2023 Protocols Flashcards

Question

Tension Pneumo Indications

Answer 1

* Unilateral decreased breath sounds with a history of chest trauma and: * Severe respiratory distress and/or * SBP ≤ 90 mmHg or loss of radial pulse due to shock

Answer 2

A dystonic reaction occurs as an idiosyncratic reaction to a phenothiazine compound. Frequently no clear history or medication use is obtainable; therefore, this reaction should be treated based on its clinical presentation. C. Although diphenhydramine is used to treat this reaction, it is not an allergic reaction to the medication. The patient should be informed of this distinction. Dystonic reactions, which may require field treatment to alleviate patient discomfort, may present as the following: 1. Facial grimacing with poor ability to voluntarily relax tensed facial muscles. 2. Torticollis or twisted posturing of the neck. 1. Establish vascular access. 2. Cardiac Monitoring 3. DIPHENHYDRAMINE- 50 mg IV (preferred) or IM 4. Monitor and reassess patient after administration of DIPHENHYDRAMINE

Answer 3

1. Establish vascular access. 2. Cardiac Monitoring and SPO2. 3. Initiate transport as soon as possible.

Answer 4

Beta Blockers/Calcium Channel Blockers IF SBP<90 Fluid challange of 500ml NS max dose 1000cc If HR <50 and SBP <90 Atropine: 1mg IV/IO, repeat q5min Max dose 3mg After max dose of atropine reached and sbp <90 and HR<50 Push Dose Epi 0.01 mg/ml (10mcg/ml) Dose - .5-2ml (5-20mcg) IV/IO every 2-5 minutes titrate to sbp>90 consider pacing if vitals are not above the 90 50

Answer 5

Fluid challange of 1000NS for SBP <90 Sodium Bicarb 1mEq/Kg slow IV push if any of the following signs of cardiac toxicity are present -HR >120bpm -SBP<90 QRS complex > 0.12 seconds Seizures PVC > 6 per minute

Answer 6

1. Hypovolemia 2. Hypoxia 3. Hydrogen Ion (acidosis) 4. Hypo-/hyperkalemia 5. Hypoglycemia 6. Hypothermia 7. Tamponade (Cardiac) 8. Thrombosis (coronary or pulmonary) 9. Tension Pneumothorax 10. Trauma (hypovolemia, increased ICP) 11. Toxins

Answer 7

Protocol applies to adults who are symptomatically bradycardic with a heart rate of < 50 bpm documented by monitor, a systolic blood pressure (SBP) < 90 mmHg, -AND- other signs or symptoms of hypoperfusion that may include decreased sensorium, diaphoresis, chest pain, capillary refill greater than two seconds, cool extremities, or cyanosis. * * Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest concentration and flow rate of O2 as possible. Profound bradycardia may require Cardiopulmonary Resuscitation (CPR)

Answer 8

Electrocardiogram Monitoring; Perform a 12-Lead ECG. Establish vascular access with Normal Saline; titrate to SBP ≥ 90 mmHg. Advanced airway adjuncts as needed.

Answer 9

Atropine .5-1mg IV/IO push every 3-5 minutes until max dose of 3mg total given TCP at 80 bpm adjust mA to capture If SBP remains < 90mmHG after Atropine/TCP: Push Dose Epinephrine 0.01 mg/ml (10mcg/ml) Dose: 0.5-2 ml (5-20mcg) IV/IO every 2-5 minutes. Titrate to SBP > 90 mmHg. NOTE: Monitor SBP while administering/titrating.

Answer 10

Transcutaneous Cardiac Pacing (TCP) without delay at 80 bpm, adjust mA to capture. Atropine 0.5mg IV/IO shall be given if administration does not delay TCP. If SBP remains < 90mmHG after Atropine/TCP: Push Dose Epinephrine 0.01 mg/ml (10mcg/ml) Dose: 0.5-2 ml (5-20mcg) IV/IO every 2-5 minutes. Titrate to SBP > 90 mmHg. NOTE: Monitor SBP while administering/titrating.

Answer 11

Midazolam if needed for sedation: * IV/IO/IN/IM- 4mg. * May give an additional 2mg dose. * IV/IO preferred route. Titrate to patient comfort. * Max dose of 6 mg

Answer 12

*Atropine should be avoided in patients with acute MI in 12-Lead setting as defined in

Answer 13

Adult Tachycardia with Pulses Narrow QRS HR > 150; Wide QRS HR > 120 Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Electrocardiogram Monitoring. Perform a 12 lead ECG if possible Establish vascular access with Normal Saline TKO; titrate to systolic blood pressure (SBP

Answer 14

Persistent Tachycardia Causing: * Hypotension * Acutely altered mental status * Signs of shock * Ischemic chest discomfort * Acute heart failure

Answer 15

Consider Versed 4mgIVIOINIM may give 2mg dose additional IVIO preferred max dose 6mg Sync Cardioversion 100j 200j max check rhythm after each shock Now wide but stable Amiodarone 150mg IV/IO over 10 minutes transport

Answer 16

Amiodarone 150. mg IVP/IO Sync cardioversion max dose energy transport

Answer 17

Sync Cardioversion max energy, check rhythm transport

Answer 18

A fib A Flutter S tach

Answer 19

Confirm SVT Valsalva if no response consider Adenosine 6mg rapid IVIO followed by 20ml NS rapid flush if no response after 2 minutes Adenosine 12mg IVIO push followed by 20ml NS rapid flush

Answer 20

VF with unsynchronized defibrillationSynchronized cardioversion doses: -100J -200J -Max setting If no response to the initial shock, increase dose in a stepwise fashion for subsequent cardioversions to a maximum of 4 attempts

Answer 21

Advanced Airway: Consider early if evidence of airway burns. 2. Cardiac Monitoring, Sp02 monitoring, and ETCO2 monitoring for intubated patients. 3. Initiate large bore vascular access in patients with major burns (>9%). * Titrate to systolic blood pressure of ≥ 90 mmHg. 8025.19-Page 2 of 2 * Administer 500 ml normal saline fluid bolus to all adult patients with a Total Body Surface Area (TBSA) of burns ≥ 50% * When possible the preferred vascular access site is an unburned area. 4. Pain Management: If partial or full thickness burn with moderate to severe pain and without evidence of or mechanism of internal head, chest, or abdominal injury , consider pain meds

Answer 22

Partial thickness >9% of body surface. * Any electrical or any chemical burn. * Evidence of possible inhalation injury. * Any burn to the face, hands, feet, genitalia, perineum, or major joints.

Answer 23

Rule of Palm: The palm of the person who is burned (not fingers or wrist area) is about 1% of the body. Use the person's palm to measure the body surface area burned.

Answer 24

- The patient is able to speak full sentences; the patient may have an elevated pulse and blood pressure; the patient may be diaphoretic and weak; mental status is unaffected; no cyanosis is present.

Answer 25

- The patient is able to speak a few words; the patient may have an elevated pulse and blood pressure; the patient may be diaphoretic and weak; mental status is unaffected; mild cyanosis of lips and digits may be present.

Answer 26

The patient is unable to speak; the patient may have decreased/elevated pulse and/or decreased/elevated blood pressure; mental status is altered; more central and profound cyanosis is present.

Answer 27

A. Patients may have several disease processes together, producing shortness of breath. Wheezing may occur in diseases other than asthma, and peripheral edema may occur in settings other than congestive heart failure (CHF). Assessment should usually yield a single treatment plan. Commit yourself to a single assessment - you may modify this assessment based on response to therapy and as additional information becomes available, modify the treatment plan. B. Patients may have diseases producing shortness of breath that cannot be relieved with any prehospital treatments. Some patients will present to the prehospital personnel so far in respiratory failure that maintenance/establishment of an airway together with expeditious transport are the only treatments possible. C. Pulmonary edema in the setting of CHF will usually have collaborating signs such as: 1. History of CHF and medications such as diuretics and/or angiotensin-converting enzyme (ACE) inhibitors. 2. Peripheral edema. 3. Jugular venous distension (JVD). 8026.22-Page 2 of 2 4. Frothy pulmonary secretions. D. Continuous Positive Airway Pressure (CPAP) and Bi-PAP, are highly effective at improving respiratory distress and should be attempted if available in all patients with moderate and severe respiratory distress. In general, one provider should monitor and manipulat

Answer 28

Assess ABC’s limit physical exertion, reduce anxiety * Consider oxygen therapy per Respiratory Distress: Airway management PD # 8020 * Cardiac Monitor and SpO2., ETCO2 (continuous waveform) when available. * Consider vascular access but do not delay airway management or treatment. * Early contact with receiving hospital.

Answer 29

Mild distress, sob , cough Albuterol 2.5 5mg via HHN mask or inline neb may repeated doses

Answer 30

Cyanosis, accessory muscle use, inability to speak > 3 word sentences, severe wheezing SOB Albuterol 5mg via HHN mask or inline neb - continous albuterol for persistant dyspnea CPAP Epi 1:1000 0.3mg IM for pt with severe asthma/bronchospasm ONLY CAUTION - Epinephrine should be used cautiously in patients > 35 years old, or with a history of CAD or HTN

Answer 31

Mild Distress - mild wheezing SOB, cough if wheezing is present - Albuterol 2.5-5mg via HHN may repeat NTG SL - 0.4mg q5min Hold NTG if SBP<90

Answer 32

**Do Not Administer NTG if patient is taking PDE-5 inhibitors within last 48hrs for Erectile Dysfunction or Pulmonary HTN: i.e Sildenafil (VIAGRA®, REVATIO), Tadalafil (CIALIS®), Vardenafil (LEVITRA®) or equivalent.

Answer 33

Cyanosis, accessory muscle use, inability to speak >3 word sentences , Diaphoresis, pedal edema, ect IF wheezing Albuterol - 2.5 - 5mg via HHN may repeat NTG -SBP 90-150 mmHg: 0.4 mg SL SBP 150-200 mmHg: 0.8 mg SL SBP > 200 mmHg:1.2 mg SL May repeat titrated doses every 5 minutes based on repeat BP. Hold NTG if BP < 90 mmHg.

Answer 34

For SPB ≤ 90 mmHG Push Dose Epinephrine Epinephrine 0.01mg/ml (10mcg/ml) DOSE: 0.5-2 ml (5-20 mcg) IV/IO every 2-5 minutes. Titrate to SBP > 90 mmHg. NOTE: Monitor SBP while administering/titrating.

Answer 35

1. Advanced airway adjuncts as needed. 2. Cardiac Montitoring 3. Consider vascular access. 4. Monitor and reassess. 5. If in cardiac arrest, refer to PD# 8031 – Medical Cardiac Arrest. 6. Transport

Answer 36

1. Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest concentration and flow rate of O2 possible. 2. Airway adjuncts as needed. 3. Place the patient in a cool area and remove clothing as appropriate. 4. Transport *If sweating is absent, proceed with cooling patients as rapidly as possible (cool packs on neck, in the axilla and inguinal areas; fanning and misting, if possible, undress patient, cover with a sheet, and wet thoroughly.)* ALS 1. Advanced airway adjuncts as needed. 2. Consider vascular access. 3. Cardiac Monitoring 4. Transport

Answer 37

1. Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest concentration and flow rate of O2 possible. 2. Airway adjuncts as needed. 3. Assess the site of the wound for swelling and redness from stings/bites. 4. Immobilize affected extremity at or slightly below the level of the heart. 5. Keep the patient at rest. 6. Transport 7. Pre-alert receiving hospital of the possible need for antivenom if moderate to severe venomous snake bite is noted. NOTE: If the patient is experiencing signs and symptoms of anaphylaxis, treat per PD# 8001 – Allergic Reaction/Anaphylaxis. 8028.15-Page 3 of 3 Degree of Envenomation Presentation None Punctures or abrasions; some pain or tenderness at the bite. Mild Pain, tenderness, and edema at the bite; perioral paresthesias may be present. Moderate Pain, tenderness, erythema, edema beyond the area adjacent to the bite; often, systemic manifestations and mild coagulopathy. Severe Intense pain and swelling of entire extremity, often with severe systemic signs and symptoms; coagulopathy Life-threatening Marked abnormal signs and symptoms; severe coagulopathy *DO NOT APPLY ICE OR A TOURNIQUET TO THE SITE * *DO NOT BRING THE DEAD SNAKE TO THE HOSPITAL; TAKE A PICTURE IF POSSIBLE ALS 1. *Assess for anaphylaxis and treat per PD# 8001* Stings / Bites: BLS 1. Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest concentration and flow rate of O2 possible. 2. Airway adjuncts as needed. 3. Assess skin for swelling, redness, and rash. If extremity, check distal circulation, sensation, and movement 4. Keep affected extremities at the level of the heart and immobilize. 5. Transport *Apply ice for insect bites, not snake bites.* NOTE: If the patient is experiencing signs an

Answer 38

ATROPINE * 2 mg IV push, repeat every 3-5 minutes until secretions improve Albuterol

Answer 39

1. ABC’s/Routine Care-Supplemental O2 as necessary to maintain SPO2 ≥ 94%. Use the lowest concentration and flow rate of O2 as possible. 2. Aspirin (ASA) - Administer 324mg chewable ASA orally, except in cases of allergy to ASA. Concurrent anticoagulation therapy is not a contraindication for ASA administration. If ASA is not administered, the reason shall be documented in the ePCR. 3. Transport ALS 1. Assessment, treatment, and transport should occur concurrently when a single good quality Electrocardiogram (ECG) is completed. Scene time for suspected STEMI patients should be ≤ 10 minutes when possible. 2. Pulse oximetry shall be used. 3. Cardiac monitor 4. Obtain 12-Lead ECG. 5. If the patient ECG is consistent with an acute STEMI by software algorithm interpretation, the following shall be performed without delay: * Transmit the 12-lead ECG to the closest designated STEMI center. * Transport to the closest designated STEMI center. * Perform a Pre-Alert notification to the closest designated STEMI center. * The primary impression of STEMI must be documented in the ePCR. * A copy of all 12-Lead ECGs shall be delivered with the patient. NOTE: NTG is contraindicated in the setting of a STEMI. 8030.26-Page 2 of 2 6. If 12-lead ECG is NOT consistent with an acute STEMI: * Administer NTG 0.4 mg sublingual if Systolic Blood Pressure (SBP) >90mmHg. May be repeated every 5 minutes. * Titrate subsequent NTG to pain relief as long as the SBP> 90 mmHg while simultaneously establishing vascular access. * Absence of vascular access shall not preclude use of NTG as long as all other criteria are met. Caution: NTG shall not be given to patients who have taken PDE-5 inhibitors [Avanafil, Sildenafil, Tadalafil, Vardenafil, Vardenafil, or equivalent] within the last 48 hours. 7. Establish vascular access. Special Considerations: 1. If NTG is contraindicated or after the third (paramedic-administered) NTG, the patient does not have relief of chest discomfort/pain; the paramedic may elect to administer pain medication as per Policy# 8066 (Pain Management) 2. If patient is nauseated and/or vomiting refer to Policy# 8063 (Nausea/Vomiting). 3. Hemodynamically unstable patients (SBP < 90 mmHg) with an acute STEMI ECG shall be transported to the time closest facility providing interventional cardiac catheterization services.

Answer 40

A. High-quality Cardiopulmonary Resuscitation (CPR) is fundamental to the management of all cardiac arrest rhythms. Periodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, and perform a pulse check when an organized rhythm is detected. B. CPR must be performed with a “Chest Compressions, Airway, Breathing” sequence (C-A-B) to emphasize the importance of maintaining blood flow with good compressions. C. Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest. D. Advanced airway placement shall be confirmed with ETCO2 detection device or waveform capnography. E. Vascular access, drug delivery, and advanced airway placement should not cause significant interruptions in chest compressions or delay defibrillation. F. Treatment on scene- Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions. Consider resuscitative efforts on scene to maximize chances of Return of Spontaneous Circulation (ROSC). G. Whenever feasible, and safe to do so, transport the medical Durable Power of Attorney (DPOA) or immediate family member with the patient to the hospital. DPOA and immediate family members can provide medical insight and consent for special therapies or termination of resuscitation to hospital staff. H. Perform an early Pre-Alert notification to the receiving hospital.

Answer 41

A. Any patient with an initial shockable rhythm (VT or VF or shocked by an AED) who has a ROSC during any part of the resuscitation and who is transported, shall be transported to a STEMI center 8031.26-Page 2 of 3 1. Any other cardiac arrest patient who is transported, shall be transported to the time closest hospital. B. Intravenous (IV) or Intraosseous (IO) fluids should be placed at, to keep open (TKO) unless hypotension is present. C. Post-resuscitation bradycardia, hypotension, shock, and pulmonary edema. 1. Bradycardia, refer to PD# 8024 – Cardiac Dysrhythmias. 2. Congestive Heart Failure/Pulmonary Edema refer to PD# 8026 – Respiratory Distress. 3. Hypotension/Shock a. Normal Saline 1000 ml bolus, may repeat once to achieve Systolic Blood Pressure (SBP) > 90 mmHg. Reassess vital signs after each bolus b. Push Dose Epinephrine 0.01 mg/ml (10mcg/ml). * Dose: 0.5-2 ml every 2-5 minutes (5-20mcg). Titrate to SBP ≥ 90 mmHg. NOTE: Once ROSC is obtained, monitor SBP frequently while administering/titrating.

Answer 42

A. Consider termination of resuscitation efforts after twenty (20) minutes of Advanced Life Support (ALS) care if BOTH of the following are present: 1. Pulseless, apneic, or agonal, respirations with no signs of life (non-reactive pupils, no response to pain, no spontaneous movement). 2. Asystole, or Pulseless Electrical Activity with HR ≤ 40 bpm.

Answer 43

IV, IO, AIrway, Cardiac Montor pads CPR 2 min IVIO access , epi every 3-5 minutes, consider advanced airway, capnography no shockable rhythm CPR 2 min

Answer 44

CPR 2 min IV IO Shock CPR 2 min , epi every 3-5 min , consider advanced airway, capno shock , cpr amiodarone

Answer 45

1mg every 3-5 minutes

Answer 46

First dose 300mg bolus Second dose 150mg

Answer 47

A. The pathophysiology of traumatic cardiac arrest differs from medical cardiac arrest and is primarily due to one of or a combination of factors: hypovolemia, obstruction of blood flow, and hypoxia. B. The initial cardiac rhythm for most patients in survivable traumatic cardiac arrest is pulseless electrical activity (PEA). Traumatic cardiac arrest PEA is most often a very low output state due to hypovolemia. C. Traumatic cardiac arrest patients undergoing resuscitation shall be transported as quickly as possible to the hospital. D. Patients with trauma in cardiac arrest who by prehospital presentation may have suffered a medical event before trauma shall undergo medical cardiac arrest resuscitation per PD# 8031 – Non-Traumatic Cardiac Arrest, with attention and appropriate management to emergent trauma needs (hemorrhage control, pneumothorax decompression as indicated, and orthopedic immobilization as indicated) E. There is no evidence-based medical support for the use of medications in traumatic cardiac arrest. In traumatic arrest, Epinephrine and Amiodarone are NOT indicated in traumatic cardiac arrest. Epinephrine will not correct arrest caused by a tension pneumothorax, cardiac tamponade, or hemorrhagic shock. If there is any doubt as to the cause of arrest, treat as a non-traumatic arrest.

Answer 48

Treat immediate threats to life 2. External hemorrhage control per PD# 8065 - Hemorrhage Control 3. Airway and Breathing: Clear airway when indicated, place OPA, BVM ventilations 4. Chest Compressions: Chest compressions should be performed when possible without delaying transport or other treatments 8032.01-Page 2 of 3 ALS 1. Optimize Oxygenation/Ventilation * Advanced airway as needed per policy * Advanced airway placement shall be confirmed with ETCO2 detection device or waveform Capnography 2. Correct potential obstructive shock - Maintain high Index of suspicion for tension pneumothorax, Bilateral needle thoracostomy per PD# 8015 – Trauma 3. Treat potential exsanguination * Obtain two (2) large-bore IV or IO access * 1 Liter normal saline bolus simultaneously via each IV/IO * Utilize pressure bag for rapid fluid administration * Reassess lung sounds after each Liter * Repeat IV fluid during arrest until SBP>90 or a maximum of 4 liters administered 4. Treat Cardiovascular Collapse * High-quality CPR * ECG monitoring and appropriate defibrillation per PD# 8031 – Cardiac Arres

Answer 49

A. Any traumatic cardiac arrest patient who has a Return of Spontaneous Circulation (ROSC) during any part of the resuscitation, and who is transported, shall be transported to a Trauma Center. B. Intravenous (IV) or Intraosseous (IO) fluids should be placed wide open with pressure bags. C. If palpable pulse becomes present: * Re-assess for and control external hemorrhage * Administer TXA as indicated per PD# 8065 – Hemorrhage Control * Titrate normal saline to SBP ≥ 90 mmHg or palpable peripheral pulses

Answer 50

Do they meet obvious death no - Is the patient pulseless, apneic, or have agonal respiration with no signs of life and absence of all pulses or wide complex asystole by monitor with PEA < 40? No - * Start CPR * Prepare for Immediate Transport * Treat reversible causes * Do not administer Epinephrine

Answer 51

* Immediately place mother on high flow O2 * Place mother in knee-chest position. * Insert gloved hand into vagina and gently push presenting part off cord. * Cover exposed cord with wet saline dressing. * When the head is crowning with the prolapsed cord, immediate delivery is the most rapid means of restoring O2 to the infant

Answer 52

* Control the decent of the fully crowned head with your gloved hand cupped over the cranium.. If cord is around neck, gently slip it over the head or across the shoulder. If cord cannot be removed, gently clamp the cord in 2 locations approximately 1 cm apart and cut the cord between the clamps. Support the head; do not allow the presenting part to press on the cord. * When head delivered, gently lower the head to deliver the anterior (upper) shoulder. Once shoulder is delivered, gently raise the head to deliver the posterior (lower) shoulder. Prepare for remainder of the baby’s body to be delivered. * Hold baby in slightly head down position. * Clamp and cut cord. Leave a minimum of 6 inches of cord for the umbilicus. There is no hurry to cut the cord * Dry and warm the baby.

Answer 53

Avoid compression of the cord by presenting part. * Allow delivery to progress passively until baby’s waist appears. * When legs and buttocks are delivered, the head can be assisted out. * If head does not deliver in 1-2 min. insert a gloved hand into the vagina and create an airway for the infant.

Answer 54

APGAR of 7 or greater-dry, place skin to skin with mother or if mother refuses, wrap warmly, place cap on baby’s head and proceed to assess mother * Suctioning should be reserved for babies who have an obvious obstruction to spontaneous breathing or require positive pressure ventilation. See Neonatal Resuscitation, PD#9009. * Always consider the possibility of multiple births. * Consider blow-by oxygen. Heated humidification systems are preferable to cool mist systems, which can produce hypothermia in the infant

Answer 55

Newborn patients needing resuscitation should be treated in accordance with PD# 9009 - Neonatal Resuscitation. * Newborns can suffer from hypothermia, which can occur in minutes. * Keep baby at or below the level of the mother’s heart until cord is clamped. * Do not pull on the umbilical cord. * Expedite transport if there is partial delivery of the infant and no further progress after 1-2 minutes. * Any patient in labor, or who delivers in the field will be taken to a facility with labor and delivery services. Consideration should be given to the patient’s pre-determined hospital for delivery, if possible.

Answer 56

If Multiple Births: * Clamp cord of first baby before the second is born * Care for the babies as you would a single delivery * Maintain identity of first born

Answer 57

A. All patients suffering traumatic injuries shall be assessed for the possibility of spinal injury, including history and exam, including a neurologic exam of all extremities and inspection and palpation of the entire spine. B. Establish and secure an airway while maintaining neutral inline immobilization. C. Assess the head and neck for obvious injuries and distended neck veins while providing neutral inline immobilization for the head and neck. D. SMR, when indicated, should apply to the entire spine due to the risk of noncontiguous injuries. E. An appropriately sized cervical collar is a critical component of SMR and should be used to limit movement of the cervical spine whenever SMR is employed. 8044.15-Page 2 of 3 F. The remainder of the spine should be stabilized by keeping the head, neck, and torso in alignment. This can be accomplished by placing the patient supine on a long backboard, a scoop stretcher, a vacuum mattress, or an ambulance gurney. G. If elevation of the head is required, the device used to stabilize the spine should be elevated at the head while maintaining alignment of the neck and torso. SMR cannot be properly performed with a patient in a sitting position. H. Transport.

Answer 58

A. Indications for SMR following blunt trauma include: 1. Midline neck or back pain and/or tenderness 2. Altered level of consciousness (e.g., GCS < 15, evidence of intoxication) 3. Focal neurologic signs or symptoms (e.g., numbness or motor weakness) 4. Anatomic deformity of the spine 5. Distracting circumstances (e.g., emotional distress, communication barrier, or age > 65 or < 5 years of age), or injury (e.g., long bone fracture, de-gloving or crush injuries, large burns, etc.) or any similar injury that impairs a patient’s ability to contribute to a reliable history and/or examination B. If the above criteria are not met, but there is still suspicion of a spinal column or spinal cord injury, the patient should be placed in SMR. C. Prehospital providers may utilize SMR for any trauma patient who, based on their clinical assessment, may have suffered a spinal injury. D. There is no role for SMR in isolated penetrating trauma.

Answer 59

A. Moving the head into a neutral inline position is contraindicated if: 1. There is pain upon starting movement 2. There is muscle spasm or back pressure upon attempting movement 3. Patient holds head angulated (tilted) to the side, and the patient cannot move the head 4. The head is rigidly held to one side 5. The maneuver cannot be safely achieved due to space or other considerations B. In these cases, the patient shall be immobilized in the position in which they are found. SMR does not take precedence over the airway, respiratory, and cardiovascular stabilization of the critical trauma patient. C. If attempting to apply SMR to a combative patient would cause further detriment, abort the procedure and document in ePCR. Notify ED staff on arrival regarding indications for SMR but the inability to apply due to combative patient. D. If modified spinal restrictions are used, documentation in the PCR is required to clearly explain why SMR could not be performed.

Answer 60

A. Stroke - A condition of impaired blood flow to a patient’s brain resulting in brain dysfunction, most commonly through occlusion or hemorrhage. B. Onset of Symptoms - The specific date and time when current symptoms were known to have started. C. Last Known Normal/Well - When the “onset of symptom” cannot be reliably determined (no witness or a poor historian), the Last Known Well time is the most recent time a reliable historian can say the patient was at their baseline health without current symptoms. D. Wake Up Stroke - Patient awakens with stroke symptoms that were not present prior to falling asleep. E. Suspected Stroke - Suspected Stroke with one (1) new onset of lateralizing neurological signs; and/or two (2) unexplained new altered level of consciousness (Glasgow Coma Scale < 14) without response to Glucose, Glucagon, or Naloxone (excluding head injury). Protocol: A. If possible, document a reliable time of day that the patient was last observed to be normal either by the patient or witness. A patient who wakes up with symptoms is considered as having an UNKNOWN time of onset.

Answer 61

1. Advanced airway adjuncts as needed. 2. Cardiac Monitoring. 3. Determine Cincinnati Prehospital Stroke Scale (CPSS). Normal response is 0, Abnormal is 1, Maximum Score is 3. 4. Initiate vascular access. If time allows, without delaying transport, initiate a second access line. Minimum 20g in AC when possible. 5. If CPSS is >0, and “last seen normal” *time, including wake-up Stroke, is twenty-four (24) hours or less, the patient is to be taken to a certified stroke center. 6. Prehospital personnel will contact the receiving hospital and clearly announce: “Stroke Alert” and give the following information if available: * Last time of day observed to be “normal,” reported by bystanders. * Patient’s name, date of birth, or medical record number, if known. * Baseline Mental Status. 7. When possible and safe to do so, transport a family member or Durable Power of Attorney (DPOA) or obtain and relay to the receiving hospital the name/contact information of the individual(s) who can verify the time of onset of symptoms or last known normal/well time. *If CPSS is=0, OR “last seen normal” time is > twenty-four (24) hours, the patient is NOT a “stroke alert,” and destination is per Policy PD# 5050 – Destination.

Answer 62

Continued Combativeness: If the patient remains combative despite restraint such that further harm to the patient or providers is possible. Midazolam: a) Intravenous (IV) - 0.1 mg/Kg (max dose 6 mg) slow IV push in 2 mg incrementstitrate to the reduction in agitation. b) Intranasal (IN) – 0.1 mg/Kg (max dose 6 mg) one-half dose in each nares. c) Intramuscular (IM) - 0.1 mg/Kg (max dose 6 mg) in single IM injection (may be split into two sites if sufficient muscle mass is not present for a single injection). 2. Monitor Patient: a) ECG Monitoring: Monitor closely for respiratory compromise. Assess and document mental status, vital signs, and extremity exam (if restrained) at least every five (5) minutes. b) SPO2 Monitoring c) Supplemental O2 as necessary to maintain Sp02 ≥ 94%. Use lowest concentration and flow rate of O2 as possible.

Answer 63

1. Advanced airway adjuncts as needed. 2. Cardiac Monitoring for possible dysrhythmias. 3. Consider vascular access and titrate to SBP ≥ 90mmHg. 4. Ondansetron: * 4mg PO/SL/IM/IV/IO. * For IV or IO Ondansetron, administer slowly (over one (1) minute) to prevent syncope. 5. For persistent vomiting, may repeat x one (1) for max dose of eight (8) mg. 6. Withhold from first trimester (< 12 weeks) pregnant patients not already using Ondansetron

Answer 64

NOTE: Analgesic medications should be considered in ALL patients complaining of pain. With the exception of Ketamine and Acetaminophen, analgesics should be avoided if the patient’s systolic blood pressure (SBP) is <90 mmHg, respiratory rate (RR) is ≤ 10 breaths per minute, and/or decreased sensorium or suspicion of traumatic brain injury.

Answer 65

1. Advanced Airway adjuncts as needed. 2. Cardiac and SpO2 monitoring. 3. Initiate vascular access. 4. Document the pain scale (sample scale attached below) with initial assessment/vital signs after each administration of medication and after all procedures. 5. Pain medications shall be titrated to relief if the pain is not effectively managed with BLS pain management methods. a. Acetaminophen For patients with mild to moderate pain) * 1000 mg IV/IO infusion over 15 minutes. * 1000 mg PO. * Do not repeat. b. Ketorolac (For patients with mild to moderate pain) * 15 mg slow IV/IO push or 30 mg IM. * Do not repeat. 8066.11-Page 2 of 3 c. Fentanyl Citrate (For patients with moderate to severe pain) * 1 mcg/kg (maximum single dose 100 mcg) slow IV, IO, or IN every 5 minutes. Maximum cumulative dose of 3 mcg/kg (300 mcg) total. d. Morphine Sulfate (if Fentanyl is unavailable) * 0.1 mg/kg (maximum single dose 10mg) slow IV, IO, or IN every 5 minutes. A maximum cumulative dose of 0.2 mg/kg (20 mg). e. Ketamine (For patients with moderate to severe pain) * Mix 0.3 mg/kg Ketamine (maximum single dose = 30mg) in 50-100cc normal saline solution (NSS) or D5W and administer slow IV drip over ten (10) minutes. * If pain remains at, or returns to, moderate or severe, you may administer a second dose of 0.3 mg/kg Ketamine (max dose=30 mg) in 50-100cc NSS or D5W and administer slow IV drip over ten (10) minutes. Precautions/Contraindications: 1. Check the patient’s allergies before administering any medication. 2. Ketamine should be avoided in the following patients: * Chest pain of suspected cardiac origin. * Pregnancy. 3. Ketorolac should be avoided in the following patients: * Active bleeding. * Active wheezing. * Age < 4 years old or > 65 years old. * Allergy to Non-Steroidal Anti-inflammatory agents (NSAIDs). * Current Anticoagulation therapy. * Head or Multisystem trauma. * History of peptic ulcer disease of upper GI bleeding. * History of renal disease or kidney transplant. * Known or suspected pregnancy. * Suspected Sepsis or Septic Shock

Answer 66

A. Sepsis: Sepsis can be a rapidly progressing, life-threatening condition due to SIRS (systemic infection). Sepsis must be recognized early and treated aggressively to prevent progression to shock and death. The most important pre-hospital interventions for Sepsis/SIRS patients include: 1. Recognition of potential Sepsis/SIRS 2. Early and aggressive fluid resuscitation 3. Pre-arrival “Sepsis Alert” notification to receiving facility.

Answer 67

A generalized inflammatory response to a non-specific injury and includes at least 2 of the following criteria; 1. Body temperature of > 38 C (100.4 F) or < 36 C (96.8 F). 2. Respiratory rate > 20 breaths per minute. 3. Heart rate > 90 bpm.

Answer 68

A. Treatment interventions and pre-arrival notification shall occur for patients meeting BOTH of the following pre-hospital sepsis criteria: 1. Confirmed or suspected presence of infection: a. By history from the patient, family, or care home. b. By signs or symptoms of urinary tract infection, respiratory infection, or skin infection. c. Older Adults or immune-compromised patients with otherwise unexplained ALOC and no findings to suggest acute STROKE per PD# 8060 – Stroke. 8067.06-Page 2 of 2 AND 2. Any two (2) of the following criteria: a. Temperature of >38 °C (100.4 °F) or < 36 °C (96.8 °F) (Acquired by EMS or if reported by patient, family, or care home). b. Respiratory rate >20 breaths per minute. c. Heart rate > 90 beats per minute. d. SBP < 90 mmHg e. Waveform capnography, if available, with a reading of < 25mmHg

Answer 69

1. Use Supplemental oxygen as necessary to maintain Sp02 ≥ 94%. Use lowest concentration and flow rate of 02 as possible. 2. Perform blood glucose determination 3. Conduct a pre-arrival “Sepsis Alert” notification to the receiving facility. 4. Transport ALS 1. Cardiac Monitoring 2. Establish vascular access. * Administer a 500 ml bolus of Normal Saline to ALL patients regardless of Systolic Blood Pressure (SBP). * If SBP remains < 90 mmHG, repeat 500 ml bolus of NS until SBP > 90 mmHG. Total amount of fluid not to exceed 2000 ml. Recheck vital signs and lung sounds after every 500 ml bolus. * Give boluses in rapid succession if SBP remains < 90 mmHG. * Albuterol if wheezing and SOB per PD# 8026 – Respiratory Distress. 3. If SBP remains < 90 mmHg after four (4) fluid boluses: * Push Dose Epinephrine 0.01 mg/ml (10mcg/ml). DOSE: 0.5-2 ml (5-20mcg) every 2-5 minutes (5-20mcg) IV/IO Titrate to SBP > 90 mmHg NOTE: Monitor SBP while administering/titrating.

Answer 70

A. Any patient who is suffering from an acute injury or suspected acute injury shall have the Trauma Triage Criteria (Policy #5053) applied by prehospital care personnel B. Transportation units, both ground, and air shall transport CTPs who are the subject of any 9-1-1, emergency, or non-emergency response, to the time closest appropriate designated trauma center (Policy #5053). If direct medical oversight is necessary, it shall be provided by the receiving Sacramento County Emergency Medical Services Agency (SCEMSA) designated trauma center C. All CTPs ≤14 years of age will be transported to a designated pediatric trauma center i.e., University California Davis Medical Center (UCDMC) with the following exceptions: 1. Pediatric patients without an effective airway may be transported to the nearest available facility for emergent airway establishment 2. Pediatric trauma patients under Cardiopulmonary Resuscitation (CPR) shall be transported to the time closest trauma facility 3. If UCDMC is closed to pediatric trauma, pediatric patients shall be taken to the time closest trauma center 4. Pediatric patients with a tourniquet in place will be transported to UCDMC D. Any adult patient with a tourniquet in place shall be transported to the appropriate trauma center. E. The paramedic with a NCTP may utilize a SCEMSA-designated trauma base station for direct medical oversight. 5052.19-Page 2 of 2 F. The CTP without an effective airway shall be transported to the closest available hospital with an emergency department for stabilization prior to transfer to a designated trauma center when a life-threatening respiratory condition exists, i.e. obstructed airway or unrelieved tension pneumothorax. G. The NCTP who, in the judgment of a base hospital, requires immediate surgical intervention or other services of a designated trauma center shall be transported to a designated trauma center. H. Direct medical oversight shall be obtained from a SCEMSA-designated trauma center for any CTP refusing to be transported to a designated trauma center to guide prehospital emergency personnel in arriving at a destination decision. I. Any patient who meets trauma triage criteria, and who has an LVAD shall be transported to UCDMC.

Answer 71

Assess Physiologic Trauma Criteria: Unable to follow commands (motor GCS < 6) Respiratory rate <10 or >29 breaths per minute Respiratory distress or need for respiratory support Note: “Respiratory support: Anything other than supplemental 02 Sustained heart rate > 120 beats per minute Room-air pulse oximetry < 90 Age 0-9: SBP < 70mm Hg + (2x age years) Age 10-64 years: SBP < 90 mmHG OR HR > SBP Age ≥ 65 years: SBP < 110 mmHg OR HR > SBP

Answer 72

Anatomic Criteria * All penetrating injuries to the head, neck, torso, and extremities proximal to the elbow and knees * Skull deformity, suspected skull fracture * Suspected Flail Chest, wall instability, or deformity * Suspected fracture of Two or more proximal long-bone * Crushed, de-gloved, mangled, or pulseless extremity proximal to wrist or ankle, or pulseless extremity * Amputation proximal to wrist or ankle * Suspected pelvic fracture * Suspected spinal injury with new motor or sensory loss * Active bleeding requiring a tourniquet or wound packing with continuous pressure

Answer 73

Mechanism of Injury Criteria: * Falls Adults: > 10 feet (one story is equal to 10 feet) Children: > 10 feet Low level falls in young children (age ≤ 5 years) or older adults (age ≥ 65 years) with significant head impact * High risk auto crash Intrusion: >12 inches occupant site; > 18 inches any site (including roof) NOTE: Intrusion refers to interior compartment intrusion, as opposed to deformation which is exterior damage. * Ejection (partial or complete) from motorized vehicle or livestock * Death in same passenger compartment * Child (Age 0-9) unrestrained or in unsecured child safety seat) * Auto vs. pedestrian/bicyclist thrown , run over, or with significant (>20 mph) impact * Motorcycle crash > 20 mph

Answer 74

SPECIAL CONSIDERATIONS WHEN TRIAGING CRITICAL TRAUMA Any patient at the extremes of age (pediatric and adult) who has suffered an injury and/or where physical examination or assessment is difficult. Critical Trauma Patients who do not meet physiological criteria with the following conditions will be transported to UCDMC: - Traumatic amputations proximal to the wrist and/ or the ankle - Traumatic burns > 9% Total Body Surface Area - Chemical or Electrical Burns - Evidence of possible inhalation injury - Any Burn to the face, hands, feet, genitalia, perineum or major joints Patients ≤ fourteen (14) years of age will be transported to UCDMC if they meet any trauma triage condition with the following exceptions: - Pediatric Critical Trauma patients with no effective established airway may be transported to the closest available facility excluding the VA per PD# 5050. - Regardless of age, Traumatic Cardiopulmonary Resuscitation patients shall be transported to the time closest designated trauma center. Regardless of age, VAD patients who meet critical trauma criteria shall be taken to UC Davis Medical Center. Emergency Medical Service Provider Judgment: Some patients not meeting clearly defined trauma triage criteria may still have a severity of injury warranting trauma center care. If the patient does not meet trauma center criteria but the Paramedic feels that trauma center care is still warranted, transport to a trauma center. (Document Reason) Possible examples of such patients include: Patients taking anticoagulation medications, excluding aspirin, or a history of bleeding disorders. A clear history of loss of consciousness. Pregnancy > 20 weeks.

Answer 75

A. Visual examination: Viewing the body with sufficient proximity and lighting to assure existence of the death determining condition. B. Physical examination: Palpation of the body and exposing the area as necessary to determine the existence of the condition. C. Absence of palpable pulses: Absence of pulses after palpating for carotid pulses for at least ten (10) seconds. D. Asystole by monitor: Cardiac monitor shows asystole in two (2) leads. E. Rigor Mortis: Physical examination with rigidity in jaw and one limb. F. Livor Mortis: Discoloration appearing on dependent parts of the body after death as a result of cessation of circulation, stagnation of blood and settling of blood by gravity

Answer 76

1. Decapitation 2. Incineration of the torso and/or head 3. Decomposition 4. Separation or destruction of brain and/or heart from the body 5. Rigor Mortis 6. Livor Mortis

Answer 77

Determination of Death- Paramedic only: A. Traumatic injuries (if appropriate; respect the possibility of a crime scene): 1. Absence of all pulses, and 2. Asystole by monitor in two (2) leads, or 3. Pulseless electrical activity (PEA) with heart rate ≤ 40 bpm. B. Documented submersion ≥ 60 minutes. C. In all other circumstances (except Do Not Resuscitate cases) full resuscitation will be initiated. D. In all cases when death has been determined, notification of the Coroner's office or law enforcement shall be done. Follow the direction of the Coroner's office/law enforcement as to who has custody of the body. Evidence of a hospice patient receiving care from a physician or registered nurse who is a member of a hospice care interdisciplinary team, within twenty (20) days before death does not require coroner notification. When the investigating agency releases prehospital personnel, only then may they depart the scene. In all cases, if requested by the Coroners Office, documentation will be forwarded within 72 hours or sooner.

Answer 78

A. Emergency Medical Technician (EMT) shall apply to EMTs and Paramedics. B. Do not resuscitate (DNR) means the patient will not receive chest compressions, defibrillation, assisted ventilation, endotracheal intubation, or cardiotonic medications. This does not exclude other treatments, especially those treatments directed to the pain and comfort of the patient. C. The State of California Emergency Medical Services Authority (EMSA) approved form Physician Orders for Life-Sustaining Treatment (POLST) is recommended for documenting do not resuscitate orders. a. Comfort-Focused Treatment (as defined in the POLST form) “primary goal of maximizing comfort” (eg, relieving pain, using oxygen, suctioning, and manual treatment of airway obstruction). b. Selective Treatment (as defined in the POLST form) “goal of treating medical conditions while avoiding burdensome measures (eg, administer IV fluids, use of CPAP or BiPAP, but DO NOT INTUBATE) D. DNR Medallion: MedicAlert® medallion, which states “Do Not Resuscitate - EMS" (or similar medallion as approved by the EMSA). E. Aid-in-Dying Drug: A drug determined and prescribed by a physician for a qualified individual, which the qualified individual may choose to self-administer to bring about death due to terminal illness. The prescribed drug may take effect within minutes to several days after self-administration. F. End of Life Option Act: This California state law authorizes an adult, eighteen (18) years or older, who meets certain qualifications and who has been determined by attending 2085.20-Page 2 of 4 physician to be suffering from a terminal disease to make a request for an “aid-in-dying drug” prescribed for the purpose of ending life in a humane and dignified manner.

Answer 79

Protocol: A. All patients who do not meet the "Determination of Death Criteria" as outlined in SCEMSA PD #2033 – Determination of Death or criteria outlined in this policy shall receive resuscitation efforts. B. Any EMT or Paramedic who is presented with one of the following at the initiation of patient care or at any time during patient care may discontinue resuscitation efforts: 1. An EMSA POLST form 2. A completed Prehospital DNR Request Form stating, "Do Not Resuscitate," "No Code," or "No CPR." 3. A written or electronic order stating, "Do Not Resuscitate," "No Code," or "No CPR" signed by a physician, with the patient's name and date the order was signed; 4. A written Advance Health Care Directive document or wallet card, including the DNR portion of a “Living Will” or equivalent, identifying the designated agent who declines resuscitation on behalf of the patient. Resuscitation attempts shall not be delayed by attempts to contact the designated agent 5. The patient is wearing a DNR medallion C. If the patient is conscious and states he/she wishes resuscitative measures, all DNR orders shall be ignored. D. The presence of a DNR order, the physician, nurse practitioner, or physician assistant’s name signing the order, and the date of the order are to be documented on the Patient Care Report (EMS Form). E. The DNR form (original or copy), DNR medallion, or a copy of the valid DNR order from the patient's medical record shall be taken to the hospital with the patient. F. If there are any questions regarding a patient’s DNR status, EMS shall provide for patient comfort, including basic life support cardiopulmonary resuscitation, if indicated, and utilize direct medical oversight. G. Paramedic providers shall follow the medical interventions indicated on the POLST form within their local scope of practice. Utilize direct medical oversight for any questions. H. DNR Patients with POLST forms that indicate “Selective treatment, request medical transfer ONLY if comfort needs cannot be met at current location” or “Comfort-focused treatment” may qualify for no transportation if all of the following apply: 1. After the assessment, the medic determines that the patient’s comfort needs are being met at their current location. 2. The patient or DPOA agrees that the patient’s needs are being met at their current location. 3. Discussion with direct medical control indicates that the patient’s comfort needs are being met at their current location.

Answer 80

In the event that a DNR patient being transported dies en route, the following shall occur: * Do not cross a county line, as deaths need to be reported and processed in the county in which they occur. 2085.20-Page 3 of 4 * If the destination was a hospital, continue on to that facility (if it’s in the same county), or select a new destination facility in the same county. * If the transport was from a hospital to another destination (care facility, home, etc.), return to the hospital of origin if in the same county, or continue on to the original destination if in the same county as the expiration. * If the receiving facility or home will not accept the deceased, contact the coroner to assist with disposition.