Field Medical Protocols 

FALL 2013 

EAGLE COUNTY PARAMEDIC SERVICES 

 

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TABLE OF CONTENTS 

GENERAL ....................................................... 1 Approval and Review ............................................................................................ 2 Use of the Protocol Manual .................................................................................. 3 Acts Allowed ......................................................................................................... 4 Agencies Adopting this Manual ............................................................................ 5 Requesting Advanced Life Support ...................................................................... 6

ADMINISTRATIVE ........................................... 7 Advance Medical Directives.................................................................................. 8 Alcohol Involved ................................................................................................... 9 Alcohol Involved Flowchart ................................................................................. 10 Consent .............................................................................................................. 11 Destination Determination .................................................................................. 12 Documentation Guidelines ................................................................................. 13 Electric Restraint Devices / Electronic Control Weapons ................................... 14 Emergency Department Bypass ......................................................................... 15 Field Pronouncement ......................................................................................... 16 Helicopter Resources at the Scene .................................................................... 17 Helishuttle / Fixed Wing Assist ........................................................................... 18 In Law Enforcement Custody.............................................................................. 19 Interfacility Transfers .......................................................................................... 20 Physician on Scene ............................................................................................ 21 Psychiatric Transfer ............................................................................................ 22 Refusal of Care ................................................................................................... 23 Signatures .......................................................................................................... 24 Skier Transports ................................................................................................. 25 Transport from Clinics ........................................................................................ 26 Typical Call Flowchart ........................................................................................ 27 Unattended Minor ............................................................................................... 28 Unattended Minor Flowchart............................................................................... 29

COMMUNICATION ........................................ 30 Communication with Medical Control ................................................................. 31 Hospital Setup .................................................................................................... 32 Medical Alert ....................................................................................................... 33 STEMI Alert ........................................................................................................ 34 Stroke Alert ......................................................................................................... 35 Trauma Alert ....................................................................................................... 36

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AIRWAY AND RESPIRATORY ......................... 37 Airway Management / Oxygen ............................................................................ 38 Basic Airway Management ................................................................................. 39 King Airway......................................................................................................... 40

Advanced Airway Management ....................................................... 41 Chest Decompression ........................................................................................ 42 Continuous Positive Airway Pressure (CPAP) .................................................... 43 Nasal Intubation .................................................................................................. 44 Needle Cricothyroidotomy .................................................................................. 45 Oral Intubation .................................................................................................... 46 Paralytic Maintenance ........................................................................................ 47 Post Intubation Management .............................................................................. 48

Rapid Sequence Intubation ............................................................ 49 Rapid Sequence Intubation ................................................................................ 50 Universal Airway Algorithm ................................................................................. 52 Crash Airway Algorithm ...................................................................................... 53 Jeopardized Airway Algorithm ............................................................................ 54 RSI Algorithm ..................................................................................................... 55 Failed Airway Algorithm ...................................................................................... 56

PRE‐HOSPITAL PROCEDURES ....................... 57 Analgesia ............................................................................................................ 58 Broselow-Luten Tape ......................................................................................... 58 Combative Patient .............................................................................................. 61 Combative Patient Algorithm .............................................................................. 62 Cyanide Gas Antidote Kit ................................................................................... 63 Diagnostic Monitoring ......................................................................................... 64 Electrical Therapy ............................................................................................... 65 Gastric Decompression ...................................................................................... 66 Intraosseous Insertion by EMT-B ....................................................................... 67 LUCAS Chest Compression System .................................................................. 68 Medication Administration .................................................................................. 69 Pelvic Binder ....................................................................................................... 70 Nerve Agent Kit .................................................................................................. 71 Pediatric Vascular Access and Fluid Resuscitation ............................................ 72 Tourniquets......................................................................................................... 73

INTERFACILITY PROCEDURES ....................... 74 Blood Gas / CO2 / SpO2 Reference Values ....................................................... 75 Blood Product Administration ............................................................................. 76 Central Line Maintenance / Access .................................................................... 77

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Chest Tube Maintenance ................................................................................... 78 Foley Catheter Placement and Maintenance ...................................................... 79 Intra Aortic Balloon Pump ................................................................................... 80 Mechanical Ventilator ......................................................................................... 81 Parenteral Nutrition Maintenance ....................................................................... 84

TREATMENT ................................................. 85

CARDIAC .................................................................................... 86 Acute Coronary Syndrome (ACS) ....................................................................... 87 Asystole .............................................................................................................. 88 Basic Life Support Guidelines............................................................................. 89 Bradycardia ........................................................................................................ 90 Hypertension ...................................................................................................... 91 Medical Cardiac Arrest: Chest Compression & Defibrillation Guide ................... 92 Non-traumatic Shock .......................................................................................... 93 Post Resuscitation Care ..................................................................................... 94 Pulseless Electrical Activity (PEA) ...................................................................... 95 ST Elevation MI (STEMI) .................................................................................... 96 Tachycardia ........................................................................................................ 97 Ventricular Fibrillation and Pulseless Ventricular Tachycardia ........................... 98

ENDOCRINE ................................................................................ 99 Hyperglycemia .................................................................................................. 100 Hypoglycemia ................................................................................................... 101

ENVIRONMENTAL ...................................................................... 102 Allergic Reaction ............................................................................................... 103 Altitude Related Illness ..................................................................................... 104 Anaphylaxis ...................................................................................................... 105 Electrical Injuries .............................................................................................. 106 Hypothermia, Submersion, Cold Injuries .......................................................... 107 Hyperthermia .................................................................................................... 108

GASTROINTESTINAL .................................................................. 109 Abdominal Pain ................................................................................................ 110 Gastrointestinal Bleeding .................................................................................. 111 Nausea / Vomiting ............................................................................................ 112

NEUROLOGIC ............................................................................. 113 CVA / TIA ......................................................................................................... 114 Headache / Migraine ........................................................................................ 115 Seizure ............................................................................................................. 116 Syncope ........................................................................................................... 117

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OBSTETRICS/GYNECOLOGY ........................................................ 118 Complications of Pregnancy ............................................................................. 119 Delivery Complications ..................................................................................... 120 Field Labor and Delivery ................................................................................... 121 Neonatal Resuscitation ..................................................................................... 122 Trauma in Pregnancy ....................................................................................... 123

PEDIATRICS ............................................................................... 124 Pediatric Bradycardia ....................................................................................... 125 Pediatric Cardiac Arrest .................................................................................... 126 Pediatric Fever and Febrile Seizures ................................................................ 127 Pediatric Respiratory Distress .......................................................................... 128 Pediatric Tachycardia ....................................................................................... 129

PSYCHIATRIC / BEHAVIORAL ....................................................... 130 Anxiety / Hyperventilation ................................................................................. 131 Depression/Mania/Schizophrenia and Attempted Suicide ................................ 132

RESPIRATORY ............................................................................ 133 Respiratory Distress - Bronchospasm from Acute Asthma ............................... 134 Respiratory Distress - Bronchospasm from COPD ........................................... 135 Respiratory Distress - Pulmonary Edema ......................................................... 136

TOXICOLOGY ............................................................................. 137 Alcohol Withdrawal ........................................................................................... 138 Carbon Monoxide ............................................................................................. 139 Poisonings / Overdose ..................................................................................... 140

TRAUMA .................................................................................... 141 Amputations...................................................................................................... 142 Blunt Trauma .................................................................................................... 143 Burns ................................................................................................................ 144 C-Spine Clearance ........................................................................................... 145 Eye Injuries ....................................................................................................... 146 Head Injury ....................................................................................................... 147 Isolated Orthopedic Trauma ............................................................................. 149 Penetrating Trauma .......................................................................................... 150 Selective C-Spine Procedure ............................................................................ 151 Spinal Trauma .................................................................................................. 152 Trauma Arrest ................................................................................................... 153 Traumatic Shock ............................................................................................... 154

COMMUNITY PARAMEDIC ............................ 155

ADMINISTRATIVE PROTOCOLS .................................................... 156

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Eagle Care Clinic Referrals .............................................................................. 157 Eagle County Health and Human Services Referrals ....................................... 158 Home Visitation ................................................................................................ 160 Medical Direction / Chain of Command ............................................................ 162 Medical Equipment ........................................................................................... 163

MEDICAL PROTOCOLS ................................................................ 164 Asthma Management ....................................................................................... 165 Cpap/Bipap/Sleep Apnea/Oxygen Sat Checks ................................................. 166 Diabetic Education ............................................................................................ 167 Follow Up / Post Discharge .............................................................................. 168 History and Physical ......................................................................................... 170 Home Medications ............................................................................................ 179 Home Safety Assessment ................................................................................ 180 Immunizations .................................................................................................. 181 Intravenous Catheter Changes ......................................................................... 182 I-STAT .............................................................................................................. 183 Lab Draw .......................................................................................................... 184 Otoscope .......................................................................................................... 185 Post-partum Visits ............................................................................................ 186 Social Assessment ........................................................................................... 187 Well Baby Checks ............................................................................................ 188 Wound Check / Post-Op Dressing Change ...................................................... 190 References ....................................................................................................... 191

PRE‐HOSPITAL FORMULARY ...................... 192 Acetaminophen ................................................................................................. 192 Adenosine (Adenocard) .................................................................................... 194 Albuterol ........................................................................................................... 195 Alcaine (Tetracaine HCL) ................................................................................. 196 Amiodarone ...................................................................................................... 197 Aspirin (acetylsalicylic acid) .............................................................................. 198 Atropine Sulfate ................................................................................................ 199 Atrovent (Ipratropium) ....................................................................................... 200 Calcium Chloride / Calcium Gluconate ............................................................. 201 Dextrose / Glucose (Oral) ................................................................................. 202 Dextrose (D50W, D25W, D12.5W) ................................................................... 203 Diphenhydramine HCL (Benadryl) .................................................................... 204 Dopamine HCL ................................................................................................. 205 Epinephrine 1:10,000 and 1:1,0000 .................................................................. 206 Etomidate ......................................................................................................... 207 Fentanyl Citrate (Sublimaze) ............................................................................ 208 Glucagon .......................................................................................................... 209 Hydromorphone (Dilaudid) ............................................................................... 210 Ketamine (Ketalar) ............................................................................................ 211 Lidocaine HCL .................................................................................................. 212

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Lorazepam (Ativan) .......................................................................................... 213 Magnesium Sulfate ........................................................................................... 214 Methylprednisolone (Solu-medrol) .................................................................... 215 Midazolam (Versed) ......................................................................................... 216 Midazolam (Versed) for Pediatrics .................................................................... 217 Naloxone HCL (Narcan) ................................................................................... 218 Nitroglycerin ...................................................................................................... 219 Ondansetron HCL (Zofran) ............................................................................... 220 Ondansetron (Zofran) Oral Disintegrating Tablet ............................................. 221 Phenylephrine HCL (Neosynephrine) ............................................................... 222 Racemic Epinephrine (Vaponephrine) .............................................................. 223 Rocuronium ...................................................................................................... 224 Sodium Bicarbonate ......................................................................................... 225

INTERFACILITY FORMULARY ...................... 226 Acetaminophen ................................................................................................. 227 Antibiotics (Guidelines) ..................................................................................... 228 Colloid Solutions ............................................................................................... 229 Diazepam (Valium) ........................................................................................... 230 Diltiazem (Cardizem) ........................................................................................ 231 Dobutamine (Dobutrex) .................................................................................... 232 Eptifibatide (Integrilin) ....................................................................................... 233 Esmolol HCL (Brevibloc) .................................................................................. 234 Fosphenytoin (Cerebyx) ................................................................................... 235 Furosemide (Lasix) ........................................................................................... 236 Haloperidol (Haldol) .......................................................................................... 237 Heparin Sodium Infusion .................................................................................. 238 Insulin Infusion .................................................................................................. 239 Labetalol (Trandate, Normodyne) ..................................................................... 240 Levalbuterol (Xopenex) .................................................................................... 241 Levetiracetam (Keppra) .................................................................................... 242 Mannitol ............................................................................................................ 243 Metoprolol (Lopressor) ..................................................................................... 244 Midazolam (Versed) Infusion ............................................................................ 245 Morphine Sulfate .............................................................................................. 246 Nicardipine (Cardene) ...................................................................................... 247 Norepinephrine Bitartate (Levophed) ................................................................ 249 Octreotide (Sandostatin) ................................................................................... 250 Phenylephrine (Neo-Synephrine) ..................................................................... 251 Phenytoin (Dilantin) .......................................................................................... 252 Pitocin (Oxytocin) ............................................................................................. 253 Promethazine HCL (Phenergan) ...................................................................... 254 Propofol (Diprovan) .......................................................................................... 255 Protonix (Pantoprazole) .................................................................................... 256 r-tPA (Recombinant Tissue Plasminogen Activator) ......................................... 257 Terbutaline (Brethine) ....................................................................................... 258

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Vecuronium (Norcuron) .................................................................................... 259

APPENDIX .................................................. 260 Acts Allowed: Authorized Procedures for Provider Levels ................................ 261

NOTES ....................................................... 266

 

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GENERAL

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APPROVAL AND REVIEW  This manual is approved and reviewed by the current Eagle County Paramedic Service Medical Director pursuant to 3-CCR-713-6. It is to be reviewed annually or at any time there is a change. Please see Master Document at Eagle County Health Service District at 1055 Edwards Village Boulevard, Edwards, CO.

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USE OF THE PROTOCOL MANUAL  The purpose of medical protocols is to provide EMS personnel with guidance in the out-of-hospital treatment / disposition of patients. Often, items that can be considered for treatment is listed in each protocol in an order most commonly used, and should be considered as options rather than sequences. Training, judgment and clinical sense should cover situations that are not specifically addressed in this manual or when unforeseen circumstances arise. Responding ALS units or on-line medical control are other sources of guidance in unusual situations. Any deviation from protocol requires documentation in the PCR stating the reason for deviation. Actions that are italicized and underlined require a written or verbal order from the base physician. If the on-line medical control physician is unavailable for consultation, this manual can be considered “standing orders,” and ALS personnel can proceed with treatment, as needed using their own best judgment. Documentation of attempted physician contact should be made in the PCR. This manual is designed for use by both basic and advanced providers. Basic providers are persons trained to the level of EMT-Basic, first responder or advanced first aid. Basic Providers can carry out any of the actions noted under the “Basic” sections of each page. Basic Providers can administer medications as noted in the formulary. Advanced providers are Paramedics employed by Eagle County Ambulance District. Advanced Providers can carry out any action noted under the “Basic” or the “Advanced” sections. Paramedic level providers can administer medications as listed in the formulary. Interfacility indicates treatment considerations for transfer patients that are facility initiated.

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ACTS ALLOWED  The acts allowed for individual certification holders are governed by 6-CCR 1015-3: Rules Pertaining to EMS Practice and Medical Director Oversight. Any change to the Practice Rules may render the acts allowed as listed in this manual obsolete. Providers are responsible for knowing their scope of practice as mandated by Rule and adhering to any limitations until this manual can be updated to reflect those changes.

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AGENCIES ADOPTING THIS MANUAL  The following agencies are subject to the guidelines within this manual: Eagle County Paramedic Services Vail Fire and Emergency Services Eagle River Fire Protection District Vail Mountain Rescue Group Vail Ski Patrol (Paramedics only) Gypsum Fire Protection District Greater Eagle Fire Protection District Rock Creek volunteer fire department All EMS agencies providing prehospital care using this manual are doing so under the medical control of name of medical director, place of employment. Any other use of this manual requires permission from the Eagle County Paramedic Services and the Medical Director. The original document is on file at Eagle County Paramedic Services. All the above agencies will be sent updates to this manual, but it is the responsibility of each agency to maintain a current protocol manual and train their staff on updates. Any questions regarding these protocols can be directed to Eagle County Paramedic Services at 970-926-5270 or contact Will Dunn via email (wdunn@ecparamedics.com).

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REQUESTING ADVANCED LIFE SUPPORT  It is appreciated that not all private requests for assistance while on private property constitutes a medical emergency. Keep in mind, however, that often the safest option for any potential patient is a paramedic assessment. This is not an all-inclusive list – err on the side of caution and patient safety by having a low threshold for calling for ALS Consider requesting ALS for:

One who is unconscious or has a history of unconsciousness that has resolved regardless of suspected etiology

Any complaint of difficulty breathing, shortness-of-breath or respiratory distress One who complains of headache, chest pain / discomfort, abdominal pain or acute

onset of back pain One who has head, chest, abdominal or flank pain secondary to trauma One who has suffered some type of trauma, no matter how minor, who is also

pregnant or on blood thinning medications Intoxicated persons with a medical complaint or trauma; or significantly impaired

from alcohol Any person aged 65 years or older with any type of complaint Anyone aged 17 or younger with any type of complaint who is unaccompanied by

a parent

 

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ADMINISTRATIVE 

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ADVANCE MEDICAL DIRECTIVES  Written and Other Forms of Declaration

Many types of advanced directives are legal under Colorado State Law and should be honored—the Colorado CPR Directive is the most common type encountered in the field.

This may include, but is not limited to, living wills, Five Wishes document, CPR directive, or other advance directives, including those from other states, and self-written forms that the patient has created and clearly made his/her wishes known.

These documents do not need to be the original; if the document at hand is a photocopy, scan, FAX, et cetera, it should still be honored.

Verbal Declaration

In cases where attempting resuscitation is not in the best interest of the patient and the family does not wish for a resuscitation attempt, it is acceptable to honor their wishes in the absence of advance directives

Should questions about attempting resuscitation arise or should there be disagreement among family members, consult medical control about proceeding

Consult MD for pronouncement / time of death

If a valid advanced directive is present, EMS personnel shall:

Withhold or withdraw CPR, intubation or other advanced airway management, artificial ventilation, defibrillation, cardiac resuscitation medication, and other related procedures

Provide comfort care including oxygen, pain medications, and suction. Provide treatment for conditions other than cardiac arrest unless it is stated

otherwise in the document Family members may not override a valid advance directive

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ALCOHOL INVOLVED  EMS is often called to evaluate people who are intoxicated. Not all intoxicated people need ambulance transport, not all people who have recently consumed alcohol are clinically intoxicated. However, alcohol is a complicating factor when conducting a history, physical exam and when making treatment and transport decisions When called to evaluate a person where alcohol is involved, several questions need to be answered

Is transport indicated / would not going to the hospital be AMA? Is the person significantly impaired from the alcohol? Does this person have Decision Making Capacity?

If there is no compelling reason to transport and the person is not significantly impaired, he or she may be released to a sober adult who has an ethical or moral responsibility for the person’s wellbeing. Significantly impaired from alcohol

Unable to walk Difficult to arouse or history of being difficult to arouse Inappropriate behavior even for being intoxicated Protracted vomiting Potential for airway compromise Bowel or bladder incontinence

Clinically Sober Alcohol affects different people differently due to a number of factors – determining who is clinically sober is based on physical exam findings:

Cooperative No physical manifestation of intoxication, e.g., slurred speech, ataxia, unsteady

gait, et cetera Decision Making Capacity If a person is not clinically sober, he or she does not have decision-making capacity,

Any physical manifestation of intoxication is evidence that the patient does not have

Decision Making Capacity.

 

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ALCOHOL INVOLVED FLOWCHART 

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CONSENT  Expressed consent

In our practice of emergency medicine, it is reasonable to assume the patient’s consent for history, physical exam, treatment and transport without expressly seeking it. The circumstance of the patient answering questions, allowing interventions and by not declining the treatment physically or verbally indicates consent.

Informed consent

Informed consent describes a detailed discussion, usually in writing, of the risks versus benefit of treatment. While clinicians may discuss the merits of certain procedures with patients, the value of virtually all treatments greatly outweigh any risks and informed consent is not necessary.

Implied consent

Implied consent applies when the patient legally or clinically does not have Decision Making Capacity. The clinician takes on the task of making decisions for the patient. Most cases of implied consent occur when the patient is intoxicated or is a minor.

DECISION MAKING CAPACITY

Age 18 or older; and Awake, alert, oriented to person, place, time and event; and Cooperative and appropriate; and Acute or chronic condition does not interfere with cognition;

and Clinically sober (see Alcohol Involved Protocol); and Not in law enforcement custody

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DESTINATION DETERMINATION  Typical receiving facilities for transports are Vail Valley Medical Center and Valley View Hospital in Glenwood Springs. The attending paramedic has final authority on patient destination with these considerations:

Appropriate and timely care available at the destination Patient preference Hospital proximity and accessibility System status Advice of medical control In cases of an MCI, destination may be dictated by a transport officer or other

authority

For critical patients, consider the most accessible facility:

Valley View from the Gypsum exit west, and when it is more accessible when west of Eagle

Vail Valley from east of the Gypsum exit, and when it is more accessible when west of Gypsum

For patients meeting “STEMI” criteria consider:

Valley View for all patients from the Eagle exit west Vail Valley for all patients east of Eagle

In times of irregular occurrence, such as an MCI or a highway closure, the alternate destinations of Beaver Creek Medical Center or Avon Urgent care may be considered pending approval from medical control and the duty operations supervisor. Also, please see the “Emergency Department Bypass” protocol.  

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DOCUMENTATION GUIDELINES  When a Patient Care Report (PCR) needs to be written: A full PCR needs to be written for all individuals whom are considered patients. Patient criteria are met when the person has and of the following:

Any complaints of illness or injury; or An obvious abnormality; or Mechanism of Injury / Nature of Illness is significant

A full PCR includes the following:

Operational information Demographic data for billing purposes Clinical data – history, physical exam, diagnostics, and treatments Signatures (see Signature Policy)

An abbreviated PCR is acceptable for the “Dry Run,” “No Transport,” or “Stand by” dispositions. See Flowchart – Typical Call for a definition of these terms. General Guidelines to Writing Patient Care Reports

PCRs should be completed as soon after the call as possible. PCRs must be completed by the end of the scheduled shift. If this is not possible, an Incident Report must be completed and the supervisor notified.

Abbreviations and acronyms should be avoided as they degrade the quality of the report. However, commonly spoken abbreviations or acronyms such as “AED” or “CPR” are acceptable.

Avoid using jargon, regionalisms, radio codes and slang. An example is the radio code “Frank” which has limited use outside our area and its use in documentation may be confusing or meaningless.

A PCR typically should not make reference to any other patients

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ELECTRIC RESTRAINT DEVICES / ELECTRONIC CONTROL 

WEAPONS  Most of the local law enforcement agencies use the TASER brand of device as a less-than-lethal option. TASER uses technology that interrupts the muscular function, which is painful and causes contractions than can be incapacitating. Multiple studies indicate that in the absence of other factors, the TASER is a safe device and unless there is a compelling reason for transport (see below) these subjects do not need physician evaluation merely because they were subjected to the TASER. Think safety—subjects who have been Tasered can remain a threat A thorough history and physical exam should be completed

Consider transport of any person with the following findings Evidence of Excited Delirium prior to being Tasered Persistent, abnormal vital signs Altered mental status Aggression, violent behavior, resistive to evaluation Abnormal subjective complaints Evidence of trauma to head, thorax or abdomen other than that from the Taser

probes Taser probes imbedded in nipple, genitalia, joint space or anywhere above the

clavicles o If found in this area, leave in place and transport

Multiple Taser applications Patients who seem impervious to pain require significant force to subdue and may

not be aware of injury; close physical exam and high index of suspicion is recommended

Taser probe removal Gently place counter pressure on each side of the probe with one hand, then

firmly tug on the probe straight back Law enforcement may keep the probes for evidence Otherwise, treat as any other contaminated sharp For subjects who do not meet transport criteria, clean probe sites and give

instructions for any other minor soft-tissue injury, recommend updating tetanus

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EMERGENCY DEPARTMENT BYPASS  Occasionally the paramedic may encounter a patient who requires specialty care not available at the closest facility. This may be obvious on a scene call or at the request of a physician or mid-level provider at a clinic or medical office. If the patient does not require prompt physician intervention, or the patient would not benefit from being transported to the closest facility and it is reasonable to bypass, this protocol may be used. Procedure:

1. Contact the duty operations supervisor to approve ED bypass o When the patient is at a clinic or physician’s office, the supervisor may

elect to send a different crew to handle the transport o If the request is denied, transport patient to closest facility

2. Contact on-line medical control for approval of ED bypass

Notes:

There is no transfer paperwork to be completed Typically, the patient should be going to the emergency department at the

receiving facility The call disposition is still “transport” Complete an incident report documenting the bypass

 

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FIELD PRONOUNCEMENT  Withholding Resuscitative Efforts Resuscitative efforts should be withheld for any patient that is pulseless, apneic, and with any of the following presentations that are considered incompatible with life:

Decapitation Blunt trauma Massive head or torso trauma Total body, full-thickness burns Decomposition Rigor mortis without hypothermia Dependent lividity Other presentation discussed with base physician

Ceasing Resuscitative Efforts Patients in persistent asystole who do not respond to resuscitation require a base physician’s order to stop resuscitative efforts. These patients have remained in asystole for at least ten minutes or two rounds of ACLS have been performed. Field Pronouncement Procedure 1. Contact base physician with appropriate information for full report 2. Document time, and notify law enforcement and coroner’s office. 3. Counsel family members on the situation, and contact support if appropriate

(consider requesting a victim’s advocate through dispatch if necessary) 4. If ever in doubt, or confrontation with family develops, then provide care and transport

to the emergency department for further clarification of patient status

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HELICOPTER RESOURCES AT THE SCENE 

Helicopters are an important part of the EMS system. However, there is significant risk to the flight crew whenever it is utilized and some studies question the benefit in many circumstances. Ultimately an operational and clinical risk / benefit analysis should be considered.

Consider use of a helicopter in circumstances where:

The patient’s location precludes timely or reasonably safe ground transport In instances where multiple patients may overwhelm local hospitals and the

patients require dispersal out of the system Where multiple patients overwhelm ground resources A safe landing zone can be established Use of the helicopter would not unreasonably delay ground transport of the patient

or any other patients at the same scene The patient is not in, nor is likely to suffer, a cardiac arrest

Procedure

The paramedic shall make the determination to launch the helicopter. Consider only making this request only after the patient has been assessed. Additionally, contingency plans shall also be formed in the event that the helicopter is unable to reach the scene or is unable to lift after receiving the patient.

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HELISHUTTLE / FIXED WING ASSIST  Instances where the patient is under the care of a flight nurse / flight physician and ambulance transport is required between the hospital and aircraft. Documentation should include:

The pick-up address should be listed as the hospital and drop-off as the helipad or airport

Patient demographic and billing information If ECPS equipment is used or a ECPS medic completes a procedure it should be

documented

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IN LAW ENFORCEMENT CUSTODY  There are many situations where the paramedic may be called to assess a person in custody of law enforcement. These people do not have decision making capacity and may be transported or released to law enforcement based on paramedic discretion. Consider transport when:

Refusal would be against medical advice Any MVA with trauma to head or thorax When patient is significantly affected by alcohol or blood alcohol is reported over

.400 Pregnancy with complaints of cramping, bleeding or labor Ingestion of illcit drugs other than marijuana At risk for excited delirium Multiple TASER applications Uncooperative

Procedure When requested by law enforcement to evaluate a person in custody, complete an appropriate patient assessment.

If there is no indication for transport, make base contact for Medical Control to approve the disposition

o Document the contact as a patient refusal / base contact is in lieu of a patient signature

o Release the patient to the law enforcement officer and communicate that the person does not need transport

If transport is indicated, treat as appropriate o Patient must be restrained in manner appropriate for their condition; o If in handcuffs, a law enforcement officer should accompany the patient

when possible and/or the attendant should have easy access to a key\ o Notify receiving facility that patient being transported is in custody

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INTERFACILITY TRANSFERS  Certain patients require further care at facilities outside Eagle County. ECPS will provide transfer to an equivalent or higher level of care in cases where a sending physician deems it necessary and appropriate. ECPS staff will assist as necessary with arranging the most appropriate method of transfer and with determining that the risks of transfer do not outweigh the benefit to the patient. Considerations

Ensure that the following paperwork has been completed, and original copies are transferred with the patient

o Medical necessity/certification forms o Transfer orders o Patient consent for transfer o M1 – mental health hold papers – in applicable cases

Bring a copy of the patient’s chart, lab results, radiographic studies, etc. for

delivery to the receiving facility

Ensure that the level of care that the patient is receiving at the sending facility can be maintained throughout the transfer.

Commence transfer with the following:

o Maintenance of ongoing therapeutics and diagnostics initiated at the sending facility

o Initiation of new therapeutics under written order, protocol, or base physician contact

o Allow family members to accompany as deemed appropriate by the transfer crew

o Telephone report to the receiving facility 10-20 minutes prior to arrival o Patient care to receiving nurse at bedside o Document the disposition of all patient belongings

Document transfer as an IFT, noting complications, treatments given, and patient

disposition

The transfer orders, Physician Certification Statement and Advance Beneficiary Notice should be returned to ECPS and turned in with shift paperwork.

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PHYSICIAN ON SCENE 

The paramedic is responsible for the care of the patient with on-line medical control and is under no obligation to yield to the wishes of a physician on scene

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PSYCHIATRIC TRANSFER  Transfer of the psychiatric patient is a common request due to the limited mental health resources available in the valley. Often this transfer is to Grand Junction where resources along the way are scarce. Plan appropriately for your patient with the following considerations. All patients should be monitored for behavior which may indicate a desire to elope. Very high risk: Patient who has a history of violence

Any patient who has been violent towards the staff or someone else is high risk to themselves and to the transfer crew. Strongly consider a paramedic attendant, sedation and early restraint.

Very high risk: Patient who has attempted to elope from the facility

Exiting a moving ambulance is often fatal. Strongly consider a paramedic attendant, sedation and early restraint.

High risk: Patient who is or has been restrained in the facility If the patient needed to be physically or chemically restrained sometime during their course, these are red flags. Consider paramedic attendant and prepare for restraint.

High risk: Patient who is manic or actively psychotic

Verbal de-escalation techniques are likely not to be successful for more than an hour. Consider paramedic attendant and prepare for restraint.

At risk: History of actual suicide attempt This is a step above ideation or gesturing – the patient who made a true attempt to end their life is high risk. Consider a paramedic as part of the crew configuration.

At risk: History of needing to be redirected; anyone the staff wants out of the hospital

This is a patient who hasn't followed the rules and had to be "redirected." This patient is showing a tendency to misbehave. Consider a paramedic as part of the crew configuration.

Low risk: None of the above

This patient is likely on an M1 for ideation or gesture only. They have not displayed any of the higher risk items above. Consider BLS crew configuration.

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REFUSAL OF CARE  Patients may opt out of treatment or transport at any time. These patients generally fall into two categories: the first who refusal of care is reasonable and appropriate; the other being where the refusal would be Against Medical Advice. Refusal The patient has a low-risk injury or abnormality that is not likely to worsen and the EMT or paramedic agrees that not being transported by ambulance is a reasonable course of action. Typically ambulance transport should be offered, a conversation about warning signs of worsening pathology should be had and both documented. The patient should sign a refusal form; no base contact is necessary. In the event that the patient does not have Decision Making Capacity, the paramedic may decide that there is no reason to transport on the patient’s behalf. Should this occur base contact should be made with the physician to approve the refusal in lieu of gathering a signature. Against Medical Advice (AMA) Refusal The patient has an injury or abnormality that is significant or is likely to worsen, however he or she declines interventions or transport. The risks of refusing and warning signs of worsening pathology should be discussed and documented. The patient should sign an AMA refusal form and the refusal further documented with base contact with a physician. Parents or legal guardians may refuse on behalf of a child. However, Colorado law allows for the EMT or paramedic to remove the child from the parent, treat and transport in cases where the clinician feels that the child’s health is in danger. Law enforcement involvement is recommended and the concern for abuse should be reported to the receiving facility.

Further information may be found in the Consent, Alcohol Involved, Unattended Minor and In Law Enforcement Custody Patient protocols.

24

SIGNATURES  For a variety of reasons, a signature is an important part of medical documentation.

For patients who are being transported, transferred or shuttled to the helipad please acquire the patient signature through the ePCR software or on the paper form. When the patient does not have decision making capacity or is physically

incapable of signing, Section II – Authorized Representative Signature should be utilized

If an Authorized Representative is unavailable, utilize Section III and gain a signature from the receiving facility or flight crew

For patients who are refusing care, the refusal signature should be gathered through the ePCR or paper form. AMA refusals should also have an AMA form signed If the patient does not have decision making capacity, only a parent or court-

appointed legal guardian may sign the refusal o In the absence of a parent or court-appointed legal guardian, base

contact must be made and the case presented to on-line medical control; the conversation with the physician replaces the signature

25

SKIER TRANSPORTS 

Patients that are contacted at the designated pickup points at the base of Vail Mountain that have been assessed and treated by Vail Ski Patrol are considered “Skier Transports.”

Should the patient require or receive an ALS diagnostic or procedure prior or during ambulance contact, or if the patient is not low risk, the call no longer meets skier transport criteria and becomes an ALS Transport. Due to the nature of injury, heavy winter clothing, short transport and/or immobilization prior to contact, the following may be considered:

Immediate transport

Abbreviated secondary assessment and partial vital signs if pulse rate and quality, respiratory rate and quality, skin color are within normal limits

Minimize interventions in order to reduce scene time and patient movement

Documentation should clearly state rationale for the items listed above

Each case is unique. Err on the side of being conservative.

26

TRANSPORT FROM CLINICS  Certain patients, undergoing initial care at an outlying clinic or physicians’ office, will require transport to a hospital for further care and diagnostics that are not available at the outlying clinic, or physicians’ office. At a clinic’s request, ECPS will provide transport to the hospital, and implement additional therapeutics and diagnostics appropriate to the patient condition. Considerations Respond to the sending facility and obtain a patient report from the attending clinician Obtain copies of all paperwork completed by the sending facility Ensure that the receiving unit has been notified Transport patient with consideration for the following:

Maintenance of therapeutics and ongoing diagnostics as initiated by the sending facility

It may be appropriate to conduct a limited physical exam or limit diagnostics in the setting of recent exam by a physician; use good judgment

Implementation of additional therapeutics and diagnostics according to protocol In rare cases, the facility may request transport to a hospital other than VVMC

o Both medical control and the shift supervisor must approve a bypass of VVMC

Update the receiving facility prior to arrival with any changes in patient condition and ETA

27

TYPICAL CALL FLOWCHART 

28

UNATTENDED MINOR  Serious Illness or Injury If a minor is seriously ill or injured, transport without attempt to contact a parent – the hospital will take on the task of parental notification. When no Transporting would be Appropriate Should the child’s illness or abnormality not need immediate treatment, nor is it likely to worsen and transport may not be indicated, a vigorous effort should be made to contact a parent to discuss potential options If parent is contacted and declines transport, he or she should come to the scene to collect the child and sign the refusal paperwork. If this is not logistically possible, work with the parent to make reasonable arrangements for the child. If no reasonable arrangement is possible, transport the child. If the parent cannot be contacted, always act in the patient’s best interest. If a refusal is appropriate and a reasonable disposition exists, release the child to an adult who has a moral and ethical responsibility to the minor. When the Minor is Being Released at the Scene to Someone Other than the Parent In any case where the parent is not available to sign the refusal, base contact must be made and Medical Control must approve the disposition. This contact documents the plan in lieu of the parent’s signature.

An adult, even a relative or teacher, who is supervising the child in the parent’s absence, is not a legal guardian and cannot make legal or medical decisions on behalf

of the child

29

UNATTENDED MINOR FLOWCHART 

30

COMMUNICATION   

31

COMMUNICATION WITH MEDICAL CONTROL  Medical control shall be obtained from the on-duty physician Emergency Medicine physician:

For transports from the scene, the receiving facility shall be medical control For transfers from Vail Valley, the Emergency Department physician is medical

control, although the sending physician may also be consulted For documenting and alternate disposition, either medical control physician may

be consulted For non-transport agencies, consult with the responding paramedic. Medical control should be contacted:

To obtain an order for any medication or procedure that requires direct order AMA refusal Refusal on behalf of a patient without decision-making capacity (This may include

an unaccompanied minor, a person who is intoxicated but does not require ambulance transport or one who is in police custody.)

Field pronouncement ED Bypass Consult for treatment plan

32

HOSPITAL SETUP  Guidelines for radio reports

Age Sex Chief complaint / brief mechanism Abnormal findings (level of consciousness, vital signs, monitor, or assessment) Significant interventions (IVs, chest needles, drugs, airway management) ETA

What Not to Say on the Radio

Patient name (patient confidentiality - the whole world is listening) Unrelated allergies, meds, or non-pertinent medical history Normal vital signs including pulse-ox Negative assessment findings Local physician Minor treatments—immobilization, splints, O2, bandaging Anything that can wait until bedside

Guidelines for Bedside Report

Give a detailed description of:

Chief complaint History of present illness Past medical, surgical and social history Medications and allergies Physical exam Vital signs Interventions and patient response

33

MEDICAL ALERT  For any patient who is significantly ill and would benefit from prompt MD evaluation, the treating paramedic may call a medical alert. This may include any patient with:

Presentation that suggests compensated shock Uncompensated shock of medical etiology Significant pathology that does not respond to treatment Acute coronary syndrome that does not meet “STEMI alert” criteria Neurologic impairment that does not meet “stroke alert” criteria Severe respiratory distress

34

STEMI ALERT  Patients experiencing an acute coronary syndrome will be triaged with the following STEMI Alert criteria. ED will be notified by radio of the STEMI Alert, in addition to normal radio reporting procedures. A STEMI Alert will be initiated when:

Patient presentation consistent with acute coronary syndrome; and ST elevation ≥ 2 mm in two or more anatomically contiguous leads; and Age > 25; and Not in a paced rhythm; and No left bundle block pattern

35

STROKE ALERT  Patients experiencing a CVA / stroke will be triaged with the following Stroke Alert criteria. ED will be notified by radio of the Stroke Alert, in addition to normal radio reporting procedures. Stroke Alert patients will not be pre-screened for CVA fibrinolysis because advanced diagnostics are required that are not available in the prehospital setting. However, any history of hypertension and other pertinent history relating to clotting or bleeding disorders, CHI, or intracranial hemorrhage should be made readily obvious to all ED staff involved in the patients care. Stroke Alert Criteria

If the patient is positive for each of the following findings, a Stroke Alert will be initiated.

Less than three hours elapsed between onset of symptoms, and ED arrival Age ≥ 18 Blood Glucose > 50 mg/dL Patient has a newly positive Cincinnati prehospital stroke scale finding (see table

below)

Cincinnati Prehospital Stroke Scale* Facial Droop – (Patient

smiles or shows teeth) Pronator Drift – (with eyes closed, patient holds arms extended for 10 seconds)

Speech – (patient repeats a sentence)

Normal Symmetrical expressions

Both arms move equally, or do not move at all

Uses correct word / no slurring

Abnormal One side of face does not move well

One arm does not move, or drifts down lower than the other

Unable to speak, wrong words, or slurs words

36

TRAUMA ALERT  For any patient who is significantly traumatized and would benefit from prompt MD evaluation, the treating paramedic may call a trauma alert. The Emergency Department shall make the determination if a Trauma Activation will be called within the hospital. When calling a Trauma Alert, include the following information:

Patient age and sex Brief history Chief complaint / pertinent complaints Vital signs including any episode of hypotension Interventions If the patient clearly meets trauma activation criteria, that can also be

communicated

37

AIRWAY AND RESPIRATORY 

38

AIRWAY MANAGEMENT / OXYGEN  Indications Consideration for appropriate airway management and oxygenation should be made for any patient with one or more of the following:

GCS < 15 or altered mental status Respiratory distress or failure Reduced SpO2 Shock or potential development of shock Suspected ischemia or hypoxia Significant trauma Medical emergencies In the setting of sedation and analgesia Toxic gas or inhaled poison exposure Should an obstetric patient require oxygenation, strongly consider a non-

rebreather Precautions/Contraindications

None in cases where the patient is managed appropriately for their condition Use caution in presence of open flame or sparks

39

BASIC AIRWAY MANAGEMENT  Basic

Oxygen administration by nasal cannula or non-rebreather mask Placement of oral or nasal pharyngeal airways Bag valve mask ventilation Consider two nasal airways and an oral airway for best ventilation Suction as appropriate

Advanced

Pre-treatment for RSI

40

KING AIRWAY  Supraglottic, rescue airway Indications

Obtunded or otherwise sedated patients without trismus or gag reflex Failed airway

Basic (agencies where allowed by the medical director) / Advanced

Placement as directed by training and manufacture’s specifications Considerations

Does not protect the airway Must be sized appropriately Not indicated for pediatrics End-tidal capnography should be used when available

Removal

Patients who have improved since placement and can no longer tolerate To upgrade to endotracheal tube

41

ADVANCED AIRWAY MANAGEMENT 

42

CHEST DECOMPRESSION  Indications Tension pneumothorax as is indicated by any of the following (most often presents in the setting of penetrating trauma):

Dyspnea Tachypnea Tachycardia Diminished lung sounds Cyanosis JVD Hypotension with chest wall trauma Deviated trachea in the sternal notch Traumatic cardiac arrest

Precautions / Contraindications

No contraindications Restrain the patient

Procedure

1. Locate a suitable location for needle decompression

Second intercostal space at the midclavicular line Fourth intercostal space at the mid axillary line

2. Clean the area with isopropyl alcohol

3. Use a 10g angiocath as supplied

4. Advance needle and catheter to rib, and then over rib into the selected intercostal space – avoid the neurovascular bundle at the bottom edge of the rib

5. Advance catheter off needle into the pleural space

6. Repeat as necessary if tension redevelops

43

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)  Indications

Any patient experiencing severe respiratory distress related to pulmonary edema or bronchospasm

Precautions / Contraindications

Pneumothorax Need for intubation (respiratory arrest, agonal respirations, unconscious) Penetrating Chest Trauma Persistent nausea/vomiting Facial anomalies, unable to maintain mask seal Hypotension (relative contraindication, contact medical control with BP <90 mmHg

systolic) Active GI bleed or history of recent gastric surgery Pediatrics (minimum 12 years of age)

44

NASAL INTUBATION  To secure an airway in patients who are breathing but cannot be effectively / safely orally intubated Indications For patients where oral intubation is not possible or desirable, and

Failure of airway maintenance or protection Failure of ventilation or oxygenation Obtunded due to etiology that is not likely to resolve with time or treatment

Considerations

Tube confirmation is more complex since the patient likely retains respiratory effort

End-tidal capnography monitoring is mandatory – be aware that carbon dioxide’s detection can still be measured if tube is non-tracheal

Consider analgesia and sedation Secure tube with tie

Precautions / Contraindications

Use caution with patients with facial injuries, particularly LeForte III Sinus / turbinate injury may occur even with best technique Contraindicated in pediatrics 10 years and younger

Procedure

Adults generally should not have smaller than a 7.0 ET tube Pretreat nares as soon as procedure may be indicated Use gentle technique following sound of respirations, particularly inhalation as a

guide Tube collar likely will be flush against the nare in proper placement Verify and document tube placement:

45

NEEDLE CRICOTHYROIDOTOMY  Indications Any patient that cannot be ventilated or oxygenated by a less invasive technique may require a semi-surgical airway utilizing the technique outlined below. These patients should meet the following criteria:

Inability to adequately oxygenate Inability to ventilate with a BVM and BLS airway Inability to nasally or orally intubate due to trauma or other structural abnormality Patient has imminent threat of morbidity/mortality from lack of oxygenation

Precautions / Contraindications There are no contraindications after exhausting all other methods to ventilate the patient. Caution should be exercised in patients where the anatomy of the neck and upper airway is obscured due to trauma or other structural abnormality. Procedure Follow procedure for needle cricoid airway by training and manufacturer’s directions

46

ORAL INTUBATION  Indications

Failure of airway maintenance or protection Failure of ventilation or oxygenation Obtunded due to etiology that is not likely to resolve with time or treatment RSI

Considerations

Prioritize accordingly for patients in cardiac arrest o AHA guidelines indicate that chest compressions and vascular access are

very important for resuscitation o Consider that early intubation frees the paramedic for other tasks

End-tidal capnography monitoring is mandatory – print a copy of the wave form just before and just after patient handoff

Consider analgesia and sedation Secure tube effectively Note tube depth

Procedure

Video laryngoscopy should be used for first attempt Adults will typically require at least a 7.5 ET tube Consult Broselow Tape for pediatric size

Verify and document tube placement Visualization of tube through the cords Bilateral lung sounds Absence of epigastric sounds End-tidal capnograph and CO2 reading in mmHg

47

PARALYTIC MAINTENANCE  Indications For purposes of maintenance during an interfacility transfer, ECPS Advanced Practice Paramedics may be granted written or verbal permission to maintain paralysis with concurrent sedation/analgesia. Precautions / Contraindications

Any contraindication / hypersensitivity to one of the component medications Interfacility

Only for use in the intubated patient All paralytic administration should have concurrent sedation / analgesia Consult written orders and the ECPS formulary for dosing ranges and intervals Non-depolarizing paralytics are preferred for maintenance applications Continuous advanced and ECG monitoring and mechanical ventilation is required

for all patients with ongoing paralysis / sedation

Ensure proper sedation orders / proper sedation effects before departing facility.

48

POST INTUBATION MANAGEMENT  Indications Typically for patients who have been orally intubated, however this could also include nasally intubated patients or where a King tube has been placed Considerations

Be fanatic about proper tube placement and tube security End-tidal capnography should be in place and closely monitored C-collar may assist in tube security Tube should be appropriately tied with twill tape or commercial device and may

not be held in place manually during patient movement Gastric tube may be helpful Sedation in patients who are not cardiac arrest Restraints in non-cardiac arrest patients Sedation and analgesia should be generous for patients who have been rapid

sequenced Consider repeat doses of sedation and paralytics as appropriate

49

RAPID SEQUENCE INTUBATION 

50

RAPID SEQUENCE INTUBATION  General

RSI is intended to facilitate orotracheal intubation for patients requiring emergent airway control and protection and other methods of airway management are inappropriate or less advantageous

Sedation and paralysis allow for the patient to become rapidly unconscious and flaccid which should allow for intubation

Paralysis may not be the treatment course in patients who may be a difficult airway

This protocol is for patients over the age of 12 or longer than the Broselow-Luten tape

Patient must be attended by two clinicians Indications

Severe closed head injury Rapidly progressing pathology where early intubation is advantageous

Considerations

Benefits should always outweigh the risks inherent in RSI Patient proximity to the hospital – transporting some patients who meet criteria for

RSI may be the safer option Instances where there is not a dual paramedic crew – consider that when there is

no second provider allowed to do the procedure, that logistically it becomes more difficult and clinically the risk to the patient may be higher

Difficult airways – may not become easier to manage with RSI Contraindications

Where BLS or King airways would not allow for adequate ventilation When there is known hypersensitivity to RSI medications Where patient presentation will resolve promptly with time or intervention

51

RAPID SEQUENCE INTUBATION (CONTINUED)  Procedure Initiate RSI checklist (read-do check list must be followed)

Pre-oxygenate patient Evaluate airway risks Determine blood glucose level and correct if hypoglycemic Monitoring

o End tidal CO2 o SPO2 o EKG o NIBP

Equipment o Oxygen on o BVM on oxygen o Suction on o Glidescope on o Direct laryngoscopy available o ETT with stylet inserted o BLS adjuncts o King Tube available o Cric kit available

Medications o Analgesia drawn and labeled o Sedative drawn and labeled o Paralytic drawn and labeled

Administer induction agent Administer paralytic Intubate patient Confirm tube placement Sedation Post intubation management

52

UNIVERSAL AIRWAY ALGORITHM  

53

CRASH AIRWAY ALGORITHM 

54

JEOPARDIZED AIRWAY ALGORITHM 

55

RSI ALGORITHM 

56

FAILED AIRWAY ALGORITHM 

57

PRE‐HOSPITAL PROCEDURES 

58

ANALGESIA  Indications

Pain

Intubated patient Precautions / Contraindications

Apnea or hypoventilation (iatrogenic) Caution should be used when combining multiple medications Patient hypersensitivities to certain medications Renal and hepatic impairment

Procedure

IV access Consider SpO2, ETCO2, or frequent conversation to guard against

hypoventilation Fentanyl should be considered first-line for any patient in pain Opiates in combination with benzodiazepines may be considered for treatment of

pain associated with spasms in orthopedic injury o Fentanyl and midazolam are the agents of choice due to rapid onset-of-

action and short half life o Fentanyl should always be given first due to synergistic effects of the

medications o Continuous monitoring of ETCO2 must be used due to the increased

concern for hypoventilation

Patients requiring pain management often have an indication for IV access. However, in cases where IV access is logistically or clinically unavailable, consider aerosolized administration.

59

BROSELOW‐LUTEN TAPE  

Basic / Advanced The use of the Broselow-Luten tape shall be used in the following circumstances:

To determine patient’s weight when calculating medication dose or fluid bolus

To determine appropriate sizing for airway management

To guide treatment when patient is in extremis or in cardiac arrest

Where knowing patient’s size would be an advantage

60

CPR AND AED Basic

Chest Compression / Defibrillation sequence based on elapsed time post arrest – see table. Chest compressions at 100/minute with ventilations no more frequently than every 6-8 seconds for adults or 3-5 seconds in pediatrics.

Apply AED—to be applied only to unconscious, pulseless, apneic patients who are over 1 year of age (10 kg)

As a last resort, an AED may be placed on an infant as long as pads are not touching

If at any time patient regains pulse, support ventilations and monitor rate. If pulse rate less than 40 beats per minute or blood pressure less than 60 mmHg then start CPR.

If patient arrests again repeat sequence Advanced

The Patient should be transferred from an AED to a manual monitor/defibrillator when the AED/ACLS sequence allows, and when there are a sufficient number of ALS providers on scene to accommodate this aspect of the resuscitation

Amiodarone or Lidocaine if successful defibrillation

Witnessed Arrest:

Unwitnessed Arrest:

1. Initiate CPR with compression to ventilation ratio of 30:2 and a compression rate of 100 / min.

2. Apply ECG Monitor or AED

3. As soon as AED is ready to analyze rhythm, stop CPR for analysis

4. Resume CPR while AED is charging

5. As soon as AED is charged, defibrillate once and immediately resume CPR

6. Power off AED

7. Resume CPR for 2 minutes (5 complete cycles of 30:2)

8. Check for pulse / responsiveness

9. Power on AED and return to step 3

1. Initiate CPR with compression to ventilation ratio of 30:2 and a compression rate of 100 / min

2. Apply ECG Monitor or AED, but DO NOT turn on power yet

3. Complete 5 full cycles of 30:2 CPR (2 minutes)

4. Power on AED and analyze rhythm, (stop CPR for analysis)

5. Resume CPR while AED is charging

6. As soon as AED is charged, defibrillate once and immediately resume CPR

7. Power off AED

8. Perform CPR for 2 minutes (5 complete cycles of 30:2)

9. Check for pulse / responsiveness

10. Power on AED and return to step 3

61

COMBATIVE PATIENT  Unless otherwise obvious, assume that the etiology of a combative patient is the result of acute pathology that is likely to rapidly deteriorate. Gain control of the patient using physical and chemical restraint in as safe a manner as possible for both patient and those attempting to assist. Also see Patient Restraint and Agitated Delirium protocols. Basic

Enlist assistance of public safety, law enforcement or other first responders Restrain patient as appropriate

Advanced

Chemical restraint Closely monitor for signs of hypoventilation Consider RSI – particularly in cases where the pathology is due to a closed head

injury

62

COMBATIVE PATIENT ALGORITHM 

63

CYANIDE GAS ANTIDOTE KIT  Indications Cyanide Gas / Liquid Poisoning. The Cyanide Antidote kit is available for known nerve agent exposure events or suspected cyanide exposure. This kit should never be used as a shield to attempt rescue in a known Hot Zone. Cyanide is also common in many natural plant seeds and pits, some agricultural processing, metallurgy and as an insect control. Consult a chemical weapons reference for more information. Precautions / Contraindications

Not for use as a safety shield. Never enter a hazardous area or Hot Zone Treatment may be effective even if the patient is apneic with a pulse

Procedure

Oxygen Amyl Nitrite Inhalant – 15 seconds followed by 15 second rest, repeat until IV

access is obtained IV access 300 mg Sodium Nitrite – 2.5-5 ml / min. (or 0.2ml/kg for pediatrics) not to exceed

10 ml total 12.5 g of Sodium Thiosulfate Consider immediate NG tube placement and gastric lavage in cases where the

cyanide was ingested

64

DIAGNOSTIC MONITORING  Blood Glucose

Patients with altered mental status; When hypo- or hyperglycemia is suspected; When using medication that affect blood sugar

Capnography

Use in all intubated patients; Use whenever combining opiates and benzodiazepines; Use whenever ventilator status should be closely monitored

Carbon Monoxide

Instances where carbon monoxide is suspected EKG

Use to determining cardiac rhythm particularly in cases of significant brady- and tachycardias;

To reveal the presence of abnormal PRI or QT/QTc particularly in syncope patients;

When pathology may be revealed with this diagnostic 12-Lead EKG

When acute coronary syndrome is suspected; Pre- and post- rhythm conversion; When the presence of pathology may be detected in rhythm or morphology

Non-invasive Blood Pressure

Notoriously inaccurate; Use only after gaining a manual blood pressure for trending; Abnormal values should be verified manually

Thermometry

Non-invasive use is inaccurate; Use for trending when monitoring blood products; Use this data judiciously

 

65

ELECTRICAL THERAPY  Indications Pursuant to the ACLS and PALS guidelines, certain unstable patients will require electrical therapy to stabilize their condition. An initial attempt to stabilize with medication should be attempted, but do not delay electrical therapy in unconscious patients. Precautions / Contraindications Care provider contact with the patient during defibrillation / cardioversion Ensure that the “Sync Function” is re-enabled for each successive cardioversion Place Quick-Combo Pads and electrodes away from pacemaker and ICD pulse

generators Procedure

1. Strongly consider that the awake patient may benefit from a trial of medication before electrical treatment

2. Apply fast patches and 3 or 4 lead ECG electrodes as necessary 3. Apply advanced monitoring 4. Consider sedation / analgesia for conscious patients, but do not delay electrical

therapy in unconscious patients

Energy Selection Chart:

Energy Selection Chart:

Defibrillation:

Cardioversion: Transcutaneous Pacing:

Adult All Biphasic Defibrillation 360J

A-Fib/A-Flutter/SVT: 200J, 300J, 360J V-Tach: 200J, 300J, 360J

Set rate of 60-80 bpm and increase energy to 2-5 mA above consistent capture.

Pediatric 1st shock - 2J/kg Subsequent shocks - 4J /kg (Use Broselow Tape for calculation)

A-Fib/A-Flutter/SVT/V-Tach: 0.5-1.0 J/kg 2J/kg if initial dose fails (Use Broselow Tape for calculation)

Not commonly used for pediatrics – see adult.

66

GASTRIC DECOMPRESSION  Indications Use for gastric decompression in patients receiving positive pressure ventilation, and for removal of liquid stomach contents in some overdoses. Contact medical control for further guidance as needed. Precautions / Contraindications

Reduced level of consciousness without intubation Basilar skull fracture (nasal placement) Oral and nasal airway obstruction

Procedure Insertion

1. Measure from nose or mouth to earlobe then to xiphoid for approximate depth of insertion

2. Use a water soluble lubricant – viscous lidocaine/neosynephrine as necessary 3. Advance tube – limit depth to 5cm with each swallow in conscious patients 4. Remove tube immediately if patient develops difficulty breathing 5. Aspirate stomach contents, and auscultate over xiphoid to ensure correct

placement 6. Secure with tape/tie

Maintenance

Reverify placement as necessary Apply suction intermittently at lower settings (20-80 mmHg), or as ordered

67

INTRAOSSEOUS INSERTION BY EMT‐B  Allowed by waiver for EMT-Basics – individuals allowed to place an I/O will be specifically notified and trained for the procedure. Indications

Patient in cardiac arrest while supervised by a paramedic Contraindications

Suspected fracture proximal to insertion site Previous orthopedic procedure Joint replacement proximal to site

Procedure

Prepare EZ-IO needle driver and needle and normal saline / pressure bag Locate insertion site and cleanse with aseptic technique Stabilize extremity and insert needle Remove driver and needle from catheter hub and dispose of needle in sharps

container Confirm placement Flush catheter rapidly Attach drip set and infuse fluid

68

LUCAS CHEST COMPRESSION SYSTEM  Indications Cardiac arrest where manual chest compressions would otherwise be used.

Contraindications

The patient is too small. Fully extended compression arm must be either touching or within 15mm (5/8 in) of patient’s chest.

The patient is too large. The support legs must be able to be locked in place without compressing the patient’s torso.

Pregnant patients Infants and children

Procedure 1. Power on the device. 2. Position back plate under the patient. 3. Assemble LUCAS and make sure arms are locked in place. 4. Pull down pressure pad making sure it contacts patient’s chest (or is within 15 mm). 5. Make sure compression pad is over the lower sternum and above the xiphoid

process. 6. Press lock button (looks like a pause sign). 7. Apply stabilization strap around the patient’s neck. 8. Turn on to either 30:2 or continuous.

Special Notes

Try not to interrupt CPR to apply device. This can be accomplished by continuing with manual chest compressions and waiting for the two minute for pulse and rhythm check.

Do not place defibrillation pads under the compression arm Check position of LUCAS after each time the patient is moved to assure proper

placement of the compression arm over the middle of the sternum. Placement that is too low can cause serious injury to abdominal organs.

69

MEDICATION ADMINISTRATION  Due to drug shortages, ECPS can no longer rely on medication packaging to be consistent in regards to mass or volume. This, in addition to Rapid Sequence Intubation medications being added to the formulary has increased both the risk and the gravity of possible medications errors. The attending paramedic is solely responsible for the preparation of any medications that will be given to the patient. Basic The EMT-Basic may only administer ALS medications when the patient is in extremis and only under the direct supervision of the paramedic Advanced The attending paramedic may delegate the administration of any medication to another paramedic Intramuscular Injection sites are in the deltoid, gluteal, or quadriceps muscles.

Use no bigger than a 20 gauge needle at 90 degrees, draw back to assure needle is not in a vessel. Injection volume is limited to 5 mL.

Subcutaneous Injection site in the upper arm, although there are many approved sites. Use a 5/8 inch 25 gauge needle, grasp the fatty tissue of the upper arm, insert needle at a 45-degree angle, draw back to assure needle is not in a vessel. Injection volume is limited to 1 mL.

Sublingual Care must be taken to make sure the patient understands the medication is not to be swallowed

Oral Patient must be able to swallow and protect his or her own airway in order to administer an oral medication

Atomized (IN) May be administered to the nasal or oral mucosa. Draw up no more than 2 mL of medication into a 3 mL syringe. Limit dose to 1 mL per nostril.

Rectal Can be administered using a 14 gauge catheter with needle removed, lubricated TB syringe with the needle removed, or a pediatric ET tube.

70

PELVIC BINDER  Indication

Suspected unstable pelvic fracture Contraindication

Pregnant Procedure 1. Slide the binder under a supine patient, or have the binder in place on a backboard

prior to immobilizing the patient. 2. Cut the free end of the binder to leave 6-8 inch gap. The binder is one size fits all. 3. Attach the Velcro straps and plate to the free end of the binder. 4. Tighten the shoelace mechanism and close the fastener.

71

NERVE AGENT KIT  Indications Kits are available for known nerve agent exposure events. This kit is primarily to be used for self-rescue in a mass casualty or weapons of mass effect event. This kit should never be used as a shield to attempt rescue in a known Hot Zone. Nerve agents necessitating the use of this kit include Sarin, Soman, Tabun, Vx, and others. Consult a chemical weapons reference for more information. Precautions / Contraindications

Never enter a known Hot Zone area. Not to be used for non-nerve agent exposures (i.e. biological, or cyanide)

Procedure

Supportive Care as available and possible (IV, O2, cardiac monitor) Administer Kit or Kits per dosing guidelines particular to the brand Hazardous materials decontamination and transport for further evaluation

72

PEDIATRIC VASCULAR ACCESS AND FLUID RESUSCITATION  Procedure

Obtain vascular access– IV access is recommended as a first attempt In critical cases, and when IV access is unavailable use IO needle at the proximal

tibia Low blood pressure is a late sign of shock in children; be alert to other signs and

symptoms and treat aggressively Fluid bolus 20mL/kg for pediatrics; 10mL/kg for infants; can be implemented with

a burette or large syringe Additional boluses may be considered

73

TOURNIQUETS  Indication Uncontrolled arterial bleeding Precaution Tourniquet should only be considered as a last resort when direct pressure or pressure dressing has failed to control hemorrhage. Procedure 1. Select a site for the tourniquet. The site should be about 2 inches proximal to the

wound. 2. Apply commercial tourniquet device and tighten it until the point at which the

hemorrhage stops. 3. The time that the tourniquet was applied should either be written directly on the

tourniquet or written on a piece of tape attached to the tourniquet. 4. The site should be left uncovered so it can be monitored for recurrent hemorrhage.

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INTERFACILITY PROCEDURES 

75

BLOOD GAS / CO2 / SPO2 REFERENCE VALUES 

 

REFERENCE VALUES:

Blood Gas Values (from arterial blood draw):

Normal Range pH 7.35-7.45 PaCO2 35-45mmHg

(PaCO2 will read 1-4 mmHg higher than an ETCO2 reading) PaO2 80 - 100 mmHg(on room air) HCO3 22 - 26mEq/L

CO2/SPo2 Values (Normal Range):

 CHI/CVA All other

cases

ETCO2 30-34mmHg 34-42mmHg SpO2 95-100% 95-100%

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BLOOD PRODUCT ADMINISTRATION  Indications Patients with one of the conditions listed below may require administration of blood products including whole blood, packed red cells, fresh frozen plasma, platelets albumin or cryoprecipitate. All blood products should be typed and crossed for EMS administration.

Acute blood loss Anemia Decreased hematocrit Hypoxia (unusual cases) Decreased clotting factors Any other physician order for administration

Precautions / Contraindications Use caution with each new unit of product, and watch for transfusion reactions as noted below. Do not administer a product that has not remained in cold storage, which appears clotted, or has not remained sterile. Procedure

1. Ensure each unit of blood product has been typed and cross-matched for your patient – match blood band number on all paperwork, patient’s wrist, and each unit of product

2. Use filtered blood tubing with 0.9% NS only (No LR, No D5W) 3. Record patient’s baseline vitals including temperature prior to beginning infusion 4. Begin infusion at 1gtt every 5 seconds for the first 5 minutes 5. Reassess patient’s vitals (temp must not rise more than 2 degrees F above

baseline) 6. Adjust to the desired flow rate if no reaction is noted 7. Repeat this procedure for each new unit of product

   

Transfusion Reactions: Symptoms Timing of Onset Treatment Acute Hemolytic

Chills, back pain, spiked core temp.,N/V, oliguria, flushing, HA, dyspnea

5-15 minutes DC infusion Treat shock Epinephrine per protocol Benadryl per protocol

Anaphylactic (rare)

Severe respiratory/cardiac distress, cyanosis, hypotension, N/V, cramping

Immediate DC infusion Treat anaphylaxis per

protocol Febrile nonhemolytic

Fever, HA, cough, N/V Immediate to 12 hours

DC transfusion APAP

Allergic Urticaria

Skin rash, hives Immediate to 1 hour

DC transfusion Treat allergic reaction

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CENTRAL LINE MAINTENANCE / ACCESS  Indications ALS providers may encounter indwelling catheters in both EMS and Interfacility patients. Catheters will vary in type and use – tunneled catheters (long term use), Porta-cath (long term, subdermal ports), non-tunneled Central Lines (short term use), PICC lines (short term). ALS staff may maintain these lines, and use them for vascular access in emergencies. Follow patients pre-existing care regimen for flushing and access whenever possible. Precautions / Contraindications Use strict aseptic techniques Do not use lines if their distal termination is in an uncertain location Do not use scissors around indwelling lines Use only Huber (non-coring needles to access Porta-cath ports) Long catheters have low flow rates (not useful for fluid resuscitation) Procedure Maintenance:

1. Follow procedures for regular IV maintenance 2. Flush catheter as needed with 10-15 mL of normal saline to maintain flow (do not

use excessive force or smaller than 3 ml syringe)

Access:

1. Note patient’s type of catheter and be sure that its distal termination matches the intended use

2. Use only non-coring/Huber needles for Porta cath access 3. Observe strict aseptic technique 4. Access previously used ports/lumens (it is preferable to leave unused

ports/lumens sterile) 5. Flush with 10-15 mL of normal saline to ensure flow – do not use excessive force

or smaller than 3 mL syringe 6. Apply appropriate tubing and set flow rate

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CHEST TUBE MAINTENANCE  Indications Patients requiring interfacility transport with a chest drainage system in place. Precautions / Contraindications None when transport requires maintenance of these systems Procedure

1. Obtain report from sending facility with respect to type of chest tube, and type and rate of output – note any deviation from baseline that occurs during transport

2. Inspect system starting at the patient, working back to the collection chamber 3. Ensure that all water chambers are filled properly, and that all suction indicators

indicate negative pressure 4. Follow the F.O.C.A.L. system for assessment as noted below 5. Trouble shoot Air leaks as noted

Air leak Troubleshooting Checklist

1. Perform systematic check of all equipment ensuring all connections are taped/secure

Chest tube Water seal tubing Collection chamber Water seal chamber Wall suction/ suction tubing

2. Check chest tube patency Clamp chest tube (pinch or use padded

clamp) close to patient If water stops bubbling, the patient

has an air leak If bubbling continues the leak is in

the drainage system Systematically move clamp down the

system until bubbling goes away and the leak has been located

Repair the leak

*Note-only clamp the chest tube long enough to locate the air leak, change a drainage unit, or to change suction devices. Bubbling should only be seen during expiration.

F.O.C.A.L. – Fluctuation, Output, Color, Air leak, Levels

Fluctuation: None is bad – fluctuation indicates a patent

tube Output: Check the amount and consistency of drainage Color: Check color, be alert to empyema with cloudy,

purulent drainage Air leak: Troubleshoot and repair – see right Levels: Ensure proper water levels in chamber Ensure proper negative pressure levels 15-

25cm/H2O is routine Change out the drainage unit as needed

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FOLEY CATHETER PLACEMENT AND MAINTENANCE  Indications Patients with the inability to control their bladder due to reduced level of consciousness, sedation, patients on diuretics or other medications causing increased urine production, and patients who are unable to use a bedpan or rise to void may require insertion or maintenance of a Foley Catheter. This is a sterile procedure, and strict aseptic technique should be observed Precautions / Contraindications

Inability to observe aseptic technique Structural abnormality in the urethra or urinary tract Pelvic trauma

Procedure

Insertion:

1. Open Foley kit and create sterile field – put on sterile gloves 2. Cleanse urethral meatus 3. Insert catheter – maintain its sterility during insertion 4. Advance catheter slowly – reposition as necessary for smooth insertion 5. After urine appears in the tubing, advance the catheter another 2-2.5cm – hold

securely 6. Inflate balloon with normal saline 7. Tape in place; avoid moving patients where the Foley is not taped as

complications may arise from tugging on the inflated balloon 8. Attach drainage system and secure the drainage system tubing to the patient’s leg

– (enough slack should remain so that the penis can point upwards towards the patients belly in males)

Maintenance:

9. Maintain intact system to prevent loss of sterility 10. Observe for urine color, turbidity, odor, output quantity, and overall patient

condition 11. Avoid excess movement; Foley should always be taped in place

80

INTRA AORTIC BALLOON PUMP  Indications Intra-Aortic Balloon Counterpulsation can be implemented for a variety of indications. These include, but are not limited to cardiogenic shock (post MI), acute anterior wall MI, mechanical defects such as acute mitral regurge or papillary muscle rupture, or for perioperative care in a CCU. Precautions / Contraindications The physician that places the balloon will ensure its appropriateness for each patient. The transport team should be aware of the following potential complications:

Limb ischemia Asymptomatic vascular complication Thromboembolism Obstruction of the major arteries Compartment syndrome Arterial artery hemorrhage

Interfacility transfer

The ongoing monitoring and adjustment of the IABP device is to be carried out by a trained perfusionist

ECPS Paramedics will provide assistance with patient management as necessary. Patient care may also include the following as ordered by the physician.

o Sedation and analgesia o Mechanical ventilation o Multiple medication infusions

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MECHANICAL VENTILATOR  INDICATIONS:

Any Patient with one or more of the following:

Apnea Acute ventilatory failure Impending ventilatory failure Severe hypoxemia Respiratory muscle fatigue Pathologic or pharmacologic reduction (or impending reduction) in mental status /

respiratory drive

PRECAUTIONS / CONTRAINDICATIONS: Automated ventilation is not contraindicated when indicated, unless it contributes to instability in another physiologic system. This can be minimized through careful titration of ventilator settings.

PROCEDURE:

Ventilator Setup and Operation:

1. Assemble circuit, ventilator,, ETCo2 monitoring, and consider the use of an Heat/Moisture Exchanger (HME) to prevent dehydration in the patient’s airways. Use the Infant circuit for patients who weigh 5 kg or less.

2. Replicate the hospital ventilator settings. Titrate to physiologic goals and patient comfort.

3. The transfer crew should set the ventilator to the parameters listed below with consideration for the patient’s oxygenation, ventilation and other physiologic needs. Titrate as needed to meet clinical goals and in accordance with sending physician’s orders.

Ventilator settings:

Mode: (AC, SIMV, CPAP) Set as needed to accommodate patient’s who are overbreathing the set number of machine breaths, and to limit patient discomfort.

Cycling: Volume or Pressure and set the value that signals the end of a breath (Tidal Volume, or PIP respectively)

Pressure Support: Add as needed to assist the patient with achieving sufficient tidal volumes during patient initiated breaths in SIMV or CPAP (BiPAP) modes.

82

FiO2: 21%-100% sufficient to maintain SpO2 above 94%.

PEEP: 5-15mmHg (High levels of PEEP can improve oxygenation, but may cause hypotension in patient’s that are not adequately fluid resuscitated).

Inspiratory Time / I:E Ratio: Leave at the preset 1:2.5 unless the patient demonstrates a need for more expiratory time (i.e. small ET Tube for patient size, bronchospasm, auto-PEEP from other causes).

Ventilator Maintenance considerations: (Note the patient’s physiologic parameters, and watch for untoward changes when transitioning to the transport vent).

PIP (reflective of pPlat - see below) In cases with rising pressures, be cognizant of the need for humidification and suction to manage pulmonary secretions.

Respiratory Rate: (is the patient overbreathing the vent?)

Level of Sedation/analgesia: (It is common for the patient to require 2x hospital levels of sedation and analgesia during the increased stimulus of transport)

Paralysis: A well sedated patient with adequate oxygenation and ventilation will typically achieve good ventilator synchrony without a need for repeated paralysis. If a patient is having trouble-achieving synchrony, check that all the patient’s physiologic needs are being met.

Reference Ranges for ABGs:

Normal Range pH 7.35-7.45 PaCO2 35-45mmHg (PaCO2 will read 1-4 mmHg higher than an

ETCO2 reading) PaO2 80 - 100 mmHg (on room air) HCO3 22 - 26mEq/L

Starting Tidal Volume and Respiratory rates based on ideal body weight:

Adult (16+) Child (8-16) Child (0-8) Respiratory Rate 8-18/min. 16-28/min. 26-40/min. Tidal Volume 6-8 ml/Kg 5-7 ml/Kg 4-6 ml/Kg

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Titration Goals:

CHI/CVA All other cases ETCO2 34-38mmHg 34-44mmHg SpO2 95-100% 95-100%

Lung Protective Ventilator Strategies:

The goal plateau pressure (pPlat) is <30 cm H2O to prevent lung injury secondary to overdistension of alveoli

Without lung disease, peak inspiratory pressure (PIP) is only slightly above the plateau pressure

In cases of increased tidal volume or decreased pulmonary compliance, the PIP and pPlat rise together proportionately

If the PIP rises with no change in pPlat, increased airway resistance should be suspected or high inspiratory gas flow rates. Check for kinked circuits, condensation in the circuit or be suspicious mucous blockages in the ET tube or airways.

pPlat (compliance) + resistance to flow during inhalation = PIP. Therefore pPlat will never be higher than the PIP. Maintaining a low PIP ensures a low pPlat.

Plateau Pressures

The goal plateau pressure is <30 cm H2O to prevent lung injury secondary to over

distension of alveoli Without lung disease, peak inspiratory pressure (PIP) is only slightly above the

plateau pressure In cases of increased tidal volume or decreased pulmonary compliance, the PIP

and plateau pressure rise together proportionately If the peak pressure rises with no change in plateau pressure, increased airway

resistance should be suspected or high inspiratory gas flow rates

84

PARENTERAL NUTRITION MAINTENANCE  Indications Critically ill patients undergoing care in the intensive care unit may require parenteral nutritional support in the form of the following:

Crystalloid/dextrose solutions Multivitamins Lipid solutions Amino acid supplementation.

The exact composition should be determined by the patient’s physician with assistance of a dietician or nutritionist. Patients undergoing interfacility transfer may benefit from maintenance of this nutritional support during transfer, and written orders for maintenance will be provided by the sending physician. Precautions / Contraindications All patients should be monitored for complications with their intravenous administration set. Please refer to the Central Venous Access protocol where appropriate. In addition to technical complications with the administration, the patient can also experience the following metabolic complications, and should be monitored for such.

Hyperglycemia Rebound hypoglycemia Hyperosmolar hyperglycemic non-ketotic (HHNK) coma Protein intolerance Electrolyte imbalances Sepsis

Procedure Follow written transfer orders for each individual patient with regards to dosing and fluid composition. Make base contact for any complication that is not readily resolved, and treat acute hypoglycemia per protocol.

85

TREATMENT 

86

CARDIAC 

87

ACUTE CORONARY SYNDROME (ACS)  (Often presents with complaint of chest pain or chest discomfort; recall constellation of signs and symptoms when considering ACS) Basic

ABC / oxygen History / vitals Reassurance Position of comfort May assist patient in taking his or her own medications Aspirin

o Aspirin has tremendous clinical benefit. A full dose of aspirin should be considered in any patient where ACS is suspected as proximal to the onset of symptoms as possible. Any dosing prior to onset of symptoms is considered ineffective and additional dosing should be considered.

Advanced

IV access Nitroglycerin

o Prioritize accordingly Fentanyl is the analgesic of choice for chest pain Treat underlying dysrhythmias

Interfacility

Anticoagulants heparin Beta blockers metoprolol Glycoprotein inhibitors Integrilin Morphine Continuous infusion of nitrates nitroglycerin

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ASYSTOLE  Consider possible causes and treat accordingly: hypovolemia, hypoxia, hypothermia, OD, hyperkalemia, acidosis, cardiac tamponade, pneumothorax, PE, AMI. Basic

Chest Compression / Defibrillation sequence based on elapsed time post arrest – see table in Medical Cardiac Arrest: Chest Compression / Defibrillation Guide

BLS airway management Ventilation with BVM at 8-10 per minute with 100% oxygen. Prepare for transport; consider backboard Consider spinal immobilization if indicated

. Advanced

Advanced airway management Vascular access Epinephrine Consider Sodium Bicarbonate in prolonged arrest with advanced airway

management and adequate ventilation

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BASIC LIFE SUPPORT GUIDELINES 

Component Recommendations 

Adults  Children  Infants 

  Recognition  

Unresponsive (for all ages)  

No breathing or no normal breathing (ie, only 

gasping) No breathing or only gasping  

No pulse palpated within 10 seconds  

CPR Sequence  C‐A‐B  

Compression Rate  At least 100/min  

Compression Depth  At least 2 inches (5cm) At least 1/3 AP diameter about 2 inches (5 cm) 

At least 1/3 AP diameter about 11/2 inches (4 cm) 

Chest Wall Recoil Allow complete recoil between compressions.  Rotate compressors every 2 minutes. 

Compression Interruptions 

Minimize interruptions in chest compressions.  Attempt to limit interruptions to <10 seconds  

Airway  Head tilt‐chin lift (suspected trauma: jaw thrust) 

Compression‐to‐Ventilation (until advanced airway placed) 

30:2 1 or 2 rescuers 

30:2, Single rescuer 15:2, 2 rescuers 

Ventilations with Advanced Airway 

1 breath every 6‐8 seconds (8‐10 breaths/min).  Asynchronous with chest compressions.  About 1 second per breath.  Visible chest rise 

Defibrillation Attach and use AED as soon as available.  Minimize interruptions in chest compressions before and after shock.  Resume CPR beginning with compressions immediately after each shock. 

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BRADYCARDIA  Patients may be bradycardic for a variety of reasons; strongly consider NOT treating bradycardias unless the patient is markedly unstable—hypoperfused with altered mental status Basic

ABC / oxygen Prepare for arrest

Advanced

Vascular access Atropine Transcutaneous Cardiac Pacing (consider analgesia) Epinephrine Dopamine

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HYPERTENSION  Basic

ABC / oxygen Relax patient Carefully monitor vital signs including breath sounds Position of comfort

Advanced

Vascular access See seizure protocol if necessary For Pregnancy Induced Hypertension / Pre-eclampsia – see Complications of

Pregnancy Protocol Interfacility

Beta blockers Esmolol, Labetalol

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MEDICAL CARDIAC ARREST: CHEST COMPRESSION & DEFIBRILLATION GUIDE 

Witnessed Arrest:

Unwitnessed Arrest:

1. Initiate CPR with compression to ventilation ratio of 30:2 and a compression rate of 100 / min

2. Apply ECG monitor or AED

3. As soon as defibrillator is ready, analyze rhythm, (stop CPR for analysis).

4. Resume CPR while defibrillator is charging

5. As soon as defibrillator is charged, defibrillate once (if indicated) and immediately resume CPR

6. Resume CPR for 2 minutes (5 complete cycles of 30:2)

7. Check for pulse / responsiveness

1. Initiate CPR with compression to ventilation ratio of 30:2 and a compression rate of 100 / min

2. Apply ECG monitor or AED

3. Complete 5 full cycles of 30:2 CPR (2 minutes)

4. Analyze rhythm, (stop CPR for analysis)

5. Resume CPR while defibrillator is charging

6. As soon as defibrillator is charged, defibrillate once (if indicated) and immediately resume CPR

7. Resume CPR for 2 Minutes (5 complete cycles of 30:2)

8. Check for pulse / responsiveness

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NON‐TRAUMATIC SHOCK  Hypotension due to medical etiology not anaphylaxis. Basic

ABC / oxygen Keep patient calm Keep patient warm NPO Position of comfort, preferably supine with legs elevated

Advanced

Vascular access; consider large bore, multiple lines Fluid bolus Dopamine

Interfacility

Pressors dopamine, dobutamine, norepinephirne

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POST RESUSCITATION CARE 

ALS Considerations

Titrate oxygen to maintain SpO2 at 94% or slightly higher. Maintain CO2 between 35-45 mmHg. Advanced airway management, consider RSI Vascular Access Maintain BP of at least 90 mmHg systolic either through fluids or dopamine. Amiodarone – for post conversion from ventricular fibrillation and pulseless

ventricular tachycardia

95

PULSELESS ELECTRICAL ACTIVITY (PEA)   Consider possible causes and treat accordingly: hypovolemia, hypoxia, hypothermia, OD, hyperkalemia, acidosis, cardiac tamponade, pneumothorax, PE, AMI. Basic

Chest Compression / Defibrillation sequence based on elapsed time post arrest – see table in Medical Cardiac Arrest: Chest Compression / Defibrillation Guide

BLS airway management Ventilation with BVM at 8-10 per minute with 100% oxygen Prepare for transport; consider backboard Consider spinal immobilization if indicated

Advanced

Advanced airway management Vascular access Fluid bolus Epinephrine Consider Sodium Bicarbonate with a wide QRS complex (TCA Overdose) or in

prolonged arrest with advanced airway management and adequate ventilation

96

ST ELEVATION MI (STEMI)  This version of the Acute Coronary Syndrome Patient is the most acute and in danger of cardiac arrest, particularly the patient with multi-wall involvement and/or reciprocal changes. Follow Acute Coronary Syndrome and; Advanced

Place Quick-Combo Pads Place additional IV access sites Emergent return

Interfacility

Anticoagulants heparin Beta blockers metoprolol Glycoprotein inhibitors Integrilin Continuous infusion of nitrates nitroglycerin

97

TACHYCARDIA  Patients may be present with significant tachycardia for many reasons. Attempting to slow a compensatory tachycardia could have dire consequences for the patient. Take into account history and physical exam findings when considering treatment.

Basic

ABC / oxygen Keep patient calm Position of comfort Consider aspirin if presentation consistent with acute coronary syndrome

Advanced

Vascular access If symptomatic, consider:

Atrial Fibrillation or Atrial Flutter

SVT Wide Complex of uncertain origin

Poly/Monomorphic VT

Symptomatic but Stable

Amiodarone Vagal maneuvers Adenosine

Amiodarone

Treat as monomorphic VT if unable to verify

origin

Monomorphic -Amiodarone

Polymorphic – Magnesium

Symptomatic and Unstable

Cardioversion Cardioversion Cardioversion Cardioversion

“Unstable” is significant hypoperfusion with significant altered mental status or unconsciousness Refer to Electrical Therapy and Drug protocols for dosing Consider analgesia for cardioversion

98

VENTRICULAR FIBRILLATION AND PULSELESS 

VENTRICULAR TACHYCARDIA  Basic

Chest Compression / Defibrillation sequence based on found down or witnessed arrest – see Medical Cardiac Arrest: Chest Compression / Defibrillation Guide

BLS airway management Ventilation with BVM at 8-10 per minute with 100% oxygen Prepare for transport; consider backboard Consider spinal immobilization if indicated

Advanced

Vascular access Epinephrine Advanced airway management Amiodarone Magnesium sulfate (Torsades des Pointes) Consider Sodium Bicarbonate in prolonged arrest with advanced airway

management and adequate ventilation

 

99

ENDOCRINE 

100

HYPERGLYCEMIA  Hyperglycemia typically presents as the causative agent that provokes the patient’s complaint. Typically genersal malaise, fatigue, near syncope, syncope, altered mental status and/or unconsciousness may be the reason EMS is activated. Ranges for hyperglycemia vary, although acute, clinically significant levels tend to be greater than 250 mg/dl and accompany a corresponding patient presentation consistent with diabetic ketoacidosis / HHNK. Field glucometers may read with alpha characters instead of numerics. Typically, it may read as “hi,” and this generally indicates a level greater than 400 mg/dl. Consult equipment documentation. Basic

ABC/oxygen Treat for hypovolemic shock

Advanced

IV access (consider multiple large bore in the setting of shock) Fluid boluses Advanced airway management as appropriate

Interfacility

Insulin Sodium Bicarbonate Potassium

101

HYPOGLYCEMIA  Hypoglycemia is very often provoked by a synthetic insulin overdose in a diabetic patient who uses insulin injections or an insulin pump. These patients often respond well to field treatment. For patients who are using medications to stimulate native insulin production (e.g., glipizide, glyburide) are at risk of having a repeat hypoglycemic event and transport is strongly recommended. Non-diabetic hypoglycemia is exceedingly rare and the etiology may be difficult to ascertain in the field. Strongly recommend transport for any patient who is non-diabetic and hypoglycemic especially in cases where there is no clear cause. Hypoglycemia is defined as a blood sugar:

< 50 mg/dL in men < 45 mg/dL in women < 40 mg/dL in infants and children

Consider only treating when clinically apparent in patient’s presentation. Field glucometers may read with alpha characters instead of numerics. Typically displayed as “lo” or “low,” this generally indicates a level below the 10 - 20 mg/dl range. Consult equipment documentation. Basic

ABC / oxygen If patient conscious and hypoglycemic, give glucose paste or other carbohydrate

by mouth Advanced

IV access Dextrose Glucagon

 

102

ENVIRONMENTAL 

103

ALLERGIC REACTION  Basic

ABC / oxygen Determine nature, extent, and history of reaction

Advanced

Diphenhydramine Albuterol Solumedrol Epinephrine 1:1000 Consider Anaphylaxis protocol

104

ALTITUDE RELATED ILLNESS  This typically affects the patient who has rapidly ascended to altitude and can mimic acute coronary syndrome. If the patient refuses, stress that they should feel better with rest and rehydration. Basic

Oxygen / ABCs Advanced

IV access / fluid Antiemetics

105

ANAPHYLAXIS  Basic

ABC / oxygen Determine nature, extent, and history of reaction May assist patient in administering epi-auto injector If insect sting; remove by scraping and then apply cold pack to area Non-traumatic shock protocol if needed

Advanced

Epinephrine 1:1000 Advanced airway as indicated

o Anaphylaxis responds well to treatment; consider trial of medication prior to intubation as appropriate

Vascular access Fluid bolus as necessary Diphenhydramine Albuterol Epinephrine 1:10,000 Solumedrol

106

ELECTRICAL INJURIES  Basic

Remove source of power ABC / oxygen Burn treatment as indicated Traumatic shock protocol Treat associated injuries

Advanced

Advanced airway management as appropriate IV access With multiple patients, treat cardiac arrests first and aggressively Analgesia

107

HYPOTHERMIA, SUBMERSION, COLD INJURIES  Basic

ABC / CPR Oxygen; assist ventilations as needed Prevent further heat loss; remove wet clothing; avoid active re-warming Frostbite:

o Gently re-warm minor frostbite (Do NOT rub) o Transport frozen parts frozen o Non-adhering dressings as appropriate

Advanced

Advanced airway management as indicated o Consider early intubation in submersion injuries – this allows for early

decontamination of the tracheobronchial tree by suctioning) IV access (warmed fluid if possible) Dextrose as indicated Naloxone as indicated Analgesia as indicated Consider single round of ACLS medications / defibrillation

108

HYPERTHERMIA  Basic

ABC / oxygen Remove patient from heat source Cool with water soaked sheets—maintain good airflow around patient Be prepared for more serious signs and symptoms

Advanced

IV access Fluid bolus Treat seizures

 

109

GASTROINTESTINAL 

110

ABDOMINAL PAIN  Basic

Oxygen Position of comfort Orthostatic vital signs Nothing by mouth Non-traumatic shock protocol if indicated

Advanced

IV access Treat for hypotension / shock if occult bleeding is suspected Analgesia Antiemetics

111

GASTROINTESTINAL BLEEDING  Basic

Oxygen/ABCs Advanced

IV Access Antiemetics Fluid bolus as necessary

Interfacility

Octreotide Protonix

112

NAUSEA / VOMITING  Basic

ABC / oxygen Nothing by mouth Consider underlying causes Non-traumatic shock protocol if indicated

Advanced

IV access—fluids as needed Zofran / Zofran ODT Consider Acute Coronary Syndrome

Interfacility

Phenergan

113

NEUROLOGIC 

114

CVA / TIA  Basic

ABC / oxygen o Aggressively manage airway and secretions

Semi sitting or left lateral recumbent position if possible Consider hypoglycemia Hypertension protocol as indicated

Advanced

Neurologic exam including Cincinnati Prehospital Stroke Scale (see below) Advanced airway management as needed Vascular access Consider RSI

Interfacility

Paralytics vecuronium, rocuronium Sedation / sedative infusion midazolam, lorazapam, propofol Seizure prophylaxis phenytoin / fosphenytoin, Keppra Calcium channel blockers nicardapine Beta blockers labetalol, emsolol

Cincinnati Prehospital Stroke Scale* Facial Droop – (Patient

smiles or shows teeth) Pronator Drift – (with eyes closed, patient holds arms extended for 10 seconds)

Speech – (patient repeats a sentence)

Normal Symmetrical expressions

Both arms move equally, or do not move at all

Uses correct word / no slurring

Abnormal One side of face does not move well

One arm does not move, or drifts down lower than the other

Unable to speak, wrong words, or slurs words

*Interpretation - If any 1 of these 3 findings is abnormal – probability of Stroke is > 70%.

115

HEADACHE / MIGRAINE  Basic

ABC / oxygen Limit loud noises and bright lights

Advanced

IV access Treat nausea / vomiting Analgesia Consider CVA pathology

116

SEIZURE  Basic

Protect and maintain airway—nasopharyngeal airways are preferred Oxygen If patient actively seizing, protect patient from further injury Do not force anything between teeth including suction catheters and oral airways If suction is necessary place catheter between cheek and teeth Spinal immobilization if indicated Left lateral recumbent position Consider hypoglycemia

Advanced

Consider advanced airway where appropriate o Patients usually respond well to interventions; consider trial of medication

before intubation IV access Lorazepam / diazepam Midazolam if no IV access available In eclampsia, - refer to Complications of Pregnancy Protocol

Interfacility

Sedation / sedative infusion midazolam, lorazapam, propofol Seizure prophylaxis phenytoin / fosphenytoin / Keppra

117

SYNCOPE  Carefully consider possible causes and treat accordingly. Some patients will have clonus or limited muscle contraction when they syncope and bystanders will report seizure. Be sure to consider syncope with any reported loss of consciousness. Basic

ABC / oxygen Position of comfort Evaluate for associated injuries and treat accordingly

Advanced

IV access Address underlying cause Consider cardiac monitoring in patients of any age

118

OBSTETRICS/GYNECOLOGY 

119

COMPLICATIONS OF PREGNANCY  Basic

ABC / oxygen Assess history – including course of prenatal care, and known complications. Position patient for comfort, avoid supine positioning Treat for shock as needed

Advanced

Vascular access Fluid bolus as needed Treat specific conditions as noted below Contact medical control for guidance in unusual cases

Condition: Etiology Signs and Symptoms Treatment Abruptio Placenta Separation of placenta

from the uterine wall. Usually occurs at >20 weeks gestation

Dark red vaginal bleeding (occult?)

Abdominal pain Hypotension Tachycardia Fetal distress Increased fundal height Other signs of shock

IV fluids O2 Treat for shock Rapid transport Prepare for emergency C-section

Placentia Previa Placenta covers cervical os, can occur during the 2nd and 3rd trimester

Painless bright red bleeding

Hypotension? Tachycardia?

O2 IV fluids Bed rest Rapid transport for heavy blood

loss PIH, Preeclampsia, Eclampsia

Complicated etiology involving the endocrine, renal and hepatic systems

HTN Proteinuria Peripheral edema Weight gain Oliguria Visual disturbances Increased liver

enzymes Hyper-reflexia Seizures Fetal stress

O2 IV access Treat seizures with Magnesium Magnesium as ordered Limit loud noises / bright lights

Preterm Labor / Premature Rupture of Membranes

Various etiologies including hormonal, trauma, and infection

Onset of contractions between 20 and 37 weeks gestation

O2 IV fluids Fluid bolus as ordered Tocolytics as ordered Treat for infection as needed

120

DELIVERY COMPLICATIONS  Basic

Oxygen

Breech Delivery:

Apply gentle abdominal or suprapubic pressure as needed to assist head in delivering

Pull gently on infants torso during each contraction Move torso up and then down to deliver shoulders in sequence If baby still won’t deliver – contact medical control for assistance and initiate rapid

transport

Cord Presentation:

Place the Mother on a Trendelenburg pram in the knee-to-chest position Hold pressure on infant’s head to remove pressure from the cord Keep cord moist with saline dressing Rapid transport – early ED notification

Limb Presentation:

Support presenting part Place mother in a Trendelenburg / knee-to-chest position Rapid transport – early ED notification

Cord around neck:

Unwrap cord or clamp and cut and deliver normally

Advanced

Vascular access Magnesium Sulfate

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FIELD LABOR AND DELIVERY  Basic / Advanced

1. Determine history – including the following: Patient age Prenatal care Gravida/para Estimated delivery date Timing of onset and rate of contraction Rupture of Membranes (ROM) ETOH/drug use Past medical history

2. Assess patien Vitals Amniotic fluid Crowning Abnormal presentation

3. Make a transport decision based on history and assessment 4. If delivery is imminent – prepare for field delivery 5. Use Labor and Delivery Kit as needed 6. Assist with delivery of the head (normal delivery will be vertex with the occiput

anterior) 7. Suction mouth and then nose 8. Deep tracheal suctioning of meconium if indicated 9. Deliver body 10. Keep infant level with the mother’s perineum 11. Clamp the cord in 2 places 8-10 inches from the infant, and cut cord between

clamps 12. Assess APGAR scores at 1 and 5 minutes – see table 13. Dry and warm the infant 14. Neonatal Resuscitation as needed 15. Do not delay transport for delivery of the placenta 16. Assess and treat mother for shock if excessive post partum bleeding develops

Massage fundus Oxygen IV fluids Have mother nurse infant to stimulate pitocin release – contracts uterus

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NEONATAL RESUSCITATION  Basic

Suction airway thoroughly before assisting ventilation Dry infant to provide stimulation and to keep warm Check respiratory rate:

Actively crying; no action Tactile stimulation, assist ventilations if needed

Check heart rate: >100; no action 60-100; ventilate with 100% oxygen via BVM <60; chest compressions and ventilation

Check color: Normal or peripheral cyanosis; dry and keep warm Central cyanosis; oxygen high concentration and assist ventilations if

needed Minimize heat loss with foil and/or blanket; cover head

Advanced

Endotracheal suctioning if meconium present Advanced airway management if needed Vascular access Epinephrine Naloxone Dextrose Fluid bolus (10ml/kg NS over 5-10 minutes by IV push.)

Pediatric Dosages (Use Broselow Tape for calculation):

Defibrillation - settings are initially 2j/kg followed by 4j/kg for subsequent shocks. Epinephrine - 0.01mg/Kg IV/IO of 1:10,000 or 0.1mg/kg ET of 1:1,000 q3-5 minutes. Fluid Bolus - Give 10ml/kg.

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TRAUMA IN PREGNANCY  Even the most minor mechanism in a pregnant patient can provoke catastrophic consequences. All pregnant trauma patients should be transported. Basic

Oxygen o Less than 20 weeks gestation consider nasal cannula o More than 20 weeks gestation use high flow by non-rebreather

Advanced

IV access o Greater than 20 weeks gestation administer fluid bolus

Analgesia If greater than 20 weeks gestation, call trauma alert

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PEDIATRICS 

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PEDIATRIC BRADYCARDIA  Basic

Oxygen Perform chest compressions if despite oxygenation and ventilation HR<60 BPM

with poor perfusion. In children, bradycardia almost always reflects hypoxia rather than a primary

cardiac problem. Oxygen and ventilation is the primary treatment for bradycardia. Other possible causes include drug overdose, vagal stimulation from a medical procedure, and congenital heart block.

Advanced

Vascular access IV fluids Epinephrine Consider transcutaneous pacing for hemodynamically unstable bradycardia

secondary to complete heart block Prepare for cardiac arrest

Special Notes

Age Heart Rate (BPM)

Newborn to 3 months 85– 205

3 months to 2 years 100– 190

2 to 10 years 60-140

> 10 years 60– 100

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PEDIATRIC CARDIAC ARREST  Basic

Initiate CPR with chest compressions Begin with 30 compression to 2 breaths for lone rescuer; 15:2 for two AED for patients over 10 kg or 1 year of age Remember that cardiac arrest in children is usually respiratory in origin

Advanced

Follow PALS guidelines Advanced airway management Continuous ETCO2 critical for monitoring tube placement Supraglottic only for patients taller than 4 feet Asynchronous ventilation/compression with advanced airway—ventilations at one

every 3-5 seconds, and compressions at 100/minute

Rhythm Based Treatment as follows:

VF or pulseless VT: Asystole/PEA:

1. Defibrillate – Consider completing 2 full minutes of CPR prior to defibrillation for unwitnessed arrest

2. CPR

3. Obtain vascular access

4. Secure Airway

5. Epinephrine every 3-5 minutes

6. Repeat defibrillation

7. Amiodarone

8. Repeat defibrillation

9. Consider Sodium Bicarbonate

1. CPR

2. Obtain vascular access

3. Secure airway

4. Epinephrine every 3 – 5 minutes

5. Consider Sodium Bicarbonate

Refer to the Broselow tape when determining patient weight and calculating weight-based therapies.

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PEDIATRIC FEVER AND FEBRILE SEIZURES  For other causes use medical seizure protocol Basic

ABC / oxygen Protect from further injury Remove blankets and undress to help cool patient

Advanced

Advanced airway control if indicated IV access if indicated If actively seizing: Midazolam or Lorazepram as appropriate Consider dextrose Acetaminophen

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PEDIATRIC RESPIRATORY DISTRESS  Basic

Position of comfort Oxygen, high concentration Suspect foreign body obstruction or anaphylaxis If croupy cough or epiglottitis is suspected:

o Do not attempt any maneuver that could increase the chances of laryngospasm including examination of oropharynx

Assist ventilations as needed Cool air may be of some benefit Be alert for fatigue followed by respiratory arrest

Advanced

Advanced airway as indicated Albuterol Cases of croup with severe respiratory distress; Racemic Epinephrine IV access IM Epinephrine

Croup vs. Epiglottitis vs. RSV

Croup Epiglottitis RSV/Bronchiolitis Age <3 Years 2-6 Years <2 Years Sex Male > Female Male = Female Male = Female Onset Gradual (at night) Rapid Gradual Infection Viral Bacterial (HI-B) Viral Fever Low Grade High Grade Low Grade Breathing Retractions Tripod position Apnea or Tachypnea Sounds Barking Cough Inspiratory stridor Staccato Cough, Rales, WheezingVoice Hoarseness Muffled N/A Occurrence Common Rare Common Other S/Sx Drooling / painful swallowing Hypoxemia

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PEDIATRIC TACHYCARDIA  Basic

ABC / oxygen Keep patient calm Position of comfort

Advanced

Vascular access Treat Rhythm in hemodynamically unstable patients

PROBABLE SINUS

TACHYCARDIA: SUGGESTIVE OF SVT: SUGGESTIVE OF

VENTRICULAR

TACHYCARDIA: QRS is 0.08 and rate is < 220 in infants or < 180 in children:

QRS is 0.08 and rate is > 220 in infants , or >180 in children:

QRS is >0.08

1. Support ABCs 2. Treat cause (i.e. dehydration,

fever, fear, pain, etc.)

1. Adenosine 2. Cardioversion

1. Amiodarone 2. Cardioversion

*Tachycardia may be well tolerated. Consider electrical therapy first in severely symptomatic patients.

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PSYCHIATRIC / BEHAVIORAL 

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ANXIETY / HYPERVENTILATION  Basic

Remove patient from any escalating stimuli; reduce the audience to a minimum Consider oxygen Verbally calm the patient and coach respiratory rate as needed

Advanced

IV access Sedation

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DEPRESSION/MANIA/SCHIZOPHRENIA AND ATTEMPTED 

SUICIDE  Basic

Utilize law enforcement personnel to ensure safe scene Make all reasonable attempts to preserve crime scenes and evidence Calm the patient verbally as needed Physical restraint Oxygen as needed Treat any self-inflicted trauma per trauma protocols

Advanced

Consent for transport may be implied if the patient lacks decision making capacity from acute or chronic condition

IV access Treat poisonings / overdoses ACLS / resuscitation as indicated Chemical restraint

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RESPIRATORY 

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RESPIRATORY DISTRESS ‐ BRONCHOSPASM FROM ACUTE 

ASTHMA  Basic

ABC Oxygen as appropriate Severe respiratory distress should receive 100% oxygen by non-rebreather Assist ventilations as needed Suspect foreign body obstruction Position of comfort May assist patient in taking his or her own medications

Advanced

Albuterol Atrovent cPAP Advanced airway procedures as necessary IV access Epinephrine 1:1000 Magnesium sulfate Epinephrine 1:10,000 (cases with imminent cardiovascular collapse)

Interfacility

Levalbuterol

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RESPIRATORY DISTRESS ‐ BRONCHOSPASM FROM COPD  Basic

ABC Oxygen as appropriate Severe respiratory distress should receive 100% oxygen by non-rebreather Assist ventilations as needed Suspect foreign body obstruction Position of comfort May assist patient in taking his or her own medications

Advanced

Albuterol Atrovent cPAP Advanced airway procedures as necessary IV access Magnesium sulfate Methylprednisolone

Interfacility

Levalbuterol

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RESPIRATORY DISTRESS ‐ PULMONARY EDEMA  Basic

ABC / oxygen as necessary Assist ventilations as needed Position of comfort, usually sitting upright

Advanced

cPAP Advanced airway procedures as needed IV access Fluid administration should be carefully considered and monitored closely Nitroglycerin

Interfacility

Nitroglycerin infusion Furosemide

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TOXICOLOGY 

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ALCOHOL WITHDRAWAL

Patients that have tremors associated with alcohol withdrawal and delirium tremens (mental confusion, constant tremors, fever, dehydration, tachycardia, and/or hallucinations) are at high risk and should be monitored appropriately and transported.

Basic

Oxygen

Advanced

Benzodiazapines

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CARBON MONOXIDE 

Basic

Oxygen – high flow with non-rebreather Advanced

Airway management as needed. IV access

0-5% Considered normal in non-smokers. When >3% with symptoms, consider high flow oxygen and evaluate environment for CO sources. Consider measuring others in same room/office/vehicle as the patient. In absence of symptoms, no further medical evaluation of SpCO is needed.

5-10% Considered normal in smokers, abnormal in non-smokers. If symptoms are present, consider high flow oxygen and inquire if others are ill. Alert fire department.

10-15% Abnormal in any patient. Assess for symptoms, consider high flow oxygen, Evaluate environment for CO sources.

>15% Significantly abnormal in any patient. Administer high flow oxygen, assess for symptoms, transport. Evaluate environment for CO sources and for other patients.

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POISONINGS / OVERDOSE 

Basic

Oxygen / ABCs Bring the poison, the container, all medications, and anything questionable in the

area to the emergency department

Advanced

Anticipate respiratory arrest, seizure activity, dysrhythmias, and/or vomiting. Consider RSI Address reversibly etiologies Consider nasogastric tube if <1 hour post ingestion. Administer antidotes in accordance with following general guidelines

Toxin Treatment

Narcotic Narcan

Calcium Channel Blocker / Beta blocker

Calcium Chloride - treat the symptoms of hypotension and bradycardia first with fluids and consider pacing in pediatrics.

Cyanide Hydroxocobalamin (Cyanokit) - if the patient presents with altered mental status and a history consistent with cyanide poisoning. This should be considered for fire fighters with altered mental status during fire rehabilitation.

Tricyclic Antidepressant

Sodium Bicarbonate - if patient presents with tachycardia, hypotension, and/or wide QRS.

Organophosphate Atropine

ROCKY MOUNTAIN POISON CONTROL

800-222-1222

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TRAUMA 

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AMPUTATIONS  Basic

ABC Control bleeding Oxygen Traumatic shock protocol Cover stump with sterile dressing Wrap severed part in sterile, saline soaked dressing and keep cool—do not soak

in fluid or freeze Splint partial amputations in alignment to facilitate blood flow Early notification of ALS units and emergency department Prepare for rapid transport

Advanced

Analgesia IV access

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BLUNT TRAUMA  Patients who have been subjected to blunt force to the head, chest or thorax are at risk for significant injury. Patients at further risk tend to also complaint of pain to the head, chest or abdomen. (See head trauma protocol) Patients at moderate risk also complain of tenderness to palpation in the area of injury and tend to have physical exam findings consistent with blunt trauma. Further, any patient also taking Beta Blocker medications and / or who are aged 65 or older are also at moderate risk. Consider that skier-vs.-skier and skier-vs-fixed object collisions also put the patient at moderate risk. Patients at high risk have all the above including signs of hypoperfusion, or any patient who has a history of blunt trauma and also taking blood thinning medications such as Coumadin/Warfarin, Plavix and Pradaxa are high risk. Basic

ABC / oxygen Spinals as needed Splint injuries as needed Traumatic shock protocol

Advanced

Vascular access—consider multiple, large-bore lines Chest decompression as needed (seldom indicated in non-cardiac arrest blunt

trauma) Airway control as needed Analgesia

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BURNS  Basic

STOP THE BURNING PROCESS! Aggressive airway management Oxygen Remove clothing and jewelry unless adhering to patient Treat associated injuries Traumatic shock protocol If greater than 10% body surface area burned, cover with dry, sterile burn sheet Cover smaller burns with moist, sterile, non-adhering dressings. USE EXTREME CAUTION WITH WATER/SALINE IN CHEMICAL BURNS!

Advanced

Advanced airway control Consider RSI early with respiratory burns Vascular access Analgesia Sedation

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C‐SPINE CLEARANCE  Indications Instances when a patient has been put into spinals prior to ALS arrival. Ultimately, this procedure should be used only when it is apparent that spinals were unnecessarily placed, so the criteria is more stringent than that of Selective C-Spine Criteria Advanced

No head or neck complaints The patient meets the Selective Spinal protocol

C-Spine Clearance

No head or neck complaints No mid-line, c-spine tenderness or deformity Reliable physical exam where

o No distracting injury o No distracting situation / events o No language barrier o Not affected by drugs or alcohol o Not elderly (when in doubt, age > 65)

No distal paresis; parathesia or neuro deficit or history of same that has resolved

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EYE INJURIES  Basic

Remove contacts unless lacerated or dislocated globe Immediate continuous irrigation if globe intact Do not attempt to remove foreign objects Avoid inadvertent pressure on globe Protect dislocated globe with rigid cup or splint, keep moist and patch opposite

eye Advanced

Alcaine o Patient must consent to transport prior to application

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HEAD INJURY  Patients at risk have history of head trauma and one of the following in isolation:

Unhelmeted Questionable loss of consciousness History of disorientation that has resolved Any signs or symptoms of head injury that have resolved Isolated head complaints Alcohol intoxication

Patients at moderate risk present with any of the following:

Any two or more items from the at-risk list Any item from the at-risk list and significant trauma to another system Resolved loss of consciousness Skier vs. skier collision Skier vs. any fixed object collision Complaints of nausea Vomiting Perseverating Persistently disoriented to person, place, time or event Peri- or post-event memory loss Resistive to evaluation or treatment Previous head injury requiring hospital admission History of or suspected existing coagulopathy Age 65 or older

Patients at high risk present with any of the following:

Any two or more items from the moderate-risk list Takes blood thinners (Coumadin/warfarin; Plavix; Pradaxa) Battle’s sign or other signs of skull fracture Seizure Unconscious Combative

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HEAD INJURY (TREATMENT)  Basic

ABC / oxygen Consider spinals

Advanced

Advanced airway management IV access Analgesia Anti-emetic Sedation / chemical restraint Treat seizures Consider RSI

Interfacility

Sedation / sedative infusion midazolam, lorazapam, propofol Seizure prophylaxis phenytoin / fosphenytoin, Keppra Mannitol Paralytics vecuronium, in the intubated patient

o Use judiciously – often the orders are written for PRN use o Consider that paralytics may mask seizure activity Seizures can deplete oxygen and glucose and should be treated

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ISOLATED ORTHOPEDIC TRAUMA  Basic

ABC Bleeding control and dressings Splint (assess distal neurovascular function before and after) Reduction of fractures and dislocations may be necessary for impaired circulation

or other special situations Ice Nothing by mouth Traumatic shock protocol

Advanced

Analgesia IV access Sedation with ETCO2

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PENETRATING TRAUMA  Basic

ABC / oxygen Control bleeding; three sided occlusive dressings in chest trauma, treat

eviscerations with saline soaked, bulky dressings, immobilize impaled objects, direct pressure.

Prepare for rapid transport Early notification of ALS units and Emergency Department. Traumatic shock protocol

Advanced

Chest decompression as indicated Airway management as needed Vascular access Analgesia

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SELECTIVE C‐SPINE PROCEDURE  Basic / Advanced Spinals shall be considered when the patient presents with:

Visible trauma above the clavicles; and / or History of head trauma; and / or Mechanism consistent with high energy transfer; and / or Patient complaint of paralysis, parasthesia or other neuro deficit

Patients who do not meet spinal criteria:

No mid-line, c-spine tenderness or deformity Reliable physical exam where

o No distracting injury o No distracting situation o No language barrier o Not affected by drugs or alcohol o Not elderly

No distal paresis; parathesia or neuro deficit or history of same that has resolved

Patients who meet the following Selective C-Spine Criteria need not be put in Spinals

No mid-line, c-spine tenderness or deformity Reliable physical exam where

o No distracting injury o No distracting situation / event o No language barrier o Not affected by drugs or alcohol o Not elderly (when in doubt, age > 65)

No distal paresis; parathesia or neuro deficit or history of same that has resolved

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SPINAL TRAUMA  The entire concept of pre-hospital intervention of trauma patients in regard to c-spine injuries has been reevaluated and continues to face closer scrutiny. Some experts in this area have concluded that permanent spinal cord damage occurs at the time of injury and there is little providers can do to worsen the condition. Further, there is overwhelming data to conclude that pre-hospital immobilization can precipitate other complications. When considering spinal immobilization, keep in mind the following: Scene management and triage take priority over interventions Ambulatory patients may still have a c-spine injury, however they are far less likely than the patient who cannot ambulate – prioritize your assessment and treatment accordingly Spinals is not a benign procedure; it should be applied judiciously and appropriately Minimum requirement for spinals is a cervical collar Basic

ABC / oxygen Be alert to other injuries Prepare for neurogenic shock - treat hypotension accordingly Identify and mark level of sensitivity

Advanced

Advanced airway as needed IV access Analgesia Sedation Dopamine in the presence of shock

Interfacility

Corticosteroids methylprednisolone

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TRAUMA ARREST  Basic

Prioritize accordingly in the presence of multiple patients ABC / oxygen Spinal immobilization as needed Prepare for rapid transport Splint chest and pelvic injuries as needed Traumatic shock protocol

Advanced

Bilateral chest decompression Advanced airway Vascular access, consider multiple, large-bore lines Fluid replacement

Research in this area indicates that patients who are found pulseless and apneic in the field from blunt trauma are not resuscitatable. In the presence of multiple patients, a blunt trauma arrest should be pronounced. Penetrating trauma to the neck, chest or thorax resulting in arrest has some chance at resuscitation although survival percentages are very small. The focus when attempting resuscitation or in preventing a critically injured patient from arresting is airway management / treatment of tension pneumo, hemorrhage control, vascular access, fluid replacement and short scene time.

154

TRAUMATIC SHOCK  While rapid transport is desired, do not sacrifice airway management or stabilization of the critical patient for short scene time – the expectation is that transport should be within 15 minutes of patient contact unless extenuating circumstances prevent it (E.g., prolonged extrication, multiple patients, et cetera.) Basic

ABC Oxygen, high concentration / assist ventilations as needed. Immobilize if indicated Control external bleeding Consider and treat causes Keep patient calm and warm Early notification of ALS units and emergency department Nothing by mouth Elevation of lower extremities if not contraindicated Report any episode of hypotension

Advanced

Advanced airway Vascular access—consider multiple, large bore with blood tubing Fluids to BP > 90mmHg (pediatrics: See Pediatric Fluid Resuscitation Protocol.) Consider analgesia as appropriate

Interfacility

Blood products

In rare cases, pressors may be considered dopamine, dobutamine, norepinephrine

155

COMMUNITY PARAMEDIC 

   

156

ADMINISTRATIVE PROTOCOLS   

157

EAGLE CARE CLINIC REFERRALS  Policy The Community Paramedic (CP) will respond to a residence on order from the Eagle Care primary care provider requesting a community paramedic to follow up to a recent clinic visit Purpose To assist the Eagle Care primary care provider with an automatic referral process to ensure the patients receive proper follow up care. Procedure

Referrals will be sent to the CP office via fax or email These referrals will be automatic upon the completion of a clinic visit for pediatric

patients 0 – 12 years of age who meet the following diagnosis criteria: o Pneumonia o RSV o Flu o UTI o Asthma o Fever (with the discretion of the provider)

If while on scene the CP discovers anything that is alarming such as but not

limited to, abnormal V/S, worsening condition of the patient that was mentioned in the patient’s last visit notes or any acute illness, the CP will contact Eagle Care while still on scene and report these findings to the provider or the clinic nurse.

158

EAGLE COUNTY HEALTH AND HUMAN SERVICES 

REFERRALS 

Policy The Community Paramedic (CP) program will accept requests from Eagle County Heath and Human Services (HHS) Adult and Child Protection caseworkers to assist them on a visit where they believe there is either a known or potentially unmet medical need in the home. In addition, the CP will work with HHS caseworkers to support the Bright-Beginnings and Postpartum home visit programs. Purpose To outline two separate types of visits, medical and non-medical. Both visits will use the same referral/order form and the type of visit will be indicated accordingly.

Adult and Child Protection referrals/orders are considered medical referrals and must be signed by the county medical officer. All of these visits will receive a medical examination by the CP.

Bright Beginnings and Post-Partum home visits are non-medical, do not need the

signature of a medical provider and will not receive a medical evaluation. If the caseworker feels that these parties might have an unmet medical need, they need to pass the case to an Adult or Child Protection caseworker and make sure that the referral has the signature of the medical provider.

Procedure Adult and Child Protection Referrals/Orders

1. The caseworker will fax a copy of the ECPS Community Paramedic referral/order form to the CP office as soon as the need is identified to the requested visit. If an urgent visit is needed during business hours, the caseworker will contact the CP directly.

2. The referral/order form must have the signature of the County Medical Officer. 3. The referral/order must also include the contact information of the caseworker,

and if known the identified Primary Care Physician (PCP). 4. The CP office will then contact the caseworker and schedule the visit. 5. If there is an emergent medical needs found upon arrival, the CP will follow the

chain of command protocol to get the patient additional medical attention. 6. Subsequent follow up will be coordinated through the patient’s caseworker and

treating medical provider.

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EAGLE COUNTY HEALTH AND HUMAN SERVICES REFERRALS 

CONTINUED 

Bright Beginnings and Post-Partum Visits

1. The caseworker will fax a copy of the referral form to the CP office one week prior to the requested visit.

2. The CP office will then contact the caseworker and schedule the visit. 3. The CP will visit the home and make sure the client is receiving all the necessary

resources to adequately provide for them and their children. 4. Following the visit, the CP will fax a copy of the report to the caseworker within 72

hours of the visit. 5. No report will be faxed to any medical provider because is not a medical visit. 6. If medical needs are identified, the CP will contact the caseworker to obtain an

order from the County Medical Officer to perform a more detailed medical exam.

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HOME VISITATION  Policy The Community Paramedic (CP) will provide home visits for patients in response to a medical provider’s order. Purpose

To outline the standardized procedure of all home visits performed by the CP. To describe the difference between initial and repeat visits for the same diagnosis. To describe the difference between medical and non-medical/educational visits.

Procedure Medical Visits

1. Medical provider referrals will be sent to the CP office via fax or email 2. The referral form (depending on which system is used) will include the patient’s

name, DOB, contact information, diagnosis, reason for visit and medical provider’s signature.

3. The CP will access the patient’s H&P, visit notes, lab results, and list of current medications through the hospital’s electronic medical record system, if available. If not, the CP will request a copy of the patient’s record from the medical provider.

4. The CP coordinator will schedule the CP visit with the patient. 5. CP will arrive at the patient’s home in an ECPS marked vehicle that is NOT an

ambulance. 6. The CP will arrive at the visit wearing an official agency uniform and wearing an

ID badge. 7. Upon arrival the CP will have the patient fill out the initial consents and program

paperwork. 8. In addition to what is ordered by the medical provider, per protocol, each initial CP

visit will receive a complete H&P including V/S and will provide the following as needed:

Home safety assessment PEAT scale Social assessment

9. Repeat visits for the same diagnosis will cover what the medical provider orders. The CP will add more services if indicated upon arrival to the patient’s home and after the initial assessment is completed.

10. Schedule any follow up visit that are necessary. 11. Upon completion of the visit the CP will document the visit notes in the ECPS

electronic patient care record.

12. After completing the visit the CP will send a copy of the patient’s care summary to the medical provider within 24 hours. This will include the patient’s care report

161

written in SOAP format and any additional services provided by the CP, such as the home safety assessment.

Non-Medical / Educational Visits

1. The CP will follow the same procedure as medical visits but without a physical exam or medical services provided

2. Non-Medical / Education visits do not require a medical provider order. The order can come from caseworkers, social workers, school health assistants, etc.

3. The CP visit will cover what services are ordered. If more services are indicated upon arrival, the CP will contact the ordering provider to obtain additional orders.

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MEDICAL DIRECTION / CHAIN OF COMMAND  Policy All Community Paramedics (CP) work in full capacity within their current scope of practice under the medical directors’ license for ECPS and more specifically the CP Program. Purpose

The Community Paramedic will follow medical provider orders and administering care within the current scope of practice for Colorado (6 CCR 1015-3-Chapter 2).

The CP report directly through spoken or written dialogue with the patient’s referring and primary physician(s).

Procedure If additional medical needs are identified during a CP visit, the following will occur based on the urgency of care needed:

1. If an emergent medical need is found upon arrival, the CP will call 911 to request an ambulance for immediate transport.

2. If there are any medical needs that do not require immediate transport to a hospital, however, the CP feels the patient should be seen urgently in a medical provider’s office, the CP will:

First attempt to contact the patient’s referring/primary medical provider. Second attempt will be to contact the ordering medical provider’s on-call

doctor. If working with Eagle County HHS, the CP will attempt to contact the

County Medical Officers’ office. Third attempt will be to contact the ECPS’s Medical Director Fourth attempt will contact the online Medical Control. If unsuccessful, the CP will attempt to make arrangements with the patient

to have them transported to an Urgent Care Center. 3. The CP will not accompany the patient in the ambulance unless the responding

crew requests their assistance.

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MEDICAL EQUIPMENT  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting a community paramedic to inspect and ensure proper usage of home medical equipment. Purpose To assist the medical provider and patient in ensuring efficacy of home medical equipment. This will be done through knowledge of patient history, educating the patient to proper usage, inspection of equipment, assistance in troubleshooting and contacting appropriate resources. Procedure

1. Obtain and review patient history and medical provider orders prior to appointment.

2. Follow medical provider orders. 3. Inspect equipment 4. Review usage with the patient 5. Troubleshoot if necessary 6. Communicate with medical provider’s office 7. Contact medical supply company and provide follow up resources for patient to

contact if needed. 8. Document the visit and notify the medical provider’s office. 9. Refer patient to PT or OT as needed through PCP

 

164

MEDICAL PROTOCOLS   

165

ASTHMA MANAGEMENT  Policy The Community Paramedic will respond to a residence on request from the medical provider or patient/parent of patient and follow guidelines outlined by the medical providers’ orders for the management of asthma. Purpose To assist the patient (family/caregiver) by increasing awareness of the disease through education on pathology. To demonstrate and review technique of all devices used to treat asthma. To evaluate and identify home triggers of disease in an effort to lesson exacerbations. To communicate with the medical provider on the general well being of the patient as well as continuing medication reconciliation. Procedure

1. Obtain and review patient health history and medical provider’s orders prior to appointment.

2. Follow medical provider’s orders. 3. Educate patient in use of inspirometer. 4. Review pathophysiology with the patient 5. Record current patient history including frequency of symptoms at rest, activity

and with sleep. Further history will include exacerbating factors including virus exposure, aeroallergen exposure, exercise, cold air, tobacco smoke, chemical irritants etc.

6. Observe home in an effort to possibly identify exacerbating factors. 7. Review devices used by the patient including short/long acting medications and

MDI/continuous neb devices. 8. Review when to call health care provider. 9. Communicate all updated information to the medical provider.

 

166

CPAP/BIPAP/SLEEP APNEA/OXYGEN SAT CHECKS  Policy The Community Paramedic will respond to a residence on request from the medical provider and/or patient and follow guidelines outlined by the medical provider’s orders for follow up on recently diagnosed and discharged or chronic sufferers of sleep apnea. Purpose To assist the medical provider in observing and documenting recently diagnosed/chronic sufferers of obstructive sleep apnea through written and /or verbal communication to ensure proper ventilation of the Patient during sleep for the purpose of avoidance of long term OSA pathologic outcomes. Procedure

1. Obtain and review patient’s health history and medical provider’s orders prior to appointment.

2. Follow medical provider’s orders. 3. Patient must be closely observed for hemodynamic instability the first 8 hours

after starting CPAP/BiPAP 4. Conduct assessment

Necessary VS assessments including PO2 and ETCO2 and weight/BMI? Sleep habits (work nights? Irregular work schedule) Alcohol/recreational drug use? Prescription drug use? Compliant?

5. Quality of life - Noticeable changes after usage. 6. Communicate with medical providers’ office. 7. Troubleshoot if necessary including ensuring proper fit of mask and use of

machine as well as general condition of machine. 8. Connect patient with necessary resources (Oxygen supply company, etc.) 9. Document the visit and notify medical provider’s office.

 

167

DIABETIC EDUCATION  Policy The Community Paramedic will respond to a residence on request from the medical provider or patient and follow guidelines outlined by the medical providers’ orders to assist in wellbeing checks for the diabetic patient. Purpose To ensure the proper maintenance of blood sugar and insulin levels in the diabetic. This will be accomplished through blood glucose monitoring, appropriate prescription drug usage, recognition of desired drug effects, and further education/resources Procedure

1. Obtain and review patient’s health history and medical providers orders prior to appointment.

2. Follow medical provider’s orders. 3. Review history and physical exam 4. Review pathology with patient including signs and symptoms of disorder and

corrective actions. 5. Receive medical providers’ orders including plan for diet, blood glucose levels,

and insulin administration. 6. Observe patient’s physical state/general wellbeing. 7. Obtain BGL and compare with home glucometer. 8. Note directions for insulin administration and record compliance. 9. Note diet. 10. Note and record patients concerns about treatment (insulin levels, blood sugar

levels). Communicate with doctor about request for prescription change. 11. Document the visit and notify medical provider’s office. 12. Determine if follow up needed with medical provider and/or community paramedic.

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FOLLOW UP / POST DISCHARGE  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders for proper follow-up from a medical provider, ER visit, and/or a hospital post discharge. Purpose To assist the medical provider in observing and documenting the patients post discharge healing and/or adjustment to new medications, and/or therapy regimen. This will allow for timely adjustment/healing as well as quick identification of unwanted results and alternative direction in care. Procedure General Follow-up:

1. Obtain and review patient history and medical provider’s orders prior to appointment.

2. Follow medical provider’s orders/ discharge pamphlets. 3. Obtain VS including P/BP/RR/temp/and ECG as necessary. 4. Discuss and review with patient the ideal recovery plan, and their current

response to treatment. 5. Discuss when to call and follow up with the medical provider. 6. Communicate unusual findings to the medical provider and assist with

arrangement of follow up.

Post-injury Follow-up: 1. Review discharge instructions with the patient to make sure they have full

understanding of limitations and expectations. 2. Assess patient’s pain control and understanding of recommended medications. 3. Assess patient’s limited mobility due to the injury. Make recommendations and/or

changes in the home environment to decrease chance of further injury. 4. Assess injury site for inflammation. Discuss using ice and non-steroidal anti-

inflammatory medications as recommended treatment. 5. Assess ability to care for injury.

Post-stroke Follow-up: 1. Assess patient’s understanding of what a stroke is and the short and long term

effects 2. Review the discharge instructions with the patient to make sure they have full

understanding of limitations and expectations.

 

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3. Review the patient’s medication list. Most likely the patient may be taking some or all of the following types of medications: Antithrombotics, ACE Inhibitors, Statins, and/or Diuretics.

4. Review the patient’s exercise plan 5. Review the patient’s diet plan 6. Discuss the warning signs of stroke 7. Discuss the need to stop smoking, if the patient is a smoker 8. Assess and review the patient’s plan for rehabilitation (PT, OT, Speech, home

health, etc.)

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HISTORY AND PHYSICAL 

Policy The Community Paramedic (CP) will respond to a residence on order from the medical provider requesting CP care and follow guidelines outlined by the medical provider’s orders for proper history and physical exam assessments. Purpose To assist the medical provider in observing and documenting objective and subjective information for the purpose of identifying the patient’s state of health and comparing it to the ideal. Procedure

Obtain and review patient’s health history and medical provider’s orders prior to appointment.

Follow medical provider’s orders. All information may be recorded prior to paramedic’s consultation. It will be

decided by the medical provider and paramedic what information to update.

Health History

1. Demographic Data (if not already recorded) Including name, gender, address and telephone #, birth date, birthplace,

race, culture, religion, marital status family or significant others living in home, social security number, occupation, contact person, advance directive, durable power of attorney for health care, source of referral, usual source of health care, type of health insurance

Reason for seeking care/ Chief Complaint

1. Present Health Status Current health promotion activities (diet, exercise, etc.), clients perceived

level of health, current medications, herbal preparations, type of drug, prescribed by whom, when first prescribed, reason for prescription, dose of med and frequency, clients perception of effectiveness of med.

Symptom analysis- location (where are the symptoms), quality (describe characteristics of symptom), quantity (severity of symptom), chronology (when did the symptom start), setting (where are you when the symptom occurs), associated manifestations (do other symptoms occur at the same time), alleviating factors, aggravating factors.

2. Past Health History

Allergies, childhood illnesses, surgeries, hospitalizations, accidents or injuries, chronic illnesses, immunizations, last examinations, obstetric history

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3. Family History Develop Genogram Family history should include questions about Alzheimer’s, Cancer,

Diabetes, Heart Disease, Hypertension, Seizures, Emotional problems, Alcoholism/drug use, Mental Illness, Developmental delay, Endocrine diseases, Sickle cell anemia, Kidney disease, Cerebrovascular accident

4. Environmental Assessment PEAT scale for all patients on initial visit Repeat PEAT scale as need arises

Review of Systems

1. General Health Status Fatigue, weakness Sleep patterns Weight, unexplained loss or gain Self-rating of overall health status

2. Integumentary System Skin disease, problems, lesions (wounds, sores, ulcers) Skin growths, tumors, masses Excessive dryness, sweating, odors Pigmentation changes or discolorations Rashes Pruritus Frequent bruising Texture or temperature change Scalp itching Hair

o All body hair, changes in amount, texture, character, distribution Nails

o Changes in texture, color, shape Head

o Headache o Past significant trauma o Vertigo o Syncope

Eyes o Discharge o Puritis

o Lacrimation o Pain o Visual disturbances o Swelling o Redness o Unusual sensations or twitching

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o Vision changes o Use of corrective or prosthetic devices o Diplopia o Photophobia o Difficulty reading o Interference with activities of daily living

Ears o Pain o Cerumen o Infection o Discharge o Hearing changes o Use of prosthetic device o Increased sensitivity to environmental noises o Change in balance o Tinnitus o Interference with activities of daily living

Nose, Nasopharynx, and Paranasal Sinuses o Discharge o Epistaxis o Sneezing o Obstruction o Sinus pain o Postnasal drip o Change in ability to smell o Snoring o Pain over sinuses

Mouth and Oropharynx o Sore throat o Tongue or mouth lesion (abscess, sore, ulcer) o Bleeding gums o Voice changes or hoarseness o Use of prosthetic devices (dentures, bridges) o Difficulty chewing

Neck o Lymph node enlargement o Swelling or masses

Pain/tenderness o Limitation of movement o Stiffness

Breasts o Pain/tenderness o Swelling o Nipple discharge o Changes in nipples o Lumps, masses, dimples o Discharge

3. Cardiovascular System

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Heart o Palpitations o CP o Dyspnea o Orthopnea o Paroxysmal nocturnal dyspnea

Peripheral vasculature o Coldness/numbness o Discoloration o Varicose veins o Intermittent claudication o Paresthesia o Leg color changes

4. Respiratory System Colds/Virus Cough, nonproductive or productive Hemoptysis Dyspnea Night sweats Wheezing Stridor Pain on inspiration or expiration Smoking history, exposure

5. Gastrointestinal System Change in taste Thirst Indigestion or pain associated with eating Pyrosis Dyspepsia

Nausea / Vomiting Appetite changes Food intolerance Abdominal pain Jaundice Ascites Bowel habits Flatus Constipation Diarrhea Changes in stool Hemorrhoids Use of digestive or evacuation aids

6. Urinary System Characteristics of urine

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Hesitancy Urgency Change in urinary stream Nocturia Dysuria Flank pain Hematuria Suprapubic pain Dribbling or incontinence Polyuria Oliguria Pyuria

7. Genitalia General

o Lesions o Discharges o Odors o Pain, burning, pruritus o Painful intercourse o Infertility

Men o Impotence o Testicular masses/pain o Prostate problems o Change in sex drive o Penis and scrotum self examination practices

Women

o Menstrual history o Pregnancy history o Amenorrhea o Menorrhagia o Dsymenorrhea o Metrorrhagia (irregular menstruation) o Dyspareunia (pain during intercourse) o Postcoital bleeding o Pelvic pain o Genitalia self-examination

8. Musculoskeletal System Muscles

o Twitching, cramping pain o Weakness

Bones and joints o Joint swelling, pain, redness, stiffness o Joint deformity o Crepitus o Limitations in joint range of motion

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o Interference with activities of daily living Back

o Back pain o Limitations in joint range of motion o Interference with activities of daily living

9. Central Nervous System History of central nervous system disease Fainting episodes or LOC Seizures Dysphasia Dysarthria Cognitive changes (inability to remember, disorientation to

time/place/person, hallucinations Motor-gait (loss of coordinated movements, ataxia, paralysis, paresis, tic,

tremor, spasm, interference with activities of daily living Sensory-paresthesia, anesthesia, pain

10. Endocrine System Changes in pigmentation or texture Changes in or abnormal hair distribution Sudden or unexplained changes in height or weight Intolerance of heat or cold Presence of secondary sex characteristic 3 P’s Anorexia Weakness

Psychosocial Status

1. General statement of patient’s feelings about self Degree of satisfaction in interpersonal relationships Clients position in-home relationships Most significant relationship Community activities Work or school relationships

o Family cohesiveness 2. Activities

General description of work, leisure and rest distribution Hobbies and methods of relaxation Family demands Ability to accomplish all that is desired during period

3. Cultural or religious practices 4. Occupational history

Jobs held in past Current employer Education preparation Satisfaction with present and past employment

5. Recent changes or stresses in clients life

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6. Coping strategies for stressful situations 7. Changes in personality, behavior, mood

Feelings of anxiety or nervousness Feelings of depression Use of medicationsor other techniques during times of anxiety, stress or

depression 8. Habits

Alcohol / Drugs Use o Type of alcohol/drugs o Frequency per week o Pattern over past 5 years; over the past year o Alcohol/drug consumption variances when anxious, stressed, or

depressed o Driving or other dangerous activities while under the influence o High risk groups: Sharing/using unsterilized needles and syringes

Smoking / Tobacco Use o Type o Amount per day o Pattern over 5 years; over the past year o Usage variances when anxious or stressed o Exposure to secondhand smoke

Caffeine: Coffee, tea, soda, etc. o Amount per day o Pattern over 5 years; over the past year o Consumption variances when anxious or stressed o Physiological effects

Other o Overeating, sporadic eating or fasting o Nail biting

Financial status o Sources of income o Adequacy of income, Recent changes in resources or expenditures

Environmental Health

1. General statement of patients assessment of environmental safety and comfort 2. Hazards of employment (inhalants, noise etc.) 3. Hazards in the home (concern about fire etc.) 4. Hazards in the neighborhood or community (noise, water and air pollution, etc) 5. Hazards of travel (use of seat belts etc.) 6. Travel outside the US

Consider Age-Related Variations in the Health History

1. Newborn 2. Infants 3. Children 4. Adolescents

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5. Older Adults

Physical Assessment

1. Techniques Inspection Palpation Percussion Auscultation

2. Positioning 3. Vital Signs

Temperature Pulse Respiration Blood Pressure

4. General Assessment Weight Height Skinfold Thickness

5. Age-Related Variations Newborns and Infants

o Recumbent Length o Head Circumference o Chest Circumference o Vital Signs-Temp, Pulse and Respirations

Children o Height and Weight o Head and Chest Circumference o Vital Signs-Temp, Blood pressure

Adolescents o Weight and Height

Older Adults o Weight and Height o Vital signs

6. Documentation

Document all information and communicate with the medical provider. If on evaluation of the patient any of the following S/S are found contact the

patient’s referring medical provider via phone while still on scene with the patient.

o Systolic BP > 190 or < 80 o Diastolic BP > 120 o Temperature when ordered of > 101.5 o Pulse at rest > 120

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o Respirations at rest >24 o O2 sat of < 88% on children < 14 y/o o O2 sat of < 86 on any patient not on O2

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HOME MEDICATIONS  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders for home medication checks. Purpose

To assist the patient in proper usage of home medications through information/education and vital sign checks.

To assist the medical provider in a thorough documentation of all prescription and non-prescription medications for the purpose of avoiding adverse drug reactions.

To ensure proper continuum of care during medical provider care provider transitions.

Procedure

1. Obtain and review patient’s health history and medical provider’s orders prior to appointment.

2. Follow medical provider’s orders. 3. Review history and physical. 4. Review patient’s information with the patient, including medical and medication

history, current medications the patient is receiving and taking, compliance, time of doses, medical provider who prescribed medications and sources of medications such as the pharmacy.

5. Ask the patient if there are any other medications or supplements they take that might be from another medical provider or over the counter.

6. Assess vital signs 7. Assist patient in sorting medications. 8. Stress importance of medication compliance. 9. Contact referring medical provider if paramedic or patient has concerns.

Document all medications whether prescribed or over the counter and communicate list and current health/reactions to medical provider.

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HOME SAFETY ASSESSMENT  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders for a home safety assessment. Purpose To ensure the home is in safe condition to meet the medical needs of the patient. Can be used to conduct a pre-surgical assessment, post-operative assessment, or an evaluation of the safety of the home at anytime. Procedure

1. Follow the Home Safety Inspection checklist including the inspection of the following areas of the home:

Outside of the house

Living room

Kitchen

Stairs

Bathroom

Bedroom

General Inspection

2. Complete the Overall Tips inspection

3. Complete comments on any sections marked “no” during the inspection

4. Complete recommendations for the resident and possible referrals

5. Discuss the findings with the patient and resources to remedy

6. Have the patient sign off the report with the understanding they understand the recommendations

7. Complete report and return a copy to the ordering medical provider.

8. If any life-threating issues are identified, notify the ordering provider immediately.

 

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IMMUNIZATIONS  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders for the purpose of ensuring the healthy physical and mental development of the young community member. Purpose To assist the primary medical provider, and/or public health nurse in administering immunizations to prevent disease transmission. Procedure

1. Obtain medical provider’s orders prior to appointment. 2. Obtain and review patient’s health history (this includes immunization history,

contraindications, health status, and allergies). 3. Obtain immunization in public health with cooler and ensure temperature stays

within normal limits for vaccine 4. Obtain necessary paperwork will include the following:

1) Vaccine Information Sheets (VIS) 2) Administrative consent forms 3) Patient’s immunization record from one of the following:

Patient’s medical provider Authorized State of CO Public Health immunization record from CIIS Authorized State of CO school immunization record. International immunization record.

5. Verify the order with the correct vaccine, person, dose, site and time. 6. Administer vaccine through proper route and technique. 7. Observe for adverse reactions for 15 minutes 8. Discuss reactions and educate parents on side effects from the vaccinations 9. If an adverse reaction occurs, follow the ECPS medical protocols. 10. Update immunization record. 11. If sequential vaccines are indicated, refer the patient for follow-up at the medical

provider’s office or public health clinic.

 

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INTRAVENOUS CATHETER CHANGES  Policy The Community Paramedic will respond to a residence on order from the primary medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders and/or ECPS’ medical protocols for the removal and reinsertion of intravenous (IV) catheters. Purpose To remove and reinsert IV catheters for the purpose of continuing IV access and avoidance of possible local and systemic infections and/or patient discomfort. Procedure

1. Obtain and review patient’s health history and medical provider’s orders prior to appointment.

2. Follow ECPS’ medical protocols for IV access. 3. Be cognizant of complications of long-term catheter use and effects of termination

of IV. Educate patient on signs of infection. 4. Take into account certain medications, which could lead to uncontrolled bleeding. 5. Communicate any unusual findings with medical provider.

 

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I‐STAT  Policy The Community Paramedic will respond to a residence on request from the medical provider and follow guidelines outlined by the medical provider’s orders for obtaining I-STAT values. Purpose To assist the medical provider in obtaining certain blood laboratory values while in the patients home. Procedure

1. Using BSI technique, obtain sample of patients’ venous blood with use of a butterfly needle of at least 20 g and a green top blood tube.

2. Roll the tube back and forth in hands at least 5 (five) times. 3. Using a 1 cc syringe with at least a 20-gauge needle, withdraw 1 cc blood from

the green top tube. 4. Expel 2 drops of blood from the syringe prior to filling I-STAT chamber. 5. Remove cartridge from the package handling the cartridge from the sides only. 6. Place cartridge on a flat surface. 7. Fill the cartridge with the blood sample only to the appropriate level as marked on

the cartridge. 8. Close cover over sample well. 9. Turn on I-STAT and enter operator and patient ID numbers. 10. Insert cartridge into analyzer (Do not remove while “cartridge locked” message is

on). 11. Print records of results and attach to the patient care report prior to faxing report

to medical provider.

Precautions 1. Avoid drawing blood from an arm with an IV already in place as this will dilute

the sample and may interfere with test results. 2. Venous stasis as with prolonged tourniquet application may alter lab results. 3. Avoid having the patient use extra muscle activity such as clenching the fist as

this may increase potassium results.

Special Notes 1. Cartridges are good for two (2) weeks at room temperature. 2. Lab results will not be interpreted in the field alone and will always be sent to

the referring medical provider. 3. If the paramedic notices a possible life threatening abnormal lab value, they

will immediately contact the referring medical provider via cell phone to discuss the results

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LAB DRAW  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders for the purpose of obtaining a lab specimen for testing. Purpose To assist the medical provider in obtaining specimens for appropriate diagnostic and testing procedures. By performing the lab draws in the home, it prevents the patients from needing to go into a medical provider’s office for a minor procedure that can be managed by the Community Paramedic. Procedure

1. Perform lab draw 2. Tubes should be collected in the order of red, green, purple, pink, and blue. 3. Fill out the label for each of the tubes to include the patient’s name, date of birth,

provider’s initials, and date and time of the lab draw. 4. Affix the label to the blood tubes 5. Complete the lab paperwork provided by the medical provider’s office or hospital 6. Put samples in a biohazard bag 7. Deliver samples to the appropriate ordering medical provider’s office or hospital

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OTOSCOPE  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders for the purpose of ensuring proper healing of a patient with an ear infection. Purpose To assist the medical provider in observing and documenting the patient’s response to medical care through follow up visual inspection of patient’s ear. Procedure Adult

1. Use otoscope with largest ear speculum that ear canal will accommodate. 2. Position the patient’s head and neck upright. 3. Grasp auricle firmly and gently pull upwards, backward and slightly away from

head. 4. Hold otoscope handle between thumb and fingers and brace hand against

patients face. 5. Insert speculum into ear canal, directing it somewhat down and forward and

through hairs. 6. Inspect ear canal noting discharge, foreign bodies, redness and/or swelling. 7. Inspect eardrum noting color and contour and perforations.

Child 1. Child may sit up or lie down. 2. Hold otoscope with handle pointing down toward child’s feet, while pulling up on

auricle. 3. Hold the head and pull up on auricle with one hand, while holding otoscope with

other hand. 4. See adult inspection above for inspecting canal and eardrum.

Findings

Acute otitis media is common in children and presents with red, bulging tympanic membrane with dull or absent light reflex. Purulent material may also be seen behind tympanic membrane.

 

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POST‐PARTUM VISITS  Policy The Community Paramedic (CP) will respond to a residence on the request of the provider to perform a postpartum check of the mother and to assess the newborn. Purpose To assess both the newborn and mother in the home and to determine if there are any unmet medical needs. To see if there is any further education that needs to be done and to provide mother and family with any information on services that could be helpful. Procedure

1. Perform a general H&P on newborn which includes: Weight Oxygen saturation check V/S including pulse, heart tones, respirations Physical examination

2. Review of mother’s post-delivery health and well being 3. Evaluate mother for postpartum depression and discuss warning signs 4. PEAT scale 5. Home safety assessment with the following additions:

Safe sleeping recommendations for the newborn Newborn equipment safety check Car seat check

6. Nutrition evaluation of both mother and newborn 7. Social evaluation 8. CP will send report of all findings to both the referring provider and also to the

patients PCP if different from referring provider within 24 hours of visit.

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SOCIAL ASSESSMENT  Policy The Community Paramedic (CP) will respond to the home on the request of the provider to perform a social assessment. Purpose To assess the social environment in which the patient lives. This will enable the CP to determine if adequate support systems are in place and to offer any assistance in providing the patient with available resources that are wanted and/or needed. This will also allow the paramedic to assess the basic financial needs of the home and be able to link the patient in with possible assistance programs. Policy

1. The CP will complete the ‘Social Evaluation Checklist’ through an interview with the patient.

2. The CP will then fax a completed copy of the report to the referring provider within 24 hours of the visit.

3. The CP will notify the CP Coordinator of any potential unmet needs and the coordinator will then be responsible for following up with the appropriate resources and relaying this information back to both the provider and the patient.

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WELL BABY CHECKS  Policy The Community Paramedic (CP) will respond to a residence on order from the medical provider requesting CP care and follow guidelines outlined by the medical provider’s orders for the purpose of ensuring the healthy physical and mental development of the young community member. Purpose To assist the medical provider in observing and documenting height and weight gain as well as recognizing proportionality for the healthy development of the child. To provide/assist in immunizations and/or blood testing for the purpose of preventing disease and/or determining physiological and biochemical states for the early detection of disease. Procedure

1. Well baby checks are advised for the following ages: 2-4 weeks, then every 2 months until 6-7 months, then every 3 months until 18 months, then 2 years, 3 years, at preschool, and every 2 years after.

2. Obtain and review patient’s health history and medical provider’s orders prior to appointment.

3. Follow medical provider’s orders. 4. Developmental assessment:

Denver II 5. Obtain Patient health history:

Note diet, feedings, mother-child interactions, signs of neglect, signs of physical abuse or obvious physical illness such as diarrhea or chronic infection.

Calorie count should be done to ensure adequate caloric intake. Prenatal care/ health prior to birth/labor and delivery/growth/development?

6. Head to toe assessment General appearance Skin

o Variations of color, texture, temp, turgor, accessory structures Lymph Nodes Head Neck Eyes

o Internal/external exam

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o Use Opthalmoscope Ears

o Internal/external exam o Use Otoscope

Nose o Internal/external exam

Mouth and Throat o Internal/external exam

Chest Lungs

o Inspection, palpation, percussion, auscultation Heart

o Inspection, palpation, auscultation

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WOUND CHECK / POST‐OP DRESSING CHANGE  Policy The Community Paramedic will respond to a residence on order from the medical provider requesting community paramedic care and follow guidelines outlined by the medical provider’s orders for the purpose of wound care and post-operative dressing changes. Purpose To assist the medical provider in attending to soft tissue injuries for the purpose of restoration of function through repair of injured tissue while minimizing risk of infection and cosmetic deformity. This will be accomplished through visual inspection, wound cleaning and dressing/bandage change, and patient education. Procedure

1. Obtain patient history including history of wound, medical illnesses (certain illnesses may delay wound healing and increase risk of infection), current vaccinations (Tdap) and medical provider’s orders.

2. Obtain VS including P/BP/RR/Temp and ECG as necessary. 3. Visually inspect dressings and wound.

Examine dressings for excess drainage. Examine wounds for infection and delayed healing including increasing

inflammation, purulent drainage, foul odor, persistent pain, and fever. If needed, document wound with digital camera and send to medical

provider with updated records. 4. If signs of infection, contact medical provider immediately for follow up. 5. If no signs of infection clean and dress wound per medical provider’s orders, and

educate patient on signs and symptoms of infection and risk management. 6. Make sure patient is up to date on vaccinations (Tetanus) and if needed offer

vaccine on sight or connect to public health. 7. Record required information and connect with medical provider.

 

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REFERENCES  The policies and procedures were compiled using the following references:

Bickley, Lynn S, MD. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Wolters Kluwer Health / Lippincott, Williams, & Wilkins, 2009.

Giddens, Jean Foret, and Susan F. Wilson. Health Assessment for Nursing Practice. 2nd ed. St Louis, MO: Mosby, 2001.

Graber, Mark A, Jennifer L. Jones, Jason K. Wilbur. The Family Medicine Handbook. 5th ed. Philadelphia, PA: Mosby, 2006.

Hockenberry, Marilyn J. Nursing care of infants and children. 7th ed. St. Louis, MO: Mosby, 2003.

Lowdermilk, Deitra Leonard, and Shannon E. Perry. Maternity and women’s health care. 8th ed. St. Louis, MO: Mosby, 2004.

“The physician’s role in medication reconciliation.” American Medical Association. 2007. http://www.ama-assn.org/ama1/pub/upload/mm/.../med-rec-mongraph.pdf.

Sanders, Mick J. Mosby’s Paramedic Textbook. 3rd ed. St Louis, MO: Mosby, 2005.

Wilkinson, Judith and Treas, Leslie. Fundamentals of Nursing – Volume 1: Theory, Concepts, and Applications. 2nd ed. Philadelphia, PA: F. A. Davis, 2010.

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PRE‐HOSPITAL FORMULARY 

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ACETAMINOPHEN  Class

Antipyretic Analgesic

Indications

Fever in children age 12 weeks to 10 years who are being transported Precautions

Allergy/hypersensitivity Overdose if already administered

Contraindicated

Age < 12 weeks If patient is not being transported

Pediatric Dose (Use Broselow tape for weight calculation)

Weight  Dose 

2 ‐ 5 kg  40 mg / 1.25 mL

6 ‐ 8 kg  80 mg / 2.5 mL

9 ‐ 11 kg  120 mg / 3.75 mL

12 ‐ 15 kg  160 mg / 1 mL

16 ‐ 21 kg  240 mg / 7.5 mL

22 ‐ 26 kg  320 mg / 10 mL

27 ‐ 31 kg  400 / 12.5 mL

* Assumes Children’s Tylenol at 160 mg / 5 mL

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ADENOSINE (ADENOCARD)  Class

Antidysrhythmic Action

Slows AV node conduction Interrupts reentry pathways through the AV node

Indications

Conversion of SVT to regular sinus rhythm Precautions

Allergy/hypersensitivity Sick sinus syndrome 2nd or 3rd degree heart block Ventricular tachycardia Atrial fibrillation of flutter Use with caution in patients with asthma

Adult Dosing

12 mg rapid IV push, repeat PRN q 5 minutes at 12 mg rapid IV push *Do not exceed a total of 24 mg

Pediatric Dosing (Use Broselow tape for calculation)

Initial dose of 0.1mg /kg rapid IV/ push (do not exceed 12 mg single dose) *Repeat once at 0.2mg /kg rapid IV push (do not exceed 12 mg single dose)

195

ALBUTEROL  Class

Bronchodilator Action

Sympathomimetic, bronchodilator Indications

Bronchospasm from reactive airway disease COPD, pneumonia Hyperkalemia (slow action)

Precautions

Hypersensitivity Cardiovascular disease, coronary insufficiency Dysrythmias Convulsive disorders Diebetes mellitus Hypokalemia

Adult Dosing

Nebulizer: 2.5 – 3.0 mg by nebulizer (dose depends on brand) repeat PRN MDI: 90 mcg/actuation, repeat PRN

Pediatric Dosing

Nebulizer: 2.5 – 3.0 mg by nebulizer (dose depends on brand) repeat PRN MDI: 90 mcg/actuation, repeat PRN

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ALCAINE (TETRACAINE HCL) 

 Class

Topical anesthetic Action

Procaine type local anesthetic Indications

Corneal and conjunctival pain relief due to abrasion or foreign body Precautions

Hypersensitivity Patient must be evaluated by a physician/optometrist following administration

Contraindications

Globe penetration or dislocation Adult Dosing

1-2 drops in the affected eye, repeat PRN Pediatric Dosing:

1-2 drops in the affected eye, repeat PRN

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AMIODARONE  Class

Antiarrhythmic Action

Class III antiarrhythmic agent, prolongs the action potential in all cardiac tissues Indications

Ventricular fibrillation / pulseless ventricular tachycardia SVT refractory to adenosine Rate control of atrial fibrillation or atrial flutter Successful AED defibrillation

Precautions

Hypersensitivity Hypotension, especially with multiple doses Possible negative inotropic effects

Contraindications

Pregnancy (teratogenic) – use magnesium or lidocaine as an alternative Significant bradycardia / 2nd / 3rd degree heart blocks

Adult Dosing

Ventricular Fibrillation / Pulseless Ventricular Tachycardia: 300mg IV push, repeat at 150mg in 3 - 5 minutes Ventricular Tachycardia / Tachycardia of Unknown Origin with Pulses/ Successful AED Defibrillation: 150mg in 10mL normal saline slow IV push, repeat q 10 minutes PRN Maintenance infusion is typically 0.5mg/min Atrial Fibrillation / Atrial Flutter with rapid ventricular response and symptomatic: 150mg in 10 mL normal saline slow IV push

Pediatric Dosing (Use Broselow tape for calculation)

Ventricular Fibrillation / Pulseless Ventricular Tachycardia: 5 mg/kg IV/IO push; repeat in 3-5 minutes; (Maximum single dose should not exceed 300mg) Wide Complex Tachycardia: 5 mg/kg over 5 minutes infusion

198

ASPIRIN (ACETYLSALICYLIC ACID)  Class

Salicylate analgesic, antipyretic Action

Thromboxane A2 inhibitor – decreased vasoconstriction and decreased platelet aggregation

Indications

Presentation consistent with Acute Coronary Syndrome Precautions

Coagulopathies Asthma Active gastric bleeding

Contraindications

Previous anaphylactic / allergic reaction to aspirin Adult Dosing

Acute Coronary Syndrome: 324 mg by mouth chewed & swallowed Other dosing as ordered by medical control

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ATROPINE SULFATE  Class

Anticholinergic, parasympatholytic, antidote Action

Inhibits muscarinic action of acetylcholine at the postganglionic parasympathetic neuroeffector sites

Decreases GI motility and secretion Vagolytic – increases heart rate

Indications

Symptomatic bradycardia Poisoning – organophosphate, some mushrooms (rapid onset of cardiovascular

collapse) Precautions

Hypersensitivity Shock High grade heart blocks

Adult Dosing

Bradycardia: 0.5mg IV/IO, repeat q 3-5 minutes to a maximum of 0.04 mg/kg Poisoning: 2-3 mg IV/IO repeated until signs of atropine intoxication appear

Pediatric Dosing (Use Broselow tape for calculation)

Bradycardia: 0.02 mg/kg IV, IO repeated once; minimum dose of 0.1 mg, maximum dose of 0.5 mg

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ATROVENT (IPRATROPIUM)  Class

Anticholinergic Action

Dries respiratory tract secretions Bronchodilator

Indications

Bronchospasm secondary to asthma, emphysema, or other COPD Precautions

Hypersensitivity Should not be used as the primary treatment – use in conjunction with a B2

agonist Adult Dosing

500 mcg via nebulizer (concurrently with albuterol), repeat PRN *DuoNeb unit dose includes Albuterol 3.0 mg, and 500 mcg Atrovent ready for use

Pediatric Dosing

Age > 2 years: 500 mcg – reassess ½ way through treatment, no repeat

201

CALCIUM CHLORIDE / CALCIUM GLUCONATE  Class

Electrolyte Action

Increases cardiac contractility in hypocalcaemia Decreases the cardiac effects of hyperkalemia Decreases the adverse neuromuscular effects of hypomagnesaemia

Indications

Severe hyperkalemia Citrate toxicity Suspected Calcium Channel Blocker overdose

Precautions

NOT compatible with sodium bicarbonate Digitalized patients (Digitalis) Known hypercalcemia

Adult Dosing

Cardiac Arrest: 1 g slow IV push Calcium Channel Blocker Overdose: 1 g slow IV push Symptomatic Hyperkalemia: 1 g slow IV push Citrate toxicity: 1 g slow IV push

Pediatric Dosing: (See Broselow Tape for calculation)

Cardiac Arrest: 20 mg /kg slow IV push Symptomatic Calcium Channel Blocker Overdose: 20 mg / kg slow IV push *Do not exceed 500 mg

202

DEXTROSE / GLUCOSE (ORAL)  Class

Carbohydrate Action

Metabolic conversion to ATP to provide cellular energy Provides 3.4 calories/g

Indications

Hypoglycemia Precautions

Use caution in patients with a decreased ability to maintain / support their own airway

Hypersensitivity DKA

Adult Dosing

Administer oral glucose paste, or other glycemic agent, in quantity sufficient to restore patient’s blood glucose Level to 70-120 mg/dl, or to a level of normal mentation

Pediatric Dosing

Administer oral glucose paste, or other glycemic agent, in quantity sufficient to restore the patient’s blood glucose level to 70-120 mg/dl, or to a level of normal mentation

203

DEXTROSE (D50W, D25W, D12.5W)  Class

Carbohydrate Action

Metabolic conversion to ATP to provide cellular energy Provides 3.4 calories/g

Indications

Symptomatic hypoglycemia Altered mentation of unknown etiology

Precautions

Rarely indicated in non-Type I diabetics; Rarely indicated in patients with a blood glucose level > 50 Hypersensitivity DKA

Adult Dosing

25 g IV; repeat once for refractory cases, consider alternate etiologies Pediatric Dosing

0.5 g/Kg IV up to 25 g, repeat PRN for refractory cases

*For under 1yr. of age- dilute to 1/2 concentration (D25W), and administer 0.5 g/Kg up to 25 g *For neonatal patients- dilute to 1/4 concentration (D12.5W), and administer 0.25-0.5 g/Kg up to 25 g total

204

DIPHENHYDRAMINE HCL (BENADRYL)  Class

Antihistamine, H1 receptor antagonist Action

Ethanolamine antihistamine with significant anticholinergic activity Limited GI side effects

Indications

Allergic reaction / anaphylaxis Dystonic reaction

Precautions

Antihistamine hypersensitivity Caution with convulsive disorders HTN and cardiovascular disease Asthma / bronchospasm

Adult Dosing

25-50 mg IV or IM Pediatric Dosing

1-2 mg/kg (max 25 mg) IV or IM slowly

205

DOPAMINE HCL  Class

Autonomic nervous system agonist Action

Alpha and beta adrenergic agonist Indications

Cardiogenic shock Septic shock Neurogenic shock

Precautions

Hypersensitivity Ventricular fibrillation or other tachydysrythmias MAO Inhibitors

Concentration

400mg in 250mL premixed or 200 mg in 125 ml of NS Adult / Pediatric Dosing

2-20 mcg/kg/min IV (Standing order post-cardiac arrest; call-in for all other indications)

400 mg in 250 mL / 1600 mcg / mL Pt weight in Kg 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120

Mcg/Kg/min 2 3 3 4 4 5 5 5 6 6 6 7 7 8 8 8 9 9 5 8 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 10 15 17 19 21 23 24 26 28 30 32 34 36 38 39 41 43 45 15 22 25 28 31 34 37 40 43 45 48 51 54 57 59 62 65 68 20 30 34 38 41 45 49 53 56 60 64 68 71 75 79 83 86 90

206

EPINEPHRINE 1:10,000 AND 1:1,0000  Class

Sympathomimetic Action

Alpha & Beta adrenergic agonist, bronchodilator Indications

Cardiac arrest Anaphylaxis Asthma / bronchospasm Pediatric / neonatal bradycardia

Precautions

Hypersensitivity Coronary insufficiency Hypertension Chronic COPD with degenerative heart disease

Adult Dosing

Cardiac Arrest: 1 mg 1:10,000 IV/IO, or 2 mg ET q 3-5 min Allergic Reaction or Asthma / Bronchospasm: 0.3 mg IM of 1:1,000 Anaphylaxis with Cardiovascular Collapse: 0.1 mg of 1:10,000 slowly IV

Pediatric Dosing (Use Broselow tape for calculation)

Bradycardia: 0.01 mg/kg IV or IO of 1:10,000; or mg/kg ET of 1:1,000 q 3-5 min Allergic Reaction or asthma related bronchospasm: 0.01 mg/kg up to 0.3mg IM of 1:1,000 Cardiac Arrest: 0.01 mg/kg IV or IO of 1:10,000, or 0.1 mg/kg ET of 1:1,000, repeat q 3-5 min

207

ETOMIDATE  Class

A carboxylated imidazole derivative, non-barbiturate, short-acting sedative Action

Modulator of GABAA receptors Provokes a loss of consciousness without hemodynamic compromise Very fast onset of action and very short half-life

Indications

Induction agent for rapid sequence intubation Precautions

Patient’s end-tidal capnography should be monitored continuously Adult Dosing (Use RSI Dosing Guide):

0.3 mg / kg IV push over 5 – 10 seconds

208

FENTANYL CITRATE (SUBLIMAZE)  Class

Opiate analgesic, narcotic Action

Analgesia and sedation through stimulation of opiate receptor sites Indications

Analgesia Pre-treatment prior to RSI

Precautions

Hypersensitivity MAO Inhibitors Potential for chest wall rigidity in high doses ( > 7 mcg / kg)

Adult/Pediatric Dosing

Analgesia: 1 -3 mcg/kg (typical dose 100 mcg) IV or atomized; repeat PRN Combined with benzodiazepines: After initial analgesia dose and benzodiazepine, 1-2 mcg/kg (typical dose 50 mcg) IV, atomized; repeat PRN Pretreatment prior to Rapid Sequence Intubation: 1 -3 mcg / kg typically 100 – 200 mcg Vented patients: 50-100 mcg IV q 20-30 minutes or infusion, consult written orders

209

GLUCAGON  Class

Hormone, antihypoglycemic agent Action

Stimulates gluconeogenesis through lipolysis in the liver Increases peristalsis

Indications

Hypoglycemia Foreign body GI tract obstruction

Precautions

Hypersensitivity Hyperglycemia / DKA Hypokalemia Acute Coronary Syndrome / AMI

Adult Dosing

Hypoglycemia: 0.5-1.0 mg IV or IM q 5-20 minutes *Other Uses require Direct Physician Order

Pediatric Dosing

Hypoglycemia: 0.1 mg/kg IV, IM q 5-20 minutes maximum of 1.0 mg

210

HYDROMORPHONE (DILAUDID)  Class

Opiate analgesic, narcotic Action

Provides analgesia and sedation through stimulation of opiate receptor sites 0.5 mg Dilaudid is roughly equivalent to 100 mcg of Fentanyl Half-life is greater than that of Fentanyl, but less than morphine Less sedation, nausea and vomiting than morphine Effects typically seen in 10 - 15 minutes, peak effect within 20 and duration of 2-5

hours Indications

Analgesia when longer peak effect than fentanyl is desired; typically dosed after fentanyl

NOT indicated for pain in Acute Coronary Syndrome Precautions

Hypersensitivity Adult Dosing

1-2 mg slow IV push *Consider diluting dose and / or giving in well-flowing line *Repeat with 1 mg if no effect after 10 minutes or PRN during longer transports or interfacility

Pediatric Dosing

Typically 0.015 mg / kg IV typically for interfacility; consult written orders

211

KETAMINE (KETALAR)  Class

Dissociative anesthetic Action

Provides significant analgesia, anesthesia and amnesia with minimal effect on respiratory drive

Believed to interact with the MDNA receptors at the GABA-receptor complex resulting in neuroinhibition and anesthesia

Short onset-of-action and short half-life Indications

Induction agent for rapid sequence intubation Precautions

Continuous end-tidal capnography should be monitored Adult Dosing

1.5 mg / kg (follow RSI dose guide)

212

LIDOCAINE HCL  Class

Antiarrhythmic Action

Suppresses automaticity in the His-Purkinje system; CNS depressant Indications

Ventricular arrhythmias Successful AED defibrillation As an adjunct to ET tube placement in the setting of CHI Local anesthetic for conscious patient with an intraosseous line

Precautions

Hypersensitivity Bradycardia Congestive heart failure Supraventricular arrhythmias Liver and renal impairment

Adult/Pediatric Dosing (See Broselow Tape for Calculation)

Ventricular Fibrillation / Ventricular Tachycardia with Pulses / Wide Complex Tachycardia of Unknown Origin / Successful AED Defibrillation: 1.0-1.5 mg/kg IV/ IO; repeat at ½ the initial dose PRN q 3-5 minutes to a max of 3 doses Pre-treat prior to intubation on closed head injury: 1.0 – 1.5 mg / kg IV Lidocaine Drip after Successful Conversion: 1-4 mg / min infusion; (1 gram into 250 mL normal saline 4mg/mL) dose 1 mg / min above conversion dose Anesthetic after Intraosseous insertion: 0.5 mg / kg maximum 50 mg

213

LORAZEPAM (ATIVAN)  Class

Benzodiazepine, antianxiety, sedative/hypnotic Action

Appears to potentiate GABA Sedation Anxiolytic

Indications

Anxiety disorders ETOH withdrawal Sedation Seizures

Precautions

Hypersensitivity Shock Coma Acute ETOH intoxication

Adult Dosing

Seizure/Alcohol Withdrawal: 2-4 mg IV, repeat PRN after 5 minutes if no effect Anxiolysis / mild sedation: 0.5 – 2 mg IV, repeat PRN max 4 mg Heavy sedation / restraint: 2 -4 mg IV repeat after 5 minutes if no effect

Pediatric Dosing

0.05-0.1 mg/kg IV/IO; repeat after 5 minutes if no effect

214

MAGNESIUM SULFATE  Class

Electrolyte Action

CNS depressant, depresses smooth, skeletal and cardiac muscle Indications

Antiarrhythmic Asthma Preeclampsia / eclampsia Tocolysis

Precautions

Hypersensitivity Heart block Impaired renal function Hypocalcaemia

Adult Dosing

Asthma: 2g IV slowly (consider dilution in NS), repeat PRN Preeclampsia: Infuse 2-4 g in 250ml of NS over 5-10 minutes Eclampsia: Bolus 4g slow IV push Antiarrhythmic (Torsades, Ventricular Fibrillation, Ventricular Tachycardia): 1-2 g IV, repeat q 3-5 minutes PRN

Pediatric Dosing (See Broselow tape for calculation)

Asthma/Antiarrhythmic: 25-50 mg/kg, IV or IO, slowly, Repeat PRN

215

METHYLPREDNISOLONE (SOLU‐MEDROL)  Class

Glucocorticosteroid Action

Anti-inflammatory Indications

Interfacility treatment of acute spinal cord injury Bronchospasm Anaphylaxis / allergic reaction

Precautions/Contraindications

Hypersensitivity Hyperglycemia Edema Hypokalemia Osteoporosis

Pediatric Dosing Bronchospasm / allergic reaction: 2 mg / kg over two minutes, max 125 mg Adult Dosing

Bronchospasm / allergic reaction: 125 mg IV Acute Spinal Cord Injury: Typically 30 mg/kg IV bolus over 15 min, followed by 5.4 mg/kg/h over 23 h; begin IV infusion 45 min after conclusion of bolus. Consult written orders.

216

MIDAZOLAM (VERSED)  Class

Benzodiazepine sedative hypnotic Action

Potentiates GABA, causing amnesia, sedation, and skeletal muscle relaxation Indications

Seizure Sedation Anxiolysis Restraint In combination with opiates for pain management

Precautions

Hypersensitivity Shock

Adult Dosing

Seizure: 2.5 mg IV or 5 mg atomized or IM, repeat PRN after 5 minutes if no effect Orthopedic trauma (after opiate): 0.5 mg IV, repeat PRN max 2 mg Anxiolysis / mild sedation: 0.5 – 1 mg IV or 1 – 2 mg atomized or IM, repeat PRN max 2 mg Heavy sedation / restraint: 2.5 mg IV or 5 mg IM, repeat after 5 minutes if no effect Maintenance of sedation for intubated patients with RSI: 0.05 -0.1 mg / kg IV q 20 minutes PRN, half dose for patients with midazolam already on board Maintenance of sedation for intubated patients for transfer: 2 – 4 mg q 20 -30 minutes; or infusion—consult written orders

217

MIDAZOLAM (VERSED) FOR PEDIATRICS  *Tables optimize dose based on Broselow-Luten system / measure patient

Seizure

IV or IO: 0.1 mg / kg, maximum of 2 mg; Atomized or IM: 0.2 mg / kg, maximum of 4 mg; *May repeat once PRN after 5 minutes if no effect

 

Orthopedic Trauma: Only for Age > 2 (after opiate) IV: 0.03 mg / kg, maximum of 1.5 mg; *May repeat once after 5 minutes if no effect and may repeat q15 -30 as necessary; MUST HAVE IV ACCESS

Sedation: Only for Age > 2 IV or IO: 0.05 mg/kg, maximum 1.0 mg; Atomized or IM: 0.1 mg/kg, maximum of 2.0 mg; *May repeat once after 5 minutes if no effect and may repeat q15 -30 as necessary

Maintenance of Sedation for intubated patient: 0.1 mg /kg IV q 20-30 minutes PRN; or infusion—consult written orders   

   GREY  PINK  RED  PURPLE YELLOW WHITE BLUE  ORANGE  GREEN 

Weight (kg)  3‐5  6‐7  8‐9  10‐11  12‐14  15‐18  19‐23 24‐29  30‐36 

IV / IO Dose  0.5  0.75  1.0  1.0  1.5  1.5  1.75  2.0  2.0 

IN / IM Dose  1  1.5  2  2  3  3  3.5  4  4 

   YELLOW WHITE BLUE  ORANGE GREEN 

Weight (kg)  12‐14  15‐18  19‐23 24‐29  30‐36 

IV Dose  0.50  0.5  0.75  1.0  1.5 

   YELLOW WHITE BLUE  ORANGE GREEN 

Weight (kg)  12‐14  15‐18  19‐23 24‐29  30‐36 

IV Dose  0.50  0.75  1.0  1.5  1.5 

IN / IM Dose  1  1.5  1.75  2  2 

218

NALOXONE HCL (NARCAN)  Class

Narcotic antagonist Action

CNS agent, narcotic receptor antagonist Indications

Hypoventilation, apnea secondary to opiate overdose Precautions

Hypersensitivity Narcotic dependence Use caution – rapid reversal can result in withdrawal syndrome

Contraindications

Use in the intubated patient Adult Dosing

0.5-2 mg IV, atomized or IM; maximum 2 mg –if no effect consider other etiologies Pediatric Dosing (Use Broselow tape for calculation)

0.1mg/kg IV, atomized or IO; maximum 2 mg-if no effect consider other etiologies

219

NITROGLYCERIN  Class

Nitrate vasodilator Action

Antianginal, antiischemic and antihypertensive action through vasodilatation Indications

Acute Coronary Syndrome / AMI Pulmonary edema

Precautions

Hypersensitivity Hypotension Hypovolemia Use of erectile dysfunction medications (Phosphodiesterase inhibitors) Right ventricular infarct

Adult Dosing

Acute Coronary Syndrome: 400 mcg spray / tablet; repeat q 3-5 min PRN if systolic BP>90 mmHg CHF/Pulmonary Edema: 400 mcg spray / tablet q 3-5 if systolic BP > 90 mmHg Infusion: 2-200 mcg/min is common, consult written orders: Decrease rate of infusion in the setting of hypotension – does not require base contact

* Table for 200mcg/ml concentration Dose in mcg/min 5 10 20 30 40 50 60 70 80 90 100 110 120

ml/hr 1.5 3 6 9 12 15 18 21 24 27 30 33 36

220

ONDANSETRON HCL (ZOFRAN)  Class

Antinausea, antiemetic Action

Blocks 5-HT3 receptor sites both peripherally and in the CNS Indications

Nausea Emesis

Precautions

Hypersensitivity Paraben allergy Liver impairment

Adult Dosing

4 mg IV slowly, repeat once PRN Pediatric Dosing

Children age < 4 years: 2 mg IV, repeat once PRN *Age > 4 use adult dose

221

ONDANSETRON  (ZOFRAN) ORAL DISINTEGRATING TABLET   Class

Antiemetic Action

5-HT3 antagonist Indications

Treatment of nausea and vomiting in patients where IV access is unavailable or delayed

Precautions

Be aware that nausea and vomiting are often provoked by syndromes that require IV access; have a low threshold for gaining access

Contraindications

Patients with known hypersensitivity Unable to swallow

Adult Dosing (Age 12 and up)

One 4mg tablet – instruct patient to allow it to dissolve in the mouth without swallowing; repeat once after five minutes if necessary

Pediatric Dosing

Age 4 – 11: One 4mg tablet – instruct patient to allow it to dissolve in the mouth without swallowing

222

PHENYLEPHRINE HCL (NEOSYNEPHRINE)  Class

Decongestant, vasopressor Action

Vasoconstrictor with potent Alpha and weak Beta agonist Indications

Topical intranasal use to prevent epistaxis during procedures Precautions

Hypersensitivity Coronary disease Hypertension MAO Inhibitors

Adult Dosing

Instill 3-5 drops in each nostril prior to procedures Pediatric Dosing

Instill 2-3 drops in each nostril prior to procedures

223

RACEMIC EPINEPHRINE (VAPONEPHRINE)  Class

Sympathomimetic, alpha and beta agonist Action

Beta agonist, bronchodilator, decreases swelling of respiratory membranes Indications

Cough associated with croup Precautions

MAO inhibitors Hypersensitivity Cardiovascular disease

Pediatric Dosing

Dilute 0.5 ml of Racemic Epinephrine in 2-5 mL normal saline and administer by nebulizer Or use 0.5 mg/Kg of Epinephrine 1:1000 undiluted (max of 5 mg) nebulized when Racemic Epinephrine is not available

224

ROCURONIUM  Class

Paralytic Action

Non-depolarizing, neuromuscular blocking agent Indications

Paralytic agent for rapid sequence intubation Maintenance of paralysis in the intubated patient

Precautions

Patient must be on continuous end-tidal capnography monitoring Concurrent sedation must accompany paralysis

Adult Dosing (Use RSI Dosing Guide for dose)

RSI: 1.2 mg/kg IV push over 5 – 10 seconds Maintenance of paralysis: 0.5 mg / kg IV

225

SODIUM BICARBONATE  Class

Electrolyte, alkalinizing agent Action

Increases plasma bicarbonate, raises pH, Increases excretion of free base in urine

Indications

Metabolic acidosis (cardiac arrest) Certain drug overdoses

Precautions

Hypersensitivity Low serum chloride levels (insensible fluid losses) Hypocalcaemia Congestive heart failure Hypernatremia

Contraindications

Respiratory acidosis Adult Dosing

Cardiac Arrest: 1.0 – 2.0 mEq/kg IV (typical dose is 50mEq) Overdose: 0.5-1.0 mEq/kg IV bolus, repeat q 5 minutes PRN as dictated by hemodynamic stability

Pediatric Dosing (Use Broselow tape for calculation)

Cardiac Arrest: 1.0 – 2.0 mEq/kg IV bolus Overdose: 0.5-1.0 mEq/kg IV bolus, repeat q 10 minutes PRN as dictated by hemodynamic stability

226

INTERFACILITY FORMULARY 

227

ACETAMINOPHEN  Class

Antipyretic Analgesic

Indications

Fever during blood transfusion Precautions

Allergy/hypersensitivity

Dose 1 gram per oral

228

ANTIBIOTICS (GUIDELINES)  Class

Various Classes including: o Penecillins o Cepahlosporins o Carbapenams o Vancomycin o Aminoglycocides o Tetracyclines o Macrolides o Lincosamides o Sulfonamides o Quinolones o Other antimicrobial and antibiotic agents

Action

The action is dependent on the class of agent in use. Please refer to written orders, and the Sanford Guide to antimicrobial therapy as necessary.

Indications IV antibiotic therapy may be used for any patient with risk for, or signs and

symptoms of infection. Agents may be given empirically, or following cultures and testing sensitivity and specificity. Consult the Sanford Guide to antimicrobial therapy as necessary.

Precautions/Contraindications Patients should be monitored for allergic reactions, hemodynamic compromise,

and other adverse reactions. Multiple agents should generally not be combined in the same tubing or

administered concurrently. Consult the written orders and Drug Reference manuals such as the Sanford

Guide to antimicrobial therapy. Adult / Pediatric Dosing

Dosing will be specific to each patient, and specific to the agent being used to treat them. Consult written orders.

*It is generally recognized that the Sanford Guide to antimicrobial therapy is a benchmark reference for antimicrobial and antibiotic therapies.

229

COLLOID SOLUTIONS  Class

Artificial and Natural Colloid Solutions – Plasmanate, Dextran, Hespan, etc. Action

Dextran or amylopectin molecules (or plasma protein fractionate in the case of plasmanate) are added to a base (saline) to create a solution with high colloid osmotic pressure. Large molecules encourage osmosis into the vascular space. These fluids help increase and maintain intravascular volume.

Indications

Hypovolemic shock Shock secondary to burns Hypoproteinemia

Precautions

Pulmonary edema Elevated blood pressure Allergic reactions (see Blood Products Administration for Natural Colloid

Solutions) Do not administer Dextran or Hespan concurrently with anticoagulants

Adult Dosing

Follow Written Orders for rate and total volume *Do not combine with other fluids or medications in the same tubing

230

DIAZEPAM (VALIUM)  Class

Benzodiazepine, sedative hypnotic, anticonvulsant, muscle relaxant Action

Potentiates GABA, an inhibitory neurotransmitter to produce CNS depression Anticonvulsant properties due to enhanced presynaptic inhibition First line in seizure management

Indications

Seizure ETOH withdrawal Anxiety /panic (severe) Musculoskeletal injuries after opiates

Precautions

Hypersensitivity Coma Shock Alcohol intoxication

Adult Dosing

Seizure: 5-10 mg IV is typical; consult written orders Orthopedic Trauma (after opiate): 1-10 mg IV is typical; consult written orders ETOH withdrawal: 5-10 mg IV is typical; consult written orders Anxiety/Panic: 2-5 mg IV is typical; consult written orders

Pediatric Dosing (Use Broselow tape for calculation)

Orthopedic Trauma (after opiate): 1-5 mg IV is typical; consult written orders Convulsions: 0.2 mg/kg IV/IO is typical; consult written orders

231

DILTIAZEM (CARDIZEM)  Class

Antiarrhythmic / Calcium Channel Blocker Action

Slows conduction through the AV node Vasodilation Decreases rate of ventricular response Decreases myocardial oxygen demand

Indications

To control rapid ventricular rates associated with atrial fibrillation and atrial flutter SVT refractory to Adenocard

Precautions

Known hypersensitivity to diltiazem Hypotension Pulmonary vascular congestion Wide-complex tachycardia

Contraindications

Conduction disturbances: WPW, sick sinus syndrome, AV block Adult Dosing

0.25 mg / kg bolus slow IV push; repeat 0.35 mg / kg bolus slow IV push and 5 – 15 mg / hr infusion is common, consult written orders

232

DOBUTAMINE (DOBUTREX)  Class

Synthetic inotropic agent Action

β1 agonist ( + inotrope > + chronotrope), β2 agonist, α1 agonist (does not release norepinephrine)

Onset: 1-2 minutes, Half Life: 2-3 minutes Indications

Cardiogenic shock, severe CHF, RV failure with increased pulmonary vascular resistance

Precautions Hypovolemia and previous hypersensitivity

Contraindications

Idiopathic hypertrophic subaortic stenosis Critical aortic stenosis

Concentration

500mg/250ml D5W or 0.9% NaCl (concentration 2mg/ml) Complications/Side Effects

Tachycardia Ventricular irritability Tachydysrhythmias Hypotension secondary to β2 stimulation Extravasation leading to tissue necrosis Hypersensitivity (fever, eosinophilia, bronchospasm, rash) Hypokalemia (rare) Nausea/vomiting, tremor, chest pain, palpitations, anxiety

Drug Interactions

May be ineffective with concomitant β-blocker use. Adult/Pediatric Dosing

5-20 mcg/kg/minute IV infusion is typical; consult written orders

233

EPTIFIBATIDE (INTEGRILIN)  Class

Glycoprotein IIb/IIIa antagonist, platelet aggregation inhibitor Action

Prevents binding of fibrinogen, von Willebrand factor and other adhesive ligands to GP IIb/IIIa

Indications

Acute Coronary Syndrome - in conjunction with ASA and heparin

Precautions Hypersensitivity Internal bleeding within last 30 days Recent surgery Uncontrolled hypertension

Adult Dosing

180mcg/Kg bolus IV (usually given by hospital staff) followed by a Maintenance infusion of 2mcg/kg/min. (can reduce to 0.5mcg/Kg/min for low platelet count or other considerations)

*75mg in 100ml infusion premix / 750 mcg / ml Pt weight in Kg

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

ml/Hr for 0.5mcg/Kg/min dosing

2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5

ml/Hr for 2.0mcg/Kg/min dosing

6 7 8 9 10

10

11

12

13

14

14

15

16 17 18 18 19 20 21

234

ESMOLOL HCL (BREVIBLOC)  Class

Autonomic nervous system agent, Beta Blocker Action

Beta adrenergic antagonist Indications

SVT Atrial fibrillation / atrial Flutter Control of HR and BP in the setting of hyperdynamic AMI Aortic Aneurism

Precautions

Hypersensitivity Greater than a 1st degree heart block Bradycardia Hypotension CHF Asthma or COPD Renal impairment

Adult Dosing

500 mcg/Kg bolus followed by 50 – 200 mcg/kg/min infusion or repeat bolus q 8-10 minutes is typical, consult written orders

*mixed 2.5 g in 250 ml (Also: consider 5g in 500 mL concentration – 10mg / mL) Pt weight in Kg 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120

Mcg/Kg/min 2 3 3 4 4 5 5 5 6 6 6 7 7 8 8 8 9 9 5 8 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 10 15 17 19 21 23 24 26 28 30 32 34 36 38 39 41 43 45 15 22 25 28 31 34 37 40 43 45 48 51 54 57 59 62 65 68 20 30 34 38 41 45 49 53 56 60 64 68 71 75 79 83 86 90

235

FOSPHENYTOIN (CEREBYX) 

  Class

Anticonvulsant Action

Class 1b sodium channel blocker. Delays repolarization by prolonging the action potential Onset: 60 minutes (peak 2-3 hours), Half Life: 10-15 hours

Indications

Seizure prophylaxis in the setting of intracranial hemorrhage Precautions

Sinus bradycardia

Contraindications 2nd or 3rd degree AV block

Concentration

Typically, 75mg/mL

* Similar dosing for phenytoin. Phenytoin is infused at a rate not greater than 50mg/min, fosphenytoin may be administered up to 150PE/min making it safer and capable of reaching the therapeutic goal more quickly. Complications/Side Effects

Mild venous irritation Hepatic/renal insufficiency Pregnancy Not effective for withdrawal seizures

Drug Interactions

Isoniazid or cimetadine use can inhibit hepatic metabolism of fosphenytoin and phenytoin and subsequent increased levels

Carbamazepine can decrease effects Adult/Pediatric Dosing

15-20 mg PE/kg loading (typically 1gram for the average adult delivered at 100-150mg PE/min IV) is typical; consult written orders.

Fosphenytoin can be delivered IM at the same dosing in a crisis.

236

FUROSEMIDE (LASIX)  Class

Loop diuretic Action

Rapid acting sulfonamide diuretic / anti-hypertensive Indications

Pulmonary edema associated with fluid overload Congestive heart failure

Precautions

Hypersensitivity to sulfonamides or furosemide Anuria or oliguria Cardiogenic shock Hypotension Potassium deficiency

Contraindications

Hypovolemia Severe hypokalemia

Adult Dosing

20-40 mg IV, repeat PRN at 1/2 initial dose is typical; consult written orders

237

HALOPERIDOL (HALDOL)  Class

Butyrophenone, antipsychotic Action

Inhibits action of dopamine in the brain Indications

Psychotic disorders Acute psychiatric situations

Precautions

Hypersensitivity Parkinson’s disease History of extrapyramidal or dystonic reaction Decreased renal function Seizure disorder Closed head injury Stimulant (e.g., cocaine) overdose Known dystonic reactions

Adult Dosing

Acute Psychiatric Situations: 5-10 mg IM/IV

238

HEPARIN SODIUM INFUSION  Class

Anticoagulant Action

Inactivates thrombin, preventing conversion of fibrinogen to fibrin Indications

Adjunct therapy of coronary occlusion in Acute Coronary Syndrome Disseminated intravascular coagulation (DIC) Prevention of deep venous thrombosis

Precautions

Hypersensitivity Recent surgery or injury

Contraindications

Porcine or bovine protein allergy Heparin induced thrombocytopenia

Adult Dosing

Maintenance of IV infusion: Dosing per written order,

*Mixed as 25000 Units in 250 ml (100 U/ml)

U/h 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900ml/h 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

239

INSULIN INFUSION  Class

Hormone, antidiabetic Action

Stimulates movement of Glucose, potassium and magnesium into cells Indications

Treatment of severe DKA or diabetic coma Hyperkalemia (with concurrent glucose administration)

Precautions

Hypersensitivity Hypoglycemia Hypokalemia Hyperglycemic, hyperosmolar non-ketotic acidosis

Concentration

Typically mixed as 100 Units of regular in 100ml of NS (1ml=1U) Adult Dosing

(See table below for assistance with Insulin types) IV Infusion: 0.1 Units per kilogram per hour is typical; consult written orders

TYPE ONSET PEAK DURATION REGULAR 0.5-1 H 1-2 H (SQ)

15-30 MIN (IV) 8-12 H

NPH 1.1-5 H 4-12 H 24 H LENTE 1-2.5 H 7-15 H 24 H ULTRALENTE 4-8 H 10-30 H >36 H

*Warning* Blood glucose levels should not be lowered faster than 100 mg/dl each hour secondary to the risk for cerebral edema

240

LABETALOL (TRANDATE, NORMODYNE)  Class

Antihypertensive

Action Selective alpha 1 adrenoreceptor antagonist and nonselective beta

adrenoreceptor antagonist Onset: Immediate, Half-Life: 3-8 hours

Indications

Severe hypertension w/suspicion of end organ damage/dysfunction Eclampsia/pre-eclampsia Aortic aneurysm or aortic dissection* Pheochromocytoma

Contraindications Moderate/severe asthma Significant congestive heart failure Cardiogenic shock Second or third degree AV block Significant bradycardia

Complications/side effects

Hypotension Congestive heart failure Bradycardia Bronchospasm

Overdose

Bronchospasm: administer inhaled beta 2 agonist, epinephrine Clinically significant bradycardia: administer atropine Cardiogenic shock: administer dopamine/dobutamine, consider glucagon 2 -

5mg IV Hypotension: administer IV fluid and norepinephrine

Concentration

1 or 2 mg/ml in 0.9% NaCl or 5% dextrose solution (infusion) Adult Dosing

20-80mg IV bolus q 10 minutes to target blood pressure is typical, consult written orders; maximum dose 300mg Infusion 0.5 – 2.0 mg/minute up to 300mg total is typical, consult written orders

241

LEVALBUTEROL (XOPENEX)  Class

Beta-2 agonist Action

R-enantiomer of albuterol; believed to have decreased Beta-1 effects Indications

Bronchospasm Precautions

Pregnancy Hypertension Hyperthyroid Diabetes Mellitus

Contraindications

Previous hypersensitivity to levalbuterol or racemic albuterol Adult Dosing

0.63 mg and 1.25 mg are typical dosing; consult written orders

242

LEVETIRACETAM (KEPPRA)  Class

Anticonvulsant Action

Precise mechanism is unknown, although presumed to selectively prevent hypersynchronization of epileptiform burst firing and propagation of seizure

Indications

Seizure treatment or prophylaxis, typically in the setting of intracranial injury Precautions / Side Effects

Somnolence Weakness Dizziness

Contraindications

Known hypersensitivity Concentration

500 mg in 5 mL vial Dilute in 100 mL or normal saline or D5W

Adult Dosing

500 mg over 15 minutes is common, consult written orders

243

MANNITOL  Class

Osmotic diuretic Action

Induces diuresis by increasing the osmolarity of the glomerular filtrate Indications

Reduction of ICP, and cerebral edema Precautions

Hypersensitivity Renal insufficiency or other renal disease Electrolyte imbalances Hypovolemia Congestive heart failure Epidural hematoma

Concentration

Typically, 100 grams in 500 mL for 0.2 g / mL *always check solution clarity, if particulate is visible the solution should be discarded)

Adult Dosing

1.5-2.0 g/kg of a 15-20% solution over 30-60 minutes (requires in-line filter) is typical; consult written orders

Pediatric Dose

0.25-0.5 g/kg over 60 minutes (requires in-line filter) is typical; consult written orders

244

METOPROLOL (LOPRESSOR)  Class

Beta-Blocker

Action Selective Beta 1 adrenoreceptor antagonist. – inotrope, - chronotrope used to

decrease MVo2 and the incidence of ventricular fibrillation in the setting of ACS and AMI. Also reduces systolic and diastolic blood pressure. Limited use as a supraventricular antidysrhythmic.

Onset: 3-5 minutes, Half-Life: 5 hours Indications

Acute myocardial infarction Acute coronary syndrome Thoracic aortic dissection* (adjunctive to vasoactive agents e.g. nitroprusside)

Contraindications

Moderate/severe asthma Significant congestive heart failure Cardiogenic shock Second or third degree AV block Significant bradycardia Wolff-Parkinson-White syndrome

Complications/side effects

Hypotension Congestive heart failure Bradycardia Bronchospasm

Overdose

Bronchospasm: Administer inhaled beta 2 agonist, epinephrine Bradycardia: Administer atropine, consider transcutaneous pacing Cardiogenic shock: Administer dopamine/dobutamine, consider glucagon Hypotension: Administer fluids

Adult Dosing

5mg IV over 2 minutes q 5 minutes x 3 (total 15mg as tolerated by HR and BP) is common; follow written orders—target heart rate is 60 – 90

245

MIDAZOLAM (VERSED) INFUSION  Class

Benzodiazepine sedative hypnotic Action

Potentiates GABA, causing amnesia, sedation, and skeletal muscle relaxation Indications

Maintenance of sedation in the intubated patient Precautions

Hypersensitivity Shock states, particularly hypovolemic shock Chronic obstructive pulmonary disease Congestive heart failure Alcohol intoxication

Complications

Respiratory depression, apnea Hypotension: Most likely to occur during loading and is transitory; Responds rapidly to fluids; consider Trendelenburg if appropriate; *In instances of prolonged, refractory hypotension, contact sending physician to

consider downward titration or halting of infusion and prepare for bolus medication

Adult/Pediatric Dosing

Infusion: 0.25-1.5 mcg/kg/minute is typical; consult written orders Orders for accompanying opiate analgesics should also be written

246

MORPHINE SULFATE  Class

Opiate analgesic, narcotic Action

Opiate receptor agonist, analgesia at the spinal level, euphoric Indications

Prolonged analgesia Pulmonary edema secondary to congestive heart failure

Precautions

Hypersensitivity Opiate hypersensitivity Bronchial asthma

Adult Dosing

Analgesia: 2-10 mg IV or IM, q 5-10 minutes Acute Coronary Syndrome: 2-4 mg IV q 3-5 minutes

Pediatric Dosing

Analgesia: 0.1-0.2 mg/kg IV, IM or IO, repeat PRN

 

247

NICARDIPINE (CARDENE) CLASSIFICATION:

Calcium channel blocker, antihypertensive MECHANISM OF ACTION:

Selective, slow calcium channel blocker which causes peripheral, cerebral and coronary vasodilatation with minimal effect of the cardiac conduction system

ONSET: 2-3 minutes HALF-LIFE: 3-4 hours after bolus, 8-12 hours after steady state achieved with IV

infusion

Indications: Clinically significant hypertension Subarachnoid hemorrhage

* Nicardipine is the agent of choice following a diagnosis of subarachnoid

hemorrhage for its cerebral vasodilatory effects to prevent vasospasm secondary to local intracerebral insult. This effect has shown promise in reducing secondary infarct extension if administered within 96 hours of onset. It is used with or without the desire for acute blood pressure reduction /control.

Contraindications:

Known hypersensitivity Clinically significant hypotension Use with caution in the setting of chronic calcium channel blocker or beta blocker

use Significant renal or hepatic insufficiency Clinically significant left ventricular outflow obstruction (critical AS, IHSS)

Concentration:

25 mg in 250ml (0.1mg/ml) 0.9% NaCl or 5% dextrose solution Dosing: Adult: Start at 5 mg/hr and titrate up by 5 mg/hr q 10-15 minutes to

maximum of 15 mg/hr; when desired blood pressure is achieved, decrease to 3mg/kg is typical, consult written orders

Pediatric: 1-3 mcg/kg/min ( age 9 days to 10 years) is typical, consult written orders

248

COMPLICATIONS/SIDE EFFECTS: Hypotension Polyuria Ventricular ectopy Heart block Heart Failure

OVERDOSE:

Stop infusion Supportive care (IV fluids, Trendelenburg, etc.) Consider calcium chloride or calcium gluconate administration Consider glucagon administration (2-5mg IV prn) for severe/refractory symptomology

INCOMPATIBILITY:

NaHCo3, lactated ringers, furosemide, heparin Cimetadine increases nicardipine levels

 

249

NOREPINEPHRINE BITARTATE (LEVOPHED)  Class

Sympathomimetic – primarily stimulates alpha adrenergic receptor sites Action

Causes peripheral vasoconstriction Indications

Refractory hypotension Neurogenic shock Septicemia

Precautions

Hypersensitivity Can cause fatal arrhythmias, palpitations, increases MVo2 Extravasation can cause necrosis Deactivated by alkaline solutions Cautious use with TCA/MAOI

Adult Dosing

0.5 - 30 mcg/min IV is typical; consult written orders Pediatric Dosing

2 mcg/min with 0.1 mcg/kg/min as a maintenance target is typical; consult written orders

*Typical Dilution: 2mg in 250ml = 8 mcg/ml mcg/min 0.5 1 2 3 4 5 6 7 8 9 10 11 12 14 16 18 ml/h 4 8 15 23 30 38 45 53 60 68 75 83 90 105 120 135

mcg/min 20 25 30 35 40 ml/h 150 188 225 263 300

250

OCTREOTIDE (SANDOSTATIN)  Class

Synthetic samatostatin analogue Action

Effective in reducing hepatic blood flow, wedged hepatic venous pressure, and azygous blood flow by inhibiting the release of vasodilatory hormones, like glucagon, and promotes splanchnic vasoconstriction and decreased portal flow

Indications

Esophageal varices Oral hypoglycemic overdose

Precautions

May effect blood glucose level in patients who have pre-existing diabetes or who may be at risk for developing Type I diabetes mellitus; consider baseline blood glucose level and be aware of the potential for changes in blood sugar

Adult Dosing

50 mcg bolus followed by 50 mcg/hr IV Infusion is common—consult written orders

251

PHENYLEPHRINE (NEO‐SYNEPHRINE)  Class

Vasopressor Action

Selective α1 adrenergic receptor agonist causing vasoconstriction with no β effects

Onset: immediate, Peak affect: 2-5 minutes, Duration:15-20 minutes Indications

Hypotension secondary to non-hypovolemic states; typically sepsis or SIRS

Precautions Use with caution in elderly patients, or in patients with heart block or existing

bradycardia

Contraindications Hypertension Concurrent MAO Inhibitors or tricyclic antideperessants

Concentration

Typically, 10mg in 1mL is diluted into 250 or 500 mL Normal Saline or D5W Complications/Side Effects

Reflex bradycardia Extravasation leading to tissue necrosis Headache Restlessness

Adult/Pediatric Dose

100-180 mcg/min IV infusion is typical; consult written orders

252

PHENYTOIN (DILANTIN)  Class

Anticonvulsant Action

Class 1b sodium channel blocker; delays repolarization by prolonging the action potential

Onset: 10 – 30 minutes, Half Life: 6 – 12 hours Indications

Seizure prophylaxis, especially in the setting of intracranial hemorrhage Precautions

Sinus bradycardia

Contraindications 2nd or 3rd degree AV block

Complications/Side Effects

Mild venous irritation Hepatic/renal insufficiency (no dosage correction required for loading dose) Pregnancy Not effective for withdrawal seizures

Drug Interactions

Isoniazid or cimetadine use can inhibit hepatic metabolism /carbamazepine can decrease effects

Notes: Continuous vital sign and EKG monitoring required / guard against hypotension Concentration

Should be diluted in normal saline to a maximum concentration of 6.7 mg per mL (preferably 5 mg /ml or less)

Adult/Pediatric Dosing

15 to 20 mg/kg is typical; consult written orders (Should be administered slowly intravenously, at a rate not exceeding 50 mg per minute)

253

PITOCIN (OXYTOCIN)  Class

Oxytocic Synthetic pituitary hormone

Action

Stimulates uterine contraction to assist with control of postpartum bleeding or atony.

Indications

Post partum hemorrhage (Other ante/peripartum indications not appropriate for use during interfacility

transport) Precautions

Hypersensitivity Incomplete delivery of all products of gestation (3rd stage of labor) Hypertension / PIH Rapid infusion may lead to hypotension and dysrhythmias

Contraindications

Uterine rupture Incomplete delivery

Adult Dosing

Intravenous Infusion: (Drip Method): To control postpartum bleeding, 10-40 units of oxytocin may be added to 1,000 mL of a non-hydrating diluent and run at a rate necessary to control uterine atony.

254

PROMETHAZINE HCL (PHENERGAN)  Class

Phenothiazine, antihistamine, antiemetic Action

Selectively blocks H1 receptors Blocks cholinergic receptors in the vomiting center of the brain

Indications

Nausea Active emesis

Precautions

Hypersensitivity to antihistamines or phenothiazine MAO Inhibitors Seizure disorders Use in caution with other sedatives or altered mental status

Adult Dosing

12.5-25 mg IV or IM is typical consult written orders +Dilute dose in 50 mL of normal saline and infuse

Pediatric Dosing

Consult Written Orders

255

PROPOFOL (DIPROVAN)  Class

Sedative hypnotic Action

Unclear, may facilitate inhibitory transmitters mediated by gamma-aminobutyricacid (GABA)

Onset: 40 – 120 seconds, Half-Life: 2 – 8 minutes p infusion, up to 1 – 3 days after prolonged infusion

Indications

Prolonged sedation for intubated/mechanically ventilated patients Contraindications

Known hypersensitivity Complications/Side effects

Hypotension: Typically occurs during loading; Treat with fluid, considering Trendelburg if appropriate; For persistent hypotension refractory to fluids, contact sending physician to downward titrate dose or discontinue – prepare to switch to benzodiazepines for sedation

Respiratory depression/apnea Decreased cerebral blood flow Bradycardia Agitation Bronchospasm

Concentration:

10 mg/ml (bolus), 1g in 100ml (10mg/ml) (infusion) Adult/Pediatric Dosing

Consult written orders; below are typical dose guidelines 2 – 100 mcg/kg/minute is typical; maximum 200 mcg/kg/minute Decreased dosing should be considered in the elderly +Orders for accompanying opiate analgesia should also be written

256

PROTONIX (PANTOPRAZOLE)   Class

Proton pump inhibitor Actions

Blocks the hydrogen / potassium adenosine triphosphatase enzyme system. Acts specifically to block hydrogen production in the gastric lumen reducing acid production.

Indications

Acute upper gastrointestinal bleeding; GERD Precautions

Hypersensitivity Adult Dosing

8 mg / hour IV Infusion is common—consult written orders *Incompatible with midazolam – use separate line or flush before and after

257

R‐TPA (RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR) Activase/Alteplase

Class: Thrombolytic Action: A recombinant plasminogen activator which catalyzes the cleavage of

endogenous plasminogen to generate plasmin, which in turn degrades the fibrin matrix of the thrombus, thereby exerting its thrombolytic action

Indications: Ischemic stroke; Massive pulmonary embolism Contraindications: Unknown onset of symptoms; Outside of dosing window; Intercranial hemorrhage or recent diagnosis of; Recent GI or urinary tract hemorrhage; Seizure during onset of symptoms Precautions: Surface bleeding (can be controlled with direct pressure) May be prone to angioedema; Mild headache Notes: Goal is systolic blood pressure of 120 – 180 mmHg and diastolic of 60-100

mmHg; Be on guard for hypotension contact base for any two consecutive systolic pressures of less than 100 mmHg; CONTACT BASE if this occurs and anticipate fluid bolus or dopamine; For worsening signs and symptoms, CONTACT BASE.

Dose: For CVA—typically ordered: total dose of 0.9 mg / kg (max of 90 mg) with

10% administered by bolus by hospital staff – remaining 90% should be infused over 60 minutes (follow written orders)

For PE—typically ordered: 100 mg over 2 hours (follow written orders)

258

TERBUTALINE (BRETHINE)  

Class

Beta-2 agonist (sympathomimetic)

Action Stimulates beta 2 receptors in smooth muscle causing relaxation. This results in

bronchodilation, vascular dilation and uterine relaxation. Onset: 5 – 10 minutes (peak 30-60 minutes), Half Life: 1.5 – 4 hours

Indications

Reversible bronchospasm Tocolysis Hyperkalemia (not common)

Precautions

Coronary artery disease* Digoxin use Hypokalemia

Contraindications

Previous sensitivity to terbutaline Adult Dosing

0.25 mg SQ q 15 minutes PRN (bronchospasm) maximum dose 0.5 mg q 4 hours is typical; consult written orders

Pediatric Dosing

0.006 – 0.01 mg/kg SQ; repeat 0.25 mg SQ if desired effect not achieved p 15 minutes is typical; consult written orders

259

VECURONIUM (NORCURON)   Class

Competitive, non-depolarizing neuromuscular blocking agent Action

Competes with acetylcholine at the cholinergic end motor plate causing striated muscle paralysis. Adequate sedation must accompany its administration.

Onset: 1 – 4 minutes, Half Life: 40 – 60 minutes Duration of Action

20 – 55 minutes Indications

Neuromuscular blockade to promote ventilator compliance Contraindications

Hypersensitivity Complications/Side effects

Prolonged musculoskeletal weakness or paralysis especially after protracted dosing

Patient alert and paralyzed secondary to inadequate sedation/analgesia Masking of seizure activity*

* Patients who are at increased risk for seizure activity i.e. TBI, status epilepticus, toxidromes, etc. should be managed with sedation/analgesia only if at all possible Adult Dosing

0.1 mg/kg IV bolus, repeat PRN is common; consult written orders *Appropriate analgesia and sedation should accompany this order

.

 

260

APPENDIX 

261

ACTS ALLOWED: AUTHORIZED PROCEDURES FOR 

PROVIDER LEVELS  Waivered Act—requires additional training and notification from Medical Director or

his/her designee that the EMT/medic has been approved to perform the act Requires Call In to Medical Control or Responding ALS Ambulance

Note – For patients in extremis, EMTs employed at ECPS can assist paramedics in ALS drug administration with direct supervision Non

Transporting

EMT

ALS

ALSI

ALSA

AIRWAY/VENTILATION/OXYGEN Capnography Y Y Y Y Y Carbon Monoxide Monitoring Y Y Y Y Y Chest Decompression N N Y Y Y CPAP N N Y Y Y Cricothyrotomy N N Y Y Y Dual Lumen Airway (King) N Y Y Y Y Gastric Decompression N N Y Y Y Intubation – Bougie N N Y Y Y Intubation - RSI N N *Y Y Y Intubation – Maintenance with Paralytics

N N *Y Y Y

Intubation – Nasotracheal N N Y Y Y Intubation – Orotracheal N N Y Y Y Pulse Oximetry Y Y Y Y Y Suction – Tracheobronchial N N Y Y Y Suction – Upper Airway Y Y Y Y Y CARDIOVASCULAR/CIRCULATORY SUPPORT Cardiac Monitoring – Application of Electrodes

Y Y Y Y Y

Cardiac Monitoring – EKG Interpretation

N N Y Y Y

Cardioversion N N Y Y Y Defibrillation – Manual N N Y Y Y Hemorrhage Control - Tourniquet Y Y Y Y Y LUCAS Chest Compression System N Y Y Y Y Pelvic Binder N Y Y Y Y Transcutaneous Pacing N N Y Y Y IMMOBILIZATION Selective Spine Stabilization Y Y Y Y Y INTRAVENOUS CANNULATION/FLUID ADMIN/FLUID MAINTENANCE Crystalloids N N Y Y Y External Jugular Cannulation (EJ) N N Y Y Y Intraosseous Cannulation (EZ IO) N Y Y Y Y Peripheral IV Cannulation – N N Y Y Y

262

excluding EJ Use of Peripheral Indwelling Catheter for IV Meds

N N Y Y Y

ROUTES OF MEDICATION ADMINISTRATION Aerosolized/Nebulized/Atomized Y Y Y Y Y Intramuscular (IM) Y Y Y Y Y Intranasal (IN) N *Y Y Y Y Intraosseous (IO) N *Y Y Y Y Intravenous (IV) N *Y Y Y Y Opthalmic N N Y Y Y Oral (PO) Y Y Y Y Y Rectal (PR) N N Y Y Y Subcutaneous (SQ) N Y Y Y Y Sublingual (SL) Y Y Y Y Y Topical N N Y Y Y Mechanical Infusion Pumps N N N Y Y MISCELLANEOUS Blood Glucose Monitoring Y Y Y Y Y Foley Catheter Placement & Maintenance

N Y Y Y Y

Restraint – Chemical N N Y Y Y DRUG FORMULARY – AIRWAY MANAGEMENT Etomidate N N *Y Y Y Ketamine N N *Y Y Y Rocuronium N N *Y *Y Y Vecuronium N N N N *Y DRUG FORMULARY – ANTIDOTES Atropine N N Y Y Y Calcium Chloride N N Y Y Y Cyanide Antidote N N Y Y Y Glucagon N N N N N Narcan N N Y Y Y Nerve Agent Antidote Y Y Y Y Y Sodium Bicarbonate N N N Y Y DRUG FORMULARY – BEHAVIORAL MANAGEMENT Anti-Psychotic – Haldol N N Y Y Y Benzodiazepine - Diazepam N N Y Y Y Benzodiazepine – Lorazepam N N Y Y Y Benzodiazepine – Midazolam N N Y Y Y Diphenhydramine N N Y Y Y DRUG FORMULARY – CARDIOVASCULAR Adenosine N N Y Y Y Amiodarone – bolus infusion only N N Y Y Y Aspirin Y Y Y Y Y Atropine N N Y Y Y Calcium Chloride N N Y Y Y Dopamine N N Y Y Y Epinephrine N N Y Y Y

263

Lidocaine – bolus and continuous infusion

N N Y Y Y

Magnesium Sulfate – bolus only N N Y Y Y Morphine Sulfate N N Y Y Y Nitroglycerin – sublingual, patient assisted

Y Y Y Y Y

Nitroglycerin – sublingual N N Y Y Y Sodium Bicarbonate N N Y Y Y DRUG FORMULARY – ENDOCRINE & METABOLISM IV Dextrose N N Y Y Y Glucagon N N Y Y Y Oral Glucose Y Y Y Y Y DRUG FORMULARY – GASTROINTESTINAL Anti-Nausea - Ondansetron N N Y Y Y Anti-Nausea - Promethazine N N Y Y Y DRUG FORMULARY – PAIN MANAGEMENT Anesthetic – Lidocaine for IO insertion

N N Y Y Y

Benzodiazepine – Diazepam N N Y Y Y Benzodiazepine - Midazolam N N Y Y Y Narcotic Anlagesic – Fentanyl N N Y Y Y Narcotic Analgesic – Hydromorphone (Dilaudid)

N N Y Y Y

Narcotic Analagesic – Morphine Sulfate

N N Y Y Y

Opthalmic Anesthetic – Tetracaine N N Y Y Y Topical Anesthetic – Lidocaine Jelly N N Y Y Y DRUG FORMULARY – RESPIRATORY & ALLERGIC REACTIONS Antihistamine – Diphenhydramine N N Y Y Y Atropine N N Y Y Y Atrovent N N Y Y Y Solumedrol N N Y Y Y Epinephrine 1:1000, IM N N Y Y Y Epinephrine, IV N N Y Y Y Epinephrine, Auto Injector Y Y Y Y Y Magnesium Sulfate – bolus N N Y Y Y Racemic Epineprhine N N Y Y Y Short Acting Bronchodilator – patient assisted MDI

Y Y Y Y Y

DRUG FORMULARY – SEIZURE MANAGEMENT Benzodiazepine – Diazepam N N Y Y Y Benzodiazepine – Lorazepam N N Y Y Y Benzodiazepine – Midazolam N N Y Y Y OB Associated – Magnesium Sulfate, bolus infusion only

N N Y Y Y

DRUG FORMULARY – VACCINES Hepatitis B – employment related N N Y Y y Tetanus –employment related N N Y Y Y

264

Influenza – employment related N N Y Y Y PPD Placement & Intrepretation – employment related

N N Y Y Y

Any vaccine in conjunction with County Public Health

N N Y Y Y

INTERFACILITY TRANSFER – PROCEDURES Chest Tube Maintenance N N N N Y Mechanical Ventilator N N N N Y Blood Product Administration N N N N Y Central Line Maintenance N N N N Y Intra Aortic Balloon Pump N N N N N Parenteral Nutrition Maintenance N N N Y Y INTERFACILITY TRANSFERS – DRUG FORMULARY The following formulary of medications are approved for interfacility transport of patients, with the requirements that the intervention must have been initiated in a medical facility under the direct order and supervision of a licensed medical providers, and are not authorized for field initiation. Amiodarone – continuous infusion N N N Y *Y Antibiotics N N N Y *Y Blood Products N N N N *Y Colloid Solutions N N N Y *Y Demamethasone (Decadron) N N N Y Y Diltiazem (Cardizem) N N N Y *Y Dobutamine (Doburex) N N N Y *Y Eptifibatide (Integrilin) N N N Y *Y Esmolol (Brevibloc) N N N N *Y Fentanyl infusion N N N N *Y Fosphenytoin (Cerebyx) N N N N *Y Furosemide N N N Y Y Glucagon N N N Y Y Haloperidol (Haldol) N N Y Y *Y Heparin Sodium Infusion N N N Y *Y Insulin Infusion N N N N *Y Labetalol (Trandate, Normodyne) N N N N *Y Levalbuterol (Xopenex) N N Y Y *Y Levetiracetam (Keppra) N N N N *Y Mannitol N N N Y *Y Metoprolol (Lopressor) N N N N *Y Midazolam (Versed) Infusion N N N N *Y Nicardipine (Cardene) N N N N *Y Nitroglycerin infusion N N N Y Y Norepinephrine Bitartate (Levophed)

N N N Y *Y

Octreotide (Sandostatin) N N N N *Y Phenytoin (Dilantin) N N N N *Y Pitocin (Oxytocin) N N N Y *Y Promethazine HCL (Phenergan) N N N Y *Y Propofol N N N N *Y

265

Protonix (Pantoprazole) N N N N *Y Solu-medrol bolus/infusion N N N Y Y Terbutaline (Brethine) N N N Y *Y Vecuronium (Norcuron) N N N N *Y

266

NOTES