Treatment Guidelines Flashcards
(30 cards)
Guidelines for use of restraints:
May be used to:
TG-01
May be used to:
•Ensure Patient safety
•Pt’s behavior may cause harm to self or others
Guidelines for use of restraints:
Patient assessment:
TG-01
Patient assessment:
•ALS must assess restrained Pt
•Direct supervision at all times Tx and transport
•Monitor: Airway/Breathing/VS+SpO2
•Extremity circulation assessed and documented q10min
•Must have cardiac monitor + strip
•Restraints warrant contact with OMD
•Min of 1 ALS provider in back
Guidelines for use of restraints:
Types of Restraint:
TG-01
Types of Restraint:
•Handcuffs when law enforcement accompanies Pt
•Only leather or approved soft restraints
Guidelines for use of restraints:
Pt positioning:
TG-01
Pt positioning:
•Positioned not to compromise airway
•Access to airway maintained for adv. airway mgmt.
•Access to chest for CPR/defibrilation
•Access to extremities for IV/IO
•ø prone position/hogtied
•ø placed between backboards/stretchers
•restrained to backboard for Pt transfer/vomiting
•restraints placed to facilitate assessment/prevent injury
Guidelines for use of restraints:
Documentation:
TG-01
Documentation:
•Reason restraint required
•Type of restraint
•Position of the Pt during Tx/Transport
•Pt response to restraints
•Data indicating constant supervision
•Status of circulation distal to restraint
•Time Pt was restrained under care of EMS
•Any assessment/Tx not completed due Pt’s state
•Pt status at time of Tx of care
Guidelines for DNR:
Resuscitative Measures listed on DNR:
TG-02
Resuscitative Measures listed on DNR:
•Cardiac compression
•Endotracheal Intubation/other advanced airway devices
•Artificial Ventilation
•Defibrillation
•Admin. of ACLS Rx and related procedures
Guidelines for DNR:
Where DNR’s do not apply:
TG-02
DNR’s do not apply:
•situations involving Mass Casualties
•medical emergencies involving children and disabled adults in public or private schools that are not licensed healthcare institutions.
Guidelines for DNR: Form Specifics:
TG-02
Form Specifics:
•Printed on orange background letter/wallet size
•Specific wording refusing resuscitative measures
•May be worn on wrist/ankle and state
•DNR
•Pt’s Name
•Pt’s Physician
•Effective until revoked or superseded by new DNR
•Photo not required
•Person appointed to be Pt’s POA shall sign if Pt no longer competent to do so.
Guidelines for DNR:
To honor DNR Requests:
TG-02
To honor DNR requests:
•Pt pulseless & apneic w/ no signs of life
•Orange DNR readily available -up to 2 min can be taken to locate the document.
•Document appears to be valid
•There is no on-scene request to resuscitate
•On-line medical direction not required but may be requested at medic’s discretion.
Guidelines for Field Termination: General Guidelines:
TG-03
General Guidelines:
•Field termination may be considered for both trauma and medical patients
•Pt’s must be in cardiopulmonary arrest in a rhythm incompatible with life
(asystole, PEA, Sustained VTach/Fib)
•Online Medical Direction is required for all field terminations
Guidelines for Field Termination:
Non-traumatic Cardiac Arrest Termination of Resuscitation:
TG-03
Non-traumatic Cardiac Arrest Termination of Resuscitation:
•Initiate Resuscitation unless called DNR available
•Perform 4 rounds CCR or ACLS
•Consider termination if following met:
•Not witnessed
•No shockable rhythm
•No ROSC
•If Pt meets all 3 after 4 rounds of CCR/ACLS, consider OMD for TOR.
•ETT not required for TOR
If ROSC » Transport
If no ROSC » consider OMD for TOR
EMS personnel can sill contact OMD for TOR in other circumstances.
*All Tubes (IV, Airway adjuncts) must be left in place unless Pt’s physician has been contacted and agrees to sign death certificate.
Guidelines for Field Termination:
Traumatic Cardiac Arrest Termination of Resuscitation:
TG-03
Traumatic Cardiac Arrest Termination of Resuscitation:
•Specific information is needed to determine Pt mgmt in traumatic arrests:
•Time of arrest
•Mechanism: Blunt vs. Penetrating
•Signs of irreversible death such as:
•decapitation
•decomposition
•dependent lividity
•rigor mortis
•Possible underlying medical cause for arrest
•Vital signs (pulseless, apneic)
•Evidence of massive bloodloss
•Evidence of massive blunt head, thoracic, abdominal trauma.
*All Tubes (IV, Airway adjuncts) must be left in place unless Pt’s physician has been contacted and agrees to sign death certificate.
Obvious and/or Apparent Death (901-H):
Obvious Death
TG-04
Obvious Death:
Decapitation or decomposition:
•Contact Law Enforcement
*A patient found pulseless/apneic w/ dependent lucidity and/or rigor mortis may be pronounced dead without contacting Medical Control. Document time and findings on the incident encounter
**Pacemaker spikes without ventricular activity are irrelevant when associated with apparent DOA findings
*** Exceptions to this policy are hypothermic patients
Obvious and/or Apparent Death (901-H):
Apparent Death
TG-04
Apparent Death:
Apneic and pulseless with dependent lividity or rigor:
•Apply monitor
•Does ECG show asystole in 2 leads over 12 sec?
•Yes » Contact Law Enforcement
•No » Preform CPR/proceed to proper protocol
*A patient found pulseless/apneic w/ dependent lucidity and/or rigor mortis may be pronounced dead without contacting Medical Control. Document time and findings on the incident encounter
**Pacemaker spikes without ventricular activity are irrelevant when associated with apparent DOA findings
*** Exceptions to this policy are hypothermic patients
Obvious and/or Apparent Death (901-H):
Other Signs of Irreversible Death
TG-04
Other Signs of Irreversible Death:
•Evidence of massive external blood loss
•Massive blunt head/thoracic/abdominal trauma
•Refer to TG-03 Guidelines for field TOR
•When in doubt contact Medical Control
*A patient found pulseless/apneic w/ dependent lucidity and/or rigor mortis may be pronounced dead without contacting Medical Control. Document time and findings on the incident encounter
**Pacemaker spikes without ventricular activity are irrelevant when associated with apparent DOA findings
*** Exceptions to this policy are hypothermic patients
Guidelines for Refusal of Treatment or Transfer:
General Guidelines
TG-05
General Guidelines:
•All Pt’s requesting transport to hospital will be
•Any Pt complaining of any pain/discomfort/problem will have assessment preformed.
•If Pt refuses assessment document manner of refusal in report.
•Assessment should include all of the items listed in Tx protocol.
•In all cases a refusal will be signed by Pt/Legal Guardian
•If Pt refuses to sign the form, document reason, have witness sign (preferably Law Enforcement)
•Signature should be witnessed by Law Enforcement, family member, friend
Guidelines for Refusal of Treatment or Transfer:
Who Can Refuse
TG-05
Who Can Refuse:
•The Pt must meet ALL of the following:
•Adult (≥18), if under released to parent/guardian, Law. If under 18 and claims to be emancipated, legal documentation must be produced and
verified with Photo ID
•Is oriented to person, place, time, and event
•Exhibits no evidence of:
•Altered LOC
•Alcohol/Rx that impairs judgement
•Understands medical condition and inherent risks and consequences of refusal
Guidelines for Refusal of Treatment or Transfer:
Who Cannot Refuse without On-line Physician Order
TG-05
Who Cannot Refuse without On-line Physician Order:
aka High Risk Refusals
Contact with a physician must be made before leaving the scene
Persons:
•stunned/stopped by Taser. Must have monitor strip/12-lead
•impaired by Alcohol/Rx (by exam or Hx)
•with injury to the head or face, or possible head injury (by exam or Hx)
•thought to be danger to themselves or others
•Pediatric Pt with reported (øobserved) apparent life threat: apnea, color ∆, limpness, choking/gagging
•administered Rx who feel better and now want to refuse.
•who would be given ALS care if they didn’t refuse
•Post-ictal
•Who cannot understand the consequences of refusal
•Do not speak/understand English ≈ consequences
•Who appear to have mental illness/retardation
•Minors that wish to be released to anyone other than parent/guardian. An adult accepting care for minor if approved by OMD
Guidelines for Refusal of Treatment or Transfer:
Who Cannot Refuse without On-line Physician Order:
Persons with substantial mechanisms
TG-05
Who Cannot Refuse without On-line Physician Order:
Persons with substantial mechanisms:
•Falls: Adults>20’, Children>10’ or 2-3x height
•Intrusion into occupant compartment > 12”, or 18” any site
•Ejection (Partial or Complete)
•Death with in same passenger compartment
•Vehicle telemetry consistent with high risk of injury
•Pedestrian vs Auto; Bicyclist vs Auto -
Thrown/run over/significant impact (>20mph)
•Motorcycle Crash >20mph
Guidelines for Refusal of Treatment or Transfer:
Who Cannot Refuse without On-line Physician Order:
Persons with characteristics or complaints
TG-05
Who Cannot Refuse without On-line Physician Order: Persons with characteristics or complaints: •Abdominal pain •AMS (from patients normal baseline) •Acute cardiac dysrhythmia •CP •Electrocution •Foreign body ingestion •Inability to ambulate (not normal for Pt) •OD/Poisoning •Pt volunteers high risk condition •Pregnancy related complaint •Seizures •Syncope/Near-Syncope •Taser Incidents •Water-related submersion incidents •Penetrating injuries
Guidelines for Refusal of Treatment or Transfer:
Documentation
TG-05
Documentation: Reports shall include: •Pt name/age/DOB •Chief Complaint •Medical Hx •2 sets Vital Signs •Mental Status exam findings •Speech •Gait •Appropriate Behavior •Cooperative •Follows instructions/Commands •Physical exam findings •Reason for refusal •Signed refusal form •Advice given •Patient understands risks of refusal •Patient understands possible outcomes
Guidelines ALS » BLS:
Criteria 1
TG-06
Criteria 1:
Must have VS WNL for Pt considering PMHx, Rx, presenting complaint, and situational circumstances.
Guidelines ALS » BLS:
Criteria 2
TG-06
Criteria 2: The following high-risk indications must be absent: •Abdominal Pain •AMS (for Pt) •Any acute cardiac dysrhythmia •CP •Electrocution •Foreign Body Ingestion •Inability to ambulate (ø normal for Pt) •OD/Poisoning •Pt volunteers high-risk condition •Pregnancy-related complaint •Seizures •Water-related submersion incidents •Penetrating injuries
Guidelines ALS » BLS:
Criteria 3
TG-06
Criteria 3:
Absence of significant findings on physical exam:
•A PE must be completed and documented.
•After evaluation the Pt must have no S/S, or Hx that would indicate (or appear to indicate) significant findings or an emergent condition.
