MEDICAL ADVISORY COMMITTEE AGENDA Tuesday May 14, 2013, 2 p.m.-4 p.m.

Conference Room – 1350 Arnold Drive

1. Introductions 5 min 2. Announcements 10 min 3. System Updates 10 min

a. STEMI/Stroke (Mia Fairbanks) b. Cardiac Arrest Data (CARES) c. QI (Craig Stroup)

4. Spinal Immobilization Task Force 5 min 5. 2014 Treatment Guidelines 30 min 6. Intraosseous Procedures Changes 10 min 7. Vascular Access – External Jugular 10 min 8. Proposed Policy Changes 15 min

a. Policy 13 – Trauma Triage – Call-in criteria b. Policy 9 – Destination – Cardiac Arrest with ROSC

9. Chlorhexidine Skin Prep 5 min 10. Equipment List Changes 5 min

a. Adenosine b. Stopcocks c. Spinal immobilization devices d. Other

11. Hospital Off-Load Issues 5 min 12. Other

Proposed Treatment Guideline and Prehospital Care Manual Changes for 2014 – May 6, 2013 A2 Chest Pain/ACS/STEMI Modify 12-lead ECG item to reflect continuous monitoring via 12-lead

Change morphine to fentanyl IV A3 Cardiac Arrest Initial Care Under Compressions rate – state 100-120 and use metronome A4 VF/VT Revised CPR/Rhythm Check to remind on q2 rhythm checks. Comment re: glucose check during arrest A5 PEA/Asystole Comment re: glucose check during arrest A6 Symptomatic Bradycardia Change morphine to fentanyl IV A10 Shock/Hypovolemia Under Sepsis screen, correct heart rate/pulse greater than 90 (not 100) A12 Public Safety Defibrillation Under compressions rate – state 100-120 G1 Anaphylaxis/Allergy Add comment that anaphylaxis may include hypotension alone. Add comment that thigh is preferred site

for epinephrine IM due to most rapid absorption, G2 ALOC Remove D50 G3 Behavioral Emergency Remove base order requirement for use of Midazolam (no repeat dose) – limit IV dose to 3 mg

Need to look at documentation requirements also G4 Burns Change morphine to fentanyl IV and IM G10 Pain Management (Non-Traumatic) Change morphine to fentanyl IV and IM

Modify contraindications and cautions G11 Poisoning-Overdose For HF exposure, Change morphine to fentanyl IV and IM

Add section on suspected carbon monoxide poisoning G13 Respiratory Distress Remove morphine for anxiety G16 Trauma – General Change morphine to fentanyl IV and IM. Modify indications and precautions G16 Trauma – Extremity Change morphine to fentanyl G17 Vomiting and Severe Nausea Changed reference from morphine to fentanyl. Removed co-administration comment (less likely). Consider

12-lead ECG P2 Cardiac Arrest Initial Care Under Compressions rate – state 100-120 and use metronome IFT1 IFT of STEMI patients Change morphine to fentanyl IV Procedure 12-lead Acquisition Add statement about continuous monitoring Procedure Spinal Immobilization Change to spinal motion restriction – revision after spinal immobilization task force (not done yet) Procedure Humeral IO Add to key procedures, modify vascular access, modify procedure manual (not yet done) Procedure Procedure – CO Monitoring (new) Add in Key Procedures Chart and add procedure Drug Adult Drug Reference Add fentanyl, remove morphine, remove D50, modify midazolam for behavioral sedation Drug Pediatric Drug Reference Add fentanyl, remove morphine Drug Color charts May Need to adjust for weight ranges to reflect new Broselow ranges (not done yet)

A2 ADULT

CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME / STEMI

OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94% CARDIAC MONITOR

ASPIRIN 325 mg po to be chewed by patient – DO NOT administer if patient has allergies to aspirin or salicylates or has apparent active gastrointestinal bleeding 12 – LEAD ECG Repeat ECGs are encouraged. Monitor 12-lead continuously. IV TKO

If ECG Does Not Indicate Acute MI or STEMI

NITROGLYCERIN

0.4 mg sublingual or spray - May repeat every 5 minutes until pain subsides, maximum 3 doses. Contact base hospital if further dosages indicated. IV placement prior to NTG recommended for patients who have not taken NTG previously. PRECAUTIONS: Do not administer NTG if: • Blood pressure below 90 systolic; • Heart rate below 50; • Patient has recently taken erectile dysfunction (ED) drugs:

o Viagra, Levitra, Staxyn or Stendra within 24 hours o Cialis within 36 hours

Consider FLUID BOLUS

500 ml NS if BP less than 90, lungs clear and unresponsive to supine positioning with legs elevated. May repeat X 1.

Consider FENTANYL CITRATE

50-200 mcg IV titrated in 25-50 mcg increments (consider 25 mcg increments in elderly patients). Consider earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort.

Acute MI / STEMI Noted by 12-Lead ECG

NITROGLYCERIN Do not administer Nitroglycerin if Acute MI / STEMI noted on 12-lead ECG. Exception: Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no other contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs)

STEMI ALERT Transmit ECG to STEMI Center and contact as soon as possible to notify facility of transport. Enter patient identifiers prior to transmission. EARLY TRANSPORT Minimize scene time

FLUID BOLUS • 500 ml NS for Inferior MI (elevation in leads II, III, aVF) if lungs clear

(regardless of blood pressure) • 500 ml NS if BP less than 90, lungs clear and unresponsive to positioning.

May repeat up to X 3.

Consider FENTANYL CITRATE

50-200 mcg IV in 50 mcg increments (consider 25 mcg increments in elderly patients). Consider earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. Caution: If Inferior MI suspected, use 25-50 mcg increments and observe carefully for hypotension

Key Treatment Considerations • Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm,

nausea, diaphoresis, dyspnea (shortness of breath), anxiety • Diabetic, female or elderly patients more frequently present atypically • Atypical symptoms can include syncope, weakness or sudden onset fatigue • Many STEMI’s evolve during prehospital period and are not noted on initial 12-lead ECG • ECG should be obtained prior to treatment for bradycardia if condition permits • Transmit all 12-lead ECGs - whether STEMI is detected or not detected

A3 ADULT CARDIAC ARREST – INITIAL CARE AND CPR

ESTABLISH TEAM LEADER

• First agency on scene assumes leadership role • Leadership role can be transferred as additional personnel arrive

CONFIRM ARREST • Unresponsive, no breathing or agonal respirations, no pulse

COMPRESSIONS

Begin Compressions: • Rate – 100-120 per minute. Use metronome. • Depth - 2 inches in adults – allow full recoil of chest (lift heel of hand) • Rotate compressors every 2 minutes if manual compression used Minimize interruptions. If necessary to interrupt, limit to 10 seconds or less. • Perform CPR during charging of defibrillator • Resume CPR immediately after shock (do not stop for pulse or rhythm check) Prepare mechanical compression device (if available) • Apply with minimal interruption • Should be placed following completion of at least one 2-minute manual CPR

cycle or at end of subsequent cycle

AED or MONITOR/ DEFIBRILLATOR

• Apply pads while compressions in progress • Determine rhythm and shock, if indicated • Check rhythm every 2 minutes • Follow specific treatment guideline based on rhythm

BASIC AIRWAY MANAGEMENT and VENTILATION

• Open airway and provide 2 breaths after every 30 compressions • Avoid excessive ventilation – no more than 8 – 10 ventilations per minute • Ventilations should be about 1 second each, enough to cause visible chest rise • Use two-person BLS Airway management (one holding mask and one

squeezing bag) • If available, use ResQPOD with two-person BLS airway management

IV / IO ACCESS • IO access is preferred unless no suitable site is available • If IV used (no IO access), antecubital vein is preferred • Hand veins and other smaller veins should not be used in cardiac arrest

ADVANCED AIRWAY

• Placement of advanced airway is not a priority during the first 5 minutes of resuscitation unless no ventilation is occurring with basic maneuvers o Exception: If ResQPOD used, early use of King Airway is appropriate

• Placement of King Airway or endotracheal tube should not interrupt compressions for more than 10 seconds

• For endotracheal intubation, position and visualize airway prior to cessation of CPR for tube passage. Immediately resume compressions after tube passage.

• Confirm tube placement and provide on-going monitoring using end-tidal carbon dioxide monitoring

TREATMENT ON SCENE

• Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions, which may be detrimental to patient outcome

• Provide resuscitative efforts on scene up to 30 minutes to maximize chances of return of spontaneous circulation (ROSC)

• If resuscitation does not attain ROSC, consider cessation of efforts per policy

A4 ADULT

VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3) DEFIBRILLATION 200 joules (low energy 120 joules) CPR For 2 minutes or 5 cycles between rhythm check

VENTILATION/AIRWAY • BLS airway is preferred method during first 5 -6 minutes of CPR • If no ventilation occurring with basic maneuvers, proceed to advanced airway

IO or IV TKO. Should not delay shock or interrupt CPR DEFIBRILLATION 300 joules (low energy 150 joules) EPINEPHRINE 1:10,000 - 1 mg IV or IO every 3-5 minutes DEFIBRILLATION 360 joules (low energy 200 joules) AMIODARONE 300 mg IV or IO DEFIBRILLATION 360 joules (low energy 200 joules) as indicated after every CPR cycle

ADVANCED AIRWAY • Should not interfere with initial 5-6 minutes of CPR – minimize interruptions • Do not interrupt compressions more than 10 seconds to obtain airway

Consider repeat AMIODARONE If rhythm persists, 150 mg IV or IO, 3-5 minutes after initial dose

TRANSPORT If indicated. If return of spontaneous circulation (ROSC), patient should be transported to a STEMI center. Patients without ROSC should be transported to closest facility.

Consider SODIUM BICARBONATE 1 mEq/kg IV or IO for suspected hyperkalemia or pre-existing acidosis

If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)

Key Treatment Considerations • Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance

takes precedence over advanced airway management and administration of medications. • To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock

administered (no pulse or rhythm check) • Rotate compressors every 2 minutes

• Avoid excessive ventilation. Provide no more than 8-10 ventilations per minute. • Ventilations should be about one second each, enough to cause visible chest rise • If advanced airway placed, perform CPR continuously without pauses for ventilation

• If available, ResQPOD impedance threshold device may be used with BLS airway or King / ET tube • If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and

performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage.

• Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement. Continuous monitoring with ETCO2 is mandatory – if values less than 10 mm Hg seen, assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earliest indicator of return of circulation.

• Prepare drugs before rhythm check and administer during CPR • Follow each drug with 20 ml NS flush

• Fingerstick glucose determinations are unreliable during cardiac arrest. Glucose checks should be reserved for patients with return of spontaneous circulation.

A5 ADULT PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3)

EPINEPHRINE 1:10,000 1 mg IV or IO every 3-5 minutes

Consider treatable causes – treat if applicable: Consider FLUID BOLUS For hypovolemia: 500-1000 ml NS IV or IO

VENTILATION For hypoxia: Ensure adequate ventilation (8-10 breaths per minute)

Consider SODIUM BICARBONATE

For pre-existing acidosis (e.g. kidney failure), hyperkalemia, or tricyclic antidepressant overdose are suspected: • 1 mEq/kg IV or IO if indicated • Should not be used routinely in cardiac arrest

Consider CALCIUM CHLORIDE

For hyperkalemia or calcium channel blocker overdose: • 500 mg IV or IO – may repeat in 5-10 minutes • Should not be used routinely in cardiac arrest

Consider WARMING MEASURES For hypothermia

Consider NEEDLE THORACOSTOMY For tension pneumothorax

If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)

Consider TERMINATION OF RESUSCITATION

Patients who have all of the following criteria are highly unlikely to survive: • Unwitnessed Arrest and • No bystander CPR and • No shockable rhythm seen and no shocks delivered during resuscitation and • No return of spontaneous circulation (ROSC) during resuscitation Patients with asystole or PEA whose arrests are witnessed and/or who have had bystander CPR administered have a slightly higher likelihood of survival. If unresponsive to interventions these patients should be considered for termination of resuscitation.

TRANSPORT If indicated. If return of spontaneous circulation (ROSC), patient should be transported to a STEMI center. Patients without ROSC should be transported to closest facility.

Key Treatment Considerations • Atropine is no longer used in cardiac arrest • Pre-existing acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or if

suspected diabetic ketoacidosis • In clear-cut traumatic arrest situations, epinephrine is not indicated in PEA or asystole. If any doubt as

to cause of arrest, treat as a non-traumatic arrest (e.g. solo motor vehicle accident at low speed in older patients).

• Fingerstick glucose determinations are unreliable during cardiac arrest. Glucose checks should be reserved for patients with return of spontaneous circulation.

A6 - ADULT SYMPTOMATIC BRADYCARDIA - Heart rate less than 50 with signs or symptoms of poor perfusion (e.g., acute altered mental status, hypotension, other signs of shock). Correction of hypoxia should be addressed prior to other treatments.

OXYGEN BLS: High flow initially ALS: Titrate to sPO2 of at least 94% CARDIAC MONITOR

IV TKO. If not promptly available, proceed to external cardiac pacing. Consider IO ACCESS if patient in extremis and unconscious or not responsive to painful stimuli. Consider FLUID BOLUS 250-500 ml NS if clear lung sounds and no respiratory distress

12-LEAD ECG Consider pre- and post-treatment if condition permits TRANSCUTANEOUS PACING

Set rate at 80 Start at 10 mA, and increase in 10 mA increments until capture is achieved

Consider SEDATION

If pacing urgently needed, sedate after pacing initiated • MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg increments

(maximum dose 5 mg), and/or • FENTANYL CITRATE 25-100 mcg IV or IO in 25-50 mcg increments for pain

relief if BP 90 systolic or greater

Consider ATROPINE

May be used as a temporary measure while awaiting transcutaneous pacing but should not delay initiation onset of pacing • 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective • Consider repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3 mg Use with caution in patients with suspected ongoing cardiac ischemia Atropine should not be used in wide-QRS second- and third-degree blocks

TRANSPORT

A10 ADULT SHOCK / HYPOVOLEMIA

HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with dry lungs, flat neck veins • May have poor skin turgor, history of GI bleeding, vomiting or diarrhea, altered level of

consciousness • May be warm and flushed, febrile, may have respiratory distress • Sepsis patients may or may not have an associated fever CARDIOGENIC SHOCK • Signs/symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema HYPOVOLEMIA WITHOUT SHOCK • No signs of shock, but history of poor fluid intake or fluid loss (e.g. vomiting, diarrhea). May

have tachycardia, poor skin turgor. OXYGEN BLS/ALS: High flow. Be prepared to support ventilations as needed.

Consider CPAP If suspected pulmonary edema / cardiogenic shock ADDRESS HYPOTHERMIA Keep patient warm if suspected hypothermia

CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline

EARLY TRANSPORT CODE 3

IV or IO TKO only if suspected pulmonary edema

FLUID BOLUS • For hypovolemic or septic shock, 500 ml NS bolus. May repeat once. • For hypovolemia (poor intake/fluid loss), 250 ml NS bolus. May repeat X 1.

Do not administer bolus if pulmonary edema or cardiogenic shock suspected

Consider 12-LEAD ECG If cardiac etiology for shock suspected

SEPSIS SCREEN

Check temperature, use sepsis screening tool and advise hospital of positive sepsis screen if indicated A positive sepsis screen in adults occurs in the setting of suspected infection when 2 of 3 conditions are met: • Heart rate/pulse greater than 90; • Respiratory rate greater than 20; • Temperature above 100.4 or below 96

BLOOD GLUCOSE Check and treat if indicated

Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12)

A12 ADULT

PUBLIC SAFETY DEFIBRILLATION BLS / LAW ENFORCEMENT

SCENE SAFETY / BSI Use universal blood and body fluid precautions at all times

CONFIRM Unconscious, pulseless patient with no breathing or no normal breathing

COMPRESSIONS

• Begin compressions at a rate of at least 100-120 per minute • Compress chest at least 2 inches and allow full recoil of chest (lift heel of hand) • Change compressors every 2 minutes • Minimize interruptions in compressions. If necessary to interrupt, limit to 10

seconds or less. • Stop compressions for analysis only – resume compressions while AED is charging • Resume compressions immediately after any shock • If available, place mechanical compression device after first rhythm analysis or

after subsequent rhythm analysis (LUCAS or Auto-Pulse)

AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

• Priority of second rescuer is to apply pads while compressions are in progress • If less than 8 years of age, attach pediatric electrodes, if available. If not, attach adult

electrodes with anterior-posterior placement (pads should not touch). • (*) Allow AED to analyze heart rhythm

o If the rhythm is shockable Resume compressions until charging of unit is complete Clear bystanders and crew (stop compressions) Deliver shock Resume CPR for 2 minutes, beginning with chest compressions – then return to (*)

o If the rhythm is NOT shockable (“No Shock Advised”) Resume CPR for 2 minutes, beginning with chest compressions – then return to (*)

BASIC AIRWAY MANAGEMENT and VENTILATION

Open airway and provide 2 breaths after every 30 compressions • AVOID EXCESSIVE VENTILATION – Provide no more than 8 –10 ventilations per minute • Ventilations should be about one second each, enough to cause visible chest rise. Use

two-person BLS Airway management (one holding mask and one squeezing bag – compressor can squeeze the bag)

If patient begins to breathe or becomes responsive: • Maintain airway • Assist ventilations as necessary

CHECK BLOOD PRESSURE

If patient begins to breathe or becomes responsive: • Check blood pressure if equipment available

DOCUMENTATION • Complete AED Use Report • Forward report to EMS whenever an AED is used (whether shock administered or not)

G1 GENERAL

ANAPHYLAXIS / ALLERGY • Systemic reactions (anaphylaxis) include upper and lower respiratory tracts, gastrointestinal or

vascular system. Symptoms include dyspnea, stridor, change in voice, wheezing, anxiety, tachycardia, tightness in chest, vomiting, diarrhea, abdominal pain, dizziness or hypotension

• Serious systemic reactions may involve hypotension alone without respiratory or skin findings • Skin and mucous membrane reactions (swelling of face, lip, tongue, palate), may be seen in either

uncomplicated allergic reactions or in anaphylaxis

OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94% EPI-PEN May assist with administration of patient’s auto-injector

CARDIAC MONITOR If systemic reaction (anaphylaxis):

EPINEPHRINE 1:1000 IM

• Adult – 0.3-0.5 mg IM (use 0.3 mg in elderly, small patients or mild symptoms) Pediatric – 0.01 mg/kg IM – maximum dose 0.3 mg May repeat in 15 minutes if systemic symptoms persist Lateral thigh site should be used for IM injection (fastest absorption)

ALBUTEROL Adult and pediatric - 5 mg/6 ml saline via nebulizer – may repeat as needed

IV TKO Consider FLUID BOLUS

• Adult – wide-open NS if hypotensive. Recheck vitals after every 250 ml Pediatric - 20 ml/kg NS bolus if hypotensive, may repeat X 2

If skin or mucous membrane reactions (itching, hives or facial/oral swelling), consider:

DIPHENHYDRAMINE • Adult - 50 mg slow IV or IM

Consider 25 mg dose if patient has taken po diphenhydramine Pediatric – 1 mg/kg IV or IM – Maximum dose 50 mg

Consider 0.5 mg/kg dose if patient has taken po diphenhydramine

If serious progression of symptoms after treatment with IM epinephrine: • Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis, severe

respiratory distress or respiratory arrest Consider IO If IV access not immediately available

FLUID BOLUS • Adult - wide open NS. Recheck vitals after every 250 ml Pediatric - 20 ml/kg NS bolus, may repeat X 2

Consider EPINEPHRINE 1:10,000 IV

If patient not responsive to IM epinephrine treatment in 5-10 minutes:

• Adult - titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg Use extreme caution with patients with cardiac history, angina, hypertension

Pediatric - titrate in up to 0.1 mg doses slow IV or IO to a maximum of 0.01 mg/kg

Key Treatment Considerations • Epinephrine IM administered early is the cornerstone of treatment in anaphylaxis

o Epinephrine is well tolerated in pediatric patients and healthy young adults o In patients with prior history of coronary artery disease (angina, MI, stent placement), use of

epinephrine IM is still indicated if symptoms are moderate to severe. If symptoms mild, careful observation is prudent. Consider base contact if any questions

• Diphenhydramine and albuterol are secondary considerations in anaphylaxis • Up to 20% of anaphylaxis patients may present without any skin findings (e.g. hives) • Gastrointestinal symptoms may predominate in some patients, especially with serious reactions to food • In pediatric patients, hypotension is late sign of shock Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

G2 GENERAL ALTERED LEVEL OF CONSCIOUSNESS

Glasgow Coma Scale less than 15 – uncertain etiology. Consider AEIOU/TIPPS

OXYGEN BLS: High flow initially. ALS: Titrate to sPO2 of at least 94%. Be prepared to support ventilations as needed.

ORAL GLUCOSE Consider if known diabetic, conscious, able to sit upright, able to self-administer • Adult - 30 g po Pediatric – 15-30 g po

CARDIAC MONITOR

BLOOD GLUCOSE Check level

EARLY TRANSPORT In patients with ALOC without low blood sugar

IV TKO NS

DEXTROSE 10% If glucose 60 or less: • Adult – DEXTROSE 10% 100 ml IV Pediatric – DEXTROSE 10% 0.5 g/kg IV (5 ml/kg)

GLUCAGON

If unable to establish IV (at least 2 attempts or if unable to find suitable site): • Adult – 1 mg IM Pediatric – 24 kg or more – 1 mg IM Pediatric – Less than 24 kg – 0.5 mg IM

BLOOD GLUCOSE Recheck if symptoms not resolved. If GLUCAGON has been administered, change in glucose/mentation may require 15 minutes or more. DEXTROSE 10% Repeat additional DEXTROSE 10% 150 ml IV if glucose remains 60 or less.

DEXTROSE 50% Administer DEXTROSE 50% 25 g IV if glucose remains 60 or less after full Dextrose 10% dose given (250 ml) Related guideline: Respiratory Depression or Apnea (G12)

Key Treatment Considerations • Naloxone should not be given as treatment for altered level of consciousness in the absence of

respiratory depression (respiratory depression = rate of less than 12 breaths per minute) • After treatment(s) for hypoglycemia, recheck glucose before considering repeat treatment. Mental

status improvement may lag behind improved glucose levels (especially in elderly patients or prolonged hypoglycemia). Further treatment when glucose is 60 or above is not indicated.

• Oral glucose is the preferred treatment when patient is able to take medication orally • Dextrose 10% is the preferred treatment when patient is unable to take oral medication • Glucagon should not be administered if patient able to take oral glucose and should be administered

only if IV starts are unsuccessful or no suitable IV sites found. It may not be effective in patients with starvation, poor oral intake, alcoholism or alcohol intoxication.

• Glucagon may take 10-15 minutes or longer to increase glucose level (peak effects in 45-60 minutes) Wait for 10-15 minutes for recheck glucose before considering additional treatment

• For diabetics with insulin pumps, the amount of insulin administered by the pump is very small and should not impede treatment of hypoglycemia. Insulin pumps should not be discontinued because of the development of hypoglycemia.

• The presence of the pump should be identified during patient report at the hospital.

• Transport is highly recommended in patients with hypoglycemia as a result of oral diabetic medications and patients over 65 years of age (higher risk of recurrent hypoglycemia).

• Transport is also highly recommended for any hypoglycemic patient who is not a diabetic (may occur with renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses and sulfa drugs or following bariatric surgery).

• Consider transport earlier in patients with poor vascular access who are not responding to glucagon or have reasons listed above for possible impaired response to glucagon

Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for D10 dose.

G3 GENERAL BEHAVIORAL EMERGENCY

• A behavioral emergency is defined as combative or irrational behavior not caused by medical illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated states or other conditions

• Combative or irrational behavior may be caused by psychiatric or other behavioral disorder

• History of event and past history are important in patient evaluation

• Past history of psychiatric condition does not eliminate need to assess for other illnesses

SCENE SAFETY • Many patients merit a weapons search by law enforcement • Physical restraints may be needed if patient exhibits behavior that presents a

danger to him/herself or others

ASSESS PATIENT • Assess for evidence of hypoxia, hypoglycemia, trauma • Consider other medical causes for behavioral symptoms

VITAL SIGNS Obtain vital signs as possible

Consider OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94% CARDIAC MONITOR Place as possible / safe

Consider BLOOD GLUCOSE Obtain as possible / safe

Consider CHEMICAL RESTRAINT

BASE ORDER REQUIRED Despite verbal de-escalation and physical restraint, if adult patient (15 years or older) remains extremely combative and struggling against restraints, consider: • MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small

patients (under 50 kg). • MIDAZOLAM 1-3 IV mg in 1 mg increments if IV established and patent.

Contact base if further medication needed.

MONITOR PATIENT Monitor closely for respiratory compromise. Assess and document mental status, vital signs, and extremity exams (if restrained) at least every 15 minutes. Related guidelines: Altered Level of Consciousness (G2), Trauma (G16)

Key Treatment Considerations • Calming measures may be effective and may preclude need for restraint in some circumstances • Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if

possible, but maintain contact with other personnel and ability to exit rapidly. • Avoid violating patient’s personal space, making direct eye contact or sudden movements. Frequent

reassurance and calm demeanor of personnel are important.

• Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position. • Assure adequate resources available to manage patient’s needs. Restraint may require up to five

persons to safely control patient. • Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior • In pediatric patients, consider child’s developmental level when providing care • Sedation with Midazolam intended for adult patients only (age 15 and over) • Not all patients will respond to Midazolam. Repeat dosage is not recommended - requires base order.

G4 GENERAL BURNS

• Damage to the skin caused by contact with caustic material, electricity, or fire • Second or third degree burns involving 20% of the body surface area, or those associated with

respiratory involvement are considered major burns SCENE SAFETY

STOP BURNING PROCESS • Remove contact with agent, unless adhered to skin • Brush off chemical powders • Flush with water to stop burning process or to decontaminate

OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94%

BURN CARE Protect the burned area. Do not break blisters, cover with clean dressings or sheets. Remove restrictive clothing/jewelry if possible. Assess for associated injuries Assess for associated injuries if other trauma suspected

Consider IV or IO TKO

Consider FENTANYL CITRATE IV

For pain relief in the absence of hypotension (systolic BP less than 90), significant other trauma, altered level of consciousness: • Adult – 50-200 mcg IV or IO, titrated in 25-50 mcg increments

(consider 25 mg increments in elderly patients). Pediatric – 1 mcg/kg IV – See Pediatric Drug Chart

Consider FENTANYL CITRATE Intranasal

If IV or IO access not available: • Adult – 100 mcg Intransal – may repeat once in 15 minutes Pediatric – 1.5 mcg/kg Intranasal – See Pediatric Drug Chart

Consider FENTANYL CITRATE IM

If IV or IO access not available and intranasal route not advisable: • Adult – 50-100 mcg IM – may repeat once in 15 minutes Pediatric – 1 mcg/kg IM – See Pediatric Drug Chart

Key Treatment Considerations • Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or

edematous mucosa in mouth are clues) • Transport to closest receiving facility for advanced airway management if it cannot be done on scene in

a timely manner. Do not wait for helicopter (air ambulance) if airway patency is a concern and care can be provided more rapidly at a receiving facility.

• Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia.

• Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section)

Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

G10 GENERAL PAIN MANAGEMENT (NON-TRAUMATIC)

• Patients of all ages expressing verbal or behavioral indicators of pain shall have an appropriate assessment and management of pain

• Fentanyl should be given in sufficient amount to manage pain but not necessarily to eliminate it Consider OXYGEN

BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94%

IV TKO

ASSESS PAIN • Assess and document the intensity of the pain using the visual analog scale • Reassess and document the intensity of the pain after any intervention that

could affect pain intensity

PAIN RELIEF MEASURES

• Psychological measures and BLS measures, including cold packs, repositioning, splinting, elevation, and/or traction splints, are important considerations for patients with pain

• If pain cannot be managed using above measures, consider FENTANYL CITRATE, especially in patients reporting pain levels of 5 or greater

Consider FENTANYL CITRATE IV

See contraindications and cautions below: For pain relief: • Adult – 50-200 mcg IV, titrated in 25-50 mcg increments to pain relief

(consider 25 mg increments in elderly patients) Pediatric – 1 mcg/kg IV – See Pediatric Drug Chart

Consider FENTANYL CITRATE Intranasal

If no IV access: • Adult - 100 mcg Intranasal. May repeat once in 15 minutes. Pediatric – 1.5 mcg/kg Intranasal – See Pediatric Drug Chart

Consider FENTANYL CITRATE IM

If no IV access and intranasal route not advisable: • Adult - 50-100 mcg IM. May repeat once in 15 minutes. Pediatric 1 mcg/kg IM – See Pediatric Drug Chart

Contraindications and Cautions for Fentanyl Citrate Contraindications for Fentanyl Citrate:

• Closed head injury • Altered level of consciousness • Headache • Respiratory failure or worsening

respiratory status • Childbirth or suspected active

labor

• Hypotension o Adults - Systolic BP less than 90 o Pediatric - Hypotension or impaired perfusion

(e.g. capillary refill > 2 seconds) Infants 1mo-1yr systolic BP < 60 mmHg Toddler 1-4 yrs systolic BP < 75 mmHg School age 5-13 yrs systolic BP < 85 mmHg Adolescent >13 yrs systolic BP < 90 mmHg

Cautions for Fentanyl: • Use with caution in patients with suspected drug or alcohol ingestion or with suspected hypovolemia • Older patients may be more sensitive to fentanyl – consider 25 mcg increments IV initially • Patients with Inferior MI (STEMI with ST elevation in II, III, aVF) may develop hypotension with morphine

o Give 1-2 mg increments IV and administer fluid bolus when indicated Key Treatment Considerations

• Have Naloxone available to reverse respiratory depression should it occur • Preferred route of administration for Fentanyl Citrate is IV • Intranasal route is preferred if IV not available and patient does not have suspected hypovolemia Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

G11 GENERAL POISONING - OVERDOSE

• If possible, determine substance, amount ingested, time of ingestion. Bring in container or label. • Be careful not to contaminate yourself and others

DECONTAMINATION Remove contaminated clothing, brush off powders, wash off liquids Irrigate eyes if affected

OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94%. Be prepared to support ventilation. CARDIAC MONITOR

Consider IV TKO if unstable patient or suspected serious ingestion

Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2), Seizures (G14), Shock/Hypovolemia (A10, P8)

TRICYCLIC ANTIDEPRESSANT OVERDOSE • Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes

and associated ventricular arrhythmias are generally signs of a life-threatening ingestion.

SODIUM BICARBONATE For adults only: For life-threatening hemodynamically significant dysrhythmias, 1 mEq/kg slow IV or IO

ORGANOPHOSPHATE POISONING • Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness,

small/pinpoint pupils, muscle twitching, and/or seizures may occur

ATROPINE For adults only: 1-2 mg IV • Repeat every 3-5 minutes as necessary until relief of symptoms • Large doses of Atropine may be required

HYDROFLUORIC ACID EXPOSURE

CALCIUM CHLORIDE For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10% solution)

Consider FENTANYL CITRATE IV

For adults only: In the absence of hypotension, significant other trauma or altered level of consciousness: 50-200 mcg IV titrated in 25-50 mcg increments to pain relief

Consider FENTANYL CITRATE IM

For adults only: If no IV access, 50-100 mcg IM. May repeat once in 15 minutes.

Consider FENTANYL CITRATE Intranasal

For adults only: If no IV access, 100 mcg intranasal. May repeat once in 15 minutes.

Key Treatment Considerations • Few overdoses have specific antidotes. Supportive care is the mainstay of treatment.

Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients

• Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium Channel Blocker overdose)

• Poison Control Center can offer information but cannot provide medical direction to EMS

SUSPECTED CARBON MONOXIDE POISONING • Symptoms may be diverse and often non-specific. Headache, dizziness, fatigue and

nausea are most common symptoms. • Neurologic symptoms may include confusion, lethargy, drowsiness, agitation, coma,

syncope, seizure or bizarre neurologic symptoms. • Other symptoms may include chest pain, palpitations, dyspnea, weakness, or flu-like

symptoms. • Evaluate for CO poisoning in suspected smoke inhalation • Suspect and evaluate in situations when multiple patients have symptoms • Consider evaluation when other causes for symptoms are not obvious OXYGEN BLS/ALS: High flow. Be prepared to support ventilations as needed CARDIAC MONITOR

CO-OXIMETRY Measure using manufacturer’s recommendation. May be unreliable if low perfusion, excessive patient motion, or excessive ambient light. Consider CPAP If patient compliant and co-oximetry readings are greater than X%. 12-lead ECG

TRANSPORT If patient pregnant or levels greater than X%, contact base hospital for potential destination determination IV TKO Related Guidelines: Chest Pain/Suspected ACS (A2), Seizure (G14)

G13 GENERAL RESPIRATORY DISTRESS

• Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema • Rales may be present in pneumonia, pulmonary edema, and many other conditions

INITIAL THERAPY OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94% CARDIAC MONITOR Consider CPAP If respiratory rate greater than 25, accessory muscle use, pulse ox less than 94% Consider IV TKO. Do not delay transport for vascular access if in extremis.

ASTHMA ALBUTEROL Adult and Pediatric – 5 mg in 6 ml NS via nebulizer. Repeat as needed.

Consider EPINEPHRINE 1:1000 SC (subcutaneously)

For use in asthma only: Use only if respiratory status deteriorating despite repeat treatment with Albuterol and transport time more than 10 minutes Do not use in patients with history of coronary artery disease or hypertension • Adult - 0.3 mg SC Pediatric - 0.01 mg/kg SC - max dose 0.3 mg Never give Epinephrine 1:1000 intravenously!

EPINEPHRINE 1:1000 IM

If respiratory arrest from asthma or bronchospasm: • Adult - 0.3 mg IM Pediatric - 0.01 mg/kg IM - max dose 0.3 mg

COPD EXACERBATION ALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed.

SUSPECTED PULMONARY EDEMA (ADULTS ONLY)

NITROGLYCERIN

0.4 mg sublingual if systolic BP between 90 and 149 0.8 mg sublingual if systolic BP 150 or greater Repeat every 5 minutes until symptoms improve Maximum dose 4.8 mg (12 - 0.4 mg doses) Discontinue if hypotension develops Caution: Do not administer if patient has taken erectile dysfunction medications Viagra, Levitra, Staxyn or Stendra within prior 24 hours or Cialis within 36 hours

(morphine deleted) Related guidelines – Chest pain / Suspected ACS (A2), Shock (A10)

Key Treatment Considerations • CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of

respiration will need assistance with BVM. • Patients with potential respiratory failure should be transported emergently • Patients requiring advanced airway management in these situations are best handled in the hospital

setting and CPAP may be a valuable “bridge” in care to potentially delay need for emergent intubation • IV access should not delay transport • For patients with significant anxiety or claustrophobia with CPAP, consider base contact for midazolam • For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If

blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg. • Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no other

contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs) • Consider cardiac etiology for diabetic patients with respiratory distress Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

G16 GENERAL TRAUMA - GENERAL

SPINAL IMMOBILIZATION As indicated

OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94% EARLY TRANSPORT Limit scene time to less than 10 minutes when possible. Load and go if high risk. WOUND / GENERAL CARE

Place splints, cold packs, dressings and pressure on bleeding sites as needed Keep patient warm – minimize exposure after assessment

Consider NEEDLE THORACOSTOMY Evaluate for and treat tension pneumothorax if indicated

IV TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS.

Consider FLUID BOLUS

Fluid resuscitation appropriate in adults if: • Head injury and hypotension (BP < 90 or unable to detect peripheral pulses) • No head injury but markedly hypotensive and unable to converse due to shock

Administer 250-500 ml NS, recheck vitals. Titrate to presence of peripheral pulses.

In pediatric patients with signs of poor perfusion or shock: Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2

BLOOD GLUCOSE Test if GCS less than 15. See Altered Level of Consciousness (G2). CARDIAC MONITOR

INDICATIONS AND PRECAUTIONS FOR FENTANYL USE

Fentanyl may be used for relief of extremity pain in the absence of head or torso trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in geriatric elderly patients or in patients with drug or alcohol intoxication.

FENTANYL CITRATE IV

See precautions above • Adult – 50-200 mcg IV in 25-50 mcg increments. Titrate to pain relief and

systolic BP greater than 100. Pediatric – 1 mcg/kg IV – See Pediatric Drug Chart

FENTANYL CITRATE IM

See precautions above When IV access not available (non-critical patients only): • Adult – 50-100 mcg IM – may repeat in 15 minutes Pediatric – 1 mcg/kg IM – See Pediatric Drug Chart

FENTANYL CITRATE Intranasal

See precautions above When IV access not available (non-critical patients only): • Adult – 100 mcg intranasal – may repeat once in 15 minutes • Pediatric – 1.5 mcg/kg intranasal– See Pediatric Drug Chart

Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Considerations

• ALS procedures in the field (IV or advanced airway) do not improve outcome in critical trauma patients o IV starts should be done en route on these patients o Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers

• Repeated IV attempts in non-critical pediatric patients should be avoided Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

G16 GENERAL TRAUMA – HEAD INJURY

AIRWAY CONTROL

• Basic airway management is preferred unless unable to manage with BLS maneuvers. Utilize jaw thrust technique to open airway.

• Intubation in head injury patients is best addressed at the hospital or with RSI (aeromedical capability)

• King Airway should be used only in arrest unless no other method to ventilate

VENTILATION

• Avoid hyperventilation if BVM used or patient with advanced airway. • Support respiratory rate to 10-12 per minute if slow. • Monitor patient with pulse oximetry and end-tidal CO2. Ideal ETCO2 is 35 mm Hg

– may be unreliable if multiple system trauma or poor perfusion. • In patients with a dilated pupil on one side or decerebrate/decorticate posturing

indicating impending brainstem herniation, modest hyperventilation (increase in rate of 2-4 per minute) is appropriate (keep ETCO2 30 or above)

CONTROL HEMORRHAGE

Scalp hemorrhage can be life threatening. Treat with direct pressure and pressure dressing.

TREAT HYPOTENSION

In adult patients, in the setting of hypotension (systolic BP 90 or less or absence of peripheral pulses), administer NS 250-500 ml. Repeat if necessary.

In pediatric patients with signs of poor perfusion or shock: Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2.

PATIENT POSITION

Elevate head of backboard 30 degrees unless contraindicated Position patient on side if needed for vomiting / airway protection

Consider ONDANSETRON

• Adults - for vomiting/nausea, 4 mg IV/IM. May repeat every 10 minutes to a total dose of 12 mg.

Pediatric – Limited to patients 4 years of age or older – 4 mg IV/IM For patients 40 kg and greater only, may repeat every 10 minutes to a total dose of 12 mg

G16 GENERAL TRAUMA - EXTREMITY

Consider TOURNIQUET

If vigorous hemorrhage not controlled with elevation and direct pressure on wound. May be used in pediatric patients. May be appropriate for hemorrhage control in multi-casualty situations.

SUSPECTED DISLOCATION If dislocation suspected or noted, splint in position found

AMPUTATIONS

• For partial amputations, splint in anatomic location and elevate extremity • If complete amputation, place amputated part in a dry container or bag and

place on ice. Seal or tie off bag and place in second container or bag. DO NOT place amputated part directly on ice or in water. Elevated extremity and dress with dry gauze.

PAIN RELIEF • Consider Fentanyl Citrate as directed in G16 Trauma - General Guideline CRUSH INJURY SYNDROME

• Caused by muscle crush injury and cell death. Most patients have an extensive area of involvement such as a large muscle mass in a lower extremity and/or pelvis.

• May develop after 1 hour in severe crush, but usually requires at least 4 hours of compression • Hypovolemia and hyperkalemia may occur, particularly in extended entrapments • Hyperkalemia should be suspected if ECG monitor reveals peaked ‘T’ waves, absent ‘P’ waves or

widened QRS complexes FLUID BOLUS 20 ml/kg NS prior to release of compression

IF ECG CHANGES SUGGEST HYPERKALEMIA:

ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer CALCIUM CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after administration of calcium chloride to avoid precipitation with sodium bicarbonate.

SODIUM BICARBONATE - 1 mEq/kg IV. Additionally, consider 1 mEq/kg added to IV 1L NS - use second IV line as other medications may not be compatible

G17 GENERAL VOMITING AND SEVERE NAUSEA

Vomiting or nausea may be due to viral illness (gastroenteritis) or other medical conditions including acute coronary syndrome, stroke, head injury, or toxic ingestion. It may be associated with a number of painful abdominal conditions, and may also occur as a result of treatment of pain with fentanyl.

Consider OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94%

POSITION PATIENT Position patient to avoid aspiration

NON-INVASIVE MEASURES Fresh air, oxygen, and removal of noxious odors may lessen nausea

Consider 12-LEAD ECG Cardiac events are often accompanied by gastrointestinal symptoms

Consider IV TKO

Consider FLUID BOLUS

Consider if patient has prolonged history of vomiting or poor intake, if vital signs or exam suggest volume depletion (rapid pulse, low blood pressure, dry mucous membranes, poor skin turgor, or capillary refill greater than 2 seconds) • Adult – 250-500 ml. Recheck vitals – may repeat X 1 Pediatric – 20 ml/kg. Recheck vitals – may repeat X 1.

Consider ONDANSETRON

For severe nausea or persistent vomiting: • Adult – 4 mg IV, IM, or po (oral disintegrating tablet - ODT). May repeat

every 10 minutes to a total of 12 mg. Pediatric – limited to patients 4 years of age or older – 4 mg IV, IM, or

po (ODT). For patients 40 kg and greater only, may repeat every 10 minutes to a total of 12 mg

NOTE: Administer IV dosage over 1 minute. Ondansetron is contraindicated if patient has a history of hypersensitivity to other similar drugs (Dolasetron – (Anzemet), granisetron (Kytril), or Palonosetron (Aloxi)

Related guidelines: Shock/Hypovolemia (A10), Pain Management (Non-Traumatic) (G10)

Key Treatment Considerations Rapid administration of ondansetron has been associated with increased incidence of side effects – most notably syncope. Ondansetron must be administered intravenously over 1 minute. Rare side effects of ondansetron include headache, dizziness, tachycardia, sedation, hypotension, or syncope. Rarely QT prolongation has been seen (with higher doses and rapid administration). Ondansetron can be used in pregnancy and with breast-feeding mothers

May be co-administered with MORPHINE SULFATE when used for pain relief

Oral disintegrating tablets should be handled with care as moisture may cause premature breakdown of tablets before administration Oral disintegrating tablets can be placed on tongue and do not need to be chewed. Medication will dissolve and be swallowed with saliva. Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

P2 PEDIATRIC CARDIAC ARREST – INITIAL CARE AND CPR

ESTABLISH TEAM LEADER

• First agency on scene assumes leadership role • Leadership role can be transferred as additional personnel arrive

CONFIRM ARREST • Unresponsive, no breathing or agonal respirations, no pulse

COMPRESSIONS

• Begin compressions at a rate of at least 100-120 per minute. Use metronome. • Compress chest approximately 1/3 of AP diameter of chest:

o In children (age 1-8) - around 2 inches o In infants (under age 1) – around 1 ½ inches

• Allow full chest recoil (lift heel of hand) • Change compressors every 2 minutes • Minimize any interruptions in compressions. If necessary to interrupt, limit to 10

seconds or less. • Do not stop compressions while defibrillator is charging • Resume compressions immediately after any shock

AED or MONITOR/ DEFIBRILLATOR

• Apply pads while compressions in progress • Determine rhythm and shock, if indicated • Follow specific treatment guideline based on rhythm

BASIC AIRWAY MANAGEMENT and VENTILATION

• Open airway – For 2-person CPR: o Provide 2 breaths:30 compressions for children over age 8 o Provide 2 breaths:15 compressions for infants > 1 month & children to age 8

• Avoid Excessive Ventilation • Ventilations should last one second each, enough to cause visible chest rise • Use 2-person BLS Airway management (one holding mask and one squeezing

bag)

MEDICATIONS AND DEFIBRILLATION

• Use length-based tape to determine weight • If child is obese and length-based tape used to determine weight, use next

highest color to determine appropriate equipment and drug dosing

• See Pediatric Drug Chart for medication dose and defibrillation energy levels

ADVANCED AIRWAY MANAGEMENT and END-TIDAL CO2 MONITORING

For patients 40 kg or greater only: • Placement of advanced airway is not a priority during the first 5 minutes of

resuscitation unless no ventilation is occurring with basic maneuvers. • Placement of endotracheal tube or King Airway should not interrupt

compressions for a period of more than 10 seconds • For endotracheal intubation, position and visualize airway prior to cessation of

CPR for tube passage. • Confirm tube placement and provide ongoing monitoring using end-tidal carbon

dioxide monitoring

BLOOD GLUCOSE Treat if indicated. Glucose may be rapidly depleted in pediatric arrest.

PREVENT HYPOTHERMIA

Move to warm environment and avoid unnecessary exposure • Pediatric arrest victims are at risk for hypothermia due to their increased body

surface area, exposure and can be exacerbated by rapid administration of IV/IO fluids

TRANSPORT Consider rapid transport to definitive care

IFT 1 TRANSFER INTERFACILITY TRANSFER OF STEMI PATIENTS

Patients with ST-elevation Myocardial Infarction (STEMI) needing interventional cardiac care require timely transfer. A scene time of 10 minutes or less at the sending facility is ideal.

OXYGEN BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to sPO2 of at least 94% Monitor IV Maintain TKO or other existing flow rate Prompt Transport Transfer for definitive care is the priority in STEMI patients

Consider FENTANYL CITRATE IV

50-200 mcg IV in 25-50 mcg increments (consider 25 mcg increments in elderly patients). Patients with STEMI often do not get complete relief with medication. Caution: If Inferior MI suspected, use 25-50 mcg increments and observe carefully for hypotension

Key Treatment Considerations Treatment during interfacility transfer varies from field approach to chest pain/ACS: • Confirmatory ECG for STEMI has been done by hospital and does not need repeat prior to transfer or en

route to accepting facility • Nitroglycerin treatment is not required and generally ineffective in patients with confirmed STEMI Aspirin or other anti-platelet treatment if indicated should be administered by sending hospital prior to patient departure

Patients generally will be directed directly to catheterization laboratory Outcome in STEMI patients directly related to timeliness of intervention to relieve coronary artery blockage. Minimizing time delay in transfer is essential.

12-LEAD MONITORING AND LEAD PLACEMENT

Limb Lead Placement: Place limb leads on distal extremities if possible Confirm correct lead placement for each limb May be moved to proximal if needed (if motion artifact)

Chest Lead Placement: To begin placement of chest leads, locate sternal angle (2nd ribs are adjacent) then count down to 4th interspace (below 4th rib)

V1 – 4th intercostal space at the right sternal border V2 – 4th intercostal space at the left sternal border V4 – 5th intercostal space at left midclavicular line Note: Place V4 lead first to aid in correct placement of V3 V3 – Directly between V2 and V4 V5 – Level of V4 at left anterior axillary line V6 – Level of V4 at left mid-axillary line

IMPORTANT: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG

Once leads have been placed, 12-lead monitoring should continue throughout call to assess for potential changes.

Sternal angle

KEY PROCEDURES Skill Indication / Comment Contraindication

12-Lead ECG

• Chest pain or suspected Acute Coronary

Syndrome (ACS) • Atypical ACS or anginal equivalents:

o Symptoms include shortness of breath, diaphoresis, syncope, dizziness, weakness, and altered level of consciousness

o Elderly patients, females and diabetics are more likely to present atypically

• Arrhythmias (both pre- and post-conversion) • Suspected cardiogenic shock • Cardiac arrest after return of spontaneous

circulation

• Uncooperative patient • Any condition in which delay to

obtain ECG would compromise immediately needed care (e.g. arrhythmia requiring immediate shock)

Autopulse (SRVFPD) • Cardiac Arrest in Adults

• Pediatric patients • Trauma patients • Patients too small or large for

the compression band

Blood Glucose Testing

• Altered level of consciousness • Patients with signs and symptoms of

hypoglycemia (may include diaphoresis, weakness, hunger, shakiness, anxiety)

• Patients not meeting any indication

Co-Oximetry (Carbon Monoxide)

• Suspected carbon monoxide poisoning • May be unreliable with poor perfusion, excessive

patient motion or excessive ambient light • None

PARAMEDIC SCOPE OF PRACTICE California Code of Regulations, Title 22, Division 9, Chapter 4: 100145. Scope of Practice of Paramedic. a) A paramedic may perform any activity identified in the scope of practice of an EMT in Chapter 2 of the

Division, or any activity identified in the scope of practice of an Advanced EMT in Chapter 3 of this Division.

b) A paramedic shall be affiliated with an approved paramedic service provider in order to perform the scope of practice specified in this Chapter.

c) A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a hospital as part of his/her training or continuing education under the direct supervision of a physician, registered nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during interfacility transfer, or while working in a small and rural hospital pursuant to section 1797.195 of the Health and Safety Code, may perform the following procedures or administer the following medications when such are approved by the medical director of the local EMS agency and are included in the written policies and procedures of the LEMSA. 1) Basic Scope of Practice:

A) Utilize electrocardiographic devices and monitor electrocardiograms, including 12-lead electrocardiograms.

B) Perform defibrillation, synchronized cardioversion, and external cardiac pacing. C) Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps. D) Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal

airway, perilaryngeal airways, stomal intubation, and adult oral endotracheal intubation. E) Utilize mechanical ventilation devices for continuous positive airway pressure (CPAP), bi-level

positive airway pressure (BPAP) and positive end expiratory pressure (PEEP) in the spontaneously breathing patient.

F) Institute intravenous (IV) catheters, saline locks, needles, or other cannulae (IV lines), in peripheral veins; and monitor and administer medications through pre-existing vascular access.

G) Institute intraosseous (IO) needles or catheters H) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer's

lactate solution. I) Obtain venous blood samples.

J) Use laboratory devices, including point of care testing, for pre-hospital screening use to measure lab values including, but not limited to: glucose, capnometry, capnography, and carbon monoxide when appropriate authorization is obtained from State and Federal agencies, including from the Centers for Medicare and Medicaid Services pursuant to the Clinical Laboratory Improvement Amendments (CLIA).

K) Utilize Valsalva maneuver. L) Perform needle cricothyroidotomy. (not currently used in Contra Costa County) M) Perform needle thoracostomy N) .Perform nasogastric and orogastric tube insertion and suction (not currently used in Contra

Costa County) O) Monitor thoracostomy tubes P) Monitor and adjust IV solutions containing potassium, equal to or less than 40 mEq/L. Q) Administer approved medications by the following routes: IV, IO, intramuscular, subcutaneous,

inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or topical. R) Administer, using prepackaged products when available, the following medications:

(1) 10%, 25% and 50% dextrose; (2) activated charcoal; (not currently used in Contra Costa County) (3) adenosine; (4) aerosolized or nebulized beta-2 specific bronchodilators; (5) amiodarone; (6) aspirin; (7) atropine sulfate; (8) pralidoxime chloride; (9) calcium chloride; (10) diazepam; (not currently used in Contra Costa County) (11) diphenhydramine hydrochloride; (12) dopamine hydrochloride; (not currently used in Contra Costa County) (13) epinephrine;

(14) fentanyl; (15) glucagon; (16) ipratropium bromide (not currently used in Contra Costa County) (17) lorazepam (18) midazolam (19) lidocaine hydrochloride; (20) magnesium sulfate; (21) morphine sulfate; (22) naloxone hydrochloride; (23) nitroglycerin preparations, except IV, unless permitted under (c)(2)(A) of this section; (24) ondansetron (25) sodium bicarbonate

PARAMEDIC SCOPE OF PRACTICE (continued) – LOCAL OPTIONAL SCOPE Paramedic Regulations (continued) 2) Local Optional Scope of Practice: A) Perform or monitor other procedure(s) or administer any other medication(s) determined to be

appropriate for paramedic use, in the professional judgment of the medical director of the local EMS agency, that have been approved by the Director of the Emergency Medical Services Authority when the paramedic has been trained and tested to demonstrate competence in performing the additional procedures and administering the additional medications.

CONTRA COSTA LOCAL OPTIONAL SCOPE

• Impedance Threshold Device (ResQPOD) • Pediatric Endotracheal Intubation (limited to patients > 40 kg)

CONTRA COSTA LOCAL OPTIONAL SCOPE ITEMS ITEMS LIMITED TO CRITICAL CARE TRANSPORT PARAMEDICS ONLY

• Blood/Blood Product Infusion • Glycoprotein IIb/IIIa Receptor Inhibitor Infusion • Heparin Infusion • KCL Infusion

• Lidocaine Infusion • Midazolam Infusion • Morphine Sulfate Infusion • Nitroglycerin Infusion • Sodium Bicarbonate Infusion • Total Parenteral Nutrition (TPN) Infusion

ADULT DRUG REFERENCE

Drug Indication Adult Dosage Precautions / Comments

DEXTROSE 50% Hypoglycemia 25 g IV Use D10 initially – use D50 if repeat dosage needed

DIPHENHYDRAMINE

Allergy – Hives / Itching

25-50 mg IV or IM

For allergy, consider lower dose if patient has already taken po dose in past two hours for symptoms Dystonic Reaction

EPINEPHRINE 1:10,000

Cardiac Arrest 1 mg IV or IO every 3-5 minutes Alpha & beta sympathomimetic. May cause serious dysrhythmias and exacerbate angina. Anaphylactic Shock

0.1 mg increments IV or IO up to 0.5 mg IV total dose

Use only if IM treatment ineffective

EPINEPHRINE 1:1000

Allergy/ Anaphylactic Shock

0.3-0.5 mg IM Use lower dose in smaller, older patients

Never administer intravenously! Do not use in asthma patients with a history of hypertension or coronary artery disease. May cause serious dysrhythmias and exacerbate angina.

Asthma

0.3 mg subcutaneously 0.3 mg IM if respiratory arrest from asthma or bronchospasm

ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments

FENTANYL CITRATE

Pain Control

50-200 mcg IV (25-50 mcg increments) 100 mcg Intranasally 50-100 mcg IM

Can cause hypotension and respiratory depression. Recheck VS between each dose. Hypotension more common in patients with low cardiac output or volume depletion. Respiratory depression reversible with naloxone. Additional IV doses (titration) can be given every 5 minutes. IM and intranasal doses can be repeated once in 15 minutes.

Sedation – Pacing 25-100 mcg IV in 25-50 mcg increments

GLUCAGON Hypoglycemia 1 mg IM Effect may be delayed 5–20 min

LIDOCAINE IO Anesthesia 40 mg IO Repeat dose 20 mg Administer slowly over 1 minute Not needed in arrest situations

MIDAZOLAM

Seizure

Titrate 1-5 mg IV in 1-2 mg increments

0.1 mg/kg IM (max. dose 5 mg IM)

With IV dosing, begin with 1 mg dose. IV increments should not exceed 2 mg.

Observe respiratory status

Use with caution in patients over age 60

Base order required for behavioral emergency indication

Sedation for pacing or cardioversion

Titrate 1-5 mg IV in 1-2 mg increments

Sedation – transfer of intubated patient

Titrate 2-5 mg IV in up to 2 mg increments

Behavioral Emergency

5 mg IM 1-3 mg IV in 1 mg increments if IV available

(Morphine deleted - pulmonary edema indication deleted)

ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments

NALOXONE

Respiratory Depression or Apnea (Respiratory rate less than 12)

2 mg intranasally (IN) 1-2 mg IV or IM

For careful titration in chronic pain or terminal patients, dilute 1:10 and give 0.1 mg increments

Intranasal administration preferred unless patient in shock or has copious secretion/blood in nares. Shorter duration of action than that of most narcotics. Abrupt withdrawal symptoms and combative behavior may occur.

NITROGLYCERIN

Chest Pain – Suspected ACS

0.4 mg sl or spray up to 3 doses

Can cause hypotension and headache. Do not give if BP less than 90 systolic or heart rate below 50. Perform 12-lead ECG before administration. Do not give if STEMI detected. Do not give if Viagra, Levitra, Staxyn or Stendra taken within 24 hours or if Cialis taken within 36 hours.

Pulmonary Edema

0.4 mg sl or spray if systolic BP 90-149

0.8 mg sl or spray if systolic BP 150 or over Max.dose 4.8 mg

ONDANSETRON Vomiting and Severe Nausea 4 mg IV, IM or po (ODT) May repeat q 10 min X 2

Give IV over 1 minute – may cause syncope if administered too rapidly

SODIUM BICARBONATE

Cardiac arrest 1 mEq/kg IV or IO

For crush injury, consider additional 1 mEq/kg added to 1L NS using second IV line

Assure adequate ventilation. Can precipitate or inactivate other drugs. In cardiac arrest, indicated for treatment of suspected hyperkalemia (history of renal failure or diabetes).

Tricyclic Antidepressant OD

Crush injury

PEDIATRIC DRUG REFERENCE Drug Indication Pediatric Dosage Precautions / Comments

DEXTROSE 10%

Hypoglycemia 0.5 g/kg IV (5 ml/kg) Maximum 250 ml Recheck glucose after administration

DIPHENHYDRAMINE Allergy - Hives / Itching 1 mg/kg IV or IM Maximum dose 50 mg

Consider lower dose (0.5 mg/kg) if patient has already taken po dose in the past two hours for symptoms

EPINEPHRINE 1:10,000

Cardiac Arrest 0.01 mg/kg IV or IO every 3-5 minutes Max. dose 1 mg

In anaphylactic shock, IM epinephrine 1:1000 should be administered first and epinephrine 1:10,000 IV should only be used if IM is ineffective Anaphylactic

Shock

Titrate in up to 0.1 mg increments slow IV or IO to a max. of 0.01 mg/kg

EPINEPHRINE 1:1000

Allergy/ Anaphylactic Shock

0.01 mg/kg IM Max single dose 0.3 mg Never administer intravenously!

If respiratory arrest from asthma or bronchospasm, administer IM Asthma

0.01 mg/kg subcutaneously Maximum dose 0.3 mg

FENTANYL CITRATE Pain Control

See drug chart for exact dosage. 1 mcg/kg IV or IM 1.5 mcg/kg Intranasal

Can cause hypotension and respiratory depression. Hypotension is more common in patients with volume depletion. Nausea may occur.

GLUCAGON Hypoglycemia Weight less than 24 kg: 0.5 mg IM Weight 24 kg or more: 1 mg IM

Effect may be delayed 5–20 minutes - if patient responds, give po sugar

PEDIATRIC DRUG REFERENCE Drug Indication Pediatric Dosage Precautions / Comments

LIDOCAINE IO Pain 0.5 mg/kg IO. Maximum dose 20 mg Give slowly over one minute. Not needed in arrest situations

MIDAZOLAM

Seizure

Titrate in up to 1 mg increments IV up to 0.1 mg/kg Maximum total IV dose 5 mg

0.1 mg/kg IM Maximum dose 5 mg IM

Observe respiratory status carefully

Sedation for Cardioversion

0.1 mg/kg IV or IO titrated in 1 mg increments Maximum dose 5 mg

Sedation and cardioversion only with base hospital order

MORPHINE Pain Control

See pain management drug chart for dosage. Use IV increments of up to 2 mg 0.1 mg/kg IM

Can cause hypotension and respiratory depression. Hypotension is more common in patients with volume depletion. Nausea is a frequent side effect.

NALOXONE Respiratory Depression or Apnea

0.1 mg/kg IM or IV Maximum dose 2 mg

May repeat as needed

Use IM route initially unless shock present. Shorter duration of action than that of most narcotics.

ONDANSETRON Vomiting and Severe Nausea 4 mg IV, IM, or po (ODT) In patients 40 kg and over, may repeat q 10 min X 2

For use in patients 4 years and up. Administer IV over 1 minute. Rapid administration may cause syncope.

Intraosseous Infusion (IO) in Adults

Indications • Cardiac arrest – IO is the preferred vascular access method • IV access unsuccessful or after evaluation of potential sites, it is determined that an IV attempt

would not be successful in the following conditions: o Shock or evolving shock, regardless of cause o Impending arrest or unstable dysrhythmia

Contraindications • Fracture of the targeted bone • IO within the past 48 hours in the targeted bone • Infection at the insertion site • Burns that disrupt actual bone integrity at insertion site • Inability to locate landmarks or excessive tissue over the insertion site • Previous orthopedic procedure near insertion site (prosthetic limb or joint)

Equipment • Chlorhexidine prep solution • IV NS 1000 ml • 10-12 ml syringe filled with normal saline for flush • Gloves • Pressure bag • EZ-IO power driver • EZ-IO needle catheters - 25mm (blue hub), or 45 mm (yellow hub) • EZ-IO catheter stabilizer • Lidocaine 2% for injection • Wristband to identify patient as patient having IO insertion Insertion Sites • Proximal humerus (preferred in patients with perfusing rhythms) • Proximal tibia • Distal tibia (can be utilized if humerus or proximal tibia unavailable) Note: Paramedics should only utilize insertion sites for which they have been formally trained to access Procedure 1) Locate insertion site:

a) The proximal humerus site is the greater tubercle, identifiable as a prominence on the humerus when the arm is rotated inward and patient’s hand is on the abdomen;

b) The proximal tibial site on the flat medial aspect of the tibia 2 finger-breadths below the lower edge of the patella and 1 fingerbreadth medial to the tibial tuberosity;

c) The distal tibial site is 2 finger-breadths above the most prominent aspect of the medial malleolus (inside aspect of ankle) in the midline of the shaft of the tibia.

2) Prep the insertion site with chlorhexidine and let air dry. 3) Select and load the appropriately sized needle onto the driver:

a) For humeral access, the 45 mm (yellow) needle is used except in very small adult patients;

b) For proximal or distal tibial access, the amount of soft tissue should be gauged to determine if a 25 mm (blue) or 45 mm (yellow) needle is appropriate.

4) Introduce the intraosseous as follows without pulling the trigger of the power driver: a) For humeral site, the direction of the needle should be a downward angle of 45 degrees (see

image); b) For tibial sites, the direction of the needle should be at a 90 degree angle to the flat surfaces of

the tibia (see images). 5) Once the needle has touched the bone surface, assess to see if the black line on the needle is visible.

If it is not visible, either a larger needle is needed or (in the case of use of 45 mm needle) the soft tissue is too thick to allow use of the IO.

6) With firm pressure, insert needle using power driver. In most cases, the hub should be flush or touching the skin. Verify that needle is firmly seated in the bone (should not wobble).

7) Remove stylet and instill lidocaine if patient not in arrest: a) For adult patients not in arrest, 40 mg (2 ml) of lidocaine 2% should be infused slowly over 1-2

minutes and allow one additional minute before starting flush. b) For patients in arrest, no lidocaine is necessary initially but may be needed if patient regains

consciousness. 8) Flush with 10 ml saline. 9) Attach stabilizer to skin. 10) Attach IV tubing to intraosseous hub, and begin infusion using pressure bag on IV bag. 11) If painful, an additional 20 mg (1 ml) of lidocaine 2% can be infused over 30 seconds, and after

another minute, infusion should be restarted. 12) Monitor site for swelling or signs of infiltration and monitor pulses distal to area of placement. 13) Place wristband included with IO set on patient.

Possible Complications Local infiltration of fluid or drugs into subcutaneous tissue due to improper needle placement Cessation of infusion due to clotting in the needle or bevel of needle lodged against posterior cortex Osteomyelitis or sepsis Fluid overload Fat or bone emboli Fracture

Intraosseous Infusion (IO) in Pediatric Patients

Indications • Cardiac arrest – IO is the preferred vascular access method • IV access unsuccessful or after evaluation of potential sites, it is determined that an IV attempt

would not be successful in the following conditions: o Shock or evolving shock, regardless of cause o Impending arrest or unstable dysrhythmia

Contraindications • Fracture of the targeted bone • IO within the past 48 hours in the targeted bone • Infection at the insertion site • Burns that disrupt actual bone integrity at insertion site • Inability to locate landmarks or excessive tissue over the insertion site • Previous orthopedic procedure near insertion site (prosthetic limb or joint)

Equipment • Chlorhexidine prep solution • IV NS 250-500 ml • 10-12 ml syringe filled with normal saline for flush (5 ml flush in small children) • Gloves • EZ-IO power driver • EZ-IO needle catheters - 10 mm (pink hub), 25mm (blue hub), or 45 mm (yellow hub) • EZ-IO catheter stabilizer • Lidocaine 2% for injection • 3-way stopcock to facilitate fluid and medication administration • 30-50 ml syringe to facilitate fluid administration • Wristband to identify patient as patient having IO insertion Insertion Sites

• Proximal tibia only Procedure 1) Locate the insertion site – for pediatric patients the location of proximal tibial site is on the flat

medial aspect of the tibia 2 finger-breadths below the lower edge of the patella and 1 fingerbreadth medial to the tibial tuberosity.

2) Prep the insertion site with chlorhexidine and let air dry. 3) Select and load the appropriately sized needle onto the driver:

a) The 15 mm (pink hub) needle is appropriate in infants or in small children with thin amounts of soft tissue in the proximal tibial site;

b) The 25 mm (blue hub) needle is appropriate for larger children or smaller children with thicker amounts of tissue in the proximal tibial site.

4) Introduce the intraosseous needle at a 90 degree angle to the flat surface of the tibia (see image) without pulling the trigger of the power driver.

5) Once the needle has touched the bone surface, assess to see if the black line on the needle is visible. If it is not visible, a larger needle is needed .

6) With mild to firm pressure, insert needle using power driver. For small children, once a “give” is sensed as the outer bony cortex is penetrated, remove finger from power driver trigger to stop insertion (do not withdraw driver when stopping).

7) Remove stylet and instill lidocaine if patient not in arrest: a) For pediatric patients not in arrest, 0.5 mg/kg of lidocaine 2% should be infused slowly over 1-2

minutes and allow one additional minute before starting flush. See pediatric drug chart for weight-based dose.

b) For patients in arrest, no lidocaine is necessary initially but may be needed if patient regains consciousness.

8) Flush with 10 ml saline (5 ml in smaller children and infants). 9) Attach stabilizer to skin or anchor with tape. 10) Attach IV tubing to intraosseous hub:

a) Begin infusion with stopcock and syringe to administer appropriate fluid dose in smaller children b) Pressure bag may be used in larger children (>50 kg).

11) Monitor site for swelling or signs of infiltration and monitor pulses distal to area of placement 12) Place wristband included with IO set on patient.

Possible Complications Local infiltration of fluid or drugs into subcutaneous tissue due to improper needle placement Cessation of infusion due to clotting in the needle or bevel of needle lodged against posterior cortex Osteomyelitis or sepsis Fluid overload Fat or bone emboli Fracture

1 - 2014 - Proposed Treatment Guideline and Prehospital Care Manual Changes7 - 2014 Revision Draft A2A - Chest Pain CHEST PAINA2SUSPECTED ACUTE CORONARY SYNDROME / STEMIOXYGENCARDIAC MONITOR

ADULT

8 - 2014 Revision Draft A2B - Chest PainFLUID BOLUS

9 - 2014 Revision Draft A3A - CPR and Cardiac ArrestA3CARDIAC ARREST – INITIAL CARE AND CPRADULT

10 - 2013 A3B - CPR and Cardiac Arrest11 - 2014 Revision Draft A4A - VF adultVENTRICULAR FIBRILLATIONA4PULSELESS VENTRICULAR TACHYCARDIAEPINEPHRINE

ADULT

12 - 2014 revision draft A4B - VF adultKey Treatment Considerations

13 - 2013 A5A - PEA - Asystole - AdultA5PULSELESS ELECTRICAL ACTIVITY / ASYSTOLEINITIAL CARE

ADULT

14 - 2014 Revision Draft A5B - PEA - Asystole - AdultKey Treatment Considerations

15 - 2014 Revision Draft A6A - sympt brady - adultA6 - ADULT

23 - 2013 A10A - Shock - Hypovolemia - adultA10SHOCK / HYPOVOLEMIAADULT

24 - 2014 Revision Draft 10B - Shock - Hypovolemia - adult27 - 2014 Revision Draft A12A Public Safety DefibrillationPUBLIC SAFETY DEFIBRILLATIONA12BLS / LAW ENFORCEMENTCOMPRESSIONS

ADULT

28 - 2013 A12B Public Safety DefibrillationVENTILATION

31 - 2014 Draft Revision G1A - allergy and anaphylaxisG1

32 - 2013 G1B - allergy and anaphylaxis33 - 2014 Revision Draft G2A - ALOCALTERED LEVEL OF CONSCIOUSNESS

34 - 2013 G2B - ALOCKey Treatment Considerations

35 - 2013 G3A - behavioral emergencyG3BEHAVIORAL EMERGENCYConsiderBLOOD GLUCOSE

GENERAL

36 - 2014 Draft Revision G3B - behavioral emergencyBASE ORDER REQUIRED

37 - 2014 Revision Draft G4A - burnsG4BURNSGENERAL

38 - 2013 G4B - BurnsKey Treatment Considerations

47 - 2014 Revision Draft G10A - pain managementG10

48 - 2014 Revision Draft G10B - pain managementContraindications and Cautions for Fentanyl Citrate

49 - 2013 G11A - poisons - overdoseG11TRICYCLIC ANTIDEPRESSANT OVERDOSE

50 - 2014 Revision Draft G11B - poisons - overdoseORGANOPHOSPHATE POISONINGHYDROFLUORIC ACID EXPOSUREKey Treatment Considerations

50 - 2014 Revision Draft G11C - poisons - overdose - carbon monoxide - NEWSUSPECTED CARBON MONOXIDE POISONING Symptoms may be diverse and often non-specific. Headache, dizziness, fatigue and nausea are most common symptoms. Neurologic symptoms may include confusion, lethargy, drowsiness, agitation, coma, syncope, seizure or bizarre neurologic symptoms. Other symptoms may include chest pain, palpitations, dyspnea, weakness, or flu-like symptoms. Evaluate for CO poisoning in suspected smoke inhalation Suspect and evaluate in situations when multiple patients have symptoms Consider evaluation when other causes for symptoms are not obvious

53 - 2013 G13A - respiratory distressG13RESPIRATORY DISTRESSINITIAL THERAPYASTHMAALBUTEROL Adult and Pediatric – 5 mg in 6 ml NS via nebulizer. Repeat as needed.Never give Epinephrine 1:1000 intravenously!COPD EXACERBATION

ALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed.

GENERAL

54 - 2014 Revision Draft G13B - respiratory distressSUSPECTED PULMONARY EDEMA (ADULTS ONLY)Key Treatment Considerations

59 - 2013 G16A - traumaG16TRAUMA - GENERALGENERAL

60 - 2014 Revision Draft G16B - trauma61 - 2013 G16C - traumaG16TRAUMA – HEAD INJURYGENERAL

62 - 2014 Revision Draft G16D - traumaG16TRAUMA - EXTREMITYConsider TOURNIQUETIf vigorous hemorrhage not controlled with elevation and direct pressure on wound.May be used in pediatric patients. May be appropriate for hemorrhage control in multi-casualty situations.SUSPECTEDDISLOCATIONIf dislocation suspected or noted, splint in position foundAMPUTATIONS For partial amputations, splint in anatomic location and elevate extremity If complete amputation, place amputated part in a dry container or bag and place on ice. Seal or tie off bag and place in second container or bag. DO NOT place amputated part directly on ice or in water. Elevated extremity and dress with dry gauze.PAIN RELIEF Consider Fentanyl Citrate as directed in G16 Trauma - General GuidelineCRUSH INJURY SYNDROME

GENERAL

63 - 2014 Revision Draft G17A - vomiting and nauseaG17Vomiting or nausea may be due to viral illness (gastroenteritis) or other medical conditions including acute coronary syndrome, stroke, head injury, or toxic ingestion. It may be associated with a number of painful abdominal conditions, and may also occur as a result of treatment of pain with fentanyl.POSITION PATIENT

64 - 2014 Revision Draft G17B - Vomiting and nausea69 - 2014 Revision Draft P2A - CPR and Cardiac ArrestP2CARDIAC ARREST – INITIAL CARE AND CPRPEDIATRIC

70 - 2013 P2B - Cardiac Arrest - CPR85 - 2014 Revision Draft IFT 1 - Transfer of STEMI PatientsIFT 1TRANSFERMonitor IVPrompt TransportKey Treatment Considerations

106 - 2014 Revision Draft - EKG 1 - 12-lead placementSternal angle

114 - 2014 Revision Draft - 2013 - KEY PROCEDURESKEY PROCEDURES12-Lead ECGKEY PROCEDURES

Helmet RemovalImpedance Threshold Device (ITD) - ResQPOD (SRVFPD)KEY PROCEDURESContraindication

KEY PROCEDURESContraindication

136 - 2014 Revision Draft Paramedic scope137 - 2014 Revision Draft - LOCAL OPTIONAL Paramedic scope142 - 2014 Revision Draft - adult drug referenceADULT DRUG REFERENCEADENOSINEALBUTEROLAMIODARONEADULT DRUG REFERENCE

ASPIRINATROPINEADULT DRUG REFERENCEDIPHENHYDRAMINE

Never administer intravenously!ADULT DRUG REFERENCE

FENTANYL CITRATEGLUCAGONADULT DRUG REFERENCE

NALOXONENITROGLYCERIN

144 - 2014 Revision Draft - peds drug referencePEDIATRIC DRUG REFERENCEADENOSINEALBUTEROLPEDIATRIC DRUG REFERENCEDEXTROSE 10%DIPHENHYDRAMINE

Never administer intravenously!PEDIATRIC DRUG REFERENCE

IO procedures.pdfAdult Intraosseous Infusion version 2Pediatric Intraosseous Infusion version 2