Prehospital Care Manual online - Contra Costa Health Services
Prehospital Care Manual online - Contra Costa Health Services
Prehospital Care Manual online - Contra Costa Health Services
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contra costa county emergency medical services agency<br />
2013 prehospital<br />
CARE MANUAL<br />
For updates throughout the year, visit www.cccems.org
instructions for use<br />
The <strong>Contra</strong> <strong>Costa</strong> <strong>Prehospital</strong> <strong>Care</strong> <strong>Manual</strong> contains both treatment guidelines<br />
and additional reference materials relevant to EMS care.<br />
Updates and corrections to this manual will be posted at www.cccems.org.<br />
• Treatment Guidelines are divided into four main groupings: Adult, General,<br />
Pediatric and Interfacility Transfer Guidelines. The General Guidelines include<br />
treatment guidelines that pertain to both adult and pediatric treatments.<br />
Treatment Guidelines A1 (Adult General <strong>Care</strong>) and P1 (Pediatric General<br />
<strong>Care</strong>) address basic concepts of care that are pertinent to all patients.<br />
This information is not repeated in other treatment guidelines.<br />
• More detailed information on performance of specific patient procedures is posted<br />
at www.cccems.org.<br />
• Policy summaries reflect critical information for field personnel. For full<br />
policies, please refer to www.cccems.org.
A1 — Adult Patient <strong>Care</strong><br />
A2 — Chest Pain/Suspected ACS/STEMI<br />
A3 — Cardiac Arrest-Initial <strong>Care</strong> and CPR<br />
A4 — Ventricular Fibrillation/Ventricular Tachycardia<br />
A5 — PEA/Asystole<br />
A6 — Symptomatic Bradycardia<br />
A7 — Ventricular Tachycardia with Pulses<br />
A8 — Supraventricular Tachycardia<br />
A9 — Other Dysrhythmias<br />
A10 — Shock/Hypovolemia<br />
A11 — Post-Cardiac Arrest <strong>Care</strong><br />
A12 — Public Safety Defibrillation<br />
Adult<br />
Treatment<br />
Guidelines
A1–ADULT ADULT PATIENT CARE<br />
These basic concepts should be addressed for all adult patients (age 15 and over)<br />
SCENE SAFETY<br />
BSI Use universal blood and body fluid precautions at all times<br />
SYSTEMATIC<br />
ASSESSMENT<br />
DETERMINE<br />
PRIMARY<br />
IMPRESSION<br />
BASE<br />
CONTACT<br />
TRANSPORT<br />
MONITORING<br />
• Assure open and adequate airway. Management of ABCs is a priority.<br />
• Place patient in position of comfort unless condition mandates other position (e.g.<br />
shock, coma)<br />
• Consider spinal immobilization if history or possibility of traumatic injury exists<br />
• Apply appropriate field treatment guideline(s)<br />
• Explain procedures to patient and family as appropriate<br />
• Contact base hospital if any questions arise concerning treatment or if additional<br />
medication beyond dosages listed in treatment guidelines are considered<br />
• Use SBAR to communicate with base<br />
• Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure<br />
• Transport patient medications or current list of patient medications to the hospital<br />
• Give report to receiving facility using SBAR<br />
• At a minimum, vital signs and level of consciousness should be re-assessed every<br />
15 minutes and should be assessed after every medication administration or<br />
following any major change in the patient’s condition<br />
• For critical patients, more frequent vital signs should be obtained when appropriate<br />
DOCUMENT Document patient assessment and care per policy
A2–ADULT<br />
CHEST PAIN<br />
SUSPECTED ACUTE CORONARY SYNDROME / STEMI<br />
OXYGEN<br />
CARDIAC MONITOR<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
ASPIRIN<br />
325 mg po to be chewed by patient – DO NOT administer if patient has allergies to<br />
aspirin or salicylates or has apparent active gastrointestinal bleeding<br />
12 – LEAD ECG Repeat ECGs are encouraged<br />
IV TKO<br />
If ECG Does Not Indicate Acute MI or STEMI<br />
NITROGLYCERIN<br />
CONSIDER<br />
FLUID BOLUS<br />
CONSIDER<br />
MORPHINE SULFATE<br />
0.4 mg sublingual or spray - May repeat every 5 minutes until pain subsides,<br />
maximum 3 doses. Contact base hospital if further dosages indicated. IV placement<br />
prior to NTG recommended for patients who have not taken NTG previously.<br />
PRECAUTIONS: Do not administer NTG if:<br />
Blood pressure below 90 systolic;<br />
Heart rate below 50;<br />
Patient has recently taken erectile dysfunction (ED) drugs:<br />
Viagra, Levitra, Staxyn or Stendra within 24 hours, Cialis within 36 hours<br />
500 ml NS if BP less than 90, lungs clear and unresponsive to supine positioning<br />
with legs elevated. May repeat X 1.<br />
2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90 and NTG not<br />
effective. Consider earlier administration to patients in severe distress from pain.<br />
Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort.
Acute MI / STEMI Noted by 12-Lead ECG<br />
Do not administer Nitroglycerin if Acute MI / STEMI noted on 12-lead ECG.<br />
Exception: Patients with suspected pulmonary edema and STEMI should<br />
NITROGLYCERIN<br />
receive nitroglycerin if no other contraindications (e.g. hypotension, bradycardia<br />
or use of erectile dysfunction drugs)<br />
Transmit ECG to STEMI Center and contact as soon as possible to notify facility<br />
STEMI ALERT<br />
of transport. Enter patient identifiers prior to transmission.<br />
EARLY TRANSPORT Minimize scene time<br />
500 ml NS for Inferior MI (elevation in leads II, III, aVF) if lungs clear (regardless<br />
of blood pressure)<br />
FLUID BOLUS<br />
500 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May<br />
repeat up to X 3.<br />
2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90.<br />
CONSIDER<br />
Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort.<br />
MORPHINE<br />
SULFATE<br />
Caution: If Inferior MI suspected, use 1-2 mg increments and observe<br />
carefully for hypotension<br />
Key Treatment Considerations<br />
• Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm,<br />
nausea, diaphoresis, dyspnea (shortness of breath), anxiety<br />
• Diabetic, female or elderly patients more frequently present atypically<br />
• Atypical symptoms can include syncope, weakness or sudden onset fatigue<br />
• Many STEMI’s evolve during prehospital period and are not noted on initial 12-lead ECG<br />
• ECG should be obtained prior to treatment for bradycardia if condition permits<br />
• Transmit all 12-lead ECGs - whether STEMI is detected or not detected
A3–ADULT CARDIAC ARREST – INITIAL CARE AND CPR<br />
ESTABLISH<br />
• First agency on scene assumes leadership role<br />
TEAM LEADER • Leadership role can be transferred as additional personnel arrive<br />
CONFIRM ARREST • Unresponsive, no breathing or agonal respirations, no pulse<br />
Begin Compressions:<br />
• Rate – at least 100/minute<br />
• Depth - 2 inches in adults – allow full recoil of chest (lift heel of hand)<br />
• Rotate compressors every 2 minutes if manual compression used<br />
Minimize interruptions. If necessary to interrupt, limit to 10 seconds or less.<br />
COMPRESSIONS • Perform CPR during charging of defibrillator<br />
• Resume CPR immediately after shock (do not stop for pulse or rhythm check)<br />
Prepare mechanical compression device (if available)<br />
• Apply with minimal interruption<br />
• Should be placed following completion of at least one 2-minute manual CPR<br />
cycle or at end of subsequent cycle<br />
AED OR MONITOR/<br />
DEFIBRILLATOR<br />
•<br />
•<br />
•<br />
Apply pads while compressions in progress<br />
Determine rhythm and shock, if indicated<br />
Follow specific treatment guideline based on rhythm<br />
• Open airway and provide 2 breaths after every 30 compressions<br />
BASIC AIRWAY • Avoid excessive ventilation – no more than 8 – 10 ventilations per minute<br />
MANAGEMENT • Ventilations should be about 1 second each, enough to cause visible chest rise<br />
AND<br />
• Use two-person BLS Airway management (one holding mask and one squeezing<br />
VENTILATION<br />
bag)<br />
• If available, use ResQPOD with two-person BLS airway management
IV / IO ACCESS<br />
ADVANCED AIRWAY<br />
TREATMENT<br />
ON SCENE<br />
• IO access is preferred unless no suitable site is available<br />
• If IV used (no IO access), antecubital vein is preferred<br />
• Hand veins and other smaller veins should not be used in cardiac arrest<br />
• Placement of advanced airway is not a priority during the first 5 minutes of<br />
resuscitation unless no ventilation is occurring with basic maneuvers<br />
o Exception: If ResQPOD used, early use of King Airway is appropriate<br />
• Placement of King Airway or endotracheal tube should not interrupt<br />
compressions for more than 10 seconds<br />
• For endotracheal intubation, position and visualize airway prior to cessation<br />
of CPR for tube passage. Immediately resume compressions after tube<br />
passage.<br />
• Confirm tube placement and provide on-going monitoring using end-tidal<br />
carbon dioxide monitoring<br />
• Movement of a patient may interrupt CPR or prevent adequate depth and<br />
rate of compressions, which may be detrimental to patient outcome<br />
• Provide resuscitative efforts on scene up to 30 minutes to maximize chances<br />
of return of spontaneous circulation (ROSC)<br />
• If resuscitation does not attain ROSC, consider cessation of efforts per policy
A4–ADULT<br />
VENTRICULAR FIBRILLATION<br />
PULSELESS VENTRICULAR TACHYCARDIA<br />
INITIAL CARE See Cardiac Arrest – Initial <strong>Care</strong> and CPR (A3)<br />
DEFIBRILLATION 200 joules (low energy 120 joules)<br />
CPR For 2 minutes or 5 cycles between rhythm check<br />
VENTILATION/AIRWAY<br />
• BLS airway is preferred method during first 5 -6 minutes of CPR<br />
• If no ventilation occurring with basic maneuvers, proceed to advanced airway<br />
IO OR IV TKO. Should not delay shock or interrupt CPR<br />
DEFIBRILLATION 300 joules (low energy 150 joules)<br />
EPINEPHRINE 1:10,000 - 1 mg IV or IO every 3-5 minutes<br />
DEFIBRILLATION 360 joules (low energy 200 joules)<br />
AMIODARONE 300 mg IV or IO<br />
DEFIBRILLATION 360 joules (low energy 200 joules) as indicated after every CPR cycle<br />
ADVANCED AIRWAY<br />
•<br />
•<br />
Should not interfere with initial 5-6 minutes of CPR – minimize interruptions<br />
Do not interrupt compressions more than 10 seconds to obtain airway<br />
CONSIDER REPEAT<br />
AMIODARONE<br />
If rhythm persists, 150 mg IV or IO, 3-5 minutes after initial dose<br />
TRANSPORT If indicated<br />
CONSIDER SODIUM<br />
BICARBONATE<br />
1 mEq/kg IV or IO for suspected hyperkalemia or pre-existing acidosis<br />
If Return of Spontaneous Circulation, see Post-Cardiac Arrest <strong>Care</strong> (A11)
Key Treatment Considerations<br />
• Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance<br />
takes precedence over advanced airway management and administration of medications.<br />
• To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock<br />
administered (no pulse or rhythm check)<br />
• Rotate compressors every 2 minutes<br />
• Avoid excessive ventilation. Provide no more than 8-10 ventilations per minute.<br />
• Ventilations should be about one second each, enough to cause visible chest rise<br />
• If advanced airway placed, perform CPR continuously without pauses for ventilation<br />
• If available, ResQPOD impedance threshold device may be used with BLS airway or King / ET tube<br />
• If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and<br />
performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR<br />
after passage.<br />
• Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide<br />
measurement. Continuous monitoring with ETCO2 is mandatory – if values less than 10 mm Hg seen,<br />
assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earliest<br />
indicator of return of circulation.<br />
• Prepare drugs before rhythm check and administer during CPR<br />
• Follow each drug with 20 ml NS flush
A5–ADULT PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE<br />
INITIAL CARE See Cardiac Arrest – Initial <strong>Care</strong> and CPR (A3)<br />
EPINEPHRINE 1:10,000 1 mg IV or IO every 3-5 minutes<br />
Consider treatable causes – treat if applicable:<br />
CONSIDER<br />
FLUID BOLUS<br />
For hypovolemia: 500-1000 ml NS IV or IO<br />
VENTILATION For hypoxia: Ensure adequate ventilation (8-10 breaths per minute)<br />
CONSIDER SODIUM<br />
BICARBONATE<br />
CONSIDER CALCIUM<br />
CHLORIDE<br />
CONSIDER<br />
For pre-existing acidosis (e.g. kidney failure), hyperkalemia, or tricyclic<br />
antidepressant overdose are suspected:<br />
• 1 mEq/kg IV or IO if indicated<br />
• Should not be used routinely in cardiac arrest<br />
For hyperkalemia or calcium channel blocker overdose:<br />
• 500 mg IV or IO – may repeat in 5-10 minutes<br />
• Should not be used routinely in cardiac arrest<br />
WARMING MEASURES<br />
For hypothermia<br />
CONSIDER NEEDLE<br />
THORACOSTOMY<br />
For tension pneumothorax<br />
If Return of Spontaneous Circulation, see Post-Cardiac Arrest <strong>Care</strong> (A11)
CONSIDER<br />
TERMINATION OF<br />
RESUSCITATION<br />
Patients who have all of the following criteria are highly unlikely to survive:<br />
• Unwitnessed Arrest and<br />
• No bystander CPR and<br />
• No shockable rhythm seen and no shocks delivered during resuscitation and<br />
• No return of spontaneous circulation (ROSC) during resuscitation<br />
Patients with asystole or PEA whose arrests are witnessed and/or who have<br />
had bystander CPR administered have a slightly higher likelihood of survival.<br />
If unresponsive to interventions these patients should be considered for<br />
termination of resuscitation.<br />
Key Treatment Considerations<br />
• Atropine is no longer used in cardiac arrest<br />
• Pre-existing acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or<br />
if suspected diabetic ketoacidosis<br />
• In clear-cut traumatic arrest situations, epinephrine is not indicated in PEA or asystole. If any doubt<br />
as to cause of arrest, treat as a non-traumatic arrest (e.g. solo motor vehicle accident at low speed in<br />
older patients).
A6–ADULT SYMPTOMATIC BRADYCARDIA<br />
Heart rate less than 50 with signs or symptoms of poor perfusion (e.g., acute altered mental status,<br />
hypotension, other signs of shock). Correction of hypoxia should be addressed prior to other<br />
treatments.<br />
OXYGEN<br />
CARDIAC MONITOR<br />
BLS: High flow initially<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
IV<br />
TKO. If not promptly available, proceed to external cardiac pacing. Consider IO<br />
ACCESS if patient in extremis and unconscious or not responsive to painful stimuli.<br />
CONSIDER<br />
FLUID BOLUS<br />
250-500 ml NS if clear lung sounds and no respiratory distress<br />
12-LEAD ECG Consider pre- and post-treatment if condition permits<br />
TRANSCUTANEOUS Set rate at 80<br />
PACING<br />
Start at 10 mA, and increase in 10 mA increments until capture is achieved<br />
If pacing urgently needed, sedate after pacing initiated<br />
CONSIDER<br />
• MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg increments<br />
SEDATION<br />
(maximum dose 5 mg), and/or<br />
• MORPHINE SULFATE 1-5 mg IV or IO in 1 mg increments for pain relief if BP<br />
90 systolic or greater<br />
May be used as a temporary measure while awaiting transcutaneous pacing but<br />
should not delay onset of pacing<br />
CONSIDER<br />
• 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective<br />
ATROPINE<br />
• Consider repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3 mg<br />
Use with caution in patients with suspected ongoing cardiac ischemia<br />
Atropine should not be used in wide-QRS second- and third-degree blocks<br />
TRANSPORT
Key Treatment Considerations<br />
• Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor / observe)<br />
• Fluid bolus may address hypotension and lessen need for pacing or treatment with atropine<br />
• Sedation prior to starting pacing is not required. Patients with urgent need should be paced first.<br />
• The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness.<br />
Patients who are in need of pacing are unstable and sedation should be done with great caution<br />
• Monitor respiratory status closely and support ventilation as needed<br />
• Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in<br />
these patients)<br />
• Patients with wide-QRS second- and third-degree blocks will not have a response to atropine because<br />
these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur.
A7–ADULT VENTRICULAR TACHYCARDIA WITH PULSES<br />
Widened QRS Complex (greater than or equal to 0.12 sec) – generally regular rhythm<br />
INITIAL THERAPY<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
CARDIAC MONITOR<br />
12-lead ECG pre-and post-treatment may be useful for comparisons at hospital.<br />
12-LEAD ECG The computerized rhythm analysis on 12-lead printout should not be used for<br />
determination of rhythm.<br />
IV TKO<br />
STABLE VENTRICULAR TACHYCARDIA<br />
AMIODARONE 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min)<br />
CONSIDER REPEAT<br />
AMIODARONE<br />
If rhythm persists and patient remains stable, 150 mg IV over 10 minutes<br />
UNSTABLE VENTRICULAR TACHYCARDIA<br />
Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF<br />
CONSIDER<br />
SEDATION<br />
SYNCHRONIZED<br />
CARDIOVERSION<br />
Prepare for CARDIOVERSION: If awake and aware, sedate with<br />
MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg)<br />
100 joules (low energy setting – 75 W/S)<br />
200 joules (low energy setting – 120 W/S)<br />
300 joules (low energy setting – 150 W/S)<br />
360 joules (low energy setting – 200 W/S)<br />
If VT recurs, use lowest energy level previously successful
Key Treatment Considerations<br />
• Document rhythm during treatment with continuous strip recording<br />
• Rhythm analysis should be based on recorded strip, not monitor screen<br />
• Be prepared for previously stable patient to become unstable<br />
• Give AMIODARONE via Infusion or slow IV push only<br />
• Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly.<br />
• AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should<br />
be considered unstable and should not receive AMIODARONE.<br />
• If sedation done for cardioversion, monitor respiratory status closely and support ventilations as<br />
needed
A8–ADULT SUPRAVENTRICULAR TACHYCARDIA<br />
Heart rate greater than 150 beats per minute – regular rhythm usually with narrow QRS complex<br />
INITIAL THERAPY<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
CARDIAC MONITOR<br />
12-lead ECG pre-and post-treatment may be useful for comparisons at hospital.<br />
12-LEAD ECG The computerized rhythm analysis on 12-lead printout should not be used for<br />
determination of rhythm.<br />
IV TKO – Antecubital IV needed for rapid medication administration<br />
STABLE SUPRAVENTRICULAR TACHYCARDIA (SVT)<br />
May have mild chest discomfort<br />
VALSALVA<br />
CONSIDER<br />
ADENOSINE<br />
6 mg rapid IV - followed by 20 ml normal saline flush<br />
If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml<br />
normal saline flush
UNSTABLE SVT<br />
• May need immediate synchronized cardioversion<br />
• Signs of poor perfusion include moderate to severe chest pain, dyspnea, altered mental status,<br />
blood pressure less than 90 or CHF<br />
• If rhythm not regular, SVT unlikely<br />
• If wide QRS complex, consider ventricular tachycardia<br />
CONSIDER<br />
ADENOSINE<br />
CONSIDER<br />
SEDATION<br />
SYNCHRONIZED<br />
CARDIOVERSION<br />
6 mg rapid IV - followed by 20 ml normal saline flush<br />
If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml<br />
normal saline flush<br />
Prepare for CARDIOVERSION. If awake and aware, sedate with<br />
MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg)<br />
100 joules (low energy setting – 75 W/S)<br />
200 joules (low energy setting – 120 W/S)<br />
300 joules (low energy setting – 150 W/S)<br />
360 joules (low energy setting – 200 W/S)<br />
Key Treatment Considerations<br />
• Document rhythm during treatment with continuous strip recording<br />
• Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen or<br />
computerized readout of 12-lead ECG<br />
• Be prepared for previously stable patient to become unstable<br />
• Proceed to cardioversion if patient becomes unstable<br />
• Hypoxemia is a common cause of tachycardia. Focus on determining if oxygenation is adequate.<br />
• Adenosine should not be administered to patients with acute exacerbation of asthma<br />
• If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed
A9–ADULT OTHER CARDIAC DYSRHYTHMIAS<br />
SINUS TACHYCARDIA – Heart rate 100-160, regular<br />
ATRIAL FIBRILLATION – Heart rate highly variable, irregular<br />
ATRIAL FLUTTER – Variable rate depending on block. Atrial rate 250-350, “saw-tooth” pattern.<br />
INITIAL THERAPY<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
CARDIAC MONITOR<br />
CONSIDER<br />
12-LEAD ECG<br />
CONSIDER IV TKO<br />
12-lead ECG pre-and post-treatment may be useful for comparisons at hospital<br />
The computerized rhythm analysis on 12-lead printout should not be used for<br />
determination of rhythm<br />
UNSTABLE ATRIAL FIBRILLATION OR ATRIAL FLUTTER<br />
Ventricular rate greater than 150, and:<br />
BP less than 80, or unconsciousness / obtundation, or severe chest pain or severe dyspnea<br />
OXYGEN High flow. Be prepared to support ventilation.<br />
CONSIDER<br />
Prepare for CARDIOVERSION. If awake and aware, sedate with<br />
SEDATION<br />
MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg)<br />
Atrial Flutter:<br />
• Initial: 100 joules (low energy setting – 75 joules)<br />
SYNCHRONIZED • Subsequent: 200, 300, 360 joules (low energy settings 120, 150, 200 joules)<br />
CARDIOVERSION Atrial Fibrillation<br />
• Initial: 200 joules (low energy setting – 120 joules)<br />
• Subsequent: 300, 360 joules (low energy settings 150, 200 joules)
Key Treatment Considerations<br />
• Sinus tachycardia commonly present because of pain, fever, anemia, or hypovolemia<br />
• Atrial fibrillation may be well-tolerated with moderately rapid rates (150-170) and often requires no<br />
specific treatment other than observation (oxygen, monitoring and transport)<br />
• If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed<br />
• Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen<br />
or computerized readout of 12-lead ECG<br />
• Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI***,<br />
***Acute MI Suspected*** or ***Meets ST-Elevation MI Criteria*** message encountered, the patient’s<br />
heart rate is important information to relate to the STEMI center at time of activation.
A10–ADULT SHOCK / HYPOVOLEMIA<br />
HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with dry lungs, flat neck veins<br />
May have poor skin turgor, history of GI bleeding, vomiting or diarrhea, altered level of<br />
consciousness<br />
May be warm and flushed, febrile, may have respiratory distress<br />
Sepsis patients may or may not have an associated fever<br />
CARDIOGENIC SHOCK<br />
Signs/symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema<br />
HYPOVOLEMIA WITHOUT SHOCK<br />
No signs of shock, but history of poor fluid intake or fluid loss (e.g. vomiting, diarrhea). May have<br />
tachycardia, poor skin turgor.<br />
OXYGEN BLS/ALS: High flow. Be prepared to support ventilations as needed.<br />
CONSIDER CPAP If suspected pulmonary edema / cardiogenic shock<br />
ADDRESS<br />
Keep patient warm if suspected hypothermia<br />
HYPOTHERMIA<br />
CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline<br />
EARLY TRANSPORT CODE 3<br />
IV OR IO TKO only if suspected pulmonary edema<br />
• For hypovolemic or septic shock, 500 ml NS bolus. May repeat once.<br />
FLUID BOLUS<br />
• For hypovolemia (poor intake/fluid loss), 250 ml NS bolus. May repeat X 1.<br />
Do not administer bolus if pulmonary edema or cardiogenic shock suspected
CONSIDER<br />
12-LEAD ECG<br />
If cardiac etiology for shock suspected<br />
Check temperature, use sepsis screening tool and advise hospital of positive<br />
sepsis screen if indicated<br />
A positive sepsis screen in adults occurs in the setting of suspected<br />
SEPSIS SCREEN<br />
infection when 2 of 3 conditions are met:<br />
• Heart rate/pulse greater than 100;<br />
• Respiratory rate greater than 20;<br />
• Temperature above 100.4 or below 96<br />
BLOOD GLUCOSE Check and treat if indicated<br />
Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12)
A11–ADULT POST-CARDIAC ARREST CARE<br />
Following resuscitation from cardiac arrest in adults<br />
BLS: High flow initially<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
Be prepared to support ventilations as needed. Avoid excessive ventilation.<br />
END-TIDAL CO2<br />
MONITORING<br />
If intubated, monitor and maintain respirations to keep ETCO2 between 35 and 40<br />
CARDIAC<br />
MONITOR<br />
Treat dysrhythmias per specific treatment guideline<br />
12-LEAD ECG<br />
Evaluate for possible STEMI. Alert and transport to STEMI center if ECG indicates<br />
***ACUTE MI*** or equivalent STEMI message<br />
TRANSPORT CODE 3<br />
IV OR IO If not previously established<br />
FLUID BOLUS For BP less than 90 systolic, begin infusion up to 1 liter NS<br />
BLOOD GLUCOSE Treat if indicated<br />
CONSIDER<br />
THERAPEUTIC<br />
HYPOTHERMIA<br />
See Indications and contraindications below.<br />
Expose patient and apply eight (8) ice packs<br />
• 2 on head, 2 on the neck over the carotid arteries, 1 on each axilla, 1 over each<br />
femoral artery<br />
Discontinue ice packs if shivering occurs or increasing level of consciousness<br />
Advise Emergency Department that hypothermia has been initiated
THERAPEUTIC HYPOTHERMIA – INDICATIONS AND CONTRAINDICATIONS<br />
All the following must be present:<br />
• Must be age 18 or greater<br />
• Return of spontaneous circulation for at least five minutes<br />
• GCS < 8<br />
INDICATIONS<br />
• Unresponsive without purposeful movements. Brainstem reflexes and<br />
posturing movements may be present<br />
• Blood pressure 90 systolic or greater<br />
• Pulse oximetry – 85% or greater<br />
• Blood glucose – 50 or greater<br />
• Traumatic cardiac arrest<br />
• Responsive post-arrest with GCS 8 or greater or rapidly improving GCS<br />
CONTRAINDICATIONS<br />
•<br />
•<br />
Pregnancy<br />
DNR or known terminal illness<br />
• Dialysis patient<br />
• Uncontrolled bleeding<br />
Consider and treat other potential causes of altered level of consciousness (e.g. hypoxia or hypoglycemia)
A12–ADULT<br />
PUBLIC SAFETY DEFIBRILLATION<br />
BLS / LAW ENFORCEMENT<br />
SCENE SAFETY / BSI Use universal blood and body fluid precautions at all times<br />
CONFIRM Unconscious, pulseless patient with no breathing or no normal breathing<br />
COMPRESSIONS<br />
AUTOMATED<br />
EXTERNAL<br />
DEFIBRILLATOR<br />
(AED)<br />
• Begin compressions at a rate of at least 100 per minute<br />
• Compress chest at least 2 inches and allow full recoil of chest (lift heel of hand)<br />
• Change compressors every 2 minutes<br />
• Minimize interruptions in compressions. If necessary to interrupt, limit to 10 seconds<br />
or less.<br />
• Stop compressions for analysis only – resume compressions while AED is charging<br />
• Resume compressions immediately after any shock<br />
• If available, place mechanical compression device after first rhythm analysis or after<br />
subsequent rhythm analysis (LUCAS or Auto-Pulse)<br />
• Priority of second rescuer is to apply pads while compressions are in progress<br />
• If less than 8 years of age, attach pediatric electrodes, if available. If not, attach adult<br />
electrodes with anterior-posterior placement (pads should not touch).<br />
• (*) Allow AED to analyze heart rhythm<br />
o If the rhythm is shockable<br />
Resume compressions until charging of unit is complete<br />
Clear bystanders and crew (stop compressions)<br />
Deliver shock<br />
Resume CPR for 2 minutes, beginning with chest compressions – then return to (*)<br />
o If the rhythm is NOT shockable (“No Shock Advised”)<br />
Resume CPR for 2 minutes, beginning with chest compressions – then return to (*)
BASIC AIRWAY<br />
MANAGEMENT<br />
AND<br />
VENTILATION<br />
CHECK BLOOD<br />
PRESSURE<br />
DOCUMENTATION<br />
Open airway and provide 2 breaths after every 30 compressions<br />
• AVOID EXCESSIVE VENTILATION – Provide no more than 8 –10 ventilations per<br />
minute<br />
• Ventilations should be about one second each, enough to cause visible chest rise.<br />
Use two-person BLS Airway management (one holding mask and one squeezing<br />
bag – compressor can squeeze the bag)<br />
If patient begins to breathe or becomes responsive:<br />
• Maintain airway<br />
• Assist ventilations as necessary<br />
If patient begins to breathe or becomes responsive:<br />
• Check blood pressure if equipment available<br />
• Complete AED Use Report<br />
• Forward report to EMS whenever an AED is used (whether shock administered or<br />
not)
G1 — Allergy and<br />
all patients<br />
G9 — Hypothermia<br />
Anaphylaxis<br />
G10 — Pain Management<br />
G2 — Altered Level of G11 — Poisoning/Overdose<br />
Consciousness G12 — Respiratory<br />
G3 — Behavioral<br />
Repression or Apnea<br />
Emergency<br />
G13 — Respiratory Distress<br />
G4 — Burns<br />
G14 — Seizure<br />
G5 — Childbirth<br />
G15 — Stroke<br />
G6 — Dystonic Reaction G16 — Trauma<br />
G7 — Envenomation G17 — Vomiting and Severe<br />
G8 — Heat Illness/<br />
Hyperthermia<br />
General<br />
Treatment<br />
Guidelines<br />
Nausea
G1–GENERAL ANAPHYLAXIS / ALLERGY<br />
• Systemic reactions (anaphylaxis) include upper and lower respiratory tracts, gastrointestinal<br />
or vascular system. Symptoms include dyspnea, stridor, change in voice, wheezing, anxiety,<br />
tachycardia, tightness in chest, vomiting, diarrhea, abdominal pain, dizziness or hypotension<br />
• Skin and mucous membrane reactions (swelling of face, lip, tongue, palate), may be seen in either<br />
uncomplicated allergic reactions or in anaphylaxis<br />
OXYGEN<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO 2 of at least 94%<br />
EPI-PEN<br />
CARDIAC MONITOR<br />
May assist with administration of patient’s auto-injector<br />
If systemic reaction (anaphylaxis):<br />
EPINEPHRINE 1:1000<br />
IM<br />
• Adult – 0.3-0.5 mg IM (use 0.3 mg in elderly, small patients or mild symptoms)<br />
Pediatric – 0.01 mg/kg IM – maximum dose 0.3 mg<br />
May repeat in 15 minutes if systemic symptoms persist<br />
ALBUTEROL Adult and pediatric - 5 mg/6 ml saline via nebulizer – may repeat as needed<br />
IV TKO<br />
CONSIDER<br />
• Adult – wide-open NS if hypotensive. Recheck vitals after every 250 ml<br />
FLUID BOLUS<br />
Pediatric - 20 ml/kg NS bolus if hypotensive, may repeat X 2<br />
If skin or mucous membrane reactions (itching, hives or facial/oral swelling), consider:<br />
• Adult - 50 mg slow IV or IM<br />
DIPHENHYDRAMINE<br />
<br />
Consider 25 mg dose if patient has taken po diphenhydramine<br />
Pediatric – 1 mg/kg IV or IM – Maximum dose 50 mg<br />
Consider 0.5 mg/kg dose if patient has taken po diphenhydramine
If serious progression of symptoms after treatment with IM epinephrine:<br />
• Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis,<br />
severe respiratory distress or respiratory arrest<br />
CONSIDER IO If IV access not immediately available<br />
FLUID BOLUS<br />
CONSIDER<br />
EPINEPHRINE<br />
1:10,000 IV<br />
• Adult - wide open NS. Recheck vitals after every 250 ml<br />
Pediatric - 20 ml/kg NS bolus, may repeat X 2<br />
If patient not responsive to IM epinephrine treatment in 5-10 minutes:<br />
• Adult - titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg<br />
Use extreme caution with patients with cardiac history, angina, hypertension<br />
Pediatric-titrate in up to 0.1 mg doses slow IV or IO to a maximum of<br />
0.01 mg/kg<br />
Key Treatment Considerations<br />
• Epinephrine IM administered early is the cornerstone of treatment in anaphylaxis<br />
o Epinephrine is well tolerated in pediatric patients and healthy young adults<br />
o In patients with prior history of coronary artery disease (angina, MI, stent placement), use of<br />
epinephrine IM is still indicated if symptoms are moderate to severe. If symptoms mild, careful<br />
observation is prudent. Consider base contact if any questions<br />
• Diphenhydramine and albuterol are secondary considerations in anaphylaxis<br />
• Up to 20% of anaphylaxis patients may present without any skin findings (e.g. hives)<br />
• Gastrointestinal symptoms may predominate in some patients, especially with serious reactions to<br />
food<br />
• In pediatric patients, hypotension is late sign of shock<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G2–GENERAL ALTERED LEVEL OF CONSCIOUSNESS<br />
Glasgow Coma Scale less than 15 – uncertain etiology. Consider AEIOU/TIPPS<br />
OXYGEN<br />
BLS: High flow initially. ALS: Titrate to sPO of at least 94%.<br />
2<br />
Be prepared to support ventilations as needed.<br />
Consider if known diabetic, conscious, able to sit upright, able to self-administer<br />
ORAL GLUCOSE • Adult - 30 g po<br />
CARDIAC MONITOR<br />
Pediatric – 15-30 g po<br />
BLOOD GLUCOSE Check level<br />
EARLY TRANSPORT In patients with ALOC without low blood sugar<br />
IV TKO NS<br />
If glucose 60 or less:<br />
DEXTROSE 10% • Adult – DEXTROSE 10% 100 ml IV<br />
Pediatric – DEXTROSE 10% 0.5 g/kg IV (5 ml/kg)<br />
If unable to establish IV (at least 2 attempts or if unable to find suitable site):<br />
GLUCAGON<br />
•<br />
<br />
Adult – 1 mg IM<br />
Pediatric – 24 kg or more – 1 mg IM<br />
Pediatric – Less than 24 kg – 0.5 mg IM<br />
BLOOD GLUCOSE<br />
Recheck if symptoms not resolved. If GLUCAGON has been administered, change<br />
in glucose/mentation may require 15 minutes or more.<br />
DEXTROSE 10% Repeat additional DEXTROSE 10% 150 ml IV if glucose remains 60 or less.<br />
DEXTROSE 50%<br />
Administer DEXTROSE 50% 25 g IV if glucose remains 60 or less after full Dextrose<br />
10% dose given (250 ml)<br />
Related guideline: Respiratory Depression or Apnea (G12)
Key Treatment Considerations<br />
• Naloxone should not be given as treatment for altered level of consciousness in the absence of<br />
respiratory depression (respiratory depression = rate of less than 12 breaths per minute)<br />
• After treatment(s) for hypoglycemia, recheck glucose before considering repeat treatment. Mental<br />
status improvement may lag behind improved glucose levels (especially in elderly patients or<br />
prolonged hypoglycemia). Further treatment when glucose is 60 or above is not indicated.<br />
• Oral glucose is the preferred treatment when patient is able to take medication orally<br />
• Dextrose 10% is the preferred treatment when patient is unable to take oral medication<br />
• Glucagon should not be administered if patient able to take oral glucose and should be administered<br />
only if IV starts are unsuccessful or no suitable IV sites found. It may not be effective in patients with<br />
starvation, poor oral intake, alcoholism or alcohol intoxication.<br />
• Glucagon may take 10-15 minutes or longer to increase glucose level (peak effects in 45-60 minutes)<br />
Wait for 10-15 minutes for recheck glucose before considering additional treatment<br />
• For diabetics with insulin pumps, the amount of insulin administered by the pump is very small and<br />
should not impede treatment of hypoglycemia. Insulin pumps should not be discontinued because of<br />
the development of hypoglycemia.<br />
• The presence of the pump should be identified during patient report at the hospital.<br />
• Transport is highly recommended in patients with hypoglycemia as a result of oral diabetic<br />
medications and patients over 65 years of age (higher risk of recurrent hypoglycemia).<br />
• Transport is also highly recommended for any hypoglycemic patient who is not a diabetic (may occur<br />
with renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses<br />
and sulfa drugs or following bariatric surgery).<br />
• Consider transport earlier in patients with poor vascular access who are not responding to glucagon or<br />
have reasons listed above for possible impaired response to glucagon<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for D10 dose.
G3–GENERAL BEHAVIORAL EMERGENCY<br />
• A behavioral emergency is defined as combative or irrational behavior not caused by medical<br />
illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated<br />
states or other conditions<br />
• Combative or irrational behavior may be caused by psychiatric or other behavioral disorder<br />
• History of event and past history are important in patient evaluation<br />
• Past history of psychiatric condition does not eliminate need to assess for other illnesses<br />
SCENE SAFETY<br />
ASSESS PATIENT<br />
• Many patients merit a weapons search by law enforcement<br />
• Physical restraints may be needed if patient exhibits behavior that presents a<br />
danger to him/herself or others<br />
• Assess for evidence of hypoxia, hypoglycemia, trauma<br />
• Consider other medical causes for behavioral symptoms<br />
VITAL SIGNS Obtain vital signs as possible<br />
CONSIDER OXYGEN<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
CARDIAC MONITOR Place as possible / safe<br />
consider<br />
BLOOD GLUCOSE<br />
Obtain as possible / safe
CONSIDER<br />
CHEMICAL<br />
RESTRAINT<br />
MONITOR PATIENT<br />
BASE ORDER REQUIRED<br />
Despite verbal de-escalation and physical restraint, if adult patient (15 years or<br />
older) remains extremely combative and struggling against restraints, consider:<br />
• MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small<br />
patients (under 50 kg).<br />
• MIDAZOLAM 1-5 IV mg in 1 mg increments if IV established and patent<br />
Monitor closely for respiratory compromise. Assess and document mental status,<br />
vital signs, and extremity exams (if restrained) at least every 15 minutes.<br />
Related guidelines: Altered Level of Consciousness (G2), Trauma (G16)<br />
Key Treatment Considerations<br />
• Calming measures may be effective and may preclude need for restraint in some circumstances<br />
• Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if<br />
possible, but maintain contact with other personnel and ability to exit rapidly.<br />
• Avoid violating patient’s personal space, making direct eye contact or sudden movements. Frequent<br />
reassurance and calm demeanor of personnel are important.<br />
• Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position.<br />
• Assure adequate resources available to manage patient’s needs. Restraint may require up to five<br />
persons to safely control patient.<br />
• Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior<br />
• In pediatric patients, consider child’s developmental level when providing care<br />
• Sedation with Midazolam intended for adult patients only (age 15 and over)<br />
• Not all patients will respond to Midazolam. Repeat dosage is not recommended.
G4–GENERAL BURNS<br />
• Damage to the skin caused by contact with caustic material, electricity, or fire<br />
• Second or third degree burns involving 20% of the body surface area, or those associated with<br />
respiratory involvement are considered major burns<br />
SCENE SAFETY Move patient to safe area<br />
STOP BURNING<br />
PROCESS<br />
OXYGEN<br />
• Remove contact with agent, unless adhered to skin<br />
• Brush off chemical powders<br />
• Flush with water to stop burning process or to decontaminate<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO 2 of at least 94%<br />
BURN CARE<br />
Protect the burned area. Do not break blisters, cover with clean dressings or<br />
sheets. Remove restrictive clothing/jewelry if possible.<br />
ASSESS FOR INJURIES Assess for associated injuries if other trauma suspected<br />
CONSIDER IV OR IO TKO<br />
CONSIDER<br />
MORPHINE SULFATE IV<br />
CONSIDER<br />
MORPHINE SULFATE IM<br />
For pain relief in the absence of hypotension (systolic BP less than 90),<br />
significant other trauma, altered level of consciousness:<br />
• Adult – 2-20 mg IV or IO, titrated in 2 - 4 mg increments<br />
Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart<br />
If IV or IO access not available:<br />
• Adult – 5-20 mg IM<br />
Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart
Key Treatment Considerations<br />
• Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or<br />
edematous mucosa in mouth are clues)<br />
• Transport to closest receiving facility for advanced airway management if it cannot be done on scene<br />
in a timely manner. Do not wait for helicopter (air ambulance) if airway patency is a concern and care<br />
can be provided more rapidly at a receiving facility.<br />
• Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia.<br />
• Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section)<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G5–GENERAL CHILDBIRTH – ROUTINE OR COMPLICATED<br />
IMMINENT DELIVERY - Regular contractions, bloody show, low back pain, feels like bearing down,<br />
crowning<br />
PREPARE FOR<br />
DELIVERY<br />
Reassure mother, instruct during delivery<br />
CONSIDER IV TKO if time allows<br />
• As head is delivered, apply gentle pressure to prevent rapid delivery of the<br />
infant<br />
DELIVER INFANT • Gently suction baby’s mouth, then nose, keeping the head dependent<br />
• If cord is wrapped around neck and can’t be slipped over the infant’s head,<br />
double-clamp and cut between clamps<br />
CLAMP/CUT<br />
CORD<br />
WARMING<br />
MEASURES<br />
PLACENTA<br />
DELIVERY<br />
POST-DELIVERY<br />
OBSERVATION<br />
Immediately double-clamp cord 6-8 inches from baby and cut between clamps (if not<br />
done before delivery)<br />
Dry baby and keep warm, placing baby on mother’s abdomen or breast<br />
If placenta delivers, save it and bring to the hospital with mother and child<br />
DO NOT PULL ON UMBILICAL CORD TO DELIVER PLACENTA<br />
Observe mother and infant frequently for complications. To decrease post-partum<br />
hemorrhage, perform firm fundal massage, put baby to mother’s breast.<br />
TRANSPORT Prepare mother and infant for transport. Neonatal care or resuscitation as indicated.
COMPLICATED DELIVERY<br />
BREECH DELIVERY – Presentation of buttocks or feet<br />
OXYGEN BLS/ALS: High flow<br />
DELIVERY<br />
• Allow delivery to proceed passively until the baby’s waist appears<br />
• Rotate baby to face-down position (DO NOT PULL)<br />
• If the head does not readily deliver in 4-6 minutes, insert a gloved hand into the<br />
vagina to create an air passage for the infant<br />
TRANSPORT Early transport if available – notify receiving hospital as soon as possible<br />
PROLAPSED CORD - Cord presents first and is compressed, compromising infant circulation<br />
OXYGEN BLS/ALS: High flow<br />
MANAGE CORD<br />
POSITION<br />
PATIENT<br />
• Insert gloved hand into vagina and gently push presenting part off of the cord<br />
• Do not attempt to reposition the cord<br />
• Cover cord with saline soaked gauze<br />
Place mother in trendelenburg position with hips elevated<br />
TRANSPORT Early transport if available – notify receiving hospital as soon as possible
G6–GENERAL DYSTONIC REACTIONS<br />
History of ingestion of phenothiazine or related compounds, primarily anti-psychotic and antiemetic<br />
medications (for nausea/vomiting). Symptoms include restlessness, muscle spasms of the<br />
neck, jaw, and back, oculogyric crisis.<br />
CONSIDER OXYGEN<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO 2 of at least 94%<br />
IV TKO<br />
DIPHENHYDRAMINE<br />
•<br />
<br />
Adult – 25-50 mg IV or 50 mg IM if unable to establish IV access<br />
Pediatric – 1 mg/kg IV or 1 mg/kg IM if unable to establish IV access<br />
Key Treatment Considerations<br />
Common drugs implicated in dystonic reactions include many anti-emetics and anti-psychotic medications<br />
• Prochlorperazine (Compazine)<br />
• Haloperidol (Haldol)<br />
• Metoclopromide (Reglan)<br />
• Phenergan (Promethazine)<br />
• Fluphenazine (Prolixin)<br />
• Chlorpromazine (Thorazine)<br />
• Many other antipsychotic and anti-depressant drugs<br />
Rarely benzodiazepine drugs have been implicated as a cause of dystonic reaction<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G7–GENERAL ENVENOMATIONS (Bites/Stings)<br />
SNAKE BITES<br />
• If the snake is positively identified as non-poisonous, treat with basic wound care<br />
INSECT STINGS<br />
• Symptoms of stings usually occur at the site of injury and have no specific treatment<br />
• Allergic reactions can be severe, and may cause anaphylactic shock<br />
CALM PATIENT With snake bite, keep patient still and calm<br />
ASSESS EXTREMITIES Remove rings, bracelets or other constricting items from affected extremity<br />
WOUND MANAGEMENT<br />
OXYGEN<br />
CONSIDER<br />
CARDIAC MONITOR<br />
CONSIDER IV TKO<br />
Snake bite: Splint extremity and keep at level of heart<br />
Insect Stings: Flick stinger off – do not squeeze stinger. Apply cold pack.<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO 2 of at least 94%. Be prepared to support ventilation.<br />
Consider if patient potentially unstable<br />
Related guidelines: Shock/Hypovolemia (A10, P8), Allergy / Anaphylaxis (G1)
G8–GENERAL HEAT ILLNESS / HYPERTHERMIA<br />
HEAT EXHAUSTION<br />
• Presentation: Flu-like symptoms, cramps, normal mental status<br />
HEAT STROKE<br />
• Presentation: Altered level of consciousness, absence of sweating, tachycardia, and<br />
hypotension<br />
OXYGEN<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
• Move patient to cool environment<br />
COOLING MEASURES<br />
•<br />
•<br />
Promote cooling by fanning<br />
Remove clothing and splash / sponge with water<br />
• Place cold packs on neck, in axillary and inguinal areas<br />
IV TKO. Perform if heat stroke or marked symptoms with heat exhaustion<br />
CONSIDER<br />
FLUID BOLUS<br />
CONSIDER<br />
BLOOD GLUCOSE<br />
If hypotensive or suspected heat stroke:<br />
• Adult – 500 ml NS bolus May repeat X 1<br />
Pediatric – 20 ml/kg NS bolus. May repeat X 1<br />
Check level if altered level of consciousness, treat as indicated<br />
Related guidelines: Altered Level of Consciousness (G2), Seizure (G14)
Key Treatment Considerations<br />
• Seizures may occur with heat stroke – treat as per treatment guideline for seizure<br />
• Increasing symptoms merit more aggressive cooling measures. With mild symptoms of heat<br />
exhaustion, movement to cooler environment and fanning may suffice.<br />
• Conditions that may lead to or worsen hyperthermia include:<br />
o Psychiatric Disorders<br />
o Heart Disease<br />
o Diabetes<br />
o Alcohol<br />
o Medications<br />
o Fever<br />
o Fatigue<br />
o Obesity<br />
o Pre-existent dehydration<br />
o Extremes of age (Elderly and pediatric)<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G9–GENERAL HYPOTHERMIA<br />
MODERATE HYPOTHERMIA<br />
• Conscious and shivering but lethargic, skin pale and cold<br />
SEVERE HYPOTHERMIA<br />
• Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations<br />
• Severe hypothermia patients may appear dead. When in doubt, begin resuscitation.<br />
BLS: Low flow unless ALOC / respiratory distress / shock.<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
Use warm humidified oxygen if available<br />
SPINAL<br />
PRECAUTIONS<br />
WARMING MEASURES<br />
CARDIAC MONITOR<br />
CONSIDER<br />
For patients with possible trauma or submersion<br />
Gently move to sheltered area (warm environment)<br />
Minimize physical exertion or movement of the patient<br />
Cut away wet clothing and cover patient with warm, dry sheets or blankets<br />
EARLY TRANSPORT<br />
Do not delay transport if patient unconscious<br />
IV TKO<br />
BLOOD GLUCOSE Check and treat if indicated<br />
CONSIDER<br />
NALOXONE<br />
CONSIDER<br />
If respiratory rate less than 12 and narcotic overdose suspected<br />
Only if unable to ventilate using BVM<br />
ADVANCED AIRWAY<br />
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12)
Key Treatment Considerations<br />
• Avoidance of excess stimuli important in severe hypothermia as the heart is sensitive and<br />
interventions may induce arrhythmias. Needed interventions should be done as gently as possible.<br />
o Check for pulselessness for 30-45 seconds to avoid unnecessary chest compressions<br />
o Defer ACLS medications until patient warmed<br />
o If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, shock X 1 and defer<br />
further shocks<br />
• Patients with prolonged hypoglycemia often become hypothermic – blood glucose check essential<br />
• Patients with narcotic overdose may develop hypothermia
G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC)<br />
• Patients of all ages expressing verbal or behavioral indicators of pain shall have an appropriate<br />
assessment and management of pain<br />
• Morphine should be given in sufficient amount to manage pain but not necessarily to eliminate it<br />
CONSIDER<br />
OXYGEN<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO 2 of at least 94%<br />
IV TKO<br />
• Assess and document the intensity of the pain using the visual analog<br />
ASSESS PAIN<br />
•<br />
scale<br />
Reassess and document the intensity of the pain after any intervention<br />
that could affect pain intensity<br />
• Psychological measures and BLS measures, including cold packs,<br />
repositioning, splinting, elevation, and/or traction splints, are important<br />
PAIN RELIEF MEASURES considerations for patients with pain<br />
• If pain cannot be managed using above measures, consider MORPHINE<br />
SULFATE, especially in patients reporting pain levels of 5 or greater<br />
CONSIDER<br />
MORPHINE SULFATE IV<br />
CONSIDER<br />
MORPHINE SULFATE IM<br />
See contraindications and cautions below:<br />
For pain relief:<br />
• Adult – 2-20 mg IV, titrated in 2-5 mg increments to pain relief<br />
Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart<br />
If no IV access:<br />
• Adult - 5-10 mg IM<br />
Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart
• Closed head injury<br />
• Altered level of consciousness<br />
• Headache<br />
• Respiratory failure or worsening<br />
respiratory status<br />
• Childbirth or suspected active<br />
labor<br />
<strong>Contra</strong>indications and Cautions for Morphine Sulfate<br />
<strong>Contra</strong>indications for Morphine:<br />
• Hypotension<br />
o Adults - Systolic BP less than 90<br />
o Pediatric - Hypotension or impaired perfusion<br />
(e.g. capillary refill > 2 seconds)<br />
Infants 1mo-1yr systolic BP < 60 mmHg<br />
Toddler 1-4 yrs systolic BP < 75 mmHg<br />
School age 5-13 yrs systolic BP < 85<br />
mmHg<br />
Adolescent >13 yrs systolic BP < 90 mmHg<br />
Cautions for Morphine:<br />
• Use with caution in patients with suspected drug or alcohol ingestion or with suspected hypovolemia<br />
• Older patients may be more sensitive to morphine – consider 1-2 mg increments IV initially<br />
• Patients with Inferior MI (STEMI with ST elevation in II, III, aVF) may develop hypotension with<br />
morphine<br />
o Give 1-2 mg increments IV and administer fluid bolus when indicated<br />
Key Treatment Considerations<br />
• Have Naloxone available to reverse respiratory depression should it occur<br />
• Preferred route of administration for Morphine Sulfate is IV<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G11–GENERAL POISONING - OVERDOSE<br />
• If possible, determine substance, amount ingested, time of ingestion. Bring in container or label.<br />
• Be careful not to contaminate yourself and others<br />
DECONTAMINATION<br />
OXYGEN<br />
CARDIAC MONITOR<br />
Remove contaminated clothing, brush off powders, wash off liquids<br />
Irrigate eyes if affected<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO of at least 94%. Be prepared to support ventilation.<br />
2<br />
CONSIDER IV TKO if unstable patient or suspected serious ingestion<br />
Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2),<br />
Seizures (G14), Shock/Hypovolemia (A10, P8)<br />
TRICYCLIC ANTIDEPRESSANT OVERDOSE<br />
Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes<br />
and associated ventricular arrhythmias are generally signs of a life-threatening ingestion.<br />
For adults only: For life-threatening hemodynamically significant<br />
SODIUM BICARBONATE<br />
dysrhythmias, 1 mEq/kg slow IV or IO
ORGANOPHOSPHATE POISONING<br />
Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness, small/<br />
pinpoint pupils, muscle twitching, and/or seizures may occur<br />
ATROPINE<br />
CALCIUM CHLORIDE<br />
CONSIDER<br />
MORPHINE SULFATE IV<br />
CONSIDER<br />
MORPHINE SULFATE IM<br />
For adults only: 1-2 mg IV<br />
• Repeat every 3-5 minutes as necessary until relief of symptoms<br />
• Large doses of Atropine may be required<br />
HYDROFLUORIC ACID EXPOSURE<br />
For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10%<br />
solution)<br />
For adults only: In the absence of hypotension, significant other trauma or<br />
altered level of consciousness:<br />
2-20 mg IV titrated in 2-5 mg increments to pain relief<br />
For adults only: If no IV access, 5-10 mg IM<br />
Key Treatment Considerations<br />
• Few overdoses have specific antidotes. Supportive care is the mainstay of treatment.<br />
Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients<br />
• Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium<br />
Channel Blocker overdose)<br />
• Poison Control Center can offer information but cannot provide medical direction to EMS
G12–GENERAL RESPIRATORY DEPRESSION OR APNEA<br />
Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest<br />
BVM VENTILATION Assist ventilation or provide ventilation if no spontaneous respirations<br />
OXYGEN<br />
BLS: High flow initially ALS: Titrate to sPO of at least 94%<br />
2<br />
Be prepared to support ventilations as needed<br />
ETCO2<br />
MONITORING<br />
CARDIAC MONITOR<br />
In borderline cases, non-invasive ETCO2 monitoring (when available) may be valuable<br />
in detection of hypoventilation and can help follow respiratory trend before and after<br />
treatment. ETCO2 monitoring is not reliable in patients with hypotension or poor perfusion.<br />
NALOXONE<br />
INTRANASAL OR IM<br />
•<br />
•<br />
<br />
Adult not in shock: 2 mg IN (intranasal) if narcotic overdose suspected<br />
Adult not in shock but unsuitable for IN (copious secretions): 1-2 mg IM<br />
Pediatric – 0.1 mg/kg IM - maximum dose 2 mg<br />
CONSIDER IV TKO if intravenous treatment indicated<br />
If patient in shock, if IN or IM routes ineffective (within 3 minutes), or if IV access already<br />
NALOXONE IV<br />
available for another reason:<br />
• Adult – 1-2 mg IV<br />
Pediatric – 0.1 mg/kg IV – maximum dose 2 mg<br />
REPEAT NALOXONE IV or IM if no response and narcotic overdose suspected – maximum dose 10 mg<br />
CONSIDER TITRATION<br />
OF DILUTED<br />
NALOXONE IV<br />
ADVANCED<br />
AIRWAY<br />
Consider for patients with chronic narcotic use for terminal disease or chronic pain: Dilute<br />
1:10 with normal saline and administer in 0.1 mg (1 ml) increments – titrate to increased<br />
respiratory rate<br />
Consider when indicated - only if naloxone ineffective and BVM ventilation not adequate<br />
Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13)
Key Treatment Considerations<br />
SAFETY WARNING!<br />
Naloxone will cause acute withdrawal symptoms<br />
in patients who are habituated users of narcotics<br />
(whether prescribed or from abuse)<br />
• Use of diluted Naloxone IV and titration with small increments may help<br />
decrease adverse effects of naloxone in patients who have chronic narcotic<br />
usage for terminal disease or pain relief<br />
• Naloxone treatment should only be given to patients with respiratory<br />
depression (rate less than 12)<br />
• Patients who are maintaining adequate respirations with decreased level of<br />
consciousness do not generally require Naloxone for management<br />
• Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small<br />
number of patients (1-2%)<br />
• Older patients are at higher risk for cardiovascular complications<br />
• Be prepared for patient agitation or combativeness after naloxone reversal of narcotic overdose<br />
In patients without hypotension or poor perfusion, ETCO2 readings below 45 generally do not require<br />
treatment with naloxone for respiratory depression. ETCO2 should be used to help monitor respiratory<br />
trend.<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G13–GENERAL RESPIRATORY DISTRESS<br />
• Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema<br />
• Rales may be present in pneumonia, pulmonary edema, and many other conditions<br />
INITIAL THERAPY<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
CARDIAC MONITOR<br />
If respiratory rate greater than 25, accessory muscle use, pulse ox less than<br />
CONSIDER CPAP<br />
94%<br />
CONSIDER IV TKO. Do not delay transport for vascular access if in extremis.<br />
ASTHMA<br />
ALBUTEROL Adult and Pediatric – 5 mg in 6 ml NS via nebulizer. Repeat as needed.<br />
CONSIDER EPINEPHRINE<br />
1:1000 SC<br />
(SUBCUTANEOUSLY)<br />
EPINEPHRINE 1:1000<br />
IM<br />
For use in asthma only: Use only if respiratory status deteriorating despite<br />
repeat treatment with Albuterol and transport time more than 10 minutes<br />
Do not use in patients with history of coronary artery disease or hypertension<br />
• Adult - 0.3 mg SC<br />
Pediatric - 0.01 mg/kg SC - max dose 0.3 mg<br />
Never give Epinephrine 1:1000 intravenously!<br />
If respiratory arrest from asthma or bronchospasm:<br />
• Adult - 0.3 mg IM<br />
Pediatric - 0.01 mg/kg IM - max dose 0.3 mg<br />
COPD EXACERBATION<br />
ALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed.
NITROGLYCERIN<br />
CONSIDER<br />
MORPHINE<br />
SULFATE<br />
SUSPECTED PULMONARY EDEMA (ADULTS ONLY)<br />
0.4 mg sublingual if systolic BP between 90 and 149<br />
0.8 mg sublingual if systolic BP 150 or greater<br />
Repeat every 5 minutes until symptoms improve<br />
Maximum dose 4.8 mg (12 - 0.4 mg doses)<br />
Discontinue if hypotension develops<br />
Caution: Do not administer if patient has taken erectile dysfunction medications<br />
Viagra, Levitra, Staxyn or Stendra within prior 24 hours or Cialis within 36 hours<br />
2-5 mg IV in 1-2 mg increments for relief of anxiety. Do not administer if BP less<br />
than 90, if patient has altered mental status or decreased respiratory effort.<br />
Related guidelines – Chest pain / Suspected ACS (A2), Shock (A10)<br />
Key Treatment Considerations<br />
• CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of<br />
respiration will need assistance with BVM.<br />
• Patients with potential respiratory failure should be transported emergently<br />
• Patients requiring advanced airway management in these situations are best handled in the hospital<br />
setting and CPAP may be a valuable “bridge” in care to potentially delay need for emergent intubation<br />
• IV access should not delay transport<br />
• For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If<br />
blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg.<br />
• Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no other<br />
contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs)<br />
• Consider cardiac etiology for diabetic patients with respiratory distress<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G14–GENERAL SEIZURE / STATUS EPILEPTICUS<br />
• Tonic-clonic movements followed by a period of unconsciousness (post-ictal period)<br />
• A continuous or recurrent seizure is defined as seizure activity greater than 10 minutes or<br />
recurrent seizures without patient regaining consciousness<br />
BLS: High flow initially<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
PROTECT PATIENT Do not forcibly restrain but protect from injuring self<br />
CARDIAC MONITOR<br />
CONSIDER IV TKO<br />
BLOOD GLUCOSE Check and treat if indicated<br />
For continuous or recurrent seizures:<br />
CONSIDER<br />
• Adult – initial dose 1 mg IV - titrate in 1-2 mg increments – max. dose 5 mg<br />
MIDAZOLAM IV<br />
Pediatric – titrate in up to 1 mg IV increments – up to 0.1 mg/kg<br />
If IV access unavailable:<br />
CONSIDER<br />
• Adult – 0.1 mg/kg IM - maximum dose 5 mg<br />
MIDAZOLAM IM<br />
Pediatric – 0.1 mg/kg IM - maximum dose 5 mg<br />
MONITOR PATIENT <strong>Care</strong>fully observe vital signs, respiratory status – support ventilations as needed<br />
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12)<br />
SAFETY WARNING:<br />
• Use caution when treating with Midazolam in pediatric patients previously<br />
treated by family or caretaker with rectal diazepam (Valium, Diastat) as a<br />
higher incidence of respiratory depression may occur<br />
• Wait five (5) minutes after last rectal dose to determine effect and need for<br />
further treatment. Consider using reduced dosage of Midazolam.
Key Treatment Considerations<br />
• Most seizures are self-limiting and do not require prehospital medication<br />
• Seizures may appear frightening to observers. Provide reassurance to parents/family.<br />
• Consider spinal immobilization if history of fall or trauma<br />
• Early administration of midazolam IM is preferable to IV route in smaller children and in other patients<br />
with potential difficult intravenous access<br />
• Febrile seizures in children are generally self-limiting<br />
• For febrile patients, remove or loosen clothing, remove blankets to address cooling measures<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G15–GENERAL STROKE<br />
• Sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit - may be<br />
associated with headache<br />
• Determination of time of onset of symptoms is the most crucial historical information needed<br />
• If patient awoke with symptoms, time patient last seen normal is the time that should be noted<br />
OXYGEN<br />
CARDIAC MONITOR<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO of at least 94%. Be prepared to support ventilation.<br />
2<br />
STROKE SCALE Note findings of stroke scale and time of onset of symptoms<br />
TRANSPORT Minimize scene time<br />
BLOOD GLUCOSE Check and treat if indicated<br />
IV TKO<br />
CONSIDER<br />
FLUID BOLUS<br />
CONTACT STROKE<br />
CENTER OR<br />
RECEIVING HOSPITAL<br />
ASSURE FAMILY/<br />
GUARDIAN<br />
COMMUNICATION<br />
250-500 ml if hypotensive or poor perfusion – reassess<br />
Stroke Alert is indicated only when Cincinnati Stroke Scale (CSS) findings are<br />
abnormal and onset (time last seen normal) is less than 4 hours from time of patient<br />
contact. Report time last seen normal (clock time), ETA, physical exam and findings<br />
of CSS using SBAR format.<br />
If family member/patient guardian available, assure their availability by either<br />
transporting them in ambulance, telling them to go immediately to the hospital or<br />
obtain phone number to allow physician to contact them<br />
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12),<br />
Seizure (G14)
CINCINNATI STROKE SCALE<br />
If any one of the three tests are abnormal and is a new finding, the Stroke Scale is abnormal and<br />
may indicate an acute stroke<br />
Finding Patient Activity Interpretation<br />
Facial Droop<br />
Arm<br />
Weakness<br />
Speech<br />
Abnormality<br />
Ask patient to smile and<br />
show teeth or grimace<br />
Ask patient to close both<br />
eyes and extend both<br />
arms out straight for 10<br />
seconds<br />
Have the patient say the<br />
words, “The sky is blue in<br />
Cincinnati”<br />
Normal: Symmetrical smile or face<br />
Abnormal: Asymmetry (one side droops or does not move)<br />
Normal: Both arms move symmetrically or do not move<br />
Abnormal: One arm drifts down or arms move<br />
asymmetrically<br />
Testing with patient holding palms upward is most sensitive<br />
way to check. Patients with arm weakness will tend to<br />
pronate (turn from palms up to sideways or palms down).<br />
Normal: The correct words are used and no slurring of<br />
words is noted<br />
Abnormal: If the patient slurs words, uses the wrong<br />
words, or is unable to speak (aphasia)
G16–GENERAL TRAUMA - GENERAL<br />
SPINAL<br />
IMMOBILIZATION<br />
OXYGEN<br />
As indicated<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
ALS: Titrate to sPO 2 of at least 94%<br />
EARLY TRANSPORT Limit scene time to less than 10 minutes when possible. Load and go if high risk.<br />
WOUND / GENERAL Place splints, cold packs, dressings and pressure on bleeding sites as needed<br />
CARE<br />
Keep patient warm – minimize exposure after assessment<br />
CONSIDER NEEDLE<br />
THORACOSTOMY<br />
Evaluate for and treat tension pneumothorax if indicated<br />
IV TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS.<br />
CONSIDER<br />
FLUID BOLUS<br />
Fluid resuscitation appropriate in adults if:<br />
• Head injury and hypotension (BP < 90 or unable to detect peripheral pulses)<br />
• No head injury but markedly hypotensive and unable to converse due to<br />
shock<br />
Administer 250-500 ml NS, recheck vitals. Titrate to presence of peripheral<br />
pulses.<br />
In pediatric patients with signs of poor perfusion or shock:<br />
Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2<br />
BLOOD GLUCOSE Test if GCS less than 15. See Altered Level of Consciousness (G2).<br />
CARDIAC MONITOR
INDICATIONS AND<br />
PRECAUTIONS FOR<br />
MORPHINE USE<br />
MORPHINE<br />
SULFATE IV<br />
MORPHINE<br />
SULFATE IM<br />
Morphine may be used for relief of extremity pain in the absence of head or torso<br />
trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in<br />
geriatric patients or in patients with drug or alcohol intoxication.<br />
See precautions above<br />
• Adult – 2-20 mg IV in 2-5 mg increments. Titrate to pain relief and systolic<br />
BP greater than 100.<br />
Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart<br />
See precautions above<br />
When IV access not available (non-critical patients only):<br />
• Adult – 5-10 mg IM<br />
Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart<br />
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12)<br />
Key Treatment Considerations<br />
• ALS procedures in the field (IV or advanced airway) do not improve outcome in critical trauma patients<br />
o IV starts should be done en route on these patients<br />
o Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers<br />
• Repeated IV attempts in non-critical pediatric patients should be avoided<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
G16–GENERAL TRAUMA – HEAD INJURY<br />
AIRWAY<br />
CONTROL<br />
VENTILATION<br />
CONTROL<br />
HEMORRHAGE<br />
TREAT<br />
HYPOTENSION<br />
PATIENT<br />
POSITION<br />
CONSIDER<br />
ONDANSETRON<br />
• Basic airway management is preferred unless unable to manage with BLS maneuvers.<br />
Utilize jaw thrust technique to open airway.<br />
• Intubation in head injury patients is best addressed at the hospital or with RSI<br />
(aeromedical capability)<br />
• King Airway should be used only in arrest unless no other method to ventilate<br />
• Avoid hyperventilation if BVM used or patient with advanced airway.<br />
• Support respiratory rate to 10-12 per minute if slow.<br />
• Monitor patient with pulse oximetry and end-tidal CO2. Ideal ETCO2 is 35 mm Hg –<br />
may be unreliable if multiple system trauma or poor perfusion.<br />
• In patients with a dilated pupil on one side or decerebrate/decorticate posturing<br />
indicating impending brainstem herniation, modest hyperventilation (increase in rate of<br />
2-4 per minute) is appropriate (keep ETCO2 30 or above)<br />
Scalp hemorrhage can be life threatening. Treat with direct pressure and pressure<br />
dressing.<br />
In adult patients, in the setting of hypotension (systolic BP 90 or less or absence of<br />
peripheral pulses), administer NS 250-500 ml. Repeat if necessary.<br />
In pediatric patients with signs of poor perfusion or shock:<br />
Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2.<br />
Elevate head of backboard 30 degrees unless contraindicated<br />
Position patient on side if needed for vomiting / airway protection<br />
• Adults - for vomiting/nausea, 4 mg IV/IM. May repeat every 10 minutes to a total dose<br />
of 12 mg.<br />
Pediatric – Limited to patients 4 years of age or older – 4 mg IV/IM. For patients<br />
40 kg and greater only, may repeat every 10 minutes to a total dose of 12 mg
G16–GENERAL TRAUMA - EXTREMITY<br />
consider<br />
TOURNIQUET<br />
If vigorous hemorrhage not controlled with elevation and direct pressure on wound.<br />
May be used in pediatric patients. May be appropriate for hemorrhage control in<br />
multi-casualty situations.<br />
DISLOCATION If dislocation suspected or noted, splint in position found<br />
For partial amputations, splint in anatomic location and elevate extremity<br />
If complete amputation, place amputated part in a dry container or bag. Seal or<br />
AMPUTATIONS<br />
tie off bag and place in second container or bag. DO NOT place amputated part<br />
directly on ice or in water. Elevated extremity and dress with dry gauze.<br />
PAIN RELIEF Consider Morphine Sulfate as directed in G16 Trauma - General Guideline<br />
CRUSH INJURY SYNDROME<br />
• Caused by muscle crush injury and cell death. Most patients have an extensive area of<br />
involvement such as a large muscle mass in a lower extremity and/or pelvis.<br />
• May develop after 1 hour in severe crush, but usually requires at least 4 hours of compression<br />
• Hypovolemia and hyperkalemia may occur, particularly in extended entrapments<br />
• Hyperkalemia should be suspected if ECG monitor reveals peaked ‘T’ waves, absent ‘P’ waves or<br />
widened QRS complexes<br />
FLUID BOLUS 20 ml/kg NS prior to release of compression<br />
ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer<br />
IF ECG CHANGES CALCIUM CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after<br />
SUGGEST<br />
administration of calcium chloride to avoid precipitation with sodium bicarbonate.<br />
HYPERKALEMIA: SODIUM BICARBONATE - 1 mEq/kg IV. Additionally, consider 1 mEq/kg added to<br />
IV 1L NS - use second IV line as other medications may not be compatible
G17–GENERAL VOMITING AND SEVERE NAUSEA<br />
Vomiting or nausea may be due to viral illness (gastroenteritis) or other medical conditions<br />
including acute coronary syndrome, stroke, head injury, or toxic ingestion. It may be associated<br />
with a number of painful abdominal conditions, and may also occur as a result of treatment of pain<br />
with morphine.<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
CONSIDER OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
POSITION PATIENT Position patient to avoid aspiration<br />
NON-INVASIVE<br />
MEASURES<br />
CONSIDER IV TKO<br />
CONSIDER FLUID BOLUS<br />
Fresh air, oxygen, and removal of noxious odors may lessen nausea<br />
Consider if patient has prolonged history of vomiting or poor intake, if vital<br />
signs or exam suggest volume depletion (rapid pulse, low blood pressure, dry<br />
mucous membranes, poor skin turgor, or capillary refill greater than 2 seconds)<br />
• Adult – 250-500 ml. Recheck vitals – may repeat X 1<br />
Pediatric – 20 ml/kg. Recheck vitals – may repeat X 1.
CONSIDER<br />
ONDANSETRON<br />
For severe nausea or persistent vomiting:<br />
• Adult – 4 mg IV, IM, or po (oral disintegrating tablet - ODT). May repeat<br />
every 10 minutes to a total of 12 mg.<br />
Pediatric – limited to patients 4 years of age or older – 4 mg IV, IM, or<br />
po (ODT). For patients 40 kg and greater only, may repeat every 10<br />
minutes to a total of 12 mg<br />
NOTE: Administer IV dosage over 1 minute. Ondansetron is contraindicated<br />
if patient has a history of hypersensitivity to other similar drugs (Dolasetron –<br />
(Anzemet), granisetron (Kytril), or Palonosetron (Aloxi)<br />
Related guidelines: Shock/Hypovolemia (A10), Pain Management (Non-Traumatic) (G10)<br />
Key Treatment Considerations<br />
Rapid administration of ondansetron has been associated with increased incidence of side effects – most<br />
notably syncope. Ondansetron must be administered intravenously over 1 minute.<br />
Rare side effects of ondansetron include headache, dizziness, tachycardia, sedation, hypotension, or<br />
syncope. Rarely QT prolongation has been seen (with higher doses and rapid administration).<br />
Ondansetron can be used in pregnancy and with breast-feeding mothers<br />
May be co-administered with MORPHINE SULFATE when used for pain relief<br />
Oral disintegrating tablets should be handled with care as moisture may cause premature breakdown of<br />
tablets before administration<br />
Oral disintegrating tablets can be placed on tongue and do not need to be chewed. Medication will dissolve<br />
and be swallowed with saliva.<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
P1 — Pediatric Patient <strong>Care</strong> / ALTE<br />
P2 — Cardiac Arrest – Initial <strong>Care</strong> and CPR<br />
P3 — Neonatal Resuscitation<br />
P4 — Ventricular Fibrillation / Ventricular Tachycardia<br />
P5 — PEA / Asystole<br />
P6 — Symptomatic Bradycardia<br />
P7 — Tachycardia<br />
P8 — Shock<br />
Pediatric<br />
Treatment<br />
Guidelines
P1–PEDIATRIC PEDIATRIC PATIENT CARE<br />
Pediatric patient is defined as age 14 or less. Neonate is 0-1 month.<br />
These basic treatment concepts should be considered in all pediatric patients<br />
SCENE SAFETY<br />
BSI Use universal blood and body fluid precautions at all times<br />
SYSTEMATIC<br />
ASSESSMENT<br />
DETERMINE<br />
PRIMARY<br />
IMPRESSION<br />
BASE CONTACT<br />
TRANSPORT<br />
• Management and support of ABCs are a priority<br />
• Identify pre-arrest states<br />
• Assure open and adequate airway<br />
• Place in position of comfort unless condition mandates other position<br />
• Consider spinal immobilization if history or possibility of traumatic injury exists<br />
• Assess environment to consider possibility of intentional injury or maltreatment<br />
• Apply appropriate field treatment guidelines<br />
• Explain procedures to family and patient as appropriate<br />
• Provide appropriate family support on scene<br />
• Contact base hospital if any questions arise concerning treatment or if additional<br />
medication beyond dosages listed in treatment guidelines is considered<br />
• Use SBAR to communicate with base<br />
• Minimize scene time in pre-arrest patient, critical trauma, shock or respiratory failure<br />
• Transport patient medications or current list of patient medications to the hospital<br />
• Give report to receiving facility using SBAR<br />
• At a minimum, vital signs and level of consciousness should be re-assessed every<br />
15 minutes and should be assessed after every medication administration or<br />
MONITORING<br />
following any major change in the patient’s condition<br />
• For critical patients, more frequent vital signs should be obtained when appropriate<br />
DOCUMENT Document patient assessment and care per policy
Key Treatment Considerations – Apparent Life-Threatening Event (ALTE)<br />
An Apparent Life-Threatening Event (ALTE) Is an event that is frightening to the observer (may think<br />
the infant has died) and involves some combination of apnea, color change, marked change in muscle<br />
tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with<br />
symptoms described under 2 years of age may be considered an ALTE.<br />
Most patients have a normal physical exam when assessed by responding personnel. Approximately half<br />
of the cases have no known cause, but the remainder of cases have a significant underlying cause such as<br />
infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS.<br />
Because of the high incidence of problems and the normal assessment usually seen, there is potential for<br />
significant problems if the child’s symptoms are not seriously addressed.<br />
OBTAIN<br />
DETAILED<br />
HISTORY<br />
ASSESSMENT<br />
Obtain history of event, including duration and severity, whether patient awake or<br />
asleep at time of episode, and what resuscitative measures were done by the parent or<br />
caretaker<br />
Obtain past medical history, including history of chronic diseases, seizure activity, current<br />
or recent infections, gastroesophageal reflux, recent trauma, medication history<br />
Obtain history with regard to mixing of formula if applicable<br />
Perform comprehensive exam, including general appearance, skin color, interaction with<br />
environment, or evidence of trauma<br />
TREATMENT Treat identifiable cause if appropriate<br />
TRANSPORT<br />
If treatment/transport is refused by parent or guardian, contact base hospital to consult<br />
prior to leaving patient. Document refusal of care.
P2–PEDIATRIC CARDIAC ARREST – INITIAL CARE AND CPR<br />
ESTABLISH<br />
TEAM LEADER<br />
• First agency on scene assumes leadership role<br />
• Leadership role can be transferred as additional personnel arrive<br />
CONFIRM ARREST • Unresponsive, no breathing or agonal respirations, no pulse<br />
COMPRESSIONS<br />
AED OR MONITOR/<br />
DEFIBRILLATOR<br />
BASIC AIRWAY<br />
MANAGEMENT<br />
AND<br />
VENTILATION<br />
• Begin compressions at a rate of at least 100 per minute<br />
• Compress chest approximately 1/3 of AP diameter of chest:<br />
o In children (age 1-8) - around 2 inches<br />
o In infants (under age 1) – around 1 ½ inches<br />
• Allow full chest recoil (lift heel of hand)<br />
• Change compressors every 2 minutes<br />
• Minimize any interruptions in compressions. If necessary to interrupt, limit to 10<br />
seconds or less.<br />
• Do not stop compressions while defibrillator is charging<br />
• Resume compressions immediately after any shock<br />
• Apply pads while compressions in progress<br />
• Determine rhythm and shock, if indicated<br />
• Follow specific treatment guideline based on rhythm<br />
• Open airway – For 2-person CPR:<br />
o Provide 2 breaths:30 compressions for children over age 8<br />
o Provide 2 breaths:15 compressions for infants > 1 month & children to age 8<br />
• Avoid Excessive Ventilation<br />
• Ventilations should last one second each, enough to cause visible chest rise<br />
• Use 2-person BLS Airway management (one holding mask and one squeezing bag)
MEDICATIONS AND<br />
DEFIBRILLATION<br />
ADVANCED AIRWAY<br />
MANAGEMENT<br />
AND<br />
END-TIDAL CO2<br />
MONITORING<br />
• Use length-based tape to determine weight<br />
• If child is obese and length-based tape used to determine weight, use next<br />
highest color to determine appropriate equipment and drug dosing<br />
• See Pediatric Drug Chart for medication dose and defibrillation energy levels<br />
For patients 40 kg or greater only:<br />
• Placement of advanced airway is not a priority during the first 5 minutes of<br />
resuscitation unless no ventilation is occurring with basic maneuvers.<br />
• Placement of endotracheal tube or King Airway should not interrupt<br />
compressions for a period of more than 10 seconds<br />
• For endotracheal intubation, position and visualize airway prior to cessation of<br />
CPR for tube passage.<br />
• Confirm tube placement and provide ongoing monitoring using end-tidal<br />
carbon dioxide monitoring<br />
BLOOD GLUCOSE Treat if indicated. Glucose may be rapidly depleted in pediatric arrest.<br />
PREVENT<br />
HYPOTHERMIA<br />
Move to warm environment and avoid unnecessary exposure<br />
• Pediatric arrest victims are at risk for hypothermia due to their increased<br />
body surface area, exposure and can be exacerbated by rapid administration<br />
of IV/IO fluids<br />
TRANSPORT Consider rapid transport to definitive care
P3–PEDIATRIC NEONATAL CARE AND RESUSCITATION<br />
WARM PATIENT Provide warmth – move to warm environment immediately<br />
CLEAR AIRWAY If needed, position airway or suction. Rapidly suction secretions from mouth or nares.<br />
DRY AND<br />
STIMULATE<br />
EVALUATE<br />
RESPIRATIONS,<br />
HEART RATE<br />
AND COLOR<br />
REASSESS /<br />
BEGIN CPR<br />
IF INDICATED<br />
Dry child thoroughly, stimulate, reposition if needed, place hat on infant<br />
• If breathing, heart rate above 100 and pink, observational care only<br />
• If breathing, heart rate above 100 and central cyanosis – OXYGEN 100% by mask<br />
– reassess in 30 seconds<br />
o If cyanosis resolves (skin pink) – observational care only<br />
o If persistent central cyanosis after oxygen, initiate bag mask ventilation at<br />
rate of 40-60/minute<br />
• If apneic, gasping, or heart rate below 100 – initiate bag mask ventilation at a rate<br />
of 40-60/minute with OXYGEN 100% – reassess in 30 seconds<br />
o If heart rate increases to above 100 and patient ventilating adequately,<br />
discontinue bag mask ventilation and continue close observation<br />
o If heart rate persists below 100 continue bag mask ventilation<br />
If heart rate less than 60 despite ventilation with oxygen for 30 seconds, begin CPR<br />
(3:1 ratio – 90 compressions and 30 ventilations/minute). Reassess in 30 seconds.
If heart rate remains less than 60 despite adequate ventilation and chest compressions:<br />
IV/IO<br />
TKO. 100-500 ml NS bag (use care to avoid inadvertent fluid administration). Do not<br />
delay transport for IV or IO access.<br />
EPINEPHRINE<br />
1:10,000, 0.01 mg/kg IV or IO. Repeat every 3-5 minutes if heart rate remains below<br />
60.<br />
CONSIDER FLUID<br />
BOLUS<br />
10 ml/kg NS IV or IO. May repeat once if needed.<br />
CONSIDER<br />
NALOXONE<br />
0.1 mg/kg IV or IO if depressed respiratory status despite efforts. Avoid use if longterm<br />
use of opioids during pregnancy known or suspected.<br />
Key Treatment Considerations<br />
• For uncomplicated deliveries, treatment priorities are to warm, dry, and stimulate the infant<br />
• Anticipate complex resuscitation if not term gestation, amniotic fluid not clear, if newborn is not<br />
breathing or crying or if newborn does not have good muscle tone<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
P4–PEDIATRIC<br />
VENTRICULAR FIBRILLATION<br />
PULSELESS VENTRICULAR TACHYCARDIA<br />
INITIAL CARE See Cardiac Arrest - Initial <strong>Care</strong> and CPR (P3)<br />
DEFIBRILLATION<br />
2-4 joules/kg<br />
• AED can be used if patient over 1 year and pediatric electrodes available<br />
(age 1-8) or if adult electrodes can be applied without touching each other<br />
• Use infant paddles and manual defibrillator up to 1 year of age or 10 kg<br />
CPR For 2 minutes or 5 cycles between rhythm check<br />
BVM VENTILATION<br />
For patients 40 kg and over, defer advanced airway unless BLS airway<br />
inadequate<br />
IO or IV TKO. Should not delay defibrillation or interrupt CPR.<br />
DEFIBRILLATION 4 joules/kg<br />
EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes - See Pediatric Drug Chart<br />
DEFIBRILLATION<br />
4 joules/kg. Higher energy levels may be considered – not to exceed 10 joules/kg<br />
or the adult maximum.<br />
AMIODARONE<br />
TRANSPORT<br />
5 mg/kg IV or IO (see Pediatric Drug Chart for dosage)<br />
If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated
Key Treatment Considerations<br />
• Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their<br />
performance takes precedence over advanced airway management and administration of medications.<br />
• To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after<br />
shock administered (no pulse or rhythm check)<br />
• Avoid excessive ventilation with BLS airway management, which may cause gastric distention and<br />
limit chest expansion. Provide breaths over 1 second, with movement of chest wall as guide for<br />
volume needed.<br />
• If advanced airway placed (40 kg and over), perform CPR continuously without pauses for ventilation<br />
• Confirm placement of advanced airway with end-tidal carbon dioxide measurement. Continuous<br />
monitoring with ETCO2 is mandatory – if values less than 10 mm Hg seen, assess quality of<br />
compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earlist indicator of return<br />
of circulation.<br />
• Prepare drugs before rhythm check and administer during CPR<br />
• Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock)<br />
• Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in<br />
adolescents).<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for medication<br />
dose and defibrillation energy levels.
P5–PEDIATRIC PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE<br />
INITIAL CARE See Cardiac Arrest – Initial <strong>Care</strong> and CPR (P3)<br />
BVM VENTILATION<br />
IV OR IO TKO<br />
Defer advanced airway (for patients 40 kg and over) unless BLS airway<br />
inadequate<br />
EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes<br />
Consider treatable causes – treat if applicable:<br />
CONSIDER<br />
FLUID BOLUS<br />
20 ml/kg NS – may repeat X 2 for hypovolemia<br />
VENTILATION Ensure adequate ventilation (8-10 breaths per minute) for hypoxia<br />
CONSIDER<br />
WARMING MEASURES<br />
CONSIDER NEEDLE<br />
THORACOSTOMY<br />
BASE CONTACT<br />
For hypothermia<br />
For tension pneumothorax<br />
To determine treatment for other identified potentially treatable causes -<br />
Hydrogen Ion (Acidosis), Hyperkalemia, Toxins<br />
Safety Warning: Unlike adult resuscitation, atropine is not used<br />
in treatment of asystole or PEA in the pediatric patient<br />
If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated
Key Treatment Considerations<br />
• Uninterrupted CPR is key to successful resuscitation. This takes precedence over advanced airway<br />
management and administration of medications.<br />
• If advanced airway placed in patients 40 kg and over, perform CPR continuously without pauses for<br />
ventilation<br />
• Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one<br />
second.<br />
• Prepare drugs before rhythm check and administer during CPR<br />
• Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in<br />
adolescents).<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
P6–PEDIATRIC SYMPTOMATIC BRADYCARDIA<br />
• 90% of pediatric bradycardias are related to respiratory depression and respond to support of<br />
ventilation<br />
• Only unstable, severe bradycardia causing cardiorespiratory compromise will require further treatment<br />
• Signs of severe cardiorespiratory compromise are poor perfusion, delayed capillary refill, hypotension,<br />
respiratory difficulty, altered level of consciousness<br />
OXYGEN<br />
CARDIAC<br />
MONITOR<br />
BLS: High flow initially<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
IV OR IO TKO. Use IO only if patient unstable and requires medication. Use 100-500 ml NS bag.<br />
CONSIDER CPR<br />
If heart rate remains less than 60 with poor perfusion despite oxygenation and ventilation,<br />
perform CPR<br />
EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO. Repeat every 3-5 minutes.<br />
CONSIDER<br />
ATROPINE<br />
SAFETY WARNING:<br />
Atropine should be considered only<br />
after adequate oxygenation/ventilation has been assured<br />
0.02 mg/kg IV, IO (0.1 mg minimum dose)<br />
Maximum single dose 0.5 mg<br />
If continued heart rate less than 60, repeat 0.02 mg/kg IV or IO<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
P7–PEDIATRIC TACHYCARDIA<br />
Sinus tachycardia is by far the most common pediatric rhythm disturbance<br />
UNSTABLE SINUS TACHYCARDIA (narrow QRS less than or equal to 0.09)<br />
• ‘P’ waves present/normal, variable R-R interval with constant P-R interval<br />
• Unstable sinus tachycardia is usually associated with shock and may be pre-arrest<br />
UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less or equal to 0.09)<br />
• ‘P’ waves absent/abnormal, heart rate not variable<br />
• History generally vague, non-specific and/or history of abrupt heart rate changes<br />
• Infants’ rate usually greater than 220 bpm, Children (ages 1 – 8) rate usually greater than 180<br />
bpm<br />
UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA - Wide QRS (greater than 0.09 sec)<br />
• In some cases, wide QRS can represent supraventricular rhythm<br />
INITIAL THERAPY – ALL TACHYCARDIA RHYTHMS<br />
OXYGEN<br />
BLS: Low flow unless ALOC / respiratory distress / shock.<br />
ALS: Titrate to sPO of at least 94% Be prepared to support ventilation.<br />
2<br />
Determine stability:<br />
CHECK PULSE<br />
AND PERFUSION<br />
•<br />
•<br />
Stable - Normal perfusion: Palpable pulses, normal LOC, normal capillary<br />
refill, and normal BP for age<br />
Unstable - Poor perfusion: ALOC, abnormal pulses, delayed cap. refill,<br />
difficult/unable to palpate BP. If unstable, transport early and treat as below.<br />
CARDIAC MONITOR Run strip to evaluate QRS Duration<br />
IV OR IO TKO. Use 100-500 ml bag NS<br />
FLUID BOLUS 20 ml/kg NS if hypovolemia suspected. May repeat X 1
UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (narrow QRS less or equal to 0.09)<br />
VAGAL MANEUVERS Consider if will not result in treatment delays. ICE PACK to face of infant/child.<br />
BASE CONTACT For all treatments listed below:<br />
0.1 mg/kg rapid IV push followed by 10-20 ml NS flush (maximum dose 6 mg)<br />
ADENOSINE<br />
If not converted, 0.2 mg/kg rapid IV push followed by 10-20 ml NS flush<br />
(maximum dose 12 mg)<br />
SYNCHRONIZED<br />
CARDIOVERSION<br />
CONSIDER SEDATION<br />
If unable to obtain IV access, prepare for Synchronized Cardioversion. Do NOT<br />
delay cardioversion to obtain IV or IO access or sedation.<br />
Consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum<br />
increments (maximum dose 5 mg)<br />
SYNCHRONIZED<br />
CARDIOVERSION<br />
0.5-1 joule/kg. If not effective, repeat at 2 joules/kg.<br />
UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA ( Wide QRS greater than 0.09 sec)<br />
BASE CONTACT For all treatments listed below:<br />
SYNCHRONIZED Prepare for CARDIOVERSION while attempting IV/IO access, but do not<br />
CARDIOVERION unduly delay care for IV access or medications<br />
CONSIDER<br />
If IV/IO access has been obtained, consider MIDAZOLAM 0.1 mg/kg IV or IO,<br />
SEDATION<br />
titrated in 1 mg maximum increments (maximum dose 5 mg)<br />
SYNCHRONIZED<br />
CARDIOVERSION<br />
0.5-1 joule/kg. If not effective, repeat at 2 joules/kg.<br />
• Early transport appropriate in unstable patients.<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
P8–PEDIATRIC SHOCK<br />
• Altered level of consciousness; cool, clammy, mottled skin; capillary refill greater than 2<br />
seconds; tachycardia; blood pressure less than 70 systolic<br />
• Listless infant or child with poor skin turgor, dry mucous membranes, history of fever may<br />
indicate sepsis, meningitis<br />
OXYGEN BLS/ALS: High flow. Be prepared to support ventilations as needed.<br />
PREVENT<br />
HYPOTHERMIA<br />
Move to warm environment. Avoid unnecessary exposure.<br />
CARDIAC MONITOR<br />
EARLY TRANSPORT CODE 3<br />
IV OR IO<br />
FLUID BOLUS 20 ml/kg NS – may repeat X 2<br />
BLOOD GLUCOSE Check and treat if indicated<br />
Related guidelines: Altered level of consciousness (G2), Tachycardia (P7)
Key Treatment Considerations<br />
Successful pediatric resuscitation relies on early identification of the pre-arrest state<br />
• Normal blood pressure, delayed capillary refill, diminished peripheral pulses and tachycardia indicates<br />
compensated shock in children<br />
• Hypotension and delayed capillary refill > 4 seconds indicates impending circulatory failure<br />
• Systolic blood pressure in children may not drop until the patient is 25-30% volume depleted. This may<br />
occur through dehydration, blood loss or an increase in vascular capacity (e.g. anaphylaxis).<br />
• Decompensated shock (Hypotension with > 5 seconds capillary refill) may present as PEA in children<br />
• Sinus tachycardia is the most common cardiac rhythm encountered<br />
• Supraventricular tachycardia should be suspected if heart rate greater than 180 in children (ages 1-8)<br />
or greater than 220 in infants<br />
• Hypoglycemia may be found in pediatric shock, especially in infants<br />
• Pediatric shock victims are at risk for hypothermia due to their increased body surface area, exposure<br />
and rapid administration of IV/IO fluids<br />
Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
IFT1 — Interfacility Transfer of STEMI Patients<br />
IFT2 — Interfacility Transfer of Intubated Patients<br />
IFT3 — Interfacility Transfer of Stroke Patients<br />
Interfacility<br />
Transfer<br />
Guidelines
IFT 1–TRANSFER INTERFACILITY TRANSFER OF STEMI PATIENTS<br />
Patients with ST-elevation Myocardial Infarction (STEMI) needing interventional cardiac care require<br />
timely transfer. A scene time of 10 minutes or less at the sending facility is ideal.<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
MONITOR IV Maintain TKO or other existing flow rate<br />
PROMPT TRANSPORT Transfer for definitive care is the priority in STEMI patients<br />
CONSIDER<br />
MORPHINE SULFATE<br />
2-20 mg in 2-4 mg increments for pain relief if BP greater than 90. Patients with<br />
STEMI often do not get complete relief with morphine treatment.<br />
Do not administer Morphine Sulfate if Right Ventricular MI is suspected<br />
Key Treatment Considerations<br />
Treatment during interfacility transfer varies from field approach to chest pain/ACS:<br />
• Confirmatory ECG for STEMI has been done by hospital and does not need repeat prior to transfer or<br />
en route to accepting facility<br />
• Nitroglycerin treatment is not required and generally ineffective in patients with confirmed STEMI<br />
• Aspirin or other anti-platelet treatment if indicated should be administered by sending hospital prior to<br />
patient departure<br />
Patients generally will be directed directly to catheterization laboratory<br />
Outcome in STEMI patients directly related to timeliness of intervention to relieve coronary artery<br />
blockage. Minimizing time delay in transfer is essential.
IFT 2–TRANSFER<br />
INTERFACILITY TRANSFER OF<br />
INTUBATED PATIENTS<br />
Patients requiring specialty care (most commonly trauma or neurosurgical care) may be transferred<br />
with an established endotracheal tube. Sedation may be required if patient agitation present because<br />
of risk of inadvertent extubation. NOTE: This treatment guideline pertains to sedation of intubated<br />
patients during interfacility transport only (not for patients with field response who are intubated).<br />
OXYGEN 100%<br />
VENTILATION As needed if patient with apnea or inadequate respiratory rate or effort<br />
CARDIAC MONITOR<br />
END-TIDAL CO 2<br />
MONITORING<br />
PULSE OXIMETRY<br />
CONSIDER<br />
MIDAZOLAM<br />
MONITOR PATIENT<br />
Continuous monitoring with waveform capnography is required and must be<br />
established prior to departure from sending facility. Maintain end-tidal CO 2 between<br />
35 and 45. ETCO 2 may not be reliable in patients with shock or significant lung injury.<br />
Maintain at least a minimum respiratory rate of 8-10 breaths per minute.<br />
For sedation in agitated or uncooperative patient: 2-5 mg IV in up to 2 mg<br />
increments. Repeat dosing with base contact only.<br />
Follow vital signs and ETCO closely. If Midazolam administered, anticipate potential<br />
2<br />
respiratory depression.<br />
Key Treatment Considerations<br />
• Some patients may need paralysis and require additional nursing or physician staff to administer these<br />
medications<br />
• If inadvertent extubation occurs, manage with basic airway maneuvers unless ventilation cannot be<br />
adequately maintained
IFT 3–TRANSFER INTERFACILITY TRANSFER OF STROKE PATIENTS<br />
Patients with acute stroke that may not qualify for thrombolytic therapy or that may not respond to thrombolytic<br />
therapy, necessitating transfer for potential interventional care<br />
BLS: Low flow unless ALOC / respiratory distress / shock<br />
OXYGEN<br />
ALS: Titrate to sPO of at least 94%<br />
2<br />
CARDIAC MONITOR<br />
MONITOR VITAL<br />
SIGNS<br />
Monitor blood pressure and Glasgow coma scale at least every 15 minutes. Use pulse oximetry -<br />
consider non-invasive end-tidal carbon dioxide monitoring if any respiratory difficulty.<br />
MONITOR IV Maintain TKO or other existing flow rate<br />
PROMPT<br />
Transfer for definitive care is the priority in stroke patients. Minimizing time delay is essential.<br />
TRANSPORT<br />
Key Treatment Considerations<br />
• Stroke patients who are transferred may have already received thrombolytic therapy or may not have qualified for<br />
thrombolysis based on length of time from stroke onset or other medical contraindications<br />
• Ongoing administration of thrombolytic therapy requires additional qualified staff (nurse or physician) for transport<br />
• Thrombolytic therapy in stroke patients is associated with around a 6% incidence of symptomatic intracerebral hemorrhage,<br />
and around a 1% of serious hemorrhage elsewhere<br />
Close monitoring is important. Significant changes in patient vital signs/GCS during transport should be reported immediately to<br />
receiving facility staff as it may affect immediate treatment:<br />
• Hypotension may occur because of external or internal hemorrhage<br />
• Hypertension may be related to acute intracranial process or underlying disease<br />
• Respiratory depression or airway compromise may occur due to stroke or intracerebral hemorrhage<br />
• Decreasing level of consciousness may occur due to stroke or intracerebral hemorrhage<br />
Cardiac dysrhythmias may occur in stroke patients (bradycardia or tachyarrhythmia)<br />
Observe for external hemorrhage in patients with prior administration of thrombolytics. Place direct pressure if hemorrhage noted.<br />
Related guidelines: Shock/Hypovolemia (A10), Altered level of consciousness (G2), Respiratory Depression or apnea (G12)
Policy 9 — Destination Determination<br />
Policy 9 — Destination – 5150 and Obstetric<br />
Policy 9 — Burn Patient Destination<br />
Policy 10 — Declining Medical <strong>Care</strong> or Transport (AMA)<br />
Policy 13 — Trauma Base Call-In Criteria<br />
Policy 13 — Trauma Triage Criteria<br />
Policy 19 — Determination of Death<br />
Policy 20 — DNR and POLST Orders<br />
Policy 23 — Reporting Requirements - Abuse<br />
Policy 30 — Restraints<br />
Policy 33C — Helicopter Transport Criteria<br />
Policy 35 — Safely Surrendered Baby<br />
Policy 36 — Hazardous Materials – Exposure Management Principles<br />
Policy 39 — 911 Activation for Non-Emergency Transport Providers<br />
note: These are summaries of policies – full policies are available at the EMS website at: http://cchealth.org/ems/policies.php<br />
Policy<br />
Summaries
DESTINATION DETERMINATION – BASIC PROCEDURE<br />
• Field personnel shall assess a patient to determine if the patient is unstable or stable<br />
• Patient stability must be considered along with a number of additional factors in making<br />
destination and transport code decisions<br />
FACTORS TO<br />
CONSIDER<br />
UNSTABLE<br />
PATIENTS<br />
STABLE<br />
PATIENTS<br />
• Patient or family’s choice of receiving hospital and ETA to that facility<br />
• Recommendations from a physician familiar with the patient’s current condition<br />
• Patient’s regular source of hospitalization or health care<br />
• Ability of field personnel to provide field stabilization or emergency intervention<br />
• ETA to the closest basic emergency department<br />
• Traffic conditions<br />
• Hospitals with special resources<br />
• Hospital diversion status<br />
• Usually transported to the closest appropriate acute care hospital emergency<br />
department or specialized care centers if indicated<br />
• If the patient or family requests, or if other factors exist which indicate that another<br />
facility be considered, field personnel are to contact the base hospital and present<br />
their findings, including ETAs to both facilities. Base personnel will assess the<br />
benefits of each destination and may direct field personnel to a facility other than<br />
the closest.<br />
• Stable patients are transported to appropriate acute care hospitals within<br />
reasonable transport times based on patient’s/family preference<br />
• If a patient does not express a preference, the hospital where the patient normally<br />
receives health care or the closest ED is to be considered
PATIENTS ON<br />
5150 HOLDS<br />
OBSTETRIC<br />
PATIENTS<br />
DESTINATION DETERMINATION – 5150 / OBSTETRIC PATIENTS<br />
A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical<br />
emergency. Based upon the history and physical examination of the patient, field personnel<br />
shall determine whether the patient is stable or unstable.<br />
Stable patients on 5150 holds shall be transported to <strong>Contra</strong> <strong>Costa</strong> Regional Medical Center<br />
Unstable patients on 5150 holds shall be transported to the closest acute care hospital:<br />
• A patient with a current history of overdose of medications is to be considered unstable<br />
• A patient with history of ingestion of alcohol / illicit street drugs is considered unstable if:<br />
o Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or<br />
o Significantly abnormal vital signs; or<br />
o Any other history or physical findings that suggest instability (e.g. chest pain, shortness<br />
of breath, hypotension, diaphoresis)<br />
A patient is considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or<br />
more. Obstetric patients should be transported to hospitals with in-patient OB services in the<br />
following circumstances:<br />
• Patients in labor<br />
• Patients whose chief complaint appears to be related to the pregnancy, or who potentially<br />
have complications related to the pregnancy<br />
• Injured patients who do not meet trauma criteria or guidelines<br />
Obstetric patients with impending delivery or unstable conditions where imminent treatment<br />
appears necessary to preserve the mother’s life should be transported to the nearest basic<br />
emergency department<br />
Stable obstetric patients should be transported to the emergency department of choice if their<br />
complaints are clearly unrelated to pregnancy
GENERAL<br />
DESTINATION<br />
PRINCIPLES<br />
PATIENT<br />
SELECTION FOR<br />
INITIAL TRANSPORT<br />
TO BURN CENTER<br />
PROCEDURE FOR<br />
BURN CENTER<br />
DESTINATION<br />
BURN PATIENT DESTINATION<br />
• Burned patients with unmanageable airways should be transported to the<br />
closest basic ED<br />
• Patients with minor burns and moderate burns can be cared for at any acute<br />
care hospital<br />
• Adult and pediatric patients with burns and significant trauma should be<br />
transported to the closest appropriate trauma center<br />
The following patients may be appropriate for initial transport to a Burn Center:<br />
• Partial thickness (2nd degree) greater than 20% TBSA<br />
• Full thickness (3rd degree) greater than 10%<br />
• Chemical or high voltage electrical burns<br />
• Smoke inhalation with external burns<br />
• Contact Burn Center prior to transport to confirm bed availability<br />
• Consult base hospital if any questions regarding destination decision
DECLINING MEDICAL CARE OR TRANSPORT (AMA)<br />
All qualified persons are permitted to make decisions affecting care, including the ability to decline care<br />
Patient<br />
Competency<br />
Qualified<br />
Person<br />
Base Contact<br />
Requirements<br />
Any person encountered by EMS personnel who demonstrates any known or suspected illness or<br />
injury OR is involved in an event with significant mechanism that could cause illness or injury OR who<br />
requests care or evaluation<br />
The ability to understand and to demonstrate an understanding of the nature of the illness/injury and<br />
the consequence of declining medical care<br />
A competent person making decision for him/herself or another qualified by:<br />
• An adult patient defined as a person who is at least 18 years old;<br />
• A minor (under 18 years old) who qualifies based on one of the following conditions:<br />
o A legally married minor;<br />
o A minor on active duty with the armed forces;<br />
o A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault;<br />
o A minor, 12 years of age or older, seeking treatment of contact with an infectious,<br />
contagious or communicable disease or sexually transmitted disease;<br />
o A self-sufficient minor at least 15 years of age, living apart from parents and managing his/<br />
her own financial affairs;<br />
o An emancipated minor (must show proof); OR<br />
• The parent of a minor child or a legal representative of the patient (of any age). Spouses or<br />
relatives cannot consent to or decline care for the patient unless they are legally designated<br />
representatives.<br />
• When, in the field personnel’s opinion, patient’s decision to decline care poses a threat to his/her<br />
well being<br />
• If the patient’s competency status is unclear (neither competent nor clearly incompetent) and<br />
treatment or transport is felt to be appropriate<br />
• Any other situation in which, in the field personnel’s opinion, that base contact would be<br />
beneficial in resolving treatment or transport issues
BASE HOSPITAL<br />
DESTINATION<br />
DECISION<br />
REQUIRED PRIOR<br />
TO TRANSPORT<br />
PRECAUTION WITH<br />
ELDERLY PATIENTS<br />
ADDITIONAL<br />
CONSIDERATIONS:<br />
TRAUMA – BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA)<br />
• Evidence of high-energy dissipation or rapid deceleration which may<br />
include:<br />
o vehicle rollover with unrestrained occupant<br />
o intrusion of passenger space by 1 foot or greater<br />
o impact of 40 mph or greater (restrained)<br />
o persons requiring disentanglement from a vehicle<br />
• Patient struck by a vehicle with impact 20 mph or less<br />
• Persons ejected from a moving object (motorcycle, horse, etc.)<br />
• Significant blunt force to the head. Symptoms may include loss of<br />
consciousness, repetitive questioning, abnormal or combative behavior,<br />
vomiting, headache, or new onset of confusion<br />
• Significant blunt force to the neck, thorax (chest/back), abdomen or pelvis<br />
• Penetrating injury to extremities (above knee or elbow) without apparent fracture<br />
• Patients 60 years of age and older may sustain significant injuries<br />
with less forceful mechanisms, and may merit call-in for less significant<br />
mechanisms (e.g. ground level fall with new alteration of mental status)<br />
• Base contact should be made if a patient meets call-in criteria and it is<br />
believed trauma center services may be needed, even in the event that the<br />
trauma has occurred several hours prior to EMS response<br />
• If no significant symptoms or physical findings noted despite above<br />
mechanism(s), call-in not required and patient may be transported to<br />
hospital of choice or to closest facility
HIGH-RISK TRAUMA CRITERIA (Direct Trauma Center Transport)<br />
The following meet high-risk criteria and merit direct transport to the trauma center:<br />
PHYSIOLOGIC • BP < 90 in adults<br />
CRITERIA<br />
• GCS 13 or below if not pre-existing<br />
• Penetrating injury to head, neck, torso, groin, pelvis or buttocks<br />
• Fracture of femur<br />
ANATOMIC<br />
CRITERIA<br />
•<br />
•<br />
•<br />
Fracture of long bone(s) resulting from penetrating trauma<br />
Traumatic Paralysis<br />
Amputation above wrist or ankle<br />
• Major burns associated with trauma<br />
• Crushed, mangled, or degloved extremity<br />
• Motor vehicle crash with:<br />
o Extrication > 20 minutes<br />
o Fatalities in the same vehicle<br />
Note: In the absence of<br />
o Ejection<br />
significant symptoms or<br />
MECHANISM • Unrestrained motor vehicle crash with:<br />
physical findings with these<br />
CRITERIA<br />
o Head on mechanism > 40 mph<br />
mechanisms,<br />
o Extrication required<br />
call base hospital for<br />
• Fall 15 feet or greater<br />
destination determination<br />
• Auto vs. pedestrian/bicyclist thrown,<br />
run over, or struck with significant impact (>20 mph)<br />
COMBINED<br />
CRITERIA<br />
(COMBINED<br />
MECHANISM<br />
AND PHYSICAL<br />
FINDINGS)<br />
•<br />
•<br />
Motorcycle crash with:<br />
o Abdominal or chest tenderness<br />
o Observed loss of consciousness<br />
Unrestrained motor vehicle crash with abdominal tenderness<br />
Note: Patients with unmanageable airways or trauma arrest not meeting field determination criteria should be transported<br />
to the closest receiving facility.
OBVIOUS<br />
DEATH<br />
MEDICAL<br />
ARREST<br />
TRAUMATIC<br />
ARREST<br />
DETERMINATION OF DEATH<br />
Pulseless, non-breathing patients with any of the following:<br />
• Decapitation, Total incineration, Decomposition<br />
• Total destruction of the heart, lungs, or brain, or separation of these organs from the<br />
body<br />
• Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or<br />
poisoning. In patients with rigor mortis or post-mortem lividity:<br />
o Attempt to open airway, assess for breathing for at least 30 seconds; assess<br />
pulse for 15 seconds<br />
o Rigor, if present, should be noted in jaw and/or upper extremities<br />
o If any doubt exists, place cardiac monitor to document asystole in 2 leads for 1<br />
minute<br />
• Mass casualty situations<br />
Definition:<br />
Cardiac arrest with total absence of observers Aor<br />
witness information; or cardiac arrest in<br />
which witness information states arrest occurred greater than 15 minutes prior to arrival of<br />
prehospital personnel and no resuscitative measures have been done<br />
Procedure:<br />
• BLS personnel – Follow Public Safety defibrillation guideline<br />
• ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no<br />
heart tones/no carotid or femoral pulses), document asystole in 2 leads for 1 minute<br />
Definition: Blunt or penetrating traumatic arrest<br />
Procedure:<br />
• BLS personnel – Follow Public Safety defibrillation guideline<br />
• ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness<br />
(no heart tones/no carotid or femoral pulses), document asystole or wide-complex<br />
pulseless electrical activity (PEA) at rate of 40 or less
VALID DNR<br />
ORDERS<br />
COMPLYING WITH<br />
AN HONORED<br />
DNR ORDER<br />
COMPLYING WITH<br />
A POLST ORDER<br />
(NOT IN ARREST)<br />
NO VALID DNR<br />
ORDER PRESENT<br />
AND REQUEST<br />
MADE FOR NO<br />
RESUSCITATION<br />
DNR and POLST ORDERS<br />
• A California EMSA/CMA <strong>Prehospital</strong> DNR Form<br />
• A California/EMSA POLST form in which Section A (Do Not Attempt Resuscitation/<br />
DNR) has been chosen<br />
• An Advanced <strong>Health</strong> <strong>Care</strong> Directive (includes living will or Durable Power of<br />
Attorney for <strong>Health</strong> <strong>Care</strong>) presented by an agent of the patient empowered to<br />
make health care decisions for the patient<br />
• An EMS-approved standard DNR medallion/bracelet e.g. Medi-Alert<br />
• A DNR order in the medical record of a licensed healthcare facility (e.g. acute care<br />
hospital, skilled nursing facility, hospice or intermediate care facility) signed by a<br />
physician. Electronic physician orders are considered signed and will be honored.<br />
• A verbal DNR order given by the patient’s physician who is present at the scene<br />
• Verify identity of patient<br />
• Perform no life-saving measures<br />
• Cancel the responding ambulance<br />
• Verify identity of patient. Review section B.<br />
o If “Full Treatment” marked, patient receives full care<br />
o If “Limited Additional Interventions” or “Comfort Measures Only” is marked, no<br />
advanced airway should be done<br />
If the patient presents with advanced or terminal disease and incomplete forms or<br />
no forms are presented and an immediate family member, agent, or conservator<br />
requests no resuscitation, resuscitative measures may be withheld if there is complete<br />
agreement of family and providers on scene. Immediate family members include<br />
spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient No base<br />
contact is required. If any question of circumstances or disagreement of family or<br />
providers, proceed with resuscitation.
ABUSE REPORTING RESPONSIBILITIES<br />
EMS personnel are mandated reporters. Report when there is reason to suspect abuse, which may<br />
be of a physical, sexual, or financial nature, or may involve neglect or domestic violence toward a<br />
child, elder, or dependent adult.<br />
BASIC<br />
ACTIONS<br />
CHILD ABUSE<br />
REPORTING<br />
ELDER ABUSE<br />
REPORTING<br />
(LONG-TERM<br />
CARE FACILITY)<br />
Notify the appropriate law enforcement agency immediately if the scene is<br />
unsafe or it is suspected that a crime has been committed<br />
Make reasonable efforts to transport the patient to a receiving hospital for<br />
evaluation, and advise the receiving hospital staff of abuse/neglect suspicions<br />
Document observations and findings on the patient care report<br />
• Contact the appropriate reporting agency by telephoning immediately or as soon<br />
as reasonably possible to provide a verbal report<br />
• Call Children & Family <strong>Services</strong> Screening Unit: (all numbers are 24 hours/day)<br />
at 1-877-881-1116<br />
• Complete a Suspected Child Abuse Report Form within 2 working days (SS<br />
8572) (available <strong>online</strong> at http://www.ag.ca.gov/childabuse/pdf/ss_8572.pdf )<br />
If the alleged abuse has occurred in a long-term care facility:<br />
• Call Ombudsman <strong>Services</strong> of <strong>Contra</strong> <strong>Costa</strong> (925) 685-2070 to make a verbal<br />
report<br />
• 24-Hour Crisis Line: 1-800-231-4024<br />
• Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working<br />
days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/entres/<br />
forms/English/SOC341.pdf
ELDER ABUSE<br />
REPORTING –<br />
(ALL OTHER<br />
SITES)<br />
SEXUAL<br />
ASSAULT<br />
DOMESTIC<br />
VIOLENCE<br />
ABUSE REPORTING RESPONSIBILITIES (Continued)<br />
If the alleged abuse has occurred anywhere else (not at a long-term care<br />
facility):<br />
• Call Adult Protective <strong>Services</strong> (925) 646-2854 or 1-877-839-4347 to make a<br />
verbal report<br />
• Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working<br />
days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/entres/<br />
forms/English/SOC341.pdf<br />
Sexual assault shall be reported as above in situations involving elder, dependent<br />
adult, child, or domestic violence.<br />
It is recommended to transport patients who have been sexually assaulted to<br />
<strong>Contra</strong> <strong>Costa</strong> Regional Medical Center for evaluation and evidentiary exam;<br />
however, the patient may be transported to the receiving hospital of choice or if<br />
medically unstable to the most appropriate facility for medical care<br />
Discourage any activity that would compromise evidence collection prior to<br />
transport such as bathing, brushing teeth, brushing hair, urinating, defecating or<br />
changing clothes<br />
• Reporting responsibilities are fulfilled by notifying the local law enforcement<br />
agency, and by reporting suspicions and patient findings to receiving hospital<br />
staff (if transported)
RESTRAINT TYPES<br />
RESTRAINT<br />
ISSUES<br />
LAW<br />
ENFORCEMENT<br />
ROLE<br />
TRANSPORT<br />
ISSUES<br />
RESTRAINTS<br />
• Leather or soft restraints may be used during transport<br />
• Handcuffs may only be used during transport if law enforcement accompanies the<br />
patient in the ambulance. Patients may not be handcuffed to the gurney.<br />
• Chemical restraint requires a base hospital order<br />
• Patients shall be placed in Fowler’s or Semi-Fowler’s position<br />
• Patients shall not be restrained in hogtied or prone position<br />
• Method of restraint should allow for monitoring of vital signs and respiratory effort<br />
and should not restrict the patient or rescuer’s ability to protect the airway should<br />
vomiting occur<br />
• Restrained extremities should be monitored for circulation, motor and sensory<br />
function every 15 minutes<br />
• Law enforcement agencies are responsible for capture and/or restraint of<br />
assaultive or potentially assaultive patients<br />
• Law enforcement agencies retain responsibility for safe transport of patients under<br />
arrest or on 5150 holds<br />
• Patients under arrest or 5150 hold should undergo a weapons search by law<br />
enforcement personnel<br />
• Patients under arrest must be accompanied by law enforcement personnel<br />
• If an unrestrained patient becomes assaultive during transport, ambulance<br />
personnel shall request law enforcement assistance, and make reasonable efforts<br />
to calm and reassure the patient<br />
• If the crew believes their personal safety is at risk, they should not inhibit a patient’s<br />
attempt to leave the ambulance. Every effort should be made to release the patient<br />
into a safe environment. Ambulance personnel are to remain on scene until law<br />
enforcement arrives to take control of the situation.
TIME CRITERIA<br />
CLINICAL<br />
CRITERIA<br />
USE AND<br />
CANCELLATION<br />
HELICOPTER TRANSPORT CRITERIA<br />
USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET<br />
• Helicopter transport generally should be used only when it provides a time advantage.<br />
Helicopter field care and transport time (which includes on-scene time, flight time, and<br />
transport from helipad to the emergency department) is optimally 20-25 minutes in most<br />
cases.<br />
• Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter<br />
arrival<br />
• Exception: Patients with potential need for advanced airway intervention (GCS 8 or less,<br />
trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when<br />
time criteria not met<br />
• Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except<br />
for:<br />
o Stable patients with isolated extremity trauma<br />
o Patients with mechanism but no significant physical exam findings<br />
• Trauma patients who do not meet high-risk criteria but by evaluation of mechanism<br />
and physical exam findings, appear to have potential significant injuries that merit rapid<br />
transport<br />
• Patients with specialized needs available only at a remote facility such as burn victims/<br />
critical pediatric<br />
• Critically ill or injured patients whose conditions may be aggravated or endangered by<br />
ground transport (e.g. limited access via ground ambulance or unsafe roadway)<br />
The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not<br />
met, helicopter should be cancelled. Considerations for IC:<br />
• Patient need<br />
• Estimated ground transport time versus air response and transport<br />
• Proximity of a helispot or need for a helicopter/ambulance rendezvous site<br />
• ETA of the helicopter
BACKGROUND<br />
SITE<br />
REQUIREMENTS<br />
PROCEDURE<br />
SAFELY SURRENDERED BABY PROGRAM<br />
• California Law permits parents to voluntarily safely surrender their infant up to 72 hours<br />
old at fire stations (hospitals and many medical clinics are also authorized)<br />
• The law was created in an effort to reduce baby abandonments which lead to death in<br />
some circumstances<br />
• Parents have a 14-day “cooling off” period to reclaim the surrendered infant. The person<br />
surrendering the child has immunity from criminal liability for child endangerment if there<br />
is no abuse or neglect involved.<br />
• Self-training is available for personnel who potentially may manage a surrendered infant<br />
at cchealth.org/baby-safe<br />
• Each Safely Surrender Site (Fire Station) should have 2 Newborn Safe Surrender Kits<br />
on hand at all times. Replacement kits are available from <strong>Contra</strong> <strong>Costa</strong> County Public<br />
<strong>Health</strong> – Maternal and Child <strong>Health</strong> – (925) 313-6254.<br />
• Accept infant – even if more than 72 hours old<br />
• By law, the parent is under no obligation to provide information – no questions should be<br />
asked although parents may voluntarily provide information<br />
• Assess for medical needs and treat as indicated<br />
• Open Newborn Safely Surrender Kit, follow directions and complete documentation<br />
• Place confidential coded ankle bracelet on infant and record code on face of kit<br />
• Parent is handed two inner envelopes in kit which has matching code, survey forms, and<br />
information about their rights. Parent may leave at this point.<br />
• Notify dispatch and request code 2 ambulance to transport to nearest emergency<br />
department<br />
• The “Notes” section on face of Kit must be completed and the envelope must<br />
accompany the patient to the emergency department<br />
• PCR documentation must include bracelet code in narrative<br />
• If suspected abuse or neglect, contact law enforcement
HAZMAT<br />
RECOGNITION<br />
WHILE<br />
RESPONDING<br />
HAZMAT<br />
RECOGNITION<br />
WHILE ON<br />
SCENE<br />
HAZARDOUS MATERIALS – EXPOSURE MANAGEMENT PRINCIPLES<br />
If alerted to a known or suspected hazmat exposure prior to scene arrival:<br />
• Request from dispatch the location and safe route to staging area or IC<br />
• If no staging area, determine location and safe route to report to IC<br />
• Do not enter contaminated areas or approach contaminated patients until<br />
cleared to do so by Incident Commander or designee<br />
• Decontaminate patient - Appropriately trained personnel shall perform<br />
decontamination in a designated area<br />
• Obtain clearance from IC prior to transport<br />
• Obtain MSDS for chemical if available<br />
• After patient decontamination, provide care as indicated per treatment<br />
guidelines<br />
• Provide early alert to hospital – repeat decontamination may be needed<br />
If EMS personnel become aware that a patient in their care may have been<br />
contaminated by a unknown or suspected hazardous material:<br />
• EMS personnel should consider themselves contaminated<br />
• Minimize exposure by evacuating to an uphill/upwind safe location<br />
• If in cloud, travel crosswind until out of cloud<br />
• Notify fire/medical dispatch and IC of exposure<br />
• Request Hazardous Materials response team through Sheriff’s Dispatch<br />
• Request backup Fire / Transport as needed for affected EMS personnel and<br />
patients
HAZMAT<br />
RECOGNITION<br />
WHILE ON<br />
SCENE<br />
(CONTINUED)<br />
HAZMAT<br />
RECOGNITION<br />
WHILE<br />
TRANSPORTING<br />
GENERAL<br />
GUIDELINES<br />
FOR ALL<br />
SITUATIONS<br />
• Remain in safe area until Incident Commander arrives and provides further<br />
instructions<br />
• Prepare to be decontaminated<br />
• Decontaminate EMS personnel and patient(s) - Appropriately trained<br />
personnel shall perform decontamination in a designated area.<br />
If EMS personnel become aware while transporting that a patient may have been<br />
contaminated by a known or suspected hazardous material:<br />
• EMS personnel should consider themselves contaminated<br />
• Determine if safe to drive (e.g. rescuers with or without symptoms)<br />
• If not safe to drive, immediate decontamination is needed. Stop transport,<br />
notify Fire/Medical Dispatch and request CCHS HazMat response. Request<br />
Fire/Transport backup as needed. Protect from further exposure and prepare<br />
to be decontaminated.<br />
• If safe to drive (decontamination is not immediately indicated), proceed to<br />
hospital decontamination staging area. Alert hospital early of the HazMat<br />
situation. Request staging site if not known. Prepare to be decontaminated.<br />
• Provide prehospital medical care as soon as it is safe<br />
• All precautions should be taken to prevent contamination of hospital<br />
emergency department and personnel
9-1-1 ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS<br />
Criteria for upgrade to advanced life support (ALS) for non-emergency transport providers<br />
DEFINITIONS<br />
UNSTABLE<br />
PATIENTS<br />
• Unstable: A patient who has life- or limb-threatening condition requiring immediate and<br />
definitive care. An unstable patient may have respiratory distress, airway compromise,<br />
neurological changes from baseline, signs of actual or impending shock or may meet criteria<br />
for transport directly to a trauma center.<br />
• Non-emergency ambulance provider: An ambulance provider holding a valid <strong>Contra</strong> <strong>Costa</strong><br />
non-emergency ambulance permit<br />
• 9-1-1 ambulance provider: An ambulance provider holding a valid <strong>Contra</strong> <strong>Costa</strong> emergency<br />
ambulance permit and/or contracting with the County to provide advanced life support<br />
ambulance response to 9-1-1 requests<br />
• Code 3: Responding to a location and/or transporting to a receiving facility using red lights<br />
and sirens<br />
• A patient, determined to be unstable and/or needing Code 3 transportation to a hospital shall<br />
be transported by a 9-1-1 provider, whenever possible.<br />
• Non-emergency ambulance providers may transport an unstable patient to the closest/<br />
appropriate facility, if they can do so safely and the time from arrival on scene to arrival at the<br />
hospital is less than 10 minutes. In all other cases the non-emergency ambulance crew shall<br />
activate the 9-1-1 system and request an ALS response.<br />
• Any non-emergency ambulance provider transporting a patient that becomes unstable during<br />
transport should divert to the closest/appropriate ED per the Patient Destination Determination<br />
Policy (Policy #9). Receiving facilities should receive notification as soon as possible of the<br />
need for diversion, patient status and the ETA to that facility.<br />
• All transports by non-emergency ambulance providers of unstable patients, and/or transports<br />
requiring Code 3 transportation are considered an unusual occurrence. For each such<br />
occurrence an EMS Event report must be completed and submitted to the EMS Agency within<br />
24 hours of the call.
ON-VIEWS<br />
• In the event that a non-emergency ambulance provider arrives on the scene of a<br />
collision, illness or injury by coincidence, the crew shall provide appropriate care and<br />
immediately activate the 9-1-1 system
12-Lead ECG, STEMI, and Transmission<br />
BLS Airway Management<br />
Key Procedures<br />
Non-Invasive ETCO2 Monitoring<br />
Oxygen Therapy<br />
Oxygen Titration and Pulse Oximetry<br />
Pain Assessment and Management<br />
Pain Assessment Tools<br />
Pediatric Assessment<br />
Pediatric Vital Signs and GCS Scoring<br />
Pediatric Medication Administration<br />
Rule of 9s – Burn Surface Area<br />
Sepsis Screening<br />
Spinal Immobilization<br />
Vascular Access<br />
Ventricular Assist Devices (VAD)<br />
Procedures and<br />
Patient <strong>Care</strong><br />
Reference
12-LEAD ACQUISITION AND LEAD PLACEMENT<br />
Sternal<br />
angle<br />
Limb Lead Placement:<br />
Place limb leads on distal extremities if possible<br />
Confirm correct lead placement for each limb<br />
May be moved to proximal if needed (if motion artifact)<br />
Chest Lead Placement:<br />
To begin placement of chest leads, locate sternal angle<br />
(2nd ribs are adjacent) then count down to 4th interspace<br />
(below 4th rib)<br />
V1 – 4th intercostal space at the right sternal border<br />
V2 – 4th intercostal space at the left sternal border<br />
V4 – 5th intercostal space at left midclavicular line<br />
Note: Place V4 lead first to aid in correct placement of<br />
V3<br />
V3 – Directly between V2 and V4<br />
V5 – Level of V4 at left anterior axillary line<br />
V6 – Level of V4 at left mid-axillary line<br />
Note: <strong>Care</strong>ful skin preparation prior to lead placement<br />
(rub with gauze or abrasive, clean skin oils with alcohol)<br />
is critical to obtaining a high-quality ECG
LOCALIZING SITE OF INFARCT<br />
• Localization of an infarct pattern adds to the accuracy of ECG interpretation<br />
• A STEMI will have 1 mm or more ST-segment elevation in 2 or more contiguous leads (which means<br />
findings noted in the same anatomical location of the infarct)<br />
o Contiguous leads for inferior infarction include II, III, and aVF<br />
o Contiguous leads for anterior infarction include V1-V4 (V1-V2 elevation also called septal infarction)<br />
o Contiguous leads for lateral myocardial infarction include Leads I, aVL, V5, and V6<br />
o Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or<br />
inferolateral)<br />
I – LATERAL aVR<br />
II - INFERIOR aVL – LATERAL<br />
V1 – SEPTAL<br />
or ANTERIOR<br />
V2 – SEPTAL<br />
or ANTERIOR<br />
V4 – ANTERIOR<br />
(V4R – RVMI)<br />
V5 – LATERAL<br />
III – INFERIOR aVF - INFERIOR V3 – ANTERIOR V6 – LATERAL
STEMI<br />
RECOGNITION<br />
STEMI<br />
REPORT<br />
DESTINATION<br />
POLICY<br />
STEMI RECOGNITION AND DESTINATION<br />
• Patients who have ECGs of acceptable quality with the following messages are<br />
candidates for transport to STEMI Receiving Centers:<br />
o ***Acute MI*** (Zoll)<br />
o ***Acute MI Suspected*** (LIFEPAK 12)<br />
o ***Meets ST-Elevation MI Criteria*** (LIFEPAK15)<br />
• The 12-lead ECG should be inspected prior to initiation of a STEMI Alert – a steady<br />
baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation<br />
• Causes of artifact include patient motion or tremor, poor lead contact, or electrical<br />
interference<br />
• Good skin preparation is essential for optimal lead contact and clear 12-lead tracings<br />
• If artifact is noted the ECG should be repeated<br />
• Paced rhythms may cause false readings – the pacemaker spike is not always detected<br />
by the computer algorithm. Inform facility if patient has a pacemaker during report.<br />
If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon<br />
as possible following completion of the ECG<br />
Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC)<br />
• Patients shall be transported to the closest SRC unless they request another facility<br />
• A SRC that is not the closest facility is an acceptable destination if estimated additional<br />
transport time does not exceed 15 minutes<br />
• Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after<br />
arrest shall be transported to the closest SRC<br />
• Patients with unmanageable airway en route shall be transported to the closest available<br />
emergency department
STEMI REPORT<br />
• A patient with a computer interpretation of ***Acute MI*** (Zoll) or ***Acute MI Suspected*** (LP-12) or<br />
***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center<br />
• Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have<br />
significant baseline artifact or other deficit before initiating a STEMI Alert<br />
SITUATION<br />
BACKGROUND<br />
ASSESSMENT<br />
RX – RECAP<br />
• Identify the call as a “STEMI Alert”<br />
• Estimated time of arrival (ETA) in minutes<br />
• Patient age and gender<br />
• Report ECG computer interpretation has a STEMI message (as listed above)<br />
• Report if subsequent ECG findings are variable or if ECG quality not optimal (e.g., if no<br />
***Acute MI*** findings noted in tracings without significant artifact)<br />
• Verify that 12-lead ECG Transmission has been completed and received<br />
• Presenting chief complaint and symptoms<br />
• Pertinent past cardiac history<br />
• History of pacemaker (important – paced rhythms may give false ECG interpretations)<br />
• General assessment<br />
• Pertinent vitals (especially heart rate and BP) and physical exam<br />
• Cardiac rhythm<br />
• Pain level<br />
• <strong>Prehospital</strong> treatments given<br />
• Patient response to prehospital treatments
TRANSMISSION OF MONITOR DATA<br />
• 12-Lead ECG transmission is an enhancement to the STEMI system that allows facilities to interpret 12-lead data prior to<br />
patient arrival, appropriately prepare, and appropriately activate resources when indicated<br />
• Transmission of cardiac arrest monitor data and data related to treatment of dysrhythmias and patient intubations allows<br />
appropriate documentation and review of care provided in those situations<br />
12-Lead ECG Transmission<br />
12-LEAD<br />
TRANSMISSION<br />
IDENTIFIERS<br />
HOSPITAL<br />
NOTIFICATION<br />
REVIEW<br />
INDICATIONS<br />
FOR<br />
TRANSMISSION<br />
• All 12-Lead ECGs are to be transmitted<br />
• Any 12-Lead that indicates that the patient is having an STEMI should be transmitted to the STEMI receiving<br />
center where the patient is being transported<br />
• All other 12-Leads should be transmitted to the destination hospital site listed on the monitor<br />
At a minimum, 12-Lead ECG labeling should include initials of the first and last name of the patient Provider<br />
agencies may require additional labeling<br />
Once a STEMI 12-Lead has been transmitted to a STEMI receiving facility, that facility should be notified as soon as<br />
possible following the transmission of the ECG to verify receipt and to complete STEMI alert<br />
Not all hospitals have ability to review transmitted ECGs and some may filter out normal or non-acute appearing<br />
ECGs. Hard copies of ECGs also must be left at all receiving facilities.<br />
Transmission of Cardiac Arrest and Other Monitor Data<br />
• Cardiac arrests<br />
• Any calls that involve the treatment of a cardiac dysrhythmia (medication, cardioversion or pacing)<br />
• Any call involving monitoring of intubated patients<br />
• Any other call in which the paramedic believes data review may add to PCR documentation of events<br />
TRANSMISSION • Transmit these calls to the Arrest/Rhythm site listed on the monitor<br />
REVIEW<br />
• This data is transmitted to the provider agency and to EMS for review but does not go to hospitals for<br />
immediate access. Code summaries should be printed and left at receiving facilities.<br />
Note: Optimally, a single monitor should be used to gather data, particularly with regard to cardiac arrest or continuous monitoring of<br />
intubated patients
GOALS<br />
VENTILATION<br />
RATES AND<br />
DELIVERY<br />
PREFERRED<br />
MANEUVERS<br />
BLS AIRWAY MANAGEMENT<br />
The goal of airway management is to ensure adequate ventilation and oxygenation.<br />
Initial airway management should always begin with BLS Maneuvers<br />
Avoid excessive ventilation. In non-arrest patients, ventilation rates:<br />
Adults – 10 / minute<br />
Children – 20 / minute<br />
Infants – 30 / minute<br />
Deliver ventilations over one second to produce visible chest rise and to avoid<br />
distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary<br />
based on patient size.<br />
Two-person technique is the preferred method to ventilate patients using bag-valve<br />
mask device<br />
Maneuvers – Use “JAWS”<br />
J—Jaw thrust maneuvers to open airway<br />
A—Airway - Use oral or nasal airway<br />
W—Work together - Ventilation using a bag-valve mask should include two<br />
rescuers – one to hold mask and other to deliver ventilations<br />
S—Slow and small ventilations to produce visible chest rise
AIRWAY<br />
POSITIONING<br />
Position the patient to optimize airway opening and facilitate ventilations (see below)<br />
• Use the sniffing position with head extended (A) and neck flexed forward (B)<br />
unless suspected spinal injury<br />
• Position with head/shoulders elevated – anterior ear should be at the same<br />
horizontal level as the sternal notch (C). This is especially advantageous in<br />
larger or morbidly obese patients.<br />
A<br />
C
KEY PROCEDURES<br />
Skill Indication / Comment <strong>Contra</strong>indication<br />
12-LEAD ECG<br />
Autopulse<br />
(SRVFPD)<br />
Blood<br />
Glucose<br />
Testing<br />
• Chest pain or suspected Acute Coronary<br />
Syndrome (ACS)<br />
• Atypical ACS or anginal equivalents:<br />
o Symptoms include shortness of breath,<br />
diaphoresis, syncope, dizziness, weakness,<br />
and altered level of consciousness<br />
o Elderly patients, females and diabetics are<br />
more likely to present atypically<br />
• Arrhythmias (both pre- and post-conversion)<br />
• Suspected cardiogenic shock<br />
• Cardiac arrest after return of spontaneous<br />
circulation<br />
• Cardiac Arrest in Adults<br />
• Altered level of consciousness<br />
• Patients with signs and symptoms of<br />
hypoglycemia (may include diaphoresis,<br />
weakness, hunger, shakiness, anxiety)<br />
• Uncooperative patient<br />
• Any condition in which<br />
delay to obtain ECG would<br />
compromise immediately<br />
needed care (e.g. arrhythmia<br />
requiring immediate shock)<br />
• Pediatric patients<br />
• Trauma patients<br />
• Patients too small or large for<br />
the compression band<br />
• Patients not meeting any<br />
indication
KEY PROCEDURES<br />
Skill Indication / Comment <strong>Contra</strong>indication<br />
Continuous<br />
Positive<br />
Airway<br />
Pressure<br />
(CPAP)<br />
Endotracheal<br />
Intubation<br />
Endotracheal<br />
Tube<br />
Introducer<br />
(Bougie)<br />
Patient has 2 or more findings:<br />
• RR >25<br />
• Pulse ox
External<br />
Cardiac<br />
Pacing<br />
Helmet<br />
Removal<br />
KEY PROCEDURES<br />
Skill Indication / Comment <strong>Contra</strong>indication<br />
Impedance<br />
Threshold<br />
Device (ITD) -<br />
ResQPOD<br />
(SRVFPD)<br />
Symptomatic bradycardia<br />
Note: Use careful titration with midazolam or<br />
morphine if required for relief of discomfort<br />
Helmet should be removed if:<br />
• Interferes with airway management or spinal<br />
immobilization<br />
• Improper fit, allowing head to move within helmet<br />
• Patient in cardiac arrest<br />
Face mask of sports helmets can be removed to<br />
facilitate easy airway access. If helmet removed,<br />
shoulder pads (if worn) must also be removed to<br />
maintain neutral spinal alignment.<br />
• Patients ≥ 9 years of age in cardiac arrest<br />
o Remove if patient resumes spontaneous<br />
breathing or regains perfusing pulse<br />
Note: If secretions encountered, clear device by<br />
removing and shaking<br />
• Cardiac arrest<br />
• Hypothermia<br />
• Pediatric Patients<br />
• Patient airway and spinal<br />
immobilization can be addressed<br />
without helmet removal<br />
• Age below 9 years<br />
• Perfusing pulse or spontaneously<br />
breathing<br />
• History of traumatic cardiac arrest<br />
due to blunt chest trauma<br />
• Flail chest
KEY PROCEDURES<br />
Skill Indication / Comment <strong>Contra</strong>indication<br />
Intranasal<br />
Naloxone<br />
King Airway<br />
LUCAS Chest<br />
Compression<br />
System<br />
• Patient with altered mental status,<br />
respiratory rate less than 12 and<br />
suspected opiate overdose<br />
Note: May be less effective in patients with<br />
prior nasal mucosal damage<br />
• Cardiac arrest<br />
• Inability to ventilate non-arrest patient<br />
(with BLS airway maneuvers) in a setting<br />
in which endotracheal intubation is not<br />
successful or unable to be done<br />
Patients with medical cardiac arrest who<br />
properly fit device.<br />
• Shock<br />
• Copious nasal secretions or bleeding<br />
• Patients with established vascular access<br />
• Presence of gag reflex<br />
• Caustic ingestion<br />
• Known esophageal disease (e.g. cancer, varices,<br />
stricture)<br />
• Laryngectomy with stoma (place ET tube in stoma)<br />
• Height less than 4 feet<br />
• Traumatic arrest<br />
• Pregnant Patients<br />
• Improper fit of device<br />
o Too small – suction cup pad does not touch<br />
chest when lowered as far as possible<br />
o Too large – support legs of LUCAS cannot be<br />
locked to back plate without compressing patient
KEY PROCEDURES<br />
Skill Indication / Comment <strong>Contra</strong>indication<br />
Needle<br />
Thoracostomy<br />
Oral Glucose<br />
Stomal<br />
Intubation<br />
Signs and symptoms of tension pneumothorax:<br />
• Altered level of consciousness<br />
• Decreased BP<br />
• Increased pulse and respirations<br />
• Absent breath sounds, hyperresonance to<br />
percussion on affected side<br />
• Jugular venous distention<br />
• Difficulty ventilating<br />
• Tracheal shift<br />
• Altered level of consciousness with known<br />
history of diabetes. Patient is conscious and<br />
should be able to sit in an upright position.<br />
• Administer up to 30 grams in the patient’s<br />
mouth. Optimally the patient will self-administer.<br />
Patients requiring intubation who have<br />
mature stoma and do not have a replacement<br />
tracheostomy tube available<br />
Note: Pass tube until cuff is just past stoma. If<br />
inserted further, mainstem bronchus intubation may<br />
occur as carina is only around 10 cm from stoma.<br />
Any condition without signs and symptoms of<br />
tension pneumothorax<br />
• Unconscious patient or unable to sit<br />
upright<br />
• If patient has difficulty swallowing,<br />
discontinue procedure and assure open<br />
airway<br />
Patients without mature stoma
KEY PROCEDURES<br />
Skill Indication / Comment <strong>Contra</strong>indication<br />
Tourniquet<br />
(Combat<br />
Application<br />
Tourniquet)<br />
Tracheostomy<br />
Tube<br />
Replacement<br />
• External hemorrhage from extremity that cannot<br />
be controlled with application of dressings with<br />
direct pressure<br />
• May be appropriate for use for hemorrhage<br />
control in multi-casualty settings<br />
• Dislodged tracheostomy tube (decannulation)<br />
• Tracheostomy tube obstruction not resolved by<br />
suction<br />
• Hemorrhage that can be controlled with<br />
pressure or dressings<br />
• Recent tracheostomy surgery (less than<br />
1 month)<br />
• Inadequately sized tract or stoma for<br />
insertion of new tube (use endotracheal<br />
tube instead)
Non-Invasive<br />
ETCO2<br />
Monitoring<br />
Indications<br />
For ETCO2<br />
Monitoring<br />
ETCO2<br />
Findings<br />
NON-INVASIVE MONITORING OF END-TIDAL CO2<br />
• In patients without shock (normal perfusion), use of non-invasive end-tidal carbon dioxide measurement<br />
(ETCO 2 ) can be valuable in monitoring respiratory rate and ventilation<br />
• ETCO 2 measurements are an earlier indicator of respiratory depression than pulse oximetry<br />
• Patients at risk for inadequate ventilation may include:<br />
o Patients with borderline respiratory rates (8-12) from overdose or other cause (may help<br />
determine if naloxone appropriate)<br />
o Patients who have received medications such as morphine or midazolam that may depress<br />
respiratory rate.<br />
o Patients with chronic lung disease and chronic hypoxia - many patients have elevated<br />
ETCO 2 levels to begin with and rapidly increasing levels may indicate that a patient has<br />
decreased respirations due to oxygen therapy (loss of hypoxic drive)<br />
• ETCO 2 readings may be unreliable if there is shock or poor perfusion<br />
• Normal ETCO 2 levels range from 32-36, but this may vary based on the patient’s underlying<br />
respiratory and metabolic status<br />
• ETCO 2 levels that rise from a normal baseline to above 40 generally indicate hypoventilation is<br />
occurring<br />
• Patient stimulation, use of BVM, or use of naloxone may be appropriate based on the situation
Oxygen Safety<br />
Initial<br />
Indications for<br />
Oxygen<br />
BLS Oxygen<br />
Administration<br />
Oxygen<br />
Delivery<br />
OXYGEN THERAPY<br />
• Oxygen has the potential to be harmful to patients – the general goal is to have normal oxygen levels (normoxemia)<br />
– high levels are not better than normal levels. When pulse oximetry can be used, an sPO 2 of 94%<br />
is considered adequate.<br />
• Conditions in which high levels may be dangerous include stroke, patients who have return of circulation<br />
following cardiac arrest, and patients with severe chronic lung disease<br />
Supplemental oxygen is indicated in the following conditions:<br />
• Altered Level of Consciousness (e.g. overdose, seizure, stroke)<br />
• Cardiac Arrest<br />
• Chest Pain or other suspected cardiac problem (rapid or irregular pulse)<br />
• Obstetric complication (e.g. breech, prolapsed cord, bleeding or pain)<br />
• Respiratory Distress / Respiratory Depression or Apnea<br />
• Shock<br />
• Smoke or other chemical Inhalation<br />
• Suspected carbon monoxide exposure<br />
• Trauma (major)<br />
Follow specific treatment guidelines where applicable<br />
In general, patients in distress should receive high-flow oxygen initially<br />
• Chest pain and stroke patients without respiratory distress or shock should receive low-flow oxygen<br />
Low flow – Use nasal cannula with 4 L/min initial flow<br />
High-flow – Non-rebreather mask with 15 L/min flow<br />
Supplement with BVM if patient is apneic or has shallow respirations
Pulse<br />
Oximetry<br />
Pulse<br />
Oximetry<br />
Pitfalls<br />
ALS Oxygen<br />
Titration<br />
OXYGEN TITRATION AND PULSE OXIMETRY MONITORING<br />
• Utilize pulse oximetry in all patients with oxygen therapy or suspected hypoxia<br />
• Pulse oximetry is a tool to measure oxygenation, but must be combined with other assessments<br />
and skills to determine best patient care<br />
• Pulse oximetry readings can be misleading with poor perfusion (shock) or cold extremities,<br />
hypothermia, anemia or in carbon monoxide poisoning.<br />
• Readings may be difficult to obtain or unreliable during with excessive patient movement<br />
(e.g.seizures) or if nail polish is present.<br />
• High flow oxygen should be maintained in patients with shock and in those with severe respiratory<br />
distress or profound hypoxia<br />
• In most conditions, titration of oxygen should occur to assure an sPO 2 of at least 94%<br />
• Titration may involve decreasing the oxygen flow for either nasal cannula or non-rebreather<br />
masks, or switching from high to low flow devices<br />
• Stable patients without distress who have sPO 2 readings of 94% or greater without therapy do<br />
not need supplemental oxygen<br />
• Some patients with chronic lung problems will not be able to attain an sPO 2 of 94% and in fact<br />
may be at baseline with readings of 90% or less<br />
o The patient’s level of distress is an important finding in these cases –patients may be without<br />
distress at lower baseline levels and do not require high-flow oxygen
PAIN ASSESSMENT AND MANAGEMENT<br />
Relief of pain and suffering is an important component of quality EMS field care. Pain assessment is the<br />
5 th vital sign and should be performed on each patient using an age appropriate pain scale. Pain<br />
is a subjective experience for the patient and should be treated following the appropriate pain treatment<br />
guideline.<br />
Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts<br />
should be made to alleviate pain using both pharmacologic (e.g, Morphine, Nitroglycerin for cardiac cases)<br />
and non-pharmacologic (e.g., splinting, immobilization) measures.<br />
Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5<br />
minutes after every medication administration<br />
Assess pain using the same pain scale before and after pain administration and document<br />
Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved.<br />
Administer medication cautiously and monitor patient.<br />
Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can<br />
alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional<br />
narcotic administration.
FACES Pain<br />
Rating Scale<br />
(Ages 3 to adult)<br />
0-10 Numeric<br />
Pain Rating Scale<br />
(Ages > 9 yo)<br />
Pain Assessment<br />
in the Very Young,<br />
Non-Verbal Infant<br />
and Child<br />
PAIN ASSESSMENT TOOLS<br />
See pain scale and English/Spanish chart on back cover of field manual<br />
• Point to each face using the words to describe the pain intensity<br />
• Ask the patient to choose the face that best describes how they are feeling. A<br />
person does not have to be crying to have the worst pain.<br />
Explain scale (0 means no pain and 10 is the most severe pain they have ever<br />
had). Ask patients what number on a scale of 0-10 they would give as the level of<br />
pain currently.<br />
Pain assessment in infants, non-verbal young children or developmentally<br />
delayed children is more complex and presents special challenges. Despite<br />
this, pain medication should be considered in cases where the infant or child is<br />
in severe pain. This includes evidence of painful mechanisms such as burns,<br />
limb fractures or other events. Using pain medication in these children requires<br />
judgment and caution. Signs and symptoms of pain in non-verbal young or<br />
developmentally delayed children include:<br />
Inconsolable crying, screaming that cannot be distracted from by a caregiver<br />
High pitched crying<br />
Any pain face expression that is continual, such as grimace or quivering chin<br />
Constant tense/stiff body tone and/or guarding<br />
“Whatever is painful to adults, is painful to children until proven otherwise”
PEDIATRIC ASSESSMENT<br />
Begin interventions immediately and transport promptly if life-threatening conditions are identified<br />
in general visual assessment or primary assessment<br />
PEDIATRIC ASSESSMENT TRIANGLE - GENERAL VISUAL ASSESSMENT<br />
Assessment Abnormal<br />
Assess TICLS: Tone, Interactiveness,<br />
Appearance Any abnormality<br />
Consolability, Look/Gaze, Speech/Cry<br />
Work of<br />
Breathing<br />
Assess effort<br />
Increased or decreased effort or abnormal<br />
sounds<br />
Circulation Assess for skin color Abnormal skin color or external bleeding<br />
PREHOSPITAL PRIMARY ASSESSMENT<br />
Assessment Signs of Life-Threatening Condition<br />
Airway Assess patency Complete or severe airway obstruction<br />
Breathing<br />
Assess respiratory rate and effort,<br />
air movement, airway and breath<br />
sounds, pulse oximetry<br />
Apnea, slow respiratory rate, very fast respiratory<br />
rate or significant work of breathing<br />
Assess heart rate, pulses, capillary Tachycardia, bradycardia, absence of detectable<br />
Circulation refill, skin color and temperature, pulses, poor blood flow (increased capillary refill,<br />
blood pressure<br />
pallor, mottling, or cyanosis), hypotension<br />
Disability<br />
Assess AVPU response, pupil size<br />
and reaction to light, blood glucose<br />
Decreased response or abnormal motor response<br />
(posturing) to pain, unresponsiveness<br />
Hypothermia, rash (petichiae/purpura) consistent<br />
Exposure Assess skin for rash or trauma with septic shock, significant bleeding, abdominal<br />
distention
PEDIATRIC VITAL SIGNS / GLASGOW COMA SCALE<br />
Age Normal RR Normal HR Hypotension by systolic blood pressure<br />
Term Neonate 30-60 100-205<br />
Infant (
PEDIATRIC MEDICATION ADMINISTRATION<br />
Patient safety in medication administration is paramount. Accurate administration of<br />
pediatric medications requires multiple steps. Follow each of these steps in every case.<br />
Remember the 6 Rights – Right patient, right drug (and indication), right dose, right<br />
Assess Patient<br />
route of administration, right timing and frequency, right documentation<br />
Obtain Weight<br />
Estimate In Kg<br />
Determine Volume<br />
On Drug Chart<br />
Draw Up<br />
Medication<br />
Double Check To<br />
Confirm Volume<br />
Administer<br />
Medication<br />
Documentation<br />
• Use Broselow tape in every child of appropriate height to determine color range of<br />
weight<br />
o Broselow applies to patients less than 147 cm tall (4 feet 10 inches)<br />
• If taller than Broselow tape, estimate weight by patient/parent history or paramedic<br />
estimate and ALWAYS convert to kg using conversion table<br />
• Consult drug chart based on medication name to determine volume in ml<br />
• If 50 kg or greater, utilize adult dosages<br />
• Verify drug being administered<br />
• Utilize smallest syringe for volume (e.g. 1 ml or less, use tuberculin syringe)<br />
• When giving IM or intranasal medication, load syringe only with amount to be<br />
administered<br />
• Double-check volume and dose with drug chart in hand –verbalize name of<br />
medication, volume, dosage and route to another paramedic or EMT on scene<br />
• Administer by appropriate route<br />
• Observe patient for any signs of adverse reaction<br />
• Always document drug dosages in chart by mg (if dextrose, in grams)<br />
• Document response to medication and any observed adverse reaction
RULE OF NINES – BURN SURFACE AREA
SEPSIS SCREENING<br />
• Sepsis is a life-threatening condition that can occur when a systemic reaction known as Systemic Inflammatory<br />
Response Syndrome (SIRS) develops and is related to an infection<br />
• The inflammatory response may be the result of exposure to infectious agents in the blood, urine, lungs, skin, or<br />
other organs<br />
RISK<br />
FACTORS<br />
INDICATIONS<br />
FOR<br />
SCREENING<br />
ASSESSMENT<br />
CRITERIA<br />
FOR POSITIVE<br />
SCREEN<br />
HOSPITAL<br />
REPORTING<br />
Common risk factors for sepsis include elderly age, diabetes, and immunocompromised states. Other risk<br />
factors include cancer, renal disease, alcoholism, injection drug use, malnutrition, hypothermia, or recent<br />
surgery or invasive procedure.<br />
Sepsis screening should be done in adults when a patient is suspected of an infection. Examples include<br />
patients with the following:<br />
• Fever;<br />
• Respiratory symptoms such as tachypnea, shortness of breath, cough, sputum production;<br />
• Abdominal symptoms such as vomiting, diarrhea, or abdominal pain;<br />
• Urinary symptoms such as flank pain or painful / frequent urination;<br />
• Skin infections (cellulitis or abscess);<br />
• General weakness, altered level of consciousness or lethargy, especially in the elderly<br />
Sepsis screening includes assessment of pulse rate, respiratory rate and temperature.<br />
It is important to note that an elevated temperature may not be seen in sepsis, particularly in elderly<br />
patients or advanced stages.<br />
A positive sepsis screen in adults occurs in the setting of suspected infection when 2 of 3 conditions are<br />
met:<br />
• Heart rate/pulse greater than 90;<br />
• Respiratory rate greater than 20;<br />
• Temperature above 100.4 or below 96.<br />
If a positive sepsis screen is encountered, the receiving facility should be notified as part of the report from the<br />
field. Report the finding as a “positive sepsis screen.” Not all patients with a positive screen will have sepsis but<br />
alerting the facility may assist in calling attention to time-sensitive steps in evaluation and care that are needed<br />
to be taken upon hospital arrival.
Penetrating Injury<br />
(Trauma to head,<br />
neck or torso)<br />
Blunt Injury<br />
(Regardless of<br />
mechanism)<br />
Blunt Injury<br />
(When mechanism of<br />
injury is concerning)<br />
INDICATIONS FOR SPINAL IMMOBILIZATION<br />
• Presence of neurologic complaint or deficit – paralysis, weakness,<br />
numbness, tingling, priapism or neurogenic shock, loss of consciousness<br />
• Anatomic deformity of spine<br />
• Altered level of consciousness (GCS < 15)<br />
• Presence of spinal pain or tenderness<br />
• Anatomic deformity of spine<br />
• Presence of neurologic complaint or deficit – paralysis, weakness,<br />
numbness, tingling, priapism or neurogenic shock<br />
• Presence of alcohol or drugs or acute stress reaction / anxiety<br />
• Distracting injury (e.g. long bone fracture, large laceration, crush or<br />
degloving injury, large burns)<br />
• Inability to communicate (e.g. speech or hearing impaired, language gap,<br />
small children, developmental or psychiatric conditions)<br />
Concerning mechanisms of injury include but are not limited to:<br />
• Violent impact to head, neck, torso, or pelvis (e.g. assault, entrapment in structural collapse)<br />
• Sudden acceleration, deceleration or lateral bending forces to neck or torso (e.g., moderate- to highspeed<br />
MVC, pedestrian struck, explosion)<br />
• Falls (especially in elderly patients)<br />
• Ejection from motorized or other transportation device (e.g. scooter, skateboard, bicycle, motor<br />
vehicle, motorcycle, recreational vehicle, or horse)<br />
• Victims of shallow-water diving incident<br />
*** USE CLINICAL JUDGMENT – IF IN DOUBT, IMMOBILIZE ***
VASCULAR ACCESS<br />
Skill Indication / Comment <strong>Contra</strong>indication<br />
Saline Lock<br />
Arm IV<br />
Antecubital IV<br />
Intraosseous<br />
Access (IO)<br />
External<br />
Jugular IV<br />
When medication alone is being given or a<br />
potential for medication is anticipated<br />
When fluids or medications needed and<br />
patient not in shock or arrest. Antecubital site<br />
not ideal unless no other vein available.<br />
• Shock<br />
• Adenosine (rapid IV bolus)<br />
• Cardiac arrest if IO cannot be obtained<br />
• Other peripheral sites not available and<br />
medications or fluids indicated<br />
• Cardiac arrest<br />
• Profound shock or unstable dysrhythmia<br />
when rapid IV access or suitable vein<br />
cannot be rapidly located<br />
o Use lidocaine for pain control in nonarrest<br />
patients PRIOR to IO flush, fluid<br />
or medication (Infusion is painful!)<br />
Unstable patient needs emergent IV<br />
medication or fluids AND no peripheral site<br />
is available AND IO not appropriate (e.g.<br />
very alert patient)<br />
No anticipated need for prehospital<br />
medication or fluid<br />
No anticipated need for prehospital<br />
medication or fluid<br />
No anticipated need for prehospital<br />
medication or fluid<br />
• If no medication or fluid is being<br />
administered (do not use for<br />
prophylactic vascular access)<br />
• If patient stable<br />
• When other routes for medications<br />
available (IM, IN)<br />
• <strong>Contra</strong>indicated in cardiac arrest<br />
unless IO and antecubital IV cannot<br />
be started (interrupts CPR)<br />
• When other routes for medications<br />
available (IM, IN) – e.g. naloxone or<br />
use of glucagon instead of dextrose
BACKGROUND<br />
INFORMATION<br />
ASSESSMENT<br />
VENTRICULAR ASSIST DEVICES (VAD)<br />
• A Ventricular Assist Device (VAD) is an implanted device used to partially or<br />
completely replace the pumping function of a failing heart. VADs are used<br />
both as a bridge device while patients are awaiting heart transplant, and now<br />
increasingly are used permanently in patients who are not transplant candidates<br />
(referred to as destination therapy).<br />
• VAD patients and their families/caretakers have been given training for their<br />
devices and they should be capable of basic troubleshooting of the device.<br />
Hospitals that implant VADs have 24-hour on-call coverage (VAD Coordinators)<br />
for families or responders to contact in case of any issues. The contact phone<br />
number should be present on the patient’s equipment and this person may be<br />
able to help the family or responding personnel in assessing the device.<br />
• Depending on the type of VAD, a patient may or may not present with a palpable<br />
pulse, and blood pressure may not be detected, particularly with automatic<br />
measurements. Most newer VADs work without generating a pulse. The pulse,<br />
if present, may not correspond to the patient’s heart rate on the monitor.<br />
• In the absence the ability to detect pulse and blood pressure, patient evaluation<br />
of skin signs, level of consciousness, oxygen saturation, non-invasive end-tidal<br />
carbon-dioxide, and general appearance may give the best clues as to the<br />
patient’s clinical status.
TREATMENT<br />
DESTINATION<br />
AND<br />
DISPOSITION<br />
• Patients may be cardioverted or defibrillated if symptomatic, but asymptomatic<br />
dysrhythmias do not require treatment<br />
• VAD devices may become dislodged with chest compressions and this may lead<br />
to massive hemorrhage. Do not perform chest compressions on patients with<br />
VADs, even if the patient is unconscious.<br />
• Treatment should otherwise follow appropriate treatment guidelines. Medical<br />
direction is provided by the base hospital (VAD coordinators cannot provide<br />
medical direction).<br />
• In most circumstances, when transport is indicated the appropriate destination<br />
for the patient is the hospital where the VAD was implanted and the patient is<br />
managed.<br />
• For very minor conditions (e.g. small laceration repair) local transport may be<br />
appropriate.<br />
• Contact the base hospital if there are questions concerning destination.<br />
• If possible, the patient’s family member or caregiver should accompany the patient<br />
in the ambulance, and all related VAD equipment (e.g. spare batteries) should also<br />
be transported with the patient.<br />
• In arrest situations, determine if DNR/POLST or advance directives are available.<br />
Many VAD patients have made end-of-life care decisions.
Multicasualty Incident Tiers and Examples<br />
Radio Communications<br />
SBAR Reporting<br />
EMT Scope of Practice<br />
Paramedic Scope of Practice<br />
Paramedic Local Optional Scope of Practice<br />
Base Hospital and Receiving Centers<br />
Burn Centers<br />
Out-of-County Specialty Centers<br />
Operational and<br />
Regulatory<br />
References
TIER<br />
ZERO<br />
TIER<br />
ONE<br />
TIER<br />
TWO<br />
TIER<br />
THREE<br />
MULTICASUALTY INCIDENTS (MCI) – TIER DEFINITIONS and EXAMPLES<br />
• Official notification of an incident that has the potential to result in activation of the MCI plan at a<br />
higher tier, even when the number of known victims is zero<br />
• Activation at this tier is required for a Community Warning System Level II or Level III incident or any<br />
receiving hospital Emergency Department closure or evacuation (not diversion or trauma bypass)<br />
• Other examples of this might include active shooter where number of victims unknown or cannot be<br />
confirmed, emergency landing at airport, actual or potential significant hazmat incident, including<br />
transportation incidents<br />
• An incident involving 6-10 patients when the scene is contained and the number of patients is not<br />
expected to rise significantly<br />
• Examples include a multi-vehicle traffic collision, multiple known shooting victims and no ongoing<br />
active shooter threat<br />
• An incident involving more than 10 patients OR an incident involving less than 10 patients when<br />
there is a substantial chance that the number of patients may rise<br />
• EMS Transportation Resource Ordering will be processed by EMS Operational Area<br />
Communications Center (Sheriff’s Dispatch)<br />
• Examples include a petrochemical incident with a dispersal cloud moving over a populated area,<br />
passenger train derailment, or an active shooter with an uncontained scene<br />
• Any incident involving more than 50 patients, mass casualties, or a reasonable expectation of mass<br />
casualties<br />
• EMS Transportation Resource Ordering will be processed by EMS Operational Area<br />
Communications Center (Sheriff’s Dispatch)<br />
• Examples include a significant explosion around occupied commercial or multi-resident structure, or<br />
in a heavily populated area, or a large-scale evacuation of a hospital or skilled nursing facility
RADIO COMMUNICATIONS<br />
Four radio channels are designated for communications with hospitals in <strong>Contra</strong> <strong>Costa</strong> County. Receiving<br />
hospital communications are done via XCC EMS 2, whereas paramedic base hospital communications may occur<br />
via XCC EMS 2 or XCC EMS 3, depending on location<br />
XCC EMS 1 T: 491.4375<br />
Use for Sheriff’s Dispatch-to-ambulance communication<br />
(formerly L9) R: 488.4375<br />
XCC EMS 2<br />
(formerly L19)<br />
XCC EMS 3<br />
XCC EMS 4<br />
T: 491.9125<br />
R: 488.9125<br />
T: 491.6125<br />
R: 488.6125<br />
T: 491.6625<br />
R: 488.6625<br />
Primary channel for base contact for West County paramedic units. Also used<br />
county-wide for BLS and helicopter radio traffic<br />
Primary channel for base contact for paramedic units operating south of Ygnacio<br />
Valley Road and west of I-680 along Highway 24<br />
Primary channel for base contact for paramedic units operating in East County and<br />
Central County north of Ygnacio Valley Road<br />
Whenever possible, paramedic personnel should use the XCC EMS channel assigned to the area in which they are<br />
responding, for ambulance-to-base hospital communications. XCC EMS 2 is the county-wide backup ALS channel and<br />
should be used if XCC EMS 3 or XCC EMS 4 is not available. Ambulance and helicopter personnel are to contact Sheriff’s<br />
Dispatch on XCC EMS 1 to request the use of XCC EMS 2 prior to utilizing the channel. The dispatcher shall be given unit<br />
identification and a description of current traffic (Code 2, Code 3 or trauma destination decision).<br />
No request for use is necessary for XCC EMS 3 or XCC EMS 4. However, each unit must monitor the channel prior to use<br />
to ensure that other units are not already using the channel. Radio identification procedures must be strictly followed, as<br />
more than one call may be occurring at the same time. If traffic is in progress on a XCC EMS channel, other ambulance<br />
personnel may either wait until current traffic is finished or find an alternate means of contacting the desired hospital.<br />
Any unit may, in cases such as trauma destination decisions, request that Sheriff’s Dispatch break into current traffic<br />
on XCC EMS 2 to request temporary use of the channel. Units using XCC EMS 3 or XCC EMS 4 may request use<br />
of the channel from a unit that is currently on that channel. When making base contact for trauma destination only,<br />
the initial transmission should make the purpose of the call clear. Cellular phones may also be used as a means of<br />
communication.
SBAR REPORTING<br />
SBAR is a tool that is recommended to assure timely, effective communication during all patientrelated<br />
communications between all health care providers. SBAR assures that urgent issues and<br />
immediate needs get addressed up front. SBAR is compatible with the trauma MIVT reporting.<br />
Routine use during base contact and patient handoff supports safe and effective patient care.<br />
Key Information SBAR Report Example<br />
SITUATION<br />
BACKGROUND<br />
ASSESSMENT<br />
RX RECAP<br />
• Identify yourself<br />
• What is the situation?<br />
• State urgent issues and immediate<br />
needs up front!<br />
• What has happened up to this point?<br />
• What past history would be important<br />
to know for further patient treatment?<br />
(e.g. high risk medications, past<br />
medical history)<br />
• How is the patient now?<br />
• Improved or worse since on scene?<br />
• Patient stable or unstable?<br />
• What field care given?<br />
• Was it effective?<br />
• Concerns?<br />
This is Unit 123 with a STEMI alert<br />
Patient is a 45 yo male with 12 lead<br />
positive for ST elevation<br />
Patient started having chest pain<br />
off and on the last 2 hours. Family<br />
called 911. Patient has no history of<br />
heart problems and takes Lipitor and<br />
metformin.<br />
RR 28 labored B/P 160/98 Diaphoretic,<br />
Pain 9 out 10, 12 lead ***Acute MI*** no<br />
significant artifact seen. No significant<br />
change with treatment. Airway stable.<br />
ASA, Nitro X 2 and 100% rebreather<br />
STEMI alert
S<br />
B<br />
A<br />
R<br />
TRAUMA BASE CALL EXAMPLE (Destination Decision Report)<br />
This is paramedic unit 123 with a trauma call, requesting destination decision. We have a 66-yearold<br />
male with a fall and altered level of consciousness, and we think the patient needs trauma center<br />
activation. Our ETA is 20 minutes.<br />
The patient was working on his roof and fell approximately 10 feet, landing on his head on a cement<br />
path. He sustained an injury to the right parietal area and there is significant swelling in that area. He<br />
has a GCS of 14. He is apparently generally healthy although he does take aspirin daily.<br />
BP 180/110, pulse 52, RR 10. SpO2 95%. His airway is stable. The patient is awake and<br />
cooperative, but is confused has repetitive questioning. He is vomiting and complains of a severe<br />
headache. He also has right chest wall tenderness but no flail chest, and has deformity of his right<br />
forearm with intact CMSTP.<br />
We have him on 100% oxygen, in spinal precautions. We are going to be splinting his right forearm<br />
and will start an IV en route. We believe he needs trauma activation.<br />
TRAUMA HAND-OFF EXAMPLE (Report at Trauma Center)<br />
S MECHANISM This is unit 123 with a 66-year-old male who fell from a roof onto a cement path<br />
B INJURIES<br />
Swelling and deformity in the right parietal area. He is confused, with repetitive<br />
questioning, vomiting, and complaining of a severe headache. He also has pain<br />
in the right chest and deformity of the right forearm which we splinted.<br />
A VITAL SIGNS BP 180/110, pulse 52, RR 10. SpO2 95%. GCS is 14<br />
R TREATMENT 100% oxygen non-rebreather, IV placed and infusing NS
EMT SCOPE OF PRACTICE (STATE REGULATION)<br />
“Emergency Medical Technician” or “EMT” means a person who has successfully completed an EMT course<br />
which meets the requirements of this Chapter, has passed all required tests, and who has been certified by<br />
the EMT certifying authority<br />
100063. Scope of Practice of Emergency Medical Technician (EMT)<br />
a) During training, while at the scene of an emergency, during transport of the sick or injured, or during<br />
interfacility transfer, a supervised EMT student or certified EMT is authorized to do any of the following:<br />
1) Evaluate the ill and injured.<br />
2) Render basic life support, rescue and emergency medical care to patients.<br />
3) Obtain diagnostic signs to include, but not be limited to the assessment of temperature, blood<br />
pressure, pulse and respiration rates, level of consciousness, and pupil status.<br />
4) Perform cardiopulmonary resuscitation (CPR), including the use of mechanical adjuncts to basic<br />
cardiopulmonary resuscitation.<br />
5) Use the following adjunctive airway breathing aids:<br />
A) oropharyngeal airway;<br />
B) nasopharyngeal airway;<br />
C) suction devices;<br />
D) basic oxygen delivery devices; and<br />
E) manual and mechanical ventilating devices designed for prehospital use.<br />
6) Use various types of stretchers and body immobilization devices.<br />
7) Provide initial prehospital emergency care of trauma.<br />
8) Administer oral glucose or sugar solutions.<br />
9) Extricate entrapped persons.<br />
10) Perform field triage.
11) Transport patients.<br />
EMT SCOPE OF PRACTICE (STATE REGULATION)<br />
12) Set up for ALS procedures, under the direction of an Advanced EMT or Paramedic.<br />
13) Perform automated external defibrillation when authorized by an EMT AED service provider.<br />
14) Assist patients with the administration of physician prescribed devices, including but<br />
not limited to, patient operated medication pumps, sublingual nitroglycerin, and selfadministered<br />
emergency medications, including epinephrine devices.<br />
15) In addition to the activities authorized by subdivision (a) of this section, the medical director<br />
of the local EMS agency may also establish policies and procedures to allow a certified<br />
EMT or a supervised EMT student in the prehospital setting and/or during interfacility<br />
transport to:<br />
A) Monitor intravenous lines delivering glucose solutions or isotonic balanced salt solutions<br />
including Ringer’s lactate for volume replacement;<br />
B) Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow and turn<br />
off the flow of intravenous fluid; and<br />
C) Transfer a patient who is deemed appropriate for transfer by the transferring physician,<br />
and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters,<br />
tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines;<br />
D) Monitor preexisting vascular access devices and peripheral lines delivering intravenous<br />
fluids with additional medications pre-approved by the Director of the EMS Authority (not<br />
currently allowed in <strong>Contra</strong> <strong>Costa</strong> County).
PARAMEDIC SCOPE OF PRACTICE<br />
California Code of Regulations, Title 22, Division 9, Chapter 4:<br />
100145. Scope of Practice of Paramedic.<br />
a) A paramedic may perform any activity identified in the scope of practice of an EMT in Chapter 2 of the Division, or<br />
any activity identified in the scope of practice of an Advanced EMT in Chapter 3 of this Division.<br />
b) A paramedic shall be affiliated with an approved paramedic service provider in order to perform the scope of<br />
practice specified in this Chapter.<br />
c) A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a<br />
hospital as part of his/her training or continuing education under the direct supervision of a physician, registered<br />
nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during<br />
interfacility transfer, or while working in a small and rural hospital pursuant to section 1797.195 of the <strong>Health</strong><br />
and Safety Code, may perform the following procedures or administer the following medications when such are<br />
approved by the medical director of the local EMS agency and are included in the written policies and procedures<br />
of the local EMS agency.<br />
1) Basic Scope of Practice:<br />
A) Perform defibrillation and synchronized cardioversion.<br />
B) Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps.<br />
C) Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway, stomal<br />
intubation, and adult endotracheal intubation.<br />
D) Institute intravenous (IV) catheters, saline locks, needles, or other cannulae (IV lines), in peripheral veins;<br />
and monitor and administer medications through pre-existing vascular access.<br />
E) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer’s lactate<br />
solution.<br />
F) Obtain venous blood samples.<br />
G) Use glucose measuring device.<br />
H) Utilize Valsalva maneuver.<br />
I) Perform needle cricothyroidotomy. (not currently used in <strong>Contra</strong> <strong>Costa</strong> County)<br />
J) Perform needle thoracostomy.<br />
K) Monitor thoracostomy tubes
PARAMEDIC SCOPE OF PRACTICE<br />
L) Monitor and adjust IV solutions containing potassium, equal to or less than 20 mEq/L.<br />
M) Administer approved medications by the following routes: intravenous, intramuscular, subcutaneous,<br />
inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or topical.<br />
N) Administer, using prepackaged products when available, the following medications:<br />
(1) 25% and 50% dextrose;<br />
(2) activated charcoal; (not currently used in <strong>Contra</strong> <strong>Costa</strong> County)<br />
(3) adenosine;<br />
(4) aerosolized or nebulized beta-2 specific bronchodilators;<br />
(5) aspirin;<br />
(6) atropine sulfate;<br />
(7) pralidoxime chloride;<br />
(8) calcium chloride;<br />
(9) diazepam; (not currently used in <strong>Contra</strong> <strong>Costa</strong> County)<br />
(10) diphenhydramine hydrochloride;<br />
(11) dopamine hydrochloride; (not currently used in <strong>Contra</strong> <strong>Costa</strong> County)<br />
(12) epinephrine;<br />
(13) furosemide; (not currently used in <strong>Contra</strong> <strong>Costa</strong> County)<br />
(14) glucagon;<br />
(15) midazolam<br />
(16) lidocaine hydrochloride;<br />
(17) morphine sulfate;<br />
(18) naloxone hydrochloride;<br />
(19) nitroglycerin preparations, except intravenous, unless permitted under (c)(2)(A) of this section;<br />
(20) sodium bicarbonate
PARAMEDIC SCOPE OF PRACTICE (continued) – LOCAL OPTIONAL SCOPE<br />
Paramedic Regulations (continued)<br />
2) Local Optional Scope of Practice:<br />
A) Perform or monitor other procedure(s) or administer any other medication(s) determined to be<br />
appropriate for paramedic use, in the professional judgment of the medical director of the local EMS<br />
agency, that have been approved by the Director of the Emergency Medical <strong>Services</strong> Authority<br />
when the paramedic has been trained and tested to demonstrate competence in performing the<br />
additional procedures and administering the additional medications.<br />
CONTRA COSTA LOCAL OPTIONAL SCOPE<br />
• Amiodarone<br />
• Esophageal Airway (King LTS-D)<br />
• External Cardiac Pacing<br />
• Impedance Threshold Device (ResQPOD)<br />
• Intraosseous Infusion<br />
• Pediatric Endotracheal Intubation (limited to patients > 40 kg)<br />
CONTRA COSTA LOCAL OPTIONAL SCOPE ITEMS<br />
ITEMS LIMITED TO CRITICAL CARE TRANSPORT PARAMEDICS ONLY<br />
• Blood/Blood Product Infusion<br />
• Glycoprotein IIb/IIIa Receptor Inhibitor Infusion<br />
• Heparin Infusion<br />
• Ipratropium<br />
• KCL Infusion<br />
• Lidocaine Infusion<br />
• Midazolam Infusion<br />
• Morphine Sulfate Infusion<br />
• Nitroglycerin Infusion<br />
• Sodium Bicarbonate Infusion<br />
• Total Parenteral Nutrition (TPN) Infusion
Hospital<br />
<strong>Contra</strong> <strong>Costa</strong> County Base Hospital<br />
Base Phone ED Phone<br />
John Muir <strong>Health</strong> - Walnut Creek Campus<br />
1601 Ygnacio Valley Road<br />
Taped:<br />
(925) 939-5804<br />
Receiving Facility<br />
Notification:<br />
(925) 947-3379<br />
Walnut Creek CA 94598<br />
ED: (925) 939-5800<br />
<strong>Contra</strong> <strong>Costa</strong> County Hospitals (Receiving Facilities)<br />
Hospital <strong>Services</strong> ED Phone<br />
<strong>Contra</strong> <strong>Costa</strong> Regional Medical Center<br />
2500 Alhambra Avenue<br />
Martinez CA 94553<br />
Doctors Medical Center – San Pablo<br />
2000 Vale Road<br />
San Pablo CA 94806<br />
John Muir <strong>Health</strong> - Concord Campus<br />
2540 East Street<br />
Concord CA 94520<br />
John Muir <strong>Health</strong> - Walnut Creek Campus<br />
1601 Ygnacio Valley Road<br />
Walnut Creek CA 94598<br />
Basic ED<br />
OB/Neonatal<br />
Basic ED<br />
STEMI Center<br />
Stroke Center<br />
Basic ED<br />
STEMI Center<br />
Stroke Center<br />
Basic ED<br />
OB/Neonatal<br />
Trauma Center<br />
STEMI Center<br />
Stroke Center<br />
XCC EMS 2<br />
Alert Code<br />
14524<br />
XCC EMS 2<br />
Alert Code<br />
(925) 370-5971 14574<br />
(510) 234-6010 13613<br />
(925) 689-0553 14214<br />
Receiving Facility<br />
Notification:<br />
(925) 947-3379<br />
ED: (925) 939-5800<br />
14524
Kaiser Medical Center – Antioch<br />
5001 Deer Valley Road<br />
Antioch CA 94531<br />
Kaiser Medical Center – Richmond<br />
901 Nevin Avenue<br />
Richmond CA 94504<br />
Kaiser Medical Center – Walnut Creek<br />
1425 South Main Street<br />
Walnut Creek CA 94596<br />
San Ramon Regional Medical Center<br />
6001 Norris Canyon Road<br />
San Ramon CA 94583<br />
Sutter/Delta Medical Center<br />
3901 Lone Tree Way<br />
Antioch CA 94509<br />
Basic ED<br />
OB/Neonatal<br />
Stroke Center<br />
Basic ED<br />
Stroke Center<br />
Basic ED<br />
OB/Neonatal<br />
STEMI Center<br />
Stroke Center<br />
Basic ED<br />
OB/Neonatal<br />
STEMI Center<br />
Stroke Center<br />
Basic ED<br />
OB/Neonatal<br />
STEMI Center<br />
(925) 813-6099 14564<br />
(510) 307-1758 13653<br />
(925) 939-1788 14284<br />
(925) 275-8338 13623<br />
(925) 779-7273 14294
BURN CENTERS<br />
Hospital <strong>Services</strong> Phone<br />
Santa Clara Valley Medical Center<br />
751 S. Bascom Avenue<br />
San Jose CA<br />
UC Davis Medical Center<br />
Regional Burn Center<br />
2315 Stockton Blvd.<br />
Sacramento CA<br />
St. Francis Burn Center<br />
900 Hyde Street<br />
San Francisco CA<br />
Adult and Pediatric Burn Center 408-885-6666<br />
Adult and Pediatric Burn Center 916-734-3636<br />
Adult and Pediatric Burn Center<br />
(No Helipad available)<br />
415-353-6255
OUT-OF-COUNTY SPECIALTY CENTERS<br />
Hospital Type ED Phone<br />
Alameda County Medical Center – Oakland (Highland) Trauma 510-535-6000<br />
Alta Bates Medical Center – Berkeley Stroke 510-204-2500<br />
Children’s Hospital – Oakland Trauma 510-428-3240<br />
Eden Medical Center – Castro Valley<br />
Trauma<br />
Stroke<br />
510-889-5015<br />
Kaiser Oakland Stroke 510-752-7667<br />
Kaiser South Sacramento Trauma 916-688-6964<br />
Marin General Hospital Trauma 415-925-7203<br />
San Francisco General Hospital Trauma 415-647-4747<br />
Summit Campus – Alta Bates Medical Center - Oakland<br />
STEMI<br />
Stroke<br />
UC Davis Medical Center - Sacramento Trauma<br />
510-869-8797<br />
916-734-3892<br />
916-734-5669<br />
Valley <strong>Care</strong> – Pleasanton STEMI 925-416-6518
Adult Drug Reference<br />
Pediatric Drug Reference<br />
Pediatric Drug Dosage Charts<br />
Drug<br />
References
ADULT DRUG REFERENCE<br />
Drug Indication Adult Dosage Precautions / Comments<br />
ADENOSINE Paroxysmal SVT<br />
ALBUTEROL<br />
AMIODARONE<br />
Bronchospasm<br />
Crush Injury –<br />
Hyperkalemia<br />
Ventricular<br />
Fibrillation or<br />
Pulseless VT<br />
Stable Ventricular<br />
Tachycardia<br />
1 st Dose – 6 mg rapid IV<br />
2 nd Dose – 12 mg rapid<br />
IV push<br />
Follow each dose with<br />
rapid bolus of 20 ml NS<br />
5 mg in 6 ml NS<br />
nebulized<br />
5 mg in 6 ml NS<br />
nebulized continuously<br />
300 mg IV or IO bolus,<br />
repeat 150 mg bolus if<br />
rhythm persists<br />
150 mg IV infusion or<br />
slow IV push over 10<br />
minutes (15 mg/minute)<br />
May cause transient heart block<br />
or asystole. Side effects include<br />
chest pressure/pain, palpitations,<br />
hypotension, dyspnea, or<br />
feeling of impending doom. Use<br />
caution when patient is taking<br />
carmbamazepine, dipyramidole,<br />
or methylxanthines. Do not<br />
administer if acute asthma<br />
exacerbation.<br />
Repeat as needed for<br />
bronchospasm<br />
Use with caution in patients taking<br />
MAO inhibitors (antidepressants<br />
Nardil and Parnate)<br />
In patient with pulses, may cause<br />
hypotension. Do not administer<br />
if patient hypotensive. When<br />
creating infusion, careful mixing<br />
needed to avoid foaming of<br />
medication (do not use filter<br />
needle).
ASPIRIN<br />
ATROPINE<br />
CALCIUM<br />
CHLORIDE<br />
ADULT DRUG REFERENCE<br />
Drug Indication Adult Dosage Precautions / Comments<br />
Chest Pain –<br />
Suspected ACS<br />
Symptomatic<br />
Bradycardia<br />
Organophosphate<br />
poisoning<br />
Hyperkalemia –<br />
Arrest<br />
Hyperkalemia –<br />
Crush Injury<br />
Hydrofluoric Acid<br />
Toxicity<br />
DEXTROSE 10% Hypoglycemia<br />
4 – 81 mg tabs – chewed<br />
0.5 mg IV or IO every 3-5<br />
minutes up to max. 3 mg<br />
1-2 mg IV or IO – repeat<br />
every 3-5 min. as needed<br />
to decrease symptoms<br />
500 mg IV or IO slowly May<br />
repeat in 5-10 minutes<br />
1 gm IV or IO slowly over<br />
60 seconds<br />
500 mg IV or IO slowly<br />
10 g initially (100 ml). If<br />
glucose remains 60 or<br />
below, give additional 15 g<br />
(150 ml)<br />
<strong>Contra</strong>indicated in aspirin or salicylate<br />
allergy. Coumadin or Plavix use is not<br />
a contraindication.<br />
Atropine can dilate pupils, aggravate<br />
glaucoma, cause urinary retention,<br />
confusion, and dysrhythmias, including<br />
V-tach and Vfib. Doses less than 0.5<br />
mg can cause paradoxical bradycardia.<br />
Increases myocardial oxygen<br />
consumption.<br />
Remove clothing of victim of<br />
organophosphate poisonings, and flush<br />
skin to remove traces of poison<br />
Use cautiously or not at all in patients<br />
on digitalis. Avoid<br />
extravasation<br />
Rapid administration can cause<br />
dysrhythmias or arrest<br />
Recheck glucose after administration
ADULT DRUG REFERENCE<br />
Drug Indication Adult Dosage Precautions / Comments<br />
DEXTROSE 50% Hypoglycemia 25 g IV<br />
Use D10 initially – use D50 if<br />
repeat dosage needed<br />
DIPHENHYDRAMINE<br />
EPINEPHRINE<br />
1:10,000<br />
EPINEPHRINE<br />
1:1000<br />
Allergy – Hives /<br />
Itching<br />
Dystonic Reaction<br />
Cardiac Arrest<br />
Anaphylactic<br />
Shock<br />
Allergy/<br />
Anaphylactic<br />
Shock<br />
Asthma<br />
25-50 mg IV or IM<br />
1 mg IV or IO every 3-5<br />
minutes<br />
0.1 mg increments IV or IO<br />
up to 0.5 mg IV total dose<br />
Use only if IM treatment<br />
ineffective<br />
0.3-0.5 mg IM<br />
Use lower dose in smaller,<br />
older patients<br />
0.3 mg subcutaneously<br />
0.3 mg IM if respiratory<br />
arrest from asthma or<br />
bronchospasm<br />
For allergy, consider lower<br />
dose if patient has already<br />
taken po dose in past two<br />
hours for symptoms<br />
Alpha & beta<br />
sympathomimetic.<br />
May cause serious<br />
dysrhythmias and exacerbate<br />
angina.<br />
Never administer<br />
intravenously!<br />
Do not use in asthma patients<br />
with a history of hypertension<br />
or coronary artery disease.<br />
May cause serious<br />
dysrhythmias and exacerbate<br />
angina.
Drug Indication<br />
ADULT DRUG REFERENCE<br />
Adult Dosage Precautions / Comments<br />
GLUCAGON Hypoglycemia 1 mg IM Effect may be delayed 5–20 min<br />
LIDOCAINE IO Anesthesia<br />
40 mg IO<br />
Repeat dose 20 mg<br />
Administer slowly over 1 minute<br />
Not needed in arrest situations<br />
MIDAZOLAM<br />
MORPHINE<br />
Seizure<br />
Sedation for pacing<br />
or cardioversion<br />
Sedation – transfer<br />
of intubated patient<br />
Behavioral<br />
Emergency<br />
Pain Control<br />
Trauma, Burn or<br />
Non-Traumatic Pain<br />
Sedation – Pacing<br />
Pulmonary Edema<br />
Titrate 1-5 mg IV in 1-2<br />
mg increments<br />
0.1 mg/kg IM<br />
(max. dose 5 mg IM)<br />
Titrate 1-5 mg IV in 1-2<br />
mg increments<br />
Titrate 2-5 mg IV in up to<br />
2 mg increments<br />
5 mg IM<br />
1-5 mg IV in 1 mg<br />
increments if IV available<br />
2-20 mg IV<br />
(2-5 mg increments)<br />
5-20 mg IM<br />
(max single dose 10 mg)<br />
1-5 mg IV in 1 mg<br />
increments<br />
2-5 mg IV in 1-2 mg<br />
increments<br />
With IV dosing, begin with<br />
1 mg dose. IV increments should not<br />
exceed 2 mg.<br />
Observe respiratory status<br />
Use with caution in patients over age 60<br />
Base order required for behavioral<br />
emergency indication<br />
Can cause hypotension and respiratory<br />
depression. Recheck VS between each<br />
dose. Hypotension more common in<br />
patients with low cardiac output or volume<br />
depletion. Nausea is a frequent side<br />
effect. Respiratory depression reversible<br />
with naloxone.
NALOXONE<br />
ADULT DRUG REFERENCE<br />
Drug Indication Adult Dosage Precautions / Comments<br />
NITROGLYCERIN<br />
ONDANSETRON<br />
SODIUM<br />
BICARBONATE<br />
Respiratory<br />
Depression or<br />
Apnea<br />
(Respiratory rate<br />
less than 12)<br />
Chest Pain –<br />
Suspected ACS<br />
Pulmonary Edema<br />
Vomiting and<br />
Severe Nausea<br />
2 mg intranasally (IN)<br />
1-2 mg IV or IM<br />
For careful titration in<br />
chronic pain or terminal<br />
patients, dilute 1:10 and<br />
give 0.1 mg increments<br />
0.4 mg sl or spray<br />
up to 3 doses<br />
0.4 mg sl or spray<br />
if systolic BP 90-149<br />
0.8 mg sl or spray<br />
if systolic BP 150 or over<br />
Max.dose 4.8 mg<br />
4 mg IV, IM or po (ODT)<br />
May repeat q 10 min X 2<br />
Cardiac arrest 1 mEq/kg IV or IO<br />
Tricyclic<br />
Antidepressant OD<br />
Crush injury<br />
For crush injury, consider<br />
additional 1 mEq/kg added<br />
to 1L NS using second<br />
IV line<br />
Intranasal administration preferred<br />
unless patient in shock or has copious<br />
secretion/blood in nares.<br />
Shorter duration of action than that<br />
of most narcotics. Abrupt withdrawal<br />
symptoms and combative behavior<br />
may occur.<br />
Can cause hypotension and<br />
headache. Do not give if BP less<br />
than 90 systolic or heart rate below<br />
50. Perform 12-lead ECG before<br />
administration. Do not give if STEMI<br />
detected. Do not give if Viagra,<br />
Levitra, Staxyn or Stendra taken<br />
within 24 hours or if Cialis taken<br />
within 36 hours.<br />
Give IV over 1 minute – may cause<br />
syncope if administered too rapidly<br />
Assure adequate ventilation. Can<br />
precipitate or inactivate other drugs.<br />
In cardiac arrest, indicated for<br />
treatment of suspected hyperkalemia<br />
(history of renal failure or diabetes).
ADENOSINE<br />
PEDIATRIC DRUG REFERENCE<br />
Drug Indication Pediatric Dosage Precautions / Comments<br />
Paroxysmal<br />
SVT<br />
1st Dose – 0.1 mg/kg rapid IV<br />
(max. 6 mg)<br />
2nd Dose – 0.2 mg/kg rapid<br />
IV (max 12 mg)<br />
Follow each dose with rapid<br />
10-20 ml NS bolus<br />
Base Order Required:<br />
May cause transient heart block<br />
or asystole. Side effects include<br />
chest pressure/pain, palpitations,<br />
hypotension, dyspnea, or feeling<br />
of impending doom. Do not<br />
administer if acute exacerbation<br />
of asthma.<br />
ALBUTEROL Bronchospasm 5 mg in 6 ml NS nebulized Repeat as needed<br />
AMIODARONE<br />
ATROPINE<br />
Ventricular<br />
Fibrillation or<br />
Pulseless VT<br />
Symptomatic<br />
Bradycardia<br />
5 mg/kg IV or IO bolus<br />
Maximum dose 300 mg<br />
0.02 mg/kg IV or IO<br />
Minimum dose 0.1 mg<br />
Maximum dose 0.5 mg<br />
Bradycardia in pediatric patients<br />
primarily related to respiratory<br />
issue – assure adequate<br />
ventilation first
PEDIATRIC DRUG REFERENCE<br />
Drug Indication Pediatric Dosage Precautions / Comments<br />
DEXTROSE 10% Hypoglycemia<br />
DIPHENHYDRAMINE<br />
EPINEPHRINE 1:10,000<br />
EPINEPHRINE 1:1000<br />
Allergy - Hives /<br />
Itching<br />
Cardiac Arrest<br />
Anaphylactic<br />
Shock<br />
Allergy/<br />
Anaphylactic<br />
Shock<br />
Asthma<br />
GLUCAGON Hypoglycemia<br />
0.5 g/kg IV (5 ml/kg)<br />
Maximum 250 ml<br />
1 mg/kg IV or IM<br />
Maximum dose 50 mg<br />
0.01 mg/kg IV or IO<br />
every 3-5 minutes Max.<br />
dose 1 mg<br />
Titrate in up to 0.1 mg<br />
increments slow IV or IO<br />
to a max. of 0.01 mg/kg<br />
0.01 mg/kg IM Max<br />
single dose 0.3 mg<br />
0.01 mg/kg<br />
subcutaneously<br />
Maximum dose 0.3 mg<br />
Weight less than 24 kg:<br />
0.5 mg IM<br />
Weight 24 kg or more:<br />
1 mg IM<br />
Recheck glucose after<br />
administration<br />
Consider lower dose (0.5 mg/kg) if<br />
patient has already taken po dose<br />
in the past two hours for symptoms<br />
In anaphylactic shock, IM<br />
epinephrine 1:1000 should be<br />
administered first and epinephrine<br />
1:10,000 IV should only be used if<br />
IM is ineffective<br />
Never administer intravenously!<br />
If respiratory arrest from asthma or<br />
bronchospasm, administer IM<br />
Effect may be delayed 5–20<br />
minutes - if patient responds, give<br />
po sugar
PEDIATRIC DRUG REFERENCE<br />
Drug Indication Pediatric Dosage Precautions / Comments<br />
LIDOCAINE IO Pain<br />
MIDAZOLAM<br />
Seizure<br />
Sedation for<br />
Cardioversion<br />
MORPHINE Pain Control<br />
NALOXONE<br />
ONDANSETRON<br />
Respiratory<br />
Depression or<br />
Apnea<br />
Vomiting and<br />
Severe Nausea<br />
0.5 mg/kg IO.<br />
Maximum dose 20 mg<br />
Titrate in up to 1 mg<br />
increments IV up to 0.1 mg/kg<br />
Maximum total IV dose 5 mg<br />
0.1 mg/kg IM Maximum dose<br />
5 mg IM<br />
0.1 mg/kg IV or IO titrated in<br />
1 mg increments<br />
Maximum dose 5 mg<br />
See pain management drug<br />
chart for dosage. Use IV<br />
increments of up to 2 mg<br />
0.1 mg/kg IM<br />
0.1 mg/kg IM or IV<br />
Maximum dose 2 mg<br />
May repeat as needed<br />
4 mg IV, IM, or po (ODT)<br />
In patients 40 kg and over,<br />
may repeat q 10 min X 2<br />
Give slowly over one minute.<br />
Not needed in arrest situations<br />
Observe respiratory status carefully<br />
Sedation and cardioversion only with base hospital<br />
order<br />
Can cause hypotension and respiratory<br />
depression. Hypotension is more common in<br />
patients with volume depletion. Nausea is a<br />
frequent side effect.<br />
Use IM route initially unless shock present. Shorter<br />
duration of action than that of most narcotics.<br />
For use in patients 4 years and up.<br />
Administer IV over 1 minute. Rapid administration<br />
may cause syncope.
Yellow (12-14 kg)<br />
2.7 mg 2nd - 0.9 ml<br />
1.7 mg 1<br />
White (15-18 kg)<br />
st - 0.6 ml<br />
3.4 mg 2nd - 1.2 ml<br />
2.1 mg 1<br />
Blue (19-23 kg)<br />
st - 0.7 ml<br />
4.2 mg 2nd - 1.4 ml<br />
2.7 mg 1<br />
Orange (24-29 kg)<br />
st - 0.9 ml<br />
5.4 mg 2nd - 1.8 ml<br />
3.3 mg 1<br />
Green (30-36 kg)<br />
st - 1.1 ml<br />
6.6 mg 2nd - 2.2 ml<br />
4 mg 1<br />
40 kg<br />
st - 1.3 ml<br />
8 mg 2nd - 2.7 ml<br />
4.5 mg 1<br />
45 kg<br />
st - 1.5 ml<br />
9 mg 2nd - 3 ml<br />
Note: Follow with rapid bolus 10-20 ml NS<br />
DOSES<br />
GIVE (ml)<br />
(mg)<br />
0.45 mg 1st - 0.15 ml<br />
0.9 mg 2nd - 0.3 ml<br />
0.66 mg 1st - 0.22 ml<br />
1.35 mg 2nd - 0.45 ml<br />
0.9 mg 1st - 0.3 ml<br />
1.8 mg 2nd - 0.6 ml<br />
1 mg 1st - 0.33 ml<br />
2 mg 2nd - 0.67 ml<br />
1.35 mg 1st - 0.45 ml<br />
Purple (10-11 kg)<br />
Red (8-9 kg)<br />
Pink (6-7 kg)<br />
Gray (3-5 kg)<br />
COLOR<br />
Concentration = 3 mg/ml<br />
1st Dose = 0.1 mg/kg IV 2nd Dose = 0.2 mg/kg IV<br />
Base Order Only<br />
ADENOSINE<br />
INDICATION: SUPRAVENTRICULAR TACHYCARDIA
40 kg 200 mg 4 ml<br />
45 kg 225 mg 4.5 ml<br />
Orange (24-29 kg) 130 mg 2.6 ml<br />
Green (30-36 kg) 170 mg 3.4 ml<br />
White (15-18 kg) 80 mg 1.6 ml<br />
Blue (19-23 kg) 100 mg 2 ml<br />
Purple (10-11 kg) 50 mg 1 ml<br />
Yellow (12-14 kg) 65 mg 1.3 ml<br />
Pink (6-7 kg) 35 mg 0.7 ml<br />
Red (8-9 kg) 45 mg 0.9 ml<br />
COLOR DOSE (mg) GIVE (ml)<br />
Gray (3-5 kg) Not given<br />
Concentration = 50 mg/ml<br />
Dose = 5 mg/kg IV<br />
AMIODARONE<br />
INDICATION – VENTRICULAR FIBRILLATION
Assure adequate ventilation before considering atropine<br />
Not indicated for asystole<br />
40 kg 0.5 mg 5 ml<br />
45 kg 0.5 mg 5 ml<br />
Orange (24-29 kg) 0.5 mg 5 ml<br />
Green (30-36 kg) 0.5 mg 5 ml<br />
White (15-18 kg) 0.35 mg 3.5 ml<br />
Blue (19-23 kg) 0.42 mg 4.2 ml<br />
Purple (10-11 kg) 0.2 mg 2 ml<br />
Yellow (12-14 kg) 0.25 mg 2.5 ml<br />
Pink (6-7 kg) 0.13 mg 1.3 ml<br />
Red (8-9 kg) 0.17 mg 1.7 ml<br />
COLOR DOSE (mg) GIVE (ml)<br />
Gray (3-5 kg) 0.1 mg 1 ml<br />
Concentration = 0.1 mg/ml<br />
Dose = 0.02 mg/kg IV<br />
Minimum Dose – 0.1 mg IV<br />
Maximum Dose – 0.5 mg IV<br />
ATROPINE<br />
INDICATION – SYMPTOMATIC BRADYCARDIA
Note: Cardioversion energy dosages are equal to<br />
first and second energy levels. Cardioversion in<br />
pediatric patients requires base hospital direction.<br />
40 kg 70 J 150 J 360 J<br />
45 kg 100 J 175 J 360 J<br />
Orange (24-29 kg) 50 J 100 J 250 J<br />
Green (30-36 kg) 70 J 125 J 300 J<br />
White (15-18 kg) 30 J 70 J 175 J<br />
Blue (19-23 kg) 30 J 70 J 200 J<br />
Purple (10-11 kg) 20 J 30 J 100 J<br />
Yellow (12-14 kg) 30 J 50 J 125 J<br />
Pink (6-7 kg) 15 J 30 J 50 J<br />
Red (8-9 kg) 15 J 30 J 70 J<br />
COLOR First Second Maximum<br />
Gray (3-5 kg) 8 J 15 J 30 J<br />
DEFIBRILLATION<br />
PHYSIO-CONTROL<br />
Energy Selection<br />
(LP-12 and LP-15)
Note: Cardioversion energy dosages are equal to<br />
first and second energy levels. Cardioversion in<br />
pediatric patients requires base hospital direction.<br />
45 kg 75 J 150 J 200 J<br />
Green (30-36 kg) 50 J 120 J 200 J<br />
40 kg 75 J 150 J 200 J<br />
Blue (19-23 kg) 30 J 75 J 150 J<br />
Orange (24-29 kg) 50 J 100 J 200 J<br />
Yellow (12-14 kg) 20 J 50 J 120 J<br />
White (15-18 kg) 30 J 50J 150 J<br />
Red (8-9 kg) 15 J 30 J 75 J<br />
Purple (10-11 kg) 20 J 30 J 100 J<br />
Gray (3-5 kg) 8 J 15 J 30 J<br />
Pink (6-7 kg) 10 J 20 J 50 J<br />
COLOR First Second Maximum<br />
DEFIBRILLATION<br />
ZOLL Energy Selection
45 kg 22.5 g 225 ml<br />
Green (30-36 kg) 17 g 170 ml<br />
40 kg 20 g 200 ml<br />
Blue (19-23 kg) 11 g 110 ml<br />
Orange (24-29 kg) 14 g 140 ml<br />
Yellow (12-14 kg) 6.5 g 65 ml<br />
White (15-18 kg) 8.5 g 85 ml<br />
Red (8-9 kg) 4.5 g 45 ml<br />
Purple (10-11 kg) 5.5 g 55 ml<br />
Gray (3-5 kg) 2 g 20 ml<br />
Pink (6-7 kg) 3.5 g 35 ml<br />
COLOR DOSE (g) GIVE (ml)<br />
Concentration = 0.1 g/ml<br />
Dose = 0.5 g/kg IV<br />
DEXTROSE 10%<br />
INDICATION – HYPOGLYCEMIA
Consider giving one-half dosage diphenhydramine if patient<br />
has taken/been given full dose within 1 hour<br />
Utilize epinephrine 1:1000 IM first if serious systemic reaction<br />
(anaphylaxis)<br />
40 kg 40 mg 0.8 ml<br />
45 kg 45 mg 0.9 ml<br />
Orange (24-29 kg) 25 mg 0.5 ml<br />
Green (30-36 kg) 35 mg 0.7 ml<br />
White (15-18 kg) 17.5 mg 0.35 ml<br />
Blue (19-23 kg) 20 mg 0.4 ml<br />
Purple (10-11 kg) 10 mg 0.2 ml<br />
Yellow (12-14 kg) 12.5 mg 0.25 ml<br />
Pink (6-7 kg) 6.5 mg 0.13 ml<br />
Red (8-9 kg) 8.5 mg 0.17 ml<br />
COLOR DOSE (mg) GIVE (ml)<br />
Gray (3-5 kg) 5 mg 0.1 ml<br />
Concentration = 50 mg/ml<br />
Dose = 1 mg/kg – Give IV or IM<br />
DIPHENHYDRAMINE<br />
INDICATION: ALLERGIC REACTION<br />
(URTICARIAL RASH or ITCHING)
** In anaphylactic shock:<br />
• Patients under 10 kg receive smaller increments (same as<br />
single dose for cardiac arrest)<br />
• For patients 10 kg and up, give 0.1 mg increments (1 ml)<br />
Epinephrine 1:10,000 IV is also used in anaphylactic shock if<br />
IM treatment ineffective<br />
40 kg 0.4 mg 4 ml<br />
45 kg 0.45 mg 4.5 ml<br />
Orange (24-29 kg) 0.27 mg 2.7 ml<br />
Green (30-36 kg) 0.33 mg 3.3 ml<br />
White (15-18 kg) 0.17 mg 1.7 ml<br />
Blue (19-23 kg) 0.21 mg 2.1 ml<br />
Purple (10-11 kg) 0.1 mg 1 ml<br />
Yellow (12-14 kg) 0.13 mg 1.3 ml<br />
Pink (6-7 kg) 0.06 mg 0.6 ml **<br />
Red (8-9 kg) 0.08 mg 0.8 ml **<br />
COLOR DOSE (mg) GIVE (ml)<br />
Gray (3-5 kg) 0.04 mg 0.4 ml **<br />
FOR CARDIAC ARREST<br />
Concentration = 0.1 mg/ml<br />
Dose = 0.01 mg/kg IV<br />
EPINEPHRINE 1:10,000
45 kg 0.3 mg 0.3 ml IM / SC<br />
40 kg 0.3 mg 0.3 ml IM / SC<br />
Green (30-36 kg) 0.3 mg 0.3 ml IM / SC<br />
Orange (24-29 kg) 0.27 mg 0.27 ml IM / SC<br />
Blue (19-23 kg) 0.21 mg 0.21 ml IM / SC<br />
White (15-18 kg) 0.17 mg 0.17 ml IM / SC<br />
Yellow (12-14 kg) 0.13 mg 0.13 ml IM / SC<br />
Purple (10-11 kg) 0.1 mg 0.1 ml IM / SC<br />
Red (8-9 kg) 0.08 mg 0.08 ml IM / SC<br />
Pink (6-7 kg) 0.06 mg 0.06 ml IM / SC<br />
Gray (3-5 kg) 0.04 mg 0.04 ml IM / SC<br />
COLOR DOSE (mg) GIVE (ml)<br />
Concentration = 1 mg/ml<br />
Dose = 0.01 mg/kg IM or SC<br />
Maximum Dose 0.3 mg IM / SC<br />
EPINEPHRINE 1:1000<br />
Anaphylaxis – use IM Route<br />
Asthma – use Subcutaneous (SC) Route<br />
NEVER GIVE EPINEPHRINE 1:1000 VIA IV ROUTE
45 kg 500 ml<br />
Green (30-36 kg) 500 ml<br />
40 kg 500 ml<br />
Blue (19-23 kg) 420 ml<br />
Orange (24-29 kg) 500 ml<br />
Yellow (12-14 kg) 260 ml<br />
White (15-18 kg) 340 ml<br />
Red (8-9 kg) 170 ml<br />
Purple (10-11 kg) 210 ml<br />
Gray (3-5 kg) 80 ml<br />
Pink (6-7 kg) 130 ml<br />
COLOR GIVE (ml)<br />
NORMAL SALINE BOLUS = 20 ml/kg IV<br />
Maximum single bolus = 500 ml<br />
INDICATION – SHOCK / HYPOTENSION<br />
FLUID BOLUS
45 kg 1 mg 1 ml<br />
Green (30-36 kg) 1 mg 1 ml<br />
40 kg 1 mg 1 ml<br />
Blue (19-23 kg) 0.5 mg 0.5 ml<br />
Orange (24-29 kg) 1 mg 1 ml<br />
Yellow (12-14 kg) 0.5 mg 0.5 ml<br />
White (15-18 kg) 0.5 mg 0.5 ml<br />
Red (8-9 kg) 0.5 mg 0.5 ml<br />
Purple (10-11 kg) 0.5 mg 0.5 ml<br />
Gray (3-5 kg) 0.5 mg 0.5 ml<br />
Pink (6-7 kg) 0.5 mg 0.5 ml<br />
COLOR DOSE (mg) GIVE (ml)<br />
Concentration = 1 mg/ml<br />
Dose = 0.5 – 1 mg/ml IM<br />
GLUCAGON<br />
INDICATION – HYPOGLYCEMIA
45 kg 20 mg 1 ml<br />
40 kg 20 mg 1 ml<br />
Green (30-36 kg) 16 mg 0.8 ml<br />
Orange (24-29 kg) 14 mg 0.7 ml<br />
Yellow (12-14 kg) 7 mg 0.35 ml<br />
White (15-18 kg) 9 mg 0.45 ml<br />
Blue (19-23 kg) 10 mg 0.5 ml<br />
Purple (10-11 kg) 5 mg 0.25 ml<br />
DOSE<br />
COLOR<br />
GIVE (ml)<br />
(mg)<br />
Gray (3-5 kg) Not given<br />
Pink (6-7 kg) 3 mg 0.15 ml<br />
Red (8-9 kg) 4 mg 0.2 ml<br />
Concentration = 2% (100 mg / 5 ml)<br />
Dose = 0.5 mg/kg IO – 20 mg max<br />
LIDOCAINE<br />
INDICATION – PAIN MANAGEMENT FOR IO<br />
(PATIENTS NOT IN ARREST)
40 kg 4 mg 0.8 ml<br />
45 kg 4.5 mg 0.9 ml<br />
Orange (24-29 kg) 2.75 mg 0.55 ml<br />
Green (30-36 kg) 3.25 mg 0.65 ml<br />
White (15-18 kg) 1.75 mg 0.35 ml<br />
Blue (19-23 kg) 2 mg 0.4 ml<br />
Purple (10-11 kg) 1 mg 0.2 ml<br />
Yellow (12-14 kg) 1.25 mg 0.25 ml<br />
Pink (6-7 kg) 0.75 mg 0.15 ml<br />
Red (8-9 kg) 0.85 mg 0.17 ml<br />
COLOR DOSE (mg) GIVE (ml)<br />
Gray (3-5 kg) 0.5 mg 0.1 ml<br />
IM administration - single dose only<br />
Titrate IV dosage in 0.5-1 mg (0.1-0.2 ml)<br />
increments to desired effect (seizure cessation)<br />
or maximum dose listed<br />
Concentration = 5 mg/ml<br />
Dose = 0.1 mg/kg IV or IM<br />
MIDAZOLAM<br />
INDICATION – SEIZURE
40 kg 4 mg 0.4 ml<br />
45 kg 4.5 mg 0.45 ml<br />
Orange (24-29 kg) 2.7 mg 0.27 ml<br />
Green (30-36 kg) 3.3 mg 0.33 ml<br />
White (15-18 kg) 1.7 mg 0.17 ml<br />
Blue (19-23 kg) 2 mg 0.2 ml<br />
Purple (10-11 kg) 1 mg 0.1 ml<br />
Yellow (12-14 kg) 1.3 mg 0.13 ml<br />
Pink (6-7 kg) 0.6 mg 0.06 ml<br />
Red (8-9 kg) 0.8 mg 0.08 ml<br />
Gray (3-5 kg) Not given<br />
COLOR DOSE (mg) GIVE (ml)<br />
IM dosing is single dose only<br />
Base contact required for repeat doses<br />
Concentration = 10 mg/ml<br />
Dose = 0.1 mg/kg IM<br />
MORPHINE IM<br />
INDICATION – PAIN MANAGEMENT
For patients 19 kg and above may titrate in 1-2 mg<br />
increments up to 10 mg maximum (1 ml) .<br />
For patients 18 kg and below, dose can be repeated<br />
once. Additional doses require base approval.<br />
40-45 kg 1 - 2 mg 0.1 - 0.2 ml<br />
Green (30-36 kg) 1 - 2 mg 0.1 - 0.2 ml<br />
Orange (24-29 kg) 1 - 2 mg 0.1 - 0.2 ml<br />
Yellow (12-14 kg) 0.7 mg 0.07 ml<br />
White (15-18 kg) 0.8 mg 0.08 ml<br />
Blue (19-23 kg) 1 mg 1.1 ml<br />
Purple (10-11 kg) 0.5 mg 0.05 ml<br />
Red (8-9 kg) 0.4 mg 0.04 ml<br />
Gray (3-5 kg) Not given<br />
Pink (6-7 kg) 0.3 mg 0.03 ml<br />
(mg)<br />
COLOR<br />
INITIAL<br />
DOSE<br />
GIVE (ml)<br />
MORPHINE IV<br />
INDICATION – PAIN MANAGEMENT<br />
Concentration = 10 mg/ml
45 kg 2 mg 2 ml<br />
Green (30-36 kg) 2 mg 2 ml<br />
40 kg 2 mg 2 ml<br />
Blue (19-23 kg) 2 mg 2 ml<br />
Orange (24-29 kg) 2 mg 2 ml<br />
Yellow (12-14 kg) 1.3 mg 1.3 ml<br />
White (15-18 kg) 1.7 mg 1.7 ml<br />
Red (8-9 kg) 0.9 mg 0.9 ml<br />
Purple (10-11 kg) 1 mg 1 ml<br />
Gray (3-5 kg) 0.4 mg 0.4 ml<br />
Pink (6-7 kg) 0.7 mg 0.7 ml<br />
COLOR DOSE (mg) GIVE (ml)<br />
Naloxone is available in other concentrations<br />
This chart is correct for 1 mg/ml concentration<br />
Concentration = 1 mg/ml<br />
Dose = 0.1 mg/kg IV or IM<br />
Maximum single dose = 2 mg (may be repeated)<br />
NALOXONE<br />
INDICATION – RESPIRATORY DEPRESSION
45 kg 45 kg 101 lbs<br />
Green 30-36 kg 67-80 lbs<br />
40 kg 40 kg 90 lbs<br />
Blue 19-23 kg 42-52 lbs<br />
Orange 24-29 kg 54-65 lbs<br />
Yellow 12-14 kg 27-32 lbs<br />
White 15-18 kg 34-41 lbs<br />
Red 8-9 kg 17-20 lbs<br />
Purple 10-11 kg 22-25 lbs<br />
Gray 3-5 kg 6-11 lbs<br />
Pink 6-7 kg 13-15 lbs<br />
COLOR Kg Pounds<br />
Always Document Weight in kg<br />
WEIGHT<br />
CONVERSION
contra costa county<br />
emergency medical services agency<br />
1340 arnold drive, ste. 126<br />
martinez ca 94553<br />
925-646-4690 phone<br />
925-646-4379 fax<br />
www.cccems.org
0<br />
0<br />
1–2<br />
MILD<br />
1–2<br />
LEVE<br />
PAIN RATING SCALE<br />
3–4 5–6<br />
MODERATE<br />
ESCALA DE VALORACIÓN DE DOLOR<br />
3–4 5–6<br />
MODERADO<br />
7–8 9–10<br />
SEVERE<br />
7–8 9–10<br />
SEVERO