will begin a rapid shift of potassium into the cells. Serum potassium will fall.

2. In profound acidosis potassium can shift outside the cells causing life-threatening arrhythmias from hyperkalemia necessitating administration of calcium and sodium bicarbonate.

DIABETIC EMERGENCIES: HYPERGLYCEMIA


3. Rapid correction of hyperglycemia (> 5.5 mmol/L /h) can cause a fall in serum osmolality and cause cerebral edema.

REFERENCES

AHS Critical Care MCPs (v2.0)/Neurological/diabetic emergencies


American Heart Association (2017). ACLS for Experienced Providers Manual and Resource Text. pp331-333.

Gilbert, J. & Goubert, J. (2013). Hyperglycemic emergencies in adults. In Canadian Journal of Diabetes S72-S76. Retrieved from http://guidelines.diabetes.ca/App_Themes/CDACPG/resources/cpg_2013_full_en.pdf.

Society of Critical Care Medicine. (2012) Fundamental Critical Care Support 5th ed. Ch 12 p18.



http://guidelines.diabetes.ca/App_Themes/CDACPG/resources/cpg_2013_full_en.pdf



METABOLIC PROTOCOL MET2

DIABETIC EMERGENCIES - HYPOGLYCEMIA

The Flight Nurse/Paramedic may implement the following protocol for stated indications.

DEFINITION

Hypoglycemia:

Mild/Moderate: serum blood glucose < 4 mmol/L or < 5.0 mmol/L in the frail, elderly/dependent

Severe: serum blood glucose < 2.5 mmol/L

INDICATIONS/SYMPTOMS

Release of endogenous catecholamines in response to hypoglycaemia may cause:

Pallor

Diaphoresis

Tachycardia and tremors

Altered mental status coma or seizures

MANAGEMENT

Mild/Moderate hypoglycemia:

1. If the patient is conscious and cooperative with an intact gag reflex, administer 4 tablets glucose 4

grams ea.

2. If the patient is unconscious or is unable to swallow, initiate an IV and administer:

D50W: 25 ml IV over 1-3 min

3. The pediatric dosage for the intravenous administration of glucose is 2-4 ml/kg of D25W or 5-10 ml

D10W. Do not administer without consultation with the Transport Physician (TP) or Pediatric Transport

Physician.

4. Repeat blood glucose testing in 15 minutes and repeat treatment until blood glucose is > 4-5 mmol/L.

Severe:

1. If the patient is conscious and cooperative with an intact gag reflex administer 5 tablets glucose 4 g

ea.

2. If the patient is unconscious or is unable to swallow, initiate an IV and administer:

50% dextrose: 50 ml IV over 1-3 min.

3. Repeat blood glucose testing in 15 minutes and repeat treatment until blood glucose is > 4-5 mmol/L.

DIABETIC EMERGENCIES - HYPOGLYCEMIA



1. Ensure and monitor patency of IV. If extravasation occurs apply cold compresses and notify physician.

2. Consider thiamine for malnourished patients.

3. Consider glucagon 1mg IM/SC. Use with caution in cardiovascular or renal disease.

4. Octreotide may be considered when hypoglycemia is secondary to oral hypoglycemic poisoning

refractory to dextrose therapy. TP order is required. Dose 50-100 mcg IVP q6-12h (reassessed with blood

glucose).

5. How to mix a dextrose infusion. Note: high concentrations of dextrose are a vesicant. Monitoring of IV

site is imperative.

TO MAKE START WITH ADD RESULT

D10W – 250 ml D5W 250 ml (12.5g

dextrose) remove 25 ml

25ml of D50W (12.5g) 25g/250ml= 10%

solution

D10W – 50 ml D50W 10ml (discard 40 ml

from 50 ml ampule)

40 ml NS 5g/50 ml = 10%

D25W – 250 ml D5W 250ml (12.5g

dextrose) remove 100 ml

100ml of D50W (50g) 57.5g/250ml = 23%

(closest to 25% easily

available)

D25W – 50 ml D50W 25 ml (discard 25

ml from 50 ml ampule)

25 ml NS 12.5g/50ml = 25%

REFERENCES

AHS Critical Care MCPs (v2.0)/Neruological/diabetic emergencies


American Heart Association (2011). Management of shock. In Pediatric Advanced Life Support Provider

Manual, pp. 85-108.

Saskatchewan Health Authority. Retrieved October 16, 2018

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/dextrose%2050%20percent.pdf

Saskatchewan Health Authority. Retrieved October 16, 2018.


Saskatoon Health Region Adult Hypoglycemia Protocol (2017)

http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/103605.pdf#search=hypoglycemia

Yale, J., et al. (2018) Hypoglycemia. 2018 Clinical practice guidelines. Canadian Journal of Diabetes

http://guidelines.diabetes.ca/docs/cpg/Ch14-Hypoglycemia.pdf





http://infonet.sktnhr.ca/clinicaldocumentation/Documents/Orders/103605.pdf#search=hypoglycemia

http://guidelines.diabetes.ca/docs/cpg/Ch14-Hypoglycemia.pdf


SECTION: NEUROLOGICAL Reviewed April 2019 Page N1-1

NEUROLOGICAL PROTOCOL N1 SEIZURES


DEFINITION

A seizure is a temporary, involuntary alteration in behavior, consciousness, motor activity, or autonomic function from excessive rates and hypersychronicity of discharges from a group of cerebral neurons. Seizures are usually self-limiting. Seizures lasting longer than 5 minutes are likely to develop into status epilepticus.

Status epilepticus is continuous seizure activity or repeated seizures without return to normal level of consciousness. Complications of status epilepticus include: trauma, hypoxic injury, airway obstruction, and aspiration.

INDICATIONS

Classifications:

1. Partial x Simple partial seizure: normal mental status, focal motor activity, no postictal period x Complex partial seizure: altered mental status but not comatose, automatism, inappropriate

feeling or actions, postictal period with inability to recall events

2. Generalized x Absence seizure: abrupt loss of consciousness following prodromal symptoms (i.e. eye flutter or

daydreaming), minimal confusion following events, usually no postictal period x Tonic-clonic seizure: abrupt loss of consciousness, loss of muscle tone, primary phase (muscle

rigidity), secondary phase (clonic activity), deviated gaze, nystagmus, snoring respirations, skin pale and cyanotic, incontinence, lengthy postictal period

MANAGEMENT

1. Terminate seizure: x Administer:

x LORazepam: 0.1 mg/kg IV to a maximum of 4 mg

Or

x midazolam: 0.2 mg/kg at a rate of 2 mg/min up to a maximum of 10 mg. Can also be given IM

x If refractory status epilepticus, secure airway and mechanically ventilate patient. Under the direction of the TP, administer:

x propofol: 1-2 mg/kg loading dose IV over 5 minutes. Use caution in the elderly and debilitated patients Followed by:

SEIZURES


x propofol: 20 mcg/kg/min titrating no higher than 80 mcg/kg/min to stop visible seizure activity

x If patient unresponsive under the direction of the TP, administer: x phenytoin: 20 mg/kg in 250 ml NS, maximum rate of infusion 25 mg/min. Use filter.

Reduce rate of infusion in the elderly or patients with cardiovascular disease

2. Hypotension: x If administering phenytoin, reduce rate of infusion x Administer NS or RL fluid challenge 500-1000ml targeted to a MAP of 65 mm Hg

3. Treat identifiable causes. Consider:

x Hypoglycemia: see Clinical Protocol MET2 - Hypoglycemia. x Hyponatremia:

x Consider, under the direction of the TP, administration of 3% hypertonic saline for serum sodium less than 125 mmol/L

x Hypocalcemia: x Consider, under the direction of the TP, administration of calcium chloride for serum

ionized calcium less than 1 mmol/L x Toxic ingestions or medications: sympathomimetics, cyclic antidepressants, cholinergics,

anticholinergics, serotonergic agents, neuroleptics, aspirin x Eclampsia: see Clinical Protocol OB8 – Hypertension in Pregnancy x Fever x Hypoxia x Structural deformities in brain x Alcohol, benzodiazepine, or opiate withdrawal x Infectious process


1. Phenytoin is a sodium channel blocker and can cause refractory fatal arrhythmias in concurrent toxic ingestion (TCA overdose, SSRI overdose, cocaine toxicity) and patients with electrolyte abnormalities.

2. Propofol must be used with caution in the elderly and debilitated patients. Profound hypotension, bradycardia, heart blocks and asystole can occur with high doses and rapid administration.

3. Avoid neuromuscular blockade because it makes seizure monitoring difficult.

REFERENCES

AHS Critical Care MCPs (v2.0)/Neurological/Seizure https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4963/view/40953/Algorithm

American Epilepsy Society. (2016). Guideline for Treatment of Prolonged Seizures in Children and Adults. Retrieved December 2018. http://www.epilepsycurrents.org/doi/full/10.5698/1535-7597-16.1.48

Nickson, C. (2016), Status Epilepticus. Retrieved December 2018. https://lifeinthefastlane.com/ccc/status-epilepticus/


Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/LORazepam.pdf

http://www.epilepsycurrents.org/doi/full/10.5698/1535-7597-16.1.48

https://lifeinthefastlane.com/ccc/status-epilepticus/

https://lifeinthefastlane.com/ccc/status-epilepticus/

SEIZURES


Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/propofol.pdf

Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/phenytoin.pdf

Saskatchewan Health Authority. Retrieved December 2019. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/midazolam.pdf

Society of Critical Care Medicine. (2012). Fundamental Critical Care Support 5th ed. Mount Prospect IL.





NEUROLOGICAL PROTOCOL N2 HEMORRHAGIC STROKE


DEFINITION

The acute neurologic impairment that follows an interruption in blood supply caused by a rupture of a blood vessel to a specific region of the brain. This includes: subarachnoid hemorrhage (SAH), and intracranial bleeds.

INDICATIONS

x New onset acute headache. Often described as the “worst headache of their life” x Nausea and vomiting x Stiff neck x Photophobia x Blurred or double vision x Transient or persistent loss of consciousness x Seizures

MANAGEMENT

1. Primary management of suspected ischemic stroke is the prompt transport of patient to a stroke centre and confirmation of hemorrhage on CT scan.

2. Elevate head of bed and maintain neck in neutral position. 3. Hypertension:

x SBP targets in the first 24 hours, or in an unsecured aneurysm:

systolic < 140 mmHg or as directed by the Neurosurgeon/TP:

o labetalol: 5-10 mg IV over 2 minutes q10 min prn until target BP is reached. Maximum 300 mg

o Consider labetalol infusion 2 mg/min titrating to response 4. Seizures:

x treat following Clinical Protocol N1 - Seizures


1. Preferred treatment of aneurysmal SAH is endovascular coiling or microsurgical clipping within 24-48 hours.

2. Symptomatic vasospasm is an acute ischemic event that requires acute treatment with induced hypertension in the absence of cardiac contraindications and after the clipping or coiling of ruptured aneurysm.

HEMORRHAGIC STROKE


3. Patients with SAH are at risk of hyponatremia reflective of cerebral salt wasting. Use normal saline as IV fluid.

REFERENCES


Casaubon, L. et. al. ( 2015) Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, update 2015 Retrieved December 2018. http://www.sasksurgery.ca/pdf/Hyperacute-Guidelines-Canadian-Stroke-Best-Practices-Update2015.pdf

Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/labetalol.pdf

Society of Critical Care Medicine. (2012). Fundamental Critical Care Support 5th ed. Society of Critical Care Medicine. Mount Prospect, IL.


http://www.sasksurgery.ca/pdf/Hyperacute-Guidelines-Canadian-Stroke-Best-Practices-Update2015.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/labetalol.pdf



NEUROLOGICAL PROTOCOL N3 ISCHEMIC STROKE


DEFINITION

The acute neurologic impairment that follows an interruption in blood supply to a specific region of the brain.

INDICATIONS

After determining that the serum glucose is > 3.0 mmol/L, the patient has one or more of the following non-resolving symptoms:

x Face: right or left facial droop

x Arm: right or left sided weakness

x Speech: slurred speech

x Time: time of onset of symptoms less than 12 hours

x Vision: gaze deviated to right or left usually away from the hemiparesis

x Aphasia: naming difficulties. Patient looks at simple objects but cannot name them. Usually goes with right hemiparesis

x Neglect: ignoring right or left side of body when both sides are touched simultaneously. Usually goes with left hemiparesis

x Altered level of consciousness or the appearance of confusion

Consider brainstem stroke with decreased level of consciousness, as assessed by the Glasgow Coma Scale (GCS), and impaired eye movement or diplopia.

MANAGEMENT

1. Primary management of suspected ischemic stroke is the prompt transport of the patient to a stroke centre.

2. Hypertension: x Target SBP < 220 mmHg and DBP < 120 mmHg if asymptomatic. Avoid aggressive BP management

unless:

Post-alteplase (tPA) administration: under the guidance of the TP, keep SBP < 185 mmHg and DBP < 105 mmHg:

o Administer: � labetalol: 5-10 mg IV over 2 minutes q10 min prn until target BP is reached. Maximum 300

mg � Consider labetalol infusion 2 mg/min titrating to response

If ineffective, consider, under the direction of the TP:

ISCHEMIC STROKE


� hydrALAZINE: 5 mg IV over 2 min. Repeat as necessary q20 min o Caution: avoid dramatic reduction in blood pressure > 15-25% over 24 hours.

3. Seizures, treat following Clinical Protocol N1 – Seizures.


1. Window for administration of alteplase is 4.5 hours.

2. For endovascular therapy, all eligible patients should be treated within a 6 hour window from the time of symptom onset (or known to be well), with select patients being treated within a 12 hour time window.

3. Essential information for documentation and handover to stroke team includes: symptom onset or last seen normal, symptom duration, arrival at ED in referring centre, GCS score, FASTVAN score, serum glucose, age, co-morbidities, current medications, allergies and vital signs.

REFERENCES


Casaubon, L. et. al. ( 2015) Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care

Guidelines, update 2015 Retrieved December 2018. http://www.sasksurgery.ca/pdf/Hyperacute-Guidelines-

Canadian-Stroke-Best-Practices-Update2015.pdf

Saskatchewan Health Authority. Retrieved December 2018

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/hydrALAZINE.pdf



Saskatchewan Surgical Initiative Acute stroke pathway: thrombolysis order set. Retrieved December 2018.

http://www.sasksurgery.ca/pdf/ASP-alteplase-(tPA)-thrombolysis-order-set.pdf

Saskatchewan Surgical Initiative Acute stroke pathway: EMS standardized stroke screen. Retrieved December

2018. http://www.sasksurgery.ca/pdf/ASP-stroke-screen-form.pdf

Saskatchewan Surgical Initiative Acute stroke pathway: Initial evaluation of possible acute stroke. Retrieved

December 2018. http://www.sasksurgery.ca/pdf/ASP-initial-evaluation-acute-stroke.pdf






http://www.sasksurgery.ca/pdf/ASP-alteplase-(tPA)-thrombolysis-order-set.pdf

http://www.sasksurgery.ca/pdf/ASP-stroke-screen-form.pdf

http://www.sasksurgery.ca/pdf/ASP-initial-evaluation-acute-stroke.pdf


SECTION: OBSTETRICAL Reviewed April 2019 Page OB1-1

OBSTETRICAL PROTOCOL OB1 BREECH PRESENTATION DELIVERY

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP) and Obstetrician is required for ongoing care once stabilization has occurred.

DEFINITION

Breech presentation can be:

x Frank breech (50-70%): hips flexed, knees extended x Complete breech (5-10%: hips flexed, knees flexed x Incomplete breech (10-30 %): one or both hips extended, foot presenting

INDICATIONS

Risk factors include:

x Preterm delivery x Polyhydramnios x Multiple gestations x Length of umbilical cord x Low birth weight x Fetal abnormalities x Uterine malformation or uterine fibroids

MANAGEMENT

1. Early notification of Obstetrician on-call and TP. 2. Prepare for emergency childbirth as described in Clinical Protocol OB3 - Emergency Childbirth 3. Management of the active second stage: NON-INTERFERENCE IS THE RULE!

x Allow bearing down ONLY if the buttocks are crowning x Support the buttocks and trunk during delivery x Do not bring out the legs. HANDS OFF! Allow them to deliver spontaneously – supporting the

heels as they deliver to prevent tearing of the perineum x Rotate:

o if the anterior scapula is visible but the arms appear stuck and do not deliver spontaneously, rotate the infant 90o and gently sweep the anterior arm out of the vagina by pressing on the inner aspect of the arm or elbow. Then rotate the infant 180o in the reverse direction, and sweep the other arm out of the vagina

o when the arms are delivered rotate the infant 90o so the back is anterior x Delivery of the head:

o DO NOT actively pull on the baby o the fetal head should be maintained in a flexed position. Avoid extreme elevation of the

body and hyperextension of the neck

BREECH PRESENTATION DELIVERY


x if the head does not deliver in 4 to 6 minutes, insert a gloved hand into the vagina to create an airway to the baby, ensuring that you do not compress the umbilical cord. TRANSPORT IMMEDIATELY - DO NOT REMOVE HAND

4. Management of third and fourth stages of labor: refer to Clinical Protocol OB3 – Emergency Childbirth.


1. All gravid women 18 weeks gestation or greater must be transported in the left (preferably) or right lateral recumbent position to avoid the supine-hypotension syndrome of pregnancy.

REFERENCES

Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (2013). Breech Delivery. In Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (Eds), Williams Obstetrics, Twenty-Fourth Edition. Retrieved November 2018. http://accessmedicine.mhmedical.com/content.aspx?bookid=1057&Sectionid=59789169.

SOGC. (2009) Clinical Practice Guideline: Vaginal Delivery of Breech Presentation. https://sogc.org/wp-content/uploads/2013/01/gui226CPG0906.pdf


http://accessmedicine.mhmedical.com/content.aspx?bookid=1057&Sectionid=59789169

https://sogc.org/wp-content/uploads/2013/01/gui226CPG0906.pdf




OBSTETRICAL PROTOCOL OB2 CORD PROLAPSE

The Flight nurse/paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP)/Obstetrician is required for ongoing care once stabilization has occurred.

DEFINITION

The descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes.

INDICATIONS

x Observation of the cord presenting from the vagina, or unexpectedly palpated during vaginal exam x May be suspected with fetal bradycardia, prolonged decelerations, and/or variable decelerations x Risk factors:

o Unengaged presenting part o Malpresentation o Hydramnios o Prematurity o Low birth weight o Multiparity o Fetal abnormalities o Breech presentation o Second twin o Low lying placenta

MANAGEMENT

1. Early notification of Obstetrician on-call and TP. 2. Position the woman left or right side lying, knees to chest, with head down and hips elevated on a pillow. 3. Insert gloved hand into vagina and exert upward pressure on the fetal presenting part to stop compression

of the cord. Keep hand into position until delivery at receiving centre. 4. If you can see cord protruding from the vagina:

x Do not attempt to replace cord above the presenting part (touching the cord may cause vasospasm)

x Wrap the cord loosely in a sterile towel or gauze saturated with sterile normal saline 5. With TP/Obstetrician guidance:

x Insert foley catheter and fill bladder with 500-750 ml of normal saline to elevate fetal head from pelvic brim

CORD PROLAPSE


REFERENCES

Kish K (2013). Chapter 19. Malpresentation & Cord Prolapse. In DeCherney A.H., Nathan L, Laufer N, Roman A.S. (Eds), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. Retrieved December 16, 2015 from http://accessmedicine.mhmedical.com/content.aspx?bookid=498&Sectionid=41008609.

RCOG.(2014).Umbilical Cord Prolapse Green-top Guideline No. 50.

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-50-umbilicalcordprolapse-2014.pdf



https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-50-umbilicalcordprolapse-2014.pdf



OBSTETRICAL PROTOCOL OB3

EMERGENCY CHILDBIRTH

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Patients who require

transport and whose cervix is ≥ 4 cm in diameter require physician accompaniment. After emergency

childbirth, consultation with the Transport Physician (TP)/Obstetrician is required for ongoing care once

stabilization has occurred.

DEFINITION

Emergency childbirth is the unexpected management of the active second, third and fourth stage of labor.

x Active second stage: full dilation with active pushing

x Third stage: immediately after delivery of the baby to delivery of the placenta

x Fourth stage: Immediately after delivery of the placenta to 1 hour post-partum

INDICATIONS

Signs of imminent child birth:

x Perineum begins to distend

x Overlying skin of perineum becomes stretched

x Fetal scalp is seen through separating labia

x Reflexive bearing-down efforts

MANAGEMENT

1. Obtain obstetrical history:

Current pregnancy:

o Maturity: gestational age, estimated due date

o Multipara

o Meconium

o Medications

General obstetrical history:

o Gravida: number of pregnancies

o Term: number of term deliveries

o Premature: number of pre-term deliveries

o Abortions: therapeutic or spontaneous

o Living: number of living children

o Multiples: number of multiple births

2. Initiate preparations for emergency childbirth:

x Consider draining the bladder with an in and out catheter.

x Fetal heart monitoring q5 min if able

x Consult TP/Obstetrician and consider prophylactic antibiotic administration to mothers with

positive group B streptococcus screening, or unknown group B streptococcus status and one of

the following:



o If < 37 weeks gestation

o Amniotic membrane rupture > 18 hours

o Temperature ≥ 38 o C

x Clean hands and don PPE

x Set up equipment: delivery kit, and neonatal resuscitation equipment

x Position patient in the upright recumbent position with legs supported

x Delay pushing until presenting part is confirmed to be engaged and the woman feels an urge to

push. Ensure the patient is fully dilated and no cervix can be palpated. Some women want to

push at 7-8 cm.

3. Management of the active second stage:

x Support the head and perineum during delivery. Following delivery of the head, pass a finger

across the fetal neck to determine whether it is encircled by the umbilical cord. Slip the cord

over the head if it is loose enough. If unable to slip over the head, apply 2 clamps and cut the

cord between the clamps.

x After the delivery of the head, allow the baby to restitute, and then apply gentle downward

traction to assist the delivery of the anterior shoulder

x Following delivery of the anterior shoulder direct the baby upwards to deliver the posterior

shoulder

x Administer oxytocin: 10 units IM or 5 units IV, with delivery of the anterior shoulder, or as soon as

possible post-delivery

4. Management of the third stage:

x Clamp the cord and cut. In infants who do not require neonatal resuscitation, delay umbilical

cord clamping for 60 seconds

x Assess fundal size and consistency. Do not massage but palpate to ensure it does not become

filled with blood from placental separation. Signs of placental separation:

o Gush of blood

o Lengthening of umbilical cord

o Rise of uterus into the abdomen

x Apply gentle traction on umbilical cord

5. Management of the fourth stage of labor:

x Assess uterine tone and lochia q15 min for 2 hours

x For management of post-partum hemorrhage see Clinical Protocol OB5 – Post-Partum

Hemorrhage

x Examine umbilical cord, membranes and placenta for completeness. Preserve placenta and

cord in a plastic bag to take to receiving center

6. Perform newborn resuscitation if required. Perform and record 1 and 5 minute APGAR scores.



retrieved November 2018 https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-

Practice/The-Apgar-Score?IsMobileSet=false


1. All gravid women 18 weeks gestation or greater must be transported in the left (preferably) or right

lateral recumbent position to avoid the supine-hypotension syndrome of pregnancy.

REFERENCES

AHS/critical care MCPs

(v2.0)/obstetrics.RetrievedNovember2018https://www.ahsems.com/public/protocols/templates/desktop/#set/

13/browse/4965/view/40974/Algorithm

Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (2013).

Vaginal Delivery. In Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M.,

Sheffield J.S. (Eds), Williams Obstetrics, Twenty-Fourth Edition. Retrieved December 16, 2015 from


Saskatchewan Health Authority. Retrieved November 2018

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/Oxytocin.pdf

SOGC. (2016). SOCG Clinical practice Guideline: Management of Spontaneous Labour at Term in Healthy Women. Retrieved November 2018. https://www.jogc.com/article/S1701-2163(16)39222-2/pdf

SOGC.(2013). SOGC Clinical Practice Guideline: The prevention of Early-Onset Neonatal Group B streptococcal Disease. Retrieved November 2018. https://sogc.org/wp-ontent/uploads/2013/09/October2013-

CPG298-ENG-Online_Final.pdf

SOGC.(2005). Maternal Transport Policy. Journal of Obstetrics and Gynaecology Canada. Volume 27, Issue

10, pp 956-959.


https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/The-Apgar-Score?IsMobileSet=false

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/The-Apgar-Score?IsMobileSet=false




https://www.jogc.com/article/S1701-2163(16)39222-2/pdf

https://sogc.org/wp-ontent/uploads/2013/09/October2013-CPG298-ENG-Online_Final.pdf

https://sogc.org/wp-ontent/uploads/2013/09/October2013-CPG298-ENG-Online_Final.pdf



OBSTETRICAL PROTOCOL OB4 HYPERTENSION IN PREGNANCY

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP)/Obstetrician is required for ongoing care once stabilization has occurred.

DEFINITION

A systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg based on the average of at least 2 measurements taken at least 15 minutes apart, using the same arm, or SBP ≥ 160 mmHg or DBP ≥ 110mmHg at any time. Hypertensive disorders of pregnancy should be classified as pre-existing hypertension, gestational hypertension, preeclampsia, severe pre-eclampsia or eclampsia.

INDICATIONS

Pre-existing hypertension: develops pre-pregnancy or at < 20 weeks gestation

Gestational hypertension: new onset hypertension at ≥ 20 weeks gestation

Pre-eclampsia: gestational hypertension presenting after 20 weeks gestation up to 1 week after delivery, with new proteinuria

Severe Pre-eclampsia: gestational hypertension with new proteinuria, and symptoms of end-organ involvement including, but not limited to: oliguria (urine output < 30 ml/h for 3 consecutive hours), acute renal failure, pulmonary edema, RUQ abdominal pain, impaired liver function, headache, visual changes and thrombocytopenia

Eclampsia: severe pre-eclampsia with generalized tonic-clonic seizures. Complications include: intracranial hemorrhage or hypertension, and stroke

MANAGEMENT

1. Hypertension: Target SBP < 160 mmHg and DBP < 110 mmHg. Under the direction of the TP, administer: x labetalol: 20 mg slow IV push. Repeat 20-80 mg IV q30 min to a maximum of 300 mg x Alternatively labetalol: 1-2 mg/min infusion x If ineffective, consider: hydralazine: 2.5-5 mg IV q 30min to a maximum of 20 mg

2. Pulmonary edema:

x Invasive or non-invasive positive-pressure ventilation may be required. Target Sp02 ≥ 94% to prevent fetal hypoxia and acidosis

x nitroGLYCERIN: infusion as directed by the TP

3. Seizures: x Administer:

x LORazepam: 0.1 mg/kg IV to a maximum of 4 mg

Or:

HYPERTENSION IN PREGNANCY


x midazolam: 0.2 mg/kg at a rate of 2mg/min up to a maximum of 10 mg. Can also be given IM

x Administer: x MgS04:4 grams IV in 100ml over 30 minutes, contact the TP/Obstetrician and initiate: x MgS04: 1 gram/h IV infusion [mixed 4g/100ml (or 20g/500ml)]

x For recurrent seizures: x MgS04: 2 grams IV in 100ml over 30 minutes x Increase MgS04 infusion to 1.5 grams/hr

x Monitor reflexes q1h and document as: x 0 Flat, no response x 1+ Somewhat diminished, low normal x 3+ Brisk, more than average x 4+ Very brisk, indicative of CNS abnormality

x Target urine output > 30ml/h


1. Intubation should be approached with caution due to the potential for hypoxemia during induction, the increased risk of aspiration and the possibility of oropharyngeal edema. Consider a smaller endotracheal tube.

2. Patients are often intravascularly fluid depleted but fluid must be given cautiously because of the increased risk of pulmonary edema.

3. Complications of MgS04 administration include: somnolence, lethargy, loss of deep tendon reflexes, hypotension, bradycardia, prolonged PR interval, prolonged QRS interval, respiratory paralysis. Toxic levels > 5 mmol/L can cause fatal arrhythmia and respiratory arrest. Treatment, under the direction of the TP, may include:

x Calcium Chloride 1-2 grams (5-10 ml) of 10% solution over 2-3 minutes x Stop MgS04 infusion

REFERENCES

AHS Critical Care MCPs (v2.0)/Poisons/Toxins https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4964/view/40959/Algorithm

Children’s Hospital of Saskatchewan (2017). Children’s Hospital of Saskatchewan Saskatoon Health Region Policy and Procedure Manual. Policy 520: Intravenous Magnesium Sulphate for the Treatment of Hypertensive Disorders in Pregnancy.

American Heart Association. (2017). ACLS for Experienced Providers Manual and Resource Text. American Heart Association.

Saskatchewan Health Authority. Retrieved December 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/hydrALAZINE.pdf

Saskatchewan Health Authority. Retrieved December 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/LORazepam.pdf

Saskatchewan Health Authority. Retrieved December 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/midazolam.pdf




HYPERTENSION IN PREGNANCY


Saskatchewan Health Authority. Retrieved December 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/magnesium%20sulfate.pdf

Society of Critical Care Medicine. ( 2012). Fundamental Critical Care Support. Mount Prospect Il.

SOGC. (2013) Diagnosis Evaluation and Management of the Hypertensive Disorders of Pregnancy. Clinical practice guideline Society.


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/magnesium%20sulfate.pdf



OBSTETRICAL PROTOCOL OB5 OBSTETRICAL HEMORRAGE: POST-PARTUM HEMORRAGE


DEFINITION

Persistent hemorrhage > 500 ml post vaginal delivery or > 1000ml post C-section.

Obstetrical hemorrhage is difficult to define because reflex tachycardia and subsequent hypotension will not occur until a large volume of blood is lost. Estimation of blood loss is difficult for inexperienced caregivers. Women with pre-eclampsia or severe pre-eclampsia may be particularly susceptible to hemorrhage because blood volume expansion is less than expected.

MANAGEMENT

1. Early notification of Obstetrician on-call and TP. 2. Determine source of bleeding:

x Tone: uterine atony, distended bladder x Tissue: retained placenta and clots x Trauma: vaginal, cervical, or uterine injury x Thrombin: coagulopathy (pre-existing or acquired)

3. If the placenta is still in situ, encourage spontaneous delivery and ask the mother to bear down. If the babe is delivered, encourage the mother to initiate breast feeding. DO NOT jerk or pull the placental cord.

4. After delivery of the placenta, perform direct fundal pressure as required to halt the bleeding. 5. Persistent hemorrhage > 500 ml post vaginal delivery or > 1000ml post C-section initiate:

x oxytocin: infusion (30 mU/500ml) at 40-80 mu/min titrating to uterine tone and to sustain uterine contractions

x Place foley catheter to ensure bladder is empty to promote contraction of the uterus 6. If bleeding persists, despite maximum oxytocin infusion, administer misoprostol: 800 mcg buccal. 7. If bleeding persists, under the direction of the TP, administer:

x tranexamic acid: 1g IV in 50 ml over 10 min 8. Hypotension:

x Administer NS or RL fluid challenge 1-2 L x If patient is unresponsive to fluid challenge, administer 2 units un-crossmatched PRBC x If the patient is unresponsive to PRBC initiate norepinephrine: infusion 0.03-1.5 mcg/kg/min

9. Bakri post-partum balloon may be in placed intra-vaginally or intra-abdominally (post C-section) by a sending physician:

x Placement is done under ultrasound to ascertain that the entire balloon is inserted past the cervical canal and internal ostium

x Volume of uterus is determined by ultrasound or direct examination. Balloon is inflated with sterile saline or water

OBSTETRICAL HEMORRAGE: POST-PARTUM HEMORRAGE


x Apply gentle traction to the balloon shaft to ensure proper contact between the balloon and tissue surface by securing the balloon shaft to the patient’s leg

x Connect drainage port to a fluid collection bag to monitor hemostasis. Clear clots from drainage port with sterile saline

x Monitor and measure drainage q15min 10. If hemorrhage begins while on route with the patient, the only option may be to provide bimanual

compression of the uterus. Place one hand in the vagina and push against the body of the uterus and with the other hand compress the fundus from above through the abdominal wall.


1. Analgesic may be necessary during the administration of fundal pressure, oxytocin, and misoprostol. 2. All gravid women 18 weeks gestation or greater must be transported in the left (preferably) or right

lateral recumbent position to avoid the supine-hypotension syndrome of pregnancy (the gravid uterus may compress the vena cava, leading to decreased venous return, decreased cardiac output, and compromised blood flow to the uterus and other organs).

Risk factors for obstetrical hemorrhage: Injuries to the Birth Canal Episiotomy and lacerations Forceps or vacuum delivery Cesarean delivery or hysterectomy Uterine rupture Previously scarred uterus High parity Hyper-stimulation Obstructed labor Intrauterine manipulation Mid-forceps rotation Breech extraction Obstetrical Factors Obesity Previous postpartum hemorrhage Sepsis syndrome Vulnerable Patients Preeclampsia/eclampsia Chronic renal insufficiency Constitutionally small size

Uterine Atony Uterine over-distention Large fetus Multiple fetuses Hydramnios Retained clots Labor induction Anesthesia or analgesia Halogenated agents Conduction analgesia with hypotension Labor abnormalities Rapid labor Prolonged labor Augmented labor Chorioamnionitis Previous uterine atony Coagulation Defects—Intensify Other Causes Massive transfusions Placental abruption Sepsis syndrome Severe preeclampsia syndrome Acute fatty liver Anticoagulant treatment Congenital coagulopathies Amnionic-fluid embolism Prolonged retention of dead fetus Saline-induced abortion

Table 41.2 Williams Obstetrics

OBSTETRICAL HEMORRAGE: POST-PARTUM HEMORRAGE


REFERENCES

Bakri postpartum Balloon Retrieved November 2018. https://www.cookmedical.com/products/wh_sosr_webds/

Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (2013). Obstetrical Hemorrhage. In Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (Eds), Williams Obstetrics, Twenty-Fourth Edition. Retrieved December 17, 2015 from http://accessmedicine.mhmedical.com/content.aspx?bookid=1057&Sectionid=59789185.

Gibbs, Ronald S.; Karlan, Beth Y.; Haney, Arthur F.; Nygaard, Ingrid E., 2008. Danforth’s Obstetrics and Gynecology, retrieved from http://ovidsp.tx.ovid.com/sp-3.11.0a/ovidweb.cgi?&S=FFFDFPBFPADDAPCANCMKCAJCIKEHAA00&Link+Set=S.sh.25%7c3%7csl_10.

Poggi S.H. (2013). Chapter 21. Postpartum Hemorrhage & the Abnormal Puerperium. In DeCherney A.H., Nathan L, Laufer N, Roman A.S. (Eds), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. Retrieved December 17, 2015 from http://accessmedicine.mhmedical.com/content.aspx?bookid=498&Sectionid=41008611.

Perinatal Services B.C. (2011) Managing Labour Decision support Tool n. 7. Postpartum Hemorrhage. Retrieved November 2018. http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/7CoreCompDSTPPHemorrhage.pdf

SOGC (2009). Clinical Practice Guideline: Active management of the Third Stage of Labour Prevention and Treatment of Postpartum Hemorrhage. Retrieved November 2018 https://sogc.org/wp-content/uploads/2013/01/gui235CPG0910.pdf

RCOG (2011). Antepartum Haemorrhage Gree-top Guideline No. 63 Retrieved November 2018. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf


https://www.cookmedical.com/products/wh_sosr_webds/


http://ovidsp.tx.ovid.com/sp-3.11.0a/ovidweb.cgi?&S=FFFDFPBFPADDAPCANCMKCAJCIKEHAA00&Link+Set=S.sh.25%7c3%7csl_10



http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/7CoreCompDSTPPHemorrhage.pdf

http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/7CoreCompDSTPPHemorrhage.pdf



https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf


SECTION: OBSTETRICAL Reviewed April 2019 OB6-1

OBSTETRICAL PROTOCOL OB6 OBSTETRICAL HEMORRHAGE – 3RD TRIMESTER


DEFINITION

Obstetrical hemorrhage is difficult to define because of the failure of the pulse and blood pressure to undergo more than moderate alterations until large volume of blood is lost. Estimation of blood loss is difficult for inexperienced caregivers. Women with pre-eclampsia or severe pre-eclampsia may be particularly susceptible to hemorrhage because blood volume expansion is less than expected.

MANAGEMENT

1. Early notification of Obstetrician on-call and TP. 2. Assess for risk factors that indicate abruption and placenta previa:

x Determine if there is pain associated with the hemorrhage. Continuous pain may indicate placental abruption. Labor should be considered if pain is intermittent

x Palpation of uterus: x Tense uterus indicates a significant abruption x Contractions may be felt if patient is in labor x Soft non-tender uterus may suggest a lower genital cause or bleeding from placenta or

vasa previa 3. Hypotension:

x Position patient in left (preferable) or right lateral recumbent position x Administer NS or RL fluid challenge 1-2 L x If patient is unresponsive to fluid challenge, administer 2 units un-crossmatched PRBC x Initiate norepinephrine: infusion 0.03-1.5 mcg/kg/min

4. If bleeding persists under the direction of the transport physician administer: x tranexamic acid: 1 gram IV in 50 ml over 10 min

5. Monitor fetal heart rate q15min: x If fetal heart tones are not reassuring administer oxygen to mother

6. With the guidance of the Obstetrician and/or TP consider corticosteroid administration to women between 24-36 weeks gestation.


1. Do not perform vaginal exam. 2. All gravid women 18 weeks gestation or greater must be transported in the left (preferably) or right

lateral recumbent position to avoid the supine-hypotension syndrome of pregnancy (the gravid uterus may compress the vena cava, leading to decreased venous return, decreased cardiac output, and compromised blood flow to the uterus and other organs).

3. Tocolytics are contraindicated in placental abruption. 4. Risk factors for obstetrical hemorrhage:

OBSTETRICAL HEMORRHAGE – 3RD TRIMESTER

SECTION: OBSTETRICAL Reviewed April 2019 PageOB6-2

x Abnormal Placentation Placenta previa Placental abruption Placenta accreta/increta/percreta Ectopic pregnancy Hydatidiform mole

x Obstetrical Factors Obesity Early preterm pregnancy Sepsis syndrome

x Vulnerable Patients Preeclampsia/eclampsia Chronic renal insufficiency Constitutionally small maternal size

x Coagulation Defects—Intensify Other Causes Massive transfusions Placental abruption Sepsis syndrome Severe preeclampsia syndrome Acute fatty liver Anticoagulant treatment Congenital coagulopathies Amniotic fluid embolism

REFERENCES Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (2013). Obstetrical Hemorrhage. In Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (Eds), Williams Obstetrics, Twenty-Fourth Edition. Retrieved December 17, 2015 from http://accessmedicine.mhmedical.com/content.aspx?bookid=1057&Sectionid=59789185.

Gibbs, Ronald S.; Karlan, Beth Y.; Haney, Arthur F.; Nygaard, Ingrid E., 2008. Danforth’s Obstetrics and Gynecology, retrieved from http://ovidsp.tx.ovid.com/sp-3.11.0a/ovidweb.cgi?&S=FFFDFPBFPADDAPCANCMKCAJCIKEHAA00&Link+Set=S.sh.25%7c3%7csl_10 RCOG (2011). Antepartum Haemorrhage Gree-top Guideline No. 63 Retrieved November 2018. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf








OBSTETRICAL PROTOCOL OB7 SHOULDER DYSTOCIA

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP)/Obstetrician is required for ongoing care once stabilization has occurred.

DEFINITION

The head emerges and retracts against the perineum and external rotation does not occur. The anterior shoulder cannot pass under the pubic arch.

INDICATIONS

Signs during birth may include:

x Slow crowning of the fetal head x Difficulty with the delivery of face or chin x Turtle sign: the head recoils against the perineum x There is no spontaneous external rotation and restitution x Failure of the shoulders to descend x Failure to deliver with maternal expulsive efforts

Risk factors:

x Previous shoulder dystocia x Fetal macrosomia. Risk factors include: excessive weight gain > 35 lbs during pregnancy, maternal

obesity, post-dates pregnancy, parity x Diabetes

Progression of symptoms is unpredictable. Patients may suddenly deteriorate into cardiac arrest.

MANAGEMENT

1. Early notification of Obstetrician on-call and TP. 2. Prepare for emergency childbirth as described in Clinical Protocol OB3 - Emergency Childbirth. 3. Management of the active second stage: ALARMER

x Ask the mother not to push x Ask for help x Lift and hyperflex woman’s legs:

o Flatten head of bed o Knees to chest, supporting mother’s legs

x Anterior shoulder disimpaction: o Assume position similar to CPR compressions o Using both hands apply the heel of clasped hands just above the pubic bone o With straight arms, use your body to apply pressure downward from the posterior aspect

of the anterior shoulder to dislodge it x Rotation of the posterior shoulder:

SHOULDER DYSTOCIA


o Push the shoulders from behind the scapula toward the face of the baby, rotating the shoulders into an oblique diameter

Or:

o Apply pressure to the anterior aspect of the posterior shoulder to rotate the posterior shoulder to the anterior position

x Manual removal of posterior arm: o Grasp the posterior arm, sweep it across chest and deliver

x Episiotomy: o Consider with obstetrician/transport physician guidance only if there is not enough room

for hand maneuvers x Roll woman onto hands and knees position

4. Management of third and fourth stages of labor: refer to Clinical Protocol OB3 – Emergency Childbirth.


1. Umbilical cord pH drops as the dystocia continues which becomes clinically significant after 5 minutes. Complications after 6 minutes include increased risk of neonatal depression, acidosis, asphyxia, central nervous system damage, and death.

2. Risks to post-partum mothers include: postpartum hemorrhage from uterine atony, vaginal and cervical lacerations, uterine rupture, rectovaginal fistulas, vaginal hematomas, bladder injuries, pubic symphysis separation, and infection.

REFERENCES

AGOC. (2017) Practice Bulletin No 178: Shoulder Dystocia. https://journals.lww.com/greenjournal/Fulltext/2017/05000/Practice_Bulletin_No_178___Shoulder_Dystocia.47.aspx

Perinatal Services BC. (2009). Registered Nurse Initiated Activities Decision support tool No. 8B Obstetrical Emergencies – Shoulder Dystocia http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/8BCoreCompDSTOBEmergShoulderDystocia.pdf

RCOG. (2012). Shoulder Dystocia Green-top guideline No. 42 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf


https://journals.lww.com/greenjournal/Fulltext/2017/05000/Practice_Bulletin_No_178___Shoulder_Dystocia.47.aspx

https://journals.lww.com/greenjournal/Fulltext/2017/05000/Practice_Bulletin_No_178___Shoulder_Dystocia.47.aspx

http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/8BCoreCompDSTOBEmergShoulderDystocia.pdf

http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/8BCoreCompDSTOBEmergShoulderDystocia.pdf



SECTION: OBSTETRICAL Reviewed April 2019 Page 0B8-1

OBSTETRICAL PROTOCOL OB8 WOMEN IN LABOR

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP)/Obstetrician is required for ongoing care if labor progresses.

DEFINITION

Clinical onset of the first stage of labor is heralded by the spontaneous release of a small amount of blood-tinged mucus from the vagina, the onset of intense, regular uterine contractions, accompanied by cervical effacement and dilation.

INDICATIONS

x Cervical effacement and dilation x Regular, intense uterine contractions

Criteria for physician escort:

x If the patient is in established labor with regular contractions less than 10 minutes apart, and the cervix is dilated ≥ 4 cm

MANAGEMENT

1. Prior to transport the referring physician, RN or NP must examine the woman in labor or with prematurely ruptured membranes to determine the status of cervical dilation and effacement within 15 minutes to transfer of care to the air medical crew.

2. Prior to transport the following information must be obtained: x Fetal heart rate and movement x Onset, frequency, strength and length of contractions, and resting tone x Membrane status, and, if ruptured, a description of the fluid x Show, bleeding, and amount x Woman’s response to labor: emotional status and pain scale x Detailed obstetrical history:

o EDC (estimated date of confinement): term/pre-term, gestational age o Para/gravida o Previous pregnancies o Previous labors and deliveries o Pre-existing medical conditions o Group B streptococcus status if known o Prenatal care o Ultrasound: number of fetus and location of placenta

x Early consultation with Obstetrician with potential complications is advised

3. All gravid women 18 weeks gestation or greater must be transported in the left (preferably) or right lateral recumbent position to avoid the supine-hypotension syndrome of pregnancy.

WOMEN IN LABOR

SECTION: OBSTETRICAL Reviewed: April 2019 Page OB8-2

4. All women with ruptured membranes must be on a stretcher for all aspects of transport.

5. Assessment of patient during labor:

x Identify uterine contraction patterns that might adversely affect oxygen delivery to the fetus. o Palpate the uterus by hand during and after contraction for frequency, duration,

intensity and resting tone x Auscultate fetal heart tones q30 min in the early stages of labour. Increase frequency to q15

min when the contractions are < 5 min apart o Place the Doppler over the area of maximum intensity of fetal heart sounds, usually over

the fetal back or shoulder o Listen to the FHR and place a finger on the mother’s radial pulse to differentiate maternal

heart rate from fetal heart rate o Establish a baseline FHR by listening for a full minute. Following this FHR should be

auscultated immediately after a contraction for a minimum of 30 seconds o Assess rhythm (regular or irregular), presence of accelerations, and presence of

decelerations

Normal FHR Abnormal FHR

x Baseline FHR 110-160 bpm x Regular rhythm x Presence of accelerations

x Baseline FHR < 110 bpm x Baseline FHR > 160 bpm x Irregular rhythm x Changing FHR x Decelerations – abrupt or gradual decrease in

FHR

Taken from Perina Managing Labour Decision Support tool No 2. Intrapartum Fetal Health Surveillance. Retrieved December 2018. http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/2CoreCompDSTIntrapartumFHS.pdf

6. If abnormal FHR assess for potential causes and intervene: x Check maternal vital signs x Improve uterine and umbilical blood flow:

o Reposition o Fluid bolus Normal Saline or Ringers Lactate 250-500ml

x Improve oxygenation: o Apply oxygen by Non-rebreathing mask

x If FHR remains abnormal consult Obstetrician and TP

7. Provide comfort measures which may include: x Encourage escort to accompany patient x Clear communication of transport expectations, treatments and procedures x Sips of water if there is a low risk of general anesthetic being required x Anti-emetics as required x Non-pharmacologic measures of comfort: repositioning, deep breathing exercises, focal point

concentration, massage x Pharmacologic measures for comfort:

o fentanyl: 25-50 mcg IV

ADDITIONAL CONSIDERATIONS

1. Documenting contractions:

http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/2CoreCompDSTIntrapartumFHS.pdf

WOMEN IN LABOR

SECTION: OBSTETRICAL Reviewed: April 2019 Page OB8-3

x Frequency of contractions are quantified as the number of contractions present in a 10 minute period, averaged over 30 minutes, or may be estimated from the beginning of one contraction to the beginning of the next and described in minutes apart

x Intensity of contractions by palpation is described as mild, moderate or strong x Resting tone by palpation is described as soft or firm

2. Documenting Fetal Heart Tones:

x Rate in beats per minute x Rhythm as regular or irregular x Presence/absence of accelerations x Presence and type of decelerations

REFERENCES

AGOC. (2018). Approaches to Limit Intervention During Labor and Birth. Retrieved December 2018. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth?IsMobileSet=false

Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (2013). Vaginal Delivery. In Cunningham F, Leveno K.J., Bloom S.L., Spong C.Y., Dashe J.S., Hoffman B.L., Casey B.M., Sheffield J.S. (Eds), Williams Obstetrics, Twenty-Fourth Edition. Retrieved December 2018 from https://accessmedicine.mhmedical.com/content.aspx?bookid=1057&sectionid=59789161#1102112739

Perinatal Services BC. (2011). Registered Nurse Initiated Activities decision support tool No. 2: Intrapartum Fetal Health Surveillance. Retrieved December 2018. http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/2CoreCompDSTIntrapartumFHS.pdf

Perinatal Services BC. (2011). Registered Nurse Initiated Activities decision support tool No. 5: Discomfort and Pain in Labour. Retrieved December 2018. http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/5CoreCompDSTLabourDiscomfortandPain.pdf

SOGC. (2016). Management of Spontaneous Labour at Term in Healthy Women. Retrieved December 2018. https://www.jogc.com/article/S1701-2163(16)39222-2/pdf

SGOC. (2005). Maternal Transport Policy. Retrieved December 2018. https://medicine.usask.ca/documents/cme/SOGCMaternalTransportGuide.pdf


https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth?IsMobileSet=false

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth?IsMobileSet=false

https://accessmedicine.mhmedical.com/content.aspx?bookid=1057&sectionid=59789161#1102112739



https://www.jogc.com/article/S1701-2163(16)39222-2/pdf

https://medicine.usask.ca/documents/cme/SOGCMaternalTransportGuide.pdf


SECTION: POISONING - TOXICITIES Reviewed April 2019 Page P1-1

POISONING – TOXICITIES PROTOCOL P1 BETA BLOCKER TOXICITY


DEFINITION

Beta blocker toxicity results in an anti-adrenergic effect on the heart that includes negative inotropic and negative chronotropic effects.

INDICATIONS

Ominous signs of a toxic dose of a beta blocker include:

x Hypotension: from anti-adrenergic effects x Bradycardia: from depression of SA node, AV node, intra-ventricular conduction or heart-block that can

progress to ventricular arrhythmias including torsades de pointes and VF, ending in PEA and cardiac arrest

x Bronchospasm x Hypoglycemia x Hyperkalemia x Decreased level of consciousness and seizures caused by hypo-perfusion of the brain (late sign) x Sudden decompensation into shock

Progression of symptoms is typically within 2-4 hours after ingestion of regular-release preparations. Failure to develop symptoms within 4-6 hours after regular-release ingestion indicates that moderate to severe toxicity is unlikely to occur. Toxic effects of controlled-release and long-acting preparations may not be seen for up to 6-18 hours after ingestion.

MANAGEMENT

1. Unstable Bradycardia: x Initiate transcutaneous pacing

2. Hypotension and shock:

x Administer NS or RL fluid challenge 500-1000ml x If patient is unresponsive to fluid bolus or if signs and symptoms of pulmonary edema prevent

further fluid resuscitation, initiate one or more of the following: x DOPamine: 5-20 mcg/kg/min x norepinephrine: 0.03-0.15 mcg/kg/min x EPINEPHrine infusion: 0.1-0.3 mcg/kg/min

3. If patient is unresponsive to vasopressors, under direction of the TP, administer:

x glucagon: 3 mg IVP followed by an infusion of 3 mg/hr. Dose varies according to patient response

BETA BLOCKER TOXICITY


4. If patient is unresponsive to glucagon under direction of the TP, administer: x humulin R insulin:1unit/kg IV x dextrose: 0.5 gram/kg IV (maximum dose 25 grams)

Followed by: x humulin R insulin: 0.5 units/kg/hr infusion x dextrose: 0.5 gram/kg/hr IV infusion of D10W, maximum 25 grams/hr or 250 ml/hr x Check serum glucose and serum potassium prior to initiating therapy x Monitor serum glucose q15 min to maintain a blood glucose 5.5-14 mmol/L x Monitor serum potassium q1h. Replace if < 2.5 mmol/L

5. Treat seizures following Clinical Protocol N1 - Seizures.


1. Other medications that may be useful under the guidance of the transport physician include an isoproterenol infusion, or intravenous lipid emulsion infusion if available.

2. How to mix a dextrose infusion. Note: high concentrations of dextrose are a vesicant. Monitoring of IV site is imperative.


D10W D5W 500ml (25g dextrose) 50ml of D50W (25g) 50g/500ml= 10% solution

REFERENCES

AHS Critical Care MCPs (v2.0)/Poisons/Toxins https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4964/view/40958/Notes


Bartlett, D. (2016) B-Blocker and Calcium Channel Blocker Poisoning: High-Dose Insulin/Glucose Therapy. Critical Care Nurse. Retrieved November 2018 http://ccn.aacnjournals.org/content/36/2/45.full

Kerns, W. (2007) Management of b-Adrenergic Blocker and Calcium Channel Antagonist Toxicity. Emergency Medicine Clinics of North America 25(2007) 3009-3311. Retrieved November 2018 https://ac.els-cdn.com/S0733862707000168/1-s2.0-S0733862707000168-main.pdf?_tid=6a6c14c7-22e4-4020-a96c-21844bf7c155&acdnat=1541178146_bdbef3ee137d2460e413261ce333fefc

Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/dextrose%2050%20percent.pdf

Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/glucagon.pdf



https://ac.els-cdn.com/S0733862707000168/1-s2.0-S0733862707000168-main.pdf?_tid=6a6c14c7-22e4-4020-a96c-21844bf7c155&acdnat=1541178146_bdbef3ee137d2460e413261ce333fefc




https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/glucagon.pdf



POISONING – TOXICITIES PROTOCOL P2 CALCIUM CHANNEL BLOCKER TOXICITY


DEFINITION

Calcium channel blocker toxicity results in an anti-adrenergic effect on the heart that includes negative inotropic and negative chronotropic effects, atrio-ventricular node blockade, and varying degrees of direct vasodilatory properties. Metabolic effects also occur because insulin release is dependent on calcium influx into cells, and calcium channel blocker-induced insulin resistance.

INDICATIONS

Ominous signs of a toxic dose of a calcium channel blocker include:

x Hypotension: from anti-adrenergic effects x Bradycardia from depression of SA node, AV node, intra-ventricular conduction or heart-block that can

progress to PEA and cardiac arrest x Hyperglycemia x Heart failure x Decreased level of consciousness and seizures caused by hypoperfusion of brain (late sign) x Sudden decompensation into shock

Progression of symptoms is typically within 2-4 hours after ingestion of regular-release preparations. Failure to develop symptoms within 4-6 hours after regular-release ingestion indicates that moderate to severe toxicity is unlikely to occur. Toxic effects of controlled-release and long-acting preparations may not be seen for up to 6-18 hours after ingestion.

MANAGEMENT

1. Unstable bradycardia: x Initiate transcutaneous pacing

2. Hypotension and shock:

x Administer NS or RL fluid challenge 500-1000ml x If patient is unresponsive to fluid bolus or if signs and symptoms of pulmonary edema or heart

failure prevent further fluid resuscitation, initiate one or more of the following: x DOPamine: 5-20 mcg/kg/min x norepinephrine: 0.03-0.15 mcg/kg/min x EPINEPHrine: 0.1-0.3 mcg/kg/min

x If patient is unresponsive to fluid bolus and vasopressors under direction of TP administer: x calcium chloride: 0.5-1 gram (5-10 ml) of a 10% solution in 100ml over 5 min. Reduce rate

of infusion if hypotension is not life-threatening x May be repeated every 10-20 minutes until clinical effect is achieved

CALCIUM CHANNEL BLOCKER TOXICITY


3. If patient is unresponsive to calcium, under direction of the TP administer: x glucagon 3 mg IVP followed by an infusion of 3mg/h. Dose varies according to patient response

4. If patient is unresponsive to glucagon, under direction of the TP administer:

x humulin R insulin: 1 unit/kg IV x dextrose: 0.5 g/kg IV (maximum dose 25 grams)

Followed by: x humulin R insulin: 0.5 units/kg/hr infusion x dextrose: 0.5 gram/kg/hr IV infusion of D10W, maximum 25 grams/hr or 250 ml/hr x Check serum glucose and serum potassium prior to initiating therapy x Monitor serum glucose q15min to maintain a blood glucose 5.5-14 mmol/L x Monitor serum potassium q1h. Replace if < 2.5 mmol/L



1. Do not administer calcium chloride if digoxin toxicity is suspected.

2. Other medications that may be useful under the guidance of the TP include intravenous lipid emulsion infusion if available.

3. How to mix a dextrose infusion. Note: high concentrations of dextrose are a vesicant. Monitoring of IV site is imperative.


D10W D5W 500ml (25g dextrose) 50ml of D50W (25g) 50G/500ml= 10% solution

REFERENCES



Bartlett, D. (2016) B-Blocker and Calcium Channel Blocker Poisoning: High-Dose Insulin/Glucose Therapy. Critical Care Nurse. Retrieved November 2018 http://ccn.aacnjournals.org/content/36/2/45.full

Kerns, W. (2007) Management of b-Adrenergic Blocker and Calcium Channel Antagonist Toxicity. Emergency Medicine Clinics of North America 25(2007) 3009-3311. Retrieved November 2018 https://ac.els-cdn.com/S0733862707000168/1-s2.0-S0733862707000168-main.pdf?_tid=6a6c14c7-22e4-4020-a96c-21844bf7c155&acdnat=1541178146_bdbef3ee137d2460e413261ce333fefc

Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/calcium%20chloride.pdf

Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/dextrose%2050%20percent.pdf






https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/calcium%20chloride.pdf


CALCIUM CHANNEL BLOCKER TOXICITY


Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/glucagon.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/glucagon.pdf



POISONING – TOXICITIES PROTOCOL P3 CHOLINESTERASE TOXICITY


DEFINITION

Cholinergic syndrome typically occurs following exposure to organophosphate or carbamate insecticides, chemical nerve agents or nicotine, muscarine/poisonous mushrooms, or neostigmine. Exposure can occur through inhalation, skin and mucous membranes, or oral ingestion.

INDICATIONS

SLUDGEM: salivation, lacrimation, urination, defecation, gastrointestinal symptoms, emesis, miosis.

DUMBELLS: diarrhea, urination, miosis, bradycardia, bronchorrhea, bronchospasm, emesis, lacrimation, salivation, secretion, sweating.

Nicotinic and muscarinic toxicity leads to altered level of consciousness, coma and seizures.

MANAGEMENT

1. Decontamination: x Preferably should be done by trained personnel prior to transport x Wear PPE including: mask, eye protection, gown and gloves x Remove all clothing and jewelry and contain in plastic bags. Do not bring exposed belongings

on aircraft

2. Airway secretions and bronchospasm: x Manage airway and mechanical ventilation as required. Refer to Clinical Protocol R1 – Airway

Management and Clinical Protocol R4 – Mechanical Ventilation. x Under TP guidance administer:

x atropine: 2-5 mg IV q5 minutes until the patient’s bronchial secretions decrease and adequate oxygenation is achieved and maintained. Continue dosing if patient symptoms recur

x If available, pralidoxime: 1-2 grams over 30 minutes followed by 500 mg/hr

3. Hypotension and shock: x Target MAP 65 mmHg x Administer NS or RL fluid challenge 500-1000ml x If patient is unresponsive to fluid bolus or if signs and symptoms of pulmonary edema or heart

failure prevent further fluid resuscitation, initiate one or more of the following: x DOPamine: 5-20 mcg/kg/min x norepinephrine: 0.03-0.15 mcg/kg/min


Cholinesterase toxicity



1. Atropine must be given before pralidoxime but after adequate ventilation has been established.

2. Atropine may cause tachycardia but this is not a contraindication for administration. It should be given in under 1 minute or paradoxical bradycardia may occur.

3. Organophosphates include: malathion, parathion, and nerve agents. Carbamates include: carbofuran, carbaryl and bisphenol-A (BPA).

4. Pralidoxime is not indicated in carbamate insecticide toxicity.

REFERENCES



Pollak, A. (2018) Critical Care Transport. Jones and Bartlett Learning. Burlington, MA.

Saskatchewan Health Authority. Retrieved January 2019 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/pralidoxime.pdf

Saskatchewan Health Authority. Retrieved January 2019 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/atropine.pdf



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/pralidoxime.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/atropine.pdf



POISONING - TOXICITIES PROTOCOL P4 COCAINE TOXICITY


DEFINITION

Cocaine stimulates the release, then blocks the re-uptake of norepinephrine, epinephrine, dopamine and serotonin. Toxicity causes myocardial ischemia due to a mismatch of oxygen delivery and supply. Increased platelet adhesiveness increases risk for clot, and beta-adrenergic effects causes increased myocardial oxygen demand. Hyperpyrexia can result from thermoregulatory problems adding to metabolic consumption. It acts as a sodium channel blocker causing ventricular arrhythmias.

INDICATIONS

x Tachycardia: x Arrhythmias above the ventricles: sinus tachycardia, SVT, rapid atrial fibrillation/atrial flutter x Arrhythmias below the ventricles: stable ventricular tachycardia, pulseless ventricular

tachycardia and ventricular fibrillation x Hypertension: pulmonary edema, intracranial hemorrhage, seizures x Hyperthermia x Diaphoresis x Mydriasis x Agitation x Acute coronary syndrome x Rhabdomyolysis and renal failure

MANAGEMENT

1. Arrhythmias above the ventricles: x midazolam: 0.05-0.1 mg/kg IV repeating as necessary to achieve a reduction in heart rate

2. Arrhythmias below the ventricles: x Widened QRS > 0.12 sec or stable ventricular tachycardia with the direction of the TP administer:

x midazolam: 2-5 mg IV repeating as necessary to achieve a reduction in heart rate x sodium bicarbonate: 1 mEq/kg IV repeat prn q5min

x Unstable or pulseless ventricular tachycardia or ventricular fibrillation: x Follow standard ACLS algorhythm but avoid epinephrine, and amiodarone x sodium bicarbonate: 1 mEq/kg IV repeat prn q5min

3. Hypertension: with the direction of the TP administer: x nitroGLYCERIN: infusion 5-100 mcg/min to achieve identified target MAP x phentolamine: 1 mg IV over 1 minute q2-3 min up to 10 mg if available

4. Pulmonary edema: x Treat hypertension x Invasive or non-invasive positive pressure ventilation

COCAINE TOXICITY


5. Chest pain: x fentanyl: 0.5-1 mg/kg IV x morphine: 2-5 mg IV

6. Treat seizures following Clinical Protocol N1 – Seizures. 7. Hyperthermia:

x Cool as able with ice packs and exposure x Monitor temperature q30min


1. Do not administer beta blockers. They have the potential to raise blood pressure by antagonizing cocaine-induced beta receptor stimulation and allowing unopposed cocaine-induced alpha receptor stimulation.

2. Phenytoin, a sodium channel blocker, is contraindicated in seizure management. 3. Amiodarone is contraindicated in arrhythmia management. 4. Cautious use of succinylcholine. Potential elevated serum potassium levels due to rhabdomyolysis.

REFERENCES

AHS Critical Care MCPs (v2.0)/Poisons/Toxins/Stimulant overdose Retrieved November 6, 2018 https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4964/view/40969/Algorithm


Saskatchewan Health Authority. Retrieved November 6, 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/phentolamine.pdf

Saskatchewan Health Authority. Retrieved November 6, 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/nitroGLYCERIN%20IV.pdf

Saskatchewan Health Authority. Retrieved November 6, 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/sodium%20bicarbonate.pdf



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/sodium%20bicarbonate.pdf



POISONING - TOXICITIES PROTOCOL P5 ACUTE DIGOXIN TOXICITY


DEFINITION

Acute toxicity of digitalis results in cardiac toxicity caused by the combination of its inhibitory effects on nodal conduction and its excitatory effects on atrial and ventricular fibers.

INDICATIONS

Ominous signs of an acute toxic dose of a digitalis include:

x Bradyarrhthmias and AV blocks resulting in heart failure. Specifically, atrial tachycardias with high-degree AV block, non-paroxysmal accelerated junctional tachycardia, multifocal VT, new-onset bigeminy, and regularized atrial fibrillation

x Unstable ventricular arrhythmias x Hyperkalemia from poisoning of the sodium potassium pump x Hypotension

MANAGEMENT

1. Arrhythmias: x Bradycardia:

x atropine: 0.5 mg IV, repeat up to total dose of 3 mg x Cautious use of transvenous pacemaker. Pacemaker-induced ventricular rhythms may

develop x Unstable ventricular tachycardia with a pulse:

x Synchronized cardioversion: 25-50 joules to minimize risk of rhythm deterioration x With the direction of the TP: digoxin-specific antibody fragment therapy if available x lidocaine: 1-1.5 mg/kg IV. If patient is responsive it may be followed by an infusion of 1-4

mg/min x magnesium sulphate: 2 grams in 50 ml over 15 minutes. If patient is responsive it may be

followed by an infusion of 0.5-1 gram/hr. Contraindicated in bradycardia or AV block. Use caution in patients with renal failure

x Ventricular fibrillation or ventricular tachycardia without a pulse: x Follow standard BLS and ACLS algorithms x Consider magnesium sulphate: 1-2 grams IV over 1-2 min

2. Hypotension:

x Administer NS or RL fluid challenge 500-1000ml x If patient unresponsive to fluid bolus or if signs and symptoms of pulmonary edema prevent

further fluid resuscitation, initiate one or more of the following and consult the TP: x DOPamine: 5-20 mcg/kg/min

ACUTE DIGOXIN TOXICITY


x norepinephrine infusion: 0.03-0.15 mcg/kg/min x EPINEPHrine infusion: 0.1-0.3 mcg/kg/min

3. Treat hyperkalemia with Clinical Protocol P1 - Hyperkalemia. Treatment of hyperkalemia with calcium is

contraindicated until digoxin-immune fab has been administered. Salbutamol may aggravate automaticity.

REFERENCES



Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/calcium%20chloride.pdf

Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/magnesium%20sulfate.pdf

Saskatchewan Health Authority. Retrieved October 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/lidocaine.pdf



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/calcium%20chloride.pdf




POISONING – TOXICITIES PROTOCOL P6 HYPERKALEMIA

The Flight Nurse/Paramedic may, after consultation with the Transport Physician (TP), initiate the following treatment protocol for the stated indications.

DEFINITION

Hyperkalemia is defined as a potassium level >5.0 mmol/L.

x Mild hyperkalemia: 5.0–6.0 mmol/L x Moderate hyperkalemia: 6.0-7.0 mmol/L x Severe hyperkalemia: > 7.0 mmol/L

INDICATIONS

The most common symptoms of hyperkalemia are nonspecific: weakness, hypotension, and paresthesias. As serum potassium rises, an ascending flaccid paralysis may develop.

Severe hyperkalemia (> 7 mmol/L) may also cause hypotension, shock, syncope, decreased LOC, dyspnea, and arrhythmias.

Cardiac manifestations include:

x Bradycardia

x Diminished conduction and contraction

x Heart block

x ECG abnormalities including peaked T waves, PR interval progression, QRS widening, diminished P waves, sine waves

https://www.researchgate.net/figure/Electrocardiographic-findings-in-hyperkalemia-The-profiles-are-schematized-the_fig5_273377800

HYPERKALEMIA


MANAGEMENT

1. Stabilize the cardiac membrane if significant ECG changes such as widened QRS and sine waves are present:

x calcium chloride 10% solution: 1-2 mg/kg to a single maximum dose of 1gram (5-10 ml) IV over 5-10 minutes. Total maximum dose: 40 mg/kg or 2 grams, whichever is less

2. Redistribute potassium: x sodium bicarbonate: 1 mmol/kg IV over 5-10 minutes x humulin R insulin: 10 units and D50W: 50 grams over 5-10 minutes intravenously x Inhaled salbutamol: 10-20 mg (salbutamol nebulizer 5 mg or MDI 10 puffs). Give q15 min prn

3. Remove potassium:

x furosemide: 1-2 mg/kg. Doses of 120 mg or less: give over 1-2 min. Doses greater than 120 mg: dilute in 50 ml and give at a maximum rate of 4 mg/min

x Isotonic fluids (Normal Saline or Ringers Lactate)

4. Perform iStat testing q30-60 minutes to monitor treatment effectiveness.

5. Monitor output via urinary catheter.


1. Causes of hyperkalemia include: x Acidosis x Cell death from rhabdomyolysis, tumour lysis, burns, hemolysis x Drugs such as potassium-sparing diuretics, ACE inhibitors, succinylcholine, NSAIDS, trimethoprim-

sulfamethxazole, etc. x Digoxin overdose. Calcium administration is contraindicated in patients with digoxin toxicity (acute

or chronic). The overdose has already increased the intracellular calcium concentration and giving additional doses may lead to cellular tetany

x Excessive intake x Hypo-aldosteronism x Renal dysfunction

REFERENCES

American Heart Association. (2017). ACLS for Experienced Providers Manual and Resource Text.pp315-316

AHS Critical Care MCPs (v2.0)/Cardiac https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4956/view/40949/Notes

Sask.Parenteral Manual – adult. Retrieved October 18, 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/furosemide.pdf

Society of Critical Care Medicine (2102). Management of life-threatening electrolyte and metabolic disturbances, in Fundamental Critical Care Support, pp. 12:1-22.



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/furosemide.pdf



POISONING – TOXICITIES PROTOCOL P7 OPIOID TOXICITY


DEFINITION

Opioid poisoning can occur through intentional overdose, and unintentional self-administration or iatrogenic administration.

INDICATIONS

Hallmark symptoms of opiate poisoning are:

x CNS depression x Respiratory depression x Miosis (small pupils)

MANAGEMENT

x Manage airway and mechanical ventilation as required. Refer to Clinical Protocol R1 – Airway

Management and Clinical Protocol R4 – Mechanical Ventilation.

x End points for opiate reversal are adequate airway reflexes and ventilation, not complete arousal. Administer:

x naloxone: 0.04–0.4 mg IV, IM or SC repeat q2-3 min escalating dose to a maximum of 2 mg/dose. Maximum total dose is 10 mg

x Consider, with the guidance of the TP: x naloxone infusion at 2/3 of initial effective bolus per hour, typically 0.25-6.25 mg/hr x Repeat ½ of the initial bolus dose 15 minutes after initiation of infusion

x Hypotension and shock:

x Target MAP of 65 mmHg x Administer Normal Saline or Ringers Lactate fluid challenge 500-1000ml x If patient is unresponsive to fluid bolus or if signs and symptoms of pulmonary edema or heart

failure prevent further fluid resuscitation, initiate one or more of the following: x DOPamine: 5-20 mcg/kg/min x norepinephrine: 0.03-0.15 mcg/kg/min

x Consider co-ingestants.

OPIOID TOXICITY



1. Use caution when administering naloxone, acute, abrupt opiate withdrawal can cause complications such as pulmonary edema, ventricular arrhythmias, and severe agitation.

REFERENCES



Saskatchewan Health Authority. Retrieved January 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/naloxone.pdf



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/naloxone.pdf



POISONING - TOXICITIES PROTOCOL P8 TOXIC ALCOHOL POISONING


DEFINITION

Toxic alcohol poisoning commonly occurs from ingestion of commonly found products. This includes: methanol (de-icing products, windshield wiper fluid, gas line anti-freeze, paint removers, shoe dyes, and embalming fluid), ethylene glycol (anti-freeze, degreasing agents, foam stabilizers and metal cleaners), and isopropyl alcohol (hand sanitizer, antiseptics, and rubbing alcohol).

INDICATIONS

Altered mental status, confusion, intoxication progressing to coma.

x Methanol: x Anion gap metabolic acidosis x Changes in vision x Altered mental status, seizures, intoxication progressing to coma

x Ethylene glycol:

x Anion gap metabolic acidosis x Altered mental status, seizures, intoxication progressing to coma x ARDS x Heart failure x Kidney injury x Hypocalcemia x Prolonged QT interval

x Isopropranolol (isopropyl alcohol):

x Severe inebriation x Fruity smelling breath x Upper GI bleed and abdominal pain

Clinical findings evolve over 6-24 hours and are dependent on ethanol co-ingestion.

MANAGEMENT

1. Hypotension and shock: x Administer NS or RL fluid challenge 500-1000ml x If patient unresponsive to fluid bolus or if signs and symptoms of pulmonary edema or heart

failure prevent further fluid resuscitation initiate one or more of the following: x DOPamine infusion: 5-20 mcg/kg/min x norepinephrine infusion: 0.03-1.5 mcg/kg/min

TOXIC ALCOHOL POISONING


2. Metabolic Acidosis of pH < 7.1, under the direction of the TP: x sodium bicarbonate: 1-2 mEq/kg IV. x Consider sodium bicarbonate: infusion 0.5 mEq/kg/hr

3. Mechanical ventilation considerations:

x Target ETC02 to 35-40 mmHg

4. For methanol or ethylene glycol toxicity if available, administer under the direction of the TP: x fomepizole: 15 mg/kg IV (maximum dose 1 gram)


1. Second-line therapy includes 10% ethanol IV infusion 10 ml/kg.

REFERENCES

AHS Critical Care MCPs (v2.0)/Poisons/Toxins retrieved November 2018 https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4964/view/40971/Algorithm

Krautz, J and Kurtz, I. (2007). “Toxic Alcohol Ingestions: Clinical Features, Diagnosis, and Management.” Clinical Journal for the American Society of Nephrology. Clin J Am Soc Nephrol 3: 208 –225, 2008. doi: 10.2215/CJN.03220807. Retrieved November 2018 https://pdfs.semanticscholar.org/da9f/9637789554f3562a1a16f665fb3de6c59317.pdf

McMartin, K. Jacobsen, D. Hoyda, K. (2016). Antidotes for poisoning by alcohols that form toxic metabolites. British Journal of Clinical Pharmacology. Retrieved November 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767193/

Sask.Parenteral Manual – adult. Retrieved November 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/fomepizole.pdf


https://pdfs.semanticscholar.org/da9f/9637789554f3562a1a16f665fb3de6c59317.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767193/

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/fomepizole.pdf



POISONING - TOXICITIES PROTOCOL P9 TRICYCLIC ANTIDEPRESSANT OVERDOSE


DEFINITION

The toxic side effects of tricyclic antidepressants (TCA) are caused by their 4 major pharmacologic properties:

x Stimulation of catecholamine release and blocking of re-uptake at post-ganglionic synapses x Central and peripheral anticholinergic actions x Inhibition of potassium channels in myocardium and sodium channels in brain and myocardium x Direct alpha-blocking actions

INDICATIONS

Ominous signs of a toxic dose of TCA include:

x Coma x Seizures x Cardiac arrhythmias: sinus tachycardia, wide-complex tachycardias, SVT, prolongation of QT interval,

sinus bradycardia, AV block x Acidosis x Hypotension

Progression of symptoms is unpredictable. Patients may suddenly deteriorate into cardiac arrest.

MANAGEMENT

1. Initiate cardiac monitoring and IV access.

2. Widened QRS > 0.10 sec: x Administer sodium bicarbonate:1 meq/kg IV

3. Seizure activity:

x Administer benzodiazepines as per Clinical Protocol N1 - Seizures x Administer sodium bicarbonate:1 meq/kg IV to all patients with active or recent seizure activity

4. Hypotension refractory to fluid bolus:

x Administer sodium bicarbonate:1 meq/kg IV while rapidly infusing normal saline and initiation of vasopressor

5. Ventricular arrhythmias: x Stable Ventricular Tachycardia:

x Administer sodium bicarbonate: 1 meq/kg IV. If unsuccessful, consider lidocaine x Unstable Ventricular Tachycardia and Ventricular Defibrillation:

TRICYCLIC ANTIDEPRESSANT OVERDOSE


x Defibrillate immediately, followed by the administration of sodium bicarbonate:1 meq/kg IV x Torsades de points: in addition to sodium bicarbonate, administer:

x magnesium sulfate: 1-2 grams diluted in 10 ml D5W IV push x In hemodynamically stable patients, administer over 1-5 min

6. Hemodynamically unstable bradyarrhythmias:

x Treat with transcutaneous pacing x If the patient is intubated, target ETC02 30-35 mmHg, pH 7.5 - 7.55 in conjunction with the

administration of IV of sodium bicarbonate


1. Amiodarone is NOT indicated for treatment of V-tach in the patient with a TCA overdose as it causes sodium channel inhibition.

2. Consider sodium bicarbonate infusion following administration of bolus dose.

3. Asymptomatic patients with normal QRS width and no ventricular arrhythmias do not require sodium bicarbonate IV.

REFERENCES

AHS Critical Care MCPs (v2.0)/Poisons/Toxins



Kerr, GW. McGuffie, AC, Wilkie, S. Tricyclic antidepressant overdose: a review. Emergency Medicine Journal, 2011; 18: 236-241.

Tsai, V. (2015). Tricyclic antidepressant toxicity treatment & management. Retrieved from: http://emedicine.medscape.com/article/819204-overview.



http://emedicine.medscape.com/article/819204-overview


SECTION: RESPIRATORY Reviewed April 2019 Page R1-1

RESPIRATORY PROTOCOL R1 AIRWAY MANAGEMENT


DEFINITION

Airway management may include: supraglottic airway placement, endotracheal intubation or surgical airway.

INDICATIONS

x Cardiopulmonary or respiratory arrest or unresponsive patient x Unable to protect airway: decreased level of consciousness, GCS ≤ 8 with airway compromise x Respiratory failure requiring mechanical ventilation x Catastrophic illness or injury with anticipated deterioration x Need for sedation and or paralysis in a combative patient x Therapeutic interventions that can only be managed with mechanical ventilation, or deep sedation of

the patient

MANAGEMENT

1. See Clinical Protocol R3 - Drug Assisted Intubation.

2. Assessment of the airway: LEMON x Look externally (short neck, facial disruption, dental shape) x Evaluate mouth opening, length of the mandible, thyromental distance x Mallampati score x Obstruction (muffled voice, difficulty swallowing secretions, stridor) x Neck mobility (ankylosing spondylitis, osteoarthritis, cervical immobilization

3. Prepare equipment:

x Bag-valve-mask (BVM) device connected to 100% oxygen x Working suction unit and suction catheters x Cardiac monitor, pulse oximetry, end-tidal CO2 monitor x Working laryngoscope with selection of blades x Oral airway kit/Magill forceps x Endotracheal tubes with stylet and cuff inflation syringe (adult) x Laryngeal mask airway (LMA), bougie, video laryngoscope available x Sterile water for cuff inflation (adult) x Patent large bore IV line x Rapid sequence induction (RSI) drug kit (prepare required drugs prior to commencing RSI) x Endotracheal tube securement device

AIRWAY MANAGEMENT


4. Pre-oxygenate the patient with 100% oxygen:

x Breathe 100% 02 for 5 minutes (or at least 5 deep breaths) x Consider the use of high flow nasal prongs

5. Time out review with team:

x Review current vital signs and patient status (including hypoxia, hypercarbia, and metabolic

acidosis) x Plan for sedation with or without neuromuscular blockade x Patient preparation including oxygenation and optimum positioning x Equipment prepared and checked: SOAPME x Plan for failed airway x Plan for post intubation sedation/analgesia x Review roles for each team member

6. Endotracheal intubation:

x Place endotracheal tube x Inflate cuff with the minimal amount of sterile water to provide occlusion pressure x Verify placement with ETC02, plus one of the following:

o Auscultation of breath sounds/gastric insufflation o Tube fogging/tube depth o Chest rise o Improving Sp02 o Chest x-ray

x Secure tube

7. Unsuccessful endotracheal intubation: Further attempts may be made after re-oxygenating and ventilating the patient, and reassessing measures required to facilitate intubation:

x Optimizing patient position x External laryngeal manipulation x Changing position of Flight Nurse or Paramedic x Reassessment of tools used: blade size and type, boogie, video laryngoscope, medications x Changing staff member attempting intubation

8. Failed intubation/ventilation:

x Ventilate using BVM, oxygen and an oropharyngeal airway x Consider LMA for transport

o Confirm placement with ETCO2 and Sp02

9. Failed supraglottic airway/ventilation: Under the guidance of the TP, perform a surgical cricothyrotomy. Contraindications to surgical cricothyrotomy are: inability to identify anatomic landmarks, pediatric patients under 8 years of age.

x Position the patient supine and head in a neutral position x Cleanse the anterior neck from the laryngeal prominence to just below the cricoid ring with

chlorhexidine and drape the patient

AIRWAY MANAGEMENT


x Identify landmarks, palpate the cricothyroid membrane and stabilize thyroid cartilage with non-dominant hand

x Make a 1-1.5 inch vertical shallow incision over the lower half of the cricothyroid membrane x Insert scalpel and carefully puncture the cricothyroid membrane taking care not to damage the

posterior tracheal wall. Rotate 90 degrees. Insert bougie into the opening x Remove the scalpel and insert the index finger of your non-dominant hand beside the bougie x With your free hand Insert a 6.0 cuffed ETT, or an appropriate sized ETT, over the bougie using the

natural curve of the tube. Advance the balloon about 1-1.5 cm below the lower margin of the incision

x Inflate with sterile water x Verify tube placement in 2 ways x Secure tube with suture and twill ties x Do not cut ETT

10. During transport tube placement will be verified and documented (ETC02 and depth of tube) with each

movement of patient: to stretcher, into road ambulance, into aircraft, out of aircraft, and onto ER cot.


1. Failure to ventilate: DOPE x Displacement of tube x Obstruction of tube x Pneumothorax x Extubation

2. Equipment preparation SOAPME

x Suction x Oxygen – BVM x Airway equipment: laryngoscope, 2 ETT, stylet, bougie, video laryngoscope, OPA, syringe and

sterile water, LMA x Pharmacologic agents: pre-treatment, sedation/analgesia, neuromuscular blocker, fluid bolus,

vasopressor x Monitoring Equipment visible: ECG, BP, Sp02, ETC02

REFERENCES

AHS Critical AHS Critical CareCPsv2.0)/Respiratory


American College of Surgeons. (2012). Advanced trauma Life Support student Course Manual 9th ed. Chicago.

Pollak, A. (2018). Critical Care Transport 2nd ed. American Academy of Orthopaedic Surgeons, American College of Emergency Physicians,. UMBC, IAFCCP. CCEMTP. Jones and Bartlett.





RESPIRATORY PROTOCOL R2 ANAPHYLACTIC SHOCK


DEFINITION

A severe, life-threatening allergic reaction producing systemic vasodilation in response to histamine release. True anaphylaxis results when the allergen binds to IgE on the cell membranes of basophils and mast cells, stimulating the release of histamine. Anaphylactoid reaction is a non-IgE mediated response that causes the rupture of mast cells and basophils which then release histamine. The response can be immediate or delayed.

INDICATIONS

x Tachycardia x Hypotension x Narrow pulse pressure x Warm, flushed skin with pruritus and hives x Bronchoconstriction x Laryngeal edema x Angioedema x Airway compromise

MANAGEMENT

1. Assess airway and consider intubation in severe respiratory distress or for patients in a peri-arrest state. 2. Remove allergen if possible. 3. Hypotension: Target MAP > 65 mmHg:

x Fluid resuscitation: o 1-2 L of NS or RL up to 4 L

x EPINEPHrine: 0.5 ml of a 1:1000 solution (0.5 mg) IM in the lateral thigh. Repeat q5 minutes up to 3 doses as necessary

x Pediatric dose: EPINEPHrine: 0.01mg/kg or 0.1 ml of a 1:1000 solution IM

If pulmonary edema develops or patient unresponsive to fluid challenge consider:

x EPINEPHrine: 1ml of 1:10,000 (0.1 mg) IV it may be repeated once after 5 minutes x EPINEPHrine: infusion 0.1-1.5 mcg/kg/min

4. Treat allergic response: x diphenhydrAMINE: 1 mg/kg IV to a maximum of 50 mg x ranitidine: 1 mg/kg IV over 10 minutes to a maximum of 50 mg x methylPREDNISolone: 1-2 mg/kg IV over 2 minutes to a maximum single dose of 125 mg

5. Bronchospasm: x Administer salbutamol nebulizer: 2.5-5 mg or 8 puffs MDI q15 minutes x Pediatric dose: salbutamol nebulizer: 2.5 mg or 5 puffs MDI q15 minutes

ANAPHYLACTIC SHOCK



1. Patients taking beta blockers have an increased incidence and severity of anaphylaxis and can develop a paradoxical response to epinephrine. Under the guidance of the TP, glucagon 1 mg IV may be considered q5min up to a total dose of 5 mg.

REFERENCES

AHS Critical Care MCPs (v2.0)/Respiratory/anaphylaxis https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4967/view/40978/Algorithm


Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/EPINEPHrine.pdf

Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/diphenhydrAMINE.pdf

Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/methylPREDNISolone.pdf



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/diphenhydrAMINE.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/diphenhydrAMINE.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/methylPREDNISolone.pdf



RESPIRATORY PROTOCOL R3 DRUG ASSISTED INTUBATION

A Saskatchewan Air Ambulance Flight Nurse/Paramedic may initiate the following protocol for the stated indications.

DEFINITION

Drug assisted intubation is a technique involving the administration of sedation and paralytic agents, if necessary, in order to establish oral endotracheal intubation in an emergent situation. It typically involves the sequential application of:

x Oxygen x Sedation x External tracheal manipulation x Short-acting paralytic agent x Oral endotracheal intubation x Continued sedation and paralysis

INDICATIONS FOR THE USE OF NEUROMUSCULAR BLOCKADE

Always consider an awake intubation (i.e. with use of lidocaine spray) prior to proceeding with drug assisted intubation

Neuromuscular blockade may be used to secure the airway in the following patients (ENSURE PATENT AIRWAY AND ADEQUATE OXYGENATION):

1. Inability to tolerate laryngoscopy and, x GCS < or equal to 8 with a resp. rate < 8 or > 35 x GCS < or equal to 8 with SpO2 < 90% on NRB mask x GSC < 8 and clenched jaw or inability to suction airway

2. Extremely agitated or combative patient; particularly with associated head injury (regardless of GCS).

3. Respiratory extremis (tachypnea with air hunger, use of accessory muscles and SpO2 < 90% on NRB). 4. Patients with a full stomach and at risk for aspiration.

When considering drug assisted intubation in children, the Pediatric Intensivist and/or the Transport Physician (TP) must be contacted prior to procedure.

MANAGEMENT

1. For intubation see Clinical Protocol R1 - Airway management. 2. Sedate with one or more of the following:

x fentanyl: 0.5-1 mcg/kg IV x ketamine: 1-1.5 mg/kg IV. Pre-administration of a benzodiazepine is recommended to avoid or

minimize emergence reactions x ketamine in shock states or in debilitated patients: 0.25-0.5 mg/kg IV

DRUG ASSISTED INTUBATION


x midazolam: x < 55 years: 2-2.5 mg as an initial dose. Do not exceed 0.1 mg/kg x > 55 years, in shock states or debilitated patients: 1-1.5 mg as an initial dose. Do not

exceed 0.07 mg/kg x propofol: (do not use in shock states)

x < 55 years: 10-20 mg or 0.5 mg/kg over 3-5 minutes incremental doses repeating as necessary

x > 55 years: use 80% of healthy adult dose

3. Neuromuscular blockade if required: x succinylcholine: 1-1.5 mg/kg IV x If succinylcholine is contraindicated, under the direction of the TP, administer:

rocuronium bromide: 1 mg/kg IV

8. Post-intubation consider adequate sedation.

9. Consider long term paralysis for transport:

ADULTS:

x rocuronium bromide: 0.5 mg/kg at 30-60 minute intervals as necessary

10. For failed intubation or ventilation, refer to Clinical Protocol R1 - Airway Management.


Considerations and contraindications to succinylcholine:

1. Open eye injuries (succinylcholine will increase intra-ocular pressure).

2. When the airway is assessed as difficult and the ability to ventilate with a bag valve mask (BVM) device is

considered unlikely (see Clinical Protocol R1 - Airway Management for assessment criteria).

3. Burns and/or spinal cord injuries > 48 hrs. (risk of hyperkalemia).

4. Myopathic patients – (muscular dystrophy, MS, rhabdomyolysis, crush injuries) – (risk of hyperkalemia).

5. Denervation injuries (stroke, Guillian-Barre syndrome, polio, spinal cord trauma, myasthenia gravis). May

cause hyperkalemia 4-5 days post injury but can be used in the initial 1-4 days post injury.

6. Chronic renal failure – avoid succinylcholine due to risk of hyperkalemia.

7. History of malignant hyperthermia – Do not use succinylcholine with patients with a personal or family history

of sensitivity.



Drug Assisted Intubation Reference Card Page 1

Medications & dosages are guidelines only. TP/Pediatric intensivist must be contacted prior to PEDIATRIC Intubation

1. Pre-oxygenate x 2-5min 50kg 60kg 70kg 80kg 90kg 100kg

2. Time Out (protocol R1)

3. Consider topical Lidocaine (10-20 sprays)

4. Sedation – Administer 1 or more

Caution: sedative agents cause hypotension in shock states. Use smallest effective dose and monitor vital signs frequently for hypotension. Consider having fluid bolus and/or pressor immediately available for administration in the event of hypotension during sedation.

Ketamine (1-1.5mg/kg) 50-75mg 60-90mg 70-105mg 80-120mg 90-135mg 100-150mg

Ketamine in shock states (0.25-0.5 mg/kg) 12.5-25 mg 15-30 mg 17.5-35 mg 20-40 mg 22.5-45 mg 25-50 mg

Midazolam < 55 years: Initial dose no more than 2-2.5 mg. Additional doses titrate to effect

> 55 years, shock states, or debilitated patients: Initial dose no more than 1-1.5 mg. Additional doses titrate to effect

Propofol (Do not use in shock states) < 55yrs: 10-20 mg or 0.5 mg/kg over 3-5 minutes. Incremental doses. Repeat as necessary

> 55yrs: 80% of healthy adult dose

Fentanyl (0.5-1 mcg/kg) 25-50mcg 30-60mcg 35-70mcg 40-80mcg 45-90mcg 50-100mcg

5. Apply BURP, prn. Give NMB as required

Succinylcholine (1-1.5mg/kg) [duration 4-6min] 50-75mg 60-90mg 70-105mg 80-120mg 90-135mg 100-150mg

Rocuronium (1 mg/kg) 50mg 60mg 70mg 80mg 90mg 100mg

6. Intubate. Consider long-term NMB and sedation

Rocuronium (0.5mg/kg) [duration 30-45min] 25mg 30mg 35mg 40mg 45mg 50mg

DRUG ASSISTED INTUBATION


Drug Assisted Intubation Reference Card Page 2

Considerations and Contraindications to Succinylcholine

Hypersensitivity to Succinylcholine, Personal or Familial Hx of Malignant Hyperthermia, Eye injuries, Hyperkalemia

Neuromuscular disorders, Burns >5% BSA (>48hrs), Massive Trauma

The Sequence

Prep of equipment & medication, check contraindications of Succinylcholine, assess for difficult airway, don PPE.

Pre-oxygenation.

Time out review with team:

x Review current vital signs and patient status (including hypoxia, hypercarbia, metabolic acidosis). x Plan for sedation +/- paralytic agent. x Patient preparation including oxygenation and optimum positioning. x Equipment prepared and checked: SOAPME x Plan for failed airway. x Plan for post intubation sedation/analgesia. x Review roles for each team member.

Premedication and sedation.

Position for laryngoscopy.

Neuromuscular blockade, only if required.

Post intubation management, secure tube, ventilation, monitoring, VS, sedation/analgesia, NMB (if required).



REFERENCES Nickson, C. (2015.) Rapid Sequence induction. Life in the fast lane. Retrieved September 24, 2018 from http://lifeinthefastlane.com/cccc/rapid-sequence-intubation/ Nickson, c. (2016). RSI Checklist and Action Plan. Life in the fast lane. Retrieved September 24, 2018 from https://lifeinthefastlane.com/wp-content/uploads/2012/03/checklist-GD.jpg Robinson, N. (2001) In-patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J. 2001 Nov;18(6):453-7. Saskatchewan Health Authority. Retrieved September 24, 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/fentaNYL%20IV.pdf Saskatchewan Health Authority. Retrieved September 24, 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/propofol.pdf Saskatchewan Health Authority. Retrieved September 24, 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/ketamine.pdf Saskatchewan Health Authority. Retrieved September 24, 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/midazolam.pdf Saskatchewan Health Authority. Retrieved September 24, 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/rocuronium.pdf Saskatchewan Health Authority. Retrieved September 24, 2018. https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/succinylcholine.pdf Zeiler, F.A., Teitelbaum, J., West, M., Gillman, L. (2014). The Ketamine Effect on ICP in traumatic Brain Injury. Neurocritical care. 21. 10.1007/sl12028-013-013-9950-y. Retrieved September 24, 2018 from https://www.researchgate.net/publication/260154219_The_Ketamine_Effect_on_ICP_in_Traumatic_Brain_Injury Zeiler, F. (2015). The impact of intravenous Lidocaine on ICP in Neurological Illness: A systematic Review. Critical Care Research and Practice Vol 2015, Article ID 485802. Retrieved Sept 24, 208 from https://www.hindawi.com/journals/ccrp/2015/485802/


https://lifeinthefastlane.com/wp-content/uploads/2012/03/checklist-GD.jpg

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/fentaNYL%20IV.pdf




https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/rocuronium.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/succinylcholine.pdf

https://www.researchgate.net/publication/260154219_The_Ketamine_Effect_on_ICP_in_Traumatic_Brain_Injury

https://www.hindawi.com/journals/ccrp/2015/485802/



RESPIRATORY PROTOCOL R4 MECHANICAL VENTILATION


DEFINITION

Positive pressure ventilation is the delivery of air to the lungs with forced or positive pressure provided with a manual pressure device or mechanical ventilator. When delivered through an endotracheal tube or tracheostomy, it is referred to as invasive positive pressure ventilation.

INDICATIONS

x Apnea or impending respiratory arrest x Acute ventilatory failure or hypoventilation (hypercapnia) x Hypoxic respiratory failure x Critically ill patients to minimize the work of breathing increasing the availability of oxygen to the tissues

to meet the increased demand

MANAGEMENT

1. Ensure equipment is functioning: x External battery packs have a full charge x Circuit the ventilator and perform a leak test

2. Assess patient and choose appropriate mode of ventilation.

3. To set up assist control volume ventilation(AC/V):

x Set mode to AC/V x Set rate to 12-14 breaths per min adjusting higher if patient condition warrants and titrating to

target ETC02 x Set VT to 6-8 ml/kg ideal body weight x Set sensitivity initially at 3L/min and titrate to patient’s work of breathing and ability to trigger

ventilator x Set PEEP to 5 cm H20, and titrate to keep Sp02 in desired range. If patient requires PEEP > 10 cm

H20, consult TP x Choose low flow oxygen source or high pressure oxygen source. Titrate Fi02 to keep Sp02 in

target range x Set i-time to 1.0 then titrate to provide an I:E ratio of at least 1:2, increasing I:E ratio as patient

condition requires. Assess patient: work of breathing, comfort, air entry, Sp02, ETC02, plateau pressure, auto-peep, and PIP. Titrate settings using assessment findings to achieve ventilator goals

x Set appropriate ventilator alarms 1-2 minutes after ventilation initiated:

MECHANICAL VENTILATION


o High peak pressure: usually 10-15 cm H20 above the peak pressure reading on the monitor display, expected setting of 45-60 cm H20

o Low peak pressure: 5-10 cm H20 below the peak inspiratory pressure on the monitor display

o Low minute volume: usually ~5 L. After about 10 minutes of ventilation read the minute volume on the monitor display and set the low minute volume at 50–75% of this value

4. To set up assist control pressure ventilation (AC/P):

x Set mode to AC/P x Set rate to 12-14 breaths per min adjusting higher if patient condition warrants and titrate to

target ETC02 x Set an inspiratory pressure. Start at 20 cm H20 and titrate to give desired VT. Peak Inspiratory

pressure will be the inspiratory pressure plus the PEEP. Monitor VT and minute volume to ensure adequate gas exchange

x Set sensitivity initially at 3L/min and titrate to patient’s work of breathing and ability to trigger ventilator

x Set PEEP to 5 cm H20 and titrate to keep Sp02 in desired range. If patient requires PEEP > 10 cm H20 call TP for order

x Choose low flow oxygen source or high pressure oxygen source. Titrate Fi02 to keep Sp02 in target range

x Set i-Time to 1.0, then titrate to provide an I:E ratio of at least 1:2 increasing I:E ratio as patient condition requires

x Attach circuit to patient and allow the ventilator to deliver breaths. Assess patient: work of breathing, comfort, air entry, Sp02, ETC02, plateau pressure, auto-peep, and PIP. Titrate settings using assessment findings to achieve ventilator goals

x Set appropriate ventilator alarms 1-2 minutes after ventilation initiated: o High peak pressure: usually 10 - 15 cm H20 above the peak pressure reading on the

monitor display, expected setting of 45 - 60 cm H20 o Low peak pressure: 5 -10 cm H20 below the peak inspiratory pressure on the monitor

display o Low minute volume: usually ~5 L. After about 10 minutes of ventilation read the minute

volume on the monitor display and set the low minute volume at 50 – 75% of this value

5. To set up Pressure Support Ventilation (PSV): x Set mode to SIMV/CPAP x Set rate to” ---“ x Set pressure support to 10 cm H20 and titrate to achieve desired VT x Set PEEP to 5 cm H20 and titrate to keep Sp02 in desired range. If patient requires PEEP > 10 cm,

consider using AC/V x Choose low-flow oxygen source or high-pressure oxygen source. Titrate Fi02 to keep Sp02 in

target range x Attach circuit to patient and allow the ventilator to deliver breaths. Assess patient: work of

breathing, comfort, air entry, Sp02, ETC02. Note that PIP will be the pressure support plus PEEP. It is not necessary to measure plateau pressures in this mode. Titrate settings using assessment findings to achieve ventilator goals

6. Monitoring and documentation requirements: x Continuous monitoring of vital signs, including ETC02, Sp02, and documentation q15 min x Plateau pressure (inspiratory hold) is to be measured once after initiation of ventilation and

again, as required if elevated, or measures taken to reduce plateau pressure



x Auto-peep is to be measured once after initiation of ventilation and again, as required if present or measures taken to eliminate auto-peep

x Identify target ETC02 and Sp02. Document ventilator settings with initiation of ventilation and with every change in settings as required to meet identified oxygenation and ventilation targets


1. Management of auto-peep: x Monitor ETC02 waveform for sloped expiratory rise x Reduce VT to 6 ml/kg ideal body weight x Reduce rate to maximize the I:E ratio to 1:4 x Reduce the i-time to maximize the I:E ratio to 1:4 x Consider cautiously increasing PEEP to splint airways open x Consider bronchodilators

2. Managing plateau pressures > 30 cm H20:

x Reduce VT to 4--6 ml/kg ideal body weight and accept permissive hypercapnia, target pH > 7.3 and ETC02 50-55 mmHg

x Ensure I:E ratio 1:2

3. Assistance with ventilation may be obtained by paging the ICU Respiratory Therapist at RUH 306-655-1000.

4. IBW calculation: Female IBW = 45.5 kg + 2.3 (height in inches – 60) Male IBW = 50 kg + 2.3 (height in inches – 60)

MALE FEMALE

Height Weight Height Weight

5ft 4in 59kg 4ft 10 in 41kg

5ft 5in 62kg 5ft 0in 46kg

5ft 6in 64kg 5ft 1 in 48kg

5ft 7 in 66kg 5ft 2in 50kg








5ft 10in 69kg



REFERENCES

Carefusion (2014). LTV 1200 Operator’s Manual. Retrieved from http://www.carefusion.com/Documents/guides/user-guides/RC_LTV-1200-and-LTV-1150_UG_EN.pdf

Fisher&Paykel Healthcare FreeMotion RT043 non-vented mask fitting guide. Retrieved December 2018. https://www.fphcare.com/en-ca/hospital/adult-respiratory/noninvasive-ventilation/freemotion-rt043/ Society of Critical Care Medicine. (2012) Fundamental Critical Care Support 5th ed. Society of Critical Care Medicine. Mount Prospect. Tobin, M. (2013) Principles and Practice of Mechanical Ventilation 3rd edition. McGraw-Hill Companies, Inc. New York.


http://www.carefusion.com/Documents/guides/user-guides/RC_LTV-1200-and-LTV-1150_UG_EN.pdf

https://www.fphcare.com/en-ca/hospital/adult-respiratory/noninvasive-ventilation/freemotion-rt043/



RESPIRATORY PROTOCOL R5 NON-INVASIVE POSITIVE PRESSURE VENTILATION


DEFINITION

Positive pressure ventilation is the delivery of air to the lungs with forced or positive pressure provided with a manual pressure device or mechanical ventilator. When delivered through a tight fitting facemask it is referred to as non-invasive positive pressure ventilation (NPPV).

INDICATIONS

x COPD with respiratory acidosis x Hypercapneic respiratory failure due to chest wall deformity or neuromuscular disease x Acute pulmonary edema x Flail chest: NPPV will splint the flail section. Caution must be used to observe the patient for

development of pneumothorax x Patients that are slowly worsening, but are likely to recover with appropriate therapy

Contraindications to NPPV include:

x Refusal or inability of patient to cooperate x Impaired consciousness, confusion or agitation, inability to protect airway x Hemodynamic instability/severe co-morbidity x Copious respiratory secretions x Consolidation on chest x-ray x Head gear or mask cannot be fitted to face due to burn, facial trauma, beard, etc. x Airway obstruction x Vomiting, GI obstruction, recent abdominal or esophageal surgery

MANAGEMENT

1. Indications and contraindications to this therapy must be carefully considered prior to use. 2. To set up NPPV:

x Perform leak test on circuit x Set mode to SIMV/CPAP x Push the Select mode button until the “NPPV” LED flashes. Release the button and press once

more to confirm the NPPV setting. The LED will continue to flash x Set IPAP to 10 cm H20. NPPV LED will stop flashing. Titrate to relieve work of breathing x Set EPAP to 5 cm H20. Titrate to improve oxygenation x Set sensitivity at 1-2 L/min x Choose low flow oxygen source or high pressure oxygen source. Titrate Fi02 to keep Sp02 in

desired range x Place mask on patient ensuring tight fit with no leaks. If leaking occurs, consider: choosing

smaller mask, deflating or inflating seal. The mask must be a non-vented mask

NON-INVASIVE POSITIVE PRESSURE VENTILATION


x Consider the use of nasal prong ETC02 monitoring x To improve patient tolerance, start at low pressures and titrate slowly. If patient requires an IPAP

of > 15 or a PEEP > 10 consider intubation. o Titrate IPAP to lessen patient’s work of breathing and ability to achieve adequate minute

ventilation o Titrate EPAP to Sp02

3. Monitor and document: x Patient rate x IPAP (pressure support) x EPAP (PEEP) x Work of breathing x Sp02 x ETC02 x Any changes in settings, and patient response to changes


1. Mask fitting: ensure the mask is non-vented when using the LTV 1200: x Place the sizing guide under the chin and the correct mask size lines up with the bridge of the

patient’s nose x Unclip the quick-release button x Place the seal the mask under the chin then over the bridge of the nose. x Slide loose head gear over the patient’s head and connect the quick-release x Adjust head gear as required first around patient’s chin then forehead. The glider will centre the

mask. The forehead cushion may or may not contact the forehead x Attach mask to circuit and gently pull the mask forward to allow the seal to inflate x Re-adjust straps as necessary each time gently pulling mask forward to allow the seal to inflate

2. Administering bronchodilators while delivering NPPV: x Medication can be administered can be delivered using a MDI and the BVM adaptor port or

the patient can be removed from NPPV and place on a nebulizer mask 3. Assistance with ventilation may be obtained by paging the ICU Respiratory Therapist at RUH 306-655-

1000.

REFERENCES

Carefusion (2014). LTV 1200 Operator’s Manual. Retrieved from http://www.carefusion.com/Documents/guides/user-guides/RC_LTV-1200-and-LTV-1150_UG_EN.pdf

Fisher&Paykel Healthcare FreeMotion RT043 non-vented mask fitting guide. Retrieved December 2018. https://www.fphcare.com/en-ca/hospital/adult-respiratory/noninvasive-ventilation/freemotion-rt043/ Society of Critical Care Medicine. (2012) Fundamental Critical Care Support 5th ed. Society of Critical Care Medicine. Mount Prospect. Tobin, M. (2013) Principles and Practice of Mechanical Ventilation 3rd edition. McGraw-Hill Companies, Inc. New York.


http://www.carefusion.com/Documents/guides/user-guides/RC_LTV-1200-and-LTV-1150_UG_EN.pdf

https://www.fphcare.com/en-ca/hospital/adult-respiratory/noninvasive-ventilation/freemotion-rt043/



RESPIRATORY PROTOCOL R6 RESPIRATORY EMERGENCIES: ASTHMA


DEFINITION

The pathophysiology of asthma consists of 3 key abnormalities: bronchoconstriction, airway inflammation, and mucous impaction. Chronic obstructive pulmonary diseases (COPD) are disease processes that cause outflow obstruction. It can be characterized by inflamed, edematous airways and/or enlargement of air spaces distal to the terminal bronchioles. All processes result in increased airway resistance.

INDICATIONS


Triggers:

x Environment: extremes of temperature, high humidity, environmental contaminants x Upper respiratory tract infections x Allergens x Exercise x Other medical conditions: COPD, gastro-esophageal reflux x Drugs: ASA, beta blockers, NSAIDS

Severe exacerbations can lead rapidly to death from bronchospasm, plugging of narrow airways with mucus, causing hyperinflation, increased oxygen consumption and hemodynamic compromise.

Mild Moderate Severe Near Death

Wheeze Expiratory Low pitched

Expiratory & inspiratory High pitched

Distant Near absent

Absent, Silent chest

Speech

Full sentences

Partial sentences

Single words, difficulty speaking

Not responding

Relief with Beta agonists

Good response

Partial relief or Beta agonists needed > q4h.

No relief No relief

Respiratory Rate and Effort

Normal to slight tachypnea

> 30 /min SOB at rest, congested, chest tightness

> 40/min Laboured

Slowing, apnea

Mentation

Normal

Normal / distracted

Distracted Disoriented

Exhausted, confused


RESPIRATORY EMERGENCIES: ASTHMA


MANAGEMENT

1. Hypoxia: x Administer high flow oxygen via NRB at 15L per minute and titrate to target Sp02 > 90%

2. Bronchoconstriction:

x salbutamol: nebulizer continuously for 1 hour, or until symptoms improve x Alternatively, salbutamol: 8 puffs via BVM MDI port q20 minutes or until symptoms improve x ipratropium bromide: nebulizer 0.5 mg q20 minutes in conjunction with salbutamol. (Note:

Combivent nebulizer provides the salbutamol/ipratropium combination). x Consider, with TP guidance:

o magnesium sulphate: 2 grams in 50 ml over 20 minutes o EPINEPHrine: nebulizer 5 ml of 1:1000 solution o EPINEPHrine: 0.3-0.5 mg 1:1000 solution SC q20 minutes up to 3 doses o methylPREDNISolone: 1-2 mg/kg IV to a maximum of 125 mg

3. Failure to improve: In consultation with the TP, consider: x Non-invasive positive pressure ventilation (NPPV), see Clinical Protocol R5. Carefully select

settings to counteract the effects of auto-PEEP. o Initial settings: IPAP 8-10 cm H20 and EPAP 3-5 cm H20

x Endotracheal intubation should only be considered in the patient whose condition deteriorates despite aggressive management:

o Failure to improve with NPPV o Association with anaphylaxis o Deterioration with fatigue and exhaustion o Confusion deteriorating to somnolence o Pa02 < 50 mmHg associated with clinical signs of hypoxemia

x Intubation: o Consider conscious intubation. See Clinical Protocol R1 – Airway Management. o Reduce bronchospasm by laryngoscopy administer:

� lidocaine: 1-2 mg/kg maximum 100 mg IV 3 minutes prior to sedation or paralytics o Sedate: choose medications with bronchodilating properties: ketamine, or propofol

x Ventilation: See Clinical Protocol R4 – Mechanical Ventilation. Initial settings: o Rate 6-10 o VT 6-8 ml/kg o Target I:E ratio 1:4-5 o Target Sp02 > 90%

4. Sudden deterioration during positive pressure ventilation: consider: x Obstruction of ETT with secretions x High end-expiratory pressure. Disconnect ventilator and allow PEEP to dissipate during passive

exhalation x Tension pneumothorax: see Clinical Protocol T9 - Emergency Needle Decompression x Continue treatment with bronchodilators


1. Caution should be exercised in patients receiving magnesium sulphate as there have been documented incidences of “rebound” bronchospasm hours after the initial presentation and have a high likelihood of needing intubation and mechanical ventilation.

RESPIRATORY EMERGENCIES: ASTHMA


2. Beta agonists may induce pulmonary vasodilation and bronchodilation. This may produce a right to left shunt. Shunting of systemic venous blood through the lungs so that it is desaturated when it returns to the left atrium.

REFERENCES



Rowe BH, et.al. (2000) Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001490.

Saskatchewan Health Authority. Retrieved December 2018 https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/magnesium%20sulfate.pdf





SECTION: TRAUMA Reviewed April 2019 Page T1-1

TRAUMA PROTOCOL T1 BURNS

The Flight Nurse/Paramedic may initiate this protocol for the stated indications. The Transport Physician (TP) must be consulted for ongoing care of the patient once stabilization has occurred.

DEFINITION

Damage to the skin or other body parts caused by extreme heat, flame, contact with heated objects, chemicals or electricity.

INDICATIONS

Classification of Burn Severity

1. First-degree burns characterized by: x Erythema x Pain x Absence of blisters

2. Partial-thickness or second-degree burns characterized by:

x Red or mottled appearance with associated swelling and blister formation x Possible weeping, wet appearance x Painfully hypersensitive, even to air current

3. Full-thickness or third degree burn characterized by:

x Appears dark and leathery/translucent or waxy white, may be red but does not blanch with pressure

x Painless, dry surface x Minimal swelling of burned tissue, surrounding tissue may swell significantly

MANAGEMENT

Priorities of care are to establish airway control, stop the burning process and gain IV access. C-spine precautions are required if trauma is associated with the burn injury.

1. AIRWAY: Assess and establish airway control. Early intubation is indicated in suspected inhalation injury. Suspect inhalation injury when: x Singeing of the eyebrows and nasal vibrissae or facial hair x Carbon deposits in the mouth and/or nose and carbonaceous sputum x Acute inflammatory changes in the oropharynx, including erythema x Hoarseness x History of impaired mentation and/or confinement in a burning environment x Explosion with burns to head and torso

BURNS


x Carboxyhemoglobin level greater than 10% in a patient who was involved in a fire x Circumferential burns of the neck x Stridor (late sign, requires immediate intubation)

2. BREATHING: Provide supplemental oxygen to keep Sp02 > 94%. Assume carbon monoxide poisoning in

patients who were burned in an enclosed area. Administer Fi02 of 1.0 and ventilate as necessary.

3. CIRCULATION: Once circulation has been assessed begin fluid resuscitation. Total body surface area is estimated by the “rule of nines” (see below).

Fluid Resuscitation:

Patients with >20% TBSA 2nd degree burns should have fluid resuscitation initiated:

x Insert two large bore IV's and initiate fluid resuscitation with crystalloid by utilizing the Parkland Burn Formula

x Base fluid resuscitation on patient physiologic response

Parkland Burn Formula: Ringers Lactate 2-4 ml/kg/%BSA (2nd or 3rd degree burn)

x Administer half of this volume in the first 8 hours x Administer the remainder over the next 16 hours x Fluid rates should be based on the initial calculation and adjusted based on urine output

irrespective of the time from injury. Target urine output: � Adults: 0.5 ml/kg/hr � Children < 30 kg: 1 ml/kg/hr

x Electrical burns with myoglobinuria in adults: 3-4 ml/kg/hr until rhabdomyolysis resolves x Electrical burns with myoglobinuria in children < 30 kg: 2 ml/kg/hr until rhabdomyolysis

resolves

4. Manage pain.

5. Patients with > 20% TBSA, are more prone to gastric dilatation due to ileus; an N/G or O/G tube should be inserted prior to transport.

6. Cover burned area with dry, sterile dressings or drape for transport. Do not apply any ointment to the burn. If referral centre has dressed burns, do not disturb dressing; reinforce prn. Elevate and pad affected limbs. Remove any jewellery.

7. Maintain normothermic temperature (this may require increasing cabin temperature).

BURNS


8. Escharotomies may be considered under the direction of the TP if swelling for circumferential burns has constricted the chest causing ventilatory problems, or limbs causing restriction to arterial flow.

ADDITIONAL CONSIDERATIONS

x Depending on the type and severity of the burn, concomitant trauma, pre-existing illness, etc., some patients may require direct transfer from the rural referral centre to an out-of-province burn unit

x Consider decontamination based on recommendations in the Safety Data Sheet (SDS) with chemical burns

x Patients who have suffered electrical burns may not necessarily show the extent of the burns on their skin. Fluid resuscitation should be initiated and urine output must be monitored to ensure proper hydration. Myoglobinuria (assume with dark urine) and electrolyte imbalances are considerations

REFERENCES

Tam, N., Cancio, L, Gilbran, N. (2008). American Burn Association Practice Guidelines burn Shock Resuscitation. Retrieved on October 18, 2018. http://www.downstate.edu/emergency_medicine/documents/burncare.pdf.

American College of Surgeons (2012). Thermal injuries. In Advanced Trauma Life Support Manual, pp. 230-244.

AHS Critical Care MCPs (v2.0)/Trauma/Environmental/Burn injury. Retrieved from the web September 2018. https://www.ahsems.com/public/protocols/templates/desktop/#set/13/browse/4972/view/41002/Algorithm

Society of Critical Care Medicine. (2012) Fundamental Critical Care Support 5th ed. pp9-18, 9-25.


http://www.downstate.edu/emergency_medicine/documents/burncare.pdf




TRAUMA PROTOCOL T2 CARDIAC TAMPONADE – EMERGENCY PERICARDIOCENTESIS

The flight Nurse/Paramedic may assist or implement the following protocol for pericardiocentesis for stated indications. It is performed under the guidance of the Transport Physician (TP) responsible for the patient. Medical control MUST be obtained prior to the performing the procedure.

DEFINITION

Pericardial tamponade is a life-threatening condition where an abundance of blood or fluid accumulates in the pericardial space. It compresses the ventricles and impairs cardiac filling and cardiac output.

INDICATIONS

Patients requiring emergency pericardiocentesis are identified based on the progressive appearance of the following life-threatening signs and symptoms with a strong index of suspicion in chest trauma (especially penetrating chest injuries).

Key symptoms: Patient in extremis: cyanosis, dyspnea, PEA, widened mediastinum on CXR, hypotension without response to usual measures of resuscitation for hemorrhagic shock and in whom cardiac tamponade is suspected. Other symptoms that may be found include:

x Beck’s triad (muffled heart sounds, narrowed pulse pressure, jugular venous distension)

x Pulsus paradoxus

x Rapid weak pulse/tachycardia

PROCEDURE FOR EMERGENCY PERICARDIOCENTESIS

Contact the TP to report your findings.

1. Assess patient to determine that the patient meets the criteria for pericardiocentesis.

2. Clean hands, assemble equipment, and don personal protective equipment:

x IV sedation/analgesic

x Ensure equipment/medications for ventilatory and cardiovascular support are prepared and ready to be administered

x Sterile surgical gloves

x Chlorhexidine

x Pericardiocentesis needle

x Several sterile 60 ml luer lock syringes

CARDIAC TAMPONADE – EMERGENCY PERICARDIOCENTESIS


x sterile three-way stopcock

x continuous cardiac, hemodynamic and ventilator monitoring

3. Cleanse with chlorhexidine.

4. Landmark: 1 to 2 cm inferior to the left of the xiphicondral junction at a 45 degree angle to the skin.

5. Puncture the skin at a 45 degree angle to the skin.

6. Carefully advance the needle cephalad and aim towards the tip of the left scapula (shoulder level mid-clavicular) while applying slight negative pressure on the syringe and watching the monitor and your patient throughout.

7. When the needle tip enters the blood-filled pericardial sac, withdraw as much blood as possible.

Note: Free flow of continuous blood indicates the needle is in the ventricle. If the needle is advanced too far an injury pattern appears on the ECG monitor (extreme ST-T wave changes or widened and enlarged QRS complex). If this occurs withdraw the needle until the previous baseline ECG tracing appears.

8. When aspiration is complete, close the stopcock and remove the syringe.

9. Secure the catheter with a transparent dressing.

10. Continually assess the patient for further signs of decompensation.


Complications:

x Aspiration of ventricular blood instead of pericardial blood

x Laceration of ventricular epicardium/myocardium

x Laceration of coronary artery or vein

x New hemopericardium

x VF/VT

x Pneumothorax

x Puncture of great vessels

x Puncture of esophagus

x Puncture of peritoneum

REFERENCES

American College of Surgeons (2012). Advanced Trauma Life Support Student course Manual 9th edition. Pollak, A (2018). Critical Care Transport. Jones and Bartlett. Burlington




TRAUMA PROTOCOL T3 DECOMPRESSION ILLNESS

The Flight Nurse/Paramedic may initiate the following protocol for the stated indications. Consultation with the Transport Physician (TP) is required for ongoing care once stabilization has occurred. Divers Alert Network can be contacted at 919-684-8111 for consultation and further management options.

DEFINITION

Evolution of nitrogen from solution within the body tissues results in decompression sickness (DCS). It can occur from sudden exposure to altitudes above 18,000 feet, or as the result of scuba diving. A person submerged 66 feet below the surface of the water is exposed to 3 times atmospheric pressure, causing nitrogen to be “supersaturated” in the tissues. DCS results when inappropriate procedures are followed during ascent to surface.

INDICATIONS

DCS susceptibility is affected by:

x Rate of ascent x Altitude x Time of exposure x Body fat x Age (> 40 years old) x Exercise x Presence of infection, illness, or injury x Alcohol ingestion x Recent scuba diving/recurrent exposure

Type I DCS:

x Skin: paresthesia, mottled or diffuse rash, itching, hot or cold sensation x Bends: mild to severe joint pain (knee, shoulder, elbow, wrist, hand, ankle, or foot). Pain increases with

movement. Pain decreases with pressure over involved joint x Lymphatics: painless pitting edema from lymphatic obstruction with bubbles

Type II DCS:

x Chokes: chest pain (deep, sharp substernal), dry cough, dyspnea x CNS:

x Spinal cord: paresthesia, weakness, tingling, numbness, paralysis x Brain: visual field defects, headache, confusion, dysphasia, seizures, coma x Shock: hypotension, pulmonary edema

MANAGEMENT

1. Primary management of suspected DCS is the rapid transport of patient to a tertiary centre by ground transport. If transporting by air, ensure cabin pressure maintained at ground level.

DECOMPRESSION ILLNESS


2. Early consult with Divers Alert network for further management 919-684-8111.

3. Hypotension and shock: x Administer NS or RL fluid challenge 500-1000ml. Target urine output 1-2 ml/kg/hr. x If patient unresponsive to fluid bolus or signs and symptoms of pulmonary edema or heart failure

prevent further fluid resuscitation initiate one or more of the following: x norepinephrine: 0.03 – 1.5 mcg/kg/min x DOPamine: 5-20 mcg/kg/min

4. Hypoxia: target Sp02 > 95%

x Administer 02 via NRB mask at a high flow rate. Goal Fi02 1.0 x Non-invasive or invasive positive pressure ventilation may be required if oxygenation cannot be

maintained x Transport to a centre with hyperbaric oxygen therapy may be necessary x Patient is at high risk for tension pneumothorax. Perform needle decompression as necessary - see

Clinical Protocol T9 – Emergency Needle Decompression

5. Arterial gas emboli: x Position patient left side down. HOB flat

REFERENCES

Canadian Association of Aero-medical Transportation Systems. (2004). Patient care and the flight environment.

In Canadian Aerospace Medicine and Aeromedical Transportation Association Level 1 training program, pp.

56-57.

Pollack, A. (2018). Critical Care Transport. Jones and Bartlett.

Bove, A. (2014). Diving Medicine. American Journal of Respiratory and Critical Care Medicine vol 189 (12). June

15, 2014.




TRAUMA PROTOCOL T4 LIFE-THREATENING HEMORRHAGE


DEFINITION

Hemorrhage is an acute loss of circulating blood volume. Hemorrhagic shock is a continuum of symptoms as a result of the amount of blood loss. Hemorrhagic shock can be a result of traumatic injury (abdominal, thoracic, pelvic, long bone) or non-traumatic injury (obstetrical, gastrointestinal).

INDICATIONS

Estimated blood loss based on patient’s initial presentation (70 kg male):

Class of Hemorrhage Class I Class II Class III Class IV

Blood Loss (ml) Up to 750 750-1500 1500-2000 >2000

Blood Loss (% blood vol.) Up to 15 % 15-30 % 30-40 % >40 %

Pulse Rate (BPM) <100 100-120 120-140 >140

Systolic Blood Pressure Normal Normal Decreased Decreased

Pulse Pressure (mmHg) Normal/increased Decreased Decreased Decreased

Respiratory Rate 14-20 20-30 30-40 >35

Urine Output (mL/hr) >30 20-30 5-15 Negligible

CNS/Mental status Slightly

anxious

Mildly

anxious

Anxious, confused Confused,

lethargic

Initial fluid replacement Crystalloid Crystalloid Crystalloid & blood Crystalloid & blood

MANAGEMENT

1. Delay in definitive management can be lethal. Prompt transport is essential.

2. Assess and treat cause of volume loss. Consider: x Direct pressure to control bleeding x Tourniquet x Wound closure with sutures or staples

LIFE-THREATENING HEMORRHAGE


x Pelvic binder x Splints

3. Treat hemorrhage:

x Under the direction of the TP, tranexamic acid (TXA) may be ordered in a variety of doses: x TXA: 1 gram over 10 minutes IV q 6-8h x TXA: 1 gram/250 ml IV over 8 hours x TXA should be administered within 3 hours of event, but may be administered outside this

window

4. Prevent the Hypothermia-Acidosis-Coagulopathy Triad: x Warm IV fluids and blood products x Limit exposure of patient and increase the ambient temperature

5. Fluid resuscitation:

x Target a MAP 65 mm Hg or SBP of 90 mm Hg to maintain end-organ perfusion: x Palpable radial pulse x Level of consciousness x Target urine output 0.5ml/kg/h

x Administer warmed ringers lactate 500-1000ml up to a maximum of 20 ml/kg x If patient is unresponsive to fluid bolus, under the direction of the TP, administer:

x Crossmatched or uncrossmatched PRBC x Under the direction of the TP, concurrently initiate the following:



1. Consider contributing factors: medications, cardiovascular disease, age.

2. Pelvic binder should be placed over greater trochanters not the iliac crests. Incorrect placement may

exacerbate hemorrhage.

REFERENCES

AHS Critical Care MCPs (v2.0)/Shock


Bulger, Eileen M., et al. (2014). "An evidence-based prehospital guideline for external hemorrhage control:

American College of Surgeons Committee on Trauma." Prehospital Emergency Care 18.2 (2014): 163-173.

American College of Surgeons (2012). Hemorrhagic shock. In Advanced Trauma Life Support, pp. 62-81.


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/tranexamic%20acid.pdf



https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/tranexamic%20acid.pdf



TRAUMA PROTOCOL T5 OPHTHALMIC EMERGENCIES – GLOBE RUPTURE


DEFINITION

Ocular trauma can be blunt, penetrating or burn, mechanical or non-mechanical.

INDICATIONS

Ocular injury may be isolated or associated with head, face or neck trauma.

Globe rupture is considered a medical emergency. Symptoms include:

x Anterior chamber appears flat or shallow x Irregular or teardrop shaped pupils, or the presence of what looks like a secondary pupil x Periorbital ecchymosis x Decreased visual acuity and extraocular movements x Severe subconjunctival hemorrhage x Nausea x Pain

MANAGEMENT

1. Primary management of suspected globe rupture is the transport of patient to an ophthalmologic centre as soon as possible.

2. Keep HOB elevated to 30 degrees. 3. Apply a rigid shield to protect the affected eye. 4. Do not place drops in the eye. 5. Provide analgesic. 6. Provide antiemetic to prevent vomiting and resulting increased intraocular pressure.


1. There are many types of ocular trauma. General interventions include: x If foreign body penetrates the globe, stabilize and immobilize x Elevate the head of the bed to decrease intraocular pressure

OPHTHALMIC EMERGENCIES – GLOBE RUPTURE

SECTION: POISONING Reviewed April 2019 Page T5-2

REFERENCES

Emergency Nurses Association. (2014). Trauma Nursing core Course Provider Manual 7th ed.




TRAUMA PROTOCOL T6

MANAGEMENT OF PNEUMOTHORAX, CHEST TUBES AND PLEURAL DRAINS

The Flight Nurse/Paramedic may implement the following protocol.

DEFINITION

Pleural drain includes: pleural chest tube or drain that is attached to a collection bag, underwater seal, or

Heimlich valve.

INDICATION

Pneumothoraxes or hemothoraxes that are causing clinically significant compromise to a patient should have,

if possible, definitive treatment by the insertion of a pleural drain prior to air transport by the sending physician

or Transport Physician (TP).

MANAGEMENT

1. When transporting a patient with chest tubes, the Flight Nurse/Paramedic must ensure that:

x A Heimlich valve is inserted between the chest tube and chest drainage device prior to any

ground or air transport. This is to ensure that fluid is not emptied back into pleural space during

inadvertent disruption of the underwater seal collection system during transport

x All connections should be securely taped to prevent accidental dislodging

x Each separate chest tube requires a separate Heimlich drain valve

x Two Kelly clamps per chest tube must be readily visible and available

x All drainage sets are secured within the aircraft

2. Following removal of a chest drain, a chest x-ray must be done 4 hours and 48 hours post drain removal

to assess for re-accumulation of the pneumothorax/hemothorax prior to air transport. Patients are not to be transported by air for at least 48 hours post-removal.

3. With an open pneurmothorax apply an occlusive dressing taped on three sides to create a flutter valve

or utilize a commercial product if available. Frequently reassess the patient and the dressing for signs of

a developing tension pneumothorax.

MANAGEMENT OF PNEUMOTHORAX, CHEST TUBES AND PLEURAL DRAINS


REFERENCES

AHS Critical Care MCPs9v2.0) / Respiratory/ Pneumothorax. Retrieved Sept 24,2018 from


Pollak, A. (Ed). (2018). Critical Care Transport. Jones and Bartlett. Burlington, MA. Triggs, P. (Ed). (2016). Canadian Aerospace Medicine and Aeromedical Transportation association Air Medical Training Program Level One 2nd Ed. Canada. CAMATA.





TRAUMA PROTOCOL T7 SEVERE HEAD INJURY


DEFINITION

Closed brain injuries include: concussions diffuse axonal injury (DAI), epidural hematomas, subdural hematomas, contusions and intracerebral hematomas. Penetrating head injuries include: gunshot wounds, and stabbings.

INDICATIONS

x A Glasgow Coma Scale (GCS) score of < 8 is generally accepted as a definition of severe brain injury x Pupillary changes x Cerebral spinal fluid (CSF) leakage from nares or ears x Symptoms of increased intracranial pressure (> 20 mmHg) and impending herniation include:

o Cushing’s reflex: hypertension, widened pulse pressure, bradycardia o Cushing’s triad: hypertension, bradycardia, abnormal respirations

x Symptoms of uncal herniation include: ipsilateral pupillary dilation with contralateral hemiparesis x Symptoms of impending brain death include:

o Absence of brain stem reflexes: gag, corneal, pupillary, Babinski and doll’s eyes reflexes and apnea

MANAGEMENT

1. Primary management of a severe head injury is the transport of patient to a trauma centre. Early notification of the TP and Neurosurgeon is advised.

2. Early intubation to manage and protect airway: x Utilize drug assisted intubation x Titrate ventilation to achieve:

o Sp02 of 90-94% o ETC02 30-35 mm Hg (pC02 35-40 mm Hg) o Cautious use of PEEP > 5 cm H20

x Oral gastric tube placement 3. Target SBP > 100 mmHg for patients 50-69 years old, and target SBP > 110 for patients 15-49 years old

and > 70 years old. Goal is to maintain cerebral perfusion pressure (CPP) 60-70 mm Hg: x Identify and manage sources of bleeding x Fluid resuscitation if required:

o Administer Normal Saline or Ringers Lactate fluid challenge 500 ml prn up to 20 ml/kg o Under direction of TP, administer PRBC if hemodynamic instability is related to blood loss.

x If patient unresponsive to fluid bolus initiate the following: o norepinephrine: 0.03-1.5 mcg/kg/min

x Avoid hypertension

SEVERE HEAD INJURY


4. Elevate HOB 30 o and keep head and neck in mid-line position. 5. Maintain normothermia. 6. Avoid agitation with short-acting sedatives and analgesia. 7. For patients with signs of impending herniation under the direction of the TP, administer:

x mannitol: 0.5-1 gram/kg over 15-20 minutes (use filter) x hypertonic saline (3%): 3 ml/kg over 20-30 minutes

8. Document neurologic assessment q15min or more frequently as required. 9. Treat seizures following Clinical Protocol N1 - Seizures. 10. Under the direction of the TP, consider prophylactic antibiotic administration for penetrating brain

injuries.


1. GCS score is derived from the BEST motor response regardless of right/left or upper/lower asymmetry. This provides the most reliable predictor of outcome.

2. Consider additional factors affecting level of consciousness such as recent seizures, toxins and metabolites.

REFERENCES

AHS Critical Care MCPs (v2.0)/trauma/environmental


American College of Surgeons, Advanced Trauma Life Support (Ninth Edition, 2012) pp. 148-169

Carney, N. et.al. (2016). Guidelines for the Management of Severe Traumatic Brain Injury, 4th ed. Brain Trauma

Foundation TBI Guidelines. Endorsed by the American Association Neurological Surgeons and the Congress of

Neurological Surgeons. Neurosurgery vol 0 (0). Retrieved December 2018

https://braintrauma.org/uploads/07/04/Guidelines_for_the_Management_of_Severe_Traumatic.97250__2_.pdf

Manget, H. et al. (2015). Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. In J Neurosurg 2015; 122: pp. 202-210.


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/mannitol.pdf


https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/sodium%20chloride%203%20percent.p

df

Dries, D. (2012). Fundamental Critical Care Support5th ed. Society of Critical Care Medicine Mt. Prospect Illinois.

York, D. et.al. (2017). Critical Care Transport core Curriculum. Air & surface Transport Nurses Association Aurora,

CO.



https://braintrauma.org/uploads/07/04/Guidelines_for_the_Management_of_Severe_Traumatic.97250__2_.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/mannitol.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/sodium%20chloride%203%20percent.pdf

https://collaboration.web.ehealthsask.ca/sites/smartpump/Monographs/sodium%20chloride%203%20percent.pdf



TRAUMA PROTOCOL T8 SPINAL INJURY AND NEUROGENIC SHOCK


DEFINITION

Isolated intracranial injuries do not cause shock. Cervical or upper thoracic spinal cord injury produce hypotension due to loss of sympathetic tone.

INDICATIONS

Classic presentation is hypotension without tachycardia or cutaneous vasoconstriction. Careful assessment to rule out concurrent torso trauma is necessary. Patients should be treated initially for hypovolemia. Failure to respond to fluid suggests continuing hemorrhagic shock or neurogenic shock.

Suspect neurogenic shock in patients with:

x Spinal cord injury above T6 x Bradycardia or the absence of tachycardia in response to hypovolemia x Hypotension that is not responsive to fluid resuscitation x Pulmonary edema in response to fluid resuscitation x Normal pulse pressure x Pink, warm, dry skin x Impaired thermoregulation

MANAGEMENT

1. Primary management of trauma is the transport of patient to a trauma centre. 2. Hypotension and shock:

x Administer Normal Saline or Ringers Lactate fluid challenge up to 1000-2000ml targeted to a MAP of 85 mm Hg

x If patient is unresponsive to fluid bolus and neurogenic shock is suspected, initiate vasopressors to a target MAP of 85 mm Hg:

x norepinephrine: 0.03-1.5 mcg/kg/min And/or:

x DOPamine: 5-20 mcg/kg/min 3. Bradycardia:

x Administer: x atropine: 0.5mg every 3-5 min to a maximum total dose of 3 mg x Consider DOPamine: 5-20 mcg/kg/min x Consider the addition of transcutaneous pacing

4. Restrict spine motion by: x Ensuring appropriately fitted cervical collar x Securing patient supine to air ambulance stretcher

SPINAL INJURY AND NEUROGENIC SHOCK



A physician can clear c-spine precautions using the The Canadian C-Spine Rule for alert (i.e. GCS=15) and stable truama patients where cervical spine injury is a concern. Exclusions include: non-trauma cases, GCS < 15, unstable vital signs, age < 16 years, acute paralysis, known vertebral disease, previous c-spine injury.

YES

NO

NO

YES UNABLE

ABLE

http://www.ohri.ca/emerg/cdr/cspine_formats.html

1. Any high-risk factor which mandates Immobilization? x Age ≥ 65 years. x Dangerous mechanism. * x Numbness or tingling in

extremities.

2. Any low-risk factor which allows safe assessment of range of motion?

x Simple rear end MVC** x Sitting position in ED x Ambulatory at any time x Delayed onset of neck pain x Absence of midline c-spine

tenderness

3. Patient voluntarily able to actively rotate neck 45o left and right regardless of pain.

No C-Spine immobilization.

C-Spine Immobilization

* Dangerous Mechanism:

x Fall from elevation≥ 4 feet/5 stairs.

x Axial Load to head. x MVC high speed (> 100 km/hr),

rollover, ejection. x Motorized recreational vehicles x Bicycle struck or collision.

** Simple Rear-end MVC excludes:

x Pushed into oncoming traffic. x Hit by bus/large truck. x Rollover. x Hit by high speed vehicle.

http://www.ohri.ca/emerg/cdr/cspine_formats.html

SPINAL INJURY AND NEUROGENIC SHOCK


REFERENCES


American College of Surgeons. (2012). Advanced Trauma Life Support Student Course Manual 9th ed. Chicago.

Congress of Neurological Surgeons. ( 2013). Guidelines for the Management of Acute Cervical spine and Spinal Cord Injuries. Joint Section on disorders of the Spine and Peripheral Nerves of the American Association

of Neurological Surgeons and the Congress of Neurological Surgeons. Retrieved December 2018.

https://www.cns.org/guidelines/guidelines-management-acute-cervical-spine-and-spinal-cord-injuries

Emergency Nurses Association. (2014). Trauma Nursing core Course Provider Manual 7th ed. U.S.A.

Heart and Stroke Foundation. (2015). Advanced Cardiovascular Life support Provider manual.





https://www.cns.org/guidelines/guidelines-management-acute-cervical-spine-and-spinal-cord-injuries



TRAUMA PROTOCOL T9 TENSION PNEUMOTHORAX – EMERGENCY NEEDLE DECOMPRESSION

The Flight Nurse/Paramedic who has been instructed and certified competent may relieve a tension

pneumothorax after all correctable reasons for hypoxemia and/or hemodynamic instability have been

addressed.

DEFINITION

Tension pneumothorax is a life-threatening condition where air or fluid accumulates in the pleural space

causing an increase in intra-thoracic pressure. This hampers the body’s ability to exchange gas, and collapses the affected lung, causing a shift in the mediastinum, resulting in ventilatory and circulatory collapse.

INDICATION

Key symptoms: hypoxia with refractory increasing oxygen requirements and hemodynamic instability

(tachycardia and hypotension) with suspected or confirmed pneumothorax. Blood pressure on 2 occasions must be less than:

x Adults: 80 systolic

x Children up to the age of ten years: 90 + (age in years x 2)

x Infants up to twelve months: 70 + (age in years x 2)

Additional symptoms

x Respiratory distress, air hunger, tachypnea

x Chest pain x Subcutaneous emphysema x Asymmetrical breath sounds/chest wall movement

x Tracheal tugging

x Hyper-resonant percussion (of limited value in the aircraft)

x Contralateral tracheal deviation (late sign)

x Distended neck veins (may not be present in the hypovolemic patient)

x Cyanosis (late sign)

Additional symptoms in a positive pressure ventilated patient:

x Increasing airway pressures on mechanical ventilator

PROCEDURE

Contact the Transport Physician (TP) to report your findings. Do not delay treatment if unable to contact the TP.

1. Assess chest and respiratory status to determine that the patient meets the criteria for needle

decompression.

2. Cleanse with chlorhexidine.

TENSION PNEUMOTHORAX – EMERGENCY NEEDLE DECOMPRESSION


3. Landmark: 2nd ICS MCL – just above the 3rd rib. Avoid the underside of the 2nd rib and the neurovascular

bundle that is located there. Alternatively the 4th ICS anterior MAL just above the 5th rib.

4. Insert the Turkel needle at a 90 degree angle until the change indicator turns green.

5. Advance the catheter into the pleural space.

6. Remove the needle and open the one way stopcock to atmosphere to release the air in the pleural

space. Alternatively place a luer lock syringe on the stopcock to remove fluid.

7. When the patient’s condition is improved close the stopcock. Leave the Turkel in place and secure. It is

likely the pleural space will need to be decompressed repeatedly during transport. It may be necessary

to re-open the stopcock to atmosphere.

8. Continually assess the patient for improvement or decompensation.

REFERENCES

AHS Critical Care MCPs9v2.0) / Respiratory/ Pneumothorax. Retrieved Sept 24, 2018 from


American College of Surgeons (2012). Advanced Trauma Life Support Student course Manual 9th ed. Chicago,

IL American College of Surgeons.

Pollak, A. (Ed). (2018). Critical Care Transport. Jones and Bartlett. Burlington, MA.



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