Protocols - Introduction V3 9-23-15
Contents
1. General Points to Remember e For each and every call the first directives are scene safety and Body Substance Isolation BSI precautions e The cardiac monitor defibrillator or AED SHALL be carried to the patient on high probability of cardiac arrest calls Rapid defibrillation of ventricular tachycardia and ventricular fibrillation is the treatment of choice in witnessed cardiac arrest and cardiac arrest where CPR is being performed correctly and this is crucial to patient survival Some examples but not limited to of calls that require you to bring the monitor to the patient are suspected AMI chest pain altered level of consciousness cardiac arrest or person down If you are away from the unit and the patient is found to be pulseless one crew member should begin CPR and the other should retrieve the cardiac monitor defibrillator or AED If the patient has been in cardiac arrest without CPR or ineffective CPR for greater than 5 minutes CPR should be performed for 2 minutes before a shock is delivered if appropriate or the AED is allowed to analyze AED s pads should be attached to analyze just prior to the 2 minute interval to achieve this goal the unit will not go past the point of connect electrodes until they are physically attached to the patient s chest Effective CPR and minimum hands off time are essential to give the patient the greatest chance of survival e Cold water drowning is addressed differently than rout2. airway maneuvers whenever endotracheal intubation takes longer than 30 seconds e Administer a 20 50 ml fluid bolus after administering a drug IV and elevate the extremity if it is a peripheral IV These measures will aid in rapid delivery of the medicine to the central circulation e Treat the patient not the monitor Introduction Adult Points R 3 0 Page 1 of 1 A 2 Protocol Manual Introduction Basic Assessment amp Management This is a general set of treatment guidelines that should be applied with each patient encounter as required This has been developed to alleviate clutter in each Standing Order Protocol Perform these measures as appropriate for each patient This Standing Order will refer you to other orders for more detailed information Personnel should not attempt any procedures that falls outside their scope of practice All references made are considered adult unless otherwise noted Pediatric doses are in a different color bold and italics after the adult dose except the cardiac dysrhythmia arrhythmia protocols which are listed separate due to some major differences in treatment STANDING ORDER Airway e Assess every patient s airway If the airway is not patent and self maintained intervene quickly Utilize the appropriate airway positioning maneuver head tilt chin lift non trauma and the modified jaw thrust trauma Airway interventions should proceed in the following order Bag valve mask ventila
3. be administered DO NOT access the central line for a TKO IV Utilize the RESQPOD as indicated in ResQPOD Procedure 29 2 Vascular access Refer to Vascular Access Procedure 31 Introduction Basic Management R 3 1 Page 3 of 10 A 3 Protocol Manual Introduction Basic Assessment amp Management Bleeding Direct pressure should be the first option to control bleeding Pressure points are no longer recommended If major bleeding is not controlled quickly with direct pressure consider tourniquet early Arterial bleeding consider a tourniquet first Tourniquets are only used on the arms and legs Commercial tourniquets are the best option Man made tourniquets may fail Bleeding from the groin or other areas a tourniquet cannot be applied use Hemostatic agent Refer to Bleeding Control Procedure 3 1 Hemostatic agents may be used in conjunction with a tourniquet e Severe bleeding may require two 2 tourniquets place the 2 above the 1 tourniquet e Refer to Bleeding Control Procedure I 3 1 Defibrillation cardioversion Wilson County EMA has all Zoll Biphasic monitor defibrillators and AED s Zoll uses Rectilinear Biphasic Waveform RBW The energy settings are different from Truncated Biphasic Waveform TBW Refer to the Electrical Therapy Procedure l 15 Physical assessment e Acknowledge and investigate the chief complaint and do a Primary Assessment ABC s e Perform
4. years of age e chest pain discomfort any age or cause e drug overdose intoxicated patients e potentially head injury patients Introduction Basic Management R 3 1 Page 9 of 10 A 3 Protocol Manual Introduction Medication Administration When a medication must be drawn up for administration the provider shall only draw up the approximate amount of medication that is indicated for that patient This will decrease the possibility of making a medication error The provider shall also use the most appropriately sized syringe to draw up the medication This will allow the provider to deliver a more accurate dosage For example If you must administer 40 mg of ketamine you would use a 1 cc syringe If you must administer 100 mg of ketamine you would use a 3 cc syringe Medication Error Reporting As diligent as everyone attempts to be mistakes can and will occur In the event providers make a medication error they shall immediately notify the receiving health care provider medical control and or poison control Once the providers are finished with the call and they have transferred patient care they should immediately contact the Compliance Officer or the EMS Chief respectively If the provider discovers the medication error at a time after the call they should contact the administrators listed above to report the incident and receive further instructions The provider shall also coordinate with the Compliance Officer and the EMS C
5. Wilson County Emergency Management Agency Protocols amp Standing Orders Manual Introduction Authorization for Standing Orders The Wilson County Emergency Management Agency WEMA Protocols and Standing Orders revision 3 0 project completed May 2015 are hereby adopted to be initiated by WEMA personnel within their scope of training and licensure whenever a patient presents with injury or illness covered by these orders When noted in the protocols where it is indicated to contact medica control direction the EMR EMT EMT IV AEMT or Paramedic must receive written or verbal orders from medical control direction before proceeding with the protocol Other orders may be obtained from medical control direction when the situation is not covered by the protocols or as becomes necessary as deemed by the EMR EMT EMT V AEMT or Paramedic In order to make future revisions or additions easier each protocol is signed individually Unless otherwise directed the protocols within this manual may be utilized as standing orders These protocols may be utilized by First Responding Agencies with a Memorandum of Understanding MOU with Wilson County Emergency Management Agency WEMA These protocols are to be used while treating a patient s in the care of First Responding Agency personnel and or Wilson County Emergency Management Agency WEMA personnel This includes full and part time on duty personnel however it shall also include both full and pa
6. a Secondary Assessment Rapid Trauma Assessment or Focused Physical Exam e Detailed Physical Exam usually completed during transport head to toe assessment on all patients with significant trauma if condition and time permit l e maintaining ABC s would take priority over a detailed assessment document accordingly e Perform a focused exam based assessment on medical patients or minor trauma patients e A limited assessment may be appropriate if there is any compromise in the ABC assessment e Patients should receive an ALS patient assessment if personnel available when time and resources permit so the patient can make an informed decision on treatment and or transport History e Historical information may be very important in determining the patient s current problem e Obtain a SAMPLE history to assist in assessment and or treatment e Medical situations should have an OPQRST assessment done Assess Vital Signs e Blood pressure Critical patients should have a blood pressure taken at 5 minute intervals Non critical patients should have a blood pressure recorded at least every 15 minutes Make sure to take a set of vital signs before administration of vasoactive drugs If you are unable to meet these time guidelines for valid reasons document accordingly If automated BP devices are utilized the first BP MUST be done manually e Pulse Document the presence strength and regularity of pulses as appropriate Document pulses or
7. atric Resuscitation Drug Chart H 13 e Remember that few pediatric arrests are primary cardiac events Most stem from respiratory airway problems dehydration metabolic imbalances or hypothermia Ensure that a child that arrests or is pending arrest is well oxygenated well hydrated and warm Prognosis is extremely poor for a child that arrests e Treat children aggressively before they arrest e Never administer a calcium channel blocker to a pediatric patient unless directed to do so by medical control direction e Refer to the Pediatric Drug Mixtures H 12 to mix pediatric drips e Utilize the Dose Medic Drug Dosing Guide to minimize drug dosage errors e To determine the lowest systolic BP 70 mm Hg plus age in years x 2 For example 4 year old 70 4 x 2 8 8 78 mm Hg e Reference materials are recommended in pediatric calls due to the low call volume e ETT size can also be determined by 1 diameter of the patients pinky finger 2 16 age in years divided by 4 example 4 year old 16 4 20 divided by 4 5 a 5 0 ETT is recommended e Pediatric ET tubes may be cuffed or un cuffed uncuffed should not leak if the correct size tube is utilized it will seal without a cuff bulb When utilizing a cuffed tube the amount of air should only be enough to seal the airway e Reference material and shortcut equations are general recommendations they may always be the exact size etc If a 5 0 ETT is r
8. be depth It is important to place the endotracheal tube to the proper depth The optimal placement of oral endotracheal tube can be best estimated by multiplying the tube size by 3 The tube depth should be measured at the front teeth Example If you are intubating with a 7 5 ET tube it should be at 22 5 cm An 8 0 ET tube should be placed at 24 cm These are general recommendations e Direct visualization if applicable This is not always a reliable method e Waveform capnography shall be used on all intubated patients Refer to Capnography 4 General Treatments e Initiate vascular access with a saline lock or IV infusion of fluid only if indicated IO access as indicated and up to your scope of practice AEMT amp Paramedic EZ IO should not be utilized on neonate patients less than 3 kg e lO access should be gained on critical adult and pediatric patients if IV access is not readily available IV should be attempted at least twice before the IO is attempted Looking and determining this is acceptable AEMT only in the physical presence of a Paramedic e Position of comfort unless contraindicated by need for spine protection or blood pressure concerns e Establish contact with Medical Control Direction when appropriate Use 155 340 to establish contact This ensures that verbal orders or denials are recorded for your protection The cellular phone may be used if you are out of radio range or your primary radio is out of servic
9. e e Initiate pain control as appropriate Remember to start slow and titrate up when administering pain medication Pain control is very important e All treatments are suggestive the patients condition a good patient assessment and good clinical judgment prevail in determining the course of treatment action for the patient Air Medical Transport Air medical services are a great asset to EMS and patient care However we must not get tunnel vision and think this is always the best for the patient There are several things to consider such as e Time of day Road conditions road construction weather etc Incident location ETA of medical transport to the scene Landing time load time on scene patient care unload time and return trip time total time Risk Benefit Scene flight versus airport may be quicker versus finding LZ setup etc Patient s condition Any patient that has been exposed to chemicals consider the risk of them and the crew inside the helicopter and would ground transport be safer Introduction Basic Management R 3 1 Page 6 of 10 A 3 Protocol Manual Introduction Basic Assessment amp Management The EMS professional should factor all circumstances before making final decision to fly a patient Under normal circumstances the EMS professional should not wait an extended time on scene awaiting air medical transport In many cases average in Wilson County an ambulance could transport to a level
10. e Should be determined as appropriate e Length Based Tape ALL pediatric patients should be measured with a length based tape to determine equipment sizes and drug doses This should be documented in the EPCR and relayed to the receiving Emergency Room during call in e Blood glucose Check blood glucose level on ALL patients that refuses transport or an altered mental status or diabetic history e End Tidal Carbon Dioxide ETC02 Any patient that has been intubated shall have ETC02 monitoring These results shall be documented The colormetric ETCO2 device shall be utilized for initial and short term determination after 6 breaths through the ETCO2 the waveform ETCO2 from the Zoll cardiac monitor defibrillator shall be used for any patient that is intubated In hypoperfusion situations the device may not function well e Carbon Monoxide Detector RAD57 Any patient suspected of CO exposure or that has vague signs and or symptoms should have the CO detector applied to determine CO level This should be used for ALL Firefighter Rehab Endotracheal Tube Confirmation It is CRITICAL that each endotracheal tube placement be confirmed initially with the colormetric device and continual waveform ETC02 monitoring with the Zoll monitor It is recognized nationally undetected esophageal intubation is a significant morbidity mortality risk No one method of checking the tube is 100 reliable If at any point you are unsure of placement reconfirm by v
11. ecommended remember to have additional sizes available and always ensure it is the best based on your post procedure patient assessment e Pediatric IV tips 1 Cut the tourniquet s width 2 Insertion may be done bevel down in neonates and infants for a better response e Pediatric patient s are not little adults e Make an extra effort to make a good visual assessment of the pediatric patient especially the respiratory efforts and overall behavior prior to interaction due to increasing the stress of the patient e In infants a toe to head patient assessment should be done to potentially decrease the stress on the patient e EZ IO should not be utilized in patients less than 3 kg Introduction Pediatric Points R 3 0 Page 1 of 1 A 6 Wilson County Emergency Management Agency Protocols amp Standing Orders Manual Introduction Reference Page The following materials were utilized in development revision of the Wilson County Emergency Management Agency protocols American Heart Association Advanced Cardiac Life Support ACLS 2010 edition American Heart Association Basic Life Support BLS 2010 edition American Heart Association Pediatric Advanced Life Support PALS 2010 edition American Heart Association and American Academy of Pediatrics Neonatal Resuscitation 4 Edition American Academy of Orthopedic Surgeons Calculations for Medication Administration Paramedic American Academy of Orthopedic Surg
12. ed to issue medication orders e RSI cannot be utilized unless the Paramedic has been approved and is in good standing within the department They must be current on skills evaluation e The senior person riding on the ambulance has the ultimate responsibility to ensure that all patient care records and reports are properly completed e Airway maintenance appropriate for the patient s condition indicates any airway maneuver adjunct or insertions of tubes that provide a patent airway Introduction General Points R 3 0 Page 1 of 3 A 5 Wilson County Emergency Management Agency Protocol Manual Introduction General Points to Remember Continued e Although the Protocol procedures have a numerical order it may be necessary to change the sequence order or even omit a procedure due to patient condition the availability of assistance or equipment Document your reason for any deviations from protocol e EMS personnel are expected to perform their duties in accordance with local state and federal guidelines in accordance with the State of Tennessee statutes and rules of Tennessee Emergency Medical Services e Each patient care contact will be documented as completely and accurately as possible as soon as possible after the patient encounter A verbal report will be given to the emergency department personnel prior to departing from the health care facility to ensure continuity of care All reports shall be transmitted to the rece
13. emember to hook up the 4 lead EKG on the patient in addition to the combo pads if this is not done the monitor will not show a rhythm e These Standing Orders are designed to optimize patient care and minimize the need to contact medical control direction prior to treatment If you initiate an order follow through with that order until o The condition resolves and further treatment is not necessary o The condition changes necessitating treatment by another Standing Order i e ventricular fibrillation changes to asystole etc o A stop treatment criteria exists i e blood pressure falls below 100 mmHg while giving Nitroglycerine chest pain is resolved etc o Arrival at the receiving facility precludes further treatment o Online medical control direction authorizes deviation from Standing Order e If itis necessary to deviate from a standing order document the reason in the patient care report e Any drug or fluid that may be administered by the intravenous route may also be administered by the Intraosseous route e These protocols standing orders are written taking into consideration all the equipment medications and supplies utilized by Wilson County EMA It is understood and acceptable that individuals EMT AEMT amp Paramedics may fulfill the capacity of first responders on duty off duty and or in their personal vehicle It is understood in these cases the first responder may not have access to all equipment medications su
14. eons Pharmacology Applications Paramedic Brady Essentials of Paramedic Care 2 Edition Brady International Trauma Life Support ITLS 7 Edition Brady Pre Hospital Emergency Pharmacology 6 Edition Journal Of Emergency Medical Services JEMS National Association of Emergency Medical Technicians NAEMT Pre Hospital Trauma Life Support Military Edition PHTLS 8 Edition Pearson Prentice Hall Pre Hospital Emergency Pharmacology 6 edition Putnam County TN EMS Robertson County TN EMS Rutherford County TN EMS Sumner County TN EMS Montgomery County TN EMS Nashville TN Fire Department Wake County North Carolina EMS Version History Version 1 0 October 2008 was the initial rewrite of protocols Any revisions before the 2 review would be version 1 1 1 2 etc Version 2 0 September 2011 was the total review of protocols Any revisions additions before the 3 review would be version 2 1 2 2 etc Version 3 0 May 2015 was a total review of protocols Any revisions additions before the 4 review would be version 3 1 3 2 etc Introduction References R 3 0 Page 1 of 1 A 7
15. etermine the need for immobilization based on the Selective Spinal Immobilization Protocol G 13 If the patient is NOT immobilized all rational to support the decision shall be documented in the patient care report Remember patients under the age of 18 or over the age of 55 are excluded from this protocol Fluid Management Medications If the systolic BP is less than 90 mm Hg and the patient has s s of shock administer 20 ml kg bolus peds systolic BP 70 2 x age in years 20cc kg bolus Repeat until BP is at least 90 mm Hg systolic or a radial pulse is present or appropriate for pediatric age If the patient has a radial pulse they are perfusing do not try to elevate the blood pressure excessively Buretrol sets should be utilized on pediatric patients renal failure patients and CHF if a precise amount of IV fluid needs to be administered To provide the best flow via IO line the bag may need to be pressure infused IV drips Secondary lines make sure the main line is clamped off while the secondary medication is infusing Once the secondary line is finished unclamp the main line and set at an appropriate rate Pediatric medication doses should not exceed the standard adult dose if calculated on body weight Trauma patients Maintain systolic BP 80 90 mm Hg bolus 20 ml kg adult amp pediatric as needed to maintain adequate systolic BP Do not induce a systolic BP greater than 90 mm Hg Blood tubing should utilize Norma
16. h narcotic administration Consideration to the age and general health of the patient should be given Patients that are greater than 65 years old or are chronically debilitated will respond to less medicine The dosage should be given slowly while watching for signs that the patient is becoming over medicated Start with the lower dosage you can always give more medicine later Be prepared for respiratory depression In certain situations narcotics may need to be administered prior to moving or splinting patient to provide some pain control Phenergan may used to prevent nausea and vomiting and potentate the narcotics Zofran is an excellent choice for nausea and vomiting especially in pediatrics and geriatrics without the sedative effects Titrate pain management to relief of pain you do not have to administer the full amount if desired effects are obtained Multiple protocols for narcotics cannot be stacked or combined to administer a higher amount of medication Monitor amp document vital signs every 10 minutes BP HR respiratory rate level of consciousness amp oxygen saturation Introduction Basic Management R 3 1 Page 8 of 10 A 3 Protocol Manual Introduction Basic Assessment amp Management If the patient becomes obtunded and or vitals deteriorate slowly administer Narcan 0 5 mg increments slow IV up to 2 mg peds 0 1 mg kg slow IV until improvement Titrate to effect patients can become violent if
17. hief on contacting and reporting the medication error to any local regional state or government entities that are required by policy and or law Advanced EMT AEMT All approved skills will be listed here as well as in some protocols specifically to follow the same format as previous protocol versions Qualifications a Must have acurrent Tennessee AEMT license a copy shall be on file with the Training Division Chief b Must be checked off on all AEMT skills by WEMA regardless of where and when the class was taken c Narcan can be administered by the AEMT via IV IN IM or IO for adult and pediatric patients d Pediatric and Adult EZ IO s are approved You MUST be checked off by WEMA approved instructors This check off includes starting a successful IO in the humeral head tibial plateau and medical malleolus in a skills evaluation ANY IO MUST BE DONE IN THE PHYSICAL PRESENCE OF A PARAMEDIC During the state EMS transition from EMT IV to AEMT all EMT IV s may still utilize the version three 3 protocols Only AEMT is listed throughout the protocols however the EMT IV may utilize all the skills under AEMT except the use of Narcan and EZ IO EMT IV license will expire in Tennessee on December 31 2016 Introduction Basic Management R 3 1 Page 10 of 10 A 3 Wilson County Emergency Management Agency Protocols amp Standing Orders Manual Introduction Definitions 1 Standing order Preapproved protocols
18. ine cardiac arrest Contact with medical control direction should be made early on to direct treatment Remember that no one is dead until they are warm and dead e Treat the patient not the monitor e Only ALS calls the Paramedic will be in charge and will be responsible for all of the actions and or activities as it relates to the Ambulance On the scene of an emergency the Paramedic will be responsible for patient care The EMR EMT or AEMT will act within their scope of practice to any request for patient care or maintenance of the unit as directed by the Paramedic e Itis the responsibility of the most qualified crew member to ensure transmission of all aspects of the patient assessment and care to the responding Emergency Unit or Medical Control Direction e When reporting a disposition to Medical Control Direction or the responding unit provide the following minimum information 1 Patient s age and chief complaint 2 Is patient stable define or unstable define including complete V S amp LOC 3 Interventions performed 4 Provide other Information as requested e Stable indicates that the patient has no or very mild signs and symptoms associated with the current problem and is unlikely to deteriorate e For any drug administration or procedures outside these Protocols but within the scope of practice for any provider must receive authorization from Medical Control Direction Paramedic s en route to the scene are not authoriz
19. isualizing the placement or extubate the patient and perform the procedure again after re oxygenation of the patient with BVM ventilation The following parameters must be documented on EVERY INTUBATION e Esophageal Intubation Detector EID If this device is used it should be utilized prior to ventilating the patient If not air is forced into the stomach then it is utilized it will re inflate giving you an incorrect response Do not use on children under the age of five 5 or forty four 44 pounds Refer to the Esophageal Intubation Detector Procedure I 18 and the user manual Reference J 45 e Epigastric sounds absent or present this should be your first assessment after intubation If epigastric sounds are heard leave the ETT in place and ventilate the patient with a BVM and mask while placing the ETT to the corner of the patients mouth this increases your chances of successful secondary intubation e Bilateral breath sounds absent or present if decreased or absent on left pull back on ETT It is a good idea to check breath sounds especially trauma patients before intubation e End Tidal CO2 detector Easycap II colormetric Refer to End Tidal CO2 User Manual J 13 amp I 14 e Chest rise and fall with ventilation equal Introduction Basic Management R 3 1 Page 5 of 10 A 3 Wilson County Emergency Management Agency Protocol Manual Introduction Basic Assessment amp Management e Endotracheal tu
20. iving Emergency Room ASAP but no greater than 24 hours to comply with the State EMS rule e In potential crime scenes any movement of the body clothing or immediate surroundings should be documented and the on scene law enforcement officer notified of such e Supportive care indicates any emotional and or physical care including oxygen therapy repositioning patient comfort measures and patient family education e All patients should be transported to the most appropriate facility according to the patient or family request or to the facility that has the level of care commensurate with the patient s condition Certain medical emergencies may require transport to a facility with specialized capability e All medical personnel will work within their scope of practice dependent on available equipment e Pulse Oximeter should be utilized for all patients complaining of respiratory distress or chest pain regardless of source e The use of a cervical collar non trauma after insertion of an advanced airway is recommended to reduce the chance of accidental removal misplacement This is in addition to the tube securing devices currently in use e If a change in cardiac rhythm occurs provide all treatment and intervention as appropriate for the new rhythm DO NOT interrupt CPR cycle to assess e Upon arrival at the receiving hospital all treatment s initiated in the field will be continued until patient care has been assumed by hospital
21. l Saline only Introduction Basic Management R 3 1 Page 7 of 10 A 3 Protocol Manual Introduction Basic Assessment amp Management Assessment indications Each protocol list assessment indications a patient may exhibit some or all of these as well as others not mentioned The patient does not have to meet each one to meet treatment criteria A CLS PALS Search for underlying cause of arrest and provide the related thera Hypovolemia fluid administration fluid challenge adult 20 ml kg peds 20 ml kg bolus Hypoxia ensure adequate ventilation by any means necessary Hydrogen lons Acidosis consider Sodium Bicarbonate 1 1 5 mEq kg IV peds 0 5 mEg kg Hyperkalemia Known Sodium Bicarbonate 1 mEq kg may repeat 0 5 mEq kg every 10 minutes peds 1 mEg kg may repeat at 0 5 mEg kg every 10 min Calcium Chloride 500 mg 1000 mg IV peds 20 mg kg DO NOT mix these two medications in the same IV line Use a secondary line or lock Hypokalemia Cardiac arrest magnesium sulfate may be used Hypothermia initiate patient re warming avoid chest compressions if spontaneous circulation Toxin Drug overdose Narcan 0 5 mg increments slow IV up to 4 mg peds 0 1 mg kg slow IV Tamponade adult up to 2 liter bolus peds 20 ml kg bolus Tension pneumothorax needle decompression Thrombosis Ml Fibrinolytic agent Thrombosis PE Fibrinolytic agent Narcotics Be aware of the potential for anaphylaxis wit
22. lack of distal to any injury as well as for overall patient assessment e Respiration Document the rate and quality of breathing Any patient with a respiratory complaint should have the oxygen saturation monitor applied e EKG Heart rate less than 60 or greater than 100 an irregular pulse respiratory distress cardiac compromise stroke and any if any medications other than oxygen are given This is a broad guideline of examples and is not meant to be all inclusive The AEMT may apply the EKG electrodes on an ALS ambulance in the physical presence of a Paramedic Introduction Basic Management R 3 1 Page 4 of 10 A 3 Protocol Manual Introduction Basic Assessment amp Management e Twelve 12 lead EKG Any medical patient over the age of 60 that is placed on the cardiac monitor should have a 12 lead EKG obtained Certain protocols list the 12 lead in the Paramedic treatment these are mandatory in those protocols but are not limited to just those listed Refer to the 12 Lead EKG placement J 1 for details on placement of electrodes for 12 lead EKG An exception exists if you have less than five 5 minute transport time to the receiving facility Electrodes may be applied by AEMT EMT IV in the physical presence of a Paramedic TN EMS rule e Oxygen saturation Should be checked on all patients It becomes a very good tool in patients with respiratory complaints significant trauma or who is critically ill e Temperatur
23. n syndrome hypertension with Bradycardia If a BVM is utilized to assist or ventilate a patient a nasal or oral airway should be in place to displace the tongue for better delivery of ventilations Use the Autovent 2000 or 3000 when not contraindicated to deliver the best tidal and minute volume decrease rescuer fatigue and free a rescuer for other tasks Minute volume is very important to access in patients this is defined as tidal volume amount of air moved with each breath x respiratory rate minute volume Although the pre hospital provider cannot access the amount of tidal volume the provider should be able to assess if it is of adequate oxygenation If the patient has inadequate oxygenation consider utilizing a BVM and airway adjunct Always maintain an open and patent airway if secretions blood emesis etc are noted suction the airway as needed Maximum time is 15 seconds for adults and 10 seconds for pediatrics Assist respirations as needed with bag valve mask and supplemental Oxygen therapy as necessary or by means of an emergency respirator AutoVent Be mindful of the ETC02 readings when ventilating a patient Maintain ETC02 between 35 45 mm Hg unless herniation A brief period of hyperventilation is indicated for prolonged hypoxia and or hypercapnia If placing a Supraglottic airway the patient should be hyper oxygenated 30 60 seconds prior to the procedure Prior to placing an advanced airway utilize the no DESAT pr
24. ocedure This is utilizing bilateral nasal airways and nasal cannula and non rebreather at 15LPM on both This should be done at least three 3 minutes prior to the attempt unless apenic Utilize the End Tidal C02 ETCO2 on the cardiac monitor to guide therapy ETCO2 shall be utilized on patients that have an advanced airway in place Routine excessive ventilation hyperventilating can cause vasoconstriction can be detrimental to cardiac output and patient survival Introduction Basic Management R 3 1 Page 2 of 10 A 3 Protocol Manual Introduction Basic Assessment amp Management Circulation Assess for quality and rate of peripheral pulses The following is a rule of thumb for rapid blood pressure analysis If this method is utilized to determine the BP it should be documented in the EMS narrative e Carotid pulse intact Blood pressure is greater than 60 mm Hg e Femoral pulse intact Blood pressure is greater than 70 mm Hg e Radial pulse intact Blood pressure is greater than 80 mm Hg If unable to palpate a carotid pulse in an unconscious patient begin Cardio Pulmonary Resuscitation by American Heart Association Standards immediately CPR when initiated should be continued until a spontaneous palpable pulse is obtained an order to stop resuscitation is received from medical control direction or the requirements of the Discontinuation Withholding of Life Support Protocol G 4 are met Obvious exceptions are s
25. one 1 trauma center or an appropriate facility before a helicopter could deliver the patient to the same facility If any potential of patient exposure to hazardous materials ensure the patient is decontaminated prior to loading into a helicopter Spinal Precautions Immobilization This should go hand in hand with initial airway assessment You can gain cervical spine control at the same time you are assessing the airway Maintain a high index of suspicion for cervical related injury in trauma patients If the decision is made to immobilize a patient take manual cervical immobilization immediately and maintain until the patient is secured on a backboard as described below Size the cervical collar to the patient and apply appropriately If a c collar will not fit correctly document accordingly Cervical immobilization requires a long spine board with 5 straps The top section will cross each other across the chest 2 straps directly below is another section to be crossed same coverage area but it covers the hip pelvis and one at the lowest point of the LSB to secure the lower legs feet Cervical Immobilization Device CID blocks on each side of the head and two 2 straps to secure the CID s and head one 1 placed across the forehead and one 1 across the chin or cervical collar Straps may be relocated if need due to traumatic injuries document accordingly Paramedics utilize the Selective spinal immobilization assessment to d
26. personnel e For external Jugular IVs attempted by Paramedics IV catheters should be 18 gauge or larger diameter based on the patient This may only be attempted once per patient Introduction General Points R 3 0 Page 2 of 3 A 5 Wilson County Emergency Management Agency Protocol Manual Introduction General Points to Remember Continued e Narcan Atropine Vasopressin Epinephrine amp Lidocaine NAVEL may all be administered endotracheally if IV IO access has not been achieved THIS IS A LAST RESORT e CPR is continued throughout all the pulseless rhythms unless prevented by defibrillation movement or accessibility of the patient Assess adequacy frequently this can be done by checking for a pulse while performing CPR and ETC02 e Standing Orders Protocols assume that the condition being treated is persistent e Refer to the Drug Reference section for directions on how to mix drips While several of these are not standard mixes they give you a means to mix drips that minimizes the amount of drug required e No section of these orders may be interpreted as authorization to practice beyond your level of licensure and or scope of practice training e When using Hands Free combo pads put the monitor in the Pads mode if you intend to monitor through the pads Remember to switch back to lead 2 if decide to monitor using the electrodes after reading through the pads e In pacing or synchronized cardioversion mode r
27. pplies and staffing to comply with each Standing Order or Protocol In instances where a treatment is called for in the Standing Orders that are not available due to lack of equipment the first responder should document appropriately For example most individuals do not have an AED in their personal vehicle therefore they could not perform that action as required in the protocol e This manual cannot cover each and every situation that may be encountered generally basic assessment amp management will cover most situations If you are in a situation and need guidance contact medical control direction e The protocols in this manual are based off the AHA 2010 guidelines Introduction General Points R 3 0 Page 3 of 3 A 5 Wilson County Emergency Management Agency Protocols amp Standing Orders Manual Introduction Pediatric Points to Remember e Aneonate is considered less than one 1 month of age e An infant is considered one 1 month old to one 1 year old e A child is older than one 1 but not reached puberty American Heart Association defines as breast development in females and underarm hair in males e Bradycardia is considered to be due to hypoxia and treated aggressively until proven otherwise e Remember in an arrest situation to use the pediatric length bases tape This will provide a good approximation of the proper equipment medication dosages and decrease the potential for dosage errors Refer to the Pedi
28. rt time personne that may be off duty and non paid personnel that are either dispatched to first respond or arrive on the scene Any personne using these protocols and standing orders shall have a valid Tennessee EMS license certification for Emergency Medical Responders that is active without any action s currently sanction or exclusion These protocols and standing orders are valid anywhere when working under mutual aid conditions as long as assistance has been requested through the proper procedures Medical Director WEMA Director WEMA ha Brian Newb rry EMS Chief UWEMA edic EMT IC Effective date amp A fe introduction Authorization R 3 0 Page 1 of 1 A 1 Wilson County Emergency Management Agency Protocols amp Standing Orders Manual Introduction Adult Points to Remember e The dosage of drugs administered by the endotracheal route should be 2 2 5 times the IV dosage A catheter which extends distal to the end of the ET tube should be used as time permits A French suction catheter works well for this THIS IS THE LAST RESORT FOR MEDICATION ADMINISTRATION e Vasopressin is a potent vasoconstrictor It may be used with Epinephrine but a certain time interval must be observed The half life of Vasopressin in the body is approximately 10 minutes e Elevate the extremity after bolus when given IV e CPR is most effective when done continuously with minimum interruption e Consider non tracheal
29. tion using the proper size BVM and mask Basic airway management oral amp nasal airways Supraglottic Airway King LT etc Advanced airway management oral or nasal intubation Paramedic only RSI may be utilized by Paramedic s that have met the department criteria Remember the main goal for airway is to oxygenate the patient This goal can be accomplished without an advanced airway just remember the goal e Manage the airway aggressively If airway control cannot be gained by one measure move quickly to the next measure e Utilize the ResQPOD as indicated in Procedure 29 1 e If the airway is obstructed follow the most current American Heart Association guidelines for obstructed airway Paramedics may utilize Magill forceps as needed e Below is a list of conditions that must be managed quickly and appropriately Listed are examples and does not include every situation that may need quick and aggressive airway control Apneic patient regardless of cause Patient unable to self maintain airway Respiration s of less than 8 per minute or greater than 30 per minute with signs of hypoxia Head injury patients with altered mental status and or pending deterioration Absent gag reflex Cyanosis or Sp02 of less than 85 that does not respond to a brief trial of high flow oxygen and or drug therapy Airway burns or involvement in blast injury If a patient has facial trauma assess for broken or damaged teeth rule out any airwa
30. to the Standard of Care and Standing Orders and Protocols 8 Advanced Emergency Medical Technician AEMT Personnel licensed by the Tennessee Department of Health Office of EMS and authorized by the Medical Director to provide limited advanced emergency care according to the Standard of Care and Standing Orders and Protocols 9 Paramedic Personnel licensed by the Tennessee Department of Health Office of EMS and authorized by the Medical Director to provide basic and advanced emergency patient care according to the EMS Standing Orders and Protocols 10 Transfer of Care Properly maintaining the continuity of care through appropriate verbal and or written communication of patient care aspects to an equal or higher appropriate medical authority 11 Higher Medical Authority Any medical personnel that possesses a current medical license or certificate recognized by the State of Tennessee with a higher level of medical training than the one possessed by EMS personnel 12 Medical Control Direction The instructions and advice provided by a physician and the orders by a physician that define the treatment of the patient To access Medical Control Direction contact the Emergency Department physician on duty of the patient s destination If unable to make contact contact UMC for Medical Control Direction Introduction Definitions R 3 0 Page 1 of 1 A 4 Wilson County Emergency Management Agency Protocol Manual Introduction
31. too much Narcan is administered If no IV is available the 1O or IN in some meds route may be utilized If acceptable for the medication give the IM or IN route may be utilized Narcotics are controlled medications refer to the policy manual for additional guidance If any narcotic is given including Tordal the cardiac monitor must be applied Complete all documentation as required per department policy Trauma Treat any injuries as indicated Always consider Air Ambulance and Trauma Destination E 2 and Trauma Destination 2011 Guidelines for Field Triage of Injured Patients E 32 Always consider the need for level 1 trauma care Air Ambulance and Trauma Destination Reference E 2 in trauma patients Always have a high index of suspicion Trauma patients should receive spinal immobilization unless the Selective Spinal Immobilization Protocol G 13 determines otherwise If immobilization is indicated but unable to be performed for any reason document well Refusals Refusals should be taken very seriously A patient assessment shall be conducted and documentation completed The following refusal situations should be evaluated by a highest level medical provider available If an ALS assessment is not completed it should be documented why l e multiple pts no ALS on scene etc e hypoglycemic patients who have responded to treatment e potentially serious illness or injury e patients less than 4
32. topping to assess defibrillate or move the patient Periodically confirm the effectiveness of CPR by palpating a carotid or femoral pulse be modest and professional when assessing If a pulse cannot be detected with compressions evaluate the CPR technique and assess for good ventricular complexes Paramedic only Adequate chest compressions should be performed at all times Providers should make all attempts to limit the amount of hands off time during CPR Hands off time should be limited to 10 seconds unless necessary for movement down stairs etc be sure to document accordingly Follow the most current AHA guidelines for BLS If an AED or manual defibrillation is delivered or no shock is indicated chest compressions should be resumed immediately Initiate intravenous therapy as appropriate for fluid resuscitation or medication route IV therapy is also applied very liberally based on patient need or anticipated need Remember saline locks as an alternative to IV infusion In critical patients remember the IO drug fluid route Determine cardiac rhythm The EKG should be applied except on clearly stable non cardiac non major trauma patients If the patient needs an IV or saline lock they should receive the cardiac monitor Treat rhythm appropriately as outlined elsewhere in this manual A central line may be utilized by paramedics that have received in service training This line should only be accessed if a medication must
33. treatment options that may be initiated without prior contact with medical control that has been approved by the WEMA medical director 2 Protocol List of treatment options that require you to contact Medical Direction Control prior to initiation 3 Medical Director The physician who has ultimate responsibility for the patient care aspects of the EMS system 4 Unstable symptomatic indicates that one or more of the following are present chest pain dyspnea hypotension systolic B P less than 90 mm Hg in a 70 kg patient or greater signs and symptoms of congestive heart failure or pulmonary edema signs and symptoms of a myocardial infarction signs of inadequate perfusion altered level of consciousness a b WS SSS OOo 2 5 Stable asymptomatic Indicates that the patient has no or very mild signs and symptoms associated with the current history of illness or trauma 6 Emergency Medical Responder EMR Personnel licensed by the Tennessee Department of Health Office of EMS and authorized by the service Medical Director to perform lifesaving interventions while awaiting additional EMS response May also assist higher level personnel at scene and during transport under medical direction and within their scope of practice 7 Emergency Medical Technician EMT Personnel licensed by the Tennessee Department of Health Office of EMS and authorized by the Medical Director to provide basic emergency care according
34. y compromise Impending airway collapse secondary to anaphylaxis Hypoxia refractory to CPAP impending respiratory failure arrest Impending airway collapse secondary to anaphylaxis Introduction Basic Management R 3 1 Page 1 of 10 A 3 Wilson County Emergency Management Agency Protocol Manual Introduction Basic Assessment amp Management Breathing Assess breathing for adequacy Observe for objective signs of hypoxia such as agitation cyanosis lethargy tachypnea etc Assess the workload of breathing Is the patient using accessory muscles of respiration retracting nasal flaring or other signs of respiratory distress Assess rate and quality of breathing Medical patients should be placed in the position of comfort to best facilitate adequate oxygenation Assess for impending respiratory failure If the patient is threatening failure intervene as soon as possible including application of CPAP and or other advanced methods within the protocol manual Apply oxygen if there is any sign or complaint of dyspnea shock multi system trauma neurological insult cardiac ischemia infarction or other conditions that benefit from supplemental oxygen administer to maintain oxygen saturation above 94 Use airway adjuncts and ventilations with 100 oxygen to treat hypoxia if no improvement from other methods is noted Hyperventilation should be avoided unless a head injury patient displays s s of cushing reflex herniatio
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