Lemhi County Medical Supervision Plan Emergency Medical Service Patient Care Protocols



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7.

INTERFACILITY TRANSFERS

Inter-facility transfer of a patient to provide optimal medical care is a frequent, necessary, and inevitable occurrence that must be anticipated and planned for. Reasons for transfer include continuity of care, definitive care, access to advanced technology, access to advanced diagnostics, obtaining a higher level of care, and patient preference. Transportation and care of these patients are fundamental roles the EMS system.

Responsibilities for patient transfers lie with the transferring physician, and must take into account the risk vs. benefit to the patient. Providing appropriate equipment, medication, and qualified staffing during transport is paramount to patient safety. Selection of these should be based on the requirements of the Patient at the time of transfer, and in anticipation of foreseen complications, deterioration, and medical needs that might arise during transport. Sometimes equipment and personnel in addition to, or in place of, the EMT and local ambulance service must be utilized. Options include physicians and nurses to complement EMT providers, and implementation of ground-based critical care transport units, or air-medical transports. In order to effect a safe transfer, transferring physicians must be knowledgeable about their respective EMS system’s provider and equipment capabilities. Out-of-hospital skills and protocols do not necessarily translate into the transfer setting. EMS personnel accompanying the patient must possess the assessment and a treatment skill appropriate for the patient’s needs, and be capable of recognizing and managing complications that occur during transfer.

Physicians and hospitals must also comply with laws regulating the transfer of patients. The Federal Emergency Medical Treatment and Active Labor Act (EMTALA) passes in 1985 as part of the Consolidated Omnibus Reconciliation Act (COBRA). Under this law regulations exist concerning the evaluation, examination, treatment, stabilization, and transfer of patients with an emergency medical condition. Physicians should read and be familiar with this law in its entirety.

Initiation of a transfer should be a carefully coordinated effort by transferring and receiving physicians, transferring and receiving facilities, and transferring unit and personnel. The following provides a guideline for selection of appropriate EMS personnel to provide inter-facility transport of patients consistent with their current scope of practice, protocols and training.

STAFFING

1 Basic EMT 1 Emergency Responder

1 EMT Advanced 1 Emergency Responder

Stable patient

No IV infusion

Oxygen for stable patient permitted

Previously inserted Foley catheter

Saline Lock permitted

Automatic External Defibrillator (AED)


Stable patient

No ongoing medications administered, or anticipated

IV infusion with 0.9% NaCl (normal saline), Lactated Ringers, or D5W, or Saline lock

Oxygen for stable patient permitted

Previously inserted Foley catheter

Automatic External Defibrillator (AED


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Medical Control During Itrerfacility Transport

Options for on-line medical responsibility and control during transport include:

1. Transferring physician assumes medical control

2. receiving physician assumes medical control.

3. Medical Director or other physician designee on the transport unit assumes medical control.

4. There is a shared, predefined responsibility between the transferring physician and receiving physician.

5.Transferring facility’s emergency physician assumes medical control.

6.Recieving facility’s emergency physician assumes medical control.

It is advisable that a medical responsibility policy determination be made in advanced by hospitals according to the needs, patient requirements, and their unique situation. This may be done through a transfer committee or other appropriate means Optimal patient care and safety are the primary consideration. Transferring physician should be immediately available or make other arrangements for medical control communication via radio, cell phone, or telephone when executing emergency transfers. If there is a communication failure, the transferring facility’s emergency physician should be the first default on-line contact, and the receiving facility’s emergency physician second.

Three categories of medical controle during interfacility transport are:

Offline: Written orders

Offline: Protocol Online: transferring physician available for voice communication with transfer personnel.

Equipment: All equipment at the level of licensed service as specified by the State of Idaho EMS Bureau.

Procedures: EMS providers may perform procedures within the scope of their license and protocols if clinically appropriate, and in consultation of medical control if necessary.


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COMMUNICATIONS
EMTs transporting patients should advise the receiving hospital of patients transport status, I, II, III. This needs to be accomplished in a timely manner.

In the event of a Mass Casualty, the receiving hospital needs to be informed of the approximant amount of patients and their approximant status.


VHF Radio

EMS may establish contact with a medical control physician via VHF radio on one of the assigned medical frequencies F1 155.340 MHz and F2 155.280 MHz . Due to the extreme topography of Lemhi County, EMS has the ability to communicate the Lemhi County’s Sheriff’s Office via the extensive repeater system. In the event EMS personnel are unable to communicate with local medical control or State Communication, relayed information can be accomplished by utilizing Lemhi County’s repeater system. Repeater names and location are:

Baldy Repeater South West of Salmon, Ramsey Repeater East Hwy 28 near Lemhi, Stein Repeater Hwy 93 N

Landline

EMS may establish contact with a medical control physician via direct communications with a telephone either hard line or cellular phone, this is a preferred method in the event of needing medical direction on discontinuing CPR, medical consultation, or to transmit pertinent patient information, such as name, incident, other private medical history.


VHF Medical Frequency Communication steps:

Initiate call to appropriate hospital and identify:

Destination to hospital

Ambulance unit calling

Status of patient, age

Vital signs

Pre hospital treatment rendered

Approximant ETA



Communications Failure
In case of communications failure with medical control due to equipment (cell phone, landline, IHERN)

Malfunction or due to incident location, the following will apply:

EMS personnel may, within limits of their certification, perform necessary Basic/I85 procedures that, under normal circumstances, would require a direct physician order.
These procedures shall be the minimum necessary to prevent the loss of life or the critical deterioration of a patient’s condition.
All procedures performed under this order and the conditions that created the communication failure need to be thoroughly documented.
Attempts must be made to establish contact with medical control as soon as possible. 10
Allergic Reaction/Anaphylaxis – Adult
DEFINITION: Anaphylaxis is suspected exposure to an allergen AND one or more of the following:


  • severe respiratory distress;

  • airway compromise/impending airway compromise (wheezing, swelling of the lips/tongue, throat tightness);

  • Signs of shock (including systolic BP < 90).


Basic/Intermediate-85 Standing Orders

Routine Patient Care.

Caution needed when administering epinephrine to patients with history of CAD, HTN, ect.

If patient has signs and symptoms of an allergic reaction (hives, itch, anxiety) but otherwise

hemo-dynamically stable, contact medical control for further direction. Follow State of Idaho protocols for administration of EPI-Pin.

DO NOT delay transport, except for epinephrine administration.

Consider ALS intercept when appropriate .

Intermediate-85

Establish IV of 0.9% Normal Saline at KVO. Consider 250-500cc bolus if patient is hemo-dynamically unstable



Allergic Reaction/Anaphylaxis – Pediatric
Anaphylaxis is suspected exposure to an allergen AND one or more of the following:

  • severe respiratory distress;

  • airway compromise/impending airway compromise (wheezing, swelling of the lips/tongue, throat tightness);

  • signs of shock (including systolic BP < 90).

Basic/Intermediate-85 Standing Orders

Routine Patient Care.

. If patient has signs and symptoms of an allergic reaction (hives, itch, anxiety) but otherwise hemodynamically stable, contact medical control for further direction.

For anaphylaxis Follow State of Idaho protocols for administration of EPI-Pen, for pediatric patient. (see appendix A)

DO NOT delay transport, except for epinephrine administration.

Consider ALS intercept when appropriate.

Establish IV access, administer fluids to maintain systolic pressure > 90mmHg

If hypotensive, infuse 0.9% Normal Saline 20ml/kg.

11.
Asthma/COPD/ Chemical/Substance Induced Reparatory Distress - Adult



Basic Standing Orders

Routine Patient Care.

Wear N95 mask if bioterrorism related event or highly infectious agent suspected.

Administer oxygen at appropriate rate for patient’s condition and medical history.

Patients with COPD, who are on home oxygen, increase their rate by 1-2 liters per minute.

Attempt to keep oxygen saturation above 90%, increase the rate with caution and observe for fatigue, decreased mental status, and respiratory failure.

If available request ALS intercept/intervention ASAP.

*Assist patient with his/her own MDI, if appropriate; only MDIs containing beta adrenergic broncodilators (e.g., albuterol, Ventolin, Proventil, Combivent) may be used: Follow State of Idaho Protocol. Contact medical control if delayed.



Intermediate -85 Standing Orders

IV access, administer cautiously fluid to maintain systolic BP > 90 mmHg.

For patient exhibiting signs/symptoms consistent with CHF, Run IV TKO ,watch for fluid overload
Asthma/ Chemical/Substance Induced Reparatory Distress -Pediatric

Basic Standing Orders

Routine Patient Care.

Wear N95 mask if bioterrorism related event or highly infectious agent suspected.

If suspected epiglottitis, limit evaluation/interventions to only those absolutely necessary.

If available request ALS intercept/intervention ASAP.

*Assist patient with his/her own MDI, if appropriate; only MDIs containing beta adrenergic bronco-dilators (e.g., albuterol, Ventolin, Proventil,) may be used: contact medical control if delayed.

For patient with croup, provide humidified oxygen

12

Diabetic Emergencies- Adult


DEFINITION: Hypoglycemia is glucose level< 80mg/dl with associated mental status changes.
Basic Standing Orders

Routine Patient Care.

Obtain glucose reading via glucose-meter, if you are trained and authorized per Medical Director per patient/or family member.

If patient can swallow and hypoglycemia is present, administer oral glucose preparation.

If Patient cannot take glucose by either oral or intravenous method. Administer Glucagon, if available and you are trained and authorized to do so

Intermediate-85 Standing Orders

Obtain glucose reading via glucometer.

IV access, obtain blood sample and administer fluid, of 0.9% Normal Saline to maintain systolic pressure>90 mmHg.

If glucose level is <80mg/dl with signs and symptoms of hypoglycemia administer Dextrose 5% W

If Patient cannot take glucose by either oral or intravenous method. Administer Glucagon, if available and you are trained and authorized to do so. (State of Idaho EMS protocol Administration of GLUCAGON

Diabetic Emergencies- Pediatric
DEFINITION: Hypoglycemia is glucose level< 80mg/di with associated mental status changes.
Basic /Intermediate-85 Standing Orders

Routine Patient Care.

Obtain glucose reading via glucometer, (State of Idaho EMS protocol)

If patient can swallow and hypoglycemia is present, administer oral glucose preparation.

Contact medical control for IV access, in fluid intervention. If Patient cannot take glucose by either oral or intravenous method. Administer Glucagon, if available and you are trained and authorized to do so. (State of Idaho EMS protocol Administration of GLUCAGON

13

BLOOD GLUCOMETRY IDAHO EMS PROTOCOLE




INDICATIONS

  • Abnormal mental status

OR

  • Sweating with rapid heart rate

OR

  • Seizure

OR

  • Focal neurological deficit

OR

  • Behavioral change

1. Before using the blood glucometer the provider must:


  • Be Trained and have demonstrated competency with the specific device before used

  • Confirm the device is working properly including calibration.

  • Confirm the test strips are not expired.

2. Procedure:

  • Prepare the device according to the manufacturer’s instructions

  • Explain the procedure to the patient.

  • Obtain verbal consent, if possible, from patient or family.

  • Use body substance isolation procedures

  • Cleanse the puncture site prior to obtaining blood sample

  • Obtain a drop of blood

  • Apply the blood to the test strip according to the manufacturer’s instructions

  • Obtain and record the reading from the device

  • Apply a dressing to the patients puncture site

  • Properly dispose of the test supplies

  • Continue your assessment and treatment of the patient

Note:

1. According to the 2010-1 EMSPC Standards Manual, automated blood glucometry is an optional skill for the EMT

2. The EMT must obtain EMS Bureau-specified training prior to skill credentialing.

3. The EMT must perform automated blood glucometry in accordance with this EMSPC protocol.


.14
GLUCAGON IDAHO EMS PROTOCOLE




INDICATIONS:


  • Patient is known (via blood glucometry or other laboratory method) to be hypoglycemic

(less than 80)

AND


  • Patient cannot take glucose by either oral or intravenous method

1. Before the administration of glucagon to any patient the provider must:



Be trained and have demonstrated competency in:


  • Pharmacology of the drug

  • Indications for the drug

  • Contraindications of the use of the drug

  • Specific route of administration of the drug

  • Specific product and the manufacturer’s instructions for administration

2. Procedure:

  • Confirm the patient is hypoglycemic

  • Explain the procedure to the patient and or family

  • Obtain verbal consent, if able

  • Confirm the drug is not expired

  • Use body substance isolation

  • Mix the drug with the supplied diluents according to the manufacturer’s instructions

  • Draw up the drug in the appropriate size syringe

  • Administer the drug either intramuscularly or subcutaneously consistent with the manufacturer’s instructions for the specific product being given

  • Continue your assessment and treatment of the patient

  • Do not administer additional doses of glucagon to the same patient

3. Dosage:

  • Adult or children> 20KG: 1mg

  • Children < 20KG: 0.5mg

Note:

1.According to the 2010-1 EMSPC Standard Manual, administration of glucagon IM or SQ is an optional skill for the EMT and AEMT

2. The EMT and AEMT must obtain EMS Bureau-specified training prior to skill credentialing

3. The EMT must administer glucagon in accordance with this EMSPC protocol

.15

Stroke
Basic Standing Orders

Routine Patient Care.

Obtain glucose reading via glucometer if you are authorized and trained to do so.

Perform Prehospital Hospital Stroke Scale.

Determine time of onset of the symptoms.

Early notification of the emergency department.

Elevate head of the stretcher 30 degrees.

Check blood pressure bilaterally.

Consider ALS intercept when appropriate.

Intermediate85 Standing Orders

Obtain glucose reading via glucometer,

IV access, obtain blood sample and administer fluids to maintain systolic pressure >90 mmHg.

Consider underlying causes.

Prehospital Stroke Scale:

Abnormal finding of any part of the exam may indicate an acute stroke.




FACIAL DROOP

Normal: ; Both sides of the face move equally well.

Abnormal ; One side of the face does not move as well as the other side.

ARM DRIFT

Normal : Both arms move the same or both arms don’t move at all.

Abnormal ; One arm does not move or one arm drifts down compared to the other.
SPEECH

Normal : Patient says correct words without slurring.

(Ask patient to repeat a phrase such as, “you can’t teach an old dog new tricks.”)



Abnormal : Patient slurs words, says wrong words or is unable to speak.

16

Hyperthermia (Environmental)


Mental Status change in the heat-challenged victim signal the onset of potentially sever heat related illness and heat stroke. Mortality and morbidity are directly related to the length of time the victim is subjected to the heat stress. Consider pharmacological causes as well.
Basic Standing Orders

Routine Patient Care.

Move victim to cool area and shield from sun or any external heat source.

Remove as much clothing as is practical and loosen any restrictive garments remaining.

If alert and oriented give small sips of cool liquids.

Monitor and record vital signs and level of consciousness.

If temperature > 104 F (40C) or if altered mental status: begin active cooling by:

Continually mist the exposed skin with tepid water while fanning the victim

Trunked( the trunk of the body) ice packs may be used, but are less effective than evaporation

Discontinue active cooling if shivering occurs and notify medical control


Intermediate85 Standing Orders

IV access, obtain blood sample and administer fluids to maintain systolic blood pressure >90 mmHg.

IV bolus of 250cc ml 0.9 Normal Saline. May repeat if systolic pressure <100 mmHg.

17.
Hypothermia (Environmental)


Basic Standing Orders

Routine Patient Care.

Avoid rough movement and excess activity.

Prevent further heat loss:



  • Insulate from the ground/water.

  • Move to a warm environment.

  • Gently remove any wet cloths.

  • Cover with warm blanket. Cover the head and neck.

*Obtain temperature _ (rectal temp preferred as appropriate).

*Maintain horizontal position.

*Trunkal warm packs.

*Consider covering patient’s mouth and nose with surgical mask to prevent respiratory heat loss.

*A minimum of 30 to 50 second assessment of pulse is necessary to confirm pulse-less/ cardiac arrest.

*Apply cardiac monitor/AED if available. If V.F. is present diliver1 shocks followed by 2 minuets of CPR , up to 3 shock may be delivered.

* If unsuccessful perform CPR. CPR is preformed with both the rate of chest compressions and ventilations are at current AHA Guild-lines . Do not initiate compressions if any palpable pulse is present.

Intermediate85 Standing Orders

IV access, obtain blood sample and administer fluids to maintain systolic blood pressure >90 mmHg If core temperature < 30°C;

Continue CPR

Limit defibrillation to a maximum of 3


If core temperature < 30°C;

Continue CPR

Repeat defibrillation /ventricular tachycardia as core temperature rises.

Severe Levels of Hypothermia and Associated Symptoms


Mild

97°F------95°F

36.1°c----35°c



Cold sensation, shivering, unable to perform complex tasks with hands

Moderate

95°°F-----93°F

35°C----33.9°C

Intense shivering, clumsy and uncoordinated, mild confusion, slow and labored movements.




93°F-----90°F

33.9°C---32.2°C



Violent shivering, difficulty with speech, sluggish thinking mild amnesia, may appear drunk.

Severs

90°F------86°F

32.2°C----30°C



Shivering stops, unable to walk, incoherent, irrational




<86°F (30°C

Progressive stupor to unconsciousness, loss of awareness




<82°F (27.8°C

Unconscious, respiration and heartbeat erratic, pulse not palpable, pulmonary edema, cardiac and respiratory arrest, death

18

OBSTETRICAL EMERGENCIES


BASIC STANDING ORDERS

Routine Patient Care.

Gather specific information:


  • Length of pregnancy, previous pregnancies, last menstrual period, due date, pre-natal care, number of expected babies, drug use.

  • Signs of near delivery; membrane rupture (“water broke”) or bloody show, contractions, urge to move bowels, urge to push, etc.

  • Signs of pre-eclampsia: hypertension, swelling of face and/or other extremities.

Expose as necessary to assess for bleeding, crowning, prolapsed cord, etc.

Do not digitally examine or insert anything into vagina. Exceptions: to manage baby’s airway in breech presentation or the treat prolapsed cord as below, may insert hand.



CONTACT MEDICAL CONTROL IF;

  • Active labor and delivery is imminent

  • Post-partum hemorrhage.

  • Breech presentation.

  • Prolapsed cord.

Place mother in left-lateral recumbent position except as noted.

Prolapsed cord: Knee-chest position or Trendelenberg position; immediately and continuously support infant head or body with your gloved hand to permit blood flow though the cord. Transport at once to closest hospital.

Consider ALS intercept

Intermediate -85 Standing Orders

For third-trimester bleeding, pre-eclampsia, placenta previa, breech presentation, post-partum hemorrhage: initiate IV- 09% (normal saline) @ TKO and consider fluid bolus of 250 ml for active bleeding


19
Neonatal Resuscitation


Basic/Intermediate85 Standing Orders
Routine Patient Care.

Suction the mouth and nose with a bulb syringe immediately upon delivery of the head before stimulation or initiation of ventilation if meconium staining is present.

If APGAR is<6 at 1 minute, or meconium present, start resuscitation.

Leave at least 6 inches of newborn’s umbilical cord when cutting the cord.

Note the 1- minute and 5-minute APGAR score. Continue to assign scores every five minutes thereafter as long as the APGAR score is less than 7.

Rapidly warm the neonate and provide tactile simulation by flicking the soles of the feet and/or rubbing the back.

Chest compressions if heart rate is less than 60 bpm.

Wrap the infant in dry linens and cover the head.




APGAR SCORES

Sign

Score = 0

Score = 1

Score = 2

Heart Rate

Absent

Below 100

Above 100

Respiratory Effort

Absent

Weak, Irregular or gasping

Good, crying

Muscle tone

Flaccid

Some flexion of extremities

Well flexed, or active movement of extremities

Reflex Irritability

No response

Grimace or weak cry

Good cry

Color

Blue all over, or pale

Acrocyanosis

(persistent bluish discoloration of extremities including hands, feet and parts of face)



Pink all over

20
Pain Management



Basic Standing Orders
Routine Patient Care.

Place the patient in a position of comfort if possible.

Give reassurance, psychological support and distraction.

Use ample padding for long and short spinal immobilization devices.

Use ample padding when splinting possible fractures, dislocations, sprains and strains. Elevate injured extremity if possible. Consider application of cold pack for 30 minutes.

Have the patient rate their pain on a 0 to 10 (or similar) scale*. Reassess patient’s pain level and vital signs every 5 minutes.


Intermediate85 Standing Orders

IV access, administer fluids to maintain systolic BP .90 mmHg.


Contact medical control For guidance with all patients with altered mental status, multi-systems trauma or abdominal pain.

21
Fever (<101.5°F/38.5°C)Adult

This protocol is not intended for patients suffering from environmental hyperthermia
Basic/Intermediate85 Standing Orders

Routine Patient Care

Wear n95 mask if bioterrorism related event or highly infectious agent suspected.

Passive cooling; remove excessive clothing/bundling.

Do not cool to induce shivering.

IV access, administer fluids to maintain systolic BP >90 mmHg


Fever (<101.5°F/38.5°C)Pediatric

This protocol is not intended for patients suffering from environmental hyperthermia (protocol 2.5).


Basic/Intermediate85 Standing Orders

Routine Patient Care

Wear n95 mask if bioterrorism related event or highly infectious agent suspected.

Obtain temperature.

Passive cooling; remove excessive clothing/bundling.

Do not cool to induce shivering.

IV access, administer fluids to maintain systolic BP >90 mmHg
Poisoning/Substance Abuse/Overdose – Adult
Basic Standing Orders

Remove patient from additional exposure.

Routine Patient Care.

Absorbable poison:

Remove clothing and fully decontaminate.

If eye is involved; irrigate at least 20 minutes without delaying transport.

Inhale/injection poison:

Administer high-flow oxygen.

NOTE: Pulse oximetry may not be accurate for toxic inhalation patients

Ingested Poison:

Consider activated charcoal. (Follow State of Idaho Protocol see appendix A).

Bring container to receiving hospital.

Envenomations:

Immobilize extremity in dependant position. Consider ice pack for bee sting.

Consider ALS intercepted/Air Medical Transport.

Intermediate85 Standing Orders

IV access, administer fluids to maintain systolic blood pressure>90mmHg.

22
Poisoning/Substance Abuse/Overdose – Pediatric
Basic/ Intermediate 85 Standing Orders

Remove patient from additional exposure.

Routine Patient Care.

Absorbable poison:

Remove clothing and fully decontaminate.

If eye is involved; irrigate at lease 20 minutes without delaying transport.

Inhale/injection poison:

Administer high-flow oxygen

NOTE: Pulse oximetry may not be accurate for toxic inhalation patients

Ingested Poison:

Bring container to receiving hospital.

Envenomations:

Immobilize extremity in dependant position. Consider ice pack for bee sting.

IV access, administer fluids KVO, Obtained blood sugar

Consider ALS intercepted/Air Medical Transport
Seizure_- Adult
Basic Intermediate85/ Standing Orders

Routine Patient Care.

Do not attempt to restrain the patient; protect patient from injury.

History preceding seizure is very important. Find out what precipitated seizure (e.g. medication non-compliance, active infection, trauma, hypoglycemia, substance abuse, third-trimester pregnancy, ect.).

When appropriate Request ALS interception for ongoing or recurrent seizure activity.

Obtained blood sugar if you are trained and authorized per medical director

IV access, and administer fluid to maintain systolic blood pressure>90mmHg.

If blood glucose reading less than 80mg/dl, see Diabetic Emergencies Protocol

When appropriate, request ALS interception for ongoing or recurrent seizure activity.

Seizure_- Pediatric

Basic Standing Orders

Routine Patient Care.

Do not attempt to restrain the patient; protect patient from injury.

History preceding seizure is very important. Find out what precipitated seizure (e.g. medication non-compliance, active infection, trauma, hypoglycemia, substance abuse, fever, ect.).

Obtain patients temperature.

Obtained blood sugar if you are trained and authorized per medical director


23
Nausea/Vomiting


Basic Standing Orders

Routine Patient Care.



Intermediate85 Standing Orders

IV access, administer fluid to maintain systolic blood pressure>90mmHg



Bradycardia (Symptomatic) – Adult

Basic Standing Orders

Routine Patient Care.

When appropriate, request ALS interception.

Intermediate85 Standing Orders

IV access, and administer fluid to maintain systolic blood pressure>90mmHg

When appropriate, consider ALS interception.
Bradycardia (Symptomatic) – Pediatric
Heart Rate Criteria:


Age

HR (bpm)

SBP (mmHg)

Newborn

<90

<50

6mo-3yrs

<80

<70

4-8yrs

<70

<80

8-12yrs

<60

<85

Basic/Intermediate85 Standing Orders

Routine Patient Care.

Consider underlying causes of bradycardia (e.g. hypoxia).

Provide high-flow oxygen and consider assisting ventilation.

Begin/continue CPR in peadiatric if HR<60 and hypoperfusion.

When appropriate, consider ALS interception

IV access, and administer fluid @ KVO.
Tachycardia – Adult

Basic/ Intermediate 85/Standing Orders

Routine Patient Care

IV access, and administer fluid to maintain systolic blood pressure>90mmHg

When appropriate, consider ALS interception

Be prepared to do CPR
Tachycardia – Pediatric

Basic/Intermediate -85 Standing Orders

Routine Patient Care

IV access, and administer fluid to maintain systolic blood pressure>90mmHg

When appropriate, consider ALS interception

Be prepared to do CPR
24

Acute Coronary Syndromes

Basic Intermediate -85 / Standing Orders

Routine Patient Care

Obtain information on if patient has taken Aspirin 324 mg PO (chewable). If patient states that they have not or that they cannot take ASA (see contraindications) or “doctors orders” call medical control for further direction.

Administer oxygen at a rate to keep oxygen saturation above 90%

Facilitate administration of patient’s own nitroglycerin if SBP>90

IV access, obtain blood sample and administer fluid to maintain systolic blood pressure>90mmHg



Salmon Advanced EMTs AMBULANCE SERVICE

Aspirin for chest pain of suspected ischemic origin

indications contraindications
pATIENT COMPLAINS OF CHEST PAIN pATIENT Is ALLERGIC TO ASPIRIN
the patient complains of any other PATIENT IS BEING TREATED FOR

signs and symptoms listed below A BLEEDING ULCER
THE POSSIBILITY OF HEART TROUBLE EXISTS PRESENTLY OVERTLY BLEEDING
DO NOT GIVE IF PRESENTLY TAKING COUMADIN



precautions
DO NOT GIVE TO CHILDREN

UNDER 12 YEARS OF AGE
do not give if the patient has HAD

RECENT HEAD TRAUMA

Signs and Symptoms
*Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain.   

  • Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. 

  • Shortness of breath with or without chest discomfort.  

  • Other signs may include breaking out in a cold sweat, nausea or lightheadedness    

As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain.

  1. ASSESS THE PATIENT, TREAT ABC PROBLEMS, OBTAIN BASELINE VITALS, AND CONSIDER TRANSPORT PLAN BASED ON GENERAL IMPRESSION

  2. ADMINISTER OXYGEN AT 15L PER NON-REBREATHER MASK

  3. check to see if the patient has already taken any aspirin. GIVE ASA PER NORMAL EVEN IF THEY HAVE ALREADY TAKEN ASPIRIN

  4. HAVE THE PATIENT CHEW 4 tablets of 81MG each of aspirin (324 mg)

  5. record the time of administration, dose administered and patient response

  6. transport promptly and continue to reassess the patient

  7. contact medical control if needed

25
Congestive Heart Failure (Pulmonary Edema)

Routine Patient Care

Place patient in semi-sitting or full sitting position

Administer oxygen at a rate to keep oxygen saturation above 90%

Facilitate administration of patient’s own nitroglycerin if SBP>90 (see Idaho specific protocol

Appendix A).



Intermediate 85Standing Orders

IV access, administer fluid to maintain systolic blood pressure>90mmHg




Cardiac Arrest – Adult
Basic Standing Orders

Routine Patient Care.

*If the patient is unresponsive and CPR has not been started yet, begin providing chest compressions and rescue breaths at a ratio of 30 compressions to two breaths, continuing until an AED arrives

*Turn on AED remove clothing from patient’s chest area. Apply pads to the chest one just right of the breastbone (sternum) just below the collarbone (clavicle), the other on the left lower chest area with the top of the pad 2” to 3” below the arm pit.

*Stop CPR

*Press the Analyze button if there is one, if not wait for the AED to analyze the cardiac rhythm.

* If no shock is advised, perform five cycles of CPR (2 minutes), reanalyze the cardiac rhythm.

* If a shock is advised, recheck to make sure the all is clear, and deliver a shock, After the shock is delivered, immediately resume CPR beginning with chest compressions if the patient remains pulse-less and apnic, for two minutes (5 cycles).

* Repeat analyzing the cardiac rhythm deliver shock if indicated.

* After the shock is delivered, immediately resume CPR beginning with chest compressions if the patient remains pulse-less and apnic, for two minutes (5 cycles).

*Prepare patient for transport. Transport continuing chest compressions and ventilations, ventilate with high flow oxygen with BVM or barrier device if available.
For Traumatic Cardiac Arrest:

Minimize on scene time, stabilize/control traumatic injuries if possible, Start CPR

OR

Consider termination of efforts or not attempt resuscitation if (see DNR Order Protocol and/or Special Resuscitation Situations and Exceptions Protocol).



Intermediate -85 Standing Orders

Document presenting cardiac rhythm.

Airway management as appropriate and trained.

Consider treatable causes; overdose, hypothermia, poisoning. Treat as per specific protocol.

IV access, administer fluid to maintain systolic blood pressure>90mmHg

For Asystole:

Contact Medical control; consider termination of efforts (see Special Resuscitation Situations and Exceptions Protocol).


26

For PEA:

Bolus IV 0.9 normal saline 250-500ml

Consider causes, Hypothermia, tension pneumothorax, cardiac tamponde.

Continue therapy as indicated by rhythm

For Trauma;

Do not delay transport for IV, or advanced airway management.

IV 1 or 2 large bore lines en route, wide open




Cardiac Arrest – Pediatric
Basic/ Standing Orders

Routine Patient Care.

*Start CPR, patients age 0-1 30:2 one person rescuer 15:2 two rescuer.

* Patients 1year to onset of puberty; Start CPR if not in progress, (30:2 one person rescuer 15:2 two rescuer), CPR is to be administered for five cycles prior to use of AED.

*AED according to the manufacturer’s instructions and follow prompts. AED use in pediatric patients should be used with pediatric-sized pads and a dose- attenuating system. However, if these are unavailable, you should use adult size pad, placement of pads one in front and one on the anterior potion of the trunk.

* Repeat analyzing the cardiac rhythm deliver shock if indicated.

* After the shock is delivered, immediately resume CPR beginning with chest compressions if the patient remains pulse-less and apnic, for two minutes (5 cycles).

Prepare patient for transport. Transport continuing chest compressions and ventilations, ventilate with high flow oxygen with BVM or barrio devise if available.

IV 1 or 2 large bore lines, TKO

For Trauma:

*Minimize on scene time, stabilize/control traumatic injuries if possible, Start CPR

IV 1 or 2 large bore lines en route, wide open
OR

*Consider termination of efforts or not attempt resuscitation if (see DNR Order Protocol and/or Special Resuscitation Situations and Exceptions Protocol).

27

DO NOT RESUSCITATE (DNR) ORDERS IDAHO EMS GUIDELINE

INDICATIONS:

Patient is in respiratory or cardiac arrest

AND

Patient has an intact, original DNR order (or

signed and dated photocopy of original),

bracelet or necklace



OR

Patient's physician has written a DNR order

for this patient for this interfacility transport or

a patient has a DNR order from another state.

CONTRAINDICATIONS:

The comfort ONE/DNR order has been

revoked by the patient, legal surrogate, or

attending physician.

comfort ONE/DNR order (or photocopy of

original, bracelet or necklace) is not

physically present or has been defaced or destroyed.

Family members vigorously and persistently

insist on resuscitation.

1. Perform routine patient assessment, resuscitation, or other medical interventions until



comfort ONE status is confirmed.

2. If unaltered comfort ONE order, photocopy, bracelet or necklace is found, obtain

reasonable assurance that the patient is the person for whom the order was written.

3. If DNR status is confirmed: EMS PROVIDERS MAY PROVIDE COMFORT CARE

Open the airway

Suction the airway

Administer Oxygen

Position for Comfort

Provide Emotional Support

Control Bleeding

Apply Splints

Administer pain medication in accordance with scope of practice and local protocol.

4. If DNR status is confirmed: EMS PROVIDERS MAY NOT

Initiate CPR

Provide Ventilator Assistance

Initiate Cardiac Monitoring

Defibrillate

Administer Resuscitative Medications

5. If resuscitative efforts have been started before learning of a valid comfort ONE DNR

order, stop those resuscitative efforts.

6. If it is determined the patient is not a comfort ONE DNR patient or does not have a DNR

order from another state or a DNR order for this interfacility transfer, proceed with all

resuscitative efforts within scope of practice. Contact medical control for any permission to

discontinue.

7. Revoking the comfort ONE DNR order may only be done by the patient, (regardless of

mental status), legal surrogate, or attending physician, either verbally, or by removing the

bracelet or necklace or destroying the original form and/or photocopy with patient. If

revoked, perform full resuscitation.

8. The DNR order may be disregarded only if there is a good faith belief the order has been

revoked, to avoid confrontation or if ordered to do so by the attending physician.

9. Complete the Idaho EMS Patient Care Report Form using applicable boxes. State in the

narrative how the patient was identified, events occurring during the EMS run, any verbal

attending physician orders and patient outcome

28

29



Abdominal Injuries (Penetrating) – Adult
Basic/ Intermediate 85 Standing Orders

Routine Patient Care.

Cover open wounds with occlusive dressings.

Stabilize all impaled objects as found; do not remove them.

Cover evisceration-type wounds with moist sterile dressings.

Do Not attempt to place organs back into body.

With hemodynamic compromised and signs and symptoms of shock place patient in Trendelenberg position.

Consider air medical transport/trauma center if indicated and appropriate.

IV access, large bore (12g-16g) administer fluid to maintain systolic blood pressure>90mmHg

Do not delay transport for IV access.

With hemodynamic compromised and signs and symptoms of shock;

250 ml fluid bolus

Establish second line 0.9 Normal saline large bore (12g-16g) 1 @ KVO.


Abdominal Injuries (Penetrating) – Pediatric

Basic/Intermediate85 Standing Orders

Routine Patient Care.

Cover open wounds with occlusive dressings.

Stabilize all impaled objects as found; do not remove them.

Cover eviscerations-type wounds with moist sterile dressings.

Do Not attempt to place organs back into body.

With hemodynamic compromised and signs and symptoms of shock place patient in Trendelenberg position.

Consider air medical transport/trauma center if indicated and appropriate

IV access 0.9 Normal saline @ KVO

Contact medical direction on fluid replacement.


Drowning/Submersion Injuries

Basic Intermediate85 / Standing Orders

Routine Patient Care.

Assume C-spine injury and stabilize C-spine.

Obtain specific history: time, temperature, associated trauma, etc.

Begin resuscitation efforts while removing the patient from the water.

Consider hypothermia.

Consider patient with submersion injuries should be transported to hospital.

Consider termination of efforts (Special Resuscitation Situations and Exceptions Protocol).

IV access, and administer fluid to maintain systolic blood pressure>90mmHg

Consider advanced airway techniques.

30

Eye and Dental Injuries
EYE
Basic Intermediate 85 / Standard Care

Routine Patient Care

Obtain visual history (use of corrective lenses, surgeries, use of protective equipment).

Obtain visual acuity, if able.

Chemical irritants: flush with copious amounts of water, or normal saline.

Thermal burns to eyelids: patch both eyes with cool saline compress.

Impaled object: immobilize object and patch both eyes.

Puncture wound: place protective device over both eyes (e.g. eye shield). Do not apply pressure.

Foreign body: patch both eyes gently.

In the event patient is unable to close eyelids, keep eye moist with sterile saline compress.

IV access, administer fluid to maintain systolic blood pressure>90mmH

Dental Avulsion
Basic/Intermediate 85Standing Orders

Routine Patient Care.

Dental avulsion should be placed in an obviously labeled container with normal saline or milk.

Burns (Thermal) – Adult
Basic Intermediate85/ Standing Orders

Routine Patient Care.

Stop burning process. Remove jewelry.

Decontaminate patient as appropriate.

Assess patient’s airway for evidence of smoke inhalation or burns: soot around mouth or nostrils, singed hair, carbonaceous septum. Maintain patent airway.

Determine extent of burn using Rule of Nine. Determine depth of injury.

If a partial thickness burn (2°) is less then 10 % body surface area, apply cool water, wet towels for a maximum of 15 minutes to burned area. Prolonged cooling may result in hypothermia. Maintain body heat.

Cover burns with dry, sterile sheet or, dry sterile dressings.

Do not apply any ointments, creams or gels to burn area.

Consider air medical transport directly to burn center.

IV access, administer fluid to maintain systolic blood pressure>90mmHg

If partial thickness (2°) or full thickness (3°) burns > 10% BSA consider: 250 ml fluid bolus.

31

Burns (Thermal) – Pediatric

Basic/Intermediate85 Standing Orders

Routine Patient Care.

Stop burning process. Remove jewelry.

Decontaminate patient as appropriate.

Assess patient’s airway for evidence of smoke inhalation or burns: soot around mouth or nostrils, singed hair, carbonaceous septum. Maintain patent airway.

Determine extent of burn using Pediatric Rule of Nine. Determine depth of injury.

If a partial thickness burn (2°) is less than 10 % body surface area, apply cool water, wet towels for a maximum of 15 minutes to burned area. Prolonged cooling may result in hypothermia. Maintain body heat.

Cover burns with dry, sterile sheet or, dry sterile dressings.

Do not apply any ointments, creams or gels to burn area.

Consider air medical transport directly to burn center.

IV access and contact medical control for fluid replacement therapy.
Adult Rule of Nine

32

Pediatric Rule of nine



33
Traumatic Brain Injury
Basic/ Intermediate85Standing Orders

Routine Patient Care

If breathing is inadequate ventilate with 100% oxygen utilizing normal ventilation parameters.

Continually monitor SBP.

Assess and document pupillary response and Glasgow Coma Scale every 5 minutes.

If SBP > 110mmHg, elevate head of backboard 15-30 degrees.

Consider ALS intercept/air medical transport.

If signs of cerebral herniation are present, such as:

SPO2<90%, GCS<9, non-reactive, dilated, or asymmetrical pupils, or persistent seizure without lucid

period, assist ventilations at the following rate:

ADULT: 20 bpm

CHILD: 30 bpm

INFANT: 35 bpm

Discontinue hyperventilation if signs/symptoms improve.

IV access, administer fluid to maintain systolic blood pressure>90mmHg
Thoracic Injuries – Adult

Basic Intermediate-85/ Standing Orders

Routine Patient Care.

Open chest wound:

Cover with non-petroleum occlusive dressing, sealed on 3 sides or commercial device; if condition deteriorates, remove the dressing momentarily then reapply.

In the case of flail segment with paradoxical movement, use positive pressure ventilation.

Consider air medical transport.

IV access, administer fluid to maintain systolic blood pressure>90mmHg

Do not delay transport for IV access.


Thoracic Injuries – Pediatric

Basic Intermediate 85 /Standing Orders

Routine Patient Care.

Open chest wound:

Cover with non-petroleum occlusive dressing, sealed on 3 sides or commercial device; if condition deteriorates, remove the dressing momentarily then reapply.

In the case of flail segment with paradoxical movement, use positive pressure ventilation.

Consider air medical transport.

IV access, 0.9 normal saline @KVO contact medical control for further direction.

Do not delay transport for IV access


34


Upper Airway Suctioning

Critical Indications:

Obstruction of airway(secondary to secretions, blood, and/or any other substance) in a patient currently being assisted with an airway adjunct such as NPA , OPA tube, Combi-tube/King Airway, tracheostomy tube or a cricothyrotomy tube.

Procedure:

Ensure the suction device is operable.

Preoxygenate the patient.

Keep an aseptic technique, attach the suction catheter to the suction unit.

If applicable, remove devices from airway.

Insert sterile end of catheter into the tube without suction. Insert until resistance is met, pull back approximately 1-2 cm.

Once the desired depth is met apply suction by occluding the port and slowly remove the catheter from the tube, using a twisting motion.

Suction duration should not exceed 15 seconds.

May use saline flush to loosen and facilitate suctioning.



Reattach the ventilation device and oxygenate the patient.


AIRWAY/BREATHING

AIRWAY/BREATHING GUIDELINES
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