EMT EMT Basic J EMT-Johnson EN EMT-Enhanced I/P ... · •EMT-B’s should assist patient with...

EMT EMT Basic

J EMT-Johnson

EN EMT-EnhancedEN EMT Enhanced

I/P Intermediate or Paramedic

P Paramedic Only

MC Medical Command

Universal Patient Care Protocol

Scene Safety/ Personal Protective Equipment

Primary SurveyInitial interventions as needed

Pulse oximetryySupplemental O2

Obtain and document Vital signs

SAMPLE history Pain assessment

OPQRST (medical)DCAP BTLS (trauma)

Cardiac monitor/ 12 Lead ECG

Appropriate Protocol/Consider Differential DiagnosesIf no protocol applies or condition is unknown, consult medical

command

Transport per guidelines

Pearls:•Complete vital signs should be taken every 5 min for critical and 15 min for non-critical pts.

•Complete vitals include a minimum of HR, RR, and BP.•On scene times should be limited to 15 minutes for medical, 10 minutes for trauma.

•Do not delay oxygen therapy to obtain pulse oximetry reading.

*if available

Do not delay oxygen therapy to obtain pulse oximetry reading.

History•Age

Physical•Pain

Differential Diagnoses

Abdominal Pain

•Past medical/ surgical history•Medications•Onset•Palliation/.provocationQ lit

•Tenderness•Nausea/ vomiting•Diarrhea•Dysuria/hematuriaC ti ti

•Trauma•Pregnancy•Pneumonia•Pulmonary embolism•Liver (hepatitis CHF)•Quality

•Radiation•Severity•Time•Fever

•Constipation•Vaginal bleeding/discharge•Pregnancy•Fever•Headache

•Liver (hepatitis, CHF)•Peptic ulcer disease•Gastritis•Gallbladder•Myocardial Infarction

•Last meal eaten•Last bowel movement/emesis•Menstrual history

•Malaise •Pancreatitis•Kidney stone•Addominal aneurysm•Appendicitis•Bladder/ prostate•Bladder/ prostate•Pelvic inflammatory•Ovarian cyst•Spleen enlargement•Diverticulitis•Bowel obstruction•Gastroenteritis

Pearls:Pearls:•Acute, undiagnosed abdominal pain should not receive analgesics in the field

without medical command

B Universal Care Protocol B

Abdominal Pain

EN IV access, bolus up to 1 liter NS EN

I/P Initiate cardiac monitor and pulse oximetry I/P

B Consider 12 Lead ECG B

I/P For persistent nausea and vomiting, consider Zofran 4 mg IV, may repeat in 10 minutes

I/P

History Physical Differential

Alcohol Related Emergencies

History Physical Differential DiagnosesHypoglycemiaTraumatic injury

Universal Care Protocol

B Monitor for respiratory depression B

B If seizures occur, refer to the Neurological/Seizure Protocol B

EN Infuse 1 liter NS over 1 hour, then 150 ml/hr EN

EN Treat suspected hypglycemia EN

I/P Initiate cardiac monitor and pulse oximetry I/P

I/P For severe agitation, tachycardia, or halluciniations, consider diazepam (Valium) 5 mg IV or midazolam (Versed) 5 mg IM, may repeat either in 10

minutes

I/P

History•Events leading to arrest

Physical•Unresponsive


Cardiac Arrest: General Management

•Estimated down time•Past medical history•Medications•Terminal illness?Si f i /li idit

•Apneic•Pulseless

•Medical vs. trauma•V-fib/pulseless v-tach•Asystole•PEA

•Signs of rigor/lividity•DNR


B Criteria for Death/ No Resuscitation? B

B CPR Interrupt compressions only as per AED prompt or every 2 minutes (5 cycles

of CPR)

B

B AEDApply immediately if witnessed or bystander CPR in progress

Use after 2 minutes of CPR when unwitnessed

B

I/P Assess Rhythm (do not use AED mode), R f t i t t l/ l ith

I/PRefer to appropriate protocol/algorithm

B Airway Management Ventilate no more than 10/min (1 breath every 6-8 seconds)

B

Pearls:Change compressors every 2 minutes.

Allow full chest recoil.Check femoral/carotid pulse to verify effective CPR.

History:•Past medical history

Physical:•Pulseless

Differential:•Medical vs. trauma

Cardiac Arrest: Asystole / Pulseless Electrical Activity

•Medications•Events leading to arrest•End stage renal disease•Estimated down timeS t d h th i

•Apneic•No electrical activity on ECG•No ascultate heart tones

•Hypoxia•Hypo-/Hyperkalemia •Drug overdose•AcidosisH th i•Suspected hypothermia

•Suspected overdose•DNR

•Hypothermia•Device error

B General Cardiac Arrest protocol B

EN Establish IV or IO Access and NS infusion EN

I/P Confirm asystole in more than one lead I/P

I/P Administer Vasopressin 40 units (one time dose)Begin epinephrine after 3-5 minutes

I/Pg p p

I/P 1 mg Epinephrine (1:10,000) IV/IO Or 2 mg ETT every 3-5 minutes up to three doses

I/P

I/P Atropine 1 mg IV/IO every 3-5 minutes up to 3 doses I/P

I/P Consider and treat for reversible causes as above I/PI/P Consider and treat for reversible causes as above I/P

MC Contact medical command for termination of efforts after establishing secure airway, IV/IO access, administering initial medications, and treating for

reversible causes

MC

Pearls:•Vasopressin should be adminstered only one time in place of either the first or

second epinephrine dose.

History•Medications

Physical• HR >150/minQ S

Differential DiagnosesHeart Disease

Cardiac: Atrial Fibrillation/Flutter

Aminophylline, Diet pills, thyroid supplements, decongestants,Digoxin

•QRS <0.12 secs•Dizziness, CP, SOB

•Heart Disease (WPW)•Sick Sinus Syndrome•Myocardial infarction•Electrolyte imbalanceDigoxin

•Diet caffeinechocolate•Drugs

•Exertion, pain, stress•Fever•Hypoxia•Hypovolemia or anemia

nicotinecaffeine•Past medical history•History of palpitations•Syncope/ near syncope

anemia•Drug effects•Hyperthyroidism•Pulmonary embolus

Syncope/ near syncope

Pearls:•Energy settings for cardioversion should be per manufacturer recommendation.

•Pharmacological rate control is preferred over cardioversion unless the patient is unstable.•Unstable is defined as BP less than 90 mmHg, altered mental status, signs of decreased

perfusion.•Adenosine is not effective in converting atrial fibrillation or flutter.

•Document all rhythm changes with monitor strips•Document all rhythm changes with monitor strips.


Cardiac: Atrial Fibrillation/Flutter

EN Establish IV access EN

B Obtain 12 Lead ECG B

I/P For a stable patient and a ventricular rate 150 or greater, consider metoprolol (Lopressor) 5 mg IV May be reated every 10 minutes to a max of 15 mg to

I/P(Lopressor) 5 mg IV. May be reated every 10 minutes to a max of 15 mg to

achieve ventricular rate of 120 or less.

I/P For an unstable patient, sychronized cardioversion at 100j, 200j, then 300j if needed.

I/P

I/P For patients who do not respond to cardioversion or who have recurrent I/PI/P For patients who do not respond to cardioversion or who have recurrent tachycardia, metoprolol (Lopressor) 5 mg IV prior to repeated cardioversion.

I/P

MC Midazolam (Versed) 2-5 mg IV prior to cardioversion. MC

History Physical Differential

Cardiac: Bradycardia

History•Past medical history•Medications

Beta blockers Calcium channel blockers

Physical•HR<60•Chest pain•Respiratory distress•Hypotension

Differential Diagnoses•Acute myocardial infarction•HypoxiaH th iClonidine

Digitalis•Pacemaker

•Altered mental status•Syncope

•Hypothermia•Sinus bradycardia•Athletes•Heat injury (ICP)•Stroke•Spinal cord lesion•Sick sinus syndrome•AV blocks•Overdose

Pearls:•TCP is the preferred treatment in 2nd degree, Type II and 3rd degree blocks.p g , yp g

•Transplanted hearts will not respond to atropine.•Fluid therapy should be initiated as an adjunct to rate therapies. Administer fluid

cautiously to patients with symptomatic bradycardia.


Cardiac: Bradycardia



I/P For a stable patient, consider Atropine 0.5-1mg repeated every 3-5 minutes as needed to a maximum of 3 mg

I/Pas needed to a maximum of 3 mg.

I/P For an unstable patient, trancutaneous pacing (begin rate at 80 bpm, energy setting a 0 mA and increase until mechanical capture is noted).

I/P

I/P Fluid bolus of 500 mL may be repeated after reassessment up to 1 liter NS as indicated to maintain BP >90 mmHG.

I/P

For patients who have not responded to TCP and atropine, consider dopamine (Intropin) 5 to 20 mcg/kg/min to maintain BP of 90 mmHg.

MC Midazolam (Versed) 2-5 mg IV during TCP. MC

History•Age

Physical•Chest Pain

(

Differential DiagnosesTrauma vs medical

Cardiac: Chest Pain/ Suspected Myocardial Event

•Medications•Use of Viagra, Cialis, Levitra•Past medical history•Recent physical exertion•Onset

(pain, pressure, aching, tightness)

•Location(substernal, epigastric, arm, jaw, neck, shoulder)

•Trauma vs. medical•Angina vs. MI•Pericarditis•Pulmonary embolism•Asthma/ COPDOnset

•Palliation/Provocation•Quality•Radiation•Severity

jaw, neck, shoulder)•Pale, diaphoretic•Dyspnea•Nausea, vomiting

•Pneumothorax•Aortic dissection or aneurysm•Reflux or hiatal hernia

•Timehernia•Esophageal spasm•Pleuritic pain•Cocaine overdose

Pearls:Metoprolol should generally be avoided in Interior and Inferior-Posterior STEMI’s (II, III, and AVL).

Metoprolol should be avoided if cocaine or methamphetamine use is known or suspected.Metoprolol should be avoided if cocaine or methamphetamine use is known or suspected.Avoid NTG if use of Viagra, Cialis, or Levitra use within the past 24 hours, contact medical command.

Inferior MI’s are preload dependent and may not tolerate NTG well, use IV fluids as needed.Diabetics, females, and geriatric patients often present with atypical chest pain or generalized complaints.


Cardiac: Chest Pain/ Suspected Myocardial Event

B Transmit 12 Lead ECG, Consult Medical Command for possible STEMI alert B

B Aspirin 162 mg (2 baby aspirin) chewed. B


B Nitroglycerin 0.4 mg every 5 minutes as needed. No maximum, keep BP >100 mmHg.

•EMT-B’s should assist patient with prescribed NTG only, max 3 doses.•EMT-J’s should administer only if patient has taken NTG in past, max 3

doses.

B

J Apply 1 inch 2% Nitropaste (15 mg) topically keeping BP >100 mmHg. J

I/P For vomiting, consider Zofran 4 mg IV repeated in 10 minutes if needed./ I/P

I/P Consider morphine sulfate 2 mg slow IV. May be repeated every 5-10 minutes to a max of 6mg keeping BP >100mmHg

I/Pminutes to a max of 6mg keeping BP 100mmHg

I/P Refer to hypotension and dysrhythmia protocols as indicated I/P

I/P Consider fluid bolus for Inferior (II, II, and AVF) STEMI’s I/P

I/P Metoprolol 5mg slow IVP if Anterior (V3, V4), Antero-spetal (V1, V2, V3, V4), or Antero lateral (V3 V4 V5 V6 I AVL) STEMI May be repeated in 15

I/Por Antero-lateral (V3, V4, V5, V6, I, AVL) STEMI . May be repeated in 15

minutes to a max dose of 15 mg.

History•Medications

Physical•HR >150


Cardiac: Narrow Complex Tachycardia- Paroxysmal SVT

AminophyllineDiet pillsThyroid supplementsDecongestantsDi i

•QRS <0.12 secs•Dizziness•CP•Dyspnea

•Heart disease•Sick sinus syndrome•Myocardial infarction•Electrolyte imbalance•Exertion pain stressDigoxin

•Dietcaffeinechocolate

•Drugs

•Exertion, pain, stress•Fever•Hypoxia•Hypovolemia or anemiag

nicotinecocaine•Past medical history•History of palpitationsS /

•Drug effect or overdose•Hyperthyroidism•Pulmonary embolism

•Synocope/ near syncope•If history of WPW, go to V-tach protocol

P lPearls:“Stable” is defined as a patient who is symptomatic with normal perfusion, normal vitals, and no alteration in mental status.

“Unstable” is defined as decreased perfusion, hypotension, altered LOC, severe chest pain or difficulty breathing.Adenosine should be administered in a proximal injection port followed by a 20 mL flush.

Perform carotid sinus massage unilaterally. CSM is contraindicated if bruits are heard, history of endarterectomy, or CVA.Use manufacturer recommendations for escalating energy settingsUse manufacturer recommendations for escalating energy settings.

Document all rhythm changes with monitor strips.

Cardiac: Narrow Complex Tachycardia- Paroxysmal SVT




I/P If patient is stable attempt vagal maneuvers I/PI/P If patient is stable, attempt vagal maneuvers. I/P

I/P Adenosine 6 mg rapid IVP. If no response, Adenosine 12 mg rapid IVP. I/P

I/P If patient is unstable, synchronized cardioversion at 50- 100 j or equivalent. I/P

I/P If no response to cardioversion or recurrent arrhythmias, consider amiodarone 150 IV i b k 10 i t

I/P150 mg IV piggyback over 10 minutes

MC Midazolam 2-5 mg IV prior to synchronized cardioversion MC

History•Estimated down time



Cardiac: Ventricular Fibrillation/ Pulseless Ventricular Tachycardia

•Past medical history•Medications•Events leading to arrest•Renal failure/ diaysisDNR

•Apneic•Pulseless•Ventricular fibrillation or ventricular tachycardia on ECG

•Aystole•Artifact/device failure•Cardiac•Endocrine/Metabolic•Drugs•DNR •Drugs•Pulmonary

B Cardiac Arrest Protocol B

I/P Defibrillate per manufacturer’s recommendation I/P•immediately if witnessed or bystander CPR

• after 2 min CPR if unwitnessed

I/P Ensure quality CPR, appropriate airway management, capnography. I/P

EN IV or IO access EN

I/P Vasopressin 40 units IV/ IO X 1 dose.(Use epinephrine after 3-5 minutes.)

I/P

I/P Epinephrine (1:10, 000) 1 mg IV/ IO every 3-5 minutes or2 mg ETT if no IV access.

I/P

I/P After 3rd shock, amiodarone 300 mg IVP. May repeat once at 150 mg. I/P

I/P Consider magnesium sulfate, 1-2 grams IVP for Torsades. I/P

I/P Search for and treat reversible causes.Consider calcium and sodium bicarbonate for renal failure or dialysis.

I/Py

MC Consider termination of efforts after approximately 20 minutes with secure airway, repeated defibrillations, and medication administration.

MC

Pearls:Follow manufacturers recommendations for energy settings.

Interruption of CPR should be minimal and occur only in 2 minute intervals

History Physical Differential Diagnoses

Cardiac: Wide Complex Tachycardia (Ventricular Tachycardia)




I/P If patient is stable, amiodarone 150 mg IV piggyback over 10 minutes. May repeat in 10 minutes if no response.

I/P

I/P If patient is unstable, synchronized cardioversion at 100 j or equivalent. I/P

MC Midazolam 2-5 mg IV prior to synchronized cardioversion MC

Pearls:“Stable” is defined as a patient who is symptomatic with normal perfusion, normal vitals, and no alteration in mental status.

“U t bl ” i d fi d d d f i h t i lt d LOC h t i diffi lt b thi“Unstable” is defined as decreased perfusion, hypotension, altered LOC, severe chest pain or difficulty breathing.Always consider wide complex tachycardia to be ventricular tachycardia unless known to be SVT with aberrant conduction.

Follow manufacturer’s recommendations for escalating energy settings.

History•Type of sting/bite

f

Physical•Rash, skin break, wound

f

Differential DiagnosesAnimal bite

Environmental: Envenomation

•Description of animal involved•Time, location, size of bite/sting•Previous reaction•Domestic vs. wild

•Pain, soft tissue swelling, redness•Blood oozing from wound•Evidence of infection•Shortness of breath, wheezing

•Animal bite•Human bite•Snake bite•Spider bite•Insect sting

•Tetanus and rabies risk•Infection risk•Immunocompromised patient

g•Allergic reaction•Hypotension

g


B Minimize activity, remove tight clothing or jewelry, immobilize extremity at level of heart.

B

B For exotic animals (Coral snakes cobra’s) contact Poison Control Do not BB For exotic animals (Coral snakes, cobra s), contact Poison Control. Do not delay transport.

B


I/P Consider morphine 2-4 mg IV, up to a total of 10 mg for pain. I/P

MC D i 2 t 20 /k / i IV i f i f h t i i t MCMC Dopamine 2 to 20 mcg/kg/min IV infusion for hypotension unresponsive to fluid therapy.

MC

Pearls:Signs of pit viper envenomation are swelling that begins at the bite mark and spreads proximally within minutes,

ecchymosis, hemorrhagic blisters, and severe pain.Constricting bands or tourniquets cold application incision suction and use of extractor devices are contraindicated in pitConstricting bands or tourniquets, cold application, incision, suction, and use of extractor devices are contraindicated in pit

viper envenomations.Black widow spider envenomations may present with painful muscle spasms.

History•Age

Physical•Altered mental status


Environmental: Hyperthermia

•Exposure to increased temperature or humidity•Past medical history/ medications•Extreme exertion

•Hot, dry or sweaty•Hypotension•Seizures•Nausea

•Fever •Dehyderation•Medications•Hyperthyroidism•Delirium tremensExtreme exertion

•Time and length of exposure•Poor PO intake•Fatigue•Muscle cramping

•Delirium tremens•Heat cramps•Heat exhaustion•Heat stroke•CNS lesions ro tumors

Pearls:Tricyclic antidepressants, phenothiazines, anticholinergics, and alcohol predispose patients to hyperthermia.

Cocaine, amphetamines, and salicylates may elevate body temperature.The major difference between heat exhaustion and heat stroke is CNS impairment.

Avoid dramatic decreases in temperature which can cause shivering and increase temperature.D h d ti d l d l ti t i l i t k Vi fl id d i i t ti lt i lDehydration and volume depletion may not occur in classic stroke. Vigorous fluid administration may result in pulmonary

edema, particularly in the elderly.


Environmental: Hyperthermia

B Obtain accurate core body temperature. B

B Move to cooler environment, remove excess clothing, protect from further heat gains.

B

B For heat exhaustion PO water if patient can tolerate If temp >103° cool with BB For heat exhaustion, PO water if patient can tolerate. If temp >103 , cool with wet towels or fans until temp reaches 100°.

B

B For heat stroke, use aggressive evaporation (fine mist water spay, ice packs to groin and axillae) unitl core temp is <104°.

B

EN Administer IV NS ENFor heat cramps/exhaustion, bolus up to 1 liter.

For heat stroke, cautiously administer NS at 250 mL/hr up to 1 liter to maintain BP >100 mmHg.

History•Past medical history

Physical•Cold, clammy


Environmental: Hypothermia

•Medications•Exposure to environment, even in normal temperatures•Exposure to extreme cold•Extremes of age

•Shivering•Altered mental status•Extremity pain or sensory abnormality•Bradycardia

•Sepsis•Environmental exposure•Hypoglycemia•CNS dysfunction•Extremes of age

•Drug use•Infections/ sepsis•Length of exposure/wetness

•Bradycardia•Hypotension

CNS dysfunctionStrokeHead injurySpinal cord injury

P lPearls:Avoid rough handling.

Maintain supine position.Warm fluids as close to 109° as possible by placing on heater or hot packs. Do not microwave.

Avoid intubation if possible in the severely hypothermic patient.Consider “urban hypothermia” with high association of poverty or drug//alcohol abuseConsider urban hypothermia with high association of poverty or drug//alcohol abuse.


Environmental: Hypothermia



B Confirm pulselessness for 30-45 seconds B

B Refer to CPR and AED protocol if needed. B

B Remove wet garments..Protect from further heat loss.

Apply heat packs if body temperature 86°-93°

B

EN Airway management EN

EN IV or IO accessNS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.

EN

I/P Modify ACLS algorithms:Temp > 86°, give IV meds as indicated as longer intervals.

I/P

Temp <86°, attempt one defibrillation. Repeat defibrillation attempts as temperature rises.

MC Consider termination of efforts if no response to initial therapy and prolonged time to definitive care.

MC

History•Submersion in water



Environmental: Near Drowning

•Associated trauma•Duration of immersion•Temperature of water•Fresh vs. salt water

•Altered mental status•Decreased vital signs•Vomiting•Cough

•Trauma•Pre-existing medical problem•Pressure injury•Pressure injuryPressure injury

barotraumadecompressoin

sickness

B Remove from water if it trained and safe to do so. B

B Spinal immobilization if indicated. B

B Pre ent heat loss refer to “H pothermia” protocol if indicated BB Prevent heat loss, refer to “Hypothermia” protocol if indicated. B

EN IV access. EN

I/P Refer to specific cardiac arrhythmias protocol as needed. I/P

Pearls:Most near drowning victims will be hypothermic to some extent.

Assess type of incident (surfact impacted, object strike, propeller trauma).Assess water conditions (depth of submersion, length of time, water temp).( p g p)

History•Blood loss

Physical•Restlessness, confusion


General Medical: Hypotension

•Fluid loss•Infection•Cardiac ischemia•MedicationsAll i ti

•Weakness, dizziness•Weak, rapid pulse•Pale, cool, clammy skin•Delayed capillary refillC ff d i

•ShockHypovolemicCardiogenicSepticNeurogenic•Allergic reaction

•Pregnancy•History of poor oral intake

•Coffee-ground emesis•Tarry stools

NeurogenicAnaphylactic

•Ectopic pregnancy•Dysrhythmias•Pulmonary embolism•Tension pneumothorax•Medication effect•Vasovagal•PhysiologicalPhysiological (pregnancy)

B If anaphylaxis, refer to Severe Allergic Reaction protocol B

EN IV access or IO accessNS 500 mL bolus may repeat up to 1 liter to maintain BP >90 mmHg

ENNS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.

I/P Dopamine 5-20 mcg/kg/min to maintain BP >90 mmHg if no response to IV therapy or if CHF is present.

I/P

Pearls:Pearls:Hypovolemia must be corrected prior to dopamine infusion.

Identify and manage underlying cause.Consider drug side effects or overdose.

History•Onset and location

Physical•Itching or hives


General Medical: Severe Allergic Reaction

•Insect bite or sting•Food allergy/exposure•New clothing, soap, detergent•Past history of reactionsP t di l hi t

•Coughing or wheezing•Chest or throat constriction•Difficulty swallowing•Hypotension or shockEd

•Rash only•Anaphylaxis•Shock•Angioedema•Aspiration/ airway•Past medical history

•Medication history•Edema•Vomiting

•Aspiration/ airway obstruction•Vasovagal event•Asthma or COPD•CHF


General Medical: Severe Allergic Reaction

B Remove from source of exposure. B

B Apply ice packs to localized area. B

B Administer epinephrine (1:1000) 0.3 mg SQ.•EMT-B’s should assist with prescribed auto injector for severe hives,

Bp j ,

respirator distress, and/or shock if >8 years or >30 kg..

J Albuterol 2.5 mg nebulized for wheezing/ bronchospasm. J

EN NS 500 mL bolus, repeated up to 1 liter for hypotension. EN

J Diphenh dramine 25 mg IM/IV for mild to moderate reactions 50 mg IM/IV for JJ Diphenhydramine 25 mg IM/IV for mild to moderate reactions, 50 mg IM/IV for severe reactions. May repeat once in 10 min.

•EMT-J’s should administer 50 mg IM.

J

EN Methylprednisolone 125 mg IV over 1 minute for severe hives or difficulty breathing.

EN

I/P Cardiac and pulse oximetry monitor. I/P

MC Epinephrine (1:10, 000) 0.5 – 1 mg IV over 5 minutes in dire circumstances. MC

MC Dopamine 5-20 mcg/kg/min to maintan BP >90 mmHg MC

MC Epinephrine 2-10 mcg/min to maintain BP >90 mmHg MC

History•Known diabetic

Physical•Change in baseline mental


Neurological: Altered Level of Consciousness

•Drugs or paraphernalia•Past medical history•Medications•History of traumaCh i diti

status•Bizarre behavior•Cool, diaphoretic skin (hypoglycemia)•Warm,dry skin, signs of

•Head trauma•Stroke•Seizure•Tumor•Infection•Change in condition Warm,dry skin, signs of

dehydration (hyperglycemia)•Fruity breath odor•Kussmaul respirations

•Infection•Cardiac•Thyroid•Shock•Diabetes•Toxicologic•Acidosis/alkalosis•Exposure•Hypoxia•Electrolyte•Electrolyte abnormality•Psychiatric disorder

Pearls:Medications are a common cause of altered mental status.

Bl d l t b h l f l b t d ti l ti l l if l b d liBlood glucose meters may be helpful but used cautiously, particularly if values are borderline.Intubated patients should not receive naloxone unless in cardiac arrest.Naloxone may be administered IM up to 1.6 mg (2 mL) per injection site.


Neurological: Altered Level of Consciousness

B Instant Glucose 15 grams. B


B 12 Lead ECG. B

EN Establish IV access. EN

EN Dextrose 50%grams slow IVP. EN

J Glucagon 1mg IM if no IV access. May be repeated in 10 minutes. J

J Naloxone 0 8 mg IM or slow IVP for suspected narcotic overdose JJ Naloxone 0.8 mg IM or slow IVP for suspected narcotic overdose. J

EN For hyperglycemia (BS >400mg/dl), infuse I liter NS over 30-60 minutes, followed by NS at 250 mL/hr.

EN

I/P Cardiac and pulse oximetry monitors. I/P

History•Reported/witnessed seizure



Neurological: Seizures

activity•Previous seizure history•Medic alert information•Seizure medications•History of trauma

•Sleepiness•Incontinence•Observed seizure activity•Evidence of traumaU i

• Head trauma•Tumor•Metabolic, hepatic, or renal failure•Hypoxia•History of trauma

•History of diabetes•History of pregnancy

•Unconsiousness Hypoxia•Electrolyte imbalance•Medication non-compliance•Infection/ feverAl h l ithd l•Alcohol withdrawal

•Eclampsia•Stroke•Hyperthermia•Hypoglycemiayp g y

Pearls:Care during the post-ictal phase should be supportive or precautionary only.

Status epilepticus is defined as 2 or more successive seizures without recovery; it is a trueStatus epilepticus is defined as 2 or more successive seizures without recovery; it is a true emergency.

Grand mal (generalized) seizures: loss of consciousness, incontinence, and tongue trauma.Focal (petit mal) seizures: effect only one part of body, usually not associated with loss of

consciousness.Jacksonian seizure: start as focal seizure then become generalized.


Neurological: Seizures

B Protect patient. Do not attempt to restrain. B


EN Dextrose 50%grams slow IVP. EN

J Glucagon 1mg IM if no IV access. May be repeated in 10 minutes. J


I/P Diazepam 5mg IVP. I/P

I/P Midazolam 5 mg IM if no IV access. I/P

I/P If patient is pregnant, refer to OB/GYN Eclamptic Seizure protocol I/P

History•Previous CVA or TIA



Neurological: Stroke/CVA

•Previous cardiac or vascular surgery•Diabetes•Hypertension•Coronary artery disease

•Weakness/ paralysis•Blindness or other sensory loss•Aphasia•Syncope

•TIA•Seizure•Hypoglycemia•Thrombotic or embolic stroke•Coronary artery disease

•Atrial fibrillation•Mediations (blood thinners)•History of trauma

•Syncope•Vertigo/dizziness•Vomiting •Headache•Seizures

embolic stroke•Hemorrhagic stroke•Tumor •Trauma

•Change in

Pearls:Obtain and document onset of symptoms, medications, and contact information for medical

decision maker.Determine whether or not the patient is taking warafin (Coumadin) or other anitcoagulants.p g ( ) g


Neurological: Stroke/CVA

B Focused neurological exam. Cincinnati Prehospital Stroke Scale. Repeat every 15 minutes.

B

B Instant glucose 15 grams for suspected hypoglycemia. B

B 12 Lead ECG BB 12 Lead ECG. B


EN Dextrose 50% 25 grams IV for suspected hypoglycemia. EN

J Glucagon 1 mg IM if no IV access and suspected hypoglycemia. J


MC For onset of symptoms <2 hours, contact medical command immediately for possible stroke alert and expedite transport.

MC

History•Due date

Physical•Spasmotic pain


OB/GYN: Childbirth, Cephalic Presentation

•Time contractions started, interval•Rupture of membranes•Vaginal bleeding•Sensation of bowel movement

•Vaginal discharge or bleeding•Crowing•Urge to push•Meconium

•Abnormal presentation•Prolapsed cord•Placenta previa•Abruptio placenta•Sensation of bowel movement

•Past medical and delivery history•Medications•Drug use

Abruptio placenta

•Gravida/ Para status•High risk pregnancy

Pearls:A pregnant patient in cardiac arrest should be managed per ACLS guidelines with rapid transport.

Do not delay transport for delivery of the placenta.Manual vaginal exams should not be performed in the field.

If birth is imminent sta and deli er the bab If high risk attempt deli er en ro te to hospitalIf birth is imminent, stay and deliver the baby. If high risk, attempt delivery en-route to hospital.Seizures during pregnancy represent a medical emergency, contact medical command promptly.

OB/GYN: Childbirth, Cephalic Presentation


B Visualize perineum for crowning and imminent delivery. B

B Transport 3rd trimester patients in left lateral recumbent position. If immobilized, tilt LSB to left.

B,

EN IV access. EN

Assess for amniotic sac rupture.Support infant’s head over perineum.

Once head appears, suction mouth then nostrils with bulb syringe.Once head appears, suction mouth then nostrils with bulb syringe.Check for cord around the neck.

Apply gentle traction downward on head until anterior shoulder appears.Guide infant upward to deliver posterior shoulder.

Keep infant at same level of placenta.Clamp cord with at 8 inches and 10 inches from the infant.

Cut cord between the clamps.Keep infant warm, particularly the head.

Record time of birth.

B A d d APGAR t 1 d 5 i t BB Assess and record APGAR at 1 and 5 minutes. B


B Vi li i f i d i i t d li B

OB/GYN: Childbirth, Prolapsed Cord/ Limb Presentation


EN IV access. EN

B Do not attempt to push the cord or limb back in.Insert 2 fingers of gloved hand into vagina to raise presenting part off cord.

B

Check cord for pulsations in vagina.Push baby’s head away to keep pressure off cord and maintain.

Place mother in knee-chest position. If unable, use Trendelenburg instead.Continue to hold pressure off cord.Keep cord moist with sterile salineKeep cord moist with sterile saline.

Transport immediately with early notification to ED.

Pearls:Always contact medical command for guidance with any complicated delivery.

Seizures during pregnancy represent a medical emergency, contact medical command promptly.


B Visualize perineum for crowning and imminent delivery B

OB/GYN: Childbirth, Breech Birth


EN IV access. EN

B Support the baby’s extremities or buttocks until the upper back appears.Grasp the baby’s hips and apply gently downward traction.

Do not apply traction to baby’s legs or back

B

Do not apply traction to baby s legs or back.Swing the infant’s body in the direction of least resistance.

By alternate swinging, both shoulders will deliver posteriorly.Splint the humerus and apply gentle traction so the arms can be delivered.

Gentle abdominal compression of the uterus to engage baby’s head.Apply downward traction until the baby’s hair is visible.

Swing legs upward until the body is in vertical position which delivers head.Suction mouth then nostrils using bulb syringe.

Clamp and cut cord at 8 inches and 10 inches from baby.Record time of birthRecord time of birth.

B Assess and record APGAR’s at 1 and 5 minutes. B

P lPearls:Always contact medical command for guidance with any complicated delivery.

Seizures during pregnancy represent a medical emergency, contact medical command promptly.

History•Past medical history

Physical•Seizures


OB/GYN: Eclamptic Seizures

•Hypertension meds•Prenatal care•Gravida/ Para

•Hypertension•Severe headache•Visual changes•Edema of hands and faceRUQ i

•Pre-eclampsia •Eclampsia

•RUQ pain


EN IV access. EN

MC Magnesium Sulfate 10% 2 to 4 grams IVP at no greater than 1 gram per minute until seizure stops or 4 grams has been given.

MC

Pearls:Hypertension in the pregnant patient is defined as 140/90 or an increase of 30 mmHg systolic or

20 mmHg diastolic from patient’s normal BP.Seizures during pregnancy represent a medical emergency, contact medical command promptly.

Side effect of magnesium include muscle weakness and respiratory depression. Treat with IV l icalcium.


OB/GYN: Sexual Assault

B Universal Care Protocol BB Universal Care Protocol B

B Confirm scene safety. B

B Do not examine genitalia unless a hemorrhage requires bleeding control. B

B Save any clothing and place in paper bag. B

B Advise patient not to urinate, defecate, douche, or wash before ED evaluation.

B

EN IV access. EN

Pearls:Pearls:Obtain only pertinent facts related to the trauma.

Do not question about prior events or information not directly related to care (assailant description, etc).Ensure law enforcement has been informed.


OB/GYN: Vaginal Bleeding

B Universal Care Protocol BB Universal Care Protocol B

B Collect any tissue or fetal parts. Place in paper bag then into plastic bag for physician examination.

B

EN IV access. EN

Pearls:Pearls:Determine last menstrual period.

Always consider pregnancy and complications in women of child bearing age.3rd trimester bleeding may constitute a medical emergency; contact medical command promptly.

History•Situational crisis

Physical•Anxiety, agitation, confusion


Psychological: Emotionally Disturbed

•Psychiatric illness/medications•Injury to self•Threat others•Medic alertS b t b / d

•Change in affect•Hallucinations•Delusional thoughts•Bizarre behaviorC b ti / i l t

•Hypoxia•Alcohol intoxication•Medication effect•Withdrawal syndromes•Substance abuse/overdose

•Diabetes•Combative/ violent•Expression of suicidal or homicidal thougths

syndromes•Depression•Bipolar disorder•Schizophrenia•Anxiety disorders


I/P Haloperidol 5 mg IM for adults to control acute agitation I/PI/P Haloperidol 5 mg IM for adults to control acute agitation.For patients over 65, Haloperidol 2 mg IM.

I/P

MC If patient refuses transport, consider Emergency Custody Order. MC

Pearls:Pearls:Substance-induced disorders, diabetic emergencies, and hypoxia must be ruled out.

Suicidal patients are not permitted to sign a refusal. Consultation with law enforcement, mental health professionals, and medical command should guide

patient disposition.

Respiratory Distress- General Management

Universal Patient Care ProtocolUniversal Patient Care Protocol

Oxygen, Pulse Ox, ETCO2*, Cardiac Monitoring

Airway and IV Protocols

Consider Differential DiagnosesCo s de e e a ag oses

Pulmonary Bronchospasm/ Pneumonia Unknown/yEdema/CHF COPD Does not fit protocol

Contact Medical CommandCommand

*if availableif available

Respiratory Distress– Pulmonary Edema/CHFHistoryCHF

PhysicalJVD


Cardiac historyDigoxin, Lanoxin, NitratesDiuretics (furosemide, Bumex)OrthopneaG d l dd t

Peripheral EdemaRales, wheezes, or rhonchiPink, frothy sputumDiaphoresisA i t

Myocardial InfarctionAsthmaAnaphylaxisAspirationCOPDGradual or sudden onset

Weight gainAnxietyAir hungerChest painHypotensionAltered LOC

COPD PneumoniaPulmonary EmbolismToxic Exposure

B General Respiratory Distress Protocol B

J Consider CPAP protocol J

EN IV ENEN IV access EN

EN NTG 0.4 mg SL every 3-5 min if BP >100 mmHg EN

EN 1 inch nitropaste if BP >100 EN

B 12 Lead EKG, proceed to Chest Pain protocol if STEMI is determined B

Pearls:All h i i t th

I/P Morphine 2-4 mg slow IV push if BP >100mmHg I/P

I/P Consider dopamine 2 to 20 mcg/kg/min I/P

•All wheezing is not asthma.•Lasix is not a first line drug.•Allow position of comfort.

•Use of nitropaste may be preferable to SL NTG if hypotension is likely to occur.•Avoid NTG with use of Viagra, Cialis, or Levitra within past 24 hours.

Respiratory Distress—COPD/BronchospasmHistory Physical Differential DiagnosesTobacco useCOPD/Emphysema/Chronic BronchitisAsthmaSudden weather change

Air hungerDiaphoresisRetractionsAccessory muscle useTripoding

AsthmaAnaphylaxisAspirationCOPDPneumoniaSudden weather change

Home O2Prescribed MDIPrescribed steroidsPrescribed bronchodilators

TripodingCyanosisClubbed fingernailsBarrel ChestJVD

PneumoniaPulmonary EmbolismPneumothoraxCardiac (MI or CHF)Hyperventilaton

WheezesSilent chest

Inhaled toxin (carbon monoxide, etc)

B General Respiratory Distress Protocol B

B Assist with prescribed MDI, may repeat in 5 min B

J Albuterol 2.5 mg/Atrovent 500 mcg neb J

EN Consider Solumedrol 125 mg SLOW IV push EN

MC Consider Epi 0.3 mg 1:1000 SQ for severe cases MCMC Consider Epi 0.3 mg 1:1000 SQ for severe cases MC

MC Consider Epi 1:10, 000 IV for dire circumstances only MC

Pearls:•Contact medical command before administering epi to patients who are > 50 years, have cardiac history, or ifContact medical command before administering epi to patients who are 50 years, have cardiac history, or if

heart rate is >150.•Silent chest is a sign of impending respiratory arrest.

Respiratory Distress– Pneumonia

History Physical Differential DiagnosesDecreased oral intakeChillsExertional dyspneaGeneral illnessAltered mental status

Fever Productive coughChest PainNausea/vomitingTachycardia

AsthmaAspirationCardiac (CHF. MI)COPDSeptic ShockAltered mental status

Prescribed or OTC medications

TachycardiaTachypneaRales or decreased breath

soundsHypotension (sepsis,

Septic ShockPulmonary effusion

dehydration)Poor skin turgor

B G l R i t Di t P t l BB General Respiratory Distress Protocol B

J Consider CPAP Protocol J

J Albuterol 2.5 mg/ Atrovent 500 mcg neb J

EN Consider IV bolus if clinical signs of dehydration are present EN

Toxicology: Poisoning/ OverdoseHistory•Ingestion of toxic


Differential Diagnoses•Tricyclic antidepressants•Ingestion of toxic

substance•Route and quantity of ingestion•Time of ingestionR ( i id id t)

•Altered mental status•Hypotension•Decrease respiratory rate•Tachycardia•Dysrhythmias

•Tricyclic antidepressants•Acetaminophen•Depressants•Stimulants•Anticholinergics

•Reason (suicide, accident)•Available meds near patient•Past medical history•Medications

•Seizures •Cardiac medications•Solvents, cleaning agents•Insecticides (organophosphates)

Pearls: Intubated patients should not receive naloxone unless in cardiac arrest.

Tachycardia is not a contraindication to atropine adminstration.Poison control should be consulted on all complex toxicology at 434-924-5543 or 1-800-451-1428.

Aeromedical resources will not transport contaminated patients.Any patient with a QRS >100 msecs should receive sodium bicarbonate.


Toxicology: Poisoning/ Overdose


J Identify substance and assure decontamination. J

J Flush skin/membranes with appropriate solution if indicated. J

EN IV access. EN

J Naloxone 0.8 mg IV or IM for suspected narcotic overdose with respiratory depression.

J

EN Diphenhydramine 1 mg/kg slow iVP for dystonic reaction secondary to phenothiazine ingestion (max dose of 50 mg).

EN

I/P For Symptomatic Tricyclic Antidepressant Overdose:( if QRS >0.12 msecs, hypotension, or dysrhythmia)

•Sodium bicarbonate 1mEq/kg slow IVP over 2 minutes

I/P

I/P For Symptomatic Calcium Channel Blocker Overdose: I/P(if bradycardic, QRS >0.12 msecs, heart block, hypotension, lethargy,

slurred speech, nausea, vomiting)•Calcium chloride 20 mg/kg slow IVP over 10 minutes

•Sodium bicarbonate 1 mEq/kg slow IVP over 2 minutes.

I/P For Symptomatic Organophosphate Poisoning: I/PI/P For Symptomatic Organophosphate Poisoning:(secretions, bronchospasm, seizures, bradycardia)

•Atropine 0.05 mg/kg IV doubled every 5-10 minutes until decreased secretions.

I/P

Trauma: AmputationHistory•Mechanism of injury

Physical•Deformity

Differential Diagnoses•Complete amputation•Mechanism of injury

•Time of injury•Wound contaminatior•Medical history•Medications

•Deformity•Diminished pulse, capillary refill

•Complete amputation•Incomplete amputation


B Spinal Immobilization. B

B Apply direct pressure to control hemorrhage. Avoid tourniquet if possible. B

B If incomplete amputation, splint entire digit or limb in physiological position.

B

B Place part in damp gauze, place in plastic bag, wrap in trauma dressing, Bplace on ice/water mix.

EN IV Acess. NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.

EN

I/P Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to i

I/Psevere pain.

Pearls: Tourniquets should be used with the smallest amount of pressure over the widest area.

Never freeze the part by placing directly on ice.

Trauma: BurnsHistory•Type of exposure

Physical•Burns pain swelling

Differential Diagnoses•Superficial•Type of exposure

•Inhalation injury•Time of injury•Past medical history•Medications

•Burns, pain, swelling•Dizziness•Loss of consciousness•Hypotension•Airway compromise

•Superficial•Partial thickness•Full thickness•Chemical•Thermal

•Other trauma•Loss of consciousness•Tetanus status

•Singed facial or nasal hair•Hoarseness/wheezing

•Electrical •Radiation

Pearls: In electrical burns, search for additional traumatic injury.In thermal burns, assess for carbon monoxide exposure.

Remove jewelry and nonadherent clothing.Avoid establishing IV distal to extremity burn.


Trauma: Burns

B Apply dry sterile dressings. B


B Irrigate chemical burn with water if water is appropriate to chemical.If powdered chemical brush off

BIf powdered chemical, brush off.

B Splint fractures after apply dressing. B

EN Advanced airway management EN

EN IV Acess. ENNS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.

Administer 300 mL/hr for electrical burns if no risk of CHF


I/P M hi lf t t 10 l IVP ith BP 90 H f d t t I/PI/P Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to severe pain.

I/P

Trauma: CNS InjuriesHistoryTime of injury

Physical•Pain swelling bleeding

Differential Diagnoses•Skull fractureTime of injury

Mechanism of injuryLoss of consciousnessBleedingMedical history

•Pain, swelling, bleeding•Altered mental status•Unconsciousness•Respiratory distress/failure

•Skull fracture•Brain injury•Epidural hematoma•Subdural hematoma•Subarachnoid

MedicationsEvidence of multi-traumaHelmet use or damage

•Vomiting•Significant mechanism of injury

hemorrhage•Spinal injury•Abuse



B Elevate head of stretcher 30° if not hypotensive. B

B Maintain patient warmth. B

EN Advanced airway management ENEN Advanced airway management EN

EN IV Acess. NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.

EN

I/P Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to severe pain

I/Psevere pain.

Pearls: GCS should be assessed and documented.

Hyperventilation (10 breaths over normal ventilation) only if evidence of herniation (blown pupilHyperventilation (10 breaths over normal ventilation) only if evidence of herniation (blown pupil, posturing, or bradycardia.

Intracranial pressure may cause hypertension, bradycardia, and altered respiratory rate.Haloperidol should not be administered to these patients.

Trauma: General ManagementHistory•Time and mechanism of

Physical•Pain swelling

Differential Diagnoses•Chest•Time and mechanism of

injury•Damage to structure or vehicle•Location in structure or vehicle

•Pain, swelling•Deformity, lesions, bleeding•Altered mental status•Hypotension

•ChestTension pneumothoraxFlail chestPericardial tamponadeOpen chest wound

vehicle•Others injured or dead•Speed and details of MVC•Restraints/ protective devices

•Arrest Hemothorax•Intra-abdominal bleed•Pelvis/ femur fracture•Spinal fracture/cord injury•Head injury•Past medical history

•Medications

•Head injury•Extremity trauma•HEENT trauma•Hypothermia



Trauma: General Management


B Notify MedCom if possible trauma alert (red or yellow category):Advise mechanism of injury, age and sex of patient, sites of injury, vital if

available, ETA.

B

available, ETA.

B For evisceration, cover with moist sterile dressing then with plastic. Do not push organs back into abdominal cavity.

B


EN IV Acess ENEN IV Acess. NS 500 mL bolus, may repeat up to 1 liter to maintain BP >90 mmHg.

EN

EN Needle Decompression Procedure if indicated EN


Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to severe pain from isolated distal extremity fracture/ dislocation

MC Consider cessation of efforts for patients in traumatic cardiac arrest. MC

Pediatrics: General Management of Cardiac Arrest or Pre-ArrestHistory•Time of arrest


Differential Diagnoses•Respiratory failure•Time of arrest

•Medical history•Medications•Possibility of foreign body•Suspected abuse

•Unresponsive•Pulseless•Apneic

•Respiratory failureForeign bodySecretionsInfection

•Hypovolemia•SIDS •Congenital heart disease

•Trauma•Tension pneumothorax•Toxin or medication•Hypoglycemia•Hypoglycemia•Acidosis

Pearls: If pediatric pads are not available, use of adult pads is acceptable. Ensure they do not touch.

IV medications should be followed by a 10 mL bolus NS.ETT doses are less desirable, flush with 2-3 mL NS.

ETT placement should be reconfirmed everytime the patient is moved or for change of status.Continuous ETCO2 is mandatory in intubated patient.

Consider orogastric tube for abdominal distentionConsider orogastric tube for abdominal distention.Use length-based resuscitation tape.

.


Pediatrics: General Management of Cardiac Arrest or Pre-Arrest


B Check adequacy of CPR.Perform chest compressions if HR persistently <60 in child/infant or <80 in

newborn.

B

B Assess and ensure patent airway BB Assess and ensure patent airway. B

B AED protocol using pediatric pads if available B

Ensure patient warmth.

B Transport immediately with BLS measures while requesting ALS.. B

EN IV or IO access. EN

EN Dextrose per pediatric medication chart or Glucagon if no IV/IO access. EN

I/P Advanced airway management I/P

I/P Evaluate cardiac rhythm. Go to appropriate protocol for further I/PI/P Evaluate cardiac rhythm. Go to appropriate protocol for further management.

I/P

Pediatrics: Asystole/ PEAHistory•Time and mechanism of injury

Physical•Unresponsive•Pulseless

Differential Diagnoses•Respiratory failure

Foreign bodyj y•Damage to structure or vehicle•Location in structure or vehicle•Others injured or dead

Pulseless•Apneic

Foreign bodySecretionsInfection

•Hypovolemia•Congenital heart disease

•Others injured or dead•Speed and details of MVC•Restraints/ protective devices•Past medical history

•Trauma•Tension pneumothorax•Toxin or medication•Hypoglycemia•Acidosis•Medications •Acidosis


B Pediatric General Management of Cardiac Arrest Protocol B

/ / O ( ) / /I/P Epinephrine IV/IO (1:10,000) 0.01 mg/kg max 1 mgOr

Epinephrine ET (1:1000) 0.1 mg/kg*For newborns <30 days, ETT dose is Epi (1:10,000) 0.01 mg/kg

Repeat Epinephrine every 3-5 minutes

I/P

Repeat Epinephrine every 3 5 minutes

I/P Identify and treat reversible causes I/PPearls:

If pediatric pads are not available, use of adult pads is acceptable. Ensure they do not touch.IV medications should be followed by a 10 mL bolus NSIV medications should be followed by a 10 mL bolus NS.

ETT doses are less desirable, flush with 2-3 mL NS.ETT placement should be reconfirmed everytime the patient is moved or for change of status.

Continuous ETCO2 is mandatory in intubated patient.Consider orogastric tube for abdominal distention.

Use length-based resuscitation tape.

Pediatrics: BradycardiaHistory•Past medical history

•Physical•Decreased HR

•Differential Diagnoses•Respiratory distress•Past medical history

•Foreign body•Respiratory distress•Apnea•Toxic or poison exposure

•Decreased HR•Decreased capillary refill•Cyanosis•Mottled, cool skin•Hypotension

•Respiratory distress•Respiratory obstruction

Foreign body/secretionsCroup/epiglotitis

•Hypovolemia•Congenital disease•Medication (maternal or infant)

•Altered level of consciousness

•Hypothermia•Infection/sepsis•Medication or toxin•Hypoglycemia•Trauma•Trauma

Pearls: Bradycardia is commonly a manifestation of hypoxia.

If pediatric pads are not available, use of adult pads is acceptable. Ensure they do not touch.IV di ti h ld b f ll d b 10 L b l NSIV medications should be followed by a 10 mL bolus NS.



Use length-based resuscitation tapeUse length-based resuscitation tape..


Pediatrics: Bradycardia

B Assure adequate oxygenation. B

B If HR is persistently <60 for child/infant or <80 for neonates, begin CPR. Refer to General Management of Cardiac Arrest or Pre-arrest protocol

B

I/P Epinephrine IV/IO (1:10,000) 0.01 mg/kg max 1 mg I/PI/P Epinephrine IV/IO (1:10,000) 0.01 mg/kg max 1 mgOr


Repeat Epinephrine every 3-5 minutes

I/P

I/P Atropine sulfate 0.02 mg/kg IV/IO repeat every 5 minutesMax single dose for child 0.5 mg: total max 1mg

I/P

I/P Consider trancutaneous pacing I/P

I/P Identify and treat reversible causes I/P

Pediatrics: Narrow Complex TachycardiaHistory•Past medical history

PhysicalHeart rate

Differential Diagnoses•Congenital heart disease•Past medical history

•Medications or ingestionAminophyllineDiet pillsThyroid supplements

Heart ratePale or cyanoticDiaphoresisTachypneaVomiting

•Congenital heart disease•Hypoxemia or anemia•Hypovolemia•Hyperthermia•Electrolyte imbalance

DecongestantsDigoxin

•DrugsNicotineCaffeine

HypotensionAltered level of consciousnessPulmonary congestionSyncope

•Tamponade•Tension pneumothorax•Anxiety, pain, stress•Fever, infection, sepsis•HypoxiaCaffeine

•Congenital heart disease•Respiratory distress•Syncope or near syncope

Syncope •Hypoxia•Hypoglycemia•Medication, toxins, drugs•Trauma


Pediatrics: Narrow Complex Tachycardia

B IV/IO Access. B

B 12 Lead ECG. B

I/P Probable Sinus Tachycardia: (P waves present and normal, variable R-R with constant P-R, infant rate

I/P(P waves present and normal, variable R R with constant P R, infant rate

<220, child rate <180)Search for and treat potential causes as listed above in differential

diagnoses.

MC Probable Supraventricular Tachycardia: MC(QRS <0.08 msecs, P waves absent, abrupt change to or from normal,

infant rate >220, child rate >180)Consider vagal maneuvers if stable

MC Adenosine 0.1 mg.kg rapid IV/IO max initial dose 6 mg, may repeat one time at twice the first dose to a max of 12 mg.

MCg

MC Synchronized cardioversion 0.5 to 1 j/kg may increase to 2 j/kg if ineffective

MC

MC Consider midazolam 0.1 mg/kg IV/IO max single dose 2 mg. Do not delay cardioversion.

MC

Pediatrics: Ventricular Fibrillation/ Pulseless VTHistory Physical Differential Diagnoses


B General Management of Cardiac Arrest Protocol B

B AED protocol using pediatric pads if possible B

I/P Attempt defibrillation at 2 j/kg I/PI/P Attempt defibrillation at 2 j/kg I/P

I/P Epinephrine IV/IO (1:10,000) 0.01 mg/kg max 1 mgOr


I/P

y p ( ) g gRepeat Epinephrine every 3-5 minutes

I/P Attempt defibrillation at 4 j/kg after 2 minutes of CPR.Continue every 2 minutes.

I/P

MC Consider amiodarone 5 mg/kg IV/IO MCg g

MC Consider magnesium sulfate 25-50 mg/kg for Torsades or hypomagnesmia. Max dose 2 grams.

MC

Pearls: Sodium bicarbonate should not be used during brief resuscitation attempts.

If pediatric pads are not available, use of adult pads is acceptable. Ensure they do not touch.If pediatric pads are not available, use of adult pads is acceptable. Ensure they do not touch.IV medications should be followed by a 10 mL bolus NS.



Use length-based resuscitation tape.

Pediatrics: Wide Complex Tachycardia (VT with Pulse)History Physical Differential Diagnoses


EN IV/IO protocol EN

B 12 Lead ECG B

I/P Confirm QRS >0 08 msec I/PI/P Confirm QRS >0.08 msec I/P

I/P If unstable, sychronized cardioversion 0.5 to 1 j/kg,may increase to 2 j/kg if ineffective.

I/P

MC Consider amiodarone 5 mg/kg IV/IO over 10 to 20 minutes MC

MC C id id l 0 1 /k IV/IO MCMC Consider midazolam 0.1 mg/kg IV/IO.Do not delay cardioversion.

MC

Pearls: VT is uncommon in the pediatric patientVT is uncommon in the pediatric patient.

The ventricular rate may vary from near normal to near 400 bpm.Slow rates may be well tolerated.

The majority of children who develop VT have underlying structural heart disease or prolonged QT syndrome.IV medications should be followed by a 10 mL bolus NS.


Pediatrics: Hyperthermia



B Move to cooler environment, remove excess clothing, protect from further h t i

Bheat gains.

B For heat exhaustion, PO water if patient can tolerate. If temp >103°, cool with wet towels or fans until temp reaches 100°.

B

B For heat stroke, use aggressive evaporation (fine mist water spay, ice packs to groin and axillae) unitl core temp is <104°

Bto groin and axillae) unitl core temp is <104 .

EN Administer IV NSFor heat cramps/exhaustion, NS 10 mL/kg IV.

For heat stroke, NS at 20 mL/kg IV. Max fluid volume is 40 cc/kg.

EN

g

Pearls:The major difference between heat exhaustion and heat stroke is CNS impairment.

Avoid dramatic decreases in temperature which can cause shivering and increase temperatureAvoid dramatic decreases in temperature which can cause shivering and increase temperature.Dehydration and volume depletion may not occur in classic stroke. Vigorous fluid administration may result in pulmonary

edema, particularly in the very young.


Pediatric: Near Drowning

B Remove from water if it trained and safe to do so. B


B Prevent heat loss, refer to “Hypothermia” protocol if indicated. B

EN IV access. EN

I/P Refer to specific cardiac arrhythmias protocol as needed. I/P

Pearls:Most near drowning victims will be hypothermic to some extent.

Assess type of incident (surface impacted, object strike, propeller trauma).Assess water conditions (depth of submersion, length of time, water temp).( p g p)

History•Onset and location•Insect sting or bite

Physical•Itching or hives•Coughing or wheezing

Differential Diagnoses•Rash only

Pediatric: Severe Allergic Reaction

Insect sting or bite•Food allergy/ exposure•Medication allergy/exposure•New clothing, soap, detergent•Past history of reactions

Coughing or wheezing•Chest or throat constriction•Difficulty swallowing•Hypotension or shock•Edema

y•Anaphylaxis•Shock•Angioedema•Aspiration/ airway obstr ction•Past medical history

•Medication history

obstruction•Asthma


B Remove from source of exposure. Bp

B Apply ice packs to localized area. B

B Administer epinephrine (1:1000) 0.01 mg SQ. Max dose 0.3 mg.•EMT-B’s should assist with prescribed auto injector (Epi-Jr 0.15 mg) for severe hives, respirator distress, and/or shock if between 2 and 8 years.

B

severe hives, respirator distress, and/or shock if between 2 and 8 years.

J Albuterol 2.5 mg nebulized for wheezing/ bronchospasm. J

EN NS 20 mL/kg bolus for hypotension or inadequate perfusion. EN

J Diphenhydramine 1 mg/kg IM or IV. Max 50 mg. J

EN Methylprednisolone 1mg/kg IV over 1 minute for severe hives, inadequate perfusion, or respiratory distress.

EN

I/P Cardiac and pulse oximetry monitor. I/P

MC Consider additional doses of Epinephrine. MC

Pearls:Any patient receiving epinephrine must be transported.

History•Known diabetic•Drugs paraphenalia

Physical•Change from baseline mental status

Differential Diagnoses•Head trauma

Pediatric: Altered Level of Consciousness

Drugs, paraphenalia•Report of drug use or toxic ingestion•Past medical history•Medications

•Bizarre behavior•Cool, diaphoretic skin (hypoglycemia)•Warm,dry skin with signs of dehydration (hyperglycemia)

•Stroke•Tumor•Seizure•Infection

•History of trauma dehydration (hyperglycemia)•Fruity breath odor•Kussmaul respirations

•Thyoid•Shock•Diabetes•Acidosis/alkalosis•EnvironmentalEnvironmental exposure•Electrolyte imbalance•Psychiatric disorder

Pearls:Contact Poison Control at 434-971-8657 or 1-800-451-1428 for suspected ingestion.


Pediatric: Altered Level of Consciousness

B Spinal immobilization if needed. B

EN IV Access EN

EN Administer glucose:•Children >8 years, Dextrose 50% 1mL/kg IV or IO.

EN

•Children 1 month to 8 years, Dextrose 25% 2 mL/kg IV or IO.•Neonates <1 month, Dextrose 12.5% 4 mL/kg IV or IO.

EN 20 mL/kg bolus for hypoperfusion and tachycardia10 mL/kg bolus over 1 hour for patients with mild signs of dehydration.

EN

Max 40 mL/kg.

EN Naloxone 0.1 mg/kg IV, IO, or IM for suspected narcotic overdose with respiratory depression.

EN


History•Fever

Physical•Observed seizure activity


Pediatric: Seizures

•Prior history of seizure•Seizure medications•Reported seizure history•Head traumaC it l b lit

•Altered mental status•Hot, dry skin •Elevated body temperature

•Fever•Infection•Head trauma•Medication or toxin•Hypoxia•Congenital abnormality •Hypoxia•Hypoglycemia•Metabolic abnormality•Tumor


B Protect patient. Do not attempt to restrain. B

EN IV Access ENEN IV Access EN

EN Administer glucose:•Children >8 years, Dextrose 50% 1mL/kg IV or IO.

•Children 1 month to 8 years, Dextrose 25% 2 mL/kg IV or IO.•Neonates <1 month, Dextrose 12.5% 4 mL/kg IV or IO.

EN

g

I/P Diazepam 0.1 mg/kg IV/IO max single dose 5 mg. May repeat once in 5 minutes for persistent seizure.

I/P

I/P Midazolam 0.1 mg/kg IM if no IV access, max single dose 5 mg. May repeat once in 5 minutes for persistent seizure.

I/P


History•Due date and gestational age

Physical •Apneic


Pediatric: Newborn Resuscitation

•Multiple gestation•Meconium•Delivery difficulties•Congenital diseaseM t l di ti

•Central cyanosis•Unresponsive•Bradycardic•Pulseless

•Airway failureSecretionsRespiratory drive

•Infection•Maternal medication•Maternal medications

•Maternal risk factors (substance abuse)

•Maternal medication effect•Hypovolemia•Hypoglycemia•Congenital heart didisease•Hypothermia

Pearls:IV fluids should be administered in less than 20 minutes.

IO access should be attempted if no peripheral access in 2 attepts or 90 seconds.

B Assess ABC’s using base of umbilical cord, brachial or femoral artery, or B

Pediatric: Newborn Resuscitation

g yascultation of heart sounds.

B Place newborn on back with neck in neutral position. B

B Suction mouth prior to suction nose. Note any meconium presence. B

B After delivery, use mild stimulation (dry, warm, suction). If effective BB After delivery, use mild stimulation (dry, warm, suction). If effective respirations are not present after 5-10 seconds of stimulation, BVM at 40-60

breaths/minute.

B

B If heart rate is <60 bpm with no improvement after BVM for 30 seconds, begin CPR.

B

B Dry the newborn, wrap in blanket, head cap to maintain warmth. Do not allow newborn to become hypothermic.

B

B Record APGAR’s at 1 and 5 minutes. B

I/P Endotracheal intubation is indicated if BVM is ineffective or tracheal suctioning when meconium aspiration is needed

I/Psuctioning when meconium aspiration is needed.

I/P Fluid therapy if signs of shock are present. NS 10 mL/kg IV/IO rapidly. May repeat once.

I/P

I/P Follow specific algorithms for bradycardia, tachycardia, or cariac arrest. I/P

History•Time of onset•Possibility of foreign body

Physical•Wheezing or stridor•Retractions

Differential Diagnoses•Asthma

Pediatric: Pulmonary Emergencies/ Respiratory Distress

Possibility of foreign body•Medial history•Medications•Fever or repiratory infection•Sick siblings

Retractions•Increased heart rate•Altered LOC•Anxious appearance

•Aspiration•Infection (pneumonia, croup, epiglotitis)•Congenital heartMedication or to in•History of trauma •Medication or toxin

•Trauma


B Allow child to assume position of comfort. B

B Assist patient with prescribed Metered Dose Inhaler. B

J Albuterol 2.5 mg and Ipratroprium nebulizer. May repeat albuterol as long as patient is symptomatic.

J

EN IV access EN

EN Epinephrine (1:1000) 0.01 mg/kg SQ, single max dose 0.3 mg for severely symptomatic patient. May repeat every 20 minutes for a max of 3 doses if

still symptomatic.

EN

EN NS 2-3 mL nebulized for suspected croup or epiglottitis. EN

MC Epinephrine (1:1000) 2-3 mL nebulized for moderate to severe patients with suspected croup or epiglottitis.

MC

MC Methylprednisolone 2 mg/kg IV for severe asthma or croup. MC

I/P Cardiac and pulse oximetry monitors. I/PI/P Cardiac and pulse oximetry monitors. I/PPearls:

“Severely symptomatic” is defined as inability to speak normally, severe wheezing, absent or diminished breath sounds, and/or poor perfusion.

In upperway airway disorders, invasive airway maneuvers should be avoided if possible.

Pediatric: Poisoning/ OverdoseHistory•Ingestion of toxic

Physical•Mental status change

Differential Diagnoses•Tricyclic antidepressants•Ingestion of toxic

substance•Route and quantity of substance ingested•Time of ingestionR ( i id id t)

•Mental status change•Hypo-/hypertension•Decreased respiratory rate•Tachycardia

•Tricyclic antidepressants•Acetaminophen•Depressants•Stimulants•Anticholinergics

•Reason (suicide, accident)•Available medications near patient•Past medical history, medications

•Dysrhythmias•Seizures

•Cardiac medications•Solvents, cleaning agents•Insecticides (organophosphates)

Pearls: Intubated patients should not receive naloxone unless in cardiac arrestIntubated patients should not receive naloxone unless in cardiac arrest.

Tachycardia is not a contraindication to atropine adminstration.Poison control should be consulted on all complex toxicology at 434-924-5543 or 1-800-451-1428.

Aeromedical resources will not transport contaminated patients.


Pediatric: Poisoning/ Overdose

J Identify substance and assure decontamination. J

J Flush skin/membranes with appropriate solution if indicated. J

EN IV access. EN

EN Naloxone 0 1 mg/kg IV or IM for suspected narcotic overdose with ENEN Naloxone 0.1 mg/kg IV or IM for suspected narcotic overdose with respiratory depression.

EN

EN Diphenhydramine 1 mg/kg slow iVP for dystonic reaction secondary to phenothiazine ingestion (max dose of 50 mg).

EN

I/P For Symptomatic Tricyclic Antidepressant Overdose: I/PI/P For Symptomatic Tricyclic Antidepressant Overdose:( if QRS >0.10 msecs, hypotension, or dysrhythmia)

•Sodium bicarbonate 1mEq/kg slow IVP over 2 minutes

I/P

I/P For Symptomatic Calcium Channel Blocker Overdose:(if bradycardic, QRS >0.12 msecs, heart block, hypotension, lethargy,

I/P

slurred speech, nausea, vomiting)•Calcium chloride 10 mg/kg slow IVP over 10 minutes

•Sodium bicarbonate 1 mEq/kg slow IVP over 2 minutes.

I/P For Symptomatic Organophosphate Poisoning: I/P(secretions, bronchospasm, seizures, bradycardia)

•Atropine 0.05 mg/kg IV doubled every 5-10 minutes until decreased secretions.

Pediatric: AmputationHistory•Mechanism of injury

Physical•Deformity

Differential Diagnoses•Complete amputation•Mechanism of injury

•Time of injury•Wound contaminatior•Medical history•Medications

•Deformity•Diminished pulse, capillary refill

•Complete amputation•Incomplete amputation


B Spinal Immobilization. B

B Apply direct pressure to control hemorrhage. Avoid tourniquet if possible. BB Apply direct pressure to control hemorrhage. Avoid tourniquet if possible. B

B If incomplete amputation, splint entire digit or limb in physiological position.

B

B Place part in damp gauze, place in plastic bag, wrap in trauma dressing, place on ice/water mix.

B

EN IV Access. NS 20 mL/ kg bolus.

EN

I/P Morphine sulfate up to 0.1 mg/kg slow IV/IO/IM. Max dose 10 mg. I/P

Pearls: Tourniquets should be used with the smallest amount of pressure over the widest area.

Never freeze the part by placing directly on ice.

Pediatric: BurnsHistory•Type of exposure•Inhalation injury

Physical•Burns, pain, swelling•Dizziness

Differential Diagnoses•Superficial•Partial thicknessInhalation injury

•Time of injury•Past medical history•Other trauma•Medications

Dizziness•Loss of consciousness•Hypotension•Airway compromise•Singed facial or nasal hair

Partial thickness•Full thickness•Chemical•Thermal•Electrical

•Loss of consciousness•Tetanus status

•Hoarseness/wheezing •Radiation


B Apply dry sterile dressings. By y g

MC Consult medical command regarding cooling procedures. MC


B Irrigate chemical burn with water if water is appropriate to chemical.If powdered chemical brush off

BIf powdered chemical, brush off.

B Splint fractures after apply dressing. B


EN IV or IO Acess. NS 20 L/k b l t t 40 L/k

ENNS 20 mL/kg bolus, may repeat up to 40 mL/kg.


I/P Morphine sulfate up to 0.1 mg/kg slow IVP or IM for moderate to severe pain.

I/P

Pearls: In electrical burns, search for additional traumatic injury.In thermal burns, assess for carbon monoxide exposure.

Remove jewelry and nonadherent clothing.Avoid establishing IV distal to extremity burn.

Trauma: CNS InjuriesHistoryTime of injury

Physical•Pain swelling bleeding

Differential Diagnosis• Skull fractureTime of injury

Mechanism of injuryLoss of consciousnessBleedingMedical history

•Pain, swelling, bleeding•Altered mental status•Unconsciousness•Respiratory distress/failure

• Skull fracture•Brain injury•Epidural hematoma•Subdural hematoma•Subarachnoid

MedicationsEvidence of multi-traumaHelmet use or damage

•Vomiting•Significant mechanism of injury

hemorrhage•Spinal injury•Abuse



B Elevate head of stretcher 30° if not hypotensive. B



EN IV or IO access ENEN IV or IO accessNS 20 mL/kg bolus, may repeat up to 40 mL/kg.

EN


Pediatric: General Trauma ManagementHistory•Time and mechanism of

Physical•Pain swelling

•ChestTension pneumothorax•Time and mechanism of

injury•Damage to structure or vehicle•Location in structure or vehicle

•Pain, swelling•Deformity, lesions, bleeding•Altered mental status•Hypotension

Tension pneumothoraxFlail chestPericardial tamponadeOpen chest woundHemothorax

vehicle•Others injured or dead•Speed and details of MVC•Restraints/ protective devices

•Arrest •Intra-abdominal bleed•Pelvis/ femur fracture•Spinal fracture/cord injury•Head injury•Extremity trauma•Past medical history

•Medications

•Extremity trauma•HEENT trauma•Hypothermia


Preservation body heat is paramount.


Pediatric: General Trauma ManagementB Universal Care Protocol B


B Notify MedCom if possible trauma alert (red or yellow category):Advise mechanism of injury, age and sex of patient, sites of injury, vital if

available ETA

B

available, ETA.

B For evisceration, cover with moist sterile dressing then with plastic. Do not push organs back into abdominal cavity.

B


EN IV or IO access. NS 20 mL/kg bolus, may repeat up to 40 mL/kg.

EN

EN Needle Decompression Procedure if indicated EN


I/P Morphine sulfate up to 0.1 mg/kg slow IVP or IM for moderate to severe pain from isolated distal extremity fracture/ dislocation. Max dose 10 mg.

I/P

MC Consider cessation of efforts for patients in traumatic cardiac arrest. MC

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