Flashcards in Miami Valley Protocol Deck (125):
What are the reasons to contact the hospital prior to arrival and transfer of care?
1.) time is needed to set up for the patient, I.e. Major trauma, cardiac arrest, bedbugs.
2.) guidance is needed for unfamiliar patient condition or medication dosage.
What should you include when calling in a trauma patient?
MIVT, ETA, GCS components, patient assessment findings (MIVT is mechanisms, injuries, vital signs, treatments)
What should you request if you want to talk to a physician?
Request medical control
When must an EMT call a hospital?
Whenever they transmit an EKG
What do you say when calling in an alert?
"We recommend a... alert"
How much time do you have to provide a completed run sheet to the hospital?
Upon delivery or within 3 hours
What do procedures marked with a diamond indicate?
Never to be performed without a medical control physician (MCP) order
What is required for advanced airway insertion?
Must use confirmation device such as end tidal co2 or colorimetric
If you put a patient on O2 in respiratory distress, what must happen?
They must stay on O2 until care is transferred to the hospital
In what circumstances is resuscitation contraindicated?
-deep, penetrating cranial injuries
-massive truncal wounds
-valid and present DNR
-rigor mortis, tissue decomp, lividity
-penetrating trauma found in arrest and patient cannot be delivered to an emergency department in 15 min (resuscitation will be initiated n victims who arrest after they are in ems care)
-blunt trauma found in cardiac arrest (unless there is focused blunt trauma to the chest I.e. Commotio cordis, the arrest was caused by a medical condition, or the patient can be delivered to an ER in 5 min
What is permitted by a DNR-CC?
Permits any medical treatment to diminish pain or discomfort that is not used to postpone death
-splinting and spinal restriction
What treatments are NOT permitted under a DNR-CC?
-airway adjuncts & CPAP, respiratory assist
-defib, cardiovert, monitoring
What does a DNR-CCA mean?
Permits appropriate standing order tx until cardiac or respiratory arrest or agonal breathing occurs
Can a durable power of attorney override a patients DNR status?
When a durable power of attorney for healthcare (DPA-HC) Is present and the "living will and qualifying condition" box is checked, the DPA-HC cannot override the patients DNR status.
How can a DNR be changed or expire?
A DNR never expires unless there is a date on it stating so, a patent may change their DNR status at any time verbally, in writing, or by action
When should you work a code on scene vs. transport to a medical center?
Patients best chance for survival is on scene. Quality of CPR diminishes while being transported. The following patients should be transported to ED if less than a 30 min transport and defib is the only needed intervention to establish a perfusing rhythm...
-documented STEMI and witnessed cardiac arrest after brief resuscitation efforts
-have ROSC after defib or ROSC with evidence of ST elevation on transmitted EKG
-patient arrests due to profound hypothermia
When is oral glucose indicated?
Blood sugar less than 60 or if there is a strong suspicion of hypoglycemia in a conscious but disoriented patient. Oral glucose can also be placed between the gum and cheek of an unresponsive patient who must be placed in the lateral recumbent position to promote drainage of secretions away from the airway
What are the 3 components of the pediatric assessment triangle?
Appearance, work of breathing, circulation
What are the components of appearance?
Reflects adequacy of oxygenation, ventilation, brain perfusion, and CNS function.
T=Tone: moves spontaneously, sits or stands
I=interaction: alert, interacts with environment
C=consolability: stops crying with comfort
L=look/gaze: makes eye contact, tracks objects
S=speech/cry: age appropriate
What are the components of work of breathing?
*more accurate indicator of oxygenation and ventilation vs adult measures
What are the components of circulation?
Mottling-indicates hypoxemia, vasoconstriction, respiratory failure. Blotchy appearance.
Cyanosis- blue, decreased O2 sat
When should a blunt trauma or MVC patient be immobilized with a c collar and backboard?
When clinical indications of a spinal injury are present I.e. Focal neurologic deficit including paralysis, altered level of consciousness, or unable to follow commands
When should you immobilize a pediatric patient on a backboard and a c collar?
In a blunt fall or trauma if the patient is less than 3 y/o with a GCS less than 15
What patients should have a c collar placed and be moved with caution in-line as a unit to the cot?
Pain on motion of the neck
High risk mechanism (high speed MVC, fall over 10 feet, axial loading injury)
How should you immobilize penetrating trauma?
These patients do not need to be immobilized. Delays in transport are to be minimized.
What if you need to perform airway management on a patient in a c-collar?
The collar may be removed with in line stabilization performed during the intervention. The collar must then be reapplied.
What should you do with equipment in a sporting injury?
Remove it prior to transport
What should you do with a patient who does not tolerate spinal or cervical restriction?
Adjust to point of removal. I.e. May not tolerate backboard but can sit up with c-collar
What oxygenation should you provide for a COPD patient?
2 lpm via nasal cannula unless prescribed higher
What is the respiratory rate of a neonate?
What is the respiratory rate of a 1-3 y/o?
What is the respiratory rate of a 4-6 y/o?
What is the respiratory rate of a 7-9 y/o?
What is the respiratory rate of a 10-14 y/o?
What is the respiratory rate of 15+ y/o?
Can EMTS suction tracheostomies?
What are the five confirmation methods for correct placement of an advanced airway?
-co2 detection methods like capnnography
-rise and fall of the chest
-condensation in the tube
When should you use capnnography?
On every intubation if the equipment is available. Titration of ventilations should be between 35-45. To increase co2, slow down ventilations and to decrease co2, speed up ventilations. Maintain until patient care is transferred at hospital.
When should you consider terminating Asystole?
Confirmed tube placement and capnograpghy is less than 10 and does not increase during resuscitation efforts
What is the maximum amount of time CPR can be interrupted for in a code?
No more than 10 seconds
How should you initially attempt to remove a foreign body in the airway?
What are some limitations of colorimetric end tidal co2?
-cannot be used longer than 2 hours
-pt. with large amounts of carbonated beverage can give a false positive
-secretions or emesis can ruin device
-if placed correctly it will turn yellow
What are the h's and t's?
Toxins, tension pneumothorax
Where do you perform compressions on a pregnant patient?
Consider need for uterine displacement and perform compressions slightly higher on the sternum
How often should you change people doing compressions?
Every two minutes if possible
What is the compression depth for adults?
At least 2 inches
What is the compression depth for children?
1/3 depth of chest
What is the compression depth for infants?
1/3 depth of chest
What is the compression depth for newborns?
1/3 depth of chest
What is the compression rate for adults, children, and infants?
100 to 120 per minute
What is the compression rate for newborns?
120 a min
What is the compression to breaths ratio for 2 person CPR on a child or infant?
What is the compression to breaths ratio for a newborn?
How many breaths do you give for an adult, child, or infant with an advanced airway?
1 every 6-8 seconds or 8-10 a min
How many breaths a min do you give a newborn with an advanced airway?
40-60 a minute
How many breaths do you give for an adult in rescue breathing?
1 every 5-6 or 10-12 a min
How many breaths do you give a child or infant when rescue breathing?
1 breath every 3-5 seconds, 12-20 a minute
How many breaths do you give a newborn with rescue breathing?
40-60 a minute
What should you do for chest pain in a pediatric patient?
Supplemental O2 and transport. Chest pain in a pediatric patient is rarely related to a cardiac event but rather usually muscle pain, injury, or respiratory difficulties.
What is the suspected cardiac chest pain algorithm?
-ask the patent if they take organic nitrates (Viagra, levitra, cialis) in the past 24,48,72 hours. Do not administer nitro if so due to profound hypotension
-give aspirin. Patient must chew and EMT's must have an order to get in drug bag. May assist with patients own aspirin
-if prescribed administer nitro as long as systolic BP is over 100 and patient is older than 25 or has a prescription. Administer up to 3 times every 5 minutes with vital signs in between doses. EMTS may assist with patients initial dose of prescribed NTG but will need MCP order for subsequent doses.
-prior to moving the patient, acquire 12 lead
-when calling report, include patients cardiologist if possible
What is revatio?
Revatio is a drug approved for tx of pulmonary arterial hypertension and contains sildenafil, which is Viagra. This makes NTG contraindicated for patients taking this medication.
Where can leg electrodes go when obtaining an EKG?
Anywhere below the waist
What is contraindicated for skin preparation when obtaining an EKG?
Do not use alcohol preps with therapeutic electrodes such as quick combo pads
What are the primary ways to reduce artifact?
-remove excess hair
-attach each electrode solidly
-prevent patient movement
-prevent cable movement
-stop the squad
- to eliminate EMI, turn off or move away from electrical devices, do not allow patient cables to touch power cords, make sure patient cables and electrodes are in good shape
When is a cardiac patent considered unstable?
-altered mental status
-unresolving chest pain
-poor skin color or diaphoresis
When do you begin chest compressions on a pediatric patient?
HR is less than 60/min
When should you especially consider performing a manual BP?
A patient presenting with s/s of shock
When should you call a stroke alert?
One or more signs of the cincinnati stroke scale is present and it is less than four hours since the patient was last seen normal
How should you transport a stoke patient?
With the bed flat if the patient can tolerate. If showing signs of ICP, do not lay patient flat
What disorders mimic stroke?
Toxic or metabolic disorders I.e. Hypoglycemia
What is a key consideration for a major trauma patient?
Maintain patients body temp
What are the only procedures that should take precedence to transport of major trauma patients?
-stabilization of neck, back, femur, pelvic fractures
What is essential in terms of vitals on a trauma patient?
-take a manual BP on all trauma patients
-repeat vitals every 5 minutes
After the extrication, how long until transport needs to happen for a trauma patient?
10 minutes or less
What should be included on the prearrival notification for the receiving facility of a trauma patient?
-GCS with components
What should be performed with crush syndrome trauma?
Contact medical control physician immediately and prior to relieving the load
What are special considerations for crush syndrome trauma?
Potential for hypo/hyper thermia
What is contraindicated in bleeding control?
List steps for hemorrhage control
-life threatening external hemorrhage takes priority over any other treatment
-if direct pressure fails to control bleeding from extremities, use a tourniquet. Tighten until bleeding stops
-place tourniquet as proximal to the wound as possible and document time and location
-only use flat and wide materials like BP cuffs or cravats for improvised tourniquets
What is your treatment for extremity injuries?
-control bleeding with direct pressure
-cover with dry, sterile dressing
-to reduce swelling, elevate extremity and apply ice
What are the listed good splinting practices
-document distal sensation and circulation pre and post splinting and pre and post spinal restriction
-if extremity is severely angulated and pulses are absent, apply gentle traction. If resistance is met, splint the extremity how it is found
-cover open wounds with a sterile dressing before splinting
-apply a well padded splint to immobilize above and below the injury
-if in doubt, splint a possible injury
What are important considerations with drownings and near drownings?
-consider spinal restriction
-evaluate neuro status
-near drowning patients go to trauma center
What are important considerations with hypothermia?
-remove all wet clothing/cover with blankets
-avoid any rough movement that could cause dysrhythmias or arrest. May be beneficial to immobilize this patient
-may be necessary to assess pulse and respirations up to 45 seconds to confirm arrest
-consider other medical conditions (overdose)
-if severe hypothermia (under 86 f core temp) limit defib attempts to one except with MCP orders
-O2 should be warmed and humidified
With burns and smoke inhalation, when should agencies call for the nearest available cyanide antidote cache?
-person trapped with exposure to smoke or fire in an enclosed area
-incident involving hydrogen cyanide
-report of mayday or firefighter down
When can you cover a burn with a wet dressing?
Superficial and partial thickness burns less than 10%
What are 3 important considerations with burn patients?
-burns greater than 10%, use dry clean dressing
-do not remove items that have adhered to the skin
-keep the patient warm
What burn patients should you consider hyperbaric oxygen treatment?
-underlying cardiovascular disease or cardiovascular symptoms
-over 60 y/o
-obvious neuro symptoms such as unconsciousness or memory loss
What are two important considerations for CO poisoning?
-pulse ox will not work because it will give false readings
-KMC has 24/7 hyperbaric chamber
What patient population is most likely to suffer from a heat exposure illness?
-patients with HX of spinal injuries
What heat environment poses the biggest risk for a heat exposure illness?
Temp above 90 f and humidity over 60%
What is the specific care for heat exposure illness?
-remove clothing and apply water to the skin
-apply cold packs to under arms and groin
-cold water submersion is acceptable for heat stroke patients, the goal is to lower temp to less than 102.5
-if conscious and not vomiting or extremely nauseous, provide oral fluids
-be prepared for seizures
-hyperthermia patients should be transported to trauma center
What is the specific care for eye injuries?
-use nasal cannula with IV tubing for irrigation
-irrigate immediately with NS or water for a minimum of 30 minutes or until transport complete
-do not irrigate if there is penetrating trauma
-cover both eyes to limit movement
-transport with head elevated at least 30 degrees
What is the appropriate procedure for a patient with pulmonary edema, asthma, or COPD?
What EPIPEN should a pediatric patient who is greater than or equal to 15 kg but less than 30 kg receive?
Adult EPIPEN (0.3mg)
What are the procedures for a diabetic refusal of transport?
-patient is older than 18
-must be a&o x3
-warn patient there is significant risk of going back
-advise patient to eat something immediately
-advise patient to contact physician
-advise patient to stay with someone
-send copy of run sheet to EMS coordinator of the hospital that replaces drug bag and supplies
What is an important consideration for a seizure patient?
BVM and NPA during seizure as needed
What is important to consider with NARCAN administration?
Titration to achieve adequate respirations. Should be used to improve respirations and not to awaken an unconscious patient
What is the pediatric dose for narcan?
Less than or equal to 20 kg is 0.1 mg/kg IN with a max of 2 mg. more than 20 kg is 2mg IN. Titrate to adequate respirations.
In most cases, why would a pediatric patient have respiratory depression?
They are either septic or have respiratory failure
What is the appropriate treatment for abdominal pain?
-exam that includes inspection, auscultation, and palpitation
-position of comfort
-give nothing by mouth
What are the main considerations for OB emergencies?
-no pregnant patients to Dayton children's
-consider ectopic pregnancy
-aggressively treat for hypovolemic shock
-take all expelled tissue to the hospital
-ask for first day of last menstrual period
How do you triage pregnant patients?
-pregnant patients over or equal to 20 weeks gestation should be taken to the maternity department; less than 20 weeks gestation go to the emergency department
How do you manage 3rd trimester bleeding?
-place patient in left lateral recumbent
-apply continuous manual displacement of the uterus to the left, or place a pillow under the right abdominal flank and hip
When is the only time you place a gloved hand in the vagina during childbirth?
Only in the case of breech delivery with entrapped head or prolapsed umbilical cord
What HX should you obtain from a pregnant mother during childbirth if possible?
-patient condition and pregnancy
-contraction duration and interval
-first day of last menstrual period
-number of pregnancies
-number of live children
When should you obtain APGAR scores?
1,5,and 10 minute intervals
What should you do if the cord is around the baby's neck?
-as baby head passes out of opening, feel for cord
-try to initially slip the cord over the neck
-if too tight, clamp the cord in two places and cut between the clamps
How do you treat a prolapsed cord?
-when umbilical cord is exposed, check for a pulse
-transport immediately with hips elevated and a moist dressing around the cord
-insert two fingers to elevate presenting part away from cord
-do not attempt to reinsert cord
How do you treat excessive bleeding in delivery complications?
-treat for shock
-post-delivery, massage uterus firmly and put baby to mothers breast
What do you do as soon as the baby is born?
-place in sniffing position with towel underneath
-suction until airway is clear
When should you suction before taking over resuscitative steps?
-if newborn is delivered with meconium stained fluid and is depressed, has poor respiratory effort, decreased muscle tone, or heart rate is less than 100 BPM. bulb suction is preferred
When should you ventilate with a BVM for a newborn?
-to increase HR if less than 100
-for apnea or persistent central cyanosis
When should you begin chest compressions on a newborn?
-HR is less than 60
-120/min, compression to ventilation 3:1
-1/3 diameter of chest
What does APGAR stand for?
Appearance, pulse, grimace, activity, respiration effort
How do you score appearance on the APGAR scale?
-blue or pale = 0
-body pink, extremities blue = 1
-completely pink = 2
How do you score pulse on the APGAR scale?
Absent = 0
Less than 100 = 1
Over 100 = 2
How do you score grimace on the APGAR scale?
No response = 0
Grimace = 1
Cough or sneeze = 2
How do you score activity on the APGAR scale?
Limp = 0
Some flexion of extremities = 1
Active motion = 2
How do you score resp effort on the APGAR scale?
Absent = 0
Slow or irregular = 1
Good crying = 2
When do you need to transport an infant with a fever?
Transport all infants less than 2 months with a HX of reported temp greater than 100.4 (38c) or less than 96 (35.6c)
What is an ALTE?
Stands for apparent life threatening event. Involves any infant under 1 y/o that is witnessed with a frightening event and involves some combination of the following...
-choking or gagging
-change in muscle tone
What are the most common causes of an ALTE?
-nervous system disorders such as seizures/tumors
-infections such as meningitis
What is step 1 in salt triage?
-if they can walk/green/assess 3rd
-wave or purposeful movement/yellow/2nd
-still or obvious life threat/red/1st
What are the only life saving interventions performed in SALT triage?
-control major bleed
-open airway (2 rescue breathes for child)