2019 Protocols (Adult) Flashcards Preview

San Diego EMS Protocols 2019 > 2019 Protocols (Adult) > Flashcards

Flashcards in 2019 Protocols (Adult) Deck (76)
Loading flashcards...
1

S-120 Abdominal Discomfort BLS

-Ensure patent airway
-O2 saturation prn
-O2 and/or ventilate prn
-NPO
-Transport suspected symptomatic aortic aneurysm to facility with surgical resources immediately available

2

S-120 Abdominal Discomfort ALS

-Monitor EKG
-IV/IO SO adjust prn
-Treat pain as per Pain Management Protocol (S-141)

Suspected volume depletion:
-500ml fluid bolus IV/IO SO

Suspected AAA:
-500ml fluid bolus IV/IO SO for BP<80 to maintain a BP of 80, may repeat x1 SO

For nausea/vomiting:
-Zofran 4mg IV/IM/ODT SO, MR x1 q10" SO

3

S-121 Airway Obstruction BLS

For a conscious patient:
-Reassure, encourage coughing
-O2 prn

For inadequate airway exchange:
airway maneuvers (AHA)
-Abdominal thrusts
-Use chest thrusts in the obese or pregnant patient

If patient becomes unconscious or is found unconscious
-Begin CPR

Once obstruction is removed:
-High flow O2, ventilate prn
-O2 saturation prn

4

S-121 Airway Obstruction ALS

If patient becomes unconscious or has a decreasing LOC:
-Direct laryngoscopy and Magill forceps SO MR prn
-Capnography SO prn

Once obstruction is removed:
-Monitor EKG
-IV/IO SO adjust prn

5

S-122 Allergic Reaction/Anaphylaxis BLS

-Ensure patent airway
-O2 Saturation prn
-O2 and/or ventilate prn
-Remove stinger/injection mechanism
-May assist patient to self-medicate with own prescribed epinephrine auto-injector or MDI ONE TIME ONLY. Base Hospital contact required prior to any repeat dose.

If available and trained:
-Epinephrine auto-injector 0.3mg IM x1

6

S-122 Allergic Reaction/Anaphylaxis ALS

-Monitor EKG
-IV/IO SO adjust prn
-Capnography SO prn

Hives (Urticaria):
-Benadryl 50mg IV/IM SO

Anaphylaxis:
-Epinephrine 1:1,000 0.3mg IM per SO. MR x2 q5" SO
then
-500ml fluid bolus IV/IO for systolic BP<90 SO
MR to maintain systolic BP>90 SO
-Benadryl 50mg IM/IV SO
-Albuterol 6ml 0.083% via nebulizer SO.
MR SO for respiratory involvement
-Atrovent 2.5ml 0.02% via nebulizer added to first dose of Albuterol SO for respiratory involvement.

-Epinephrine 1:10,000 0.1mg IV/IO BHO. MR x2 q3-5" BHO
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP>90 BHO

7

S-122 Allergic Reaction/Anaphylaxis/Angioedema criteria

Anaphylaxis criteria (may include any):
1. Unknown exposure : Skin AND Respiratory AND/OR cardiovascular
2. Likely allergen exposure (eg beesting, peanut): 2/4 systems involved (skin, GI, respiratory, cardiovascular)
3. Known allergen exposure

Angioedema:
lip/tongue/face swelling/difficulty swallowing/throat tightness, hoarse voice

8

S-123 Altered Neurological Function BLS

-Ensure patent airway, O2 and/or ventilate prn
-O2 saturation prn
-Spinal stabilization prn
-Secretion problems, position on affected side
-Do not allow patient to walk
-Restrain prn
-Monitor blood glucose prn (if trained and available)

Symptomatic suspected opiods OD (with respiratory rate <12)*:
(Use caution with opioid dependent pain management patients)
-Naloxone nasal spray 4mg preload single dose device
-Administer full dose in one nostril
OR
-Naloxone assemble 2m syringe and atomizer
-Administer 1mg (1ml) in each nostril

Hypoglycemia (suspected) or patient's glucometer results read <60
-If patient is awake and able to swallow, give 3 oral glucose tabs or past (15g total).
Patient may eat or drink if able.
-If patient unconscious, NPO

CVA/Stroke:
See S-144 Stroke/Transient Ischemic Attack for details.

Seizures:
Protect airway, and protect from further injury
-Treat associated injuries

Behavioral Emergencies:
(S-422 and S-142)

9

S-123 Altered Neurological Function ALS

-Monitor EKG
-Capnography SO prn
-IV/IO SO adjust prn
-Monitor blood glucose prn SO

Symptomatic suspected opioids OD (with respiratory rate <12):
(Use caution in opioid dependent pain management patients)
-Naloxone 2mg IN/IM/IV SO. MR SO, titrate IV dose to effect, to drive respiratory rate.
-If patient refuses transport, give additional Naloxone 2mg IM SO

Hypoglycemia: Symptomatic patient with altered LOC or unresponsive to oral glucose agents:
-D50 25Gm IV SO if BS <60
-If patient remains symptomatic and BS remains <60 MR SO
-If no IV: Glucagon 1ml IM SO if BS <60

Hyperglycemia : Symptomatic patient with diabetic history
-500ml fluid bolus IV/IO if BS >350 or reads high SO x1

Seizures:
A. Ongoing generalized seizure lasting >5 minutes (includes seizure time prior to arrival of prehospital provider) SO
B. Recurrent tonic-clonic seizures without lucid interval SO
C. Eclamptic seizure of any duration SO
-Versed IN/IM/IV/IO SO to a max dose of 5mg (d/c if seizure stops) SO MR x1 in 10 minutes SO. Max 10mg total

10

S-124 Burns BLS

-Move patient to a safe environment
-Break contact with causative agent
-Ensure patent airway, O2 and/or ventilate prn
-O2 saturation prn
-Treat other life threatenting injuries
-Carboxyhemoglobin monitor prn, if available

Thermal burns:
-Do not allow patient to become hypothermic
Burns of <10% body surface area:
-Stop burning with non-chilled water or saline
Burns of >10% body surface area
-Cover with dry dressing and keep warm

Toxic inhalation (CO exposure, smoke, gas, etc.):
-Move patient to safe environment
-100% O2 via mask
For suspected carbon monoxide poisoning for unconscious or pregnant patient
-Consider transport to facility with hyperbaric chamber

Chemical burns:
-Brush off dry chemicals
-Flush with copious amounts of water

Tar burns:
-Cool with water, transport; do not remove tar

11

S-124 Burns ALS

-Monitor EKG
-IV/IO SO adjust prn
-Treat pain per Pain Management Protocol (S-141)

For patients with >20% partial thickness or >5% full thickness burns and >15 yo:
-500ml fluid bolus IV/IO then TKO SO

In the presence of respiratory distress with bronchospasm:
-Albuterol 6ml 0.083% via nebulizer SO. MR SO

12

Burn Center Criteria

Patients with burns involving:
->20% BSA partial thickness or
->5% BSA full thickness
-Suspected respiratory involvement or significant smoke inhalation in a confined space
-Injury of the face, hands, feet or perenium, or circumferential
-Electrical injury due to high voltage; (>120 volts)

13

S-126 Discomfort/Pain Of Suspected Cardiac Origin BLS

-Ensure patent airway
-O2 saturation prn
-Only use supplemental O2 to maintain O2 saturation 94-98%
-O2 and/or ventilate prn
-Do not allow patient to walk
-If systolic BP>100, may assist patient to self-medicate own prescribed NTG SL (maximum 3 doses, including those patient has taken)
-May assist with placement of 12 lead
-May assist patient to self-medicate own prescribed Aspirin (81mg to max dose of 325mg)

14

S-126 Discomfort/Pain Of Suspected Cardiac Origin ALS

-Monitor EKG
-IV/IO SO adjust prn
-Obtain 12 lead EKG and transmit (if capable).
If STEMI, notify base immediately and transport to appropriate STEMI center.*
-ASA 324mg chewable PO SO

If systolic BP>100:
-NTG 0.4mg SL SO. MR q3-5" SO
-NTG ointment 1 inch SO
-Treat pain per Pain Management Protocol (S-141)

If systolic BP<100:
-NTG 0.4mg SL BHO. MR BHPO
-Treat pain per Pain Management Protocol (S-141)

Discomfort/Pain of suspected Cardiac Origin with Associated Shock:
-250ml fluid bolus IV/IO without rales SO.
MR to maintain systolic BP>90 SO
If BP refractory to second fluid bolus:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP>90 BHO

15

S-126 Discomfort/Pain Of Suspected Cardiac Origin Note/*Report

Note:
-If discomfort/pain is relived prior to arrival, continue treatment with NTG ointment and ASA. ASA should be given regardless of prior daily dose(s).
-If any patient has taken an erectile dysfunction medication such as Viagra, Cialis, Levitra within 48 hours, NTG is contraindicated.
-May encounter patients taking similar medication for pulmonary hypertension (Revatio, Flolan, Veletri). NTG is contraindicated in these patients as well.

*Report:
-12 lead interpretation of STEMI
-Bundle Branch Block (LBBB, RBBB).
-Poor quality EKG, artifact, paced rhythm, atrial fibrillation or atrial flutter for consideration of false positive reading STEMI.
-Repeat the 12 lead EKG only if the original EKG interpretation is NOT ***ACUTE MI SUSPECTED***, and patient's condition worsens. Do not delay transport to repeat.
-Document findings on the PPR and transmit EKG if available and leave EKG with patient.

16

S-127 Dysrhythmias, Unstable Bradycardia BLS

BLS:
-O2 and/or ventilate prn
-O2 Sat prn

17

S-127 Dysrhythmias, Unstable Bradycardia ALS (Narrow complex)

Unstable Bradycardia with Pulse:
(BP<90 AND chest pain, dyspnea, or altered LOC)

Narrow Complex Bradycardia:
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-Atropine 0.5mg IV/IO for pulse <60 SO. MR q3-5" to max 3mg SO

If rhythm refractory to a minimum of Atropine 1mg:
-External cardiac pacemaker SO**
If capture occurs and BP>100, consider medication for discomfort:
-Treat pain per Pain Management Protocol (S-141)
For discomfort related to pacing and not relieved with analgesics and BP>100:
-Midazolam 1-5mg IV/IO SO

-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip, titrate to BP>90 (after max Atropine or initiation of pacing) BHO

18

S-127 Dysrhythmias, Unstable Bradycardia ALS (Wide complex)

Unstable Bradycardia with Pulse:
(BP<90 AND chest pain, dyspnea, or altered LOC)

Wide Complex Bradycardia:
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-External cardiac pacemaker SO**

If capture occurs and BP>100, consider medication for discomfort:
-Treat pain per Pain Management Protocol (S-141)
For discomfort related to pacing and not relieved with analgesics and BP>100:
-Midazolam 1-5mg IV/IO SO

-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip, titrate to BP>90 (after initiation of pacing) BHO

If external pacing unavailable:
-may give Atropine 0.5mg IV/IO for pulse <60 SO
MR q3-5" to max 3mg SO

19

S-127 Dysrythmias (Bradycardia Pacing Notes)

**Note:
-Document rate setting, milliamps, and capture
-External pacing on standing orders should begin with minimum rate set at 60/min. Energy output should be dialed up until capture occurs, usually between 50 and 100mA. The mA should then be increased a small amount, usually about 10%, for ongoing pacing.

20

S-127 Dysrythmias, Supraventricular Tachycardia BLS

-O2 and/or ventilate prn
-O2 Sat prn

21

S-127 Dysrythmias, Supraventricular Tachycardia ALS

-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-VSM SO. MR SO
-Adenosine 6mg rapid IV/IO, followed with 20ml NS rapid IV/IO SO
(Patients with history of bronchospasm or COPD BHO)
-Adenosine 12mg rapid IV/IO followed with 20ml NS rapid IV/IO SO
If no sustained rhythm change, MR x1 in 1-2" SO

If patient unstable OR rhythm refractory to treatment:
Conscious (BP<90 AND chest pain, dyspnea, or altered LOC)
-Midazolam 1-5mg IV/IO prn pre-cardioversion BHO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer's recommended energy dose BHO, MR BHO

Unconscious:
-Synchronized cardioversion at manufacturer's recommended energy dose SO. MR x3 SO. MR BHO

22

S-127 Dysrhythmias, Unstable Atrial Fibrillation/Atrial Flutter BLS

-O2 and/or ventilate prn
-O2 Sat prn

23

S-127 Dysrhythmias, Unstable Atrial Fibrillation/Atrial Flutter ALS

Unstable Atrial Fibrillation/Atrial Flutter:
(BP<90 AND chest pain, dyspnea, or altered LOC)
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO

In presence of ventricular response with heart rate >180:
Conscious:
-Midazolam 1-5mg IV/IO prn pre-cardioversion BHPO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer's recommended energy dose BHPO, MR BHPO

Unconscious:
Synchronized cardioversion at manufacturer's recommended energy dose SO, MR x3 SO. MR BHO

24

S-127 Dysrhythmias, Ventricular Tachycardia BLS

-O2 and/or ventilate prn
-O2 Sat prn

25

S-127 Dysrhythmias, Ventricular Tachycardia ALS

-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-Lidocaine 1.5mg/kg IV/IO SO
MR at 0.5mg/kg IV/IO q 8-10" to max 3mg/kg (including initial bolus) SO
*OR*
-Amiodorone 150mg in 100ml of NS over 10" IV/IO SO
MR x1 in 10" SO

If patient unstable (BP<90 AND chest pain, dyspnea, or altered LOC):
Conscious:
-Midazolam 1-5mg IV/IO prn pre-cardioversion SO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer's recommended energy dose SO, MR x3 SO. MR BHO

Unconscious:
-Synchronized cardioversion at manufacturer's recommended energy dose SO, MR x3 SO. MR BHO

26

S-127 Dysrhythmias, Reported/Witnessed >2 AICD firing, or >1 AED shock delivered (BLS/ALS)

BLS:
-O2 and/or ventilate prn
-O2 Sat prn
ALS:
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO

If pulse >60:
-Lidocaine 1.5mg/kg IV/IO SO
MR at 0.5mg/kg IV/IO q8-10" to max 3mg/kg (including initial bolus) SO
*OR*
-Amiodorone 150mg in 100ml NS over 10" IV/IO SO

27

S-127 Dysrhythmias, VF/Pulseless VT BLS

-CPR
-10:1 compression ratio at a rate of 110/min continuous compressions with ventilations every 6 seconds
-Rotate compressor every 2 minutes
-Metronome at rate of 110/minute for manual CPR
-Team Leader role-CPR quality, monitor, rhythm checks
-If arrest witnessed by medical personnel perform CPR until ready to defibrillate
-If unwitnessed arrest perform CPR for 2 minutes prior to rhythm check
-TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
-AED
-Assist ventilations with BVM
-Monitor O2 Sat

28

S-127 Dysrhythmias, VF/Pulseless VT ALS

-Monitor EKG
-Defibrillate when ready every 2 min while VF/VT persists
-Charge monitor prior to rhythm checks, do not interrupt CPR while charging defibrillation
-Capnography
-Rhythm check-minimize interruption of compressions less than 5 seconds
-IV/IO do not interrupt CPR
-Epinephrine 1:10,000 1mg IV/IO q3-5" SO

After first shock if still refractory
-Amiodorone 300mg IV/IO, MR 150mg (max of 450mg) SO
*OR*
-Lidocaine 1.5mg/kg IV/IO, MR x1 q3-5" (max 3mg/kg) SO

-Document EtCO2 during BVM, if zero do not intubate
continue ti ventilate BVM
-Intubate/PAA SO without interrupting compressions
-NG/OG prn SO

If persistent or shock refractory VF/VT after 3 rounds of drugs, contact base hospital for direction

ROSC:
-Obtain 12 lead
-Ventilate with goal of EtCO2 of 40
-Check blood pressure
-Transport to closest STEMI Center regardless of 12 lead reading SO

29

S-127 Dysrhythmias, VF/Pulseless VT (Notes)

-For drug administration and intubation perform high quality CPR with goal of appropriate rate (110), depth (1/3 of anterior/posterior chest diameter), allow full recoil, and minimize interruptions.
-Do not interrupt compressions
-Compression ratio 10:1 continuous compressions with ventilations every 6 seconds
-EtCO2 <10 = Poor survivability
-Use mechanical CPR device if available
-Do not over-ventilate
-Transport traumatic arrests to trauma centers
-Transfer monitor data to QA/QI department if able
-Consider reviewing call with crew post event

30

S-127 Dysrhythmias, PEA BLS

-CPR
-10:1 compression ratio at a rate of 110/min continuous compressions with ventilations every 6 seconds
-CPR rotate compressor every 2 minutes
-Start metronome at rate of 110/minute for manual CPR
-Team Leader role-CPR quality, monitor, rhythm checks
-TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
-AED
-Assist ventilations with BVM
-Monitor O2 Sat