TUCSON MEDICAL CENTER BASE HOSPITAL ADMINISTRATIVE/STANDING INDEX
Base Hospital
1. Abdominal Pain
2. ALS/BLS General
3. ALS Stabilization
4. Behavioral Emergency
5. Burn (SAEMS)
6. Cardiac Arrest (SAEMS)
7. Chest Pain
8. Dead on Scene (SAEMS)
9. Dyspnea-Anaphylaxis/Allergic Reaction (SAEMS)
10. Dyspnea-Asthma/COPD (SAEMS)
11. Dyspnea-CHF/Volume Overload (SAEMS)
12. EMT Stabilization
13. ETOH
14. Eye Injury
15. HAZMAT Patients (SAEMS)
16. Hyperthermia
17. Hypo-Hyperglycemia
18. Hypothermia (SAEMS)
19. Nausea and Vomiting
20. OB-GYN-Vaginal Bleeding (SAEMS)
21. OB-GYN- Eclamptic Seizure (SAEMS)
22. OB-GYN-Post-Partum Hemorrhage (SAEMS)
23. OB-GYN-Presumed Pregnant with Contractions and/or SROM (SAEMS)
24. Pain Management
25. Peds Cardiac Arrest (SAEMS)
26. Refusal of Transport under 18 years
27. Refusal of Transport over 18 years
28. Seizure
29. Sepsis-Shock
30. Sexual Assault (SAEMS)
31. Snakebite (SAEMS)
32. Stroke (SAEMS)
33. Tourniquet
10/09; updated 2013-2015; 01-16; 12-19;revised 2-20
This administrative order should not be used on patients who are:
Pregnancy - follow OB/GYN SO
Meeting Level One or abdominal trauma - follow ALS/BLS Stabilization AO BLS
If patient’s condition deteriorates, call Medical Direction Authority
Consider transport to closest facility Provide appropriate receiving facility notification
Use administrative order on patients complaining of abdominal pain
ALS
Follow BLS orders
If patient stable with complaints of nausea and/or vomiting, administer Ondansetron HCL IV/IM/PO: o Adult size(>30 kg)
o Ondansetron 4 mg IV over 2-5 minutes, if no response, may repeat once after 15 minutes
o If unable to obtain IV, give Ondansetron 8mg PO, Orally Dissolving Tablet (ODT), Do NOT Repeat
o Or Ondansetron 4 mg IM, if no response, may repeat once after 15 minutes
o Pediatric size(<30kg) o Pediatric <15kg Ondansetron 0.15 mg/kg slow IVP over 2-5
minutes, Do NOT Repeat o Pediatric >15kg Ondansetron 4 mg Orally Dissolving Tablet
(ODT), Do NOT Repeat
If patient stable, may follow Pain Management AO
If patient unstable, and unable to start IV, use I/O for fluid bolus
ABDOMINAL PAIN AMINISTRATIVE ORDER
I NCL
E X C L
Initiate Immediate Supportive Care:
Oxygen to maintain O₂ sat ≥ 94%
Complete primary and secondary survey as indicated
Vital signs including FSBG and temperature as indicated
ALS Cardiac Monitor
ORDER
S
Stable: SBP >90 or HR <130
Initiate IVNS/LR (if permitted)
Transport in position of comfort with supportive measures as indicated Unstable: SBP <90 or HR >130
Follow stable orders
To keep SBP> 90, bolus 20 ml/kg maximum, reassess hemodynamic and pulmonary status at 500 ml intervals
Base Hospital
Base Hospital
10/09;undated 2013-16;09/16;01/19
If patient’s condition deteriorates call, Medical Direction Authority Consider transport to closest facility
Provide appropriate receiving facility notification
Initiate immediate supportive care:
Oxygen to maintain O₂ sat ≥ 94%
Complete primary and secondary survey as indicated
Vital signs including FSBG and temperature as indicated
ALS BLS
General weakness
≤ 3 months old with any symptoms of illness or injury
Fever- 55 years of age and older with Temp > 102 or above
Dizziness
Overdose
Lightheaded
Lacerations Hypertensive patient with no other medical issues ***Requires cardiac monitor***
Nose bleeds-minor with stable vital signs
Finger lacerations
Toe injuries
Cactus needles
Earache
Cough- low grade fever under 18 years of age
Cold symptoms
General minor complaints ***No cardiac monitor required***
ALS IV NS/LR TKO as indicated
If indicated- bolus 20 ml/kg maximum, reassess hemodynamic and pulmonary status at 500 ml intervals
12 ECG as indicated
Febrile patient follow Over-the-Counter Medication Protocol BLS
Prepare for transport
Basic supportive care as needed
Febrile patient follow Over-the-Counter Medication Protocol
ALS/BLS GENERAL ADMINISTRATIVE ORDER
O R D E R S
Base Hospital
10/09; updated 2010-2016; 01/17, 01/19
If patient’s condition deteriorates, call Medical Direction Authority Consider transport to closest facility
Provide appropriate receiving facility notification
Us
Initiate Immediate Supportive Care:
O2 to maintain sat > 94%
Complete primary and secondary survey as indicated
Cardiac monitor, vital signs including FSBG and temperature as indicated
12 Lead EKG as indicated
ALS STABILIZATION ADMINISTRATIVE ORDER
Airway maintenance, control and ventilation
Follow Airway Management Protocol as needed
Follow Medicated Facilitated Intubation Protocol if indicated, if patient condition worsens or unable to secure airway Midazolam (Versed) Dosing: IV/IO/IM
Age 14 years of age or older: 1-10 mg, may repeat to max of 20 mg
Age 9-14 years of age: 1-4 mg slow push, may repeat to max of 15 mg
Age 8 years of age or younger: 1-2 mg slow push, may repeat to max 10 mg
IM Dosing all ages: 0.2mg/kg IM, same max per age
CPAP Adult Sedation: with Dyspnea SO, follow Sedation Protocol
Croup Management: Epi 3mg 1:1,000 mixed in 3 ml NS via SVN along with Dyspnea SO
Emergency treatment of ACLS/PALS conditions
Follow the appropriate ACLS/PALS algorithm
Electrical therapy with pacing, defibrillation or cardioversion
Use Sedation Protocol as needed
I/O consider following lidocaine dosing sheet for pain control
Injury Triage Criteria
Follow Trauma Triage Protocol as indicated
ATLS/ABCDE-injury area
Consider C-Spine precautions-follow -SMR Protocol documenting use
Initiate IV/IO NS/LR TKO as appropriate-Bolus to maintain systolic BP ≥ 90
Manage extremity injuries as appropriate
If TBI suspected follow EPIC Protocol for Adult or Peds
Needle Decompression per SAEMS protocol
If unable to control bleeding, follow External Hemorrhage Control Protocol and/or TQ AO
Pain Management AO as needed if stable
Falls- evaluate, describe impact surface, height of fall
Painful procedure follow the Sedation Protocol
Physical Assault
Hypotension
SBP ≤90, pulse≥120, increased respirations, pale, cool skin, diaphoresis, altered mental status, agitation, or restlessness, progression to profound hypotension
NS/LR bolus 20 ml/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals
Consider causes
Initiate Dopamine drip (if heart rate ≤ 100) 2-20 mcg/kg/min titrate to SBP≥80 if time permits or follow Push Dose Epi Protocol
Unconscious/unresponsive patient unresponsive or responsive only to painful stimuli
Manage airway as above
Initial IV with NS/LR TKO
Bolus 20 mL/kg k maximum, reassess hemodynamic status and pulmonary status at 500 mL intervals to maintain SBP ≥90
Administer Naloxone IV/IO/IN/IM 0.5 mg-2.0 mg, titrate to effect
FSBG≤70, give 1mL/kg of D10 and 100mg Thiamine (if available). May hold Thiamine if no history of alcohol abuse or malnourishment)
If status improves after treating FSBG, follow Hypoglycemia AO
If FSBG >400, follow Hyperglycemia AO
Base Hospital
10-09; updated 2013-2015; 01-16
Initiate immediate supportive care: Oxygen to maintain sat ≥ 94%
Complete primary and secondary survey as indicated
Vital Signs including FSBG as indicated
ALS patient cardiac monitor
I
Call Poison Control for suspected or verified Ingestions/overdose/exposures as needed
800-222-1222
Protect patient from harming self and others
Calm patient with reassuring voice and gestures
If patient is violent or exhibiting behavior that is dangerous to self or others and the EMS provider can safely perform the following:
Restrain all four extremities with either padded leather restraints or soft restraints. Pt. must remain in the supine position. Restraints must allow for quick release. Handcuffs are for law enforcement use only.
Paramedic o Chemical Restraint Protocol as needed
Pepper spray: decon with H2O, apply ice packs, discourage eye rubbing
Tazer Probes: Ask Law Enforcement to remove; if imbedded in face, neck or groin, transport for ED removal; do NOT remove
TMC BEHAVIORAL ADMINISTRATIVE ORDER
O R D E R S
Contact Medical Direction Authority If:
The patient wishes to refuse
The EMS providers cannot safely restrain the patient
Condition deteriorates
Provide appropriate receiving facility notification
Assess for immediate danger
Protect yourself and others
Protect patient from injury
Summon Law Enforcement as needed
Use AO on patients with these symptoms:
History of recent crisis, emotional trauma, bizarre or abrupt changes in behavior
Suicidal Ideation
Acute psychiatric complaint
No identified acute medical needs
+
D DRAFT 6-22-09 DRAFT
Initiate immediate supportive care: • Assure ABC’s • 100% Oxygen • IV/IO NS or LR • Cardiac Monitor
BURN STANDING ORDER
Use standing order on ALL patients with these symptoms: • Partial thickness burns > 10% total body surface area (TBSA) • Full thickness burn > 5% TBSA • Significant burns that involve the face, hands, feet, genitalia, perineum, or major joints • Electrical burns, including lightning injury • Inhalation injury • Significant burn injury in patients with preexisting medical disorders that could complicate management,
prolong recovery, or affect mortality, such as: diabetes, cardiac disease, pulmonary disorders, pregnancy, cirrhosis, morbid obesity, immunosuppression, bleeding disorders
Special Notes: Patients meeting inclusion criteria should be transported to the regional burn facility.
• If appropriate airway measures are not successful in the field, transport to closest facility.
• In outlying areas with a transport time of greater than 30 minutes to the regional burn facility, transport the patient to the closest facility or, consider air transport directly to the closest burn facility.
• Regional burn facility currently in SAEMS: UAMC University Campus
I N C LUSI O N
E X C L U S I O N
Patients with burns who also meet any of SAEMS Trauma Triage Decision Scheme criteria should be transported to a trauma center for initial stabilization following on-line medical direction.
• Stop the burning process, remove smoldering clothing and jewelry • Continually monitor airway • Cover burn area with a clean dry dressing. Prevent hypothermia (warm fluids/environment). Never use ice • Estimate involved body surface area (BSA) using an appropriate burn estimation guide • IV/IO NS or LR: administer initial fluid bolus of 20 ml/kg • Consider early aggressive airway management in patients at risk for inhalation injury
ADULT Pain/Nausea Management • Consider Morphine Sulfate 5-10 mg every 5 min up to a max dose of 20mg, OR • Fentanyl 50-100 mcg every 5 min as needed up to a max dose of 200 mcg or respiratory/mental status depression
occur • For nausea or vomiting, administer Ondansetron per N/V Standing Order
PEDS Pain/Nausea Management • Consider Morphine Sulfate 0.1 mg/kg in increments of 1-2 mg every 5 min to a max dose of 10 mg, OR • Fentanyl 0.5 – 1 mcg/kg every 5 min as needed to a max dose of 100 mcg or respiratory/mental status depression
occur • For nausea or vomiting, administer Ondansetron per N/V Standing Order
O R D E R S
Approved 4-19-11 Revised 10-15-13
Relay information must include percent, location, and type of burn.
Initial Orders: Initiate Chest Compressions with Rate of 100-120 compressions per minute
If ROSC at ANY time
Prepare for rapid transport per appropriate SAEMS Triage Protocol (CRC, Trauma, Peds, OB)
• If NO response, apply Dead On Scene SO • Consider transport for a patient with:
persistent VF, PEA with elevated EtCO2 (> 20 mmHg), patients under age 18 years
INCLUSION
Out of Hospital Cardiac Arrest
EXCLUSION
• Patients meeting SAEMS Dead on Scene SO • Age less than 8 years old
Special notes: ACLS Interventions
Hypoxia Airway Management
Hydrogen ion or acidosis 500cc fluid bolus Adjust EtCO2 to 40
Hyperkalemia • Administer: Calcium Chloride
1gm IV/IO and Sodium Bicarbonate 50mEq IV/IO
Hypovolemia 500ml fluid bolus
Hypoglycemia Dextrose
Hypothermia Hypothermia SO
Tension pneumothorax Needle decompression
Trauma Rapid transport
Toxins: TCA overdose, administer bicarb beta-blocker or calcium channel blocker overdose, consider glucagon & cardiac pacing Opiate overdose, consider Narcan
Patient Destination: Patients should be transported per SAEMS Cardiac Receiving Center Triage Protocol * if transitioning from MICR to ACLS give only a total of 2mg Epi
Effective: 10/16/18
ACLS • Apply SAEMS Airway Management Protocol • Perform CPR checking rhythm (and
pulse when indicated), defibrillating if indicated every 2 min with ventilation rate of 10 breaths / minute
• ALS: • Administer Epi 1mg IV/IO (as early as
possible) to max total dose of 2mg with doses separated by 8 min.*
• Consider ACLS H’s & T’s - treat per current ACLS guidelines*
• Avoid hyperthermia BLS
• IF no shock indicated and patient meets Dead on Scene SO criteria for termination, no transport or further interventions are indicated
Minimally Interrupted Cardiac Resuscitation (MICR) - first 8 minutes
• NRB mask, max flow O2 & NPA/OPA • Perform 4 rounds of CPR
- 200 compressions - Check rhythm (and pulse when indicated),
defibrillate if indicated between rounds - Minimize interruptions
• ALS: • Administer Epi 1mg IV/IO (as early as
possible) to max total dose of 2mg with doses separated by 8 min.
• IF VF after first shock, administer Amiodarone 300mg IV/IO or lidocaine 1mg/kg IV/IO x 1
• If continued VF after THIRD shock administer Amiodarone, 150mg IV/IO or lidocaine 1mg/kg IV/IO x 1
ORDERS ORDERS
Likely Non-Cardiac Cause Likely Cardiac Cause
Cardiac Arrest Standing Order
NO
Response
Base Hospital
04-09; updated 2011-2015; 01-16;
01/17, 1/19, 12/19, revised 2/20
Use this Administrative Order for patient’s ≥25 years of age with these symptoms
Dull aching or substernal/ epigastric pressure
Possible radiation of pain/pressure to arm/neck/shoulder/jaw
Associated diaphoresis/or shortness of breath
Back pain or epigastric discomfort for women
Past medical history of cardiac disease or angina
Use on patients ≤25 years of age with hx of recent drug use
Administrative order should not be used on patients with these symptoms:
Pulmonary edema- follow Dyspnea SO
ALS-Dysarrythmia’s Specific- follow ALS Stabilization AO
BLS Administer: Aspirin (4) 81mg chewable tablets or Aspirin 324 mg
Initiate IV NS/LR TKO (if permitted)
SBP ≥ 110: give one* Nitroglycerine 0.4 mg SL/spray or patient assist self-administration every 5 minutes X 3 or until pain relieved
Hold Nitroglycerin if SBP drops below 90mm Hg o If SBP drops ≤90– place patient in Trendelenburg and give 250 ml fluid bolus,
reassess hemodynamic and pulmonary status and repeat as needed
ALS Follow BLS orders
Obtain 12-lead EKG and send to receiving facility, if possible
o Use Nitroglycerin cautiously in patients with ST –segment elevation in
leads II, III, and AVF (inferior MI)
For nausea or vomiting follow Nausea and Vomiting AO
Morphine Sulfate IV/IM:
o 2-5mg IV every 5 minutes to a max dose of 20 mg
o If unable to obtain IV, give Morphine Sulfate 2-5 mg IM, if no response, may
repeat after 15 minutes to a max dose of 20 mg
If patient allergic to Morphine, administer Fentanyl IV/IN/IM:
o 25mcg-50mcg slow IVP, over 2 minutes. May repeat every 5 minutes to a max dose
of 200 mcg
o If unable to obtain IV, give Fentanyl 25mcg-50mcg IN/IM, may repeat dose after 15
minutes to a max dose of 200mcg
If at any point during medication administration, SBP≤90 drops follow above orders for
fluid bolus and management
CHEST PAIN ADMINISTRATIVE ORDER
I N C L
U
E X C L
O R D E R
S
Initiate immediate supportive care:
Oxygen to maintain O₂ sat ≥ 94%
Complete primary and secondary survey as indicated
Vital signs including FSGB
ALS cardiac monitor
EMT cardiac monitor (non interruptive) if available
STEMI Alert If the EMS provider has clinical impression and/or the
computerized interpretation identifies ST segment elevation or an acute MI,
alert facility this is a STEMI alert.
SAEMS Dead On SceneStanding Order
SPECIAL NOTE:If there are scene or patient circumstances in which providers, family, or other stakeholders would benefit from transporting a patient unlikely to survive their illness/injury, the treating EMS team can elect to do so in a safe manner. If asked for a time of death please provide the “TIME at which resuscitation was withheld/withdrawn.”
Pulseless
Inclusion
Hypothermia, lightning strikes, submersion
Exclusion
Conditions Incompatible with Life• Decapitated• Decomposed• Burned beyond recognition• Absence of signs of life in a patient with a signed DNR order
ORDERSWithdraw OR
Withhold resuscitative
efforts
Non-traumatic Cardiac Arrest
Penetrating Trauma & Cardiac Arrest
Blunt Trauma & Cardiac Arrest• IF airway obstruction or tension pneumothorax: Consider OPA/NPA and
bilateral needle thoracostomyAND• IF continued pulseless on scene
ALL OF THE FOLLOWING• Un-witnessed Arrest• > 30 min down time• No pulse for 60 sec• PEA/Asystole or non-
shockable rhythm on AED
ALL OF THE FOLLOWING• Witnessed Arrest• 20 minutes of resuscitation with
o PEA & EtCO2 < 10OR
o Asystole or non-shockablerhythm on AED
OR
Approved: 1/19/16
• IF airway obstruction or tension pneumothorax: Consider OPA/NPA and bilateral needle thoracostomy
AND• IF continued pulseless AND time to Level I trauma center > 15 min
Dyspnea Standing Order
BLS Care:• Place patient in position of comfort• Obtain vital signs• IV Access if capable• Supplemental O2 to achieve O2 Sat >94%• Assist ventilations if indicated:
- BVM with 100% O2
INCLUSION
All patients complaining of dyspnea, cough, tachypnea, or in respiratory distress
EXCLUSION
Standing order should NOT be used on patients with the following symptoms:• Chest Pain • Dysrhythmia (ACLS) • Hemorrhage• Smoke Inhalation • Toxic Exposure • Seizure• Absent Breath Sounds • Trauma
SPECIAL NOTE:• Other causes of dyspnea include pneumonia, pneumothorax, pulmonary contusion, pulmonary embolism, or toxic
ingestion (i.e. aspirin). • Aspirin ingestions can cause severe tachypnea due to metabolic acidosis: If ETI is performed, ENSURE ventilation rate
after ETI matches the patient’s respiratory rate prior to ETI.• If BVM ventilation or an advanced airway is placed, examine for presence of potential tension pneumothorax and
decompress if present.
ALS Care:• Follow BLS Interventions• Cardiac monitor• If respiratory failure:
- Consider Airway Management Protocol
Dyspnea SO
Anaphylaxis
Dyspnea SO
CHF / Volume Overload
Dyspnea SO
Asthma / COPD
Contact Medical Direction if unclear clinical presentation or patient wishes to refuse and does not meetRefusal Standing Order. Notify receiving facility of incoming patient and/or if CPAP therapy has been initiated.Consider Critical Pediatrics Triage Criteria
Initiate supportive care:
Approved: 1/19/16
Anaphylaxis/Allergic Reaction Standing Order
ORDERS
For STABLE allergic reaction OR
following the administration of epinephrine:
BLS Care if respiratory involvement:• Albuterol nebulized therapy
- Single unit dose. May repeat every five minutes to a max of three doses.
ALS Care:• Albuterol and Ipratropium nebulized
therapy- May repeat Albuterol every five minutes to a max of three doses.
• IV access and NS/LR fluid bolus:- 20ml/kg to a max of 1000ml
• Diphenhydramine- 1mg/kg IVP to a max of 25mg
• Methylprednisolone- 2mg/kg IVP to a max of 125mg
ORDERS
For UNSTABLE allergic reaction:
BLS Care:• Administer Epinephrine:
- via Adult auto-injector (wt >30kg)- via Pediatric auto-injector (wt <30kg)
• Continue with orders outlined in Stable Allergic Reaction.
ALS Care:• Epinephrine 0.01mg/kg to a max of
0.5mg. May repeat every 5 minutes for hypotension or airway edema.- 1:1000 solution IM (preferred)* or may substitute age/weight appropriate epinephrine auto-injector- 1:10,000 solution IV
• Consider early airway management per Airway Management Protocol
• Continue with orders outlined in Stable Allergic Reaction.
SPECIAL NOTE:• Multiple diseases may mimic anaphylaxis (i.e: Angioedema, Scombroid Toxicity, Anaphylactoid Reaction, etc).
Treatment for these diseases is the same as anaphylaxis as outlined above.• *Administration of IV epinephrine can result in significant tachycardia / hypertension and complications such as heart
attack and stroke
EXCLUSION• If none of the above, use Stable
Allergic Reaction Inclusion/Order set only.
INCLUSIONUnstable Allergic Reaction:
• Signs of shock, severe respiratory distress or airway compromise
INCLUSIONStable Allergic Reaction:
• Urticaria (Hives)• Sense of dyspnea• Sense of oropharyngeal swelling• Sense of throat tightness
Approved: 1/19/16
Asthma/COPD DyspneaStanding Order
ORDERS
Initial BLS Care:• Albuterol nebulized therapy
- Single unit dose. May repeat every five minutes to a max of three doses.
INCLUSION
History of respiratory disease (asthma, COPD), wheezing with increased work of breathing.
Initial ALS Care:• Albuterol and Ipratropium nebulized
therapy- May repeat Albuterol every five minutes to a max of three doses.
• IV access and NS/LR fluid bolus:- 20ml/kg to a max of 1000ml
• Methylprednisolone- 2mg/kg IVP to a max of 125mg
ORDERS
For Presumed Asthma and severe respiratory distress unresponsive to initial therapy:
ALS Care:• Epinephrine 0.01mg/kg to a max of 0.5mg
- 1:1000 solution IM (preferred)* or may substitute age/weight appropriate epinephrine auto-injector- 1:10,000 solution IV
• Magnesium Sulfate 25mg/kg to max of 2 grams IV- dilute in 50cc bag of crystalloid and administer over 15 minutes
ORDERS
For Presumed COPD and severe respiratory distress unresponsive to initial therapy:
ALS Care:• CPAP
- Initiated per CPAP protocol- Limited to CPAP systems that allow administration of Albuterol and Ipratropium while CPAP is applied
If respiratory failure, support ventilation with BVM. Consider Airway Management Protocol
SPECIAL NOTE:• In the management of patients with asthma, ETI should be used as a last resort. Following ETI, ventilate slowly (keep
respiratory rate to 10/min or less) and with a low tidal volume (6cc/kg (ideal body weight)).• *Administration of IV epinephrine can result in significant tachycardia / hypertension and complications such as heart
attack & stroke
Approved: 1/19/16
CHF/Volume Overload DyspneaStanding Order
ORDERS
• If altered mental status or failure to respond to CPAP, support ventilation with BVM. Consider Airway Management Protocol.
ORDERS
For Normotensive (SBP>90) patients:
ALS Care:• Initiate CPAP Protocol• 12-lead ECG and continuous cardiac
monitor• IV saline lock• Nitroglycerin
- 0.4mg SL. Repeat every five minutes to a max of three doses. Hold if SBP <90
ORDERS
For Hypotensive (SBP<90) patients:
ALS Care:• Initiate CPAP Protocol• 12-lead ECG and continuous cardiac
monitor• IV saline lock• Dopamine (If heart rate < 100)*
- 10-20mcg/kg/min titrate to SBP>80 to a max dose of 20mcg/kg/min
SPECIAL NOTE:• Furosemide and Morphine are no longer considered appropriate first line prehospital interventions in the management of
CHF/Volume overload in the prehospital setting. Should a provider feel that these interventions might be appropriatecontact medical direction.
* Infusion of dopamine for patients with congestive heart failure and a heart rate greater than 100 decreases cardiac outputand has been shown to increase mortality and morbidity.
INCLUSION
History of volume overload (CHF, Renal Failure) with increased work of breathing or dyspnea.
Approved: 1/19/16
Base Hospital
10-09; updated 6-10, 7-11, 12-13, 1-15, 1-16
If patient’s condition deteriorates call, Medical Direction Authority. Consider transport to closest facility. Provide appropriate receiving facility notification
Initiate Immediate Supportive Care:
O2 to maintain sat ≥ 94%
Complete primary and secondary survey as indicated
Cardiac monitor (non-interruptive) if available, vital signs including FSBG and temperature as indicated
EMT STABILIZATION ADMINISTRATIVE ORDER
Airway maintenance, control and ventilation
Follow Airway Management Protocol
Dizzy or Lightheaded
Treat BLS ABC
Consider causes
Start IV NS/LR at TKO (if permitted)
Injury Triage Criteria
Follow Trauma Triage Protocol as indicated
ABCDE-injury area
Consider C-Spine precautions-follow SMR Protocol documenting use
Initiate IV NS/LR TKO as appropriate-bolus to maintain systolic BP≥90
Manage extremity injuries as appropriate
If TBI suspected follow EPIC protocol for Adult or Peds
If unable to control bleeding, follow External Hemorrhage Control Protocol and/or TQ AO
Pain Management AO as needed if stable
Falls- evaluate, describe impact surface, height of fall
Physical assault Hypotension
SBP ≤90, pulse ≥120, increased respirations, pale, cool skin, diaphoresis, altered mental status, agitation, or restlessness, progression to profound hypotension
NS/LR bolus 20 mL/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals
Consider causes
Unconscious/unresponsive patient unresponsive or responsive only to painful stimuli
Manage airway as above
Initial IV with NS/LR TKO
Bolus 20 mL/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals to maintain SBP≥90
If status improves after treating FSBG, follow Hypoglycemia AO
If suspected overdose-administer Naloxone per Naloxone Protocol
Symptoms of dehydration and/or as indicated
IV with NS/LR bolus 20 mL/kg maximum, reassess hemodynamic status and pulmonary status at 500 ml intervals (if permitted)
Febrile patient follow Over-the-Counter Medication Protocol
Anaphylaxis/Allergic Reaction/Urticaria
Follow Dyspnea Anaphylaxis/Allergic Reaction SO
Follow Over-the-Counter Medication Protocol for diphenhydramine administration
Base Hospital
10-09; updated 2013-2015; 01-16
If patient’s condition deteriorates call, Medical Direction Authority
Consider transport to closest facility Provide appropriate receiving facility notification
Initiate immediate supportive care: Oxygen to maintain O₂ sat ≥ 94%
Complete primary and secondary survey as indicated
Vital Signs including FSBG, temperature as indicated
Use Administrative Order on patients that present with the following:
ETOH consumption
No other emergent medical need
Patient has not received any ALS treatment (this excludes ALS assessments such as EKG)
Calm patient with reassuring voice and gestures
Initiate IV NS/LR (If permitted)
Bolus 20 mL/kg maximum, reassess hemodynamic and pulmonary status at 500 ml intervals
Utilize law enforcement assistance if necessary
Restrain as indicated for patient or provider safety per Behavioral AO
Transport to the closest most appropriate facility
O R D E R
S
E X C L U
AO should not be used on patients with these symptoms:
Patients that are unconscious/unresponsive
Patients that fall under another Standing/Administrative Order
INCLU
All of the following must be present:
Glasgow coma score 13 or greater
Blood Pressure: Systolic: 100-180 Diastolic: 60-100
Pulse rate of 60-120
Respiratory rate of 16-28
Blood Glucose 70-400 adult
ETOH ADMINISTRATIVE ORDER
3-10; reviewed 3-12; Update 2011-2015; 01/16
Base Hospital
If patient’s condition deteriorates, call Medical Direction Authority
Consider transport to closest facility Provide appropriate receiving facility notification
EYE INJURY ADMINISTRATIVE ORDER
PENETRATING INJURY WITH FOREIGN BODY O R D E R S
Initiate Immediate Supportive Care:
Oxygen to maintain O₂ sat ≥ 94%
Complete primary and secondary survey as indicated
Vital signs including FSGB and temperature as indicated
ALS cardiac monitor
Use Administrative Order on patients with:
Blunt or penetrating trauma to the eye
Chemical substance in the eye
Follow SAEMS Trauma Triage Protocol
Stabilize foreign body
Do not remove any foreign body
Transport patient with head slightly elevated and BOTH eyes closed or loosely covered
Pain Management AO as indicated CORNEAL BURN/ABRASION
OR CHEMICAL EXPOUSRE
O R D E R S
Irrigate with Normal Saline for at least 20 minutes
Continuous irrigation en route to facility
Pain Management AO as indicated
Medical Management of HAZMAT Patients Standing Order
INCLUSION
Suspected Hazardous Material Exposure with or without symptoms
EXCLUSION
Patient with medical complaint likely unrelated to hazardous materials
Assess Scene: • Assess for contamination, need for decontamination, and inform Incident Commander (IC).
• Do not enter the hot zone or contaminated area without proper training & PPE
• The IC structure, need for decontamination, and procedure for decontamination should be determined by
agency SOP.
Assess
Toxidrome
Cholinergic
Syndrome
Primary
Respiratory
Cardio-
pulmonary
Symptoms
Skin
Symptoms
No Initial
Symptoms
SPECIAL NOTE: • Although Poison Control my give advice regarding the management of patients with toxic exposures, they do not have the
ability to provide online medical direction or give orders for the medical management of patients. Therefore all contact with
the poison control center must occur through an appropriate Medical Direction Authority
Pre-Decon Treatment Decontamination Post-Decon Treatment
Organophospate SO
Chlorine Gas SO
Carbonmonoxide SO
Cyanide SO
Hydrocarbon SO
Hydrofloric Acid SO
Radiation/Nuclear SO
Decon procedures will very based on the substance & symptoms encountered.
Two Standing Orders
exist to guide decon
procedures:
The need for decon
as well as the decon
procedures will be
determined by the IC
and agency SOPs
Organophospate SO
Chlorine Gas SO
Carbonmonoxide SO
Cyanide SO
Hydrocarbon SO
Hydrofloric Acid SO
Radiation/Nuclear SO
Eye Decon SO
General Decon SO
Organophosphate/Carbamate/Nerve Agent Standing Order
I N C
Suspected Organophosphate, Carbamate, or Nerve Agent exposure
AND
Symptoms of mild, moderate, or severe toxicity
E X C L
Suspected Organophosphate, Carbamate, or Nerve Agent exposure
AND
No evidence of toxicity
Decontamination Age < 10 Age > 10
SPECIAL NOTE: Mild Symptoms: Dim vision, Lacrimation, Rhinorrhea, Nausea
Moderate Symptoms: Urinary Incontinence, Wheezing, Vomiting, Fasciculations, Bradycardia
Severe Symptoms: Unconscious, Seizures, Respiratory Distress
*Antidote Kits: Several different auto injector kits are available for treatment of cholinergic syndrome. All contain
1mg of atropine and 600mg of 2-PAM (pralidoxime). Some commonly used kits include Mark I & Duodote™
The specific decon
procedures required
for an incident should
be determined by the
IC or their designee.
Medical guidance for
decon procedures is
as follows:
• Administration of
antidote therapy
should not delay
decontamination
except for patients with
cardiac
arrest/dysrhythmia
T O X M E D I C
• Mild - Contact Med
Direction
• Mod – 2 x antidote kit*
• Severe – 3 x antidote kits*
(If Antidote Kit not available: 1-2mg Atropine IM)
T O X M E D I C
• Mild - Contact Med Direction
• Mod - Contact Med Direction
• Severe - 1 x antidote kit*
(If antidote kit not available: 0.05 mg/kg Atropine IM)
Decontamination
T O X M E D I C
Supportive Care:
• Cardiac monitor, IV, supplemental O2, BVM or ETI if indicated
Continued Antidote Therapy:
• Administer Atropine, every 5min as needed to control all symptoms:
- Age>10: 1-2mg IV/IO* - Age≤10: 0.05mg/kg IV/IO
• Administer Benzodiazepines IF seizures activity:
• Midazolam/Versed per Seizure SO
• If needed, contact Medical Direction Authority and request a Poison Control
dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
Eye Decon SO
General Decon SO
Chlorine Gas Standing Order
I N C
Suspected chlorine gas inhalation or exposure
AND
Symptoms of pulmonary or eye toxicity
E X C L
Suspected chlorine gas inhalation or exposure
AND
No evidence of toxicity
Decontamination Age < 10 Age ≥ 10
SPECIAL NOTE: Chlorine Gas
Properties: water soluble irritant gas which when dissolved produces hydrochloric acid and hypochloric
acid. These acids cause irritation of mucous membranes.
Symptoms: coughing, choking, dyspnea, wheezing, lacrimanation, burning sensation in
eyes/armpits/etc. Severe cases may progress to pulmonary edema and resulting respiratory failure.
Sources: pools, pool pumps, pool service trucks, water treatment plants, rail cars, commercial trucks,
etc.
Effective 4-16-2014
The specific decon
procedures required for
an incident should be
determined by the IC or
their designee. Medical
guidance for decon
procedures is as
follows:
• Administration of
antidote therapy should
not delay
decontamination except
for patients with cardiac
arrest/dysrhythmia
• Remove clothing
• Full dry & wet skin
decon is usually not
necessary.
• Eye decon if eye
irritation occurs.
T O X M E D I C
• Perform primary survey
• Provide supplemental O2
and/or assist ventilation with
BVM or ETI if needed
T O X M E D I C
• Perform primary survey
• Provide supplemental O2
and/or assist ventilation with
BVM or ETI if needed
Decontamination
T O X M E D I C
Supportive Care:
• Cardiac monitor, IV bolus @20ml/kg, supplemental O2, BVM if
indicated. If severe respiratory distress consider supporting ventilation
with CPAP, BVM or Airway Management Protocol
Antidote Therapy:
• If bronchospasm, administer: Albuterol 2.5mg nebulized repeat x 2 for
continued bronchospasm
• If needed, contact Medical Direction Authority and request a Poison Control
dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
Eye Decon SO
Carbon Monoxide (CO) & Simple Asphyxiant Toxicity Standing Order
Decontamination
The specific decon
procedures required for
an incident should be
determined by the IC or
their designee. Medical
guidance for decon
procedures is as
follows:
General: • Carbon Monoxide
(CO) and Simple
Asphyxiants are gases.
Removal of the victim
from the source will
likely be the only decon
measure required for
isolated exposures.
INCLUSION
Suspected Carbon Monoxide (CO) exposure
EXCLUSION
None
O R D E R S
PRE-DECON ORDERS: - Remove from source
Decontamination (If Indicated)
ORDERS
POST-DECON ORDERS: • Supportive Care: vital signs, primary & secondary survey, cardiac monitor,
IV access
• Antidote Therapy: High flow oxygen, consider Airway Management
Protocol if insufficient oxygen/ventilation despite high flow O2.
• Dysrhythmias: Treat per ACLS guidelines
SPECIAL NOTE: • Severe exposure: altered mental status, dyspnea/respiratory failure, seizure, hypotension/tachycardia,
cardiac dysrhythmias; Mild exposure: headache, nausea, mild tachypnea
• Carbon Monoxide (CO) Toxicity: Carbon Monoxide binds to the oxygen binding sites of hemoglobin(Hb)
decreasing the ability of Hb to both carry and release O2 causing systemic hypoxia.
• Simple Asphyxiants decrease the inhaled concentration of Oxygen. Examples include: carbon dioxide,
nitrogen, etc.
• Effective 4-16-2014
• If needed, contact Medical Direction Authority and request a Poison Control
dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
Cyanide Toxicity Standing Order
SPECIAL NOTE: • Symptoms:
- Major Symptoms: include altered LOC, loss of consciousness, dyspnea/respiratory failure, seizures,
hypotension/tachycardia and cardiac dysrhythmias.
- Minor Symptoms: include headache, nausea and mild tachypnea.
• Cyanokit Information: Each vial contain 2.5g of hydroxycobalamin. The medication is red in color. It
cannot be infused in the same tubing as multiple other medications. This medication interferes with future
diagnostic testing, if possible obtain blood samples when IV is placed.
Effective 4-16-2014
INCLUSION
Suspected cyanide exposure and MAJOR* symptoms
EXCLUSION
Suspected cyanide exposure and MINOR* symptoms
Age ≥ 10
T O X M E D I C
• Cyanokit (hydroxycobalamin):
- Reconstitute each vial with
100ml of saline
- Administer 2 vials using IV
tubing included in kit and
infuse over 15min
T O X M E D I C
• Cyanokit (hydroxycobalamin):
- Reconstitute each vial with
100ml of saline
- Administer 70mg/kg using
IV tubing included in kit
- Each vial in 100ml of NS
creates 250mg/ml of
solution
Decontamination (If Indicated)
ORDERS (Pre-Decon) • Supply max flow Oxygen via non-rebreather mask
• BVM ventilation if necessary
ORDERS (Post-Decon)
• Supportive Care: vital signs, primary & secondary survey, IV access,
Cardiac monitor (Dysrhythmia: treat per ACLS)
• If possible draw a “rainbow” of blood collection tubes prior to administration
of cyanokit.
• If respiratory failure consider using Airway Management Protocol
Age < 10
• If needed, contact Medical Direction Authority and request a Poison
Control dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
Decontamination
The specific decon
procedures required
for an incident should
be determined by the
IC or their designee.
Medical guidance for
decon procedures is
as follows:
• Administration of
antidote therapy
should not delay
decontamination
except for patients with
cardiac
arrest/dysrhythmia
Eye Decon SO
General Decon SO
Hydrocarbon Toxicity Standing Order
Decontamination
The specific decon
procedures required for
an incident should be
determined by the IC or
their designee. Medical
guidance for decon
procedures is as
follows:
• Administration of
antidote therapy should
not delay
decontamination except
for patients with cardiac
arrest/dysrhythmia
General: • Removal from source
(only step for gas
exposure)
INCLUSION
Suspected hydrocarbon exposure and MAJOR* symptoms
EXCLUSION
Suspected hydrocarbon exposure and MINOR* symptoms
O R D E R S
Initial Care:
• Supply max flow O2 via non-rebreather mask
• BVM ventilation
Decontamination (If Indicated)
ORDERS
• Supportive Care: vital signs, primary & secondary survey, IV access,
cardiac monitor
• Hypoxia or hypoventilation unresponsive to high flow O2: Consider use of
Airway Management Protocol
• Dysrhythmias: Treat per ACLS guidelines avoiding epinephrine due to
sympathomimetic effect of hydrocarbons
• Seizure: Ensure adequate oxygenation(as above). Administer benzo per
Seizure SO
SPECIAL NOTE: • Symptoms:
- Major Symptoms: include altered LOC, seizure, coma, cardiac dysrhythmias, hypoxia
- Minor symptoms: include PVCs, eye irritation
• Examples:
- Aliphatics include: methane, ethane, propane, butane, hexane, cyclohexane. Aliphalitcs from
petroleum include: gasoline, mineral spirits, kerosene. Aliphalitcs from pine: include turpentine, pine oil,
pine tar. Aromatic hydrocarbons: benzenes, Halogenated hydrocarbons
Effective 4-16-2014
Eye Decon SO
General Decon SO
• If needed, contact Medical Direction Authority and request a Poison
Control dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
Hydrofluoric Acid (HF) Toxicity Standing Order
Decontamination
The specific decon
procedures required for
an incident should be
determined by the IC or
their designee. Medical
guidance for decon
procedures is as
follows:
• Administration of
antidote therapy should
not delay
decontamination except
for patients with cardiac
arrest/dysrhythmia
INCLUSION
Known or Presumed exposure to Hydrofluoric Acid(HF)
EXCLUSION
Exposure to other acid or base solutions
Age ≥ 10 Age < 10
T O X M E D I C
Initial Care:
• If unstable (cardiac
dysrhythmia or arrest)
initiate IV and administer
Calcium Gluconate
100mg/kg IVP
T O X M E D I C
Initial Care:
• If unstable (cardiac
dysrhythmia or arrest)
initiate IV and administer
Calcium Gluconate 10-
20ml(1-2gm, 1-2 amps)
IVP
Decontamination (If Indicated)
TOXMEDIC
POST-DECON ORDERS: • Supportive Care: vital signs, primary & secondary survey, IV access,
cardiac monitor. If pain may use Pain Management SO.
• Continued antidote therapy:
- Administer Calcium Gluconate gel to the affected site. If Calcium gel is
not available then mix 10cc of Calcium Cloride solution with one 1oz
package of water soluable lube and apply to affected area. If lube
unavailable then apply Calcium Gluconate solution directly to wound
SPECIAL NOTE: Calcium Gluconate: Ca-glu is the drug of choice for treatment of HF exposure and toxicity. In the
event of cardiac arrest Calcium Chloride may be given. This medication can cause severe peripheral
venous irritation and damage therefore administration via peripheral IV should be limited to the
management of critical patients.
Effective 4-16-2014
Eye Decon SO
General Decon SO
• If needed, contact Medical Direction Authority and request a Poison
Control dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
Radiation / Nuclear Standing Order
Decontamination
• Decon for a radiation
or nuclear event
may differ
significantly from
other decon
procedures.
• Identification of
contamination and
focused removal of
contamination may
be sufficient.
• Protect yourself:
- limit time expose
- Maximize distance
- Use appropriate
shielding (rarely
helpful for
radioactive
material)
INCLUSION
Suspected radiation exposure and Major Injury
EXCLUSION
Suspected radiation exposure and Minor Injury
SPECIAL NOTE: Exposure to radiation does not represent an emergency medical condition. Therefore treatment of a
traumatic injury or medical condition should take priority over management of exposure to radioactive
substance.
Effective 4-16-2014
Decontamination (If Indicated)
ORDERS
PRE-DECON ORDERS: • Treat life-threatening conditions prior to decon. Treatment and transport
of critically injured patients should take precedent over decontamination.
ORDERS
POST-DECON ORDERS: • Care of patients with minor injuries
• If needed, contact Medical Direction Authority and request a Poison
Control dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
General Decontamination Standing Order
O R D E R S
Initial Care: Evaluate ABC’s
and perform the following if
indicated:
• Open Airway
- Head tilt / jaw thrust
- Insert OPA or NPA
• Insert Airway device
- Supraglotic device is
recommended over ETI
• Tension pneumothorax
- Needle decompress
• Antidote autoinjector
• Hemorrhage Control
- Compressive dressing
- Tourniquet
• Spinal Immobilization
INCLUSION
All victims with presumed exposure and contamination with a toxic material
EXCLUSION
Victims triaged as Black/Dead may require decon however,
decontamination of these victims should NOT be performed emergently
Chemical
General Considerations: • Skin Decon - Remove clothing, Wash with water and mild
detergent, under ideal conditions for 15 minutes
• Eye Decon (per SO), under ideal conditions for minimum 20
minutes, continue during transport if resources allow.
SPECIAL NOTE: • Transportation via air medical services is contraindicated prior to decontamination
• The DHS does not recommend full decontamination in the field for patients contamination with white powders
that may contain Anthrax spores. Rather patients should be instructed to wash their hands and face, return
home, change clothes, and shower.
•Effective 4-16-2014
Biological
General Considerations: • Skin Decon – Generally not necessary and may be done at
home by patient. If required remove clothing, washing from
head down with water and mild detergent.
• Eye Decon – generally not indicated
Radiation / Nuclear
*** patient treatment takes priority over decon*** *** use detector to identify contaminants***
General Considerations: • For field decon of medically stable patients:
- Cut clothing off and rolling any contamination up in clothing
- Identify skin contaminants and use moist gauze to remove
- Continue to wipe until detector reads < 2 x background or
skin redness noted
Eye Decontamination Standing Order
• Eye decontamination may start during general decon if victims allow water to rinse out eyes
• This SO should be used AFTER the General Decon process
B L S
Or
A L S
O R D E R S
Initial Care: (NOTE: Initiation of eye irrigation should not be delayed if the advanced medications listed below are not available or a paramedic with advanced training in the use of the techniques listed is not present)
• Irrigate eyes with tap water or normal saline
• Discontinue when
- Toxmedic assumes care
- Patient can not tolerate due to pain
- 15 min of irrigation has been performed
and eyes are no longer irritated
INCLUSION
All patients with presumed hazardous material exposure and eye irritation
EXCLUSION
Patients with no known exposure to the eye or lack of eye irritation
T O X M E D I C
O R D E R S
• Tetracaine 2gtts into affected eye, may
repeat every 5-10min as needed for eye
discomfort.
• Place Morgan Lens or other eye irrigation
tool under eye lid and irrigate eyes with tap
water or normal saline.
• Discontinue when
- Patient can not tolerate due to pain
- 15 min of irrigation has been preformed
and eyes are no longer irritated
SPECIAL NOTE: Eye Decon should NOT delay further assessment of the patient.
Transportation via air medical services contraindicated prior to decontamination
Effective 4-16-2014
PATIENT CARE DURING EYE DECONTAMINATION: • If any vital sign abnormalities are present obtain IV access, supply supplemental O2, and cardiac monitor.
• Evaluate for toxidrome and if present treat using toxic exposure SO.
• If needed, contact Medical Direction Authority and request a Poison Control dual patch or consult for assistance.
• Inform receiving facility of toxic exposure, setting, and decon procedures.
Base Hospital
10/09; updated 2011-2015; 01/16; 01/19
If patient’s condition deteriorates, call Medical Direction Authority
Consider transport to closest facility Provide appropriate receiving facility notification
HYPERTHERMIA ADMINISTRATIVE ORDER
Initiate immediate supportive care:
Oxygen to maintain O₂ sat ≥ 94%
Vital signs including FSBG and temperature
Move patient to cooler environment and begin cooling measures
ALS Cardiac Monitor
EMT Cardiac Monitor (non-interpretive) if available
Use administrative order on patients with hyperthermia symptoms:
Heat Cramps/Exhaustion
History of heat exposure
Painful muscle cramps
Nausea and vomiting
Abdominal pain
Heat Stroke
History of heat exposure
Fainting or Loss of consciousness
Altered mental status: confusion, combativeness, or seizure
ORDERS
ALS/BLS:
Initiate cooling measures based on patient condition (active vs. passive)
Keep patient NPO
Establish IV/IO NS/LR to maintain adequate peripheral perfusion (If permitted) o 20mL/kg bolus, may repeat bolus once. Reassess hemodynamic and
pulmonary status at 500ml intervals
If shivers develop stop rapid cooling
For seizures follow with treatment Seizure AO
For nausea or vomiting follow with treatment Nausea/Vomiting AO
Monitor for other complications:
AMI or heart failure
Weakness or paralysis
Electrolyte abnormalities may result in dysrhythmias; treat per ACLS guidelines
Develop: 01/15; updated 01/16, 01/19
HYPOGLYCEMIA
For neonates with FSBG ≤40 mg/dl or for patients ≥ one month of age with a FSGB ≤70 mg/dl
If patient’s condition deteriorates, call Medical Direction Authority
Consider transport to closest facility
Transport to closest pediatric care facility if condition permits
If rural area, transport to closest facility
Provide appropriate receiving facility notification
HYPERGLYCEMIA
Base Hospital
Special Note:
Dilute D50 (dextrose 50% containing 25 Grams
of dextrose) to a 1:4 solution. To prepare, obtain
a 250mL container of normal saline for IV use,
waste 50mL and add 50mL of dextrose 50%.
The resulting solution is dextrose 10% in normal
saline or 10 Grams/100mL
ALS/BLS (> 15 years of age)
If alert and maintaining their airway, administer 1 to 2 tubes of oral glucose
Initiate IV NS/LR at TKO (if permitted)
Reassess FSBG (> 1-14 years of age)
If alert and maintaining their airway, administer 1 tube oral glucose
Initiate IV NS/LR (if permitted)
Reassess FSBG ALS
Initiate IV/IO NS/LR at TKO(saline lock not acceptable for administration)
Reassess FSBG after each treatment
Dosage: Dextrose 10% (D10) 1ml/kg, max 250 ml
Flush IV with 10 ml NS/LR after D10 infusion
May repeat dose to maintain FSBG < 70 Glucagon administration: If unable to initiate IV
Adult Size (≤60 kg) 1 mg IM may repeat in 7-10 minutes
Pediatric Size (≤ 60 kg) 0.5 mg IM may repeat in 7-10 minutes
HYPO/HYPER-GLYCEMIA ADMINISTRATIVE ORDER
If patient ≥18 years, condition improves and they do not wish further evaluation, no medical direction is required if all of the following are present:
This was an acute hypoglycemic event and patient has regained a normal mental status
Patient has history of Diabetes or Hypoglycemia
Current FSBG is ≥ 70
A responsible adult is present
Further caloric intake is assured
There are no clinical findings consistent with acute illness
For patients > one month of age with a FSBG > 400
ALS/BLS (>8 years of age)
Initiate IV/IO NS/LR
Bolus 20 mL/kg maximum, reassess pulmonary status at 500 mL intervals
Slow rate to TKO after fluid boluses
Reassess FSBG (<8 years of age)
Initiate IV NS/LR
Bolus 20 ml/kg maximum, reassess pulmonary status once half of the bolus is infused
Decrease rate to TKO
Reassess FSBG
Initiate immediate supportive care:
Secure & maintain airway
Oxygen to keep O₂ sat >94%
Complete primary and secondary survey as indicated
Vital Signs including FSBG
If FSBG ≥ 70 and ≤400, and patient is unconscious, follow Stabilization AO
Effective: 01/2008 Revised: 6/14, 10/17/2017
+
Supportive care:
• Be gentle (rough handling of patient may precipitate arrhythmias)
• Secure and maintain airway
• Remove all wet garments (cut off to avoid jostling the patient)
• Move patient to warm/dry environment and protect from heat loss
• Oxygen to keep SpO2 > 94%
• Obtain vital signs including temperature and blood glucose
• Cardiac monitoring if available
HYPOTHERMIA STANDING ORDER
Use Standing order on patients that are hypothermic with signs/symptoms:
Use the following treatment orders:
I N C LUSI O N
O R D E R S
Special Notes:
• Because field temperature measurement may be imprecise, the recognition of each stage is more important than exact categories.
• If resuscitative measures are indicated: Intubate only if patient is in V-fib or asystole, give IV medications as indicated (although generally ineffective), limit to one shock for VF/VT.
Mild Hypothermia 90 – 95°F (32-35°C)
OR
Ataxia Slurred Speech
Confusion Impaired judgment
Shivering
Severe Hypothermia < 82°F (<28°C)
OR
Weak/absent pulse Hypotensive
Unresponsive Fixed/dilated pupils Pulmonary edema
Ventricular dysrhythmia
Moderate Hypothermia 82 – 90°F (28-32°C)
OR
Bradycardia (afib/flutter) Hyporeflexia
Decreased/absent shivering
Mild Hypothermia 90 – 95°F (32-35°C)
Passive external rewarming
Moderate Hypothermia 82 – 90°F (28-32°C)
Active external rewarming Warm packs to groin, axillae, neck and trunk (avoid surface
burns)
20ml/kg NS bolus (warmed if possible)
Severe Hypothermia <82°F (<28 °C)
Continue with moderate rewarming hypothermia tx
guidelines.
Confirm pulse/rhythm every 30-45 seconds
Base Hospital
10-09; updated 2015-2015; 01-16; 09-19; 12-20; revised 2-20
If patient’s condition deteriorates, call Medical Direction Authority
Consider transport to closest facility Provide appropriate receiving facility notification
Use administrative order on patients with the following symptoms:
Complaints of nausea and/or vomiting
Diarrhea with either of the above
BLS
Establish IV NS/LR: If evidence of dehydration or hypo-perfusion to maintain adequate peripheral perfusion: (if permitted)
Bolus 20 mL/kg maximum, reassess pulmonary status at 500 ml intervals ALS
Follow BLS orders
Administer Ondansetron HCL IV/IM/PO:
Adult size(>30 kg) o Ondansetron 4 mg IV over 2-5 minutes, if no response, may repeat once
after 15 minutes o If unable to obtain IV, give Ondansetron 8mg PO, Orally Dissolving Tablet
(ODT) , Do NOT Repeat o Or Ondansetron 4 mg IM, if no response, may repeat once after 15 minutes
Pediatric size(<30kg) o Pediatric <15kg Ondansetron 0.15 mg/kg slow IVP over 2-5 minutes, Do
NOT Repeat o Pediatric >15kg Ondansetron 4 mg Orally Dissolving Tablet (ODT), Do NOT
Repeat
o
NAUSEA/VOMITING ADMINISTRATIVE ORDER
I N
C
L
O R D E R
S
Special Note:
Ondansetron in general is ineffective for motion sickness Caution: avoid volume overload in geriatric patients
Initiate immediate supportive care:
Oxygen to keep O2 Sats ≥94%
Complete primary and secondary survey as indicated
Vital Signs including FSBG and temperature as indicate
Effective 4-16-2014
OB/GYN STANDING ORDER
INCLUSION
Special Note: Follow High Risk OB Triage Protocol as appropriate
Eclamptic Seizure
Post Partum Hemorrhage
Use standing order on gravid patients, postpartum patients, or patients with vaginal bleeding.
Presumed Pregnant with Contractions and/or SROM Standing Order
Initiate Immediate Supportive Care: BLS Care:
• Vital signs • FSBG • Oxygen to maintain sat ≥ 94% • IV access if permitted
ALS Care: • Follow BLS Interventions • Cardiac monitor
OB/GYN SO
OB/GYN-SO
OB/GYN SO
Contact Medical Direction Authority if unclear clinical presentation Or patient wishes to refuse and does not meet Refusal Standing Order
OB/GYN SO
Vaginal Bleeding
Effective 4-16-2014
VAGINAL BLEEDING STANDING ORDER
INCLUSION Vaginal bleeding
• Gestational • Non-traumatic • Non-gestational
EXCLUSION
• Contractions • Traumatic vaginal bleeding • Sexual Assault
BLS/ALS Care: Stable:
• IV NS/LR at TKO if permitted • If applicable, place products of conception in container and transport with patient
Unstable: If SBP ≤ 90 or HR ≥ 110 or estimated blood loss ≥ 250 ml
• NS/LR bolus 20 ml/kg, reassess patient at 500 ml intervals • Shock position:
o ≥ 20 weeks: Left lateral o <20 weeks or not pregnant: Trendelenburg
O R D E R S
Transport to most appropriate receiving facility Or per High Risk OB Triage Protocol
Provide appropriate receiving facility notification
If patient condition deteriorates or no improvement-contact medical direction authority
Effective 4-16-2014
ECLAMPTIC SEIZURE STANDING ORDER
INCLUSION
• Gestational age 20 weeks or greater • Postpartum • New onset seizure
BLS Care: • Place patient in left lateral recumbent position • High flow oxygen via NRB • IV NS/LR at TKO if permitted
ALS Care:
• Follow BLS orders • Administer Magnesium Sulfate 4-6 gram bolus IV/IO over 10-15
minutes o Hold for SBP ≤ 90 o Monitor for respiratory depression
O R D E R S
Transport to most appropriate receiving facility
Per High Risk OB Triage Protocol Provide appropriate receiving facility notification
.
If patient condition deteriorates or no improvement-contact medical direction authority
• History of seizure disorder, follow Seizure Standing Order
EXCLUSION
Effective 4-16-2014
POST PARTUM HEMORRHAGE STANDING ORDER
INCLUSION
• Postpartum
BLS Care: • High flow oxygen via NRB • Two large bore IV if permitted • NS/LR bolus 20 ml/kg, reassess patient at 500 ml intervals • Fundal massage
ALS Care:
• Follow BLS care • Administer Pitocin 20 units in NS/LR 1000 ml wide open
(if available)
O R D E R S
If patient condition deteriorates or no improvement-contact medical direction authority
Transport to the most appropriate receiving facility Per High Risk OB Triage Protocol
Provide appropriate receiving facility notification .
Effective 4-16-2014
PRESUMED PREGNANT WITH CONTRACTIONS AND/OR SROM STANDING ORDER
INCLUSION
• Pregnant • Signs of labor • Spontaneous rupture of membranes (SROM) • Cord presentation • Limb/breech/shoulder presentation
BLS/ALS Care: • Measure patient temperature • Place patient in left lateral recumbent position • Large bore IV NS/LR if permitted • Initiate bolus 500 ml-reassess patient. If labor persists after
assessment rebolus with 500 ml • Prepare for possible delivery • Cord around neck:
o Loosen cord o If too tight- apply two clamps, cutting between clamps
• Prolapsed cord: o Transport mother with hips elevated and knees to chest o Insert gloved finger to relieve pressure on cord o Assess pulsations o DO NOT pull on cord o Protect exposed cord
• Limb/breech/shoulder presentation: o Do not encourage mother to push o Support but do not pull presenting parts o Insert gloved finger to relieve pressure on cord if needed
O R D E R S
If patient condition deteriorates or no improvement-contact medical direction authority
Transport to the most appropriate receiving facility Per High Risk OB Triage Protocol
Provide appropriate receiving facility notification
.
Base Hospital
3-10; update; 2013-2015; 1-16; 12-19, revised 2-20
Do not use Administrative Order on patients with: Decreased mental status
Pregnancy
BLS Treatment Determine pain score assessment using standard pain scale
3 months of age-4 years: Observational scale (FLACC)
4-12 years: Face pain scale
≥ 12 years: Numeric Rating Scale Initiate IV NS/LR TKO (if permitted) Analgesic (if no nausea, vomiting, abdomen pain) Acetaminophen (oral liquid, rectal suppository or tablet/capsule) ONE TIME DOSE
Adult( ≥ 15 years) up to 650 mg PO
Pediatric (6-14 years) 10 mg/kg PO or PR
Pediatric (≤ 6 years) rectal: ≤10 kg-120 mg suppository 10-20 kg-160 mg suppository ≥ 20 kg 325 mg suppository
Ibuprofen ONE TIME DOSE
≥ 6 months of age (oral, liquid or tablet/capsule) (maximum dose 600 mg)
Adult( ≥ 15 years) 200-600 mg PO Pediatric ( ≥ 6 months-14 years)
5 mg/kg
PAIN MANAGEMENT ADMINISTRATIVE ORDER
INCLUSIO
N
E X C
Initiate Immediate Supportive Care:
O2 to maintain sat ≥ 94 %
Complete primary and secondary survey as indicated
Vital signs including FSBG and temperature as indicated
Following Standing Order/Administrative Order as indicated
Use Administrative Order on patients with:
Acute extremity injuries to include but not limited to hip, pelvic, and shoulder
Acute back pain
Burns ≤ 10% BSA
Eye injuries
Acute flank Pain
Snake Bites-stable
Abdomen pain-stable
ALS Treatment Continued Morphine Sulfate IV/IO/IM
Adult size (≥30kg) 2-5 mg IVP, may repeat after 5 minutes to a max dose of 20 mg
o If IV unavailable, may give IM 2-5 mg, may repeat after 15 minutes to a max dose of 20mg
o If patient is unstable and unable to obtain an IV, may give IO 2-5mg, may repeat every 15 minutes to max dose of 20 mg
Pediatric size (≤30kg) IV/IO, 0.1mg/kg in increments of 1-2mg, if no response, may repeat after 5 minutes to a max dose of 10mg
Fentanyl IV/IN/IM/IO
Adult: (≥ 15 years) 25-50 mcg SLOW IVP, over 2 minutes, max individual dose of 50 mcg. If no response, may repeat every 5 minutes to a max total dose of 200mcg
o Intranasal dosing max 1ml per nostril o If IV unavailable, may give IM 25-50
mcg, may repeat after 15 minutes to max dose of 200 mcg
o If patient is unstable and IV unavailable, may give IO 25-50mcg, may repeat every 15 min to max dose of 200mg
PEDS: (2 years-14 years) IV/IO/IN o 1mcg/kg SLOW IVP, over 2-5minutes
Not to exceed 50 mcg, May repeat every one hour as needed.
o If unable to obtain IV, may give IN ½ of the dose per nostril.
Do not continue dosing unless SBP remains ≥90mmHg, patient remains alert, and both respiratory rate and effort remain normal
ALS Treatment Follow BLS Treatment Cardiac Monitor Ondansetron IV/IM/IO for nausea or vomiting
Adult size(≥30 kg) o Ondansetron 4 mg IV over 2-5 minutes, may
repeat once after 15 minutes o If unable to obtain IV, give Ondansetron
8mg PO, Orally Dissolving Tablet (ODT), Do NOT Repeat
o Or Ondansetron 4mg IM, may repeat after 15 minutes to max dose of 8mg
Pediatric size(≤30kg) o Pediatric <15kg Ondansetron 0.15 mg/kg
slow IVP over 2-5 minutes, Do NOT Repeat o Pediatric >15kg Ondansetron 4 mg Orally
Dissolving Tablet (ODT), Do NOT Repeat
EFFECTIVE: 3/96 REVISED 9/99; 6/2004; 10/2007; 10/15/2013
Initiate PALS Cardiac Arrest Algorithm • C - Start CPR – Compression rate 100/min+ • A - Establish airway with OPA/NPA • B - Ventilate with BVM @ 100% high flow O2 (15:2)
If adequate bystander compressions are being provided, apply pads without interrupting compressions, analyze rhythm. ■ With Severe Hypothermia (below 86°F / 30°C) use caution, consider
Hypothermia Standing Order or contact Medical Direction
Pediatric Cardiac Arrest Standing Order
ALS/BLS
Use standing order on ALL patients 8 years of age or younger who appear to be the victims of sudden cardiac arrest/death.
Standing order should not be used on patients:
• Greater than 8 years of age. If age unknown: pt with physical signs of puberty. • Involved in a traumatic or submersion (near-drowning) event • Where evidence of primary respiratory arrest is present as in poisoning or asphyxia • Meeting SAEMS Dead on Scene criteria: Decapitated, Burned beyond recognition,
Decomposed, SIDS, VALID Prehospital Medical Care Directive
Patient meets ANY exclusion criteria
Begin appropriate resuscitative efforts,
Contact Medical Direction Authority or
implement appropriate standing order.
Patient meets inclusion criteria and is pulseless
PEA/ Asystole: or AED recommends NO shock (Perform treatments without interrupting
compression cycles.)
1. Complete 2 min. uninterrupted CPR cycles analyzing rhythm between each compression cycle.
2. Establish IV/IO access, 3. Consider Airway Management Procedure
Protocol
ALS ▪ Administer Epi 0.01mg/kg (1:10,000) every 3-5 min. as early as possible. ▪ Treat reversible causes: 6H’s/ 5T’s
VF/PULSELESS VT: or AED recommends shock (Perform treatments without interrupting
compression cycles.)
1. Complete 2 min. uninterrupted CPR cycles analyzing rhythm between each compression cycle.
2. If no rhythm change, defibrillate between each compression cycle.
3. Establish IV/IO access, 4. Consider Airway Management Procedure
Protocol ALS
▪ Administer Epi 0.01mg/kg (1:10,000) IV/IO every 3-5 min. as early as possible. ▪Administer Amiodarone or Lidocaine
• Amiodarone IV/IO 5mg/kg (max single dose 300mg), may repeat once after 10 min. 5mg/kg up to total dose 15mg/kg in 24 hrs. or
• Lidocaine 1mg/kg IV/IO ▪ Administer Magnesium 25 to 50mg/kg IV/IO (max 2 grams) ▪ Treat reversible causes: 6H’s/ 5T’s
E X C L U S I O N
I N C
O R D E R S
Transport to closest appropriate facility or, if ROSC Pediatric Critical Care Facility. Consider Air Medical Transport for transports over 30 minutes. Critical Pediatric Decision Scheme
Most common cause of Peds CA
is Hypoxic / Asphyxial Arrest
Look for potentially reversible causes
Developed 1-15; 01-16
Base Hospital
PATIENT REFUSAL TRANSPORT FOR UNDER 18 YEARS OF AGE ADMINISTRATIVE ORDER
Use of the same refusal criteria for adults, with the following steps added
Patient cannot refuse and other arrangements will need to be made-Possible Law Enforcement involvement or transport
Phone contact with Parent/Legal Guardian will not suffice meeting the on-scene requirement
Contact Medical Direction and Law Enforcement if:
Life threatening conditions exist
Possible abuse situation
Communication and documentation of patient refusal encounters will comply with agency specific policy
Document refusal on PCR with all information above
Legal guardian or Parent not on scene Legal guardian or Parent on scene
Legal Guardian defined as: An adult who is legally responsible for protecting the well being of a minor
If person on scene has release form for decision making on behalf of patient- review form
Review the situation with the Parent/Legal Guardian. Explain the risks of refusing treatment or transport, including the possibility of permanent disability, worsening condition or even death if not evaluated.
Parent/Legal Guardian must meet the following criteria:
Alert and oriented to person, place, time and event
Does not appear to be impaired by drugs or alcohol
Able to verbalize an understanding of the risks of refusing transport
Is able to pass the cognitive screening tool
Assumes complete responsibility for the decision not to transport the patient
Developed 1-15; 01-16
Base Hospital
PATIENT REFUSAL TRANSPORT FOR 18 YEARS OR OLDER
ADMINSITRATIVE ORDER
Initial patient assessment as indicated to include, but not limited to:
Vital signs including FSGB
Appropriate body system assessment
Use this AO on patient’s > 18 years of age or emancipated minors
Emancipated minors will have identifier on Drivers’ License or ID Card Patient must meet the following criteria:
Alert and oriented to person, place, and time
Does not verbalize a danger to self or others
Does not appear impaired by drugs or alcohol
No evidence of neurological injury
No evidence of hemodynamic instability
No evidence of hypoglycemia, hypothermia, or hypoxia
Ability to verbalize an understanding of the risks of refusing transport up to and including permanent disability, worsening condition, or death.
Assumes complete responsibility for the decision not to be transported
Use cognitive screening tool on all patients wishing to refuse
For patients with a chief complaint related to altered mental status, cardiac, hyperthermia, or syncope, orthostatic vital signs must be performed and documented
Consider: Reviewing situation, discussing options with patient by asking the following:
Who called?
Why don’t they want to go?
What would change their mind?
Communication and documentation of patient refusal encounters will comply with agency specific policy
Document refusal on PCR with all information above
04-10; Updated 2013-2015; 01-16
04/16
Base Hospital
If patient’s condition deteriorates, call Medical Direction Authority
Consider transport to closest facility Provide appropriate receiving facility notification
BLS
If patient actively seizing o Call for ALS Transport (if possible) o IV NS/LR TKO (if permitted)
ALS
If patient actively seizing administer Midazolam IM first o ≤ 12 kg: administer 0.2mg/kg IM o 13-40 kg: administer 5 mg IM o 40 kg: administer 10 mg IM
If IV access already established, give half (½) the above IM dose
IV/IO at TKO
If unable to start IV/IO, may be given Intranasal (IN) with mucosal atomizer device (1ml per nare)
Continued seizure 5-10 minutes after initial medication or Midazolam NOT available or NOT given. Administer one additional dose of a single medication. (Listed in order of preference of use) Midazolam:
IM/IN-repeat full dose
IV/IO-repeat at half the initial dose Lorazepam: IV/IO
≤ 12kg: 0.05-0.1 mg/kg
13-40 kg: 2 mg
40 kg and all adults: 4mg Diazepam: IV/IO
0.2 mg-0.3 mg/kg (max of 5 mg) If received rectal Diazepam prior to arrival, half the above dose
SEIZURE ADMINISTRATIVE ORDER
O R D E R
S
BLS transport
Single seizure with:
Known seizure disorder
Hemodynamically stable and returned to baseline metal status
Initiate immediate supportive care:
Protect patient from injury
Oxygen to keep O2 sat > 90%
Complete primary and secondary survey as indicated
Vital signs including FSBG and temperature as indicated
ALS cardiac monitor
EMT cardiac monitor (non interpretive) if available
I N
C
Use Administrative Order on the following patients:
Seizure activity
Postictal mental status
Do not use on the following patients:
Pregnant > 20 weeks gestation, follow OB SO E X C
Special Note: Suspected febrile seizures in pediatric patients, remove clothing
and blankets to help cool patient off
Base Hospital
Develop 9/16
For Inclusion and Exclusion follow Shock/SIRS Protocol
Follow with AO Pyretic Use OTC Protocol
Abnormal Blood Glucose Use Hypoglycemic AO Serious Dysrhythmias follow ACLS/PALS
For pediatrics patient bolus maximum 60 ml/kg total (until vital signs/perfusion normal or rales or hepatomegaly on exam) USE OF BRASLOW TAPE IS REQUIRED
Exception: volume-sensitive conditions, 10 ml/kg increments
Neonates (0-28 days), congenital heart disease, chronic lungs disease
BLS Treatment Establish IV NS/LR (if permitted)
20ml/kg bolus x1
Reassess hemodynamic and
pulmonary status frequently
Sepsis/ Shock Administrative Order
Initiate Immediate Supportive Care:
Oxygen to maintain O2 sat ≥ 94%
Complete primary and secondary survey as indicated
Vital signs including FSGB and temperature
ALS cardiac monitor
EMT cardiac monitor (non-interruptive) if available
ALS Treatment
Follow BLS Orders
IV/IO as needed
Capnography (if available)
Obtain 12 lead ECG
Adults The initial treatment of septic shock involves maximizing perfusion with IVF boluses, not vasopressors. If fluid challenge fails to restore adequate blood pressure or if hypotension is life threatening during fluid resuscitation, consider vasopressor (DOPAmine drip or push-dose epi).
DOPAmine infusion: Mix infusion using agency prescribed concentration, and administer 5-20 mcg/kg/min. Generally, start at 5 mcg/kg/min and increase every 10 minutes by an additional 5 mcg/kg/min until SBP ≥100 mmHg. DO NOT exceed 20 mcg/kg/min unless ordered by medical direction.
Push-Dose Epi follow protocol after medical direction approval Pediatrics
Call medical direction for dosing
Special Notes
When in service area where Paramedic is available, arrange an ALS intercept, but do not delay transport
Consider performing orthostatic VS
Decreasing heart rate is a sign of impending collapse
Patients predisposed to shock o Immunocompromised (chemotherapy, acquired immunodeficiency), adrenal
insufficiency, transplant pts, elderly, infants
Approved: 10/18/11 Revised: 06/16/15
• Transport to the closest emergency department
• Reassure patient, provide emotional support
• Treat injuries as appropriate
• Consider same sex attendant
• Document patient demeanor and statements related to the assault.
• Discourage use of restroom or cleansing
• Do not discard first voided urine; place on ice if possible.
SEXUAL ASSAULT STANDING ORDER
I
N
C
L
U
S
I
O
N
E
X
C
L
U
S
I
O
N
O
R
D
E
R
S
If patient is 18 or older, provide with contact information for SARS Advocate
(520) 349-8221
Currently in SAEMS, TMC has SA Forensic Exam capability and can process these patients fully.
Patient/guardian wishes to refuse
Patient meets criteria for standing order
If patient is under 18 release to law enforcement.
Use standing order on patients with a report of a sexual assault (SA) or concern for a possible sexual assault.
Standing order should not be used on patients meeting SAEMS Trauma Triage Decision Scheme
Initiate immediate supportive care as indicated:
• Oxygen to keep O2 Sat > 90%
• Cardiac Monitor
• Position of comfort
• Notify Law Enforcement; they will determine the need for a forensic exam
Initiate immediate supportive care:
• Obtain vital signs
• Oxygen to keep SpO2 > 94% • Cardiac monitor (if available)
Symptomatic or Asymptomatic Snake Bite
D
Revised: 1/208; 4/2011
• Note estimated time bite occurred
• Prepare for immediate transport, do not delay until onset of symptoms
• Remove all watches, rings, jewelry, etc. (including shoes) from all extremities
• Immobilize affected extremity in an extended position, keep patient as still as possible*
• Elevate limb to the level of the heart
• Perform neurovascular checks and mark the edge of any discoloration or swelling and write the time on the line, if possible
• Monitor every 15 minutes
• Initiate IV in unaffected extremity
• If SBP <90 administer 20 ml/kg bolus of NS, may repeat as needed and reassess patient after each bolus
• Follow Pain Management SO
SNAKE BITE STANDING ORDER
INCLUSION
O R D E R S
Special Notes:
1. Local reactions include swelling, tenderness, redness, ecchymosis, or blisters at the bite site.
2. Systemic reactions include
hypotension, bleeding beyond the puncture site, refractory vomiting, diarrhea, angioedema and neurotoxicity.
3. Do NOT wrap extremity
• No constricting bands, ice or tourniquets
• No suction or cut to the bite
• *Ensure immobilization device or dressing does not result in constriction due to swelling
4. All hospitals in Southern Arizona carry rattlesnake antivenom.
Effective: 1/2008 Revised: 04/11, 10/12, 10/17/2017
Contact Medical Direction for:
• Allergic Reaction
• Deterioration in patient condition
• Management of a tourniquet placed prior to EMS arrival
• Non-native/exotic snakebites
Approved 6-16-09 Revised 11-10; 10-11; 01-12; 9-14
Initiate immediate supportive care:
O2 (keep O2 sat > 94%)
Finger Stick Blood Glucose Cardiac Monitor (if available)
Use standing order on patients 18 years or older with these symptoms: (may be transient or persistent)
Facial droop
Unequal grips/ arm drift
Slurred speech
Change in mental status -as documented by friend or family member – not related to drugs, alcohol, trauma, seizure or diabetes
Sudden loss of vision (complete or a portion of a visual field)
Ataxia [dramatic, acute changes in coordination (arms, legs, or gait) or inability to make smooth, intentional movements in a patient with normal mental status]
Sudden, severe, atypical headache
I N C L U S I O
N
This standing order should not be used on patients with these characteristics:
Age <18 years
Shock and/or respiratory distress
Symptom onset > 6 hours or unknown
Cardiac dysrhythmias where resuscitative measures might be needed
Unconscious/unresponsive
FSBG < 60
Head trauma, drug or alcohol intoxication or seizure with postictal state likely
E
X
C
L
U
S
I
O
N
O R D E R
S
Special note: Evaluate neurologic changes using Cincinnati Prehospital Stroke Scale which is a 3-item scale to diagnose a potential stroke in prehospital setting. If any one of the three tests shows abnormal findings, the patient may be having a stroke. Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke. If all 3 findings are present, the probability of an acute stroke is more than 85%
1. Facial Droop 2. Arm Drift 3. Slurred Speech
If clear, acute neurologic changes meeting Cincinnati Prehospital Stroke Scale CRITERIA are present:
Initiate IV NS/LR TKO
Establish and relay “STROKE ALERT” with time last seen normal
Transport to nearest Primary Stroke Center if symptom onset is <6 hours
In outlying areas with a transport interval of >30 minutes to a Primary Stroke Center, transport the patient to the closest facility, or consider air transport directly to a Primary Stroke Center
Patient does not meet inclusion
criteria, or meets any exclusion criteria, or
wishes to refuse transport
Transport to closest facility and/or
contact medical direction authority If patient condition deteriorates contact medical direction authority
Consider intubation following Airway Management Procedure Protocol if:
Respiratory rate <8 OR
Patient unable to protect airway
A Primary Stroke Center is designated by TJC or another third-party certifying body. Currently in SAEMS: NMC, OVH, TMC, SJH, SMH, BUMC-T and VA
STROKE STANDING ORDER
Developed 1-15; 01-16
Base Hospital
TOURNIQUET ADMINISTRATIVE ORDER
This AO is to be used in conjunction with the ALS/BLS Stabilization AO
Use this AO on patients with the following symptoms:
Significant hemorrhage
Arterial bleeding
Significant venous bleeding
Extremity bleeding in the tactical environment (RTF functions)
Any partial or total extremity amputation with or without hemorrhage
Extremity bleeds where direct pressure and pressure dressings are not feasible due to limited manpower or where the patient has multiple life threatening injuries
Contraindications:
Mild bleeding
Bleeding that can be controlled with direct pressure or pressure dressings
Patients meeting inclusion criteria:
Firm, direct pressure to bleeding site
Fully expose the injury. Remove clothing as needed
Apply TQ to bare skin, approx 2-3 inches proximal (above wound). TQ should not be placed distal to the knee or elbow
If the patient is in extremis, has massive hemorrhage or the tactical situation is unsafe, then the device should be placed high up on the extremity and over the clothing
Remove all slack from the strap so that it is snug prior to tightening
Tighten TQ until cessation of bleeding. (venous oozing is acceptable)
Check for absence of distal pulse (if still palpable, tighten until no longer is)
Do not cover the tourniquet with a dressing
Note the time the TQ was placed
Reassess the wound and TQ each time the patient is moved to ensure it is still tight
If bleeding is not controlled with first TQ, apply a second TQ proximally
Monitor patient for signs of shock
Field removal of TQ’s:
Consider consultation with medical direction authority is recommended
If unable, apply pressure to the injury site, slowly release TQ, and check for bleeding. If there is significant bleeding, retighten TQ. If bleeding is controlled by a pressure dressing, keep TQ loosely on affected extremity in case bleeding resumes.
Special Note: All TQ patients should go to a Level I Trauma facility Field TQ’s should not remain in place for more than 2 hours
Top Related