NORTHWEST MEDICAL CENTER · HAZMAT Patients (SAEMS) 16. Hyperthermia 17. Hypo-Hyperglycemia 18....

TUCSON MEDICAL CENTER BASE HOSPITAL ADMINISTRATIVE/STANDING INDEX

Base Hospital

1. Abdominal Pain

2. ALS/BLS General

3. ALS Stabilization

4. Behavioral Emergency

5. Burn (SAEMS)

6. Cardiac Arrest (SAEMS)

7. Chest Pain

8. Dead on Scene (SAEMS)

9. Dyspnea-Anaphylaxis/Allergic Reaction (SAEMS)

10. Dyspnea-Asthma/COPD (SAEMS)

11. Dyspnea-CHF/Volume Overload (SAEMS)

12. EMT Stabilization

13. ETOH

14. Eye Injury

15. HAZMAT Patients (SAEMS)

16. Hyperthermia

17. Hypo-Hyperglycemia

18. Hypothermia (SAEMS)

19. Nausea and Vomiting

20. OB-GYN-Vaginal Bleeding (SAEMS)

21. OB-GYN- Eclamptic Seizure (SAEMS)

22. OB-GYN-Post-Partum Hemorrhage (SAEMS)

23. OB-GYN-Presumed Pregnant with Contractions and/or SROM (SAEMS)

24. Pain Management

25. Peds Cardiac Arrest (SAEMS)

26. Refusal of Transport under 18 years

27. Refusal of Transport over 18 years

28. Seizure

29. Sepsis-Shock

30. Sexual Assault (SAEMS)

31. Snakebite (SAEMS)

32. Stroke (SAEMS)

33. Tourniquet

10/09; updated 2013-2015; 01-16; 12-19;revised 2-20

This administrative order should not be used on patients who are:

Pregnancy - follow OB/GYN SO

Meeting Level One or abdominal trauma - follow ALS/BLS Stabilization AO BLS

If patient’s condition deteriorates, call Medical Direction Authority

Consider transport to closest facility Provide appropriate receiving facility notification

Use administrative order on patients complaining of abdominal pain

ALS

Follow BLS orders

If patient stable with complaints of nausea and/or vomiting, administer Ondansetron HCL IV/IM/PO: o Adult size(>30 kg)

o Ondansetron 4 mg IV over 2-5 minutes, if no response, may repeat once after 15 minutes

o If unable to obtain IV, give Ondansetron 8mg PO, Orally Dissolving Tablet (ODT), Do NOT Repeat

o Or Ondansetron 4 mg IM, if no response, may repeat once after 15 minutes

o Pediatric size(<30kg) o Pediatric <15kg Ondansetron 0.15 mg/kg slow IVP over 2-5

minutes, Do NOT Repeat o Pediatric >15kg Ondansetron 4 mg Orally Dissolving Tablet

(ODT), Do NOT Repeat

If patient stable, may follow Pain Management AO

If patient unstable, and unable to start IV, use I/O for fluid bolus

ABDOMINAL PAIN AMINISTRATIVE ORDER

I NCL

E X C L

Initiate Immediate Supportive Care:

Oxygen to maintain O₂ sat ≥ 94%

Complete primary and secondary survey as indicated

Vital signs including FSBG and temperature as indicated

ALS Cardiac Monitor

ORDER

S

Stable: SBP >90 or HR <130

Initiate IVNS/LR (if permitted)

Transport in position of comfort with supportive measures as indicated Unstable: SBP <90 or HR >130

Follow stable orders

To keep SBP> 90, bolus 20 ml/kg maximum, reassess hemodynamic and pulmonary status at 500 ml intervals

Base Hospital

Base Hospital

10/09;undated 2013-16;09/16;01/19

If patient’s condition deteriorates call, Medical Direction Authority Consider transport to closest facility

Provide appropriate receiving facility notification

Initiate immediate supportive care:




ALS BLS

General weakness

≤ 3 months old with any symptoms of illness or injury

Fever- 55 years of age and older with Temp > 102 or above

Dizziness

Overdose

Lightheaded

Lacerations Hypertensive patient with no other medical issues ***Requires cardiac monitor***

Nose bleeds-minor with stable vital signs

Finger lacerations

Toe injuries

Cactus needles

Earache

Cough- low grade fever under 18 years of age

Cold symptoms

General minor complaints ***No cardiac monitor required***

ALS IV NS/LR TKO as indicated

If indicated- bolus 20 ml/kg maximum, reassess hemodynamic and pulmonary status at 500 ml intervals

12 ECG as indicated

Febrile patient follow Over-the-Counter Medication Protocol BLS

Prepare for transport

Basic supportive care as needed

Febrile patient follow Over-the-Counter Medication Protocol

ALS/BLS GENERAL ADMINISTRATIVE ORDER

O R D E R S

Base Hospital

10/09; updated 2010-2016; 01/17, 01/19

If patient’s condition deteriorates, call Medical Direction Authority Consider transport to closest facility


Us


O2 to maintain sat > 94%


Cardiac monitor, vital signs including FSBG and temperature as indicated

12 Lead EKG as indicated

ALS STABILIZATION ADMINISTRATIVE ORDER

Airway maintenance, control and ventilation

Follow Airway Management Protocol as needed

Follow Medicated Facilitated Intubation Protocol if indicated, if patient condition worsens or unable to secure airway Midazolam (Versed) Dosing: IV/IO/IM

Age 14 years of age or older: 1-10 mg, may repeat to max of 20 mg

Age 9-14 years of age: 1-4 mg slow push, may repeat to max of 15 mg

Age 8 years of age or younger: 1-2 mg slow push, may repeat to max 10 mg

IM Dosing all ages: 0.2mg/kg IM, same max per age

CPAP Adult Sedation: with Dyspnea SO, follow Sedation Protocol

Croup Management: Epi 3mg 1:1,000 mixed in 3 ml NS via SVN along with Dyspnea SO

Emergency treatment of ACLS/PALS conditions

Follow the appropriate ACLS/PALS algorithm

Electrical therapy with pacing, defibrillation or cardioversion

Use Sedation Protocol as needed

I/O consider following lidocaine dosing sheet for pain control

Injury Triage Criteria

Follow Trauma Triage Protocol as indicated

ATLS/ABCDE-injury area

Consider C-Spine precautions-follow -SMR Protocol documenting use

Initiate IV/IO NS/LR TKO as appropriate-Bolus to maintain systolic BP ≥ 90

Manage extremity injuries as appropriate

If TBI suspected follow EPIC Protocol for Adult or Peds

Needle Decompression per SAEMS protocol

If unable to control bleeding, follow External Hemorrhage Control Protocol and/or TQ AO

Pain Management AO as needed if stable

Falls- evaluate, describe impact surface, height of fall

Painful procedure follow the Sedation Protocol

Physical Assault

Hypotension

SBP ≤90, pulse≥120, increased respirations, pale, cool skin, diaphoresis, altered mental status, agitation, or restlessness, progression to profound hypotension

NS/LR bolus 20 ml/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals

Consider causes

Initiate Dopamine drip (if heart rate ≤ 100) 2-20 mcg/kg/min titrate to SBP≥80 if time permits or follow Push Dose Epi Protocol

Unconscious/unresponsive patient unresponsive or responsive only to painful stimuli

Manage airway as above

Initial IV with NS/LR TKO

Bolus 20 mL/kg k maximum, reassess hemodynamic status and pulmonary status at 500 mL intervals to maintain SBP ≥90

Administer Naloxone IV/IO/IN/IM 0.5 mg-2.0 mg, titrate to effect

FSBG≤70, give 1mL/kg of D10 and 100mg Thiamine (if available). May hold Thiamine if no history of alcohol abuse or malnourishment)

If status improves after treating FSBG, follow Hypoglycemia AO

If FSBG >400, follow Hyperglycemia AO

Base Hospital

10-09; updated 2013-2015; 01-16

Initiate immediate supportive care: Oxygen to maintain sat ≥ 94%


Vital Signs including FSBG as indicated

ALS patient cardiac monitor

I

Call Poison Control for suspected or verified Ingestions/overdose/exposures as needed

800-222-1222

Protect patient from harming self and others

Calm patient with reassuring voice and gestures

If patient is violent or exhibiting behavior that is dangerous to self or others and the EMS provider can safely perform the following:

Restrain all four extremities with either padded leather restraints or soft restraints. Pt. must remain in the supine position. Restraints must allow for quick release. Handcuffs are for law enforcement use only.

Paramedic o Chemical Restraint Protocol as needed

Pepper spray: decon with H2O, apply ice packs, discourage eye rubbing

Tazer Probes: Ask Law Enforcement to remove; if imbedded in face, neck or groin, transport for ED removal; do NOT remove

TMC BEHAVIORAL ADMINISTRATIVE ORDER

O R D E R S

Contact Medical Direction Authority If:

The patient wishes to refuse

The EMS providers cannot safely restrain the patient

Condition deteriorates


Assess for immediate danger

Protect yourself and others

Protect patient from injury

Summon Law Enforcement as needed

Use AO on patients with these symptoms:

History of recent crisis, emotional trauma, bizarre or abrupt changes in behavior

Suicidal Ideation

Acute psychiatric complaint

No identified acute medical needs

+

D DRAFT 6-22-09 DRAFT

Initiate immediate supportive care: • Assure ABC’s • 100% Oxygen • IV/IO NS or LR • Cardiac Monitor

BURN STANDING ORDER

Use standing order on ALL patients with these symptoms: • Partial thickness burns > 10% total body surface area (TBSA) • Full thickness burn > 5% TBSA • Significant burns that involve the face, hands, feet, genitalia, perineum, or major joints • Electrical burns, including lightning injury • Inhalation injury • Significant burn injury in patients with preexisting medical disorders that could complicate management,

prolong recovery, or affect mortality, such as: diabetes, cardiac disease, pulmonary disorders, pregnancy, cirrhosis, morbid obesity, immunosuppression, bleeding disorders

Special Notes: Patients meeting inclusion criteria should be transported to the regional burn facility.

• If appropriate airway measures are not successful in the field, transport to closest facility.

• In outlying areas with a transport time of greater than 30 minutes to the regional burn facility, transport the patient to the closest facility or, consider air transport directly to the closest burn facility.

• Regional burn facility currently in SAEMS: UAMC University Campus

I N C LUSI O N

E X C L U S I O N

Patients with burns who also meet any of SAEMS Trauma Triage Decision Scheme criteria should be transported to a trauma center for initial stabilization following on-line medical direction.

• Stop the burning process, remove smoldering clothing and jewelry • Continually monitor airway • Cover burn area with a clean dry dressing. Prevent hypothermia (warm fluids/environment). Never use ice • Estimate involved body surface area (BSA) using an appropriate burn estimation guide • IV/IO NS or LR: administer initial fluid bolus of 20 ml/kg • Consider early aggressive airway management in patients at risk for inhalation injury

ADULT Pain/Nausea Management • Consider Morphine Sulfate 5-10 mg every 5 min up to a max dose of 20mg, OR • Fentanyl 50-100 mcg every 5 min as needed up to a max dose of 200 mcg or respiratory/mental status depression

occur • For nausea or vomiting, administer Ondansetron per N/V Standing Order

PEDS Pain/Nausea Management • Consider Morphine Sulfate 0.1 mg/kg in increments of 1-2 mg every 5 min to a max dose of 10 mg, OR • Fentanyl 0.5 – 1 mcg/kg every 5 min as needed to a max dose of 100 mcg or respiratory/mental status depression

occur • For nausea or vomiting, administer Ondansetron per N/V Standing Order

O R D E R S

Approved 4-19-11 Revised 10-15-13

Relay information must include percent, location, and type of burn.

Initial Orders: Initiate Chest Compressions with Rate of 100-120 compressions per minute

If ROSC at ANY time

Prepare for rapid transport per appropriate SAEMS Triage Protocol (CRC, Trauma, Peds, OB)

• If NO response, apply Dead On Scene SO • Consider transport for a patient with:

persistent VF, PEA with elevated EtCO2 (> 20 mmHg), patients under age 18 years

INCLUSION

Out of Hospital Cardiac Arrest

EXCLUSION

• Patients meeting SAEMS Dead on Scene SO • Age less than 8 years old

Special notes: ACLS Interventions

Hypoxia Airway Management

Hydrogen ion or acidosis 500cc fluid bolus Adjust EtCO2 to 40

Hyperkalemia • Administer: Calcium Chloride

1gm IV/IO and Sodium Bicarbonate 50mEq IV/IO

Hypovolemia 500ml fluid bolus

Hypoglycemia Dextrose

Hypothermia Hypothermia SO

Tension pneumothorax Needle decompression

Trauma Rapid transport

Toxins: TCA overdose, administer bicarb beta-blocker or calcium channel blocker overdose, consider glucagon & cardiac pacing Opiate overdose, consider Narcan

Patient Destination: Patients should be transported per SAEMS Cardiac Receiving Center Triage Protocol * if transitioning from MICR to ACLS give only a total of 2mg Epi

Effective: 10/16/18

ACLS • Apply SAEMS Airway Management Protocol • Perform CPR checking rhythm (and

pulse when indicated), defibrillating if indicated every 2 min with ventilation rate of 10 breaths / minute

• ALS: • Administer Epi 1mg IV/IO (as early as

possible) to max total dose of 2mg with doses separated by 8 min.*

• Consider ACLS H’s & T’s - treat per current ACLS guidelines*

• Avoid hyperthermia BLS

• IF no shock indicated and patient meets Dead on Scene SO criteria for termination, no transport or further interventions are indicated

Minimally Interrupted Cardiac Resuscitation (MICR) - first 8 minutes

• NRB mask, max flow O2 & NPA/OPA • Perform 4 rounds of CPR

- 200 compressions - Check rhythm (and pulse when indicated),

defibrillate if indicated between rounds - Minimize interruptions

• ALS: • Administer Epi 1mg IV/IO (as early as

possible) to max total dose of 2mg with doses separated by 8 min.

• IF VF after first shock, administer Amiodarone 300mg IV/IO or lidocaine 1mg/kg IV/IO x 1

• If continued VF after THIRD shock administer Amiodarone, 150mg IV/IO or lidocaine 1mg/kg IV/IO x 1

ORDERS ORDERS

Likely Non-Cardiac Cause Likely Cardiac Cause

Cardiac Arrest Standing Order

NO

Response

Base Hospital

04-09; updated 2011-2015; 01-16;

01/17, 1/19, 12/19, revised 2/20

Use this Administrative Order for patient’s ≥25 years of age with these symptoms

Dull aching or substernal/ epigastric pressure

Possible radiation of pain/pressure to arm/neck/shoulder/jaw

Associated diaphoresis/or shortness of breath

Back pain or epigastric discomfort for women

Past medical history of cardiac disease or angina

Use on patients ≤25 years of age with hx of recent drug use

Administrative order should not be used on patients with these symptoms:

Pulmonary edema- follow Dyspnea SO

ALS-Dysarrythmia’s Specific- follow ALS Stabilization AO

BLS Administer: Aspirin (4) 81mg chewable tablets or Aspirin 324 mg

Initiate IV NS/LR TKO (if permitted)

SBP ≥ 110: give one* Nitroglycerine 0.4 mg SL/spray or patient assist self-administration every 5 minutes X 3 or until pain relieved

Hold Nitroglycerin if SBP drops below 90mm Hg o If SBP drops ≤90– place patient in Trendelenburg and give 250 ml fluid bolus,

reassess hemodynamic and pulmonary status and repeat as needed

ALS Follow BLS orders

Obtain 12-lead EKG and send to receiving facility, if possible

o Use Nitroglycerin cautiously in patients with ST –segment elevation in

leads II, III, and AVF (inferior MI)

For nausea or vomiting follow Nausea and Vomiting AO

Morphine Sulfate IV/IM:

o 2-5mg IV every 5 minutes to a max dose of 20 mg

o If unable to obtain IV, give Morphine Sulfate 2-5 mg IM, if no response, may

repeat after 15 minutes to a max dose of 20 mg

If patient allergic to Morphine, administer Fentanyl IV/IN/IM:

o 25mcg-50mcg slow IVP, over 2 minutes. May repeat every 5 minutes to a max dose

of 200 mcg

o If unable to obtain IV, give Fentanyl 25mcg-50mcg IN/IM, may repeat dose after 15

minutes to a max dose of 200mcg

If at any point during medication administration, SBP≤90 drops follow above orders for

fluid bolus and management

CHEST PAIN ADMINISTRATIVE ORDER

I N C L

U

E X C L

O R D E R

S




Vital signs including FSGB

ALS cardiac monitor

EMT cardiac monitor (non interruptive) if available

STEMI Alert If the EMS provider has clinical impression and/or the

computerized interpretation identifies ST segment elevation or an acute MI,

alert facility this is a STEMI alert.

SAEMS Dead On SceneStanding Order

SPECIAL NOTE:If there are scene or patient circumstances in which providers, family, or other stakeholders would benefit from transporting a patient unlikely to survive their illness/injury, the treating EMS team can elect to do so in a safe manner. If asked for a time of death please provide the “TIME at which resuscitation was withheld/withdrawn.”

Pulseless

Inclusion

Hypothermia, lightning strikes, submersion

Exclusion

Conditions Incompatible with Life• Decapitated• Decomposed• Burned beyond recognition• Absence of signs of life in a patient with a signed DNR order

ORDERSWithdraw OR

Withhold resuscitative

efforts

Non-traumatic Cardiac Arrest

Penetrating Trauma & Cardiac Arrest

Blunt Trauma & Cardiac Arrest• IF airway obstruction or tension pneumothorax: Consider OPA/NPA and

bilateral needle thoracostomyAND• IF continued pulseless on scene

ALL OF THE FOLLOWING• Un-witnessed Arrest• > 30 min down time• No pulse for 60 sec• PEA/Asystole or non-

shockable rhythm on AED

ALL OF THE FOLLOWING• Witnessed Arrest• 20 minutes of resuscitation with

o PEA & EtCO2 < 10OR

o Asystole or non-shockablerhythm on AED

OR

Approved: 1/19/16

• IF airway obstruction or tension pneumothorax: Consider OPA/NPA and bilateral needle thoracostomy

AND• IF continued pulseless AND time to Level I trauma center > 15 min

Dyspnea Standing Order

BLS Care:• Place patient in position of comfort• Obtain vital signs• IV Access if capable• Supplemental O2 to achieve O2 Sat >94%• Assist ventilations if indicated:

- BVM with 100% O2

INCLUSION

All patients complaining of dyspnea, cough, tachypnea, or in respiratory distress

EXCLUSION

Standing order should NOT be used on patients with the following symptoms:• Chest Pain • Dysrhythmia (ACLS) • Hemorrhage• Smoke Inhalation • Toxic Exposure • Seizure• Absent Breath Sounds • Trauma

SPECIAL NOTE:• Other causes of dyspnea include pneumonia, pneumothorax, pulmonary contusion, pulmonary embolism, or toxic

ingestion (i.e. aspirin). • Aspirin ingestions can cause severe tachypnea due to metabolic acidosis: If ETI is performed, ENSURE ventilation rate

after ETI matches the patient’s respiratory rate prior to ETI.• If BVM ventilation or an advanced airway is placed, examine for presence of potential tension pneumothorax and

decompress if present.

ALS Care:• Follow BLS Interventions• Cardiac monitor• If respiratory failure:

- Consider Airway Management Protocol

Dyspnea SO

Anaphylaxis

Dyspnea SO

CHF / Volume Overload

Dyspnea SO

Asthma / COPD

Contact Medical Direction if unclear clinical presentation or patient wishes to refuse and does not meetRefusal Standing Order. Notify receiving facility of incoming patient and/or if CPAP therapy has been initiated.Consider Critical Pediatrics Triage Criteria

Initiate supportive care:

Approved: 1/19/16

Anaphylaxis/Allergic Reaction Standing Order

ORDERS

For STABLE allergic reaction OR

following the administration of epinephrine:

BLS Care if respiratory involvement:• Albuterol nebulized therapy

- Single unit dose. May repeat every five minutes to a max of three doses.

ALS Care:• Albuterol and Ipratropium nebulized

therapy- May repeat Albuterol every five minutes to a max of three doses.

• IV access and NS/LR fluid bolus:- 20ml/kg to a max of 1000ml

• Diphenhydramine- 1mg/kg IVP to a max of 25mg

• Methylprednisolone- 2mg/kg IVP to a max of 125mg

ORDERS

For UNSTABLE allergic reaction:

BLS Care:• Administer Epinephrine:

- via Adult auto-injector (wt >30kg)- via Pediatric auto-injector (wt <30kg)

• Continue with orders outlined in Stable Allergic Reaction.

ALS Care:• Epinephrine 0.01mg/kg to a max of

0.5mg. May repeat every 5 minutes for hypotension or airway edema.- 1:1000 solution IM (preferred)* or may substitute age/weight appropriate epinephrine auto-injector- 1:10,000 solution IV

• Consider early airway management per Airway Management Protocol

• Continue with orders outlined in Stable Allergic Reaction.

SPECIAL NOTE:• Multiple diseases may mimic anaphylaxis (i.e: Angioedema, Scombroid Toxicity, Anaphylactoid Reaction, etc).

Treatment for these diseases is the same as anaphylaxis as outlined above.• *Administration of IV epinephrine can result in significant tachycardia / hypertension and complications such as heart

attack and stroke

EXCLUSION• If none of the above, use Stable

Allergic Reaction Inclusion/Order set only.

INCLUSIONUnstable Allergic Reaction:

• Signs of shock, severe respiratory distress or airway compromise

INCLUSIONStable Allergic Reaction:

• Urticaria (Hives)• Sense of dyspnea• Sense of oropharyngeal swelling• Sense of throat tightness

Approved: 1/19/16

Asthma/COPD DyspneaStanding Order

ORDERS

Initial BLS Care:• Albuterol nebulized therapy

- Single unit dose. May repeat every five minutes to a max of three doses.

INCLUSION

History of respiratory disease (asthma, COPD), wheezing with increased work of breathing.

Initial ALS Care:• Albuterol and Ipratropium nebulized

therapy- May repeat Albuterol every five minutes to a max of three doses.

• IV access and NS/LR fluid bolus:- 20ml/kg to a max of 1000ml

• Methylprednisolone- 2mg/kg IVP to a max of 125mg

ORDERS

For Presumed Asthma and severe respiratory distress unresponsive to initial therapy:

ALS Care:• Epinephrine 0.01mg/kg to a max of 0.5mg

- 1:1000 solution IM (preferred)* or may substitute age/weight appropriate epinephrine auto-injector- 1:10,000 solution IV

• Magnesium Sulfate 25mg/kg to max of 2 grams IV- dilute in 50cc bag of crystalloid and administer over 15 minutes

ORDERS

For Presumed COPD and severe respiratory distress unresponsive to initial therapy:

ALS Care:• CPAP

- Initiated per CPAP protocol- Limited to CPAP systems that allow administration of Albuterol and Ipratropium while CPAP is applied

If respiratory failure, support ventilation with BVM. Consider Airway Management Protocol

SPECIAL NOTE:• In the management of patients with asthma, ETI should be used as a last resort. Following ETI, ventilate slowly (keep

respiratory rate to 10/min or less) and with a low tidal volume (6cc/kg (ideal body weight)).• *Administration of IV epinephrine can result in significant tachycardia / hypertension and complications such as heart

attack & stroke

Approved: 1/19/16

CHF/Volume Overload DyspneaStanding Order

ORDERS

• If altered mental status or failure to respond to CPAP, support ventilation with BVM. Consider Airway Management Protocol.

ORDERS

For Normotensive (SBP>90) patients:

ALS Care:• Initiate CPAP Protocol• 12-lead ECG and continuous cardiac

monitor• IV saline lock• Nitroglycerin

- 0.4mg SL. Repeat every five minutes to a max of three doses. Hold if SBP <90

ORDERS

For Hypotensive (SBP<90) patients:

ALS Care:• Initiate CPAP Protocol• 12-lead ECG and continuous cardiac

monitor• IV saline lock• Dopamine (If heart rate < 100)*

- 10-20mcg/kg/min titrate to SBP>80 to a max dose of 20mcg/kg/min

SPECIAL NOTE:• Furosemide and Morphine are no longer considered appropriate first line prehospital interventions in the management of

CHF/Volume overload in the prehospital setting. Should a provider feel that these interventions might be appropriatecontact medical direction.

* Infusion of dopamine for patients with congestive heart failure and a heart rate greater than 100 decreases cardiac outputand has been shown to increase mortality and morbidity.

INCLUSION

History of volume overload (CHF, Renal Failure) with increased work of breathing or dyspnea.

Approved: 1/19/16

Base Hospital

10-09; updated 6-10, 7-11, 12-13, 1-15, 1-16

If patient’s condition deteriorates call, Medical Direction Authority. Consider transport to closest facility. Provide appropriate receiving facility notification


O2 to maintain sat ≥ 94%


Cardiac monitor (non-interruptive) if available, vital signs including FSBG and temperature as indicated

EMT STABILIZATION ADMINISTRATIVE ORDER

Airway maintenance, control and ventilation

Follow Airway Management Protocol

Dizzy or Lightheaded

Treat BLS ABC

Consider causes

Start IV NS/LR at TKO (if permitted)

Injury Triage Criteria

Follow Trauma Triage Protocol as indicated

ABCDE-injury area

Consider C-Spine precautions-follow SMR Protocol documenting use

Initiate IV NS/LR TKO as appropriate-bolus to maintain systolic BP≥90

Manage extremity injuries as appropriate

If TBI suspected follow EPIC protocol for Adult or Peds

If unable to control bleeding, follow External Hemorrhage Control Protocol and/or TQ AO

Pain Management AO as needed if stable

Falls- evaluate, describe impact surface, height of fall

Physical assault Hypotension

SBP ≤90, pulse ≥120, increased respirations, pale, cool skin, diaphoresis, altered mental status, agitation, or restlessness, progression to profound hypotension

NS/LR bolus 20 mL/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals

Consider causes

Unconscious/unresponsive patient unresponsive or responsive only to painful stimuli

Manage airway as above

Initial IV with NS/LR TKO

Bolus 20 mL/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals to maintain SBP≥90

If status improves after treating FSBG, follow Hypoglycemia AO

If suspected overdose-administer Naloxone per Naloxone Protocol

Symptoms of dehydration and/or as indicated

IV with NS/LR bolus 20 mL/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals (if permitted)

Febrile patient follow Over-the-Counter Medication Protocol

Anaphylaxis/Allergic Reaction/Urticaria

Follow Dyspnea Anaphylaxis/Allergic Reaction SO

Follow Over-the-Counter Medication Protocol for diphenhydramine administration

Base Hospital

10-09; updated 2013-2015; 01-16

If patient’s condition deteriorates call, Medical Direction Authority


Initiate immediate supportive care: Oxygen to maintain O₂ sat ≥ 94%


Vital Signs including FSBG, temperature as indicated

Use Administrative Order on patients that present with the following:

ETOH consumption

No other emergent medical need

Patient has not received any ALS treatment (this excludes ALS assessments such as EKG)

Calm patient with reassuring voice and gestures

Initiate IV NS/LR (If permitted)

Bolus 20 mL/kg maximum, reassess hemodynamic and pulmonary status at 500 ml intervals

Utilize law enforcement assistance if necessary

Restrain as indicated for patient or provider safety per Behavioral AO

Transport to the closest most appropriate facility

O R D E R

S

E X C L U

AO should not be used on patients with these symptoms:

Patients that are unconscious/unresponsive

Patients that fall under another Standing/Administrative Order

INCLU

All of the following must be present:

Glasgow coma score 13 or greater

Blood Pressure: Systolic: 100-180 Diastolic: 60-100

Pulse rate of 60-120

Respiratory rate of 16-28

Blood Glucose 70-400 adult

ETOH ADMINISTRATIVE ORDER

3-10; reviewed 3-12; Update 2011-2015; 01/16

Base Hospital



EYE INJURY ADMINISTRATIVE ORDER

PENETRATING INJURY WITH FOREIGN BODY O R D E R S




Vital signs including FSGB and temperature as indicated

ALS cardiac monitor

Use Administrative Order on patients with:

Blunt or penetrating trauma to the eye

Chemical substance in the eye

Follow SAEMS Trauma Triage Protocol

Stabilize foreign body

Do not remove any foreign body

Transport patient with head slightly elevated and BOTH eyes closed or loosely covered

Pain Management AO as indicated CORNEAL BURN/ABRASION

OR CHEMICAL EXPOUSRE

O R D E R S

Irrigate with Normal Saline for at least 20 minutes

Continuous irrigation en route to facility

Pain Management AO as indicated

Medical Management of HAZMAT Patients Standing Order

INCLUSION

Suspected Hazardous Material Exposure with or without symptoms

EXCLUSION

Patient with medical complaint likely unrelated to hazardous materials

Assess Scene: • Assess for contamination, need for decontamination, and inform Incident Commander (IC).

• Do not enter the hot zone or contaminated area without proper training & PPE

• The IC structure, need for decontamination, and procedure for decontamination should be determined by

agency SOP.

Assess

Toxidrome

Cholinergic

Syndrome

Primary

Respiratory

Cardio-

pulmonary

Symptoms

Skin

Symptoms

No Initial

Symptoms

SPECIAL NOTE: • Although Poison Control my give advice regarding the management of patients with toxic exposures, they do not have the

ability to provide online medical direction or give orders for the medical management of patients. Therefore all contact with

the poison control center must occur through an appropriate Medical Direction Authority

Pre-Decon Treatment Decontamination Post-Decon Treatment

Organophospate SO

Chlorine Gas SO

Carbonmonoxide SO

Cyanide SO

Hydrocarbon SO

Hydrofloric Acid SO

Radiation/Nuclear SO

Decon procedures will very based on the substance & symptoms encountered.

Two Standing Orders

exist to guide decon

procedures:

The need for decon

as well as the decon

procedures will be

determined by the IC

and agency SOPs

Organophospate SO

Chlorine Gas SO

Carbonmonoxide SO

Cyanide SO

Hydrocarbon SO

Hydrofloric Acid SO

Radiation/Nuclear SO

Eye Decon SO

General Decon SO

Organophosphate/Carbamate/Nerve Agent Standing Order

I N C

Suspected Organophosphate, Carbamate, or Nerve Agent exposure

AND

Symptoms of mild, moderate, or severe toxicity

E X C L

Suspected Organophosphate, Carbamate, or Nerve Agent exposure

AND

No evidence of toxicity

Decontamination Age < 10 Age > 10

SPECIAL NOTE: Mild Symptoms: Dim vision, Lacrimation, Rhinorrhea, Nausea

Moderate Symptoms: Urinary Incontinence, Wheezing, Vomiting, Fasciculations, Bradycardia

Severe Symptoms: Unconscious, Seizures, Respiratory Distress

*Antidote Kits: Several different auto injector kits are available for treatment of cholinergic syndrome. All contain

1mg of atropine and 600mg of 2-PAM (pralidoxime). Some commonly used kits include Mark I & Duodote™

The specific decon

procedures required

for an incident should

be determined by the

IC or their designee.

Medical guidance for

decon procedures is

as follows:

• Administration of

antidote therapy

should not delay

decontamination

except for patients with

cardiac

arrest/dysrhythmia

T O X M E D I C

• Mild - Contact Med

Direction

• Mod – 2 x antidote kit*

• Severe – 3 x antidote kits*

(If Antidote Kit not available: 1-2mg Atropine IM)

T O X M E D I C

• Mild - Contact Med Direction

• Mod - Contact Med Direction

• Severe - 1 x antidote kit*

(If antidote kit not available: 0.05 mg/kg Atropine IM)

Decontamination

T O X M E D I C

Supportive Care:

• Cardiac monitor, IV, supplemental O2, BVM or ETI if indicated

Continued Antidote Therapy:

• Administer Atropine, every 5min as needed to control all symptoms:

- Age>10: 1-2mg IV/IO* - Age≤10: 0.05mg/kg IV/IO

• Administer Benzodiazepines IF seizures activity:

• Midazolam/Versed per Seizure SO

• If needed, contact Medical Direction Authority and request a Poison Control

dual patch or consult for assistance.

• Inform receiving facility of toxic exposure, setting, and decon procedures.

Eye Decon SO

General Decon SO

http://www.saems.net/Downloads/SeizureSO41013.pdf

Chlorine Gas Standing Order

I N C

Suspected chlorine gas inhalation or exposure

AND

Symptoms of pulmonary or eye toxicity

E X C L

Suspected chlorine gas inhalation or exposure

AND

No evidence of toxicity

Decontamination Age < 10 Age ≥ 10

SPECIAL NOTE: Chlorine Gas

Properties: water soluble irritant gas which when dissolved produces hydrochloric acid and hypochloric

acid. These acids cause irritation of mucous membranes.

Symptoms: coughing, choking, dyspnea, wheezing, lacrimanation, burning sensation in

eyes/armpits/etc. Severe cases may progress to pulmonary edema and resulting respiratory failure.

Sources: pools, pool pumps, pool service trucks, water treatment plants, rail cars, commercial trucks,

etc.

Effective 4-16-2014

The specific decon

procedures required for

an incident should be

determined by the IC or

their designee. Medical

guidance for decon

procedures is as

follows:


antidote therapy should

not delay

decontamination except

for patients with cardiac

arrest/dysrhythmia

• Remove clothing

• Full dry & wet skin

decon is usually not

necessary.

• Eye decon if eye

irritation occurs.

T O X M E D I C

• Perform primary survey

• Provide supplemental O2

and/or assist ventilation with

BVM or ETI if needed

T O X M E D I C

• Perform primary survey

• Provide supplemental O2

and/or assist ventilation with

BVM or ETI if needed

Decontamination

T O X M E D I C

Supportive Care:

• Cardiac monitor, IV bolus @20ml/kg, supplemental O2, BVM if

indicated. If severe respiratory distress consider supporting ventilation

with CPAP, BVM or Airway Management Protocol

Antidote Therapy:

• If bronchospasm, administer: Albuterol 2.5mg nebulized repeat x 2 for

continued bronchospasm




Eye Decon SO

Carbon Monoxide (CO) & Simple Asphyxiant Toxicity Standing Order

Decontamination

The specific decon





guidance for decon

procedures is as

follows:

General: • Carbon Monoxide

(CO) and Simple

Asphyxiants are gases.

Removal of the victim

from the source will

likely be the only decon

measure required for

isolated exposures.

INCLUSION

Suspected Carbon Monoxide (CO) exposure

EXCLUSION

None

O R D E R S

PRE-DECON ORDERS: - Remove from source

Decontamination (If Indicated)

ORDERS

POST-DECON ORDERS: • Supportive Care: vital signs, primary & secondary survey, cardiac monitor,

IV access

• Antidote Therapy: High flow oxygen, consider Airway Management

Protocol if insufficient oxygen/ventilation despite high flow O2.

• Dysrhythmias: Treat per ACLS guidelines

SPECIAL NOTE: • Severe exposure: altered mental status, dyspnea/respiratory failure, seizure, hypotension/tachycardia,

cardiac dysrhythmias; Mild exposure: headache, nausea, mild tachypnea

• Carbon Monoxide (CO) Toxicity: Carbon Monoxide binds to the oxygen binding sites of hemoglobin(Hb)

decreasing the ability of Hb to both carry and release O2 causing systemic hypoxia.

• Simple Asphyxiants decrease the inhaled concentration of Oxygen. Examples include: carbon dioxide,

nitrogen, etc.

• Effective 4-16-2014




http://www.saems.net/Downloads/AirwayManagementProtocol042014.pdf


Cyanide Toxicity Standing Order

SPECIAL NOTE: • Symptoms:

- Major Symptoms: include altered LOC, loss of consciousness, dyspnea/respiratory failure, seizures,

hypotension/tachycardia and cardiac dysrhythmias.

- Minor Symptoms: include headache, nausea and mild tachypnea.

• Cyanokit Information: Each vial contain 2.5g of hydroxycobalamin. The medication is red in color. It

cannot be infused in the same tubing as multiple other medications. This medication interferes with future

diagnostic testing, if possible obtain blood samples when IV is placed.

Effective 4-16-2014

INCLUSION

Suspected cyanide exposure and MAJOR* symptoms

EXCLUSION

Suspected cyanide exposure and MINOR* symptoms

Age ≥ 10

T O X M E D I C

• Cyanokit (hydroxycobalamin):

- Reconstitute each vial with

100ml of saline

- Administer 2 vials using IV

tubing included in kit and

infuse over 15min

T O X M E D I C

• Cyanokit (hydroxycobalamin):

- Reconstitute each vial with

100ml of saline

- Administer 70mg/kg using

IV tubing included in kit

- Each vial in 100ml of NS

creates 250mg/ml of

solution


ORDERS (Pre-Decon) • Supply max flow Oxygen via non-rebreather mask

• BVM ventilation if necessary

ORDERS (Post-Decon)

• Supportive Care: vital signs, primary & secondary survey, IV access,

Cardiac monitor (Dysrhythmia: treat per ACLS)

• If possible draw a “rainbow” of blood collection tubes prior to administration

of cyanokit.

• If respiratory failure consider using Airway Management Protocol

Age < 10

• If needed, contact Medical Direction Authority and request a Poison

Control dual patch or consult for assistance.


Decontamination

The specific decon

procedures required

for an incident should

be determined by the

IC or their designee.

Medical guidance for

decon procedures is

as follows:


antidote therapy

should not delay

decontamination

except for patients with

cardiac

arrest/dysrhythmia

Eye Decon SO

General Decon SO


Hydrocarbon Toxicity Standing Order

Decontamination

The specific decon





guidance for decon

procedures is as

follows:



not delay



arrest/dysrhythmia

General: • Removal from source

(only step for gas

exposure)

INCLUSION

Suspected hydrocarbon exposure and MAJOR* symptoms

EXCLUSION

Suspected hydrocarbon exposure and MINOR* symptoms

O R D E R S

Initial Care:

• Supply max flow O2 via non-rebreather mask

• BVM ventilation


ORDERS

• Supportive Care: vital signs, primary & secondary survey, IV access,

cardiac monitor

• Hypoxia or hypoventilation unresponsive to high flow O2: Consider use of

Airway Management Protocol

• Dysrhythmias: Treat per ACLS guidelines avoiding epinephrine due to

sympathomimetic effect of hydrocarbons

• Seizure: Ensure adequate oxygenation(as above). Administer benzo per

Seizure SO

SPECIAL NOTE: • Symptoms:

- Major Symptoms: include altered LOC, seizure, coma, cardiac dysrhythmias, hypoxia

- Minor symptoms: include PVCs, eye irritation

• Examples:

- Aliphatics include: methane, ethane, propane, butane, hexane, cyclohexane. Aliphalitcs from

petroleum include: gasoline, mineral spirits, kerosene. Aliphalitcs from pine: include turpentine, pine oil,

pine tar. Aromatic hydrocarbons: benzenes, Halogenated hydrocarbons

Effective 4-16-2014

Eye Decon SO

General Decon SO






Hydrofluoric Acid (HF) Toxicity Standing Order

Decontamination

The specific decon





guidance for decon

procedures is as

follows:



not delay



arrest/dysrhythmia

INCLUSION

Known or Presumed exposure to Hydrofluoric Acid(HF)

EXCLUSION

Exposure to other acid or base solutions

Age ≥ 10 Age < 10

T O X M E D I C

Initial Care:

• If unstable (cardiac

dysrhythmia or arrest)

initiate IV and administer

Calcium Gluconate

100mg/kg IVP

T O X M E D I C

Initial Care:

• If unstable (cardiac

dysrhythmia or arrest)

initiate IV and administer

Calcium Gluconate 10-

20ml(1-2gm, 1-2 amps)

IVP


TOXMEDIC

POST-DECON ORDERS: • Supportive Care: vital signs, primary & secondary survey, IV access,

cardiac monitor. If pain may use Pain Management SO.

• Continued antidote therapy:

- Administer Calcium Gluconate gel to the affected site. If Calcium gel is

not available then mix 10cc of Calcium Cloride solution with one 1oz

package of water soluable lube and apply to affected area. If lube

unavailable then apply Calcium Gluconate solution directly to wound

SPECIAL NOTE: Calcium Gluconate: Ca-glu is the drug of choice for treatment of HF exposure and toxicity. In the

event of cardiac arrest Calcium Chloride may be given. This medication can cause severe peripheral

venous irritation and damage therefore administration via peripheral IV should be limited to the

management of critical patients.

Effective 4-16-2014

Eye Decon SO

General Decon SO




Radiation / Nuclear Standing Order

Decontamination

• Decon for a radiation

or nuclear event

may differ

significantly from

other decon

procedures.

• Identification of

contamination and

focused removal of

contamination may

be sufficient.

• Protect yourself:

- limit time expose

- Maximize distance

- Use appropriate

shielding (rarely

helpful for

radioactive

material)

INCLUSION

Suspected radiation exposure and Major Injury

EXCLUSION

Suspected radiation exposure and Minor Injury

SPECIAL NOTE: Exposure to radiation does not represent an emergency medical condition. Therefore treatment of a

traumatic injury or medical condition should take priority over management of exposure to radioactive

substance.

Effective 4-16-2014


ORDERS

PRE-DECON ORDERS: • Treat life-threatening conditions prior to decon. Treatment and transport

of critically injured patients should take precedent over decontamination.

ORDERS

POST-DECON ORDERS: • Care of patients with minor injuries




General Decontamination Standing Order

O R D E R S

Initial Care: Evaluate ABC’s

and perform the following if

indicated:

• Open Airway

- Head tilt / jaw thrust

- Insert OPA or NPA

• Insert Airway device

- Supraglotic device is

recommended over ETI

• Tension pneumothorax

- Needle decompress

• Antidote autoinjector

• Hemorrhage Control

- Compressive dressing

- Tourniquet

• Spinal Immobilization

INCLUSION

All victims with presumed exposure and contamination with a toxic material

EXCLUSION

Victims triaged as Black/Dead may require decon however,

decontamination of these victims should NOT be performed emergently

Chemical

General Considerations: • Skin Decon - Remove clothing, Wash with water and mild

detergent, under ideal conditions for 15 minutes

• Eye Decon (per SO), under ideal conditions for minimum 20

minutes, continue during transport if resources allow.

SPECIAL NOTE: • Transportation via air medical services is contraindicated prior to decontamination

• The DHS does not recommend full decontamination in the field for patients contamination with white powders

that may contain Anthrax spores. Rather patients should be instructed to wash their hands and face, return

home, change clothes, and shower.

•Effective 4-16-2014

Biological

General Considerations: • Skin Decon – Generally not necessary and may be done at

home by patient. If required remove clothing, washing from

head down with water and mild detergent.

• Eye Decon – generally not indicated

Radiation / Nuclear

*** patient treatment takes priority over decon*** *** use detector to identify contaminants***

General Considerations: • For field decon of medically stable patients:

- Cut clothing off and rolling any contamination up in clothing

- Identify skin contaminants and use moist gauze to remove

- Continue to wipe until detector reads < 2 x background or

skin redness noted

Eye Decontamination Standing Order

• Eye decontamination may start during general decon if victims allow water to rinse out eyes

• This SO should be used AFTER the General Decon process

B L S

Or

A L S

O R D E R S

Initial Care: (NOTE: Initiation of eye irrigation should not be delayed if the advanced medications listed below are not available or a paramedic with advanced training in the use of the techniques listed is not present)

• Irrigate eyes with tap water or normal saline

• Discontinue when

- Toxmedic assumes care

- Patient can not tolerate due to pain

- 15 min of irrigation has been performed

and eyes are no longer irritated

INCLUSION

All patients with presumed hazardous material exposure and eye irritation

EXCLUSION

Patients with no known exposure to the eye or lack of eye irritation

T O X M E D I C

O R D E R S

• Tetracaine 2gtts into affected eye, may

repeat every 5-10min as needed for eye

discomfort.

• Place Morgan Lens or other eye irrigation

tool under eye lid and irrigate eyes with tap

water or normal saline.

• Discontinue when

- Patient can not tolerate due to pain

- 15 min of irrigation has been preformed

and eyes are no longer irritated

SPECIAL NOTE: Eye Decon should NOT delay further assessment of the patient.

Transportation via air medical services contraindicated prior to decontamination

Effective 4-16-2014

PATIENT CARE DURING EYE DECONTAMINATION: • If any vital sign abnormalities are present obtain IV access, supply supplemental O2, and cardiac monitor.

• Evaluate for toxidrome and if present treat using toxic exposure SO.

• If needed, contact Medical Direction Authority and request a Poison Control dual patch or consult for assistance.


Base Hospital

10/09; updated 2011-2015; 01/16; 01/19



HYPERTHERMIA ADMINISTRATIVE ORDER



Vital signs including FSBG and temperature

Move patient to cooler environment and begin cooling measures

ALS Cardiac Monitor

EMT Cardiac Monitor (non-interpretive) if available

Use administrative order on patients with hyperthermia symptoms:

Heat Cramps/Exhaustion

History of heat exposure

Painful muscle cramps

Nausea and vomiting

Abdominal pain

Heat Stroke

History of heat exposure

Fainting or Loss of consciousness

Altered mental status: confusion, combativeness, or seizure

ORDERS

ALS/BLS:

Initiate cooling measures based on patient condition (active vs. passive)

Keep patient NPO

Establish IV/IO NS/LR to maintain adequate peripheral perfusion (If permitted) o 20mL/kg bolus, may repeat bolus once. Reassess hemodynamic and

pulmonary status at 500ml intervals

If shivers develop stop rapid cooling

For seizures follow with treatment Seizure AO

For nausea or vomiting follow with treatment Nausea/Vomiting AO

Monitor for other complications:

AMI or heart failure

Weakness or paralysis

Electrolyte abnormalities may result in dysrhythmias; treat per ACLS guidelines

Develop: 01/15; updated 01/16, 01/19

HYPOGLYCEMIA

For neonates with FSBG ≤40 mg/dl or for patients ≥ one month of age with a FSGB ≤70 mg/dl


Consider transport to closest facility

Transport to closest pediatric care facility if condition permits

If rural area, transport to closest facility


HYPERGLYCEMIA

Base Hospital

Special Note:

Dilute D50 (dextrose 50% containing 25 Grams

of dextrose) to a 1:4 solution. To prepare, obtain

a 250mL container of normal saline for IV use,

waste 50mL and add 50mL of dextrose 50%.

The resulting solution is dextrose 10% in normal

saline or 10 Grams/100mL

ALS/BLS (> 15 years of age)

If alert and maintaining their airway, administer 1 to 2 tubes of oral glucose

Initiate IV NS/LR at TKO (if permitted)

Reassess FSBG (> 1-14 years of age)

If alert and maintaining their airway, administer 1 tube oral glucose

Initiate IV NS/LR (if permitted)

Reassess FSBG ALS

Initiate IV/IO NS/LR at TKO(saline lock not acceptable for administration)

Reassess FSBG after each treatment

Dosage: Dextrose 10% (D10) 1ml/kg, max 250 ml

Flush IV with 10 ml NS/LR after D10 infusion

May repeat dose to maintain FSBG < 70 Glucagon administration: If unable to initiate IV

Adult Size (≤60 kg) 1 mg IM may repeat in 7-10 minutes

Pediatric Size (≤ 60 kg) 0.5 mg IM may repeat in 7-10 minutes

HYPO/HYPER-GLYCEMIA ADMINISTRATIVE ORDER

If patient ≥18 years, condition improves and they do not wish further evaluation, no medical direction is required if all of the following are present:

This was an acute hypoglycemic event and patient has regained a normal mental status

Patient has history of Diabetes or Hypoglycemia

Current FSBG is ≥ 70

A responsible adult is present

Further caloric intake is assured

There are no clinical findings consistent with acute illness

For patients > one month of age with a FSBG > 400

ALS/BLS (>8 years of age)

Initiate IV/IO NS/LR

Bolus 20 mL/kg maximum, reassess pulmonary status at 500 mL intervals

Slow rate to TKO after fluid boluses

Reassess FSBG (<8 years of age)

Initiate IV NS/LR

Bolus 20 ml/kg maximum, reassess pulmonary status once half of the bolus is infused

Decrease rate to TKO

Reassess FSBG


Secure & maintain airway

Oxygen to keep O₂ sat >94%


Vital Signs including FSBG

If FSBG ≥ 70 and ≤400, and patient is unconscious, follow Stabilization AO

Effective: 01/2008 Revised: 6/14, 10/17/2017

+

Supportive care:

• Be gentle (rough handling of patient may precipitate arrhythmias)

• Secure and maintain airway

• Remove all wet garments (cut off to avoid jostling the patient)

• Move patient to warm/dry environment and protect from heat loss

• Oxygen to keep SpO2 > 94%

• Obtain vital signs including temperature and blood glucose

• Cardiac monitoring if available

HYPOTHERMIA STANDING ORDER

Use Standing order on patients that are hypothermic with signs/symptoms:

Use the following treatment orders:

I N C LUSI O N

O R D E R S

Special Notes:

• Because field temperature measurement may be imprecise, the recognition of each stage is more important than exact categories.

• If resuscitative measures are indicated: Intubate only if patient is in V-fib or asystole, give IV medications as indicated (although generally ineffective), limit to one shock for VF/VT.

Mild Hypothermia 90 – 95°F (32-35°C)

OR

Ataxia Slurred Speech

Confusion Impaired judgment

Shivering

Severe Hypothermia < 82°F (<28°C)

OR

Weak/absent pulse Hypotensive

Unresponsive Fixed/dilated pupils Pulmonary edema

Ventricular dysrhythmia

Moderate Hypothermia 82 – 90°F (28-32°C)

OR

Bradycardia (afib/flutter) Hyporeflexia

Decreased/absent shivering

Mild Hypothermia 90 – 95°F (32-35°C)

Passive external rewarming

Moderate Hypothermia 82 – 90°F (28-32°C)

Active external rewarming Warm packs to groin, axillae, neck and trunk (avoid surface

burns)

20ml/kg NS bolus (warmed if possible)

Severe Hypothermia <82°F (<28 °C)

Continue with moderate rewarming hypothermia tx

guidelines.

Confirm pulse/rhythm every 30-45 seconds

Base Hospital

10-09; updated 2015-2015; 01-16; 09-19; 12-20; revised 2-20



Use administrative order on patients with the following symptoms:

Complaints of nausea and/or vomiting

Diarrhea with either of the above

BLS

Establish IV NS/LR: If evidence of dehydration or hypo-perfusion to maintain adequate peripheral perfusion: (if permitted)

Bolus 20 mL/kg maximum, reassess pulmonary status at 500 ml intervals ALS

Follow BLS orders

Administer Ondansetron HCL IV/IM/PO:

Adult size(>30 kg) o Ondansetron 4 mg IV over 2-5 minutes, if no response, may repeat once

after 15 minutes o If unable to obtain IV, give Ondansetron 8mg PO, Orally Dissolving Tablet

(ODT) , Do NOT Repeat o Or Ondansetron 4 mg IM, if no response, may repeat once after 15 minutes

Pediatric size(<30kg) o Pediatric <15kg Ondansetron 0.15 mg/kg slow IVP over 2-5 minutes, Do

NOT Repeat o Pediatric >15kg Ondansetron 4 mg Orally Dissolving Tablet (ODT), Do NOT

Repeat

o

NAUSEA/VOMITING ADMINISTRATIVE ORDER

I N

C

L

O R D E R

S

Special Note:

Ondansetron in general is ineffective for motion sickness Caution: avoid volume overload in geriatric patients


Oxygen to keep O2 Sats ≥94%


Vital Signs including FSBG and temperature as indicate

Effective 4-16-2014

OB/GYN STANDING ORDER

INCLUSION

Special Note: Follow High Risk OB Triage Protocol as appropriate

Eclamptic Seizure

Post Partum Hemorrhage

Use standing order on gravid patients, postpartum patients, or patients with vaginal bleeding.

Presumed Pregnant with Contractions and/or SROM Standing Order

Initiate Immediate Supportive Care: BLS Care:

• Vital signs • FSBG • Oxygen to maintain sat ≥ 94% • IV access if permitted

ALS Care: • Follow BLS Interventions • Cardiac monitor

OB/GYN SO

OB/GYN-SO

OB/GYN SO

Contact Medical Direction Authority if unclear clinical presentation Or patient wishes to refuse and does not meet Refusal Standing Order

OB/GYN SO

Vaginal Bleeding

http://www.saems.net/protocols/protocols2013/HighRiskOB102006.pdf

Effective 4-16-2014

VAGINAL BLEEDING STANDING ORDER

INCLUSION Vaginal bleeding

• Gestational • Non-traumatic • Non-gestational

EXCLUSION

• Contractions • Traumatic vaginal bleeding • Sexual Assault

BLS/ALS Care: Stable:

• IV NS/LR at TKO if permitted • If applicable, place products of conception in container and transport with patient

Unstable: If SBP ≤ 90 or HR ≥ 110 or estimated blood loss ≥ 250 ml

• NS/LR bolus 20 ml/kg, reassess patient at 500 ml intervals • Shock position:

o ≥ 20 weeks: Left lateral o <20 weeks or not pregnant: Trendelenburg

O R D E R S

Transport to most appropriate receiving facility Or per High Risk OB Triage Protocol


If patient condition deteriorates or no improvement-contact medical direction authority


Effective 4-16-2014

ECLAMPTIC SEIZURE STANDING ORDER

INCLUSION

• Gestational age 20 weeks or greater • Postpartum • New onset seizure

BLS Care: • Place patient in left lateral recumbent position • High flow oxygen via NRB • IV NS/LR at TKO if permitted

ALS Care:

• Follow BLS orders • Administer Magnesium Sulfate 4-6 gram bolus IV/IO over 10-15

minutes o Hold for SBP ≤ 90 o Monitor for respiratory depression

O R D E R S

Transport to most appropriate receiving facility

Per High Risk OB Triage Protocol Provide appropriate receiving facility notification

.


• History of seizure disorder, follow Seizure Standing Order

EXCLUSION



Effective 4-16-2014

POST PARTUM HEMORRHAGE STANDING ORDER

INCLUSION

• Postpartum

BLS Care: • High flow oxygen via NRB • Two large bore IV if permitted • NS/LR bolus 20 ml/kg, reassess patient at 500 ml intervals • Fundal massage

ALS Care:

• Follow BLS care • Administer Pitocin 20 units in NS/LR 1000 ml wide open

(if available)

O R D E R S


Transport to the most appropriate receiving facility Per High Risk OB Triage Protocol

Provide appropriate receiving facility notification .


Effective 4-16-2014

PRESUMED PREGNANT WITH CONTRACTIONS AND/OR SROM STANDING ORDER

INCLUSION

• Pregnant • Signs of labor • Spontaneous rupture of membranes (SROM) • Cord presentation • Limb/breech/shoulder presentation

BLS/ALS Care: • Measure patient temperature • Place patient in left lateral recumbent position • Large bore IV NS/LR if permitted • Initiate bolus 500 ml-reassess patient. If labor persists after

assessment rebolus with 500 ml • Prepare for possible delivery • Cord around neck:

o Loosen cord o If too tight- apply two clamps, cutting between clamps

• Prolapsed cord: o Transport mother with hips elevated and knees to chest o Insert gloved finger to relieve pressure on cord o Assess pulsations o DO NOT pull on cord o Protect exposed cord

• Limb/breech/shoulder presentation: o Do not encourage mother to push o Support but do not pull presenting parts o Insert gloved finger to relieve pressure on cord if needed

O R D E R S


Transport to the most appropriate receiving facility Per High Risk OB Triage Protocol


.


Base Hospital

3-10; update; 2013-2015; 1-16; 12-19, revised 2-20

Do not use Administrative Order on patients with: Decreased mental status

Pregnancy

BLS Treatment Determine pain score assessment using standard pain scale

3 months of age-4 years: Observational scale (FLACC)

4-12 years: Face pain scale

≥ 12 years: Numeric Rating Scale Initiate IV NS/LR TKO (if permitted) Analgesic (if no nausea, vomiting, abdomen pain) Acetaminophen (oral liquid, rectal suppository or tablet/capsule) ONE TIME DOSE

Adult( ≥ 15 years) up to 650 mg PO

Pediatric (6-14 years) 10 mg/kg PO or PR

Pediatric (≤ 6 years) rectal: ≤10 kg-120 mg suppository 10-20 kg-160 mg suppository ≥ 20 kg 325 mg suppository

Ibuprofen ONE TIME DOSE

≥ 6 months of age (oral, liquid or tablet/capsule) (maximum dose 600 mg)

Adult( ≥ 15 years) 200-600 mg PO Pediatric ( ≥ 6 months-14 years)

5 mg/kg

PAIN MANAGEMENT ADMINISTRATIVE ORDER

INCLUSIO

N

E X C


O2 to maintain sat ≥ 94 %



Following Standing Order/Administrative Order as indicated

Use Administrative Order on patients with:

Acute extremity injuries to include but not limited to hip, pelvic, and shoulder

Acute back pain

Burns ≤ 10% BSA

Eye injuries

Acute flank Pain

Snake Bites-stable

Abdomen pain-stable

ALS Treatment Continued Morphine Sulfate IV/IO/IM

Adult size (≥30kg) 2-5 mg IVP, may repeat after 5 minutes to a max dose of 20 mg

o If IV unavailable, may give IM 2-5 mg, may repeat after 15 minutes to a max dose of 20mg

o If patient is unstable and unable to obtain an IV, may give IO 2-5mg, may repeat every 15 minutes to max dose of 20 mg

Pediatric size (≤30kg) IV/IO, 0.1mg/kg in increments of 1-2mg, if no response, may repeat after 5 minutes to a max dose of 10mg

Fentanyl IV/IN/IM/IO

Adult: (≥ 15 years) 25-50 mcg SLOW IVP, over 2 minutes, max individual dose of 50 mcg. If no response, may repeat every 5 minutes to a max total dose of 200mcg

o Intranasal dosing max 1ml per nostril o If IV unavailable, may give IM 25-50

mcg, may repeat after 15 minutes to max dose of 200 mcg

o If patient is unstable and IV unavailable, may give IO 25-50mcg, may repeat every 15 min to max dose of 200mg

PEDS: (2 years-14 years) IV/IO/IN o 1mcg/kg SLOW IVP, over 2-5minutes

Not to exceed 50 mcg, May repeat every one hour as needed.

o If unable to obtain IV, may give IN ½ of the dose per nostril.

Do not continue dosing unless SBP remains ≥90mmHg, patient remains alert, and both respiratory rate and effort remain normal

ALS Treatment Follow BLS Treatment Cardiac Monitor Ondansetron IV/IM/IO for nausea or vomiting

Adult size(≥30 kg) o Ondansetron 4 mg IV over 2-5 minutes, may

repeat once after 15 minutes o If unable to obtain IV, give Ondansetron

8mg PO, Orally Dissolving Tablet (ODT), Do NOT Repeat

o Or Ondansetron 4mg IM, may repeat after 15 minutes to max dose of 8mg

Pediatric size(≤30kg) o Pediatric <15kg Ondansetron 0.15 mg/kg

slow IVP over 2-5 minutes, Do NOT Repeat o Pediatric >15kg Ondansetron 4 mg Orally

Dissolving Tablet (ODT), Do NOT Repeat

EFFECTIVE: 3/96 REVISED 9/99; 6/2004; 10/2007; 10/15/2013

Initiate PALS Cardiac Arrest Algorithm • C - Start CPR – Compression rate 100/min+ • A - Establish airway with OPA/NPA • B - Ventilate with BVM @ 100% high flow O2 (15:2)

If adequate bystander compressions are being provided, apply pads without interrupting compressions, analyze rhythm. ■ With Severe Hypothermia (below 86°F / 30°C) use caution, consider

Hypothermia Standing Order or contact Medical Direction

Pediatric Cardiac Arrest Standing Order

ALS/BLS

Use standing order on ALL patients 8 years of age or younger who appear to be the victims of sudden cardiac arrest/death.

Standing order should not be used on patients:

• Greater than 8 years of age. If age unknown: pt with physical signs of puberty. • Involved in a traumatic or submersion (near-drowning) event • Where evidence of primary respiratory arrest is present as in poisoning or asphyxia • Meeting SAEMS Dead on Scene criteria: Decapitated, Burned beyond recognition,

Decomposed, SIDS, VALID Prehospital Medical Care Directive

Patient meets ANY exclusion criteria

Begin appropriate resuscitative efforts,

Contact Medical Direction Authority or

implement appropriate standing order.

Patient meets inclusion criteria and is pulseless

PEA/ Asystole: or AED recommends NO shock (Perform treatments without interrupting

compression cycles.)

1. Complete 2 min. uninterrupted CPR cycles analyzing rhythm between each compression cycle.

2. Establish IV/IO access, 3. Consider Airway Management Procedure

Protocol

ALS ▪ Administer Epi 0.01mg/kg (1:10,000) every 3-5 min. as early as possible. ▪ Treat reversible causes: 6H’s/ 5T’s

VF/PULSELESS VT: or AED recommends shock (Perform treatments without interrupting

compression cycles.)

1. Complete 2 min. uninterrupted CPR cycles analyzing rhythm between each compression cycle.

2. If no rhythm change, defibrillate between each compression cycle.

3. Establish IV/IO access, 4. Consider Airway Management Procedure

Protocol ALS

▪ Administer Epi 0.01mg/kg (1:10,000) IV/IO every 3-5 min. as early as possible. ▪Administer Amiodarone or Lidocaine

• Amiodarone IV/IO 5mg/kg (max single dose 300mg), may repeat once after 10 min. 5mg/kg up to total dose 15mg/kg in 24 hrs. or

• Lidocaine 1mg/kg IV/IO ▪ Administer Magnesium 25 to 50mg/kg IV/IO (max 2 grams) ▪ Treat reversible causes: 6H’s/ 5T’s

E X C L U S I O N

I N C

O R D E R S

Transport to closest appropriate facility or, if ROSC Pediatric Critical Care Facility. Consider Air Medical Transport for transports over 30 minutes. Critical Pediatric Decision Scheme

Most common cause of Peds CA

is Hypoxic / Asphyxial Arrest

Look for potentially reversible causes

http://www.saems.net/protocols/protocols2013/CRITICALPEDIATRICDECISIONSCHEME.pdf

Developed 1-15; 01-16

Base Hospital

PATIENT REFUSAL TRANSPORT FOR UNDER 18 YEARS OF AGE ADMINISTRATIVE ORDER

Use of the same refusal criteria for adults, with the following steps added

Patient cannot refuse and other arrangements will need to be made-Possible Law Enforcement involvement or transport

Phone contact with Parent/Legal Guardian will not suffice meeting the on-scene requirement

Contact Medical Direction and Law Enforcement if:

Life threatening conditions exist

Possible abuse situation

Communication and documentation of patient refusal encounters will comply with agency specific policy

Document refusal on PCR with all information above

Legal guardian or Parent not on scene Legal guardian or Parent on scene

Legal Guardian defined as: An adult who is legally responsible for protecting the well being of a minor

If person on scene has release form for decision making on behalf of patient- review form

Review the situation with the Parent/Legal Guardian. Explain the risks of refusing treatment or transport, including the possibility of permanent disability, worsening condition or even death if not evaluated.

Parent/Legal Guardian must meet the following criteria:

Alert and oriented to person, place, time and event

Does not appear to be impaired by drugs or alcohol

Able to verbalize an understanding of the risks of refusing transport

Is able to pass the cognitive screening tool

Assumes complete responsibility for the decision not to transport the patient


Base Hospital

PATIENT REFUSAL TRANSPORT FOR 18 YEARS OR OLDER

ADMINSITRATIVE ORDER

Initial patient assessment as indicated to include, but not limited to:

Vital signs including FSGB

Appropriate body system assessment

Use this AO on patient’s > 18 years of age or emancipated minors

Emancipated minors will have identifier on Drivers’ License or ID Card Patient must meet the following criteria:

Alert and oriented to person, place, and time

Does not verbalize a danger to self or others

Does not appear impaired by drugs or alcohol

No evidence of neurological injury

No evidence of hemodynamic instability

No evidence of hypoglycemia, hypothermia, or hypoxia

Ability to verbalize an understanding of the risks of refusing transport up to and including permanent disability, worsening condition, or death.

Assumes complete responsibility for the decision not to be transported

Use cognitive screening tool on all patients wishing to refuse

For patients with a chief complaint related to altered mental status, cardiac, hyperthermia, or syncope, orthostatic vital signs must be performed and documented

Consider: Reviewing situation, discussing options with patient by asking the following:

Who called?

Why don’t they want to go?

What would change their mind?

Communication and documentation of patient refusal encounters will comply with agency specific policy

Document refusal on PCR with all information above

04-10; Updated 2013-2015; 01-16

04/16

Base Hospital



BLS

If patient actively seizing o Call for ALS Transport (if possible) o IV NS/LR TKO (if permitted)

ALS

If patient actively seizing administer Midazolam IM first o ≤ 12 kg: administer 0.2mg/kg IM o 13-40 kg: administer 5 mg IM o 40 kg: administer 10 mg IM

If IV access already established, give half (½) the above IM dose

IV/IO at TKO

If unable to start IV/IO, may be given Intranasal (IN) with mucosal atomizer device (1ml per nare)

Continued seizure 5-10 minutes after initial medication or Midazolam NOT available or NOT given. Administer one additional dose of a single medication. (Listed in order of preference of use) Midazolam:

IM/IN-repeat full dose

IV/IO-repeat at half the initial dose Lorazepam: IV/IO

≤ 12kg: 0.05-0.1 mg/kg

13-40 kg: 2 mg

40 kg and all adults: 4mg Diazepam: IV/IO

0.2 mg-0.3 mg/kg (max of 5 mg) If received rectal Diazepam prior to arrival, half the above dose

SEIZURE ADMINISTRATIVE ORDER

O R D E R

S

BLS transport

Single seizure with:

Known seizure disorder

Hemodynamically stable and returned to baseline metal status


Protect patient from injury

Oxygen to keep O2 sat > 90%



ALS cardiac monitor

EMT cardiac monitor (non interpretive) if available

I N

C

Use Administrative Order on the following patients:

Seizure activity

Postictal mental status

Do not use on the following patients:

Pregnant > 20 weeks gestation, follow OB SO E X C

Special Note: Suspected febrile seizures in pediatric patients, remove clothing

and blankets to help cool patient off

Base Hospital

Develop 9/16

For Inclusion and Exclusion follow Shock/SIRS Protocol

Follow with AO Pyretic Use OTC Protocol

Abnormal Blood Glucose Use Hypoglycemic AO Serious Dysrhythmias follow ACLS/PALS

For pediatrics patient bolus maximum 60 ml/kg total (until vital signs/perfusion normal or rales or hepatomegaly on exam) USE OF BRASLOW TAPE IS REQUIRED

Exception: volume-sensitive conditions, 10 ml/kg increments

Neonates (0-28 days), congenital heart disease, chronic lungs disease

BLS Treatment Establish IV NS/LR (if permitted)

20ml/kg bolus x1

Reassess hemodynamic and

pulmonary status frequently

Sepsis/ Shock Administrative Order


Oxygen to maintain O2 sat ≥ 94%


Vital signs including FSGB and temperature

ALS cardiac monitor

EMT cardiac monitor (non-interruptive) if available

ALS Treatment

Follow BLS Orders

IV/IO as needed

Capnography (if available)

Obtain 12 lead ECG

Adults The initial treatment of septic shock involves maximizing perfusion with IVF boluses, not vasopressors. If fluid challenge fails to restore adequate blood pressure or if hypotension is life threatening during fluid resuscitation, consider vasopressor (DOPAmine drip or push-dose epi).

DOPAmine infusion: Mix infusion using agency prescribed concentration, and administer 5-20 mcg/kg/min. Generally, start at 5 mcg/kg/min and increase every 10 minutes by an additional 5 mcg/kg/min until SBP ≥100 mmHg. DO NOT exceed 20 mcg/kg/min unless ordered by medical direction.

Push-Dose Epi follow protocol after medical direction approval Pediatrics

Call medical direction for dosing

Special Notes

When in service area where Paramedic is available, arrange an ALS intercept, but do not delay transport

Consider performing orthostatic VS

Decreasing heart rate is a sign of impending collapse

Patients predisposed to shock o Immunocompromised (chemotherapy, acquired immunodeficiency), adrenal

insufficiency, transplant pts, elderly, infants

Approved: 10/18/11 Revised: 06/16/15

• Transport to the closest emergency department

• Reassure patient, provide emotional support

• Treat injuries as appropriate

• Consider same sex attendant

• Document patient demeanor and statements related to the assault.

• Discourage use of restroom or cleansing

• Do not discard first voided urine; place on ice if possible.

SEXUAL ASSAULT STANDING ORDER

I

N

C

L

U

S

I

O

N

E

X

C

L

U

S

I

O

N

O

R

D

E

R

S

If patient is 18 or older, provide with contact information for SARS Advocate

(520) 349-8221

Currently in SAEMS, TMC has SA Forensic Exam capability and can process these patients fully.

Patient/guardian wishes to refuse

Patient meets criteria for standing order

If patient is under 18 release to law enforcement.

Use standing order on patients with a report of a sexual assault (SA) or concern for a possible sexual assault.

Standing order should not be used on patients meeting SAEMS Trauma Triage Decision Scheme

Initiate immediate supportive care as indicated:

• Oxygen to keep O2 Sat > 90%

• Cardiac Monitor

• Position of comfort

• Notify Law Enforcement; they will determine the need for a forensic exam


• Obtain vital signs

• Oxygen to keep SpO2 > 94% • Cardiac monitor (if available)

Symptomatic or Asymptomatic Snake Bite

D

Revised: 1/208; 4/2011

• Note estimated time bite occurred

• Prepare for immediate transport, do not delay until onset of symptoms

• Remove all watches, rings, jewelry, etc. (including shoes) from all extremities

• Immobilize affected extremity in an extended position, keep patient as still as possible*

• Elevate limb to the level of the heart

• Perform neurovascular checks and mark the edge of any discoloration or swelling and write the time on the line, if possible

• Monitor every 15 minutes

• Initiate IV in unaffected extremity

• If SBP <90 administer 20 ml/kg bolus of NS, may repeat as needed and reassess patient after each bolus

• Follow Pain Management SO

SNAKE BITE STANDING ORDER

INCLUSION

O R D E R S

Special Notes:

1. Local reactions include swelling, tenderness, redness, ecchymosis, or blisters at the bite site.

2. Systemic reactions include

hypotension, bleeding beyond the puncture site, refractory vomiting, diarrhea, angioedema and neurotoxicity.

3. Do NOT wrap extremity

• No constricting bands, ice or tourniquets

• No suction or cut to the bite

• *Ensure immobilization device or dressing does not result in constriction due to swelling

4. All hospitals in Southern Arizona carry rattlesnake antivenom.

Effective: 1/2008 Revised: 04/11, 10/12, 10/17/2017

Contact Medical Direction for:

• Allergic Reaction

• Deterioration in patient condition

• Management of a tourniquet placed prior to EMS arrival

• Non-native/exotic snakebites

Approved 6-16-09 Revised 11-10; 10-11; 01-12; 9-14


O2 (keep O2 sat > 94%)

Finger Stick Blood Glucose Cardiac Monitor (if available)

Use standing order on patients 18 years or older with these symptoms: (may be transient or persistent)

Facial droop

Unequal grips/ arm drift

Slurred speech

Change in mental status -as documented by friend or family member – not related to drugs, alcohol, trauma, seizure or diabetes

Sudden loss of vision (complete or a portion of a visual field)

Ataxia [dramatic, acute changes in coordination (arms, legs, or gait) or inability to make smooth, intentional movements in a patient with normal mental status]

Sudden, severe, atypical headache

I N C L U S I O

N

This standing order should not be used on patients with these characteristics:

Age <18 years

Shock and/or respiratory distress

Symptom onset > 6 hours or unknown

Cardiac dysrhythmias where resuscitative measures might be needed

Unconscious/unresponsive

FSBG < 60

Head trauma, drug or alcohol intoxication or seizure with postictal state likely

E

X

C

L

U

S

I

O

N

O R D E R

S

Special note: Evaluate neurologic changes using Cincinnati Prehospital Stroke Scale which is a 3-item scale to diagnose a potential stroke in prehospital setting. If any one of the three tests shows abnormal findings, the patient may be having a stroke. Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke. If all 3 findings are present, the probability of an acute stroke is more than 85%

1. Facial Droop 2. Arm Drift 3. Slurred Speech

If clear, acute neurologic changes meeting Cincinnati Prehospital Stroke Scale CRITERIA are present:

Initiate IV NS/LR TKO

Establish and relay “STROKE ALERT” with time last seen normal

Transport to nearest Primary Stroke Center if symptom onset is <6 hours

In outlying areas with a transport interval of >30 minutes to a Primary Stroke Center, transport the patient to the closest facility, or consider air transport directly to a Primary Stroke Center

Patient does not meet inclusion

criteria, or meets any exclusion criteria, or

wishes to refuse transport

Transport to closest facility and/or

contact medical direction authority If patient condition deteriorates contact medical direction authority

Consider intubation following Airway Management Procedure Protocol if:

Respiratory rate <8 OR

Patient unable to protect airway

A Primary Stroke Center is designated by TJC or another third-party certifying body. Currently in SAEMS: NMC, OVH, TMC, SJH, SMH, BUMC-T and VA

STROKE STANDING ORDER


Base Hospital

TOURNIQUET ADMINISTRATIVE ORDER

This AO is to be used in conjunction with the ALS/BLS Stabilization AO

Use this AO on patients with the following symptoms:

Significant hemorrhage

Arterial bleeding

Significant venous bleeding

Extremity bleeding in the tactical environment (RTF functions)

Any partial or total extremity amputation with or without hemorrhage

Extremity bleeds where direct pressure and pressure dressings are not feasible due to limited manpower or where the patient has multiple life threatening injuries

Contraindications:

Mild bleeding

Bleeding that can be controlled with direct pressure or pressure dressings

Patients meeting inclusion criteria:

Firm, direct pressure to bleeding site

Fully expose the injury. Remove clothing as needed

Apply TQ to bare skin, approx 2-3 inches proximal (above wound). TQ should not be placed distal to the knee or elbow

If the patient is in extremis, has massive hemorrhage or the tactical situation is unsafe, then the device should be placed high up on the extremity and over the clothing

Remove all slack from the strap so that it is snug prior to tightening

Tighten TQ until cessation of bleeding. (venous oozing is acceptable)

Check for absence of distal pulse (if still palpable, tighten until no longer is)

Do not cover the tourniquet with a dressing

Note the time the TQ was placed

Reassess the wound and TQ each time the patient is moved to ensure it is still tight

If bleeding is not controlled with first TQ, apply a second TQ proximally

Monitor patient for signs of shock

Field removal of TQ’s:

Consider consultation with medical direction authority is recommended

If unable, apply pressure to the injury site, slowly release TQ, and check for bleeding. If there is significant bleeding, retighten TQ. If bleeding is controlled by a pressure dressing, keep TQ loosely on affected extremity in case bleeding resumes.

Special Note: All TQ patients should go to a Level I Trauma facility Field TQ’s should not remain in place for more than 2 hours

NORTHWEST MEDICAL CENTER · HAZMAT Patients (SAEMS) 16. Hyperthermia 17. Hypo-Hyperglycemia 18....

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Transcript of NORTHWEST MEDICAL CENTER · HAZMAT Patients (SAEMS) 16. Hyperthermia 17. Hypo-Hyperglycemia 18....