Lemhi County Medical Supervision Plan Emergency Medical Service Patient Care Protocols



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GUIDELINES OF AIRWAY ASSESSMENT

PARTIAL OBSTRUCTION

  • May include coughing with some air movement. Give 100% Oxygen and encourage the patient to cough. Monitor for change. Transport immediately.

FOREIGN BODY AIRWAY OBSTRUCTION(FBAO)

  • Should be removed immediately if able, Using AHA guidelines for airway obstruction (Abdominal trusts, or on unconscious victim CPR. Visualize airway and either suction or sweep out liquids and other materials Solids must be with finger or instrument.




GUILDLINES OFBREATHING ASSESSMENT

STRIDOR

  • High pitched crowing sound caused by obstruction of upper airway. (Epiglottis/Croup)

WHEEZING

  • A whistling or sighing sound, usually lower airway and found upon expiration (Asthma)

RALES

  • Fine to course crackle representing fluid in the lower airway (CHF)

COPD

  • Pulmonary disease (emphysema/chronic bronchitis) that is characterized by chronic typically irreversible airway obstruction resulting in slower rate of exhalation.

EPIGLOTTITIS

  • Inflammation of the epiglottis is usually caused by Hemophilus influenza type B bacteria



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KEY POINTS

Airway Assessment:

  • If you don’t have an airway_ you don’t have anything

  • C-Spine precautions must be considered prior to insertion of airway adjuncts. Provide manual stabilization prior to insertion

  • See PEDIATRIC Section for pediatric airway management.


Breathing Assessment:

  • Be sure the airway is open before assessing breathing

  • When assessing breathing , observe rate, quality, and equality of chest movement.

  • Maintain continual assessment when applying high flow oxygen (15 liters per non-re-breather)

  • on ALL COPD patients. Some may stop breathing with long term high flow. Be prepared to support breathing with BVM.

  • Always record vital signs when treating breathing problems.


AIRWAY/BREATHING

AIRWAY ADJUNCTS

ADJUNCT

INDICATIONS

CONTRAINDCATIONS

COMMENTS

Suction



Indispensable for all patients with fluid or particulate debris in airway

NONE

No more than 15 seconds per attempt

Modified jaw thrust


Initial airway maneuver for all trauma patients


NONE


Does not protect against aspiration in a patient with a depresses level of consciousness

Head Tilt Chin Lift

Opening airway of non-trauma patient

Potential cervical spine injury

Same as above

Nasal airway

Obstruction by tongue with gag reflex present

Potential mid-face injury. Not to be used if suspicion of Head injury

Same as above

Oral airway

On all patients with the inability to maintain airway (i.e.) tongue obstruction

Positive gag reflex

Same as above

King LT-D Airway

Size:


Green: Size 2:12-25 kg

Yellow: Size:3 4-5 feet tall

Red Size 4:5-6 feet tall

Purple Size 5: > 6 feet tall



Pulses/ apnic patient, inability to adequately ventilate patient with Bag Valve Mask or longer EMS transport distances.

Positive gag reflex

Known esophageal disease,

Ingestion of caustic substance


Remove dentures and use caution if trauma with broken teeth.

(see procedure guide)




Combitube

Size:


37 FR 4-5 feet tall

41 FR > 5 feet tall



Pulses/ apnic patient, inability to adequately ventilate patient with Bag Valve Mask or longer EMS transport distances.

Height under 4 Feet

Positive gag reflex

Known esophageal disease,

Ingestion of caustic substance





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Lemhi County EMS

KING LT-D Airway Procedure


Skill Level: ILS 85 or Higher

Procedure:

1. Preoxygenate the patient.

2. Select the appropriate tube size for patient.

3. Lubricate the tub, using water soluble lubricant (KY).

4. Grasp the patients tongue and jaw with gloved hand and pull forward.

5. Remove any ill fitting dentures, suction any fluid.

6. Gently insert the tub rotating laterally 45 degrees so that the blue orientation line is touching the corner of the mouth Once the tip is at the base of the tongue, rotated the tube back to midline. Insert the airway until the base of the connector is in line with the teeth and gums.

7. Inflate the pilot balloon with 25-80 ml of air depending on the size of the device used.

8. Ventilate the patient while gently withdrawing the airway until the patient is easily ventilated.

9. Auscultate for breath sounds and the sounds over the epigastrium and look for the chest to rise and fall.

10. The large pharyngeal balloon secures the device. Inflate Size 4 ,70 ml Size 5, 80 ml Inflation

11. Confirm tube placement using end-tidal CO2 detector.

12. It is required that the airway and tube placement be monitored continuously.
Competency Based Skill Requirements:

Maintain knowledge of the indications, contraindications, technique, and possible complication of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, class room demonstrations, skills stations, or other mechanism as deemed appropriate. Assessment should include direct observation at lease quarterly per certification cycle.


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Lemhi County EMS

Combi-tube


Skill Level: ILS 85 or Higher

Procedure:

1. Ventilate the patient per AHA guidelines (1-2 seconds per ventilation) using a BVM with supplemental oxygen for at least two minutes prior to attempting to insert the CombiTube.

2. Select the appropriate tube size for patient.

3. Lubricate the tub, using water soluble lubricant (KY).

4. Grasp the patients tongue and jaw with gloved hand and pull forward.

5. Remove any ill fitting dentures, suction any fluid.

With patient in supine position, head placed in neutral or "sniffing" position, grasp the mandible between thumb and forefingers. If C-Spine precautions are not a factor, the patient's head may be placed in the head-tilt position to facilitate placement

6 Lift the mandible anteriorly, keeping the C-Spine aligned as appropriate.

7 Holding the CombuTube in the other hand, with its curve towards the pharynx, insert the tip into the mouth and advance it into the phaynx and esophagus.

8. Advance the airway gently until the black printed lines on the proximal end of the airway, straddle the teeth or gums. If any resistance is met during insertion, withdraw, re-evaluate the patient and re-attempt placement.

9.The insertion procedure should be accomplished in less than 20 seconds.

10.Inflate the proximal cuff with approximately 100cc's of air. you should notice the airway moving slightly as the cuff inflates and seats in the posterior oropharynx. Inflate the distal cuff with approximately 15cc's of air.

11.Using a BVM, ventilate through the port labeled #1 (blue tube). Auscultate lung sounds bilaterally. If lung sounds are present, epigastric sounds are absent and the chest rises, it is positioned in the esophagus and continued ventilation shoud be performed. If the chest does not rise and lung sounds are not heard, or epigastric sounds are heard, attempt ventilation through the port labeled #2 (clear tube). Auscultate breath sounds again. If breath sounds are heard, the tube has been placed into the trachea and ventilation should be continued. Insure that the proximal and distal cuffs are inflated and continue ventilations.

12. Ventilate the patient while gently withdrawing the airway until the patient is easily ventilated.

13. Auscultate for breath sounds and the sounds over the epigastrium and look for the chest to rise and fall.

14. The large pharyngeal balloon secures the device.

15. Confirm tube placement using end-tidal CO2 detector.

16. It is required that the airway and tube placement be monitored continuously.


Competency Based Skill Requirements:

Maintain knowledge of the indications, contraindications, technique, and possible complication of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, class room demonstrations, skills stations, or other mechanism as deemed appropriate. Assessment should include direct observation at lease quarterly per certification cycle. 38



BLOODBORNE/AIRBORN PATHOGENS

BLOODBORNE PATHOGENS


Emergency Medical personnel should assume that all body fluids and tissues are potentially infectious with bloodborne pathogens including HIV (causing AIDS), HBV, and HCV (causing hepatitis), and must protect themselves accordingly by use of body substance isolation (BSI).
Body substance isolation procedures include the appropriate use of hand washing, protective barriers (such as gloves, masks, goggles, etc.), and care in the use of disposal of needles and other sharp instruments. EMT’s are also encouraged to obtain the hepatitis B vaccine series to decrease the likelihood of hepatitis B transmission.
EMT’s who have exudative lesions, weeping dermatitis, or open wounds should refrain from all direct patient care and from handling patient-care equipment as they are at increased risk of transmission and reception of bloodborne pathogens through these lesions. Transmission of bloodborne pathogens has been shown to occur when the blood of the infected patient is able to come in contact with the blood of the health-care worker.
EMT’s who have had a direct bloodborne pathogen exposure should immediately wash the exposed area with soap and water and a suitable disinfectant. The exposed area should then be covered with a sterile dressing. Upon arrival at the destination hospital, after responsibility for the patient has been transferred to the emergency department, the EMT should thoroughly cleanse the exposed site. Report the exposure to the attending Emergency Room charge RN. If the exposure is significant complete the State of Idaho Exposure Form. Contact Emergency Service Coordinator for this form. Follow post-exposure procedure (see pg 62.)
AIRBORNE PATHOGENS

EMTs who believe they have been exposed to an airborne pathogen may proceed a above in getting timely medical. It is expected that a properly filled out Patient Care Report will allow hospital infection control staff to contact EMTs involved in patient care where that patient was subsequently found to have a potential airborne pathogen such as Tuberculosis, Neisseria meningitis, SARS, etc.



AIRBORNE PERSONAL PROTECTIVE EQUIPMENT (APPE)

Recommended APPE consists of a fit-tested N95 respirator. In the absence of an N95 mask, the EMS providers should wear a surgical mask.

Apply APPE if the patient presents with the following signs and symptoms:

Cough


Fever

Rash


Limit the number of personnel in contact with suspected patient to reduce the potential of exposure to other providers and bystanders.

Patients suspected of being infected with a possible airborne pathogen should be masked if tolerated. Patients requiring oxygen therapy should receive oxygen through a maskwith a surgical mask placed over the oxygen mask to block pathogen release. Close monitoring of the patients respiratory status and effort should be maintained

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Airborne pathogens continued
APPE should be in place when performing suction, airway management, and ventilation assistance.

Limit procedures that may result in the spread of the suspected pathogen, e.g. nebulizer treatments.


Exchange of fresh air into the patient compartment is recommended during transport of a patient with a suspected airborne pathogen.
Early notification to the receiving hospital should be made such that the receiving hospital may enact its receptive airborne pathogen procedures.
DECONTAMINATION
In addition to accepted decontamination steps of cleaning surfaces and equipment with an approved solution and proper disposal on contaminated disposable equipment, the use of fresh air ventilation should be incorporated (open all doors and windows to allow fresh air after arrival at the hospital).
All personnel after contact with the patient should wash hand thoroughly with warm water and an approved hand-cleaning solution.
Ambulance equipment with airborne filtration systems should be cleaned and maintained in accordance with manufactures guidelines.

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Behavioral Emergencies including Suicide Attempts and Threats

Scene Safety


  • Avoid the use of light and sirens on approach

  • Secure the area and move bystanders away.

  • Approach in teams of two, with one rescuer focusing on patient and other on scene control.

  • Approach in calm supportive manner.

  • Offer reassurance: Let them know you can help them/get them help.

  • Respect the dignity and privacy of the individual.

  • Keep distance from patient if the rescuers presence increases the patient’s agitation.

  • Avoid care of an agitated patient in room with only a single entrance/exit, if possible.

  • Position yourself to allow easy egress for either yourself or the patient.

  • Never leave a rescuer alone with a potentially violent or dangerous patient.

  • Do not leave an at risk or potentially dangerous patient unattended or unsupervised even briefly

  • Talk in conversational tones, reflect back to them what they said (insures accuracy)

  • Respond to hallucinations or delusions by talking about the patients feeling rather than what he/she is saying.

  • Give firm, clear directions; one person should talk to the patient

  • Explain clearly what will happen next and allow patient choice when possible

Basic/ Intermediate -85 Standing Orders:

Routine Patient Care

Observe and record patients behavior.

Determine if the patient is under the care of mental health professional and record contact information

Assess for the rick to self and others


  • Ask directly “ Are you thinking about killing yourself or someone else, hurting yourself or hurting others”

  • If yes, ask directly “ Have you thought about how you will do this”

  • If yes, find out if he or she has the means available, or is attempting to procure the means to carry out his/her thoughts. Ask directly , “Do you have or know where you can get{ gun, pills, rope car, etc.}”

  • If yes, “Have planned out where and when you will do this?”

  • If yes,” Does anyone else know about your plans?” ( Teenagers and young adults sometimes engage in suicide pacts with another person).

If the patient is a risk for suicide or violence towards others:

  • Transport to the hospital for evaluation by mental health professionals

  • If patient refuses transport, contact law enforcement for assistance

  • Restrain if necessary and only for the patient’s and crew’s safety.

Restraint Notes:

Use the minimum force necessary. Restraint is never for punitive reasons.

Frequent airway monitoring

DO NOT restrain patient:



  • face down,

  • with hands behind back,

  • with both hand over head to the top bar of stretcher (one hand is accepted),

  • with straps over lower thorax or upper abdomen

  • using a “sandwich” restraint with scoop and backboard.

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Crime Scene/Preservation and Evidence
*If you believe a crime has been committed, immediately contact law enforcement.

*Protect yourself and other EMS personnel. You will not be held liable for failing to act if a scene is not safe to enter. Once crime scene is deemed safe by law enforcement, initiate patient contact and care.

*Have all EMS providers use the same path of entry and exit. Do not walk through fluids on the floor.

*Observe and document original location of items that are moved by the crew.

*When removing the patients clothing, leave intact as much as possible. DO NOT cut through clothing holes made by gunshot or stabbing.

*If you remove any item from the scene, such as impaled object or medication bottle, document your action and advise investigating officers.

*DO NOT sacrifice patient care to preserve evidence.

*Consider requesting a law enforcement officer to accompany the patient in the ambulance to the hospital.

*Document comments made by the patient and bystanders on the EMS PCR form.

* Inform the staff at the hospital that this is a “crime scene” patient.

* If the patient is obviously dead, contact medical control for directions to withhold resuscitation measures and do not touch the body.

* For traffic accidents, preserve the scene by parking away from skid marks and debris.

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Management of Patient Subdued by Taser

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Abuse & Neglect- Child, Elderly or Other Vulnerable Individuals


Purpose: To provide the process for identification, assessment, management and reporting of patients with suspected physical abuse (children, elderly, or other vulnerable individuals), exploitation and/or neglect.
Procedure for Assessment:

Treat and document only physical injuries requiring immediate attention using appropriate medical treatment protocols, without causing undue emotional trauma for non life–threatening injuries. Secure and bag (in paper), when possible, any clothing or items that could be preserved for evidence.

Interviews with patients shall be conducted calmly, with respect and privacy, and should include close observation for:


  • Over-sedation

  • Inappropriate fears

  • Avoidance behaviors

  • Poor parent-child bonding

  • Inappropriate interaction with care giver

DO NOT address specifics of abuse or neglect.

Obtain pertinent history relating to presenting injuries.

Carefully and specifically document verbatim any patient statements of incidences of rough handling, sexual abuse, alcohol/drug abuse, verbal or emotional abuse, isolation or confinement, misuse of property, threats, and gross neglect such as restriction of fluid, food, or hygiene.

Note problems with living conditions and the environment.

Note any of the following indicators of an abusive history or environment:


  • Unsolicited history provided by the patient

  • Delay in seeking care of injury

  • Injury inconsistent with history provided

  • Conflicting reports of injury from patient and care-giver

  • Patient unable or unwilling to describe mechanism of injury

  • Lacerations, bruising, ecchymoses in various stages of healing

  • Multiple fractures in various stages of healing

  • Scald burns with demarcated immersion lines without splash marks

  • Scald buns involving anterior or posterior half of extremity.

  • Scald burns involving buttocks or genitalia

  • Cigarette burns

  • Rope burns or marks

  • Patient confined to restrictive space or position

  • Pregnancy or presents of sexually transmitted disease in a child less than 12 years

Special Considerations

Law enforcement may be contacted at the discretion of the EMS provider, however assure the safety of EMS personnel before entering the scene.

If patient is not transported, the suspected abuse must still be reported. If a parent/guardian refuses treatment of a minor child whom you feel needs medical attention, contact law enforcement immediately.

Careful and specific documentation is vital because the “story” often changes as the investigation proceeds. 44

Child Abuse: Follow Idaho Specific Code CHILD PROTECTIVE ACT (see appendix A)

Elderly Abuse: Follow Idaho Specific Code Idaho Code 39-5303

NOTE: Nothing contained herein shall be construed to mean that any minor of sound mind is legally incapable of consenting to medical treatment provided that such minor is of sufficient maturity to understand the nature of such treatment and the consequences thereof.


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