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Home My WebLink Aboutacems-fm-2022-final1000 SAN LEANDRO BLVD. | SUITE 200 | SAN LEANDRO, CA 94577 PHONE: 510.618.2050 | WEB: ems.acgov.org | Email: alcoems@acgov.org 202222202 Summary of High-Quality CPR Components for BLS Providers Component Adults andAdolescents Children(Age 1 Year to Puberty) Infants(Age Less Than 1 Year,Excluding Newborns) Scene safety Make sure the environment is safe for rescuers and victim Recognition ofcardiac arrest Check for responsiveness No breathing or only gasping (ie, no normal breathing) No deﬁ nite pulse felt within 10 seconds (Breathing and pulse check can be performed simultaneously in less than 10 seconds) Activation ofemergencyresponse system If you are alone with no mobile phone, leave the victim to activate the emergency response system and get the AED before beginning CPR Otherwise, send someone and begin CPR immediately; use the AED as soon as it is available Witnessed collapseFollow steps for adults and adolescents on the left Unwitnessed collapseGive 2 minutes of CPRLeave the victim to activate the emergency response system and get the AED Return to the child or infant and resume CPR;use the AED as soon as it is available Compression-ventilation ratio without advanced airway 1 or 2 rescuers30:2 1 rescuer30:2 2 or more rescuers15:2 Compression-ventilation ratio with advanced airway Continuous compressions at a rate of 100-120/minGive 1 breath every 6 seconds (10 breaths/min) Compression rate 100-120/min Compressiondepth At least 2 inches (5 cm)* At least one third AP diameter of chest About 2 inches (5 cm) At least one third AP diameter of chest About 1½ inches (4 cm) Hand placement 2 hands on the lower half of thebreastbone (sternum) 2 hands or 1 hand (optional for verysmall child) on the lower half of the breastbone (sternum) 1 rescuer 2 ﬁ ngers in the center of the chest,just below the nipple line 2 or more rescuers2 thumb–encircling hands in thecenter of the chest, just below thenipple line Chest recoil Allow full recoil of chest after each compression; do not lean on the chest after each compression Minimizinginterruptions Limit interruptions in chest compressions to less than 10 seconds Deﬁ brillation Attach and use AED/ Deﬁ brillator as soon as available Minimize interruptions in chest compressions before and after shock Resume CPR beginning with compressions immediately after each shock *Compression depth should be no more than 2.4 inches (6 cm).Abbreviations: AED, automated external deﬁ brillator; AP, anteroposterior; CPR, cardiopulmonary resuscitation. I TABLE OF CONTENTS AMBULANCE REROUTING CRITERIA ..................................................................V EMERGENCY MEDICAL SERVICES - STAFF DIRECTORY .................................VI CERTIFICATION | RECERTIFICATION | ACCREDITATION CHECKLIST ............VII APPROVED ABBREVIATIONS ...............................................................................VIII GENERAL POLICIES TAB GENERAL POLICIES TOC .....................................................................................1 AN OVERVIEW OF PATIENT CARE POLICIES .....................................................2 ASSAULT | ABUSE | DOMESTIC VIOLENCE ........................................................3 BURN PATIENT CARE ............................................................................................6 BURN PATIENT CRITERIA .....................................................................................8 CARDIOPULMONARY RESUSCITATION (CPR) ...................................................9 ADDITIONAL INFORMATION: ..........................................................................10 MECHANICAL CPR DEVICES: .........................................................................10 PIT CREW ROLES: ...........................................................................................11 CRUSH INJURY SYNDROME ................................................................................12 EXTREMITY INJURY ..............................................................................................13 HYPERKALEMIA .....................................................................................................14 HYPERTHERMIA / HEAT ILLNESS ........................................................................15 HYPOTHERMIA .......................................................................................................16 INFECTION CONTROL ...........................................................................................18 OB/GYN EMERGENCIES .......................................................................................19 SCOPE OF PRACTICE - LOCAL OPTIONAL .........................................................20 SMOKE INHALATION / CO MONITORING ............................................................21 TRANSPORT GUIDELINES ....................................................................................23 TRAUMA PATIENT CARE .......................................................................................24 TRAUMA PATIENT CRITERIA ................................................................................25 TXA - TRANEXAMIC ACID ......................................................................................28 ADULT POLICIES TAB ADULT POLICIES TOC ...........................................................................................29 ACUTE STROKE .....................................................................................................30 AIRWAY OBSTRUCTION ........................................................................................32 ALTERED LEVEL OF CONSCIOUSNESS .............................................................33 II ANAPHYLAXIS / ALLERGIC REACTION ...............................................................34 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY .............................................35 BRADYCARDIA .......................................................................................................36 CHEST PAIN - SUSPECTED CARDIAC/STEMI .....................................................37 DYSTONIC REACTION...........................................................................................38 MEDICATIONS – AUTHORIZED | STANDARD INITIAL DOSE .............................39 PAIN MANAGEMENT ..............................................................................................41 POISONING | INGESTION | OVERDOSE ..............................................................42 PULMONARY EDEMA / CHF ..................................................................................43 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) .......44 RESPIRATORY DISTRESS ....................................................................................45 RETURN OF SPONTANEOUS CIRCULATION - ROSC ........................................46 ROUTINE MEDICAL CARE – ADULT .....................................................................47 SEIZURE .................................................................................................................49 SEPSIS ....................................................................................................................50 SEVERE NAUSEA ...................................................................................................51 SHOCK: HYPOVOLEMIC/CARDIOGENIC .............................................................52 SUBMERSION .........................................................................................................53 SUSPECTED OPIOID WITHDRAWAL ....................................................................54 TACHYCARDIA .......................................................................................................55 VENTRICULAR ASSIST DEVICES -VAD ...............................................................56 VENTRICULAR FIBRILLATION | VENTRICULAR TACHYCARDIA: PULSELESS 58 PEDIATRIC POLICIES TAB PEDIATRIC POLICIES TOC ...................................................................................59 AIRWAY OBSTRUCTION ........................................................................................60 ANAPHYLAXIS / ALLERGIC REACTION ...............................................................61 ALTERED LEVEL OF CONSCIOUSNESS .............................................................62 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE .............................................63 BRADYCARDIA .......................................................................................................64 NEONATAL RESUSCITATION ................................................................................65 PAIN MANAGEMENT ..............................................................................................66 PEDIATRIC DRUG CHART - (DRUGS NOT ON THE LBRT) .................................68 POISONING | INGESTION | OVERDOSE ..............................................................69 PULSELESS ARREST: ASYSTOLE, PEA ...............................................................70 PULSELESS ARREST: VF/ VT ...............................................................................71 III RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) .......72 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY .................................73 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY .............................74 ROUTINE MEDICAL CARE - PEDIATRIC ..............................................................75 SEIZURE .................................................................................................................76 SEIZURE - MIDAZOLAM DRUG CHART ...............................................................77 SEVERE NAUSEA ...................................................................................................78 SHOCK AND HYPOTENSION ................................................................................79 SUBMERSION .........................................................................................................80 TACHYCARDIA .......................................................................................................81 OPERATIONAL POLICIES TAB OPERATIONAL POLICIES TOC .............................................................................83 ALS RESPONDER ..................................................................................................84 BLS/ALS FIRST RESPONDER ...............................................................................85 END OF LIFE CARE................................................................................................86 DEATH IN THE FIELD .............................................................................................87 DEATH IN THE FIELD - GRIEF SUPPORT ............................................................92 EMS AIRCRAFT TRANSPORT ...............................................................................93 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION ......................97 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ...................................98 INTERFACILITY TRANSFERS ...............................................................................105 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 106 MEDICAL PERSONNEL ON THE SCENE ..............................................................107 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE ..........................109 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS ................110 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING ............111 RESTRAINTS ..........................................................................................................112 UNUSUAL OCCURENCES .....................................................................................113 PROCEDURES TAB PROCEDURE POLICIES TOC ...............................................................................115 ADVANCED AIRWAY MANAGEMENT ....................................................................116 ASSESS AND REFER GUIDELINES ......................................................................118 CONSENT AND REFUSAL GUIDELINES ..............................................................119 CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP ......................................124 IV EKG - 12 LEAD ........................................................................................................126 HEMORRHAGE CONTROL ....................................................................................128 IMPEDANCE THRESHOLD DEVICE (ITD) ............................................................130 INTRANASAL (IN) MEDICATION ADMINISTRATION ............................................131 INTRAOSSEOUS ACCESS PROCEDURE ............................................................132 PLEURAL DECOMPRESSION ...............................................................................133 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES.............................................134 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE ...................135 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS.............................................136 REPORTING FORMAT ............................................................................................137 SEDATION ...............................................................................................................138 SPINAL INJURY ASSESSMENT.............................................................................140 SPINAL MOTION RESTRICTION (SMR) ...............................................................142 STOMA AND TRACHEOSTOMY .............................................................................143 TRANSCUTANEOUS PACING - TCP .....................................................................145 TRANSFER OF CARE ............................................................................................146 MCI/ DISASTER/ WMD TAB MCI/ DISASTER/ WMD TOC ...................................................................................147 ACTIVE SHOOTER RESPONSE ............................................................................148 BIOLOGICAL ATTACK ............................................................................................149 BIOLOGICAL ATTACK ............................................................................................150 CHEMICAL ATTACK ................................................................................................151 CHEMPACK DEPLOYMENT ...................................................................................152 CYANIDE POISONING ...........................................................................................153 DECONTAMINATION INCIDENT ............................................................................154 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” ..................155 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE ................................157 MULTI-CASUALTY INCIDENT - EMS RESPONSE ................................................159 NERVE AGENT AUTOINJECTOR ADMINISTRATION...........................................162 NERVE AGENT TREATMENT .................................................................................164 SUSPICIOUS POWDER PROCESS .......................................................................166 INDEX TAB POLICY LOCATOR INDEX .....................................................................................167 KEYWORD INDEX ..................................................................................................171 V AMBULANCE REROUTING CRITERIA (Abbreviated version - see Ambulance Rerouting policy in the Administration Manual for the complete policy) REASONS FOR REROUTING OF AMBULANCES – Conditions that may necessitate REROUTING are: ►CT Failure - When the CT scanner is inoperative, patients demonstrating neurological signs/symptoms of stroke, or acute head injury will be diverted ►Trauma Center Overload - When it has been determined that the hospital is unable to meet the criteria for a Level II Trauma Center in Alameda County (O.R. is full) ►STEMI Diversion - STEMI/Cardiac Arrest Receiving Centers may divert due to diagnostic or treatment equipment failure or scheduled maintenance for patients experiencing acute MI or post cardiac arrest ►Stroke Center Diversion - Certiﬁ ed Stroke Centers may divert due to diagnostic or treatment equipment failure or scheduled maintenance for patients exhibiting signs of acute stroke symptoms/stroke alert ►Physical Plant Casualty (Internal Disaster) - An unforeseeable physical or logistical situation/ circumstance - (e.g., ﬁ re, bomb threat, power outage, etc.) that curtails routine patient care and renders continued routine ambulance delivery unsafe. A receiving hospital or trauma center may divert any patient, including critical trauma patients (CTP) as deemed necessary by the facility during this type of incident. The hospital must come oﬀ Physical Plant diversion immediately upon resolution of the issue Reasons for Rerouting Maximum time allowed Condition Types of patients rerouted Appropriate facility for rerouted patients Computerized Tomography (CT) Until resolved CT inoperative ►Acute head injury ►Acute Stroke by CPSS ►Nearest Trauma Center ►Closest Stroke Center Trauma Center Overload Until resolved Trauma resources depleted Critical Trauma Patients Designated Trauma Center STEMI (equip. failure)Until resolved Diagnostic, Equipment failure or Scheduled Maintenance STEMI/ post cardiac arrest Closest STEMI/Cardiac Arrest Center Stroke Center (equip. failure)Until resolved Diagnostic, Equipment failure or Scheduled Maintenance Stroke patients Closest Stroke Center Physical Plant Casualty Until resolved Physical plant breakdown (bomb threat, ﬁ re, etc.)All Closest appropriate facility AREA INTENTIONALLY BLANK VI EMERGENCY MEDICAL SERVICES - STAFF DIRECTORY EMS Ofﬁ ce 618-2050 (main number) 618-2099 (fax #) On-call EMS Staff (925) 422-7595 – ACRECC EMS Website- http://ems.acgov.org | EMS Email- alcoems@acgov.org EMS DIRECTOR Lauri McFadden 618-2055 lauri.mcfadden@acgov.org DEPUTY EMS DIRECTOR William McClurg 618-2030 william.mcclurg@acgov.org SPECIAL PROJECTS Anne Kronenberg 618-2035 anne.kronenberg@acgov.org MEDICAL DIRECTOR Karl Sporer, MD 618-2042 karl.sporer@acgov.org DEPUTY MEDICAL DIRECTOR Jocelyn Garrick, MD 618-2044 jocelyn.garrick@acgov.org EMS COORDINATORS Cynthia Frankel EMS for Children | ReddiNet | AED/PAD Prog. | EMS Plan 618-2031 cynthia.frankel@acgov.org Kreig Harmon Field Protocols | Digital Content | Logistics 667-7984 kreig.harmon@acgov.org Mike Jacobs Specialty Systems of Care 618-2047 michael.jacobs@acgov.org Elsie Kusel Specialty Programs 481-4197 elsie.kusel@acgov.org Jim Morrissey - Supervisor MHOAC | Emergency Preparedness and Response 618-2036 jim.morrissey@acgov.org Ryan Preston CA OES Region II Regional Disaster Medical Health Specialist (RDMHS)618-2033 ryan.preston@acgov.org Scott Salter Professional Standards 618-2022 scott.salter@acgov.org Lee Siegel CCTP | Clinical Quality Improvement | HEMS 667-3083 lee.siegel@acgov.org Leslie Simmons Receiving Facility Liaison | Ambulance Ordinance 667-7412 leslie.simmons@acgov.org Andrew Sulyma CA OES Region II Regional Disaster Medical Health Specialist (RDMHS) | Dispatch Liaison | Fire Department Liaison 667-7533 andrew.sulyma@acgov.org Gerald Takahashi Educational Programs 292-9306 gerald.takahashi@acgov.org Yolanda Takahashi CATT Project Manager | 911 EOA Transport Provider Liaison | | Unusual Occurences | Compliance 618-2003 yolanda.takahashi@acgov.org CERTIFICATIONS Sonya Lee 618-2034 sonya.lee@acgov.org VII CERTIFICATION | RECERTIFICATION | ACCREDITATION CHECKLIST EMT INITIAL CERTIFICATION ►A signed EMT Certiﬁ cation application (available at http://ems.acgov.org or from the EMS Agency). ►A copy of your EMT course completion certiﬁ cate. ►A copy of your NREMT card. ►A copy of your driver’s license, ID card, or valid military ID card (with photo). ►A copy of your completed Live Scan application. ►Pay the application fee (online, money order, cashier’s check or municipal purchase order payable to Alameda County EMS - no personal checks or cash). EMT RECERTIFICATION ►A signed EMT Recertiﬁ cation application (available at http://ems.acgov.org or from the EMS Agency). ►A copy of your driver’s license, ID card, or valid military ID card (photo id). ►Document your continuing education course(s) or your refresher course on the application. ►A copy of your Skills Veriﬁ cation form. ►A copy of your completed Live Scan application form if this is your ﬁ rst recertiﬁ cation with Alameda County EMS. ►Pay the application fee (money order, cashier’s check or municipal purchase order payable to Alameda County EMS - no personal checks or cash). ►If your certiﬁ cate has expired, see the back of the application for more information. MAINTAINING PARAMEDIC ACCREDITATION Your accreditation is continuous as long as you: ►Maintain your California Paramedic license. ►Are employed by an approved paramedic provider agency. ►Meet local requirements for updates in local policy, procedure, protocol and local optional scope of practice, and comply with the requirements in the system-wide quality improvement program. If any of the above requirements are not met or maintained, accreditation to practice shall be withdrawn until successful completion of the requirement(s). A paramedic whose accreditation has been withdrawn for more than one year shall be required to re-apply for initial accreditation. You may only work in your basic scope of practice until your accreditation is current. Rev. 10/2021 This is an abbreviated version of the requirements.For more information see the EMT Certiﬁ cation policyand Paramedic Accreditation policy in the EMS Administration Manual. VIII AAA Abdominal aortic aneurysm Ab abortion ABC airway, breathing, circulation abd abdomen, abdominal ABG arterial blood gases abn abnormal AC antecubital AED automated external deﬁ brillator A-ﬁ b atrial ﬁ brillation AIDS Acquired Immune Deﬁ ciency Syndrome ALCO Alameda County ALOC altered level of consciousness ALS advanced life support am or a.m.morning AMA against medical advice amb ambulatory amp.ampule A+O alert and oriented ant anterior approx approximately ASA aspirin ASAP as soon as possible ASHD Arteriosclerotic heart disease AV atrioventricular BBB bundle branch block BCP birth control pills bicarb sodium bicarbonate bid twice a day bilat.bilateral BLS basic life support BM bowel movement BP or BP blood pressure BS breath sounds or blood sugar C centigrade c with C-2 Code 2 C-3 Code 3 CA carcinoma CaCl calcium chloride caps capsules cath catheter/catheterize CAT computerized axial tomography cc cubic centimeter CC chief complaint CCU Coronary Care Unit CHF congestive heart failure cm centimeter CMED Central Medical Emergency Dispatch CNS central nervous system c/o complains of CO carbon monoxide cod codeine consc conscious cont continued COPD chronic obstructive pulmonary disease CP chest pain CPAP Continuous positive airway pressure CPR Cardiopulmonary resuscitation CSF cerebrospinal ﬂ uid CSM Circulation, sensation, and movement C-Section cesarean section C-Spine cervical spine CT Computerized Tomography CVA cerebrovascular accident D & C dilatation and curettage d/c or dc’d Discontinue, discontinued DCAP-BTLS deformities, contusions, abrasions, punctures, burns, tenderness, lacerations, swelling D5W Dextrose 5%. in water DDS Doctor of Dental Surgery Dig Digitalis Disch discharged (from hospital) DM diabetes mellitus DOA dead on arrival DOE dyspnea on exertion DPT diphtheria, pertussis, tetanus DT’s delirium tremens Dr.doctor dsg dressing Dx diagnosis EB or E/B eastbound ED emergency department EDC estimated date of conﬁ nement EDD Esophageal detection device EEG electroencephalogram EHR Electronic Health Record EKG electrocardiogram Emb embolus ENT Ear, nose and throat E/O east of Epi Epinephrine ER Emergency Room ET Endotracheal ETI Endotracheal Intubation ETT Endotracheal tube Approved Abbreviations IX ETCO2 Endtidal CO2 ETA estimated time of arrival ETDLA Esophageal tracheal double lumen airway ETOH ethyl alcohol exam examination ext external F Fahrenheit FB foreign body FBO foreign body obstruction FHT fetal heart tone fr.french FUO fever of unknown origin fx fracture g gauge GC Gonococcus GI gastrointestinal gm gram GOA gone on arrival gr grain GSW gunshot wound gtt. or gtts drop/drops GU genitourinary GYN gynecology H or hr hour H2O water HCTZ Hydrochlorothiazide HEENT Head, ears, eyes, nose, and throat HOB head of bed HS hour of sleep ht height HTN hypertension Hx history irreg irregular ICU Intensive Care Unit IFO in front of 1M intramuscular IN intranasal inj or injs injury(ies) IV intravenous IVP intravenous push JVD jugular venous distention K+potassium KCl potassium chloride kg kilogram L liter LA left arm lat lateral lac laceration lb or lbs pound(s) LBB left bundle branch block lido Lidocaine LLL Left Lower Lobe LLQ Left Lower Quadrant LMP Last Menstrual Period LNMP Last Normal Menstrual Period LOC Loss Of Consciousness LPM Liters per Minute LSD lysergic acid diethylamide LS lung sounds LUL Left upper lobe LUQ left upper quadrant max maximum MCA motorcycle accident mcg micrograms meds Medicines mEq Milliequivalent mg or mgs Milligram (s) MI Myocardial Infarction Min. or mins.Minute (s) min minimum ml milliliter mm millimeter mod moderate MRI Magnetic Resonance Imaging MS Morphine sulfate MVA Motor vehicle accident N & V or NV Nausea and vomiting NaHC03 Sodium bicarbonate N/A Not applicable NAD no acute distress NB or N/B northbound NC Nasal cannula N/G or NG nasogastric NKA No known allergies NKDA No known drug allergies N/O North of NORM normal NPO Nothing by mouth NRB non-rebreather NRBM non-rebreather mask NS Normal saline NSR Normal sinus rhythm NTG nitroglycerine O2 oxygen OB obstetrics OBS Organic Brain Syndrome X Occ occult OD overdose OPA oropharyngeal airway Ortho orthopedic oz ounce P pulse PAC Premature Atrial Contraction palp palpate PCR Patient Care Report Form PE or P. E.physical exam Ped pedestrian Pedi pediatric PERL Pupils Equal, Reactive to Light PERRLA Pupils Equal, Round, Reactive to Light Accommodation PID pelvic inﬂ ammatory disease pm or p. m.afternoon - evening PMD private medical doctor PNB pulseless non- breathing PND paroxysmal nocturnal dyspnea po by mouth POV privately owned vehicle poss possible post-op after surgery PRN as needed or when necessary psych psychiatric pt or pts patient(s) PTA prior to arrival Pul pulmonary Pulse Ox Pulse oximetry PVC or PVCs premature ventricular contraction(s) qd every day qh every hour q2h every 2 hours qid four times a day qod every other day qt quart R right RA right arm RBBB right bundle branch block reg regular resp respiration r/o rule out RLL right lower lobe RLQ right lower quadrant ROM range of motion RR respiratory rate Rt or R right RUL Right upper lobe RUQ Right upper quadrant Rx prescription s without SB or S/B southbound SL or s1 sublingual S/O south of SOAP subjective, objective, assessment, plan SOB shortness of breath SpO2 pulse oximetry (saturation of peripheral oxygen) stat immediately STEMI ST elevation myocardial infarction SW stab wound sub-q or sq subcutaneous SGA Supraglottic Airway device Surg surgery Sx symptom sz seizure tab tablet TB tuberculosis Tbsp or T tablespoon TCN Tetracycline TCP Transcutaneous pacing temp temperature TIA transient ischemic attack tid three times a day TKO to keep open trans transport tsp or t teaspoon Temp temperature Tx treatment u units UA urinalysis URI upper respiratory infection UTI urinary tract infection vag vaginal VD venereal disease vs vital signs V-tach or VT Ventricular tachycardia WB or W/B westbound Wk or wks Week(s) WNL within normal limits WO west of ws or w/s watt seconds wt weight x times yo year old yr or yrs year(s) XI HOSPITALS ACMC Alameda County Medical Center (Highland) AH Alameda Hospital ABMC Alta Bates Medical Center CHO Children’s Hospital EMC Eden Medical Center JMMC John Muir Medical Center KF Kaiser Fremont KO Kaiser Oakland KSL Kaiser San Leandro KWC Kaiser Walnut Creek SLH San Leandro Hospital SRH St. Rose Hospital SRR San Ramon Regional SMC Summit Medical Center SUH Stanford University Hospital VCMC ValleyCare Medical Center WR Willow Rock WTH Washington Township Hospital PROVIDER AGENCIES ALA Alameda Fire Depa rtment ACF Alameda County Fire Department ALB Albany Fire Department BER Berkeley Fire Department CHP California Highway Patrol PRK Camp Parks Fire Department EBY East Bay Regional Parks Fire Department FLK Falck Ambulance FRE Fremont Fire Department HAY Hayward Fire Department LAP Livermore-Pleasanton Fire Department OKL Oakland Fire Department PIE Piedmont Fire Department SYMBOLS c with s without a before p after <less than >greater than ≤less than or equal to ≥greater than or equal to ♀Female ♂Male ↑Increase ↓Decrease =equal ≈approximately -negative +positive “inches ‘feet #pounds °degree @ at Δ change %percent 2°Secondary to XII THIS PAGE INTENTIONALLY LEFT BLANK Patient Care Policy (General) Modiﬁ ed On: May 10, 2021 1 GENERAL POLICIES TOC GENERAL POLICIES TOC GENERAL POLICIES TOC .........................................................................................1 AN OVERVIEW OF PATIENT CARE POLICIES ........................................................2 ASSAULT | ABUSE | DOMESTIC VIOLENCE............................................................3 BURN PATIENT CARE ...............................................................................................6 BURN PATIENT CRITERIA ........................................................................................8 CARDIOPULMONARY RESUSCITATION (CPR) ......................................................9 ADDITIONAL INFORMATION: ..........................................................................10 MECHANICAL CPR DEVICES: .........................................................................10 PIT CREW ROLES: ...........................................................................................11 CRUSH INJURY SYNDROME ....................................................................................12 EXTREMITY INJURY..................................................................................................13 HYPERKALEMIA ........................................................................................................14 HYPERTHERMIA / HEAT ILLNESS ...........................................................................15 HYPOTHERMIA ..........................................................................................................16 INFECTION CONTROL ..............................................................................................18 OB/GYN EMERGENCIES ...........................................................................................19 SCOPE OF PRACTICE - LOCAL OPTIONAL ............................................................20 SMOKE INHALATION / CO MONITORING ................................................................21 TRANSPORT GUIDELINES .......................................................................................23 TRAUMA PATIENT CARE ..........................................................................................24 TRAUMA PATIENT CRITERIA ...................................................................................25 TXA - TRANEXAMIC ACID .........................................................................................28 Patient Care Policy (General) Modiﬁ ed On: April 10, 2012 2 AN OVERVIEW OF PATIENT CARE POLICIES AN OVERVIEW OF PATIENT CARE POLICIES 1. Treatment algorithms should be used as a guideline and are not intended as a substitute for sound medical judgment. Unusual patient presentations make it impossible to develop a protocol for every possible patient situation 2. Patient care protocols are to be utilized by ﬁ eld personnel and Base Hospital Physicians. All procedures and/or medications must be within the scope of practice for ﬁ eld personnel and authorized in Alameda County policies 3. Where scope of practice allows, cardiovascular protocols are consistent with current American Heart Association, Emergency Cardiovascular Care guidelines 4. Medications/Procedures contained in non-shaded boxes may be performed without base contact, or may be called in to the base hospital for consultation with the Base Hospital Physician 5. Medications/Procedures contained in shaded boxes require a Base Physician order 6. Base contact - Paramedics should contact the Base Physician for consultation: 6.1 At any point in a policy or treatment algorithm where base hospital contact is required and/or any time consultation would be in the patient’s best medical interest 6.2 For complicated patient presentations or in situations where a deviation from the standard protocol seems indicated 6.3 For any patient attended by a physician at the scene. (See “Medical Personnel on the Scene - page 106) 6.4 For out-of-protocol medication administration. Unusual circumstances may indicate special applications of medications carried by paramedics that are not covered in the treatment algorithms (e.g. glucagon for beta-blocker overdose) 6.5 An EMT may make base contact for consultation with a physician for destination decisions, unusual patient presentations, and/or procedures within the EMT scope of practice. An EMT may not make base contact or accept orders for the patient on behalf of a paramedic 7. If direct communication with the Base Physician cannot be made or maintained, consider immediate transport and attempt base contact en route, if applicable 8. If a diﬀ erence between policies exists, the policy with the most recent date prevails Patient Care Policy (General) Modiﬁ ed On: May 10, 2021 3 ASSAULT | ABUSE | DOMESTIC VIOLENCE ASSAULT | ABUSE | DOMESTIC VIOLENCE 1. CHILD ABUSE / ELDER ABUSE / DOMESTIC VIOLENCE: In any situation where EMS personnel knows or reasonably suspects a person suﬀ ering from any wound or other physical injury inﬂ icted upon the person where the injury is the result of assaultive or abusive conduct: 1.1 Immediately notify the appropriate law enforcement agency 1.2 Reasonable eﬀ ort will be made to transport the patient to a receiving hospital for evaluation. Immediately inform hospital staﬀ of your suspicions 1.3 Document all pertinent observations on the patient care report 1.4 Immediately (or as soon as practical) contact the appropriate agency by telephone and give a verbal report 1.5 A written report for child/elder abuse must be ﬁ led within 36 hours 2. SEXUAL ASSAULT: Patients should be transported to the appropriate facility for evaluation regardless of the hospital’s diversion status 2.1 Adult patients: Alameda County Medical Center or Washington Hospital 2.2 Pediatric patients: Children’s Hospital (≤13 y.o.) ►TO REPORT CHILD ABUSE: Child Protective Services 24100 Amador St. Hayward, CA 94544 (510) 259-1800 - 24 hour number ►TO REPORT ELDER OR DEPENDENT ADULT ABUSE: By staﬀ at a licensed health care facility contact: Ombudsman (800) 231-4024 At home, or by a visitor or another resident at a licensed health care facility contact: Adult Protective Services 6955 Foothill Blvd., Suite 300 Oakland, CA 94605 (866) 225-5277 - 24 hour number After 5 pm M-F and weekends, an operator answers this line and can page a social worker (if needed.) If the patient was assaulted or has suﬀ ered serious neglect contact local law enforcement. ►TO REPORT DOMESTIC VIOLENCE:Domestic violence is deﬁ ned as the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. Notify receiving hospital staﬀ Perform DV Assessment (see section 3) • Routine Medical Care • Level of distress - Is patient a trauma victim? If yes, see trauma protocol• Provide emotional support to the victim and the family• Contact appropriate law enforcement agencies APS ONLINE REPORT bit.ly/aps-report Patient Care Policy (General) Modiﬁ ed On: July 21, 2017 4 ASSAULT | ABUSE | DOMESTIC VIOLENCE ASSAULT | ABUSE | DOMESTIC VIOLENCE 3. DOMESTIC VIOLENCE (DV) LETHALITY SCREEN 3.1 Determine level of distress – is patient injured or complaining of any medical complaints? ►Assess and treat as appropriate ►If patient c/o or presents with medical complaints, assess for signs & symptoms of possible strangulation ►Attempt private audience with patient (maintaining regard for safety) ►If patient is NOT transported - and if safe, appropriate and feasible - perform a DV Lethality Screen  If patient screens HIGH RISK, refer patient to the Family Violence Law Center (FVLC) by calling the FVLC 24/7 hotline # 800-947-8301  Brieﬂ y describe the DV circumstances to the FVLC advocate without providing any patient identifying information  If patient consents to speaking with FVLC advocate, hand patient the phone  If patient does not consent to speaking with FVLC advocate, give patient discreet FVLC resource information and advise that he/she can call 24/7  Repeat basic safety planning tips that the FVLC advocate provides ►If patient is transported, be sure to inform receiving facility of lethality risk (determined by tool) and DV advocacy steps taken 3.2 Questions used in the Domestic Violence Lethality Screen for First Responders A “yes” response to any of Questions 1–3 automatically triggers the protocol referral 1. Has he/she ever used a weapon against you or threatened you with a weapon? 2. Has he/she threatened to kill you or your children? 3. Do you think he/she might try to kill you? Negative responses to Questions 1–3, but positive responses to at least four of Questions 4–11, trigger the protocol referral 4. Does he/she have a gun or can he get one easily? 5. Has he/she ever tried to choke you? 6. Is he/she violently or constantly jealous or does he/she control most of your daily activities? 7. Have you left him/her or separated after living together or being married? 8. Is he/she unemployed? 9. Has he/she tried to kill himself? 10. Do you have a child that he/she knows is not his/hers? 11. Does he/she follow or spy on you or leave threatening messages? If patient consents, any ﬁ rst responder may trigger the protocol referral to FVLC if not already triggered above, as a result of the victim’s response to the below question, or whenever the ﬁ rst responder believes the victim is in a potentially lethal situation Is there anything else that worries you about your safety? (If “yes”) What worries you? Patient Care Policy (General) Modiﬁ ed On: May 10, 2019 5 ASSAULT | ABUSE | DOMESTIC VIOLENCE ASSAULT | ABUSE | DOMESTIC VIOLENCE '9,QFLGHQW VXVSHFWHG" 1RWLI\/DZ (QIRUFHPHQW 7UDQVSRUW &RQWLQXHURXWLQHFDUH 1RWLI\UHFHLYLQJIDFLOLW\RI VXVSHFWHGDEXVH ,VLWVDIH DSSURSULDWH DQGIHDVLEOHWR SHUIRUP/$3DQG FDOO)9/&" 3HUIRUP'9/HWKDOLW\ $VVHVVPHQW 3DWLHQWVFUHHQV DV+,*+5,6." &DOO)9/& DQGEULHIO\GHVFULEH FLUFXPVWDQFHVZLWKRXW SURYLGLQJDQ\LGHQWLI\LQJ SDWLHQWLQIRUPDWLRQ 3DWLHQWFRQVHQWV WRVSHDNLQJZLWKD )9/&DGYRFDWH" 5HSHDWEDVLFVDIHW\SODQIURP DGYRFDWHWRSDWLHQW DQG 3URYLGHGLVFUHHW'9UHVRXUFH LQIRUPDWLRQ +DQGSKRQHWRSDWLHQW DQG 3URYLGHGLVFUHHW'9UHVRXUFH LQIRUPDWLRQ <HV <HV &RQWLQXHURXWLQH HYDOXDWLRQFDUH1R 1R 3URYLGHGLVFUHHW '9UHVRXUFH LQIRUPDWLRQ 1R<HV <HV 3URYLGHGLVFUHHW '9UHVRXUFH LQIRUPDWLRQ 1R <HV 1R Patient Care Policy (General) Modiﬁ ed On: July 1, 2014 6 BURN PATIENT CARE BURN PATIENT CARE A. BASIC MANAGEMENT 1. Rule out airway damage 1.1 Assess for inhalation injury 1.2 High ﬂ ow oxygen is critical 1.3 Be prepared for intubation 2. Assess and expose 2.1 Assess ABCs 2.2 Perform a mini neurological exam - level of consciousness 2.3 Expose and examine the patient for other areas of burn 2.4 Remove jewelry, but do not remove stuck clothing 3. Start IV’s 3.1 Two large bore IV’s (for major burns) 4. Give IV ﬂ uids – See ALCO PRE-HOSPITAL FLUID FORMULA Fluid resuscitation is particularly important! 5. Document severity and treat the pain 5.1 Estimate the severity of the burns using the ABA Classiﬁ cation or the “Rule of 9s” 5.2 Treat pain. Pain management should be considered mandatory for moderate to severe burns. See Pain Management Policies – Adult (page 41) and Pediatric (page 66) 6. Protect against hypothermia and infection - dress burns 6.1 Dry, sterile dressing for any burn involving >10% TBSA (Total Body Surface Area) 6.2 Keep patient warm to prevent hypothermia (use sheets or blankets) 6.3 Moist, sterile dressings are OK for small burns (<10% TBSA) 7. Elevate burned body parts - 30° 8. Address psychological needs 8.1 Be honest and compassionate 8.2 Consider anxiolytics – Contact Base Physician for midazolam 9. Maintain body temperature and observe for hypothermia B. ELECTRICAL BURNS 1. Turn oﬀ the power source if patient is still attached 2. See ﬁ rst responder deﬁ brillation protocol if patient is unconscious and pulseless • Routine Medical Care • Rescuer safety• Assume airway/respiratory involvement• Stop the burning process - DO NOT USE COLD PACKS• Assess for associated trauma Patient Care Policy (General) Modiﬁ ed On: May 10, 2019 7 BURN PATIENT CARE BURN PATIENT CARE C. TAR BURNS 1. Do not attempt to remove the tar 2. Cool with water 3. Maintain body temperature and observe for hypothermia D. CHEMICAL BURNS 1. Remove clothing 2. Liquid chemicals: Flush immediately with copious amounts of tepid water for 10 - 15 minutes 3. Dry chemicals: Brush oﬀ as much as possible, then ﬂ ush with copious amount of tepid water for 10 - 15 minutes 4. Identify chemical 5. Assess for associated respiratory burns 18% 18%9%9% 13.5% 13.5% 1% 18%Back 9% 1% 9% 18% 18% 9% 18% 18%Back ALCO PRE-HOSPITAL FLUID FORMULA weight in kg x TBSA (%) 8 = rate (mL/HR) Patient Care Policy (General) Modiﬁ ed On: July 21, 2017 8 BURN PATIENT CRITERIA BURN PATIENT CRITERIA 1. INTRODUCTION -The intent of this policy is to transport patients with critical burns, who have a manageable airway, directly to a facility that is staﬀ ed and equipped to care for the medical needs of the patient, bypassing other receiving facilities. Minor to moderate burn patients will be transported to the closest, most appropriate receiving hospital. 2. BURN PATIENT CRITERIA (from the American Burn Association – Burn Unit Referral Criteria) 2.1 Partial thickness burns greater than 10% total body surface area 2.2 Moderate to severe burns that involve the face, hands, feet, genitalia, perineum, or major joints 2.3 Full thickness burns in any age group 2.4 Electrical burns, including lightning injury 2.5 Chemical burns 2.6 Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or aﬀ ect mortality 3. DESTINATION 3.1 Adult and Pediatric patients who meet burn patient criteria 2.1-2.6 may be transported directly to an out-of-county burn center (see #5 below). 3.2 Exceptions: 3.2.1 Potenitially unmanageable airway - (e.g. - soot in the mouth and/or nose, inhalation injury, etc.) transport to the closest trauma center. 3.2.2 Unmanageable Airway - The patient requires intubation, and the paramedic is unable to intubate, and an adequate airway cannot be maintained with B.V.M. device, transport to closest basic E.D. 3.2.3 Patient meets Critical Trauma Patient Criteria - “Physiologic” or “Anatomic” - transport to the closest most appropriate designated trauma center 4. OUT-OF-COUNTY TRANSPORT 4.1 Transporting medic must ﬁ rst contact out-of-county hospital to conﬁ rm bed availability. This can be done through the appropriate dispatch center or via land-line from the ﬁ eld 4.2 Contact the Base Physician if medical consultation is needed 4.3 Consider EMS Aircraft transport for land transport times greater than 45 minutes 4.4 Give a brief report to the receiving facility including ETA Out-Of County Burn Centers: FACILITY TRAUMA HELIPAD LOCATION PHONE # UC Davis Medical Center YES YES 2315 Stockton Blvd., Sacramento (916) 734-3636 Santa Clara Valley Medical Center YES YES 751 S. Bascom Ave., San Jose (408) 885-6666 St. Francis Memorial Hospital NO NO 900 Hyde Street, San Francisco (415) 353-6255 Patient Care Policy (General) Modiﬁ ed On: July 21, 2017 9 CARDIOPULMONARY RESUSCITATION (CPR) CARDIOPULMONARY RESUSCITATION (CPR) Summary of High-Quality CPR Components for BLS Providers Component Adults andAdolescents Children(Age 1 Year to Puberty) Infants(Age Less Than 1 Year,Excluding Newborns) Scene safety Make sure the environment is safe for rescuers and victim Recognition ofcardiac arrest Check for responsiveness No breathing or only gasping (ie, no normal breathing) No deﬁ nite pulse felt within 10 seconds (Breathing and pulse check can be performed simultaneously in less than 10 seconds) Activation ofemergencyresponse system If you are alone with no mobile phone, leave the victim to activate the emergency response system and get the AED before beginning CPR Otherwise, send someone and begin CPR immediately; use the AED as soon as it is available Witnessed collapse Follow steps for adults and adolescents on the left Unwitnessed collapse Give 2 minutes of CPR Leave the victim to activate the emergency response system and get the AED Return to the child or infant and resume CPR; use the AED as soon as it is available Compression-ventilation ratio without advanced airway 1 or 2 rescuers 30:2 1 rescuer 30:2 2 or more rescuers 15:2 Compression-ventilation ratio with advanced airway Continuous compressions at a rate of 100-120/min Give 1 breath every 6 seconds (10 breaths/min) Compression rate 100-120/min Compressiondepth At least 2 inches (5 cm)* At least one third AP diameter of chest About 2 inches (5 cm) At least one third AP diameter of chest About 1½ inches (4 cm) Hand placement 2 hands on the lower half of the breastbone (sternum) 2 hands or 1 hand (optional for very small child) on the lower half of the breastbone (sternum) 1 rescuer 2 ﬁ ngers in the center of the chest, just below the nipple line 2 or more rescuers 2 thumb–encircling hands in the center of the chest, just below the nipple line Chest recoil Allow full recoil of chest after each compression; do not lean on the chest after each compression Minimizinginterruptions Limit interruptions in chest compressions to less than 10 seconds Deﬁ brillation Attach and use AED/ Deﬁ brillator as soon as available Minimize interruptions in chest compressions before and after shock Resume CPR beginning with compressions immediately after each shock *Compression depth should be no more than 2.4 inches (6 cm). Abbreviations: AED, automated external deﬁ brillator; AP, anteroposterior; CPR, cardiopulmonary resuscitation. Patient Care Policy (General) Modiﬁ ed On: May 21, 2021 10 CARDIOPULMONARY RESUSCITATION (CPR) CARDIOPULMONARY RESUSCITATION (CPR) ADDITIONAL INFORMATION: 1. Minimize interruptions in chest compressions 2. Use a mechanical compression device whenever possible 2.1 Refer to manufacturer’s instructions for speciﬁ c information regarding mechanical CPR device 2.2 Upon ROSC, you must discontinue mechanical CPR device AND ResQPOD® 3. If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and deﬁ brillation attempts or demonstrates ROSC. (2015 AHA Guidelines) 4. Emphasis is on high quality, uninterrupted CPR - ”push hard and fast” – allow for complete recoil 5. Two minutes CPR between drug doses 6. Once an advanced airway is established, give continuous chest compression without pauses for breaths. Avoid hyperventilation 7. Check rhythm q 2 minutes 8. Deﬁ brillation: Device speciﬁ c. While both monophasic and biphasic wave form deﬁ brillators are acceptable, biphasic is preferred. Energy level is dependant upon the manufacturer 9. Newborn: Unresponsive, not breathing but has a pulse: 40-60 ventilations/minute. Compression/ventilation ratio: 3:1 (90 compressions : 30 ventilations per minute) 10. Unresolved or persistent arrest, look for and treat: 11. If patient regains ROSC, refer to Return of Spontaneous Circulation - ROSC (see page 46) MECHANICAL CPR DEVICES: 12. PURPOSE: Eﬀ ective and uninterrupted compressions are important for survival; AHA/ERC Guidelines for CPR (Cardio-Pulmonary Resuscitation) 2005 emphasize the signiﬁ cance of compressions to provide critical blood ﬂ ow to vital organs and in the end to increase the chances of a successful survival. Mechanical CPR allows for consistent, quality CPR that enables caregivers to focus on other aspects of resuscitation while maximizing eﬀ ectiveness of therapeutic interventions 13. Indications: ►Use mechanical CPR devices wherever manual CPR is indicated ►IMPORTANT NOTE: If ROSC is obtained, mechanical CPR device must be discontinued 14. Contraindications: Hypovolemia Hypoxia or ventilation problem Hydrogen Ion (acidosis) Hypo/ Hyperkalemia Hypothermia Hypoglycemia (pediatric only) Toxins Tamponade (cardiac) Tension pneumothorax Thrombosis (coronary/pulmonary) Trauma (hypovolemia or ICP) AutoPulse Contraindications ≤ 17 years of age Patients with traumatic injury (wounds resulting from sudden physical injury or violence) LUCAS Contraindications If it is not possible to position LUCAS safely or correctly on the patient’s chest Too small patient: if the LUCAS device alerts with 3 fast signals when lowering the Suction Cup, and you cannot enter the PAUSE mode or ACTIVE mode Too large patient: If you cannot lock the Upper Part of LUCAS to the Back Plate without compressing the patient’s chest Patient Care Policy (General) Modiﬁ ed On: December 1, 2011 11 CARDIOPULMONARY RESUSCITATION (CPR) CARDIOPULMONARY RESUSCITATION (CPR) PIT CREW ROLES: The roles and responsibilities detailed below are guidelines. There may be fewer personnel on hand for these roles. It is important that there is always a Pit Crew Leader (similar to an Incident Commander on a scene of any MCI). This concept is known as ‘The Pit Crew’ concept and is the standard of care for resuscitations in Alameda County. The roles are as follows: Position and Responsibilities Pit Crew Leader:• Overall team leader• Assigns roles• Monitors time intervals (2 min. CPR, drug intervals, etc.)• Assures quality of CPR• Assures use of proper equipment and adjuncts (e.g., EtCO2)• Serves as scribe (ﬁ eld notes)• Supervises and assigns crowd control• Supervises DNR/POLST issues• Performs NO patient care• Responsible for overall conduct of resuscitation Airway Leader:• Performs appropriate airway techniques, procedures• Supervises airway decisions• Uses conﬁ rmatory adjuncts• Completes EHR at hospital (if appropriate) (with med leader)• Communicates with law/family as needed• Deﬁ brillates if medication leader not available• Inserts advanced airway (see page 114) * (NOTE: Do not interrupt chest compressions to place an advanced airway) Medication Leader:• Deﬁ brillates• Initiates IV or IO• Administers (or supervises) medications• Tracks and notiﬁ es team of all monitor changes• Completes EHR (with airway leader)• Communicates with family/law as needed• Terminates resuscitative eﬀ orts (with team leader)• Sets up mechanical CPR device* (see page 10)• Monitors mechanical CPR device* (see page 10) CPR Chief:• Supervises and performs CPR (with team leader)• Assists with equipment/medication setup• Performs communications Team Assistant:• Assists with CPR• Assists with communications• Assists with setup Team Leader/Airway Assistant (optional)• Serves at assistant to team leader• Assists airway leader * Indicates vital task to be completed Patient Care Policy (General) Modiﬁ ed On: July 21, 2017 12 CRUSH INJURY SYNDROME CRUSH INJURY SYNDROME  Crush Injury syndrome Deﬁ nition: Crush injury syndrome is the name given to the systemic manifestations of muscle crush injury and cell death. Crush injury syndrome should be suspected in patients with certain patterns of injury. Most patients in whom the syndrome develops have an extensive area of involvement such as a lower extremity and/or pelvis. It requires more involvement than just one hand or foot. The syndrome may develop after one hour in a severe crush situation, but usually requires 4 – 6 hours of compression for the processes that cause crush injury syndrome to occur. • Routine Medical Care• Trauma Patient Care (see page 24)• Note: Hypovolemia and hyperkalemia may occur, particularly with extended entrapment (usually > 4 hours). Once compression is released cellular toxins and potassium may be released into the body. Administering sodium bicarbonate alkalinizes the urine, controls hyperkalemia and acidosis Note: entrapment more than 4 hours and/ or abnormal EKG findings – peaked “T” wave, absent “P” waves and widened “QRS” Cardiac Monitor 12 Lead EKG Albuterol 10-20 mg via nebulizer Fluid resuscitation 20 ml/kg NS Pain Management – see pain management policy Adult: page 41 Pediatric: page 66 Use caution if other major traumatic injuries are suspected Calcium Chloride 1 gm slow IVP (over 2 min.) Note: flush IV tubing after administering CaCl to avoid precipitation Sodium Bicarbonate 1 mEq/kg IVP over 60 seconds Note: make sure to have a second IV line as other medications may not be compatible. Care of crush injury patient after release of compression Hyperkalemia suspected? (see note) Yes Reassess as needed No Immediate care of crush injury patient (prior to release) Patient Care Policy (General) Modiﬁ ed On: December 1, 2011 13 EXTREMITY INJURY EXTREMITY INJURY 1. ASSESSMENT: 1.1 Routine Medical Care 1.2 Document mechanism of injury 1.3 Document past medical history including history of previous injuries 1.4 Check for deformity, open wounds, swelling, shortening, and/or rotation 1.5 Document range of motion, pulses, sensation, and color of the extremity 1.6 Assess severity of pain (1-10 scale) 1.7 Assess for other associated injuries 2. GENERAL CARE: (all patients) 2.1 Control any external bleeding with direct pressure 2.2 Elevate and apply cold packs 2.3 Splint injured extremity. Hand injuries should be positioned in the “safe position” 2.4 Cover open wounds with sterile dressings 2.5 Provide Pain control – see Pain Management page 41 (Adult) or page 66 (Pediatric) 2.6 Remove rings or other possibly constricting items 3. FRACTURE/DISLOCATION: 3.1 If the extremity is pulseless, attempt to place it in normal anatomic position by gentle in-line traction 3.2 If repositioning does not restore circulation, do not manipulate further, transport immediately. 3.3 Start IV NS in uninjured extremity 4. AMPUTATION: 4.1 Place amputated part in dry, sterile dressing, place in sealed plastic bag, and place on top of ice or cold packs (do not place part directly in ice - prevent frostbite) 4.2 Start IV of NS in uninjured extremity 4.3 If hypotensive (SBP < 90 or signs of poor perfusion), give ﬂ uid challenge (500 mL NS, reassess and repeat if indicated) 5. HIGH-PRESSURE INJECTION INJURY: 5.1 Compressed air injuries, although they may initially look innocuous require immediate transport, especially if paint, paint thinner or grease is involved. These wounds must be debrided in the operating room as soon as possible to prevent further damage and/or amputation 6. SNAKE BITE: 6.1 Gently wash the area with cool, wet cloth 6.2 Avoid constricting bands 6.3 Do not elevate Position of function Patient Care Policy (General) Modiﬁ ed On: July 24, 2018 14 HYPERKALEMIA HYPERKALEMIA Deﬁ nition:Hyperkalemia is common in patients with severe renal failure (particularly those on dialysis) and should be suspected when these patients have weakness/fatigue, nausea/vomiting, chest pain, palpitations, shortness of breath, or numbness/tingling. Hyperkalemia can lead to ECG changes that can ultimately result in life-threatening dysrhythmias. Treatment in the prehospital setting is based on the severity of the ECG, is temporizing until deﬁ nitive treatment is achieved in the hospital, and aims to stabilize patients with the potential to arrest or become unstable 1. Peaked T Waves 2. Flattened-Absent P waves 3. Widened QRS complex 4. Sinusoidal pattern 5. Ventricular Fibrillation Cardiac Monitor 12 Lead ECG x Weakness/Fatigue x Nausea/Vomiting x Chest Pain x Palpitations x Shortness of Breath x Numbness/Tingling Calcium Chloride 1 gm slow IVP (over 2 min.) Note: flush IV tubing after administering CaCl to avoid precipitation Sodium Bicarbonate 1 mEq/kg IVP over 60 seconds Albuterol (only)10-20mg by nebulizer or BVM Note: make sure to have a second IV line as other medications may not be compatible. XAlbuterol may exacerbate tachycardia XSodium Bicarbonate may exacerbate volume overload Patient Care Policy (General) Modiﬁ ed On: December 1, 2011 15 HYPERTHERMIA / HEAT ILLNESS HYPERTHERMIA / HEAT ILLNESS 1. SIGNS AND SYMPTOMS OF A HEAT EMERGENCY Weakness or exhaustion Dizziness Headache Sweating may or may not be present Fainting or feeling faint Rapid heart rate Muscle cramps Altered mental status (coma, seizures, delirium) 2. PREEXISTING CONDITIONS THAT CAN CONTRIBUTE TO A HEAT EMERGENCY: 3. TREATMENT: 3.1 If the patient is conscious: 3.1.1 Remove patient from hot environment 3.1.2 Loosen or remove clothing 3.1.3 Place in supine position with legs elevated 3.1.4 Administer O2 3.1.5 Fan the patient 3.1.6 Water may be given if patient is alert, has a gag reﬂ ex, and is not nauseated 3.2 If altered mental status is present: (see above) 3.2.1 Place on left side and monitor airway 3.2.2 Wet the skin and fan aggressively 3.2.3 Apply cold packs to the axillae, groin and neck (if available) 3.2.4 Administer IV ﬂ uid challenge (250-500 mL NS) 3.2.5 Transport immediately • Routine Medical Care • Protect patient from environment.• If the patient is in extremis, begin treatment prior to secondary survey.• Consider: the environment, patient age, and pre-existing conditions ►Psychiatric disorder (both because of the medications taken and perhaps the patient’s poor judgement) ►Heart disease ►Diabetes ►Alcohol ►Fever ►Fatigue ►Obesity ►Dehydration (either decreased ﬂ uid intake or sweating) ►Medications Patient Care Policy (General) Modiﬁ ed On: May 6, 2013 16 HYPOTHERMIA HYPOTHERMIA 1. INTRODUCTION: Hypothermia is a reduced core temperature where the cold challenge overwhelms heat production and heat retention factors. The rate of onset can be: 1.1 Acute (minutes to hours) e.g. immersion in cold water 1.2 Sub-acute (hours) 1.3 Chronic (often over several days) Homeless, drug users, alcoholics, and compromised individuals are at high risk. Elderly persons and those taking certain medicines are also at risk. Injured and seriously ill individuals can become hypothermic quickly Note: a hypothermic critical trauma patient has a very high mortality and morbidity rate! 2. SIGNS AND SYMPTOMS OF HYPOTHERMIA: 2.1 Altered mental status including: confusion, mood changes, and speech diﬃ culties. The patient’s judgment may be aﬀ ecting causing him/her to exhibit inappropriate behaviors such as removing clothing 2.2 Decreased motor function, poor coordination 2.3 Diminished sense of cold sensation 2.4 Pupils that respond slowly or sluggishly 3. TREATMENT: 3.1 General: 3.1.1 Remove the patient from the cold environment and prevent further heat loss 3.1.2 Remove wet clothing, begin rewarming - cover with blankets, turn up the heat in the ambulance 3.1.3 Do not let the patient walk or exert him/herself 3.1.4 Administer O2 - titrate to 94-99% SpO2 (warmed and humidiﬁ ed is preferred) 3.1.5 Closely monitor cardiac rhythm 3.1.6 Check blood glucose levels. Administer glucose as needed (see ALOC page 33 – adult or page 62 - pediatric) 3.1.7 Transport immediately 3.2 BLS: 3.2.1 CPR should be initiated if there is any doubt about pulselessness 3.2.2 Severely hypothermic patients may appear dead. If you ﬁ nd an unresponsive, hypothermic patient, take time (30-45 seconds) to try and ﬁ nd a pulse before beginning CPR. Chest compressions should be avoided if any signs of life are present 3.2.3 If VT or VF is present, deﬁ brillation should be attempted. If one shock is unsuccessful, subsequent shocks should be deferred • Routine Medical Care • Protect the patient from the environment• If patient is in extremis, begin treatment prior to secondary survey• Check skin temperature Patient Care Policy (General) Modiﬁ ed On: December 1, 2011 17 HYPOTHERMIA HYPOTHERMIA 3.3 ALS: 3.3.1 Give ﬂ uid challenge with heated N.S. if possible 3.3.2 Do not delay urgent procedures (IV lines and intubation) but perform them “gently.” The severely cold heart is sensitive to a variety of stimuli, and fatal dysrhythmias can be caused by forceful treatment eﬀ orts 3.3.3 Defer ACLS medications until rewarming occurs (> 30° C / 86° F) Patient Care Policy (General) Modiﬁ ed On: May 21, 2021 18 INFECTION CONTROL INFECTION CONTROL 1. INTRODUCTION: The following guidelines are general recommendations to help to protect healthcare personnel by reducing the risk of further disease transmission when they are caring for patients with a potentially infectious disease. 2. PRE-INCIDENT 2.1 Ensure familiarity with organizational policies and procedures related to infection control including, but not limited to proper particulate respirator ﬁ t testing. 2.2 Ensure availability and familarity with appropriate PPE and proper donning/doﬃ ng procedures for all types of PPE. 2.3 Ensure availablity of appropriate cleaning supplies and their usage along with organizational policies and procedures surrounding their usage. 3. DURING INCIDENT: 3.1 Upon dispatch to an incident, utilize provided information to make an initial determination about the potential risk associated with the call. (i.e. a respiratory distress incident has a potentially higher risk associated vs an acute injury). 3.2 Follow standard universal precautions for all incidents. 3.3 If dispatch or initial information gathered at the scene indicates a potentially increased risk for disease transmission, minimize personnel having contact with the patient. 3.4 Apply a procedure or surgical mask to the patient to contain droplets if possible. 3.5 Use caution when performing aerosol generating procedures or high-risk procedures (e.g., mechanical ventilation, ETI, nebulized medications, and/or suctioning). 3.5.1 If you are performing an aerosol generating or other high-risk procedure on a patient with a suspected infectious disease, you are required to wear a N95, P-100, or equivalent respirator during the procedure(s) 3.5.2 It is recommended that a BVM with a HEPA ﬁ lter be utilized for ventilation. 3.6 Optimize environmental the vehicle’s ventilation to increase the volume of air exchange during transport 3.7 Minimize personnel and/or additional riders during transport. 3.8 Notify the receiving facility early as possible 4. POST INCIDENT 4.1 Follow standard operating procedures for routine cleaning of the emergency vehicle and reusable patient care equipment 4.2 Document all assessment ﬁ ndings and treatments appropriately. Patient Care Policy (General) Modiﬁ ed On: December 1, 2011 19 OB/GYN EMERGENCIES OB/GYN EMERGENCIES 1. VAGINAL BLEEDING (Abnormal bleeding between menses, during pregnancy, postpartum or post operative) 1.1 If postpartum, gently massage the fundus to decrease bleeding 1.2 Monitor vital signs frequently 2. SPONTANEOUS ABORTION 2.1 If fetus is > 20 weeks or 500 grams, see neonatal resuscitation protocol (page 65). If non-viable, save and transport any tissue or fetal remains 2.2 Have patient place a sanitary napkin or bulky dressing material over vaginal opening - Do not pack the vagina with anything 3. SEVERE PRE-ECLAMPSIA / ECLAMPSIA 3.1 Attempt to maintain a quiet environment 3.2 Monitor vital signs frequently 3.3 Observe for seizures, hypertension or coma. If seizures occur, go to the appropriate seizure policy 4. BREECH DELIVERY 4.1 Allow delivery to proceed passively until the baby’s waist appears. Gently rotate the baby to a face down position and continue with the delivery 4.2 If the head does not readily deliver insert a gloved hand into the vagina to relieve pressure on the cord and create an air passage for the infant. Transport. Monitor vital signs and infant condition frequently 5. PROLAPSED CORD 5.1 Place the mother supine position with head lower than hips 5.2 Insert a gloved hand into the vagina and gently push the presenting part (e.g.: the neonate’s head or shoulder oﬀ the cord. DO NOT TUG ON THE CORD 5.3 Place ﬁ ngers on each side of the neonate’s nose and mouth, split ﬁ ngers into a “V” to create an opening. Do not attempt to re-position the cord. Do not remove your hand. Cover the exposed cord with saline soaked gauze 6. LIMB PRESENTATION 6.1 Deﬁ ned as the presentation of a single limb - arm or leg 6.2 It is unlikely that the baby will deliver and immediate transport should be initiated 6.3 Place the mother supine position with head lower than hips • Routine Medical Care • Level of distress: Estimate blood loss (if any) Is the patient in shock? If yes, Go to page 52 “Shock” protocol • Consider immediate transport or prepare for delivery • Determine stage (trimester) of pregnancy Patient Care Policy (General) Modiﬁ ed On: May 21, 2021 20 SCOPE OF PRACTICE - LOCAL OPTIONAL SCOPE OF PRACTICE - LOCAL OPTIONAL 1. Approved for use in Alameda County – all items require additional training 1.1 BLS PERSONNEL: 1.1.1 Aspirin 1.1.2 Epinephrine 1.1.3 Glucometry 1.1.4 Narcan 1.1.5 Pulse Oximetry 1.2 ALS PERSONNEL: 1.2.1 12-lead EKG 1.2.2 Continuous Positive Airway Pressure (CPAP) 1.2.3 End-tidal CO2 detection 1.2.4 Intraosseous Infusion – Adult and Pediatric 1.2.5 Length-based resuscitation tape 1.2.6 Pulse-oximetry 2. Local Optional Scope of Practice – requires authorization from State EMS Authority and additional training 2.1 ALS PERSONNEL: 2.1.1 Hydroxocobalamin (optional) 2.1.2 Ketamine (Ketalar) 2.1.3 Ketorolac (Toradol) 2.1.4 Olanzapine (Zyprexa) 2.1.5 Sodium Thiosulfate 2.1.6 Tranexamic Acid 3. Field personnel will not perform any skill that is not a part of his/her scope of practice or has not been authorized by the Alameda County Health Oﬃ cer and/or EMS Medical Director 4. During an inter-facility transfer or during a mutual aid response into another jurisdiction, a paramedic may utilize the scope of practice for which he/she is trained and accredited 5. Paramedics will not draw blood unless approved in advance by the EMS Medical Director 6. Field personnel are prohibited from carrying any medical equipment or medications that have not been authorized for prehospital use by the Alameda County EMS Medical Director Patient Care Policy (General) Modiﬁ ed On: July 21, 2017 21 SMOKE INHALATION / CO MONITORING SMOKE INHALATION / CO MONITORING • Routine Medical Care • Symptoms of Carbon Monoxide (CO) poisoning: Initial symptoms are similar to the ﬂ u with no fever and can include dizziness, severe headaches, nausea, sleepiness, fatigue/weakness and disorientation/confusion • Note: Carbon Monoxide is a colorless, odorless and tasteless poisonous gas that can be fatal when inhaled. CO inhibits the blood’s capacity to carry oxygen. CO can be produced when burning any fuel. CO is a by- product of incomplete combustion. Suspect CO in the presence of any ﬁ re. SpCO = carboxyhemoglobin 1. Pulse oximetry values may be unreliable in SI patients 2. Cyanide and/or the combination of cyanide and carbon monoxide may be responsible for the majority of SI deaths 3. SI should be particularly suspected in patients rescued from closed-space structure ﬁ res 4. Sodium thiosulfate should not be given prophylactically 5. Remove victim from the source of exposure 5.1 Completely remove victim’s clothing prior to transport 5.2 Perform Spinal Motion Restriction (SMR) if indicated 5.3 Evaluate patient for facial burns, hoarseness, black sputum, and soot in the nose or mouth 5.4 Monitor SpCO (if available) 5.5 Assess and treat for traumatic and/or thermal injuries (go to appropriate policy) 6. Administer 100% oxygen via NRB 6.1 Control airway early. Perform endotracheal intubation / SGA placement if indicated 6.2 Use BVM with airway adjuncts 6.3 If bronchospasm present, go to appropriate respiratory policy 7. Provide cardiopulmonary support (go to appropriate cardiac arrest policy, if indicated) 8. Initiate IV NS. Consider ﬂ uid bolus 250-500 ml 9. ONLY if the patient exhibits serious signs and symptoms of smoke inhalation (SI) 9.1 Administer sodium thiosulfate or hydroxocobalamin 9.1.1 Sodium thiosulfate IV slowly over 10 minutes Adults: 12.5 g/50 ml | Children: 0.4 g/kg - to a maximum 12.5 g) to SI patients with any of the following signs of cyanide poisoning: Unconsciousness, non-responsiveness Hypotension Severely altered level of consciousness with soot in the mouth or nose 9.1.2 Hydroxocobalamin - Optional (Additional Training Required) Adults: 5g over 15 minutes 10. Treatment of cyanide poisoning must include immediate attention to airway patency, adequacy of oxygenation and hydration, cardiovascular support, and management of any seizure activity 11. If seizures present, go to appropriate seizure policy 12. If cardiac arrhythmia present, go to appropriate arrhythmia policy 13. Ensure rapid transport Patient Care Policy (General) Modiﬁ ed On: July 21, 2017 22 SMOKE INHALATION / CO MONITORING SMOKE INHALATION / CO MONITORING Measure SpCO (if available) 9Transport on 100% O2 9Consider CPAP SpCO >25% or >15%if pregnant? Loss of consciousness? Neurologic impairment? SpCO 3-25% Transport on 100% O2 for ED evaluation No further CO measurement required Yes No Yes No NOTE: If unexplained shock/hypotension develops, consider concomitant CO and/or cyanide poisoning Sodium Thiosulfate 12.5 grams over 10 minutes Remove victim from source of exposure Does patient show serious signs and symptoms of smoke inhalation?* Maintain airway and adequate respirations. Oxygen IV/IO NS Administer Sodium Thiosulfate 12.5 g/ 50 ml over 10 minutes Yes No *Signs and symptoms of smoke inhalation: 9Unconsciousness, non-responsiveness 9Hypotension 9Severely altered level of consciousness with soot in the mouth or nose Patient Care Policy (General) Modiﬁ ed On: July 21, 2017 23 TRANSPORT GUIDELINES TRANSPORT GUIDELINES Note: In addition, see “Trauma Patient Criteria” page 25, “Burn Patient Criteria” page 8, “Acute Stroke” page 30, “Chest Pain/MI” page 37, and “12-lead EKG” page 124 for speciﬁ c transport instructions. 1. GENERAL TRANSPORT GUIDELINES: All patients who wish to be transported by ambulance to the hospital should be transported 1.1 Patient Destination: 1.1.1 Patients should be transported to the closest hospital appropriate for their medical needs within a reasonable transport time or as speciﬁ ed in the patient care protocols 1.1.2 In general, patients should be transported to the hospital choice of the patient and/or family, if allowed by the protocols, and if there is no compelling reason to take them somewhere else 1.1.3 Paramedics should contact the Base Physician for any questions regarding transport destinations. If the Base Hospital is contacted for medical direction, the ultimate responsibility for determining patient destination will rest with the Base Hospital Physician 2. TRANSPORT DECISIONS: Transport decision should be based on paramedic judgment. Paramedics should take the following into consideration before transport: 2.1 Patient condition or ability of ﬁ eld personnel to provide ﬁ eld stabilization and/or emergency intervention. TRANSPORT OF ACUTE PATIENTS: Any patient with an acute, unstable appearance and/or severe symptoms may be transported Code 3 (lights and siren). Code 3 transport (lights and siren) has signiﬁ cant, inherent risks for the public and the patient. If Code 3 transport of an acute patient does NOT signiﬁ cantly decrease transport time to the hospital, the acute patient should be transported Code 2 (no lights and siren). The hospital must be notiﬁ ed of the patient's Code 3 acuity even if transported Code 2 2.2 Scene assessment and/or potential extrication diﬃ culties 2.3 ETA to the destination facility including traﬃ c delays 2.4 Instructions within speciﬁ c algorithms to “initiate early transport” 2.5 Hospital diversion status - See “Ambulance Rerouting” page v 2.6 Recommendation from a physician familiar with the patient’s current condition, or the patient’s regular source of hospitalization/healthcare. For physician on-scene - see page 106 2.7 Hospitals with specialized services (e.g.: trauma center, burn center, STEMI Center ( SRC), etc.) 3. TRANSFER OF CARE: Any paramedic level personnel may transfer care of a BLS patient to any EMT as long as the care required by the patient is within the scope of practice of an EMT, and the patient has no injury or illness that requires or is likely to require monitoring or treatment by an ALS provider 4. RECEIVING HOSPITAL NOTIFICATION: Transport units should contact the receiving hospital prior to arrival with the patient’s chief complaint, a summary of treatment given and the ETA. 5. OUT OF COUNTY TRANSPORTS: 5.1 Patients may be transported to hospitals outside Alameda County if the out-of-county hospital is the closest most appropriate hospital for the medical needs of the patient. Base contact is not required but should be attempted if there are any questions regarding the transport 5.2 Contact the receiving facility by radio or landline. If unable, contact the appropriate dispatch agency to relay information to the receiving facility. This will provide information on bed availability. Do not transport patient to out-of-county hospital without obtaining prior authorization Patient Care Policy (General) Modiﬁ ed On: May 21, 2021 24 TRAUMA PATIENT CARE TRAUMA PATIENT CARE CRITICAL/TIME SENSITIVE INTERVENTIONS: ►Control major external hemorrhage (see page 126) ►Control the Airway - Consider endotracheal intubation or supraglottic airway device if indicated (See below for patients with closed head trauma) ►Keep patient warm ►Determine patient severity (see “Trauma Patient Criteria” - see page 25): Meets Physiologic and/or Anatomic Factors Meets Mechanism of Injury Criteria Transport to the Trauma Center In accordance with Transport Guidelines (page 22). ADULT - Establish one (1) large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). Establish 2nd IV if appropriate. PEDIATRIC- Establish one (1) appropriate large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). Transport to the Trauma Center code 2. ADULT/PEDIATRIC - Establish one (1) large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). Do NOT delay transport to establish IV/IO access See “Trauma Patient Criteria" (page 25) for additional judgment decisions on code 2 transports ►Consider spinal motion restriction (SMR) for blunt trauma (see page 140) ►Administer Oxygen - Titrate SpO2 to 94-99% ►IV ﬂ uid resuscitation: SBP < 90 mmHg, NS IV/IO 250 – 500ml bolus > 90 mmHg, IV/IO TKO or Saline Lock Reassess BP q 5 minutes ►Consider TXA for patients with signs of shock or uncontrolled bleeding (see page 28) ►Care of the patient with a closed head injury (GCS < 8): Advanced airway (ETT or SGA) End-tidal CO2 should be between 30-35 mmHg Track respirations or ventilate to a rate of approx 12 times/minute with 100% O2(AVOID HYPERVENTILATION) IV/IO NS in 500 mL increments to maintain mean arterial pressure (MAP) of at least 80 mmHg. Reassess BP q 5 minutes IMPORTANT CONSIDERATIONS ►Contact the Base Hospital, if appropriate ►Contact the Trauma Center, as soon as possible ►Consider pain management when appropriate ►Splint fractures and dress wounds ONLY if time permits • Routine Medical Care• Critical Interventions - See below• Transport Decision - Determine need for rapid intervention/transport• Transport• If traumatic arrest is suspected do not use ACLS medications FORMULA FOR ESTIMATING MAP MAP = diastolic + (systolic - diastolic) 3 Patient Care Policy (General) Modiﬁ ed On: July 1, 2014 25 TRAUMA PATIENT CRITERIA TRAUMA PATIENT CRITERIA 1. INTRODUCTION: The goal of the Alameda County trauma system is to transport conﬁ rmed Critical Trauma Patient(s) (CTP) or, potential CTPs who might beneﬁ t from care at a trauma center directly to a designated Trauma Center in a timely manner, bypassing non-trauma centers 2. CRITICAL TRAUMA PATIENT CRITERIA 2.1 A patient is identiﬁ ed as a CTP when any of the following physiologic and/or anatomic factors are present. These patients should be transported code 3 2.2 Physiologic criteria: ►Glasgow Coma Scale ≤ 13 or; ►Blood pressure < 90 systolic or; ►Respiratory rate < 10 or > 29 (< 20 in infant < one year) or need for ventilatory support 2.3 Anatomic injury factors: ►Penetrating injury to the torso, head, neck, groin, or extremity proximal to the knee or elbow ►Flail chest ►Evidence of two or more proximal long bone fractures (femur, humerus) ►Crushed, degloved, mangled, or pulseless extremity ►Traumatic amputation above the wrist or ankle ►Evidence of pelvic fracture ►Open or depressed skull fracture ►Traumatic paralysis 3. MECHANISM OF INJURY: In addition to CTP criteria, the following mechanisms of injury may be used to identify a CTP. In general, these patients are transported code 2, however, diﬀ ering ﬁ eld circumstances and/or patient condition may require a code 3 transport 3.1 Falls ►Falls greater than twenty (20) feet ►Falls greater than ten (10) feet (≤14 or ≥55 years of age) 3.2 High-risk auto crash ►Intrusion including roof: > 12 in. occupant site; > 18 in. any site ►Ejection of patient (partial or complete) from a moving object (automobile, motorcycle, scooter, horse, etc.) ►Death of an occupant in the same passenger space ►Vehicle telemetry data consistent with high risk of injury 3.3 Auto vs. pedestrian/ bicyclist thrown, run over, or with signiﬁ cant (> 20 mph) impact 3.4 Motorcycle crash > 20 mph 3.5 Suspected closed head injury Patient Care Policy (General) Modiﬁ ed On: July 1, 2014 26 TRAUMA PATIENT CRITERIA TRAUMA PATIENT CRITERIA 4. SPECIAL PATIENT CONSIDERATIONS: Patients with the following considerations should be considered for transport to a trauma center. It is highly recommended that you make base contact in these situations 4.1 Age 4.1.1 Older adults Risk of injury and/or death increases after age 55 SBP <110 may represent shock after age 65 Low impact mechanisms (e.g. ground level falls) may result in severe injury 4.1.2 Children (≤ 14 Years of age) should be triaged preferentially to a pediatric-capable trauma center (e.g.- Children's) 4.2 Anticoagulation and bleeding disorders Patients with head injury are at high risk for rapid deterioration 4.3 Burns Without other trauma mechanism: Triage to burn center With trauma mechanism: Triage to trauma center 4.4 Pregnancy > 20 weeks 4.5 EMS provider judgement 5. TRANSPORT: Patients identiﬁ ed as a CTP will be transported to the closest, most appropriate, designated Trauma Center. Exception: The patient is identiﬁ ed as a CTP or Potential CTP but presents with one of the following: PATIENT PRESENTATION ACTION UNMANAGEABLE AIRWAY: The patient requires intubation, and the paramedic is unable to intubate, and an adequate airway cannot be maintained with B.V.M. device. Closest Basic E.D. ADULT TRAUMA ARREST - BLUNT or PENETRATING:Determination of Death in the Field (page 86)Note: Coroner’s personnel must transport all dead bodies. If ordered to move a body by law enforcement, note the time, name, and badge number of the oﬃ cer, and comply with the request. Ensure that the police oﬃ cer on scene has contacted the Coroner’s Bureau for permission to move the body PEDIATRIC TRAUMA ARREST BLUNT or PENETRATING: ETA to the Pediatric Trauma Center ≤ 20 minutes Pediatric Trauma Center ETA to the Pediatric Trauma Center ≥ 20 minutes Closest Adult Trauma Center Patient Care Policy (General) Modiﬁ ed On: July 24, 2018 27 TRAUMA PATIENT CRITERIA TRAUMA PATIENT CRITERIA 6. TRAUMA BASE CONTACT: Varying ﬁ eld circumstances make rigid application of any set of rules impractical. These criteria should serve as guidelines. Clinical circumstances may dictate that transport be undertaken immediately with Trauma Base contact made en route 6.1 Designated trauma base hospital - Highland Hospital is the Base Station for all trauma patients requiring base contact 6.2 Trauma base contact is not required if the patient meets "Critical Patient Criteria" or "Mechanism of Injury" and is transported to a Trauma Center 6.3 If the patient meets any of the "Special Patient Considerations” and Trauma Base contact cannot be established or maintained, transport the patient to a Trauma Center 6.4 Contact the trauma Base Physician if: ►The patient meets the criteria listed in the "Mechanism of Injury" criteria but the paramedic is requesting transport to a basic ED ►The patient requires medical treatment not covered in the "Trauma Patient Care” protocol (see page 24) ►The patient would beneﬁ t from consultation with the Base Physician 7. OUT-OF-COUNTY TRANSPORT 7.1 Patients who meet "Trauma Patient Criteria" may be transported directly to an out of county Trauma Center 7.2 Prior to transporting to an out-of-county Trauma Center, the transporting medic must: ►Contact the out-of-county Trauma Center by landline to determine if they can accept the patient ►Give a brief report including E.T.A. ►Contact the Alameda County Base Hospital if medical consultation is required (see #6 above) 7.3 Out-of-County Trauma Centers: TRAUMA CENTER PEDIATRIC CAPABLE LOCATION PHONE # STANFORD UNIVERSITY MEDICAL CENTER X PALO ALTO (650) 723-7337 SAN FRANCISCO GENERAL HOSPITAL SAN FRANCISCO (415) 206-8111 REGIONAL MEDICAL CENTER SAN JOSE (408) 729-2841 SANTA CLARA VALLEY MEDICAL CENTER X SAN JOSE (408) 885-6912 JOHN MUIR MEDICAL CENTER WALNUT CREEK (925) 947-4444 SAN JOAQUIN GENERAL FRENCH CAMP (209) 982-1975 Patient Care Policy (General) Modiﬁ ed On: May 21, 2021 28 TXA - TRANEXAMIC ACID TXA - TRANEXAMIC ACID 1. DESCRIPTION - Tranexamic Acid ( TXA) is a Lysine analogue that works to inhibit the formation of plasmin, which is a molecule responsible for clot degradation. It has had multiple medical applications in the past including pre-operative use, menorrhagia, hemophilia and hereditary angioedema. It has recently been shown in multiple studies to reduce mortality in trauma patients meeting speciﬁ c physiologic criteria or who have obvious signs of massive hemorrhage. 2. INCLUSION CRITERIA EXCLUSION CRITERIA Within three hours of onset of injury or illness, prehospital administration of TXA should be considered for all patients with blunt or penetrating trauma or other massive uncontrolled bleeding (vaginal hemorrhage, etc.) that have signs and symptoms of hemorrhagic shock and meet any one of the following inclusion criteria: ►Any patient <15 years of age ►Any patient more than three hours post- injury ►Isolated penetrating cranial injury ►Traumatic brain injury with brain matter exposed ►Suspected cervical cord injury with motor deﬁ cits ►SBP < 90 mmHg ►Signiﬁ cant hemorrhage with a HR > 120 ►Bleeding not controlled by direct pressure or tourniquet ►Major amputation of any extremity above the wrists or ankles 3. ADMINISTRATION 3.1 Administer TXA 1 gram in 100ml NS or D5W IV/IO over 10 minutes Do NOT administer IV push. This will cause hypotension. 3.2 Place an approved wristband on the patient. 3.3 Ensure that RN/MD at receiving facility is notiﬁ ed that TXA was administered. 3.4 Follow IV ﬂ uid resuscitation guidelines on page 24, “Trauma Patient Care” Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 29 ADULT POLICIES TOC ADULT POLICIES TOC ADULT POLICIES TOC ..............................................................................................29 ACUTE STROKE ........................................................................................................30 AIRWAY OBSTRUCTION ...........................................................................................32 ALTERED LEVEL OF CONSCIOUSNESS .................................................................33 ANAPHYLAXIS / ALLERGIC REACTION ..................................................................34 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY ................................................35 BRADYCARDIA ..........................................................................................................36 CHEST PAIN - SUSPECTED CARDIAC/STEMI ........................................................37 DYSTONIC REACTION ..............................................................................................38 MEDICATIONS – AUTHORIZED | STANDARD INITIAL DOSE ................................39 PAIN MANAGEMENT .................................................................................................41 POISONING | INGESTION | OVERDOSE .................................................................42 PULMONARY EDEMA / CHF......................................................................................43 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) ...........44 RESPIRATORY DISTRESS........................................................................................45 RETURN OF SPONTANEOUS CIRCULATION - ROSC ............................................46 ROUTINE MEDICAL CARE – ADULT.........................................................................47 SEIZURE .....................................................................................................................49 SEPSIS .......................................................................................................................50 SEVERE NAUSEA ......................................................................................................51 SHOCK: HYPOVOLEMIC/CARDIOGENIC ................................................................52 SUBMERSION ............................................................................................................53 SUSPECTED OPIOID WITHDRAWAL .......................................................................54 TACHYCARDIA ...........................................................................................................55 VENTRICULAR ASSIST DEVICES -VAD ..................................................................56 VENTRICULAR FIBRILLATION | VENTRICULAR TACHYCARDIA: PULSELESS ..58 Patient Care Policy (Adult) Modiﬁ ed On: May 10, 2019 30 ACUTE STROKE ACUTE STROKE 1. PURPOSE: To identify acute stroke patients who may be candidates for thrombolysis and specialized care at a certiﬁ ed stroke center. Information in this policy is based on the Cincinnati Prehospital Stroke Scale (CPSS). The CPSS evaluates using FASTT criteria (Facial droop, Arm drift, Speech abnormalities, Time of onset/Transport) 2. Certiﬁ ed Stroke Centers: The following hospitals have been designated as certiﬁ ed stroke centers. If possible patient should be transported to the patient’s regular source of hospitalization and/or healthcare. Alameda Hospital , Alameda Eden Medical Center, Castro Valley Kaiser Hospital, Fremont Kaiser Hospital, Oakland Kaiser Hospital. San Leandro Summit Medical Center, Oakland ValleyCare Hospital, Pleasanton Washington Hospital, Fremont Consider transport to one of the following out-of-county centers, if appropriate. Contact the stroke center prior to transport. San Ramon Medical Center, San Ramon Stanford University Medical Center, Palo Alto John Muir Medical Center, Walnut Creek Kaiser Hospital, Walnut Creek Regional Medical Center, San Jose 3. Assessment and transport of suspected Acute Stroke patient: Provide routine medical care including pulse oximetry Obtain blood glucose Assess the patient using the Cincinnati Prehospital Stroke Scale ►Note: Early transport is essential if CPSS is positive Patient Care Policy (Adult) Modiﬁ ed On: May 10, 2019 31 ACUTE STROKE ACUTE STROKE Cincinnati Prehospital Stroke Scale Sign/Symptom How Tested Normal Abnormal Facial Droop Have the patient show their teeth or smile Both sides of the face move equally One side of the face does not move as well as the other Arm Drift The patient closes their eyes and extends both arms straight out for 10 seconds Both arms move the same, or both do not move at all. One arm either does not move, or one arm drifts downward com- pared to the other. Speech The patient repeats “The sky is blue in Cincinnati." The patient says correct words with no slurring of words. The patient slurs words, says the wrong words, or is unable to speak Time of Onset must be within 24 hours, observed by a reliable witness or reported by a reliable patient (for thrombolysis) Transport The patient is considered a possible Acute Stroke patient if any of the tested signs/symptoms are abnormal and must be transported to the closest, most appropriate certiﬁ ed stroke center. If possible, patient should be transported to the patient’s regular source of hospitalization and/or healthcare. 4. The patient may be a candidate for thrombolysis if all of the following are true: One or more of the CPSS signs/symptoms are present. CPSS signs/symptoms were initially observed within 24 hours of contact by a reliable witness or reported by a reliable patient. Please note: Ask when the patient was last seen at normal baseline and when the onset of new stroke signs and symptoms appeared. Normal blood glucose level is obtained Make sure to either: ►transport the witness to the stroke center in the ambulance (PREFERRED); OR, ►if driving, tell him/her to leave immediately and meet you at the stroke center; AND, ►obtain a contact number where the witness can be reached by the attending physician 5. Treatment and support guidelines (to be done en route) Transport patient in supine position. If this position is not tolerated or there is evidence of increasing intracranial pressure/ intracranial hemorrhage, transport in semi-fowlers with no more than 30° head elevation O2 – titrate to 94-99% SpO2 Establish IV access en route using an 18 gauge (no smaller than 20 gauge) proximal to wrist (AC preferred). No more than 1 AC attempt and no more than 2 IV attempts total. Maintain with a saline lock or IV infusion set TKO Obtain a 12-Lead EKG en route when a dysrhythmia or ACS symptoms are present (speciﬁ cally watch for STEMI and/or atrial ﬁ brillation) 6. Immediately call the designated stroke center via phone and/or radio and notify them that you are transporting a “possible Acute Stroke patient by the Cincinnati Prehospital Stroke Scale (CPSS), ETA ____ minutes”. (Reminder: See “Diversion Criteria” or the information on page v of the ﬁ eld manual regarding CT Diversion) 7. For patients whose onset of S/S is between 6-24 hrs, consider not utilizing red lights and siren during transport 8. Document the results of the assessment on the EHR and speciﬁ cally describe any of the CPSS signs and/or symptoms that were abnormal Patient Care Policy (Adult) Modiﬁ ed On: April 10, 2012 32 AIRWAY OBSTRUCTION AIRWAY OBSTRUCTION • Routine Medical Care• If obstruction due to laryngeal trauma, see page 24 "Trauma Patient Care"• Obstruction due to epiglottitis: Do not attempt to visualize the throat or insert anything into the mouth Minimize outside stimulation. Keep the patient calm. Position of comfort. • Do not use a tongue/jaw lift or perform blind ﬁ nger sweeps• Rapid Transport *Severe signs of obstruction? Suspect epiglottitis? Position of comfort Attempt Intubation or Assist Ventilation with Bag-Valve-Mask Able to ventilate adequately? Yes No Yes Maintain airway and Oxygen Transport to the closest ED Yes *Signs of severe obstruction: 9Poor air exchange 9Increased breathing difficulty 9Silent cough 9Cyanosis 9Inability to speak or breathe 9Ask the patient “Are you choking”? If patient nods yes, act Maintain airway and Oxygen If the patient deteriorates, or becomes completely obstructed, positive pressure ventilation via bag-valve-mask should be attempted first. If airway can not be maintained with BVM Consider: Intubation (see page 116) Continue abdominal and chest thrusts. If the patient becomes unresponsive: Begin CPR Check mouth for F.B. No Apply abdominal thrusts in rapid sequence. If ineffective, or the patient is obese or in the late stages of pregnancy, consider chest thrusts. Patient Care Policy (Adult) Modiﬁ ed On: July 1, 2014 33 ALTERED LEVEL OF CONSCIOUSNESS ALTERED LEVEL OF CONSCIOUSNESS • Routine Medical Care• Obtain a complete patient history including current medications• Identify and document neurological deﬁ cits• Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 8 breaths per minute) (see page 44)• Note: Glucose paste may be administered if the patient: 1) is able to hold head upright; 2) has a gag reﬂ ex; and, 3) can self-administer the medication • Dextrose should not be given with suspected Acute Stroke unless blood sugar reading is < 60 mg/dL• Perform 12-Lead EKG, as appropriate, and transport to a STEMI Receiving Center if STEMI is identiﬁ ed. (See page 124 - EKG 12-Lead) for STEMI Receiving Center information• SMR for trauma or suspicion of trauma (see page 139)• Contact the Base Physician if: the Blood Glucose reading is > 60 mg/dL but hypoglycemia is suspected Maintain airway and adequate respirations. O2 – titrate to 94-99% SpO2 IV/IO NS Check blood glucose Result < 60 mg/dL ? Dextrose 10% First dose10g (100 ml) IV/IO or Glucagon 1 mg IM (if unable to start IV or IO) or Oral Glucose 30 gms insert into oral mucosa (See note above) Recheck blood glucose 5-10 minutes after D10 administration. If the patient’s blood glucose remains < 60 mg/dl Give additionalDextrose 10% 15g (150 ml) IV/IO Consider AEIOU – TIPSAppropriate Response? Yes No No Reassess as needed Yes Patient Care Policy (Adult) Modiﬁ ed On: May 10, 2019 34 ANAPHYLAXIS / ALLERGIC REACTION ANAPHYLAXIS / ALLERGIC REACTION • Epinephrine IM is the cornerstone of treatment of anaphylaxis and should be given as early as possible. It is best absorbed from an injection in the lateral thigh • If the patient is in severe distress, administer Epinephrine IM and consider immediate transport• SIGNS OF ANAPHYLAXIS (Systemic Reaction) – wheezing, repetitive cough, tightness in chest, stridor, diﬃ culty swallowing or tightness in throat, change in voice, dizziness or feeling faint, abdominal complaints (pain, repeated vomiting, diarrhea or incontinence), anxiety, lethargy• SIGNS OF ANAPHYLACTIC SHOCK – pallor, hypotension, cool, clammy mottled skin, altered sensorium• Facial/oral swelling (Angioedema) can accompany anaphylaxis, but is not always present ANAPHYLAXIS (Systemic Reaction) EPINEPHRINE 1mg/ml BLS Providers: 0.3mg IM ALS Providers: 0.3mg-0.5mg IM May Repeat x 1 in 15 min. For persistent wheezing or respiratory distress ALBUTEROL 5 mg in 6 mL NS via hand-held nebulizer, mask, or BVM Consider for Urticaria (Hives/Itching) DIPHENHYDRAMINE§ 1 mg/kg IV/IO/IM up to 50mg Reassess 5-10 mins. after IM epi. If VS not improved with ﬂ uid bolus: EPINEPHRINE 0.1mg/mL 1mL (0.1mg) IV/IO slowly*** • Max single dose 0.1 mg• May repeat q 10 minutes IV/IO NS FLUID BOLUS 1-2 liters NS Assist ventilations with BVM as required OXYGEN If Any Distress *ALLERGIC REACTION (Skin or mucous membrane symptoms only without signs of anaphylaxis or airway obstruction) Consider for Urticaria (Hives/Itching) DIPHENHYDRAMINE§ 1 mg/kg IV/IM up to 50mg YES NOSIGNS OF SHOCK? If no responseBase Physician consult NOTES* If patient develops signs of anaphylaxis, go to other arm of this algorithm ** In elderly, small, or in patients with mild symptoms or history of CAD, consider lower dose (0.3mg IM). *** IV/IO epinephrine should only be used if symptoms are unresponsive to IM epinephrine and patient has signs of profound shock § Diphenhydramine may lessen dis- comfort from rash/itching but is not an essential treatment of anaphylaxis. Consider reduced dosage if patient has taken diphenhydramine in the past 1-2 hrs. Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 35 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY CPR (see note above) ECG / AED BLS Airway BVM ventilation with 10-15 lpm O2 ITD (Placed closest to patient - see page 130) ETCO2 Monitoring IV/ IO NS Epinephrine 0.1mg/mL 1 mg IV/IO (1st dose ASAP – preferably within 5 min from start of CPR) Q 10 minutes, up to 3 doses Organized Rhythm and pulse present?NoYes To V-fib.V-tach page 58 Shockable rhythm? 2 minutes or 5 cycles of CPR Check rhythm Yes No Go to: Return of Spontaneous Circulation page 46 or Appropriate Dysrhythmia Policy Consider: ^Discontinue CPR See page 87 or Continue CPR Transport ^Discontinuation of CPR: If non-shockable rhythm persists, despite appropriate, aggressive ALS interventions for 30 minutes (OR if ETCO2 is <10mmHg after 20 minutes in a patient with an advanced airway), consider discontinuation of CPR. REVERSIBLE CAUSES • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • Thrombosis, coronary Do not interrupt CPR to administer medications or perform airway management Consider advanced airway If renal failure or hyperkalemia suspected: Calcium Chloride 1 gm slow IVP (over 2 min.) Note: flush IV tubing after administering CaCl to avoid precipitation Sodium Bicarbonate 1 mEq/kg IVP Note: make sure to have a second IV line as other medications may not be compatible • Routine Medical Care• Consider and treat other possible causes – See CPR page 9• Note: Use of a mechanical CPR device is required whenever available and appropriate pa e 5 e CPR torin Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 36 BRADYCARDIA BRADYCARDIA Maintain airway, assist breathing as needed 02 – titrate to 94Ͳ99% SpO2 Monitor IV/ IO NS Consider 12Ͳlead if stable **Signs or symptoms of poor perfusion caused by bradycardia? Observe/ Monitor я Transcutaneous Pacing: Begin at 80bpm, 0 mA; increase in 10 mA increments until capture obtained then increase the output level by 10%. (see TCP page 145) я Consider: Sedation (see note above & sedation policy) я Consider: Pain Management – titrate to effect яConsider: Atropine 1 mg IV/ IO while waiting for TCP. May repeat q 3Ͳ5 minutes to a total dose of 3 mg. я Consider: Epinephrine 0.5 mL (5 mcg) IV/IO, every 3 minutes, titrate to a SBP > 90 If capture maintained but patient remains symptomatic, consider: я Increase rate by 10 bpm to a max of 100bpm я Fluid challenge, particularly if evidence of right ventricular MI Push Dose Epinephrine mixing instructions: ››Take Epinephrine 1 mg of 0.1 mg/ml preparation (CardiacEpinephrine) and waste 9 ml of Epinephrine ››In that syringe, draw 9 ml of normal saline from thepatient’s IV bag and shake well ››Mixture now provides 10 ml of Epinephrine at a 0.01 mg/ml (10 mcg/ml) concentration **if patient is symptomatic, do not delay pacing to start an IV or wait for Atropine to take effect Yes No Consider: Base Physician consult if patient remains symptomatic • Routine Medical Care • Bradycardia: < 50 beats/minute, 2nd degree block, 3rd degree block• Serious signs and symptoms: Acute altered mental status Hypotension On-going chest pain Other signs of shock • Note: If utilizing Transcutaneous Pacing (TCP), verify mechanical capture and patient tolerance (see page 145) Use sedation with caution in the hypotensive patient (see page 138) If patient symptomatic and pacing not available, consider rapid transport Consider Hyperkalemia cr m nt Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 37 CHEST PAIN - SUSPECTED CARDIAC/STEMI CHEST PAIN - SUSPECTED CARDIAC/STEMI • Routine Medical Care• Signs of Shock - 2 or more of the following: Pulse > 120/minute Pale, cool and/or diaphoretic skin signs BP < 90/systolic Altered Mental Status • If cardiac chest pain is suspected and the patient is able to swallow, give Aspirin 162 - 324 mg po as soon as possible (tablet or chewable – not enteric coated)• NTG may be prioritized as needed based on patient presentation• Perform 12-Lead EKG, as appropriate, and transport to a STEMI Receiving Center if STEMI is identiﬁ ed. See page 124 - EKG 12-Lead for EKG transmission and STEMI Receiving Center information• Note: If the patient has taken erectile dysfunction (ED) medication within the last 24 hours (Viagra/ Levitra) or 36 hours (Cialis), withhold nitroglycerin Monitor AssessABC’s O2–titrateto94Ͳ99% Aspirin162Ͳ324mg IV/IONS *NTG0.4mg upto3doses,q3Ͳ5minutesfor continuingpain/discomfort Ifunresponsivetonitrates: PainManagement (seepage41) (^^seenote) 12ͲleadEKG STEMI? TransmitEKGtoSTEMI ReceivingCenter(SRC) (seepage126) TransporttoSRC Establish2ndIVenͲroute Yes Ifcardiogenicshock, tachycardia,orlife threateningdysrhythmia gotoappropriatepolicy No Donotdelaytransportif technicaldifficulties impedeEKGtransmisison. AttempttosendenͲroute wheneverpossible. ^^Note:IfB/Pdropsbelow90 systolicordrops>30mm/Hg frombaselineatanypoint;or, heartrateis<50or>120bpm, contactthebasephysician beforeadministering/ continuingNTGand/orPain Management Patientswhohaveoxygensaturationsof greaterthan94%withoutsignsor symptomsofhypoxiaorimpendingairway compromiseshouldnotreceiveoxygen. Patient Care Policy (Adult) Modiﬁ ed On: December 1, 2011 38 DYSTONIC REACTION DYSTONIC REACTION • Routine Medical Care• History includes ingestion of phenothiazines: Chlorpromazine (Thorazine, Largactil) Promazine (Compazine) Triﬂ upromazine (Vesprin) Levomepromazine (Nozinan) Piperidines (Haloperidol, Risperidone) Promethazine (Phenergan) • Signs and Symptoms (often mistaken for a seizure disorder or tetany): Agitated/frightened appearance Small pupils Hypotension Facial grimaces Protruding tongue Jaw muscle spasm Oculogyric crisis (circular movement of the eyeballs) Torticollis (twisting of the neck) Spasms of the back muscles, causing the head and legs to bend backward and the trunk to arch up O2 – titrate to 94-99% SpO2 Maintain airway IV NS Signs and/or symptoms present? Diphenhydramine 1 mg/kg IV, IO or IM up to 50 mg If initial dose given IV/IO: May repeat dose in 15 minutes for continuing signs/symptoms. Reassess as needed Yes No Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 39 MEDICATIONS – AUTHORIZED | STANDARD INITIAL DOSE MEDICATIONS – AUTHORIZED | STANDARD INITIAL DOSE Adenosine 1st dose: 6 mg; 2nd dose: 12 mg (rapid IV/IO push) Albuterol 5 mg in 6 ml normal saline Amiodarone Wide complex Tachycardia: 150 mg IV/IO over 10 minsVF/VT: 1st dose: 300 mg IV/IO; 2nd dose: 150 mg IV/IO Follow each dose with 20mL NS ﬂ ush. (two doses only) Aspirin 162 mg chewable or 324 mg (5gr.) tablet – not enteric coated) Atropine sulfate Bradycardia: 1 mg IV/IO - (max total 3 mg) Calcium chloride 10%1 gm over 2 minutes IV/IO Charcoal 1 gm/kg (Max 50 gms) PO Dextrose 10%10 gms IV/IO Diphenhydramine (Benadryl)Allergic Reaction: 1 mg/kg IV/IO/IM up to 50 mg Epinephrine 1mg/mL Anaphylaxis: 0.3 mg-0.5 mg IMBronchospasm: 0.01 mg/kg IM (max dose 0.5mg) Epinephrine 0.1mg/mL Anaphylactic shock: 1mL (0.1mg) IV/IO slowlyCardiac arrest: 10mL (1 mg) IV/IOCardiogenic/Distributive Shock: Diluted to 0.01mg/ml (10mcg/ml), 0.5ml (5mcg) slow IV/IO Fentanyl Pain Management: 25-100 mcg IV/IO/IM/IN (max. single dose 100 mcg) Glucagon 1 mg IM Oral Glucose 30 gms PO Ipratropium (Atrovent)500 mcg (2.5 ml unit dose) Via nebulizer Lidocaine 2%40 mg IO (2 mL) slowly (1 ml over 30 seconds) Ketamine (Ketalar)0.3 mg/kg IV/IO/IM/IN - IV/IO dose to be mixed in 100ml NS/D5W and in-fused over 10 min Ketorolac (Toradol)15 mg IM/IV/IO Midazolam (Versed)Sedation: IV (slowly) / IN (briskly): 1-2 mg, IM: 2-4 mg (if no IV)Seizure: IM/IN: 10 mg, IV/IO: 0.1 mg/kg - max dose 10 mg Naloxone (Narcan)Initial dose: Titrated up to 2 mg IV/IM/IN BLS Providers may only use IN Route. Max. initial dose is 2 mg Nitroglycerine spray 0.4 mg metered spray or tablet Normal saline 250 - 500 ml IV/IO ﬂ uid bolus Olanzapine (Zyprexa)10 mg PO orally dissolving tablet Ondansetron (Zofran)4 mg IV †Slowly over 30 seconds or 4 mg IM/PO (oral dissolving tablets)(†rapid IV administration <30 seconds can cause syncope) Oxygen(titrate to 94%-99% SpO2)2 - 6 L/nasal cannula | 15 L/non-rebreather mask Sodium bicarbonate 1 mEq/kg IV/IO Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 40 MEDICATIONS – AUTHORIZED | STANDARD INITIAL DOSE MEDICATIONS – AUTHORIZED | STANDARD INITIAL DOSE Sodium thiosulfate 12.5 grams IV/IO over 10 minutes Tranexamic Acid- TXA 1 gram in 100ml NS or D5W IV/IO over 10 minutes Hydroxocobalamin Smoke Inhalation/Cyanide Poisoning: 5g IV/IO over 15 minutes Atropine Sulfate Nerve agent exposure: Patient: 2 mg IV/IM (for use only by Paramedics or specially-trained EMTs) Autoinjector antidote kit: 2 mg in 0.7mL 1 - 3 kits depending on exposure (given with Pralidoxime chloride) ►Additional atropine may be needed until a positive response is achieved Pralidoxime Chloride (2-PAM) Nerve agent exposure: Patient: 1 - 2 grams IV/IM (for use only by Paramedics or specially-trained EMTs) Autoinjector antidote kit: 600 mg in 2 ml’s 1 - 3 kits depending on exposure (given with atropine) Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 41 PAIN MANAGEMENT PAIN MANAGEMENT • Routine Medical Care• Pain management should be initiated as early as possible and before transport in the stable patient. Consider pain management prior to the manipulation of suspected fractures• Document the level of pain prior to and after any interventions BLSInterventions: ї Positioning ї Cold Pack(s) ї Splinting ї Coaching MinorͲModeratePain: Ketorolac Ͳ IM/IV/IO 15 mg x 1 Ͳ (No repeat dose) Preferred firstͲline medication for minorͲmoderate pain and for patients with suspected kidney stones or chronic pain conditions. (May start with Fentanyl or Ketamine if appropriate or if Ketorolac is contraindicated) ModerateͲSeverePain: Fentanyl IV/IO: 1 mcg/kg (50Ͳ100 mcg) Slow push. Repeat q 5min PRN to a max. cumulative dosage of 200 mcg IM/IN: 1 mcg/kg (50Ͳ100 mcg) Repeat q 10min PRN to a max. cumulative dosage of 200 mcg Basecontactrequiredifcontraindicationsarepresentor>200mcgisneeded OR Ketamine IV/IO: 0.3 mg/kg in 100ml of NS/D5W Slow IV Infusion over 10 minutes. (max. dose is 30 mg, no repeat) IM/IN 0.3 mg/kg (max. dose is 30 mg, no repeat) KetorolacConsiderations: xContraindications: Ŷ Patients who meet Trauma Criteria Ŷ NSAID Allergy (e.g. Ibuprofen, Naproxen, Aspirin) Ŷ Pregnancy Ŷ History of: GI Bleed, Ulcers, Renal disease Ŷ Current anticoagulant use xNote: Standards doses of Fentanyl OR Ketamine may be administered if Ketorolac is ineffective Fentanyl&KetamineConsiderations: xDONOTCOͲADMINISTERFENTANYLANDKETAMINE xPatientMonitoring Continuous monitoring of the patient’s LOC and respiratory status via direct observation/ETCO2/SpO2, etc is required. xContraindications: Ŷ Decreased respiratory rate Ŷ Altered mental status/LOC Ŷ Suspected Traumatic Brain Injury xNotes: Consider lower doses of Fentanyl for older adults Have Naloxone readily available when administering Fentanyl Ketorolac may be administered if Fentanyl or Ketamine is ineffective Patient Care Policy (Adult) Modiﬁ ed On: August 1, 2016 42 POISONING | INGESTION | OVERDOSE POISONING | INGESTION | OVERDOSE • Routine Medical Care• Protect Yourself! - See Hazardous Materials Incidents - EMS Response page 157• Identify substance - Bring any containers, labels or a sample (if safe) into the hospital with the patient. Determine type, amount and time of the exposure.• Consult the Base Physician: If organophosphate poisoning suspected* If calcium channel or beta blocker OD suspected* For treatment options for speciﬁ c exposures * Consider contacting Poison Control for other substances 800-222-1222 • Remove contaminated clothing. Brush oﬀ powders, wash oﬀ liquids with copious amounts H2O O2 – titrate to 94-99% SpO2 Maintain airway and adequate ventilation IV/ IO NS TKO Ventilating adequately, alert with a good gag reflex? If non-acid, non-caustic, non-petroleum consider: Charcoal 1 gm/kg po if within one hour of ingestion Max dose of 50 grams Assist respiration with bag-valve-mask or, Intubate as needed Fluid Challenge 500 ml if B/P < 90/sys If tricyclic antidepressant suspected (widened QRS, hypotension unresponsive to fluids) consider: Sodium Bicarbonate 1 mEq/kg For patients with suspected narcotic OD go to Respiratory Depression page 44 Yes No For late stage seizure complications go to Seizure page 49 Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 43 PULMONARY EDEMA / CHF PULMONARY EDEMA / CHF • Routine Medical Care• It will be necessary to brieﬂ y remove the CPAP mask to administer aerosolized/oral medications; this will not harm the patient. Ensure a tight ﬁ t is obtained upon mask re-application• Consider ASA, 162 – 324 mg po, for acute coronary syndrome patients• Perform 12-Lead EKG, and transport to a STEMI Receiving Center if STEMI is identiﬁ ed. (See page 126 - EKG 12-Lead) for STEMI Receiving Center information • Rapid transport if on scene stabilization is unlikely O2 – titrate to 94-99% SpO2 IV NS *B/P > 90 systolic? CPAP page 124 NTG 0.4 mg q 5 minutes for continuing symptoms If the patient's B/P is >150/systolic, double ^NTG to 0.8 mg q 5 minutes. Maximum total dose: 8.0 mg *Note #1: Consult the base physician if the B/P drops below 90/ systolic at any point, before continuing NTG, or for any questions regarding dosage ^ Note #2: 9Repeat vital signs between doses. 9Only increase NTG dose to 0.8 mg while the B/P is > 150/systolic. 9If B/P drops below 150/systolic resume 0.4 mg dose. Yes Go to: Cardiogenic Shock page 52 No Reassess as needed Patient Care Policy (Adult) Modiﬁ ed On: May 10, 2019 44 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) • Routine Medical Care• Naloxone can cause acute withdrawal symptoms (agitation,vomiting, etc.) in patients who are chronic utilizers of narcotics• Naloxone can cause cardiovascular side eﬀ ects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%)• Older patients are at higher risk for cardiovascular complications• Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management Naloxone: IN/IM/IV- Initial dose: Titrated dose to maintain respiratory rate 8, up to 2 mg Repeat as needed to maintain respiratory rate 8 (no max. dose) BLS Providers may only utilize the IN administration route Respiratory rate 8 Monitor/Reassess If BVM ventilation and Naloxone are ineffective, consider Advanced Airway placement (see page 116) Monitor/Reassess NoYes Maintain airway patency and adequate respirations with BLS airway adjuncts and BVM as needed Oxygen- titrate to SpO2 of 94-99% Consider vascular access If patient is a known/ suspected chronic utilizer of narcotics, consider 1:10 dilution of Naloxone:Normal Saline Administer in 0.1 mg (1 ml) increments to maintain respiratory rate 8 Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 45 RESPIRATORY DISTRESS RESPIRATORY DISTRESS • Routine Medical Care Asthma COPD Bronchospasm Pulmonary edema (see page 43) • Limit physical exertion, reduce patient anxiety O2 – titrate to 94-99% SpO2IV NS Mild Respiratory Distress - Mild wheezing/SOB - Cough Moderate to Severe Distress any of the following: - Cyanosis - Accessory muscle use - Inability to speak > 2 syllables - Severe wheezing/SOB Albuterol (only) 5 mg in 6 mL NS by nebulizer If respiratory distress continues, may repeat Albuterol CPAPorAssist respirations Intubate as needed for severe distress Albuterol 5 mg in 6 mL NS and Ipratropium 500 mcg (2.5 mL) by nebulizer, CPAP, or BVM Epinephrine 1mg/mL 0.01 mg/kg IM max dose 0.5 mg Pt must have no history of coronary artery disease or hypertension If respiratory distress continues Albuterol (only) 5 mg in 6 mL NS by nebulizer or via BVM May repeat x1 if respiratory distress continues NOTE: For patients with COPD, oxygen supplementation should be given to achieve an oxygen saturation of 88%-92%. Higher oxygen saturations in COPD patients have been shown to be harmful. Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 46 RETURN OF SPONTANEOUS CIRCULATION - ROSC RETURN OF SPONTANEOUS CIRCULATION - ROSC • Routine Medical Care • Remove Impedance Threshold Device (ITD) • Monitor for reoccurrence of arrest rhythm• Transport patients with ROSC at any time to STEMI Center (except critical trauma patients)• If appropriate, transport pediatric patients to Children's Hospital• Note: Transcutaneous Pacing (page 145): Begin at 80 bpm, 0 mA; increase in increments of 10 mA until capture obtained then increase the output level by 10% If capture maintained but patient remains symptomatic consider increasing the rate by 10 bpm, to a maximum of 100 bpm 9MonitorandsupportABCs 9ConfirmPalpablepulseandauscultatedBP 9MonitorEtCO2(maintain35Ͳ40mmHgwithPPV) 9O2titrateto94Ͳ99% 9Perform12ͲLEAD 9Checkbloodglucose B/P<90systolic B/Pш90systolic Pulse <60BPM Pulse ш60BPM Atropine 1mgIV/IO Repeatq5minas needed Max.doseis3mg TranscutaneousPacing ifindicated (seenoteabove) B/P<90Systolic and HRч60bpm? Gotoappropriatearm ofthisalgorithm FluidChallenge 500ml Consider: Epinephrine 0.5ml(5mcg)SIVPevery3 minutes,titratetoaSBPofш90 Monitor PushDoseEpinephrineMixingInstructions: їTakeEpinephrine1mgof0.1mg/mlpreparation (CardiacEpinephrine)andwaste9mlofEpinephrine їInthatsyringe,draw9mlofnormalsalinefromthe patient’sIVbagandshakewell їMixturenowprovides10mlofEpinephrineata0.01 mg/ml(10mcg/ml)concentration Yes No Consider: Epinephrine 0.5ml(5mcg)SIVPevery3 minutes,titratetoaSBPofш90 Patient Care Policy (Adult) Modiﬁ ed On: June 10, 2013 47 ROUTINE MEDICAL CARE – ADULT ROUTINE MEDICAL CARE – ADULT 1. DEFINITIONS: Baseline vital signs: Pulse rate Blood pressure Respiratory rate Pulse Oximetry Consider temperature SAMPLE History: S = Signs & symptoms A = AllergiesM = MedicationsP = Pertinent past historyL = Last oral intakeE = Events leading to the injury/illness Adapted from Emergency Care and Transportation of the Sick and Injured, 8th Edition 2. SCENE SIZE-UP: Substance isolation Scene safety Determine mechanism of injury | nature of illness Determine number of patients Request additional assistance 3. INITIAL ASSESSMENT: Form general impression of the patient Assess mental status Assess the airway Assess breathing Assess circulation Identify priority patients 4. TRAUMA PATIENTS: Focused History and Physical Exam - Reconsider mechanism of injury Signiﬁ cant Mechanism of Injury: Rapid trauma assessment Baseline vital SAMPLE History Transport Detailed physical exam No Signiﬁ cant Mechanism of Injury: Focused assessment based on chief complaint Baseline vital signs SAMPLE History Transport Detailed physical exam 5. MEDICAL PATIENTS - Focused History and Physical Exam - Evaluate responsiveness Responsive: History of illness SAMPLE history Focused physical exam based on Chief complaint Baseline vital signs Re-evaluate transport decision Detailed physical exam Unresponsive: Rapid medical assessment Baseline vital signs SAMPLE history Re-evaluate transport decision Detailed physical exam 6. ONGOING ASSESSMENT Repeat initial vitals signs  Reassess vital signs Repeat focused assessment  Reassess interventions Patient Care Policy (Adult) Modiﬁ ed On: May 10, 2019 48 ROUTINE MEDICAL CARE – ADULT ROUTINE MEDICAL CARE – ADULT 7. TREAT AS APPROPRIATE, WITHIN SCOPE OF PRACTICE (See speciﬁ c treatment protocols) 7.1 Airway: ►Open airway – suction, as needed ►Head tilt / Chin lift or jaw thrust without head extension if C-spine injury suspected ►Oropharyngeal | Nasopharyngeal airway 7.2 Breathing: 7.2.1 Oxygen Administration: ►Administer O2 – titrate to 94-99% SpO2 appropriate to patient condition ►If there is a history of COPD, observe for respiratory depression and support respirations as needed. Do not withhold oxygen from a patient in distress because of a history of COPD ►The patient presents with signs and symptoms of pulmonary edema or severe respiratory distress, O2 should be initiated at 15L/minute by non-rebreather mask 7.2.2 Assist ventilation. 7.2.3 CPAP (see page 124) 7.2.4 ETI or SGA (see Advanced Airway Management see page 116) 7.3 Circulation: ►Initiate CPR, as needed.(see page 9) 7.4 Fluid Administration: ►Start an intravenous/intraosseous line as needed ►When IV access is needed, most of the time a saline lock is suﬃ cient. Consider an IV line with Normal Saline when the patient may need to receive volume or when frequent IV meds are being given (e.g. - cardiac arrest) ►When starting an IV/IO/saline lock, use chlorhexidine as a skin prep. Label insertion site with “PREHOSPITAL IV – DATE AND TIME" 8. PATIENT POSITION 8.1 Conscious, no trauma, good gag reﬂ ex: Position of comfort 8.2 Depressed Level of Consciousness, no trauma, decreased gag reﬂ ex: Left lateral position 8.3 Trauma: Spinal Motion Restriction (SMR), as needed. (see Spinal Motion Restriction (SMR) Procedure page 139). Make sure the patient can be rolled to the side in the event of vomiting 8.4 Pregnancy: Do not lay the patient ﬂ at if more than 20 weeks pregnant. Transport either in semi-fowlers position or left lateral decubitus position. If patient requires SMR, secure to a backboard ﬁ rst then tilt the board 20 – 30 degrees to the left 8.5 Respiratory distress: Fowler’s position or position of comfort 9. PATIENT MEDICATIONS 9.1 Field personnel must either bring all medication bottles with the patient to the hospital (preferred), or make a list of the medications, including the drug name, dose and frequency. 9.2 Field personnel may assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices Patient Care Policy (Adult) Modiﬁ ed On: May 10, 2019 49 SEIZURE SEIZURE • Routine Medical Care• Midazolam should not be given unless the patient is actively seizing - 3 or more seizures in ≤ 5 minutes or any seizure lasting > 5 minutes.• Protect the patient from further injury by padding or moving objects as necessary; do not forcibly restrain the patient 0DLQWDLQDLUZD\ DQGDGHTXDWH UHVSLUDWLRQV 2[\JHQ $FWLYHO\ VHL]LQJ" &KHFN %ORRG *OXFRVH 5HVXOW PJG/" ,ISDWLHQWFRQWLQXHV WRVHL]HFRQVLGHU $GGLWLRQDO0LGD]RODP 5HDVVHVVDV QHHGHG ,I$/2& FRQVLGHUHG *RWR SDJH <HV 1R <HV 1R 0LGD]RODP ,0PJpreferred route 25 ,1PJPJLQHDFKQDUH 25 ,9,2PJNJLQPJLQFUHPHQWV WRDPD[GRVHRIPJ *RWR$/2& SDJH Patient Care Policy (Adult) Modiﬁ ed On: August 18, 2017 50 SEPSIS SEPSIS NONO Does patient meet TWO or more of the following SIRS criteria?-Temp > 100.4 or < 96-HR > 90-RR > 20 Push Dose Epinephrine mixing instructions: »Take Epinephrine 1 mg of 0.1 mg/ml preparation (Cardiac Epinephrine) and waste 9 ml of Epinephrine »In that syringe, draw 9 ml of normal saline from the patient's IV bag and shake well »Mixture now provides 10 ml of Epinephrine at a 0.01mg/ml (10 mcg/ml) concentration Monitor EtCO2*Call a SEPSIS ALERT to the receiving hospital YESYES YES *Consider: Sepsis Alert patients present with various signs and symptoms. Additionally, patients with ≥ 2 SIRS criteria, an EtCO2 of ≤ 25 mmHg are strongly correlated with lactate levels > 4 mM/L and increased mortality If patient also has signs and symptoms of shock, administer IV/IO NS in 500-1000ml boluses. Reassess. Titrate ﬂ uid boluses to SBP > 90 or to 30 ml/kg total ﬂ uid dose If patient continues to have signs and symptoms of shock after 30ml/kg total ﬂ uid dose, consider Epinephrine diluted to 0.01mg/ml (10mcg/ml), 0.5ml (5mcg) slow IV/IO, titrate to SBP > 90 1. Risk Factors ►Age (Elderly, Newborn) ►Diabetes ►Compromised immune system including:• Cancer• Renal Disease• Alcoholism / IV Drug Abuse• Malnutrition• Hypothermia• Recent surgery or invasive procedure 2. Although sepsis patients can be any age, the Prehospital Sepsis Screening Tool triages for sepsis patients aged 15 years and older. For these patients, notify the receiving hospital of a SEPSIS ALERT as early as possible via radio or phone. Sepsis is the body's overwhelming and life-threatening response to infection. In Sepsis, when an infection occurs at any potential site in the body, the immune system's inﬂ ammatory response can be overwhelmed leading to SIRS (Systemic Inﬂ ammatory Response Syndrome) which causes tissue damage that can lead to organ dysfunction, failure and death. The symptoms of SIRS can include fever, tachypnea, tachycardia or hypotension. Does patient have suspected or documented infection? NONO Observe and monitor Initiate Fluids IV/IO Patient Care Policy (Adult) Modiﬁ ed On: May 13, 2015 51 SEVERE NAUSEA SEVERE NAUSEA • Routine Medical Care• Indications: Intractable vomiting or severe nausea• Contraindications: Hypersensitivity to 5-HT3 receptor antagonists (i.e. – dolasetron (Anzemet), granisetron (Kytril)• Relative Contraindications: Zofran administration during ﬁ rst trimester of pregnancy is not recommended• Note #1: Consider other treatable causes• Note #2: Administering Zofran rapidly can cause syncope • Note #3: If patient has s/s of anaphylaxis/allergic reaction, follow Anaphylaxis/Allergic Reaction policy O2 – titrate to 94-99% SpO2 Maintain airway IV NS Is the patient severely nauseated and/ or vomiting? Zofran (ondansetron) 4 mg IV/ IM/ PO Slowly (over 30 sec.) if given IV Reassess as needed Yes No If no improvement of symptoms May repeat x1 q 15 minutes Patient Care Policy (Adult) Modiﬁ ed On: August 18, 2017 52 SHOCK: HYPOVOLEMIC/CARDIOGENIC SHOCK: HYPOVOLEMIC/CARDIOGENIC • Routine Medical Care• Shock - 2 or more of the following: Pulse > 120/minute  Altered Mental Status BP < 90/systolic  Pale, cool and/or diaphoretic skin signs • Initiate early transport and treat en route, if appropriate.• NOTE: A ﬂ uid bolus of up to 500 ml Normal Saline may be given to an adult patient in cardiogenic shock with clear lung sounds.• If anaphylaxis suspected, see page 34 • If trauma suspected, see page 24• If sepsis suspected, see page 50 High Flow O2 - Assist respirationsas needed with Bag-Valve-mask Monitor IV/ IO NS enroute Cardiogenic Shock Ischemic chest pain with signs and symptoms of shock Hypovolemic Shock If lung sounds clear Fluid bolus 250-500 ml IV/ IO (see note) Go to appropriate dysrhythmia protocol Dysrhythmia Present? Control Bleeding Second IV NS run IV to maintain B/P > 90/systolic Consider: Tourniquet if extremity bleeding is uncontrolled page 128 Yes No Consider: 12-LeadEKG Consider: Fluid Bolus 500 ml IV/ IOEpinephrine 0.5 mL (5 mcg) IV, every 3 minutes, titrate to a SBP > 90 Push Dose Epinephrine mixing instructions: »Take Epinephrine 1 mg of 0.1 mg/ml preparation (Cardiac Epinephrine) and waste 9 ml of Epinephrine »In that syringe, draw 9 ml of normal saline from the patient's IV bag and shake well »Mixture now provides 10 ml of Epinephrine at a 0.01mg/ml (10 mcg/ml) concentration page 12 Patient Care Policy (Adult) Modiﬁ ed On: December 1, 2011 53SUBMERSION SUBMERSION • Routine Medical Care• Consider spinal precautions prior to extrication if possibility of neck trauma• Rapid extrication from water• If hypothermia suspected and the patient is in Ventricular Fibrillation, rapid transport to the closest receiving hospital is essential for rewarming. Patients who are hypothermic rarely respond to treatment. (see Hypothermia page 16) • Consider CPAP - see CPAP procedure (page 124) for indications O2 –titrate to 94-99% SpO2 Consider: Spinal Immobilization Remove wet clothing Keep warm Trauma Patient Care page 24page 24 Patient Care Policy (Adult) Modiﬁ ed On: May 27, 2021 54 SUSPECTED OPIOID WITHDRAWAL SUSPECTED OPIOID WITHDRAWAL • Routine Medical Care• Indications: Post Naloxone Administration Patient stated complaint of opioid withdrawals or seeking assistance for Opioid Use Disorder (OUD) Patient presenting with signs/symptoms consistent with any positive score on the Clinical Opiate Withdrawal Scale (COWS) • Goals Reduce patient suﬀ ering and; Patient entry into a CA Bridge Program (www.cabridge.org) for treating Opioid Use Disorder Patientmeeting indication(s)listed above? Proceedtoappropriate treatmentalgorithm Treatsign(s)/symptom(s)asappropriatetoreduce patientsuffering: ¾Dehydration–IVFluids ¾PainManagement–nonͲopioidsarepreferred ¾N/V–Ondansetron ¾PersistentItchingͲDiphenhydramine EvaluateseverityofS/Sutilizing COWSScoreonALCOEMSApp TransporttoCABridgefacilityisnotrequired, butencouragedandpreferred, regardlessofinsurancestatus CABridgefacilities: ŶHighlandŶSanLeandroŶSummit ReportfindingsincludingCOWS ScoretoReceivingFacility Documentfindingsandtreatment(s) NoYes TolocatetheCOWSScoringToolinthe ALCOEMSApp,OpentheApp>Adult> SuspectedOpioidWithdrawal>Clickthe!in upperrightͲhandcorner Patient Care Policy (Adult) Modiﬁ ed On: June 10, 2013 55 TACHYCARDIA TACHYCARDIA • Routine Medical Care• Serious Signs and Symptoms: Chest Pain  Acute MI  BP < 90/systolic  Shortness of Breath Shock  CHF  Decreased LOC  Pulmonary Congestion • Synchronized Cardioversion:• Stop if rhythm converts to Sinus Rhythm• Immediate cardioversion is seldom needed for heart rate < 150 beats/min• Precardioversion sedation in the awake patient whenever possible, however, use with caution in the hypotensive patient. See Sedation page 138 O2 – titrate to 94-99% SpO2 Monitor ** Is patient stable? 9IV/ IO NS 9Consider: precardioversion sedation with Midazolam 9Consider Pain Management titrate to effect (see page 41) 9Immediate Synchronized Cardioversion 100 J, 200 J, 300 J, 360 J monophasic energy dose (or clinically equivalent biphasic energy dose ++) If any delay in synchronized cardioversion, and the patient is critical, go to defibrillation. Look for and treat underlying cause **If patient is unstable, do not delay cardioversion to start an IV Monitor for recurrence. Treat with ^Adenosine No Regular rhythm? Base Physician consult IV/ IO NS 12-lead EKG or rhythm strip 9Vagal maneuver 9If no conversion: ^Adenosine Regular rhythm? 9Monitor 9If patient becomes unstable go to appropriate arm of this algorithm Rhythm converts?? If V-tach or uncertain: Amiodarone Drip: 150 mg in 100 ml D5W give over 10 mins. (= 100 gtts/min with 10 gtts/ml tubing) Narrow QRS Wide QRS > 0.12 sec Yes Yes No Yes No Yes No ^Adenosine dose: 96 mg rapid IV If no response in 2 minutes: 912 mg rapid IV ++Both monphasic and biphasic waveforms are acceptable Patient Care Policy (Adult) Modiﬁ ed On: July 17, 2014 56 VENTRICULAR ASSIST DEVICES -VAD VENTRICULAR ASSIST DEVICES -VAD OVERVIEW: 1. The VAD assists the native ventricle pumping action and provides the cardiac output needed to survive. 2. These devices are either pulsatile or continuous ﬂ ow (non-pulsatile/pulseless). They are further divided into: Left Ventricular Assist Devices (LVAD), The more common continuous ﬂ ow pump located in the patient’s thorax attached to the patients’ left ventricle and aorta Right Ventricular Assist Devices (RVAD), Biventricular Assist Devices (BiVAD). ASSESSMENT: 3. Assess for presence of a DNR, POLST or Advance Directive. 4. First ASSESS THE PATIENT, not the device. The reason for the call may or may not be a problem with the VAD. VAD patients can and frequently do have other medical conditions. Patients with a continuous ﬂ ow VAD may have no discernible pulse or blood pressure. ►Because there may be no palpable pulse, utilize other parameters for patient assessment (level of consciousness, skin signs, capillary reﬁ ll, etc.) ►Pulse oximetry may be unreliable. Utilize the American Heart Association’s C-A-B recommendations, with one addition: ►C = Circulation / Connections and Function (device) ►A = Airway ►B = Breathing ETCO2 will read accurately and be useful in assessment. 5. Assess the device to see if it is working. Information regarding the type of device, the implantation hospital, and/or the VAD Coordinator contact telephone number may be available by a tag on the device, on the refrigerator, or on a medical alert bracelet. If a caregiver is present, utilize his/her knowledge. The patient and their caregiver are the experts on scene for all issues related to the VAD. Listen to their directions regarding VAD device management until you are able to contact the VAD Coordinator. The VAD Coordinator can help you decide the best course of action regarding assessment of the equipment. NOTE: Only the base hospital is legally allowed to give orders regarding patient care. If the patient has a continuous ﬂ ow VAD (non-pulsatile / pulseless), auscultate the left upper quadrant of the patient’s abdomen for the “hum” of the VAD, which can help direct the appropriate actions. ►A pulsatile VAD will make an audible sound without auscultation. ►Pulsatile VADs are usually older devices which pump blood via pulsatile mechanism, generating a peripheral pulse. Determine if the device has power. ►If the device has power it does not necessarily mean that it is working, so the previous step is very important. ►If the device has power, you will see a green light on the HeartMate II, the most commonly implanted device ►On the HeartWare device, the display will clearly tell you the Liters per Minute (LPM) of blood ﬂ ow. Check the VAD for secure connections and that the batteries are charged and functional. 6. Remain patient-centric. Check the VAD device as directed, but remain aware of how your patient is doing clinically. Deliver routine medical care as required. If the pump is pumping then the problem is usually with the patient, not the device. Do ABCs in conjunction with your VAD assessment. TREATMENT/TRANSPORT: Patient Care Policy (Adult) Modiﬁ ed On: May 10, 2019 57 VENTRICULAR ASSIST DEVICES -VAD VENTRICULAR ASSIST DEVICES -VAD 7. If the patient's condition is related to their VAD, and it is safe and reasonable, it is preferred to transport the patient to their Bay Area VAD centers (Kaiser Santa Clara, Stanford, UCSF, and CPMC) unless the patient has any of the following conditions: 7.1 MINOR medical or trauma patients with adequate perfusion: Follow appropriate protocol and transport to ANY basic ED or hospital of record. 7.2 Suspected STROKE (STROKE ALERT) patient: Follow Acute Stroke policy and transport to closest Stroke Center. 7.3 Suspected STEMI (STEMI ALERT) patient: Follow CP Suspect Cardiac/STEMI policy and transport to closest STEMI Center. 7.4 Trauma patient (activation): Follow Trauma Care Policy and transport to closest Adult Trauma Center. 7.5 Cardiac Arrest or critical / unstable patients (poor perfusion): Follow Shock or appropriate resuscitation policy and transport to closest STEMI / Cardiac Arrest Center. 7.6 “Ring down” the receiving hospital early to help the facility prepare for this highly specialized patient. VAD CENTER 24-HOUR HOTLINE Stanford Hospital and Clinics Lucille Packard Children’s Hospital at Stanford* 650-723-6661 (ask operator to page the VAD Coordinator- pager code #12502) California Paciﬁ c Medical Center 415-600-1051 UC San Francisco 415-443-5823 (pager number) Kaiser Santa Clara 408-851-3750 *Stanford Hospital and Clinics & Lucille Packard Children’s Hospital at Stanford share the same VAD Coordinators Patient Care Policy (Adult) Modiﬁ ed On: July 24, 2018 58 VENTRICULAR FIBRILLATION | VENTRICULAR TACHYCARDIA: PULSELESS VENTRICULAR FIBRILLATION | VENTRICULAR TACHYCARDIA: PULSELESS • Routine Medical Care• Note: Use of a mechanical CPR device is required whenever available and appropriate Witnessed/Unwitnessed Arrest CPR until defibrillator available/charged 9 **Defibrillate (see note) 9 Resume CPR 9 Consider advanced airway 9 IV/IO NS Shockable rhythm? 9 CPR while defibrillator charging 9 **Defibrillate (see note) 9 Resume CPR 9 Epinephrine 0.1mg/mL 1 mg IV/ IO Q 10 minutes, up to 3 doses Shockable Rhythm? 9 CPR while defibrillator charging 9 **Defibrillate (see note) 9 Resume CPR 9 +Amiodarone 300 mg IV/ IO 9 Repeat Epinephrine 0.1mg/mL 1 mg IV/ IO Q 10 minutes, up to 3 doses 9 +Amiodarone 150 mg IV/ IO 3-5 minutes after 1st dose Go to Policy: 9 Asystole/PEA page 35 9 Return of Spontaneous Circulation page 46 Yes No No Yes +Amiodarone: may only be given twice. Flush tubing with 20 ml NS 2 minutes or 5 cycles of CPR Check Rhythm 2 minutes or 5 cycles of CPR Check Rhythm Do not interrupt CPR to administer medications O2 - High Flow ITD Monitor ETCO2 Shockable rhythm?Yes No **Note -Defibrillation: Refer to manufacturer’s documentation for energy dose recommendations Refractory VF/VT patients should be transported to the closest, most appropriate STEMI Center p n page 46 A page 35 Patient Care Policy (Pediatric) Modiﬁ ed On: December 1, 2011 59 PEDIATRIC POLICIES TOC PEDIATRIC POLICIES TOC PEDIATRIC POLICIES TOC .......................................................................................59 AIRWAY OBSTRUCTION ...........................................................................................60 ANAPHYLAXIS / ALLERGIC REACTION ..................................................................61 ALTERED LEVEL OF CONSCIOUSNESS .................................................................62 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE ................................................63 BRADYCARDIA ..........................................................................................................64 NEONATAL RESUSCITATION ...................................................................................65 PAIN MANAGEMENT .................................................................................................66 PEDIATRIC DRUG CHART - (DRUGS NOT ON THE LBRT) ....................................68 POISONING | INGESTION | OVERDOSE .................................................................69 PULSELESS ARREST: ASYSTOLE, PEA ..................................................................70 PULSELESS ARREST: VF/ VT ...................................................................................71 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) ...........72 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY .....................................73 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY .................................74 ROUTINE MEDICAL CARE - PEDIATRIC .................................................................75 SEIZURE .....................................................................................................................76 SEIZURE - MIDAZOLAM DRUG CHART ...................................................................77 SEVERE NAUSEA ......................................................................................................78 SHOCK AND HYPOTENSION ....................................................................................79 SUBMERSION ............................................................................................................80 TACHYCARDIA ...........................................................................................................81 Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 60 AIRWAY OBSTRUCTION AIRWAY OBSTRUCTION • Pediatric Routine Medical Care• If airway obstruction is caused by laryngeal trauma, see page 24 "Trauma Patient Care"• Do not use a tongue/jaw lift or perform blind ﬁ nger sweeps• Obstruction due to suspected epiglottitis: Do not attempt to visualize the throat or insert anything into the mouth Minimize outside stimulation. Keep the patient calm. Position of comfort. • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 116) if BVM ventilation is not adequate. • Rapid Transport 6HYHUHVLJQV RIREVWUXFWLRQ" $EOH WRYHQWLODWH DGHTXDWHO\" 0DLQWDLQ DLUZD\ DQG2[\JHQ 7UDQVSRUWWR WKHFORVHVW (' 6LJQVRIVHYHUHREVWUXFWLRQ 93RRUDLUH[FKDQJH 9,QFUHDVHGEUHDWKLQJGLIILFXOW\ 96LOHQWFRXJK 9&\DQRVLV 9,QDELOLW\WRVSHDNRUEUHDWKH 9$VNWKHSDWLHQW³$UH\RXFKRNLQJ´" ,ISDWLHQWQRGV\HVDFW 2EVHUYH $VVLVW9HQWLODWLRQ ZLWK%DJ9DOYH0DVN VHHQRWH ,IWKHSDWLHQWEHFRPHV XQUHVSRQVLYH %HJLQ&35 &KHFNIRU)% 2QO\UHPRYHLIVHHQLQWKH SKDU\Q[ 9,IWKHSDWLHQWLV\HDUROG 'HOLYHUEDFNEORZV IROORZHGE\FKHVW WKUXVWV 9,IWKHSDWLHQWLV!\HDUROG $SSO\DEGRPLQDOWKUXVWV LQUDSLGVHTXHQFH ,ILQHIIHFWLYHFRQVLGHU FKHVWWKUXVWV 1R<HV <HV 1R Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 ANAPHYLAXIS / ALLERGIC REACTION 61ANAPHYLAXIS / ALLERGIC REACTION • Epinephrine IM is the cornerstone of treatment of anaphylaxis and should be given as early as possible. It is best absorbed from an injection in the lateral thigh• If the patient is in severe distress, administer Epinephrine IM and consider immediate transport• SIGNS OF ANAPHYLAXIS (Systemic Reaction) – wheezing, repetitive cough, tightness in chest, stridor, diﬃ culty swallowing or tightness in throat, change in voice, dizziness or feeling faint, abdominal complaints (pain, repeated vomiting, diarrhea or incontinence), anxiety, lethargy• SIGNS OF ANAPHYLACTIC SHOCK – pallor, hypotension, cool, clammy mottled skin, altered sensorium• FACIAL/ORAL SWELLING (Angioedema) can accompany anaphylaxis, but is not always present• Use a length-based resuscitation tape (LBRT) to determine pediatric drug doses and ﬂ uid bolus ANAPHYLAXIS (Systemic Reaction) For persistent wheezing or respiratory distress ALBUTEROL 5 mg in 6 ml NS via hand-held nebulizer, mask, or BVM Consider for Urticaria (Hives/Itching) DIPHENHYDRAMINE 1 mg/kg IV/IO/IM up to 50mg Reassess 5-10 mins. after IM epi. If VS not improved with ﬂ uid bolus: EPINEPHRINE 0.1mg/mL 0.01 mg/kg IV/IO slowly*** • Max single dose 0.1 mg• May repeat q 10 minutes IV/IO NSFLUID BOLUS NS 10-20 ml/kg Assist ventilations with BVM as required OXYGEN If Any Distress *ALLERGIC REACTION (Skin or mucous membrane symptoms only without signs of anaphylaxis or airway obstruction) Consider for Urticaria (Hives/Itching) DIPHENHYDRAMINE 1 mg/kg IV/IM up to 50mg YESYES NO** SIGNS OF SHOCK? If no responseBase Physician consult NOTES * If patient develops signs of ana- phylaxis, go to other arm of this al- gorithm **Shock in children may be subtle and hard to recognize. BP readings may be diﬃ cult to determine or in- accurate and may be a late sign of shock. ***IV/IO epinephrine should only be used if symptoms are unresponsive to IM epinephrine and patient has signs of profound shock § Diphenhydramine may lessen dis- comfort from rash/itching but is not an essential treatment of anaphy- laxis. Consider reduced dosage if patient has taken diphenhydramine in the past 1-2 hrs. EPINEPHRINE 1mg/ml BLS Providers: 0.15mg IM ALS Providers: 0.01 mg/kg IM Minimum single dose 0.1 mg Maximum single dose 0.5 mg May Repeat x 1 in 15 min. Patient Care Policy (Pediatric) Modiﬁ ed On: July 1, 2014 62 ALTERED LEVEL OF CONSCIOUSNESS ALTERED LEVEL OF CONSCIOUSNESS • Pediatric Routine Medical Care• Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 12 breaths per minute) (see page 72)• Note: Oral Glucose may be administered if the patient: 1) is able to hold head upright; 2) has a gag reﬂ ex; and, 3) can self-administer the medication• Consult with the Base Physician if the Blood Glucose reading is ≥ 60 mg% but hypoglycemia is suspected• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) Check Blood Glucose Results < 60 mg mg/dL? (<40 mg/dL for newly born) Adequate response? Reassess As needed Yes No NoYes Oral Glucose 15 - 30 gms po (see note above) Or Glucagon 0.1 mg/kg IM maximum dose 1 mg IV/ IO Access?Yes No Consider AEIOU – TIPS Maintain airway and adequate respirations. O2 – titrate to 94-99% SpO2IV/ IO NS Newly Born (< 30 mins. of life) Dextrose 10% 0.2 g/kg = 2 ml/kg IV/ IO > 30 minutes and 14 y.o. Dextrose 10% 0.5 g/kg = 5 ml/kg IV/ IO maximum initial dose 10g (100 ml) Give additional DEXTROSE 10% 5g (50 ml) increments to total 15g (150 ml) if Glucose remains 60 or less Patient Care Policy (Pediatric) Modiﬁ ed On: September 5, 2017 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE 63BRIEF RESOLVED UNEXPLAINED EVENT - BRUE 1. DEFINITION: 1.1 An Brief Resolved Unexplained Event (BRUE) was formally known as a Apparent Life Threatening Event- ALTE 1.2 A BRUE is an episode that is frightening to the observer (may think the infant has died) and involves some combination of: ►Apnea (central or obstructive) ►Color change (cyanosis, pallor, erythema, plethora) ►Marked change in muscle tone (limpness) ►Choking or gagging 1.3 Usually occurs in infants < 12 months old, however, any child less than 2 years old who exhibits the symptoms in 1.2 may be considered a BRUE 1.4 Most have a normal physical exam when assessed by responding ﬁ eld personnel 1.5 50–60% have no known etiology 1.6 40–50% have an identiﬁ able etiology (e.g. Child abuse, SIDS, swallowing dysfunction, infection, bronchiolitis, seizures, CNS anoma- lies, tumors, cardiac disease, chronic respiratory disease, upper airway obstruction, metabolic disorders, or anemia) 2. MANAGEMENT 2.1 Assume the history given is accurate 2.2 Determine the severity, nature and duration of the episode ►was the patient awake or asleep at the time of the episode ►details of the resuscitation required 2.3 Obtain a medical history ►known chronic diseases ►evidence of seizure activity ►current or recent infections ►gastroesophageal reﬂ ux ►inappropriate mixture of formula ►recent trauma ►medication history (current and recent) 2.4 Do a comprehensive physical exam that includes the general appearance of the child, skin color, extent of interaction with environment, and evidence of trauma 2.5 Perform glucose analysis if hypoglycemia suspected (see ALOC page 62 if B.S. < 60mg/ dL) 2.6 Treat any identiﬁ able causes 2.7 Transport 2.8 Note: Contact the Base Physician for consultation if the parent/guardian is refusing medical care and/or transport, prior to completing a Refusal of Care form • Pediatric Routine Medical Care Patient Care Policy (Pediatric) Modiﬁ ed On: May 26, 2016 64 BRADYCARDIA BRADYCARDIA • Pediatric Routine Medical Care• Consider and treat other possible causes: Hypoxemia Hypothermia Head Injury Heart Block Toxins/ drugs Beta Blockers or calcium channel blockers • Note: TCP reserved for children with profound symptomatic bradycardia refractory to BLS and ALS. Use pediatric electrodes if child weighs < 15 kg• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) 9Support ABCs - if needed 9O2 – titrate to 94-99% SpO2 9Attach monitor Persistent symptomatic bradycardia? 9Begin CPR 9NS IV/ IO Epinephrine 0.1mg/mL IV/IO: 0.01 mg/kg (0.1 ml/kg) Repeat q 3-5 min If increased vagal tone or primary AV block: Atropine 9First dose: 0.02 mg/kg 9May repeat q 3-5 minutes: minimum dose 0.1 mg. maximum total dose 1 mg. If asystole develops, go to: Pulseless Arrest - Asystole page 71 Yes Base Physician Consult Persistent symptomatic bradycardia? Observe Transport No 9Consider TCP – see page 145 (see note above) 9Consider sedation with: Midazolam - see page 138 NoYes page145 w : 138 s Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 NEONATAL RESUSCITATION 65NEONATAL RESUSCITATION • Pediatric Routine Medical Care• Resuscitation should be initiated on all premature infants who meet the following criteria:Weight: > 500 gms or 1 pound and Gestational Age: ≥ 20-24 weeks • If naloxone considered for persistent respiratory depression, HR and color must ﬁ rst be restored• Avoid naloxone for neonates whose mothers are suspected of long-term exposure to opiods• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 116) if BVM ventilation is not adequate.• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) 7HUP*HVWDWLRQ" $PQLRWLFIOXLGFOHDU" %UHDWKLQJRUFU\LQJ" *RRGPXVFOHWRQH" 93URYLGHZDUPWK 9&OHDUDLUZD\LIQHHGHG 9'U\RII 9$VVHVVFRORU 93URYLGHZDUPWK 93RVLWLRQ&OHDUDLUZD\LI QHHGHG 9'U\VWLPXODWHUHSRVLWLRQ %UHDWKLQJ +5!" 0RQLWRUPink? 6XSSOHPHQWDO2Cyanotic? Pink? 3RVLWLYHSUHVVXUHYHQWLODWLRQ EUHDWKVPLQXWH <HV Persistent Cyanosis? 1R Apneic or HR < 100 +5 " 9&RQWLQXHYHQWLODWLRQ 9$GPLQLVWHUFKHVWFRPSUHVVLRQV FRPSUHVVLRQYHQWLODWLRQUDWLR IRUDWRWDORI FRPELQHGHYHQWVPLQXWH 1R 9(SLQHSKULQHPJP/ PJNJ,9,2PONJ 9)OXLGEROXVPONJ±PD\ QHHGWRUHSHDW <HV 1R <HV 3RVW 5HVXVFLWDWLRQ FDUH <HV +5 " 1R Effective ventilation, HR > 100 & color pink NOTE: Routine suctioning of vigorous, full term newborns at birth is not indicated. Wiping the face, nose, mouth is preferred Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 66 PAIN MANAGEMENT PAIN MANAGEMENT ASSESSMENT: Document level of pain (as a fraction - e.g.: 2/10 or 6/10) prior to and after any interventions are performed:►< 3 years old – Behavioral tool or FACES Scale:►3–7 years old – FACES scale or visual analog scale ►8–14 years old – visual analog scale Face 0 No particular expression or smile 1 Occasional grimace or Frown, withdrawn, disinterested 2 Frequent to constant frown Clenched jaw, quivering chin Legs 0 Normal or relaxed position 1 Uneasy, restless, tense 2 Kicking, or legs drawn up Activity 0 Lying quietly, normal position, moves easily 1 Squirming, tense, shifting Back and forth 2 Arched, rigid or jerking Cry 0 No cry (awake or asleep) 1 Moans or whimpers; occasional complaint 2 Cries steadily, screams, sobs, frequent complaints Consolability 0 Content, relaxed 1 Reassured by “talking to, hugging; distractible 2 Diﬃ cult to console or comfort From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pe- diatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission. Instructions: Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Ask the person to choose the face that best describes how he/she is feeling Face 0 is very happy because he doesn't hurt at all Face 2 hurts just a little bit Face 4 hurts a little more Face 6 hurts even more Face 8 hurts a whole lot Face 10 hurts as much as you can imagine, although you don't have to be crying to feel this bad • Pediatric Routine Medical Care. If oxygen is adminstered, titrate to 94-99% SpO2• Pain management should be initiated as early as possible and before transport in the stable patient. Consider pain management prior to the manipulation of suspected fractures• The preferred route of administration is intranasal (IN) VISUAL ANALOG SCALE 0 1 2 3 4 5 6 7 8 9 10 No Pain Worst Pain Ever Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 PAIN MANAGEMENT 67PAIN MANAGEMENT Pediatric Fentanyl Dose Chart (2 mcg/kg) 50 mcg/mL WEIGHT DOSE VOLUME 5 kg 10 mcg 0.2 mL 10 kg 20 mcg 0.4 mL 20 kg 40 mcg 0.8 mL 30 kg 60 mcg 1.2 mL 40 kg 80 mcg 1.6 mL > 50 kg 100 mcg 2 mL • Pediatric Routine Medical Care. If oxygen is adminstered, titrate to 94-99% SpO2• Pain management should be initiated as early as possible and before transport in the stable patient. Consider pain management prior to the manipulation of suspected fractures• The preferred route of administration is intranasal (IN) %/6,QWHUYHQWLRQV 3RVLWLRQLQJ &ROG3DFNV 6SOLQWLQJ &RDFKLQJ $/6,QWHUYHQWLRQ )HQWDQ\O ,1,0PFJNJPD[VLQJOHGRVHPFJ 5HSHDWTPLQPD[WRWDOGRVHPFJ ,9,2PFJNJPD[VLQJOHGRVHPFJ6ORZSXVK 5HSHDWTPLQPD[WRWDOGRVHPFJ %DVH3K\VLFLDQFRQVXOW LISDWLHQWUHTXLUHV!PFJ RULIFRQWUDLQGLFDWLRQVDUH SUHVHQW Fentanyl Considerations: &RQWUDLQGLFDWLRQV x$JHDGMXVWHG K\SRWHQVLRQ x'HFUHDVHGUHVSLUDWRU\ UDWH x$OWHUHGPHQWDOVWDWXV x6XVSHFWHG7UDXPDWLF %UDLQ,QMXU\ 1RWHV x&DSQRJUDSK\PRQLWRULQJ LVUHFRPPHQGHG x%XUQSDWLHQWVPD\ UHTXLUHKLJKHUGRVHV x+DYH1DOR[RQHUHDGLO\ DYDLODEOH 0RQLWRU5HDVVHVV Patient Care Policy (Pediatric) Modiﬁ ed On: May 26, 2016 68 PEDIATRIC DRUG CHART - (DRUGS NOT ON THE LBRT) PEDIATRIC DRUG CHART - (DRUGS NOT ON THE LBRT) Gr e e n 30 – 3 6 66 – 7 9 . 2 5 m g i n 6 m l N S 15 0 - 1 8 0 m g Re f e r t o P e d i a t r i c A L O C P o l i c y o n pa g e 6 2 30 - 3 6 m g 30 - 3 6 m g 0. 3 m g ^ 0. 1 m g + 60 - 7 2 m c g 15 – 3 0 g m s 50 0 m c g ( 2 . 5 m l ) 0. 5 m g / k g ( m a x d o s e 2 0 m g ) s l o w l y ( 1 m l o v e r 3 0 s e c o n d s ) Fo r s p e c i ﬁ c d o s i n g , p l e a s e r e f e r t o p e d i a t r i c s e i z u r e o n pa g e 7 6 1. 5 - 1 . 8 m g 3- 3 . 6 m g 1. 5 - 1 . 8 m g 3- 3 . 6 m g 60 0 - 7 2 0 m g 10 0 0 m g 12 – 1 2 . 5 g m Or a n g e 24 – 2 8 52 . 8 – 6 1 . 6 12 0 - 1 4 0 m g 24 - 2 8 m g 24 - 2 8 m g 0. 2 4 - 0 . 2 8 m g 0. 1 m g + 48 - 5 6 m c g 1. 2 - 1 . 4 m g 2. 4 - 2 . 8 m g 1. 2 - 1 . 4 m g 2. 4 - 2 . 8 m g 48 0 - 5 6 0 m g 96 0 - 10 0 0 m g 9. 6 - 1 1 . 2 g m Bl u e 19 – 2 2 41 . 8 – 4 8 . 4 95 - 1 1 0 m g 19 - 2 2 m g 19 - 2 2 m g 0. 1 9 - 0 . 2 2 m g 0. 1 m g + 38 - 4 4 m c g 0. 9 5 - 1 . 1 m g 1. 9 - 2 . 2 m g 0. 9 5 - 1 . 1 m g 1. 9 - 2 . 2 m g 38 0 - 4 4 0 m g 76 0 - 8 8 0 m g 7. 6 – 8 . 8 g m Wh i t e 15 – 1 8 33 – 3 9 . 6 75 - 9 0 m g 15 - 1 8 m g 15 - 1 8 m g 0. 1 5 - 0 . 1 8 m g 0. 1 m g + 30 - 3 6 m c g 0. 7 5 - 0 . 9 m g 1. 5 - 1 . 8 m g 0. 7 5 - 0 . 9 m g 1. 5 - 1 . 8 m g 30 0 - 3 6 0 m g 60 0 - 7 2 0 m g 6 – 7 . 2 g m Ye l l o w 12 – 1 4 26 . 4 – 3 0 . 8 60 - 7 0 m g 12 - 1 4 m g 12 - 1 4 m g 0. 1 2 - 0 . 1 4 m g 0. 1 m g + 24 - 2 8 m c g 0. 6 - 0 . 7 m g 1. 2 - 1 . 4 m g 0. 6 - 0 . 7 m g 1. 2 - 1 . 4 m g 24 0 - 2 8 0 m g 48 0 - 5 2 0 m g 4. 8 – 5 . 6 g m Pu r p l e 10 – 1 1 22 – 2 4 . 2 50 - 5 5 m g 10 - 1 1 m g 10 - 1 1 m g 0. 1 - 0 . 1 1 m g 0. 1 m g + 20 - 2 2 m c g 0. 5 - 0 . 5 5 m g 1- 1 . 1 m g 0. 5 - 0 . 5 5 m g 1- 1 . 1 m g 20 0 - 2 2 0 m g 40 0 - 4 4 0 m g 4 – 4 . 4 g m Re d 8 – 9 17 . 6 – 1 9 . 8 40 - 4 5 m g 8 - 9 m g 8 - 9 m g 0. 1 m g # 0. 0 8 - 0 . 0 9 m g 16 - 1 8 m c g 0. 4 - 0 . 4 5 m g 0. 8 - 0 . 9 m g 0. 4 - 0 . 4 5 m g 0. 8 - 0 . 9 m g 16 0 - 1 8 0 m g 32 0 - 3 6 0 m g 3. 2 – 3 . 6 g m Pi n k 6 – 7 13 . 2 – 1 5 . 4 30 - 3 5 m g 6 - 7 m g 6 - 7 m g 0. 1 m g # 0. 0 6 - 0 . 0 7 m g 12 - 1 4 m c g 0. 3 - 0 . 3 5 m g 0. 6 - 0 . 7 m g 0. 3 - 0 . 3 5 m g 0. 6 - 0 . 7 m g 12 0 - 1 4 0 m g 24 0 - 2 8 0 m g 2. 4 – 2 . 8 g m Gr e y 3 – 5 6 - 1 1 15 - 2 5 m g 3 - 5 m g 3 - 5 m g 0. 1 m g # 0. 0 3 - 0 . 0 5 m g 6- 1 0 m c g 0. 1 5 - 0 . 2 5 m g 0. 3 - 0 . 5 m g 0. 1 5 - 0 . 2 5 m g 0. 3 - 0 . 5 m g 60 - 1 0 0 m g 12 0 - 2 0 0 m g 1. 2 – 2 g m We i g h t k g l b s AL B U T E R O L AM I O D A R O N E D R I P 5 m g / k g Mi x i n 1 0 0 m L D 5 W G i v e o v e r 2 0 - 6 0 m i n . (5 0 t o 1 7 g t t s / m i n . ) 1 0 g t t s / m l t u b i n g DE X T R O S E 1 0 % DI P H E N H Y D R A M I N E ( B e n a d r y l ) 1 m g / k g I M Al l e r g i c R e a c t i o n : 1 m g / k g I M EP I N E P H R I N E – No t c a r d i a c a r r e s t 1m g / m L - 0 . 0 1 m g / k g I M mi n . d o s e : 0 . 1 m g # / m a x . d o s e : 0 . 3 m g ^ 0. 1 m g / m L - 0 . 0 1 m g / k g I V / I O ma x . d o s e : 0 . 1 m g + FE N T A N Y L 2m c g / k g I V / I O / I M / I N OR A L G L U C O S E IP R A T R O P I U M ( A t r o v e n t ) Li d o c a i n e 2 % MI D A Z O L A M ( V e r s e d ) Se i z u r e s : 0 . 2 m g / k g I N / I M Se d a t i o n : 0 . 0 5 m g / k g I V / I N 0. 1 m g / k g I M MO R P H I N E S U L F A T E 0. 0 5 m g / k g I V 0. 1 m g / k g I M PR A L I D O X I M E C H L O R I D E ( 2 - P A M ) Ho t z o n e : 2 0 m g / k g I M Wa r m Z o n e : 2 0 - 4 0 m g / k g I V / I M SO D I U M T H I O S U L F A T E 0 . 4 g m / k g I V s l o w l y o v e r 1 0 m i n s . Ma x d o s e : 1 2 . 5 g m Re q u i r e s B a s e P h y s i c i a n C o n s u l t F o r u s e o n l y b y p a r a m e d i c s a s m e m b e r s o f m e d i c a l h a z / m a t t e a m s Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 POISONING | INGESTION | OVERDOSE 69POISONING | INGESTION | OVERDOSE • Pediatric Routine Medical Care• Protect Yourself! - See page 157 "Hazardous Materials Incidents - EMS Response"• Identify substance – contact the Base Physician regarding other treatment options. Bring any containers, labels or a sample (if safe) into the hospital with the patient• Determine type, amount, and time of the exposure• Base Physician consult for treatment options if suspecting: organophosphate poisoning, or calcium channel or beta blocker OD. Consider contacting Poison Control for other substances 800-222-1222• Remove contaminated clothing. Brush powders oﬀ , wash oﬀ liquids with large amount of water• Withhold charcoal if rapidly decreasing level of consciousness a possibility (e.g., tricyclic OD)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 116) if BVM ventilation is not adequate.• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) 9HQWLODWLQJ DGHTXDWHO\DOHUW ZLWKDJRRGJDJ UHIOH[" ,IQRQDFLGQRQFDXVWLF QRQSHWUROHXPFRQVLGHU &KDUFRDOJPNJSR ,IZLWKLQRQHKRXURILQJHVWLRQ 0D[GRVHRIJUDPV ,IWULF\FOLFDQWLGHSUHVVDQW VXVSHFWHG %LFDUEP(TNJ,9 5HDVVHVVDV QHHGHG $VVLVWUHVSLUDWLRQ ZLWK%90 VHHQRWHDERYH )RUSDWLHQWVZLWK VXVSHFWHGQDUFRWLF2' JRWR5HVSLUDWRU\ 'HSUHVVLRQSDJH $GHTXDWH UHVSRQVH" )RUPRUHWKDQ RQHGRVHRI 1DOR[RQH 1R<HV <HV 1R %DVH 3K\VLFLDQ RUGHU )RUODWHVWDJHVHL]XUH JRWR 6HL]XUHSDJH ` Patient Care Policy (Pediatric) Modiﬁ ed On: May 27, 2021 70 PULSELESS ARREST: ASYSTOLE, PEA PULSELESS ARREST: ASYSTOLE, PEA • Pediatric Routine Medical Care• In PEA, identify other causes and treat (See CPR page 9)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 116) if BVM ventilation is not adequate.• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) CPR O2 – High Flow Monitor ETCO2 Resume CPR IV/ IO NS Epinephrine 0.1mg/mL 0.01 mg/kg IV/IO (0.1 ml/kg) (1st dose ASAP – preferably within 5 min from start of CPR) Q 10 minutes, up to 3 doses Non-shockable rhythm continues?No 9Continue CPR and drug administration 9Transport Shockable rhythm?No Go to: Pulseless Arrest – V-fib/V-tach Yes Shockable rhythm? 2 minutes CPR 30:2 5 cycles 1 rescuer 15:2 10 cycles 2 rescuers Check rhythm Yes No Do not interrupt CPR to administer medications ^Discontinuation of CPR Go to appropriate dysrhythmia protocol Yes If pulse present - post resuscitation care Base Physician Consult^Discontinuation of CPR: If non-shockable rhythm persists, despite appropriate, aggressive ALS interventions for 30 minutes (OR if ETCO2 is <10mmHg after 20 minutes in a patient with an advanced airway), consider discontinuation of CPR REVERSIBLE CAUSES • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypoglycemia • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • Thrombosis, coronary Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 PULSELESS ARREST: VF/ VT 71PULSELESS ARREST: VF/ VT • Pediatric Routine Medical Care• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 116) if BVM ventilation is not adequate• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) 9 Defibrillate 2 J/kg 9 Resume CPR 9 IV/ IO NS 9 CPR while defibrillator charging 9 Defibrillate 4 J/kg 9 Resume CPR 9 Epinephrine 0.1mg/mL IO/IV: 9 CPR while defibrillator charging 9 Defibrillate 4 J/kg 9 Resume CPR 9 +Amiodarone 5 mg/kg bolus IV/IO x Pulseless Arrest – Asystole/PEA x If pulse present - post resuscitation care +Flush tubing with 20ml NS 2 minutes CPR 30:2 5 cycles 1 rescuer 15:2 10 cycles 2 recuers Check rhythm Do not interrupt CPR to administer medications O2 –High Flow Monitor ETCO2 Witnessed/Unwitnessed Arrest CPR until defibrillator available/charged o t : x P l l Arr – As stol PEA x I pulse present ost it ti n r Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 72 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) • Routine Medical Care• Naloxone can cause acute withdrawal symptoms (agitation,vomiting, etc.) in patients who are chronic utilizers of narcotics• Naloxone can cause cardiovascular side eﬀ ects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%)• Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management Respiratory rate 12 Monitor/Reassess Monitor/Reassess NoYes Naloxone: IN/IM/IV- Initial dose: 0.1 mg/kg up to 2 mg Titrated to maintain respiratory rate 12 Repeat as needed to maintain respiratory rate 12 (no max. dose) BLS Providers may only utilize the IN administration route If BVM ventilation and Naloxone are ineffective, consider Advanced Airway placement (see page 116) Maintain airway patency and adequate respirations with BLS airway adjuncts and BVM as needed Oxygen- titrate to SpO2 of 94-99% Consider vascular access If patient is a known/ suspected chronic utilizer of narcotics, consider 1:10 dilution of Naloxone:Normal Saline Administer in 0.1 mg (1 ml) increments to maintain respiratory rate 12 Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY 73RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY • Pediatric Routine Medical Care• CROUP/EPIGLOTTITIS: If the patient deteriorates, or becomes completely obstructed, positive pressure ventilation via bag-valve-mask should be attempted Do not attempt to visualize the throat or insert anything into the mouth if epiglottitis suspected Allow a parent to hold the child or the O2 mask if the presence of the parent calms the child Minimize outside stimulation. Keep the patient calm Position of comfort• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 116) if BVM ventilation is not adequate• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) 6XVSHFW IRUHLJQ ERG\" *RWR$LUZD\ 2EVWUXFWLRQ SDJH 6XVSHFW DOOHUJLF UHDFWLRQ" *RWR$OOHUJLF 5HDFWLRQ SDJH 6XVSHFW HSLJORWWLWLV" 0DLQWDLQDLUZD\ DQG2[\JHQ ,IDSQHLFRUQHDU DSQHLF&RQVLGHU %909HQWLODWLRQ VHHQRWH 2±WLWUDWHWR6S2 YLDEORZE\RU 1RQUHEUHDWKHU0DVN 0DLQWDLQDLUZD\DQGR[\JHQ ,IGHFUHDVHG/2&RUDSQHD &RQVLGHU %909HQWLODWLRQ VHHQRWH <HV 1R <HV 1R <HV 1RSDJH SDJH Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 74 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY • Pediatric Routine Medical Care• Position of comfort• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 116) if BVM ventilation is not adequate• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) O2 –titrate to 94-99% SpO2via blowby or non-rebreather mask Moderate to Severe Distress Any of the following: Cyanosis Accessory muscle use Inability to speak > 2 syllables Severe wheezing/SOB Mild Respiratory Distress Mild wheezing/SOB Cough Assist respirations (see note) Albuterol 5 mg in 6 ml NS and Ipratropium 500 mcg (2.5 ml) by nebulizer or via BVM Epinephrine 1mg/mL 0.01 mg/kg IM Maximum single dose: 0.3 mg May repeat x1 in 20 mins. Albuterol (only) 5 mg in 6 ml NS by nebulizer or via BVM May repeat x1 if respiratory distress continues Maintain airway and oxygen If decreased LOC or apnea Consider: BVM Ventilation (see note) Albuterol 5 mg in 6 ml NS via hand-held nebulizer, mask or BVM May repeat x1 Patient Care Policy (Pediatric) Modiﬁ ed On: May 27, 2021 ROUTINE MEDICAL CARE - PEDIATRIC 75ROUTINE MEDICAL CARE - PEDIATRIC The deﬁ ned age of a pediatric patient is 14 years old or less, and unless speciﬁ ed otherwise, pediatric protocols should be used to treat these patients. Note: An infant is considered to be < 1 year old. A child is considered to be ≥ 1 year old. Speciﬁ ed ages for transport or treatment other than 14 years old include: TRANSPORT5150 Psych Evaluation (page 134): Children ( ≤ 11 y.o.) – Children’s Hospital Adolescents ( ≥ 12 y.o. & ≤ 17 y.o.) – Willow RockTrauma Destination (page 26): ≤ 14 y.o. – Children’s Hospital ≥ 15 y.o. – Closest Adult Trauma CenterSexual Assault (page 3): Children ( ≤ 13 y.o.) – Children’s Hospital All Others ( ≥ 15 y.o.) – Highland or Washington TREATMENTAdvanced Airway Management (page 116): <40kg- authorized airway is OPA/NPA, BVM, or SGA CPAP (page 122): < 8 y.o. – Absolute Contraindication IO Access (page 132): Refusal of Care (page 119): ≤ 17 y.o. may not refuse transport or treatment unless legally emancipated A pediatric LBRT will be used to determine drug doses, ﬂ uid volumes, deﬁ brillation settings and equipment sizes. The tape is designed to estimate a child’s weight based on length (head to heel). PRIMARY SURVEY SPECIAL CONSIDERATIONS Establish level of responsiveness ►AVPU: Alert, Verbal, Painful, Unresponsive Evaluate airway and protective airway reﬂ exes ►Identify signs of airway obstruction and respiratory distress, including: cyanosis  intercostal retractions  choking stridor  absent breath sounds  grunting drooling  apnea or bradypnea  nasal ﬂ aring tachypnea Secure airway ►Open airway using jaw-thrust and chin-lift (and/or head tilt if no suspected spinal trauma). Suction as needed. Consider placement of an oral or nasal airway adjunct if the child is unconscious ►If cervical spine trauma is suspected, see page 140Consider Spinal Motion Restriction (SMR) ►Use chest rise as an indicator of ventilation ►Use pulse oximetry Assess need for ventilatory assistance ►CPR as needed (see CPR page 9) ►Assess perfusion using the following indicators: heart rate  mental status  skin signs quality of pulse  capillary reﬁ ll  blood pressure Evaluate and support circulation. Stop Hemorrhage ►Perform a head-to-toe assessment, including temperature ►Obtain a patient history ►Do environmental assessment, consider possibility of intentional injury Continue with secondary survey ►Perform a head-to-toe assessment, including temperature ►Obtain a patient history ►Do environmental assessment, consider possibility of intentional injury Determine appropriate treatment protocols ►Provide family psychosocial support ►For drugs not on the LBRT see page 68 “Pediatric Drug Chart” ►When starting an IV/IO/saline lock, use chlorhexidine as a skin prep ►Label insertion site with “PREHOSPITAL IV – DATE and TIME” ►Pediatric patients are subject to rapid changes in body temperature. Steps should be taken to prevent loss of or increase in body temperature ►Compared to the adult patient, a small amount of ﬂ uid, lost from or administered to, a pediatric patient can result in shock or pulmonary edema ►Scene time for treatment of pediatric patients should be kept at a minimum. Most treatment should be done en route Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 76 SEIZURE SEIZURE • Pediatric Routine Medical Care• Midazolam should not be given unless the patient is actively seizing - 3 or more seizures in ≤ 5 minutes or any seizure lasting > 5 minutes• Cooling Measures: Loosen clothing and/or remove outer clothing/blankets• Use the ALCO EMS mobile app, the chart on the following page, or an LBRT to determine pediatric drug dosages. $FWLYHO\ VHL]LQJ" 0LGD]RODP ,1PJNJpreferred route KDOIRIGRVHLQHDFKQDUH 25 ,0PJNJ 25 ,9,2PJNJLQPJ LQFUHPHQWV 8SWRDPD[LPXPGRVDJH RIPJIRUDOOURXWHV &RQWLQXHV WRVHL]H" &KHFN%ORRG *OXFRVH 5HVXOWV PJG/" *RWR $/2& SDJH ,ISDWLHQWFRQWLQXHV WRVHL]HFRQVLGHU $GGLWLRQDO0LGD]RODP %DVH 3K\VLFLDQ RUGHU <HV <HV <HV 1R ,IIHEULOH &RROLQJ PHDVXUHV 5HDVVHVVDV QHHGHG 1R 1R SDJH Patient Care Policy (Pediatric) Modiﬁ ed On: May 10, 2019 SEIZURE - MIDAZOLAM DRUG CHART 77SEIZURE - MIDAZOLAM DRUG CHART MI D A Z O L A M ( V e r s e d ) 5 m g / m l P e d i a t r i c D o s e C h a r t (F o r I n d i c a t e d S e i z u r e s O n l y ) WE I G H T GR E Y P I N K R E D P U R P L E Y E L L O W W H I T E B L U E O R A N G E G R E E N OT H E R O T H E R kg 3 – 5 6 – 7 8 – 9 1 0 – 1 1 1 2 – 1 4 1 5 – 1 8 1 9 – 2 2 2 4 – 2 8 3 0 – 3 6 4 0 4 5 lb s 6– 1 1 1 3 – 1 5 1 7 – 2 0 2 2 – 2 5 2 7 – 3 1 3 3 – 4 0 4 2 – 4 9 5 3 – 6 2 6 5 – 8 0 9 0 1 0 0 IN T R A V E N O U S / I N T R A O S S E O U S 0. 1 m g / k g IV / I O D o s e 0. 4mg 0. 6 5 mg 0 . 8 5 mg 1mg 1. 2 5 mg 1. 7 5 mg 2mg 2. 5mg 3. 3mg 4mg 4. 5mg 0. 1 m g / k g IV / I O Vo l u m e 0. 0 8ml 0. 1 3 ml 0. 1 7 ml 0. 2ml 0. 2 5ml 0. 3 5ml 0. 4ml 0. 5ml 0. 6 5ml 0. 8ml 0. 9ml IN T R A N A S A L / I N T R A M U S C U L A R 0. 2 m g / k g IN / I M D o s e 0. 7 5 mg 1. 2 5 mg 1. 7 5 mg 2mg 2. 5mg 3. 5mg 4mg 5mg 5mg 5mg 5mg 0. 2 m g / k g I N / I M Vo l u m e 0. 1 5ml 0. 2 5 ml 0. 3 5 ml 0. 4ml 0. 5ml 0. 7ml 0. 8ml 1ml 1ml 1ml 1ml US E A 1 M L S Y R I N G E F O R M I D A Z O L A M A D M I N I S T R A T I O N T O P E D I A T R I C P A T I E N T S Patient Care Policy (Pediatric) Modiﬁ ed On: May 13, 2015 78 SEVERE NAUSEA SEVERE NAUSEA • Routine Medical Care• Indications: Intractable vomiting or severe nausea in patients aged 4 years and older• Contraindications: Hypersensitivity to 5-HT3 receptor antagonists (i.e. – dolasetron (Anzemet), granisetron (Kytril)• Note #1: Consider other treatable causes• Note #2: Administering Zofran rapidly can cause syncope• Note #3: If patient has s/s of anaphylaxis/allergic reaction, follow Anaphylaxis/Allergic Reaction policy O2 – titrate to 94-99% SpO2 Maintain airway IV NS Is the patient severely nauseous and/ or vomiting?* *Zofran (ondansetron) 0.1 mg/kg IV/IM Slowly (over 30 sec.) if given IV Max single dose 4 mg IV/ IM 4 mg PO Reassess as needed Yes No If symptoms do not improve Is the patient > 40kg? Repeat x1 q 15 minutes Contact Base Hospital Yes No *PO is the preferred route of administration for pediatric patients Patient Care Policy (Pediatric) Modiﬁ ed On: May 27, 2021 SHOCK AND HYPOTENSION 79SHOCK AND HYPOTENSION • Pediatric Routine Medical Care• NOTE: Shock in children may be subtle and hard to recognize. Determining BP may be diﬃ cult and readings may be inaccurate• IMPORTANT SIGNS OF SHOCK: Cool, clammy, mottled skin Pallor - due to decreased skin perfusion Altered level of consciousness - due to decreased perfusion to the brain BP < 70 systolic• Initiate early transport and treat en route, if appropriate Go to Trauma Patient Care (page 24) if trauma suspected Go to Allergic Reaction (page 61) if anaphylaxis suspected• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) Cardiogenic Shock Hypovolemic Shock Septic Shock Spinal Shock Contact base physician 9Control Hemorrhage, if appropriate 9NS IV/ IO 10-20 ml/kg 9Fluid Bolus Continuing signs of shock? Repeat Fluid Bolus Reassess as needed Base physician consult Yes No Patient Care Policy (Pediatric) Modiﬁ ed On: April 10, 2012 80 SUBMERSION SUBMERSION • Pediatric Routine Medical Care• Contact the Base Physician if patient is also showing signs of pulmonary edema before moving to the appropriate policy• Consider CPAP (see CPAP page 122 for indications)• Consider spinal precautions prior to extrication if possibility of neck trauma. Otherwise place the patient on his/ her side to protect the airway and prevent aspiration; be prepared to suction • Rapid extrication from water• Note: If hypothermia is suspected and the patient is in ventricular ﬁ brillation, rewarming is essential. Remove wet clothing, wrap in warm blankets and place in warm ambulance• Initiate rapid transport to the closest most appropriate receiving hospital hypothermia suspected, see note above O2 –titrate to 94-99% SpO2 9 Consider: Spinal Immobilization 9 Remove wet clothing 9 Keep warm Trauma Patient Care page 24page 24 Patient Care Policy (Pediatric) Modiﬁ ed On: June 6, 2012 81 TACHYCARDIA TACHYCARDIA • Pediatric Routine Medical Care• Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) Sinus Tachycardia < 220/min - infant < 180/min - child 9P waves - present/normal 9R to R - variable 9PR - constant Supraventricular Tachycardia (SVT) > 220/min - infant > 180/min - child 9P waves - absent/abnormal 9Heart rate - constant Treat underlying cause, consider: Fluid bolus Consider: Vagal Maneuver Adenosine 90.1 mg/kg - rapid IV push (max 1st dose 6 mg) 9May repeat 0.2 mg/kg - rapid IV push (max 2nd dose 12 mg) Consult with Base Physician for Amiodarone 5 mg/kg IV/IO Over 20-60 minutes Synchronized Cardioversion 0.5 - 1 J/kg If not effective, increase to 2 J/kg Consider Sedation but do not delay cardioversion See Sedation page 138 9Support ABCs if needed 9O2 – titrate to 94-99% SpO2 9Attach monitor Evaluate QRS duration Wide QRS >0.08 sec Narrow QRS < 0.08sec Evaluate rhythm Consider causes: compensatory vs. non-compensatory If unstable (with pulses but poor perfusion) If stable (with pulses and good perfusion) If unstable (with pulse but poor perfusion) If stable (with pulses and good perfusion) Possible/ probable V-tach n page 13 82 THIS PAGE INTENTIONALLY LEFT BLANK Operations Modiﬁ ed On: May 27, 2021 83 OPERATIONAL POLICIES TOC OPERATIONAL POLICIES TOC OPERATIONAL POLICIES TOC ................................................................................83 ALS RESPONDER ......................................................................................................84 BLS/ALS FIRST RESPONDER ..................................................................................85 END OF LIFE CARE ...................................................................................................86 DEATH IN THE FIELD ................................................................................................87 DEATH IN THE FIELD - GRIEF SUPPORT ...............................................................92 EMS AIRCRAFT TRANSPORT ..................................................................................93 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION .........................97 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ......................................98 INTERFACILITY TRANSFERS ...................................................................................105 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT ...106 MEDICAL PERSONNEL ON THE SCENE .................................................................107 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE .............................109 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS ....................110 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING ...............111 RESTRAINTS .............................................................................................................112 UNUSUAL OCCURENCES.........................................................................................113 Operations Modiﬁ ed On: September 10, 2017 84 ALS RESPONDER ALS RESPONDER 1. ALS PERSONNEL - In Alameda County, an "ALS responder" is deﬁ ned as: An individual who is licensed as a paramedic in the state of California and accredited to practice in Alameda County. 2. MEDICAL MANAGEMENT 2.1 An ALS responder is responsible for the care of the patient after accepting responsibility from the ﬁ rst responder personnel until the care of the patient is turned over to the staﬀ at the receiving hospital (if transported), or until the patient leaves the scene 2.2 Consider a second accredited paramedic to accompany the transporting paramedic for critical patients (e.g. - arrest, complicated airway, ROSC, severe trauma, STEMI, etc.) 2.3 Initiate "START" triage if appropriate. (See page 159 "Multi-Casualty Incident - EMS Response (MCI)") 2.4 If it is determined that helicopter transport of the patient might be necessary, activate the air ambulance and secure an appropriate landing zone. (see page 93 "EMS Aircraft") 2.5 A verbal and Electronic Health Record (EHR) must be completed for every patient, describing the care rendered and given to the staﬀ at the receiving hospital. 2.5.1 First Responder and transport personnel providing patient care are responsible for accurately documenting all available and relevant patient information on the electronic health record 2.5.2 Exception: Multi-Casualty Incident – EMS Response (MCI) page 159 Refusal of Service page 119 2.6 The EHR should include a chief complaint, a general assessment, a physical assessment and emergency care rendered by the ALS responder. 3. PATIENT CARE 3.1 The following should be performed for each patient during an emergency response: 3.1.1 A physical assessment and initiation of emergency ﬁ rst aid, basic life support, and/or advanced life support, as necessary 3.1.2 A EHR must be completed for every patient (exception: Multi-Casualty Incident and Refusal of Service) 3.2 ALS responders are held to the following standards during patient care: 3.2.1 American Heart Association, or an approved equivalent, for: ►CPR ►Basic Life Support (healthcare provider) ►Advanced Cardiac Life Support ►Emergency Cardiac Care 3.2.2 PEPP (Pediatric Education for Prehospital Personnel), or Pediatric Advanced Life Support (PALS), or Emergency Pediatric Care (EPC), or an approved equivalent 3.2.3 "S.T.A.R.T. Triage" 3.2.4 OSHA and CAL-OSHA for infection control 3.2.5 International Trauma Life Support (ITLS), PreHospital Trauma Life Support (PHTLS), Assessment and Treatment of Trauma (ATT) or an approved equivalent 3.2.6 Approved training program curriculum for emergency ﬁ rst aid and patient assessment 3.2.7 Alameda County EMS policies for patient care not covered by, or in addition to the above Operations Modiﬁ ed On: July 24, 2018 85 BLS/ALS FIRST RESPONDER BLS/ALS FIRST RESPONDER 1. FIRST RESPONDER PERSONNEL - In Alameda County, First Responder personnel are: 1.1 Public Safety personnel (life guard, ﬁ reﬁ ghter or peace oﬃ cer) trained in "First Aid and CPR Standards for Public Safety Personnel", according to the standards deﬁ ned in Title 22, Chapter 1.5 1.2 Individuals who are certiﬁ ed as an EMT by a California local EMS agency, the California State Fire Marshall's Oﬃ ce, or another certifying authority 1.3 California Licensed, Alameda County Accredited Paramedics 2. MEDICAL MANAGEMENT 2.1 The First Responder is responsible for the care of the patient, once contact with the patient has occurred and continues that responsibility until care of the patient is turned over to the arriving ambulance personnel 2.2 If it is determined that the incident does not involve illness or injury, the First Responder shall cancel the ambulance response (see page 111 "Responding Units - Canceling/Upgrading/Downgrading ") 2.3 If it is determined that helicopter transport of the patient might be necessary, activate the air ambulance and secure an appropriate landing zone (see page 93 "EMS Aircraft") 2.4 A verbal report must be given to the arriving ambulance personnel before the care of the patient may be turned over. The First Responder form should include a chief complaint, physical assessment and emergency care rendered by the First Responder 2.5 The First Responder must remain on scene until an approved ambulance provider arrives and patient care is transferred. The First Responder may return to service once patient care is transferred, or remain on scene and assist as necessary 2.6 Initiate "START" or "JumpSTART" triage as necessary (see page 159 "Multi-Casualty Incident - EMS Response") 3. PATIENT CARE 3.1 The following should be performed for each patient during an emergency response: 3.1.1 A physical assessment and initiation of emergency ﬁ rst aid or basic life support as necessary (see page 47 "Routine Medical Care"). 3.1.2 A First Responder form must be completed for every patient (exception: see page 159 “Multi- Casualty Incident - EMS Response” and page 119 “Refusal of Service”). 3.2 First Responders are held to the following standards during patient care: 3.2.1 American Heart Association for CPR and Basic Life Support (including airway obstruction and ventilation techniques). 3.2.2 Approved training program curriculum for emergency ﬁ rst aid. 3.2.3 "START" or "JumpSTART" Triage for MCI. 3.2.4 Alameda County Policy “Multi-Casualty Incident - EMS Response” page 159 for medical management at a MCI. 3.2.5 OSHA and CAL-OSHA for infection control. 3.2.6 Alameda County EMS policies for protocols not covered by, or in addition to the above Operations Modiﬁ ed On: May 27, 2021 86 END OF LIFE CARE END OF LIFE CARE • Routine Medical Care• Indications: Patient has a life limiting or terminal illness, prefers comﬁ rt-focused treatment, and has one of the following: • POLST form specifying DNAR and comfort-focused treatment and/or: • Patient is enrolled in hospice care • Goals: Reduce patient symptom distress and; Maintain patient dignity by aligning care with stated end-of-life preferences Allinterventionsshouldbeminimallyinvasivewiththe goaltomaintainpatientcomfort ¾Airway–Position/SuctionPRN ¾Breathing–OxygenPRN ¾Circulation–Controlhemorrhage ¾Positionofcomfort ¾ReviewandverifyPOLST/DNARDocumentation Isthepatienton hospicecare? Contacthospiceservice anddiscusscareplanalong withthepatient/family PainManagement–Opioidsarepreferred SeePainManagementProtocol Yes No Naloxone administration isnotadvised Discusshomecareand/ortransportoptionswith patientorpersonholdinglegalauthoritytomake medicaldecisionsforthepatient InitiateAssessandRefertoHospiceCare/Primary CareProvideriftransportisdeclinedortransportper agreeduponcareplan Ifthereareany unresolvableissues regardingan appropriatecareplan– contacttheBaseMD Operations Modiﬁ ed On: May 27, 2021 87 DEATH IN THE FIELD DEATH IN THE FIELD 1. INTRODUCTION 1.1 EMTs and paramedics do not pronounce death but rather determine death based on predetermined criteria. An assessment by paramedics and consultation with the base hospital physician is required for determination of ﬁ eld death not covered by this policy 1.2 Prehospital personnel are not required to initiate resuscitative measures when death has been determined or the patient has a valid "Prehospital Do Not Resuscitate" directive. Paramedics should contact the Base Physician anytime support in the ﬁ eld is needed. 1.3 If a DNR directive is not present at the scene, but a person who is present and who can be identiﬁ ed as an immediate family member or spouse requests no resuscitation and has the full agreement of any others who are present on scene, resuscitation may be withheld or stopped if it has already been initiated. 1.4 If any doubt exists, begin CPR immediately. Once initiated, CPR should be continued unless it is determined the patient meets determination of death criteria (section 2), a valid DNR form is presented (section 3) or the patient meets criteria to discontinue CPR (section 4), or criteria listed in Section 1.3 1.5 Multi-casualty incidents are an exception to this policy 1.6 The local public safety agency having jurisdiction will be responsible for the body once death has been determined. A dead body may not be moved or disturbed until a disposition has been made by the coroner's bureau 2. DETERMINATION OF DEATH 2.1 CRITERIA FOR DETERMINATION OF DEATH IN THE FIELD: 2.1.1 Apnea 2.1.2 Pulselessness - No heart tones and no carotid or femoral pulses. 2.1.3 Documented non-shockable rhythm: ►EMTs: A non-shockable rhythm on the monitor for one minute ►Paramedics: non-shockable rhythm on the monitor screen for one minute documented in 2 leads 2.2 Only the following patients who exhibit all of the above criteria for determination of death and one or more of the following conditions may be determined dead: 2.2.1 PATIENTS WHO ARE OBVIOUSLY DEAD **Documentation of all Determination of Death criteria may not be necessary or possible in these patients ►Decomposition of body tissues** ►Total decapitation** ►Total incineration** ►Total separation or destruction of the heart or brain** ►Any degree of rigor ►Lividity (dependant pooling of blood resulting in skin discoloration) 2.2.2 PATIENTS WHO ARE IN ARREST ►Medical (Cardiac) Arrest - Discontinuation of CPR: if non-shockable rhythm persists, despite appropriate, aggressive ALS interventions for 30 minutes (OR if ETCO2 is <10mmHg after 20 minutes in a patient with an advanced airway), consider discontinuation of CPR. ►Trauma Arrest: Adults only. (only paramedics may determine death using trauma arrest criteria) ►Blunt trauma arrest ►Penetrating trauma arrest ►Prolonged extrication (> 15 minutes) with no resuscitation possible during extrication Operations Modiﬁ ed On: May 27, 2021 88 DEATH IN THE FIELD DEATH IN THE FIELD Exception: Patients with suspected hypothermia will be resuscitated and transported to the closest most appropriate emergency department 2.3 Actions 2.3.1 Immediately notify the coroner and appropriate public safety agency (if not already done) and remain on the scene until they arrive 2.3.2 Complete an Electronic Health Record (EHR) documenting the above and assure that the EHR is sent to the Coroner's Bureau 2.3.3 Search for a donor card (see page 90) 2.3.4 Attach ECG readings to the EHR, if available 3. DO NOT RESUSCITATE (DNR) 3.1 Authority: Health and Safety Code, Division 2.5, Section 1798. Information contained in this policy is based on "Guidelines for EMS Personnel regarding Do Not Resuscitate Directives", Published by Emergency Medical Services Authority 3.2 Purpose: To establish criteria for ﬁ eld personnel to determine the appropriateness of withholding or discontinuing resuscitative measures based on the wishes of the patient 3.3 Philosophy: Despite pre-planning, 9-1-1 is frequently activated when death is imminent. It is the intent of this policy to honor the wishes of the patient not to perform an unwanted resuscitation by establishing procedures whereby legitimate DNR directives are honored 3.4 Deﬁ nition: Do Not Resuscitate (DNR) means no: ►assisted ventilation ►chest compressions ►deﬁ brillation ►endotracheal intubation ►cardiotonic drugs 3.5 Approved Prehospital DNR Directives: - The Prehospital DNR form may be an original or a copy. All forms require the patient's signature (or signature of appropriate surrogate) and the signature of the patient's physician to be valid. Field personnel may withhold or discontinue resuscitative measures, if presented with any one of the following: ►A Physician Orders for Life-Sustaining Treatment (POLST) Program form. ►An approved medallion (e.g. “Medic-Alert”) inscribed with the words: "Do Not Resuscitate-EMS". Call the 800 number on the medallion for access to advance healthcare directives, including living wills, durable power of health care attorney documents, and organ, tissue, and anatomical gift donation information ►The patient's physician is present on scene and issues a DNR order, or issues a DNR order verbally over the phone to ﬁ eld personnel ►A DNR order signed by a physician in the patient's chart at a licensed health facility. ►An EMSA/CMA “Prehospital Do Not Resuscitate” form 3.6 Medical Treatment of the patient with a DNR or End of Life Act directive: If the patient requests treatment, including resuscitation, the request should be honored. The patient should receive treatment for pain, dyspnea, major hemorrhage, relief of choking or other medical conditions. ►However, if the patient is in cardiac arrest, the DNR directive should be honored ►Resuscitation should be witheld if there are DNR orders or evidence (e.g. - Final Attestation Form) that the patient is exercising their rights under the End of Life Act. 3.7 Patient Identiﬁ cation: Correct identiﬁ cation of the patient is crucial, but after a good faith attempt Operations Modiﬁ ed On: May 27, 2021 89 DEATH IN THE FIELD DEATH IN THE FIELD to identify the patient, the presumption should be that the identity is correct if proper documentation is present and the circumstances are consistent. A reliable witness may be used to identify the patient, if available 3.8 PROCEDURE - With an approved prehospital DNR directive (The POLST form is preferred) or meets criteria in Section 1.3 of this protocol: 3.8.1 Field personnel should not start resuscitation. If CPR or other resuscitative measures were initiated prior to the discovery of the DNR directive, discontinue resuscitation immediately 3.8.2 EMTs cancel the ambulance response 3.8.3 If the patient is transported, a copy of the DNR directive should go with the patient 3.8.4 If the patient arrests en route: 1) do not start resuscitation and 2) continue to the original destination 3.9 Documentation: 3.9.1 If resuscitation was started and then discontinued, document the time on the EHR 3.9.2 A copy of the DNR directive should be attached to the EHR. If a copy is unavailable, document the following: ►The type of DNR directive (e.g.: written in the patient chart at a licensed care facility, issued verbally over the phone) ►The date the order was issued ►The name of the physician 3.9.3 If the patient’s physician issued the DNR order verbally while on scene, document the name of the physician and have the physician sign the EHR 3.9.4 Other forms or directives: Advanced Health Care Directive (AHCD) (enacted in 2000) replaces the California Durable Power of Attorney for Health Care, the California Natural Death Act and living wills; although all of these forms are considered valid. The AHCD contains a section called “Health Care Instructions” that has speciﬁ c information regarding options selected by the patient regarding resuscitation 4. DISCONTINUATION OF CPR 4.1 CPR may be discontinued: ►If CPR was started prior to the discovery of an approved DNR directive ►Upon further examination the patient meets the determination of death criteria ►Following an unsuccessful resuscitation - paramedics only ►Upon request of an immediate family member or spouse (as speciﬁ ed in section 1.3) 4.2 Once CPR has been discontinued: all therapeutic modalities initiated during the resuscitation must be left in place until it has been determined by the coroner's bureau that the patient will not be a coroner's case. This includes equipment such as: airways, endotracheal tubes, IV catheters, monitor electrodes, and personal items including clothing, jewelry etc. 4.3 If the coroner's bureau releases the body while ﬁ eld personnel are still on scene: ►Document the name and badge number of the coroner's investigator on the EHR ►Remove and properly dispose of all medical equipment used during the resuscitation attempt Operations Modiﬁ ed On: May 27, 2021 90 DEATH IN THE FIELD DEATH IN THE FIELD 5. SEARCH FOR A DONOR CARD (Authority: § 7152.5 Health & Safety Code) 5.1 The following persons shall make a reasonable search for a document of gift or other information identifying the bearer as a donor or as an individual who has refused to make an anatomical gift: ►A law enforcement ofﬁ cer upon ﬁ nding an individual who the oﬃ cer believes is dead or near death ►Ambulance or emergency medical personnel, upon providing emergency medical services to an individual, when it appears that death of that individual may be imminent. This requirement shall be secondary to the requirement that ambulance or emergency medical personnel provide emergency medical services to the patient 5.2 If a document of gift or evidence of refusal to make an anatomical gift is located by the search required above, the hospital and/or coroner’s bureau (as applicable) shall be notiﬁ ed of the contents and the document or other evidence shall be sent with the patient 5.3 The above search and the results of the search must be documented on the EHR 5.4 A person who fails to discharge the duties imposed by this section is not subject to criminal or civil liability but is subject to appropriate administrative sanctions Operations Modiﬁ ed On: May 27, 2021 91 DEATH IN THE FIELD DEATH IN THE FIELD HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY EMSA #111 B (Effective1/1/2016)* Physician Orders for Life-Sustaining Treatment (POLST) First follow these orders, then contact Physician/NP/PA.A copy of the signed POLST form is a legally valid physician order. Any section not completed implies full treatment for that section. POLST complements an Advance Directive and is not intended to replace that document. Patient Last Name: Date Form Prepared: Patient First Name: Patient Date of Birth: Patient Middle Name: Medical Record #: (optional) A Check One CARDIOPULMONARY RESUSCITATION (CPR):If patienthas no pulse and is not breathing. Ifpatient is NOTin cardiopulmonary arrest, follow orders in Sections B and C. Attempt Resuscitation/CPR (SelectingCPR in Section A requires selecting Full Treatment in Section B) Do Not Attempt Resuscitation/DNR (Allow Natural Death) B Check One MEDICAL INTERVENTIONS:If patientis found with a pulse and/or is breathing. Full Treatment –primary goal of prolonging life by all medically effective means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Trial Period of Full Treatment. Selective Treatment –goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment,use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care. Request transferto hospital only if comfort needs cannot be met in current location. Comfort-Focused Treatment –primary goal of maximizing comfort. Relieve painand suffering with medication by anyrouteas needed; use oxygen, suctioning, andmanual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatmentunlessconsistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. Additional Orders:___________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________ C Check One ARTIFICIALLY ADMINISTERED NUTRITION:Offer food by mouth if feasible and desired. Long-term artificial nutrition, including feeding tubes. Additional Orders:________________________ Trial period of artificial nutrition, including feeding tubes. __________________________________________ No artificial means of nutrition, including feeding tubes. __________________________________________ D INFORMATION AND SIGNATURES: Discussed with: Patient (Patient Has Capacity)Legally Recognized Decisionmaker Advance Directive dated _______, available and reviewed Æ Advance Directive not available No Advance Directive Health Care Agent if named in Advance Directive: Name: ________________________________________ Phone: _______________________________________ Signature of Physician / Nurse Practitioner/Physician Assistant (Physician/NP/PA) My signature below indicates to the best of my knowledge that these orders are consistent with the patient’smedical condition and preferences. Print Physician/NP/PA Name: Physician/NP/PA Phone #: Physician/PA License #, NP Cert. #: Physician/NP/PA Signature: (required)Date: Signature of Patient or Legally Recognized Decisionmaker I am aware that this form is voluntary.By signing this form,the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of,and with the best interest of, the individual who is the subject of the form. Print Name: Relationship: (write self if patient) Signature: (required)Date:FOR REGISTRY USE ONLYMailing Address(street/city/state/zip): Phone Number: SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED Operations Modiﬁ ed On: May 27, 2021 92 DEATH IN THE FIELD - GRIEF SUPPORT DEATH IN THE FIELD - GRIEF SUPPORT 1. PHILOSOPHY 1.1 The intent of this policy is to provide grief support to the families of deceased individuals who are not transported from the ﬁ eld. Grief Support will be available to assist families in dealing with the death of a family member. 1.2 Field personnel should identify the need for grief support as soon as possible, especially for an unexpected death or if considering discontinuation of CPR in the ﬁ eld. 1.3 Field personnel should follow their agency/department procedure for initiating grief support 2. RESPONSIBILITIES 2.1 Assist the family in dealing with the death, or anticipated death, of the patient. 2.2 If resuscitation is in progress determine if the family wants the patient transported to the hospital. 2.3 Once death has been determined: ►remain on scene with the family to provide support and assist with decisions ►contact all appropriate agencies (e.g. Police, Coroner) if not already done ►remove all medical equipment used during the resuscitation if cleared by the Coroner's bureau (see "Death in the Field - Discontinuation of CPR" page 89). ►assist with the notiﬁ cation of clergy, if requested ►provide information regarding the disposition of the remains 3. GRIEF SUPPORT GUIDELINES: Breaking the News. . .• Physically join the family.• Introduce yourself.• Go over with the family what has been done, what interventions have been tried.• "The paramedics (we) found your [husband, wife, daughter, etc.] not breathing. We began CPR. I am very sorry to tell you but your [husband, wife, daughter, etc.] has died."• Give the family time to react don't leave. Grief Support Skills• Ask the family if there is someone they would like you to call. Find a neighbor.• Things to say: ►"Mrs. Smith, tell me what happened today" ►"I am sorry Joe has died.” ►“This is a diﬃ cult time, it is OK to cry” ►"You may not remember all I have said right now and that's OK.” ►“I will be available later to talk to you” ►"I don't know but I will ﬁ nd out"• Remember: You cannot ﬁ x grief. Just give it an honest and safe place to exist.• Give the family the grief support brochure. Tell the family what happens next• The coroner must be notiﬁ ed (Paramedics and/or police to do this)• Ask if the family has selected a mortuary.• Get the private doctors name and as much patient history as possible (including medications that indicate speciﬁ c medical conditions) Coroner's Case• Cause of death must be investigated.• Investigator can explain more.• Police must stay if a coroner's case. (may choose to stay until mortuary arrives if not a coroner's case)• Mortuary will pick up at coroner's oﬃ ce.• Explain scene preservation nothing may be moved or disturbed. Mortuary Case• Family should choose and call a mortuary.• Ask family/friends/church for suggestion.• Mortuary will come to the scene.• Remove and dispose of all medical equipment.• Body may be left with family if they are OK and not a coroner's case. Ask how they feel. Knowing when to Leave• Tell them it is time for you to go "is there anything else I can do?"• Go through the grief support brochure, point out referral numbers. Give them your card or how they can reach you.• Oﬀ er your condolences shake hands or touch if appropriate.• Leave Operations Modiﬁ ed On: December 1, 2011 93EMS AIRCRAFT TRANSPORT EMS AIRCRAFT TRANSPORT NOTE: EMS Aircraft utilized in Alameda County for prehospital emergency care will meet the qualiﬁ ca- tions speciﬁ ed in Title 22, Chapter 8. 1. INITIATING EMS AIRCRAFT RESPONSE 1.1 The decision to request an EMS Aircraft is based on medical and scene management considerations 1.2 Prior to arrival at the scene - An EMS Aircraft may be activated by any responding agency if there may be a potential need for air transport based on the incident type or location of the victim(s) 1.3 All responding agencies shall be notiﬁ ed when an EMS Aircraft has been requested 1.4 When on-scene, the decision to activate an EMS Aircraft shall be made by the IC (Incident Commander or his/her designee). upon: ►the advice of on-scene medical personnel and/or ►the suitability of the scene for helicopter operations 2. CONSIDERATIONS FOR REQUESTING EMS AIRCRAFT: (one or more of the following conditions exists) 2.1 Long response times to scene (>20 minutes) 2.2 Inaccessibility to the scene by ground personnel or equipment 2.3 Extended extrication 2.4 Extended transport to an appropriate facility > 20 minutes (e.g. remote area, peak traﬃ c, closest most appropriate facility closed) 2.5 Patients meeting Critical Trauma Patient Criteria (see page 25) with extended transport time to an approved Trauma Center 2.6 Patients requiring advanced skills not in the Alameda County Paramedic scope of practice. (e.g. RSI, Surgically places thoracostomy tubes) 2.7 Patient conditions where a decrease in transport time to an appropriate medical facility may be a signiﬁ cant factor 2.8 Patients in cardiac arrest from drowning or penetrating trauma with a short down time. In general, all other patients with cardiac arrest should not be transported in an air ambulance or rescue aircraft 2.9 A multi-casualty incident exists with a need for increased resources 3. EMS AIRCRAFT DISPATCH 3.1 All EMS Aircraft activations shall be made through ALCO-CMED. ALCO should be given the following information if available: ►Number of Patients and acuity of each ►Type and extent of injuries ►Location of Landing Site (use Thomas Brothers Map coordinates or Longitude and Latitude, if possible) ►Nearest landmarks (e.g., highways, railroad tracks, water towers) ►Weather conditions, especially high winds, fog or visibility problems. 4. COMMUNICATION 4.1 ALCO-CMED shall request activation of the EMS Aircraft that has the shortest total response time to the scene/rendezvous site 4.2 The responding EMS Aircraft may contact ALCO on VHF TAC 4 (154.070) while en route to the scene to conﬁ rm radio frequency and ground contact/incident identiﬁ er ►The preferred frequency for helicopter to ground unit communications is: CALCORD (156.075) ►Alternate frequencies are VHF TAC 4 (154.070) and VHF TAC 5 (154.235), but should be Operations Modiﬁ ed On: December 1, 2011 94 EMS AIRCRAFT TRANSPORT EMS AIRCRAFT TRANSPORT coordinated through ALCO-CMED ►Fire White (154.280) is not authorized for cross patch to an ambulance or helicopter 4.3 The responding EMS Aircraft will advise ALCO of ETA in minutes and clock hours. ALCO shall advise the requesting agencies of the EMS Aircraft's ETA 4.4 ALCO shall keep responding/on scene ground personnel updated as to aircraft status (cancellation, delays, inability to respond, etc.) 4.5 If multiple aircraft are responding to the scene or in the area of the incident, ALCO shall attempt to notify each aircraft of multiple aircraft response 4.6 The EMS Aircraft shall contact the receiving hospital prior to arrival. A patient care report and an ETA should be given 5. UTILIZATION OF RESCUE AIRCRAFT 5.1 A number of public agencies, including East Bay Regional Park District, California Highway Patrol, Coast Guard and various military units, operate aircraft which are classiﬁ ed as ALS Rescue Aircraft, BLS Rescue Aircraft or Auxiliary Aircraft 5.2 The decision to transport in a rescue aircraft should be made by on-scene medical personnel and is based on patient condition and availability of other resources 5.3 Considerations for utilizing rescue aircraft: ►the patient is in an area that is inaccessible to ground transport vehicle, ►the ETA of a ground ambulance and/or Air Ambulance exceeds the loading and lift-oﬀ time by the rescue aircraft ►an air ambulance is unavailable ►the patient clearly does not require the level of service provided by an air ambulance ►a rescue requiring the use of a hoist device is indicated 5.4 When an EMT-P accompanies a patient in a BLS rescue aircraft, the EMT-P must: ►have available all appropriate medical equipment needed to care for the patient; ►receive orientation to the aircraft and to medical air transport procedures according to Title 22, Chapter 8, Section 100302 6. SAFETY/LANDING - Safety rules at the scene include: 6.1 Landing Zone considerations (L-Z): ►75' x 75' during daylight, 100' x 100' during night hours, ►clear of cross wires, debris, or other obstacles, relatively ﬂ at ►Consult CHP/Law Enforcement when landing on roadways 6.2 Ground personnel should coordinate with public safety agency for road closures, if necessary 6.3 The ﬁ re department should determine the landing zone and assure scene safety during landing 6.4 Before clearing EMS aircraft to land the IC must ensure that the helicopter will not block the transport of patients out of the scene by ground. If ground transport will be blocked then the IC must make sure that ground units with critical patients have departed before clearing aircraft to land 6.5 The pilot in command shall have the ﬁ nal authority as to the safe operation of the air transport. If, in the pilot's judgment, patient transport by an EMS aircraft would be unsafe, regardless of the patient's condition, the patient should be transported by ground ambulance 6.6 Ground personnel shall not approach the aircraft unless directed to do so and accompanied by the aircraft crew 6.7 Regardless of how the request was initiated, only the IC shall authorize the landing of a helicopter at Operations Modiﬁ ed On: December 1, 2011 95EMS AIRCRAFT TRANSPORT EMS AIRCRAFT TRANSPORT the scene. Coordination between medical personnel and the IC is essential 7. CANCELING EMS AIRCRAFT RESPONSE 7.1 Ground transport should be utilized if: ►the overall prehospital time will not be decreased by the use of air transport and/or ►the patient does not meet criteria identiﬁ ed in Section 3 for Requesting EMS Aircraft. 7.2 Regardless of how an EMS Aircraft activation was initiated, only the IC shall cancel the response. The IC will cancel the EMS Aircraft response if so advised by on-scene medical personnel (see 9.1 below) . Coordination among all medical personnel and the IC is essential 7.3 The IC should only cancel an EMS Aircraft response if on scene and aware of the patient’s condition 7.4 EMS Aircraft response can be canceled by: ►notifying ALCO, who will then notify all responding agencies ►the IC if in contact with the responding Aircraft 7.5 The IC shall be immediately advised of the decision to transport by ground 7.6 If the EMS Aircraft arrive on scene prior to the ground ambulance, the responding ground ambulance shall not be canceled until: ►the EMS Aircraft has left the scene with the patient aboard; and, ►it is determined by the IC or his/her designee that there are no additional patients to be transported 8. TRANSPORT 8.1 The transporting ALS provider shall have authority and responsibility to determine mode of patient transport (air vs. ground) and patient destination. The transporting ALS provider must consult with ﬁ rst responder personnel and EMS Aircraft crew, if applicable, prior to making this decision 8.2 Alameda County transport policies shall be followed for all patients requiring air transport. Patients shall be transported to the closest hospital most appropriate for the medical needs of the patient with an approved Helipad or EMS Landing Site 8.3 Trauma Centers with approved helipads or emergency landing sites are: ►Eden Hospital (Castro Valley) ►Children's Hospital (Oakland) ►John Muir Hospital (Walnut Creek) ►Highland General Hospital (Coast Guard Island) ►Regional Medical Center (San Jose) ►Valley Medical Center (San Jose) ►Stanford University Hospital (Palo Alto) 8.4 Alameda County Receiving Hospitals with approved helipads or emergency landing sites are: ►Eden Hospital ►Washington Hospital ►Valley Care Medical Center ►Children's Hospital 9. PATIENT CARE RESPONSIBILITIES 9.1 Transfer of care shall occur: ►upon arrival/landing of the responding personnel at the scene when patient contact is made ►after a verbal patient care report is given to the transporting agency in accordance with page 145, "Transfer of Care" 9.2 The EMS Aircraft crew may release the patient to an ALS ground transport unit if ground transport is Operations Modiﬁ ed On: December 1, 2011 96 EMS AIRCRAFT TRANSPORT EMS AIRCRAFT TRANSPORT determined appropriate 9.3 The EMS Aircraft or ALS ground ambulance crew may release a patient to BLS rescue aircraft if the patient does not require ALS care but air transport is determined to be appropriate. 10. DOCUMENTATION - Appropriate documentation must be completed on all patients transported by the EMS Aircraft crew and faxed immediately to ALCO EMS at (510) 618 – 2099 11. REQUEST FOR MILITARY AIRCRAFT 11.1 Military assistance may be used when non-disaster inland search and rescue operations may exceed local and state capabilities. Examples: water rescue, rescue in inclement weather. hoist rescue 11.2 One hour response time minimum time should be expected. An ETA can only be given after the request is made and an assessment of available resources has been completed 11.3 If hoist rescue requested do not place the patient on a stretcher or stokes basket, although the patient may be placed on a backboard. The hoist equipment requires specialized equipment 11.4 The incident commander determines the need for military aircraft and contact ALCO with the following information: ►Incident location and longitude and latitude if known ►Incident description including the number of injured, types of injuries and topography ►If a hoist is requested, an estimate of the distance the patient will need to lifted from the ground to the aircraft ►Altitude of incident if known ►Air to ground contact frequencies 11.5 Notiﬁ cation Procedure - ALCO: ►For maritime rescue: call Coast Guard Dispatch directly at (415) 556-2105 or (415) 556-2103 ►For land (non-maritime) rescue or assistance call: State OES Law Division at (800) 852-7550 for approval Coast Guard dispatch (415) 556-2103 to give the Coast Guard helicopter ﬂ ight crew an advanced notiﬁ cation. Since the Coast Guard’s primary responsibility is maritime search and rescue, they can notify ALCO of their availability 11.6 If additional information is needed, ALCO will direct the questions to the requesting IC's dispatch center for direct contact. Operations Modiﬁ ed On: May 28, 2019 97 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION 1. EQUIPMENT AND SUPPLIES: The provider agency is responsible for providing a full inventory of equipment and supplies to its units 2. All ALS and BLS patient care response vehicles (transporting and non-transporting) shall have at a minimum, all equipment and supplies speciﬁ ed in "Equipment and Supply Speciﬁ cations - ALS/BLS" (page 98). This policy does not supersede the California Vehicle Code or California Code of Regulations, Title 13 requirements for ambulance equipment. In addition, each patient care response vehicle shall have: 2.1 Adequate space in the patient care compartment to accommodate one stretcher, a patient(s) and two providers. There must be suﬃ cient space to allow for patient care activities during transport 2.2 County approved communications equipment capable of contact with receiving hospitals, base hospitals, and other provider agencies during an MCI or mutual aid situation 2.3 Personal protective equipment in accordance with Cal/OSHA standards and/or California EMSA Guideline #216 3. Each ALS provider (transport and non-transport) shall have an approved controlled substance/medication restock procedure on ﬁ le with the EMS Agency 4. INSPECTION: Alameda County EMS Agency personnel may inspect any BLS, CCT and/or ALS mobile unit at any time for compliance with the identiﬁ ed standards for equipment and personnel – see “Equipment and Supply Speciﬁ cations - ALS/BLS” page 98 ►Deﬁ ciencies may result in the unit's removal from service until the deﬁ ciencies are remedied ►The Alameda County EMS Agency will notify the service provider agency's designated management representative immediately of the infraction Operations Modiﬁ ed On: May 27, 2021 98 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ►MINIMUM SUPPLY SPECIFICATIONS BLS ALSNon-Transport ALSTransport AIRWAY EQUIPMENT ▼Airways: ●Oropharyngeal (Sizes 0 - 6)...................................................... 1 each 1 each 2 each ●Nasopharyngeal (soft rubber) »14 Fr., 18 Fr., 22 Fr., 26Fr. .................................................... 1 each 1 each 1 each »30 Fr. .................................................................................... 1 1 1 »32 Fr. .................................................................................... 1 1 2 »34 Fr. .................................................................................... 1 1 1 ►Atomizer for intranasal medication administration 2 1 3 ►County Approve Continuous Positive Airway Pressure (CPAP) Device 1 1 ►Impedance Threshold Device (ResQPOD® ITD-16) ...... ........................ 1 1 ▼Intubation Equipment: ●County approved video laryngoscopy device ....................................................... 1 (optional) 1 (optional) ●Laryngoscope (handle) ......................................................................................... 1 1 ●Batteries (extra) .................................................................................................... 1 set 1 set ●Blades (curved McIntosh): ●Adult »# 4 ........................................................................................ ........................ 1 1 »# 3 ........................................................................................ ........................ 1 1 ●Pediatric »# 2 ........................................................................................ ........................ 1 1 »# 1 ........................................................................................ ........................ 1 1 ●Adult (Straight Miller) »# 4 ........................................................................................ ........................ 1 1 »# 3 ........................................................................................ ........................ 1 1 ●Pediatric »# 2 ........................................................................................ ........................ 1 1 »# 1 ........................................................................................ ........................ 1 1 ●Magill forceps: »Adult .................................................................................... ........................ 1 1 »Pediatric ............................................................................... ........................ 1 1 ●Adult (cuﬀ ed with adaptor) »Size 6.0 ................................................................................ ........................ 1 2 »Size 6.5 ................................................................................ ........................ 1 2 »Size 7.0 ................................................................................ ........................ 1 2 »Size 7.5 ................................................................................ ........................ 1 2 »Size 8.0 ................................................................................ ........................ 1 2 ●Stylet »Adult .................................................................................... ........................ 1 1 Operations Modiﬁ ed On: May 27, 2021 99EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ►MINIMUM SUPPLY SPECIFICATIONS BLS ALSNon-Transport ALSTransport ●i-gel Supraglottic Airway »Size 1.0................................................................................. 1 (optional) 1 (optional) »Size 1.5................................................................................ 1 1 »Size 2.0................................................................................ 1 1 »Size 2.5................................................................................ 1 1 »Size 3................................................................................... 1 1 »Size 4................................................................................ 1 1 »Size 5................................................................................ 1 1 ●Disposable Waveform Capnography............................................. 2 (optional) 2 5 ●ET Tube Holder »Adult .................................................................................... ........................ 2 3 ●Tracheal tube introducer (bougie) ......................................................................... 1 2 ▼Nebulizer ●Patient Activated ................................................................................................... 1 2 ●Hand-held for Inhalation ....................................................................................... 1 2 ●In-Line nebulizer equipment with 22 & 24 mm “T-piece” ...................................... 1 2 ▼Oxygen equipment and supplies: ●O2 Tank (portable) ........................................................................ 1 1 1 ●Non-rebreather masks (transparent) »Adult .................................................................................... 2 1 2 »Pediatric/Infant ..................................................................... 1 1 1 »Nasal cannula for O2 administration ..................................... 2 1 2 »Portable Pulse-Oximetry ...................................................... 1 1 1 »Adult end-tidal CO2 sampling nasal cannula......................... ........................ 1 1 »Pediatric end-tidal CO2 sampling nasal cannula........................................... 1 1 ►County-approved pleural decompression kit 1 2 ▼BVM with O2 reservoir and facemask ●Adult ............................................................................................. 1 1 1 ●Pediatric ....................................................................................... 1 1 1 ●Infant ............................................................................................ 1 1 1 ▼Suction equipment and supplies: ●Rigid Suction Catheter.................................................................. 1 1 2 ●Suction apparatus (portable) ........................................................ 1 1 1 ●Suction catheters, pediatric: » 6 Fr ..................................................................................... 1 1 1 »10 Fr .................................................................................... 1 1 1 »18 Fr .................................................................................... 1 1 1 ●Suction Canisters .......................................................................... 1 1 1 Operations Modiﬁ ed On: May 27, 2021 100 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ►MINIMUM SUPPLY SPECIFICATIONS BLS ALSNon-Transport ALSTransport DRESSING MATERIALS ►County Approved Chest Seals ............................................. ........................ 2 3 ►Adhesive bandages (Assorted) ........................................... 1 container 1 container 1 container ►Cold Pack .................................................................................... 2 2 2 ▼Dressing Materials ●4” x 4” gauze ............................................................................... 12 6 12 ●10 x 30” or larger universal dressings ......................................... 2 2 3 ●ABD pad (9 x 5”) ........................................................................... 2 2 2 ●Roller bandages »2” ......................................................................................... 2 1 2 »3” ......................................................................................... 2 1 2 »4" ......................................................................................... 2 2 2 ●QuikClot® Combat Gauze™ ................................................................................ 1 (Optional) 1 (Optional) ►Elastic Bandage 3” (ACE Style Bandage)............................... 1 1 1 ►Scissors (heavy duty) .................................................................. 1 1 1 ▼Splints - cardboard splint with a soft or cushioned surface, ﬂ exible, form-ﬁ tting splint (e.g. SAM or vacuum splint): ●Adult Arm....................................................................................... 1 1 2 ●Adult Leg....................................................................................... 1 1 2 ●Traction Splint 1 1 ▼Tape ●1” ................................................................................................... 1 roll 1 roll 1 roll ●2” ................................................................................................... 1 roll 1 roll 1 roll ►Triangular Bandage ................................................................. 1 1 2 ►County Approved Tourniquet (for hemorrhange control)1 1 1 EQUIPMENT AND SUPPLIES ▼Automated External Deﬁ brillator (AED) equipment ●Automated External Deﬁ brillator - pediatric ready ........................ 1 ●“Hands- oﬀ ” deﬁ b pads »Adult .................................................................................... 1 set »Pediatric ............................................................................... 1 set ►Blanket Disposable 1 1 1 ▼Blood pressure cuff (portable): ●Adult .............................................................................................. 1 1 1 ●Obese ................................................................................................................... 1 1 ●Pediatric ........................................................................................ 1 1 1 ●Infant ..................................................................................................................... 1 1 ►Bulb Syringe (optional if supplied in Delivery Kit) 1 1 1 ►Burn Sheets (sterile) 1 1 1 ►CO Monitor 1 (Optional) 1 (Optional) Operations Modiﬁ ed On: May 27, 2021 101EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ►MINIMUM SUPPLY SPECIFICATIONS BLS ALSNon-Transport ALSTransport ▼Delivery Kit Sterile, prepackaged to include: ●a minimum of two (2) umbilical cord clamps ●scissors (may be packaged separately) ●aspirating bulb syringe ●gloves ●drapes ●antiseptic solution 1 1 1 ►EMS Field Manual (may be print or digital copy) 1 1 1 ►Gloves, disposable 1 box 1 box 2 boxes ►Glucometer 1 1 1 ▼Irrigation Equipment: »Sterile Saline or Sterile Water for irrigation........................... 2 1 (Optional) 2 »Tubing for irrigation .............................................................. ........................ 1 ►EMS Approved Length Based Resuscitation Tape - (LBRT)1 1 ►Lubricant, water soluble 2 packs 2 packs 2 packs ►County Approved Mechanical CPR Device 1 (Optional) 1 (Optional) ▼Monitor/deﬁ brillator equipment: ●Deﬁ brillator Must have strip recorder, synchronized cardioversion and transcutaneous pacing capability, and be portable & operational. Both monophasic and biphasic waveform deﬁ brillators are acceptable; however, biphasic is preferred. Energy level dependent upon manufacturer. 1 1 ●Batteries, extra (if available) ................................................................................. 1 set 1 set ●“Hands-oﬀ ” deﬁ b pads »Adult .................................................................................... ........................ 1 set 1 set »Pediatric ............................................................................... ........................ 1 set 1 set ●EKG electrodes...................................................................................................... 3 packs 6 packs ●12-lead EKG capability .........................................................................................1 1 ►Pen Light 1 1 1 ►Point of Wounding (POW) Kit (Items located in this kit may be counted towards minimums of other items in this table)1 1 1 ►Radio unit(s) Must be able to function with all facets of the current EBRCS radio system 1 1 1 ►Thermometer - patient safe 1 1 (optional) 1 ►Triage Tags 20 20 20 ►Triage Tape 1 roll ea. - red, yellow, green, black ►Scoop Stretcher or equivalent 1 (optional for IFT)1 ►Flexible multi-positional patient carrying device 1 (optional) 1 (optional) 1 (optional) Operations Modiﬁ ed On: May 27, 2021 102 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ►MINIMUM SUPPLY SPECIFICATIONS BLS ALSNon-Transport ALSTransport ►Stethoscope 1 1 1 ►Stretcher 1 1 IMMOBILIZATION EQUIPMENT ►Cervical collars - Stiff: Sizes to ﬁ t all patients over one year old 1 each size 1 each size 2 each size ►Head immobilizer that provides lateral and built-in occipital support 1 1 2 ▼Spine boards (rigid) ●Long board (72" x 14") .................................................................. with removable 5-strap adjustable immobilization device 1 1 1 ●Pediatric with velcro straps and head harness .............................1 (optional for IFT)1 1 (LBRT holder optional) ►Vacuum Mattress 1 (optional) 1 1 ►Athletic helmet face mask removal tool (optional) 1 1 1 IV EQUIPMENT/SYRINGES/NEEDLES ▼Armboards ●Short ............................................................................................................................................. 1 ●Pediatric ................................................................................................................ 1 1 ▼Catheters ●16 gauge ............................................................................................................... 1 (optional) 2 ●18 gauge ............................................................................................................... 2 2 ●20 gauge ............................................................................................................... 2 2 ●22 gauge ............................................................................................................... 2 2 ●24 gauge ............................................................................................................... 2 2 ►Chlorhexidine ..................................................................................................... 6 12 ▼Handheld Battery Powered Intraosseous Equipment ●EZ-IO® Driver ........................................................................................................ 1 1 ●15 mm Needle Set (pink hub, 3kg-39kg) .............................................................. 1 (optional) 2 (optional) ●25 mm Needle Set (blue hub, >3kg) ..................................................................... 1 2 ●45 mm Needle Set (yellow hub, >40kg with excessive tissue) ............................. 1 2 ●Vascular access pack ........................................................................................... 1 2 ▼Needles ●22 g x 1.5".............................................................................................................. 1 4 ●23 g x 1"........................................................................................ ........................ 1 2 ●18 g x 1½" 5 micron ﬁ lter needle (optional) ........................ 1 2 ►Pressure Infusion Bags 1 1 ►Saline Lock 2 2 ▼Syringes - Luer-Lock type ●1 mL .............................................................................................. 1 1 2 ●3 mL ...................................................................................................................... 1 2 ●10 mL .................................................................................................................... 2 2 Operations Modiﬁ ed On: May 27, 2021 103EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ►MINIMUM SUPPLY SPECIFICATIONS BLS ALSNon-Transport ALSTransport ●30 mL .................................................................................................................... 1 2 ►T-connector 1 2 ►Tourniquet (for IV start)1 1 ►Tubing - Adjustable ﬂ ow 3-way administration set 1 2 MEDICATIONS AND SOLUTIONS - preloads preferred ►Adenosine 6 mg / 2 mL NS 1 2 ►Adenosine 12 mg / 4 mL NS 1 2 ►Albuterol 2.5 mg in 3 mL NS 2 4 ►Amiodarone 150 mg in 3 mL or 150 mg in 100ml premixed bag 2 3 ►Aspirin 81 mg chewable tablet or 325 mg/5 gr. tablet 1 bottle 1 bottle 1 bottle ►Atropine Sulfate 1 mg / 10 mL 3 3 ►Autoinjector antidote kit (optional) (atropine 2mg in 0.7mL’s & pralidoxime chloride 600mg in 2 mL’s) 3 per person 3 per person 3 per person ►Calcium Chloride 1 gm / 10 mL 1 1 ►Charcoal, 25 grams 1 bottle 2 bottles ►Dextrose 10% in 250mL bags 1 2 ►Diphenhydramine 50 mg / 1 mL 1 2 ►Epinephrine 1mg / mL 1 mg / 1 mL 2 2 ►Epinephrine 0.1mg/mL 1 mg / 10 mL 3 3 ►Epinephrine Auto-Injectors Adult 0.3mg, Pediatric 0.15mg ►Epinephrine 1mg / mL 1 mg / 1 mL 1 of each Auto-injector or 1 vial ►Fentanyl 100 mcg / 2 mL 2 2 ►Glucagon 1 mg Kit 1 1 ►Glucose (Oral) - 31 gms 2 2 2 ►Hydroxocobalamin 5g / 250ml Optional ►Ipratropium (Atrovent) 500 mcg (2.5 mL) 1 2 ►Ketamine (Ketalar) 500 mg / 10 ml (50 mg / ml) OR 10 mg / ml concentration Min. 30 mg Min. 30 mg ►Ketorolac (Toradol) 15mg / 1ml 1 1 ►Lidocaine 2% 40 mg / 2 mL 1 1 ►Midazolam 10 mg / 2 mL 2 2 ►Naloxone 2 mg / 2 mL 2 2 2 ►Nitroglycerine 1 bottle 1 bottle ►Olanzapine (Zyprexa) 10mg oral dissolving tablets 2 2 ►Ondansetron (Zofran) 4mg / 2 mL for IV/IM injection 1 2 ►Ondansetron (Zofran) 4mg oral dissolving tablets 2 4 ►Saline, sterile (for injection) 10 mL 2 2 Operations Modiﬁ ed On: May 27, 2021 104 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ►MINIMUM SUPPLY SPECIFICATIONS BLS ALSNon-Transport ALSTransport ►Sodium bicarbonate 50 mEq / 50 mL 1 2 ►Sodium Thiosulfate 12.5 gms with 10 gtt/mL vented tubing 1 (Supervisor or Battalion Chief) ►Tranexamic Acid 1 1 ▼Bags for infusion ●D5W or Normal Saline 100mL 1 2 ●Normal Saline (NS)- May use 500mL or 1000mL bags 1,000mL 2,000mL Operations Modiﬁ ed On: July 24, 2018 105 INTERFACILITY TRANSFERS INTERFACILITY TRANSFERS Note: This policy pertains to emergency transfers to a higher level of care that come through the 9-1-1 system. See “Scheduled Interfacility Transfers Using Paramedic Personnel” (policy #4605 Administration Policy Manual) for more information. 1. All patient care rendered by prehospital care personnel must be within the deﬁ ned scope of practice according to Title 22 and Alameda County EMS protocols 2. A paramedic may only take orders from a base hospital physician. (See 5.2 below) There are no provisions for an EMT to take orders from a physician 3. EMT-Bs may only transfer a patient without an emergency medical condition; or, with an emergency medical condition that has been stabilized and has no potential (within reasonable probability) to deteriorate en route 4. Paramedics (in addition to 3) may only transport a patient who has not been stabilized to a facility that provides a higher level of care. The transferring physician must determine if the care that may be required during transport is within the scope of practice of a paramedic. If not, appropriate hospital staﬀ and/or equipment should be sent with the patient 5. Base Contact by Paramedics 5.1 Base Contact is required prior to transport if the transferring physician orders any ALS treatment and/or the patient has not been stabilized 5.2 Paramedics may follow transferring physician's written orders ONLY when 1) the transferring physician speaks to the Base Physician, and they mutually agree on the course of treatment; 2) the proposed treatment plan is within the paramedic's scope of practice 5.3 Base Physician contact shall be made: ►When there is a request to transfer a patient to a higher level of care facility that is not the "closest, most appropriate" higher level of care facility. 5.4 Base Contact is not required if the patient is stable and no ALS treatment has been ordered by the transferring physician. If the patient's condition changes during transport see the appropriate patient care policy and treat accordingly 6. Base Contact may be made anytime a paramedic has a question regarding patient condition, destination and/ or the appropriateness of the transfer 7. An Alameda County Unusual Occurrence (U.O.) form should be completed for any problem-oriented interfacility transfers. The U.O. form should be sent to the EMS oﬃ ce for review. [See Administration Manual UNUSUAL OCCURRENCES (#2300)] 8. Refer to “Interfacility Transfer Guidelines” [see Administration Manual INTERFACILITY TRANSFER GUIDELINES (# 5600)] for transfer approval process Operations Modiﬁ ed On: December 1, 2011 106 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 1. PURPOSE: To deﬁ ne the scope of practice of the EMT and paramedic with respect to the management of patients during emergency or routine transport from the ﬁ eld or during an interfacility transfer 2. Certiﬁ ed EMT or a supervised EMT student may: ►Assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices ►Monitor intravenous lines delivering glucose solutions or isotonic balanced salt solutions including Ringer’s lactate for volume replacement; ►May monitor, maintain, and adjust if necessary in order to maintain, a preset rate of ﬂ ow and turn oﬀ the ﬂ ow of intravenous ﬂ uid; ►May transfer a patient, who is deemed appropriate for transfer by the transferring physician, and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines ►May Monitor preexisting vascular access devices and intravenous lines delivering ﬂ uids with additional medications pre-approved by the Director of the EMS Authority 3. Licensed Paramedics, in addition to the above may: ►Monitor and administer medications through pre-existing vascular access ►Monitor and adjust IV solutions containing potassium equal to, or less than, 20 mEq/L ►Transport and monitor a patient that has ﬂ uid and/or medication running through a central line, central venous access device, or heparin lock as long as the medications are within the paramedic scope of practice. Medications not included in the paramedic scope of practice may not be administered during transport. (12/21/05) 4. Infusion Devices - An EMT or Paramedic may transport a patient with an infusion device under the following conditions: ►The transport is authorized, in writing, by the patient's physician or is approved by the Base Hospital physician ►For BLS transport - the patient must be stable, non-critical and the purpose of the transport must be of a routine nature, such as a pre-scheduled appointment to a medical facility for examination or treatment (e.g. dialysis, chemotherapy, doctor's oﬃ ce visit) ►Paramedics should transport the patient if the reason for the transport is a change in condition or a new medical complaint ►The patient or trained family member must be present to monitor and regulate the device during the transfer, without any assistance from the EMT or paramedic ►If any doubt exists as to the ability of the patient or family member to manage the device or the device is not functioning properly, the patient should be assessed by ALS personnel and if appropriate, consultation with the Base Physician should be obtained 5. Ventilators: ►If during a response to a 911 or scheduled interfacility transport, an EMT – I discovers a patient on a ventilator that requires transport, a CCT – Paramedic or CCT – RN response shall be initiated ►Paramedics may disconnect the patient from the ventilator and assist ventilation using a bag-valve device. If it is in the best interest of the patient to remain on a ventilator during transport and a delay in transport will not compromise patient care or comfort, a CCT – Paramedic or CCT – RN response shall be initiated. If any doubt exists regarding the condition of the patient, the Base Physician should be consulted 6. Thoracostomy tubes: Only CCT - Paramedics may monitor thoracostomy tubes Operations Modiﬁ ed On: December 1, 2011 107MEDICAL PERSONNEL ON THE SCENE MEDICAL PERSONNEL ON THE SCENE 1. MEDICAL PERSONNEL ON THE SCENE (non-physician) - If a bystander at the scene of an emergency identiﬁ es him/herself as a medical person, other than a physician, the First Responder or paramedic should: 1.1 Inform the individual that they may assist the emergency response team and/or oﬀ er suggestions, but may not assume medical management for the patient 1.2 Maintain overall scene management 2. PHYSICIAN ON THE SCENE - If a bystander at an emergency scene identiﬁ es him/herself as a physician: 2.1 BLS responder will work in conjunction with the physician until the arrival of ALS. 2.2 Paramedics should: ►give the physician a "Note to Physicians on Involvement with EMTs and Paramedics" card. (available at the EMS Oﬃ ce or on the EMS website.) The document below is a representation of the actual card) ►determine the alternative the physician has chosen (1, 2, or 3 on the card below) STATE OF CALIFORNIA cma CALIFORNIAMEDICAL ASSOCIATION ENDORSED ALTERNATIVES FOR PHYSICIAN INVOLVEMENT After identifying yourself by name as a physician licensed in the Sate of California, and, if requested, showing proof of identity, you may choose one of the following: 1. Oﬀ er your assistance with another pair of eyes, hands or suggestions, but let the life support team remain under base hospital control; or, 2. Request to talk to the base station physician and directly oﬀ er your medical advice and assistance; or, 3. Take total responsibility for the care given by the life support team and physically accompany the patient until the patient arrives at a hospital and responsibility is assumed by the receiving physician. In addition, you must sign for all instructions given in accordance with local policy and procedures. (Whenever possible, remain in contact with the base station physician) (REV. 1/12) 88 49638 Provided by the EMS Authority NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMTs AND PARAMEDICS A life support team (EMT or Paramedic) operates under stan- dard policies and procedures developed by the local EMS agency and approved by their Medical Director under Authority of Division 2.5 of the California Health and Safety Code. The drugs they carry and procedures they can do are restricted by law and local policy. If you want to assist, this can only be done through one of the alternatives listed on the back of this card. These alternatives have been endorsed by CMA, State EMS Authority, CCLHO and BMQA. Assistance rendered in the endorsed fashion, without com- pensation, is covered by the protection of the Good Samaritan Code@ (see Business and Professional Code, Sections 2144, 2395-2298 and Health and Safety Code, Section 1799.104). (over) ►ALTERNATIVE #1 - If the physician on scene chooses alternative #1, the physician should assist the paramedic team or oﬀ er suggestions but allow the paramedics to provide medical treatment according to County protocol ►ALTERNATIVE #2 or ALTERNATIVE #3 - If the physician on scene chooses alternative #2 or #3 the paramedics should ask to see the physician's medical license, unless the physician is known to the paramedics. Contact the Base Physician and have the physician on scene speak directly with the Base Physician 3. BASE HOSPITAL PHYSICIAN RESPONSIBILITY - After speaking to the physician on scene, the Base Physician should evaluate the situation and decide which of the available alternatives is in the best interests of the patient. These alternatives include: 3.1 retain medical control and request the physician on scene to assist the paramedics and/or oﬀ er suggestions only (alternative #1); or, 3.2 retain medical control but consider suggestions oﬀ ered by the physician on scene (alternative #2); or, 3.3 delegate medical control to the physician on scene (alternative #3) Operations Modiﬁ ed On: December 1, 2011 108 MEDICAL PERSONNEL ON THE SCENE MEDICAL PERSONNEL ON THE SCENE 4. PARAMEDIC RESPONSIBILITY 4.1 Alternative #1 or #2: ►Maintain medical control of the patient and provide medical treatment according to County Protocol 4.2 Alternative #3: ►ALS equipment and supplies should be made available to the physician. Oﬀ er assistance as needed ►The physician must go with the patient in the ambulance to the receiving hospital ►Document all care rendered to the patient on the EHR and ensure that the physician signs for all instructions and medical care given ►If appropriate, maintain communication with the Base Hospital or recontact if any problems arise 5. An EMS Unusual Occurrence Form shall be completed: 5.1 On any Physician or Medical Personnel on-scene calls if there was a problem associated with care rendered 5.2 For physician on-scene call if Alternative #3 was chosen (paramedics only) Operations Modiﬁ ed On: December 1, 2011 109ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE 1. INTRODUCTION: Ambulance response to the scene of a motor vehicle accident shall only be dispatched through County Dispatch (ALCO-CMED 925-422-7595). If a non-contract ambulance company is called to respond to an accident, the dispatcher should immediately call County Dispatch to initiate the appropriate public safety and ambulance response. 2. Ambulance First on Scene 2.1 If an ambulance unit witnesses an accident, the accident should be reported to their dispatch for initiation of appropriate public safety and/or emergency ALS ambulance personnel 2.2 If there are no ﬁ rst responders on scene and the crew is not en route to a medical emergency or transporting a patient code 3, they should stop to ascertain if there are injuries. If there are injuries, they are to render appropriate care within their scope of practice 2.3 If an emergency ALS ambulance has already been dispatched, the ambulance should not transport unless the delay might jeopardize the patient. The decision to transport should be made based upon the patient’s condition and the estimated time of arrival (ETA) of the emergency ALS ambulance 2.4 If an emergency ALS ambulance has not been dispatched but the patient’s condition is such that immediate transport is not required, the crew should request County Dispatch to dispatch an emergency ALS ambulance 3. Public Safety on Scene (police, CHP, ﬁ re) but no Ambulance Personnel 3.1 Stop to ascertain if assistance is required. The crew should notify the oﬃ cer on-scene that they have not been dispatched to this call 3.2 If an emergency ALS ambulance is not on the scene, medical authority rests with the most medically qualiﬁ ed responder. The decision to wait for an emergency ALS ambulance or to authorize transport by the ambulance is the responsibility of the most medically qualiﬁ ed responder, who should consider the condition of the patient, whether an ambulance has been requested through County Dispatch and the ETA of the emergency ALS ambulance 3.3 If the emergency ALS ambulance arrives on scene, medical authority rests with the personnel of the emergency ALS ambulance. This individual(s) should determine if assistance from the on viewing ambulance is required 4. Responsibility of an Ambulance Transporting from Scene 4.1 If the ambulance transports a patient(s) from an accident scene in accordance with this policy, and no other patients remain at the scene, County Dispatch should be immediately informed so that any additional responding units may be cancelled 4.2 The transporting ambulance should notify the receiving hospital emergency department by radio, cellular phone, or through their dispatch of their imminent arrival (see page 137) 4.3 A patient care report on the patient’s condition and treatment should be left at the emergency department. A copy of the report and an unusual occurrence form explaining the circumstances of the transport shall be submitted to the county within ten (10) days Operations Modiﬁ ed On: December 1, 2011 110 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS 1. PURPOSE: To allow Paramedic Field Supervisors to utilize ALS skills, within their scope of practice, while functioning in the role of Field Supervisor 2. Paramedic Field Supervisors must carry all of the ALS equipment authorized in Alameda County as per policy 3. Paramedic Field Supervisors must be able to perform all ALS procedures authorized in Alameda County as per policy 4. Each ALS provider agency planning to use Paramedic Field Supervisors in the role of care- giver must develop policies and procedures to assure that appropriate equipment and supplies are stocked and checked 5. In all instances, if a Paramedic Field Supervisor initiates any ALS procedure or administers any medications, prior to the arrival of an ALS unit, he/she must assist with documentation on the EHR and sign the EHR as a team member 6. The paramedic Field Supervisor may transfer the care of the patient to the arriving ALS unit after giving a report 7. The paramedic Field Supervisor will not be required to accompany the patient to the hospital unless requested to by the arriving ALS unit Operations Modiﬁ ed On: July 24, 2018 111 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING 1. GENERAL PRINCIPLES: In general, it is better to respond with more personnel and equipment than is needed and cancel excess assigned resources, than fail to dispatch appropriate personnel and equipment. First Responder and transport units should be dispatched in accordance with MPDS-based guidelines as approved by County EMS when there is a report of people who are ill or injured 2. CANCELING RESPONDING UNITS: Medical personnel ﬁ rst on the scene of an incident: 2.1 shall cancel a responding ambulance unit upon determination that, in the best judgment ofthe ﬁ rst responder, the incident does not involve an injury or illness. The ambulance should not be canceled if the patient is requesting care and transport, even if there is no apparent illness or injury 2.2 shall cancel the ambulance response if the patient meets the "Determination of Death" criteria or the patient has a valid Alameda County or California Medical Association (CMA) "Do Not Attempt Resuscitation" form (see "Death in the Field" page 87) 2.3 Ambulance personnel arriving ﬁ rst on the scene of a medical emergency shall cancel the First Responder/Law enforcement response only if assistance is not needed and a potential public safety risk does not exist at the emergency scene 3. UPGRADING RESPONDING UNITS: Medical personnel ﬁ rst on the scene of an incident should upgrade a responding unit to a "non-divertible" response status: 3.1 If it is determined by ﬁ rst on-scene medical personnel that the patient’s illness/injury meets any of the time-sensitive conditions requiring expedited transport criteria below: 3.1.1 Patients found to be experiencing a STEMI by 12-lead ECG 3.1.2 Patients shown to have ﬁ ndings of an active CVA within the current time treatment window 3.1.3 Patients who meet “Trauma Patient Criteria” as deﬁ ned on page 25 of this book 3.1.4 Patients who have signiﬁ cant compromise to their airway, breathing, circulation and/or vital signs 3.2 If a life-threatening scene safety issue(s) exists 4. DOWNGRADING RESPONDING UNITS: Medical personnel ﬁ rst on the scene of an incident: 4.1 shall reduce the responding resource(s) from Code 3 to Code 2 upon determination that, in the best judgment of the ﬁ rst medical personnel on-scene, the illness or injury is not immediately life threatening or that the diﬀ erence in Code 3 and Code 2 response time would not likely have an impact on patient outcome. Operations Modiﬁ ed On: May 27, 2021 112 RESTRAINTS RESTRAINTS 1. Patient restraints are to be utilized only when necessary and in those situations where the patient is exhibiting behavior deemed to present danger to him/herself or to the ﬁ eld personnel. When restraints are used: 1.1 The minimum restraint necessary, to accomplish necessary patient care and safe transportation, should be utilized 1.2 Circulation to the extremities (distal to the restraints) will be evaluated q 5 minutes 1.3 Leather or soft-restraints, designed speciﬁ cally for patient restraint, are the only authorized method of restraining patients. 1.4 The restraints must not be placed in such a way as to preclude evaluation of the patient's medical status (e.g. airway, breathing, circulation) necessary patient care activities, or in any way jeopardize the patient medically 2. If the patient is under arrest and handcuﬀ s are applied by law enforcement oﬃ cers: 2.1 The patient will not be cuﬀ ed to the stretcher and a law enforcement oﬃ cer shall accompany the patient in the ambulance, if the handcuﬀ s are to remain applied 2.2 A law enforcement oﬃ cer may elect to follow the ambulance in a patrol car to the receiving facility if the patient has been restrained on the gurney using leather restraints Operations Modiﬁ ed On: May 28, 2019 113 UNUSUAL OCCURENCES UNUSUAL OCCURENCES 3. Investigative reports will not disclose conﬁ dential or proprietary information collected during the investigation 4. The EMS Agency shall provide a report of the ﬁ ndings and action to the reporting party 5. This is an abbreviated version of the Unusual Occurence Policy. Please see the Alameda County EMS Agency Administration Manual for the complete version 1. PURPOSE: To set standards for reporting of incidents for the purpose of identiﬁ cation of opportunities for improvement in clinical outcomes and/or systems structures and processes 2. POLICY OVERVIEW: Level IPeer to Peer Reporting Level IIUnusual Occurence Reporting Level IIIMandatory Reporting ►For minor interpersonal issues, misunderstandings, or operational issues not involving patient care ►Resolve as soon as possible after the incident in person or by telephone with Supervisors or Management Representatives ►If unsure whether the issue is Level I or II, or if the issue cannot be resolved at this level, an Unusual Occurence Form should be submitted ►For patient care issues, complete an ALCO EMS Unusual Occurence Form and email to provider management (This includes commendations) ►For system issues involving patient care, email a completed Unusual Occurence Form to ALCO EMS: alco.uo@acgov.org ►Reporting party may also call provider management or ALCO EMS to verbally report an incident which will be documented on an Unusual Occurence form by the provider Includes, but not limited to incidents involving: ►Clinical acts or omissions that may be a threat to public health and safety, considered negligent, or contributing to poor patient outcome ►Use of intoxicants or impaired ability due to alcohol or drugs while on duty ►Email a completed Unusual Occurence Form to ALCO EMS: alco.uo@acgov.org ►Reporting Party shall also call provider management or ALCO EMS to verbally report an incident which will be documented on an Unusual Occurence Form by the provider 114 THIS PAGE INTENTIONALLY LEFT BLANK Procedures Modiﬁ ed On: May 27, 2021 115 PROCEDURE POLICIES TOC PROCEDURE POLICIES TOC PROCEDURE POLICIES TOC ...................................................................................115 ADVANCED AIRWAY MANAGEMENT .......................................................................116 ASSESS AND REFER GUIDELINES .........................................................................118 CONSENT AND REFUSAL GUIDELINES..................................................................119 CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP .........................................124 EKG - 12 LEAD ...........................................................................................................126 HEMORRHAGE CONTROL ........................................................................................128 IMPEDANCE THRESHOLD DEVICE (ITD) ................................................................130 INTRANASAL (IN) MEDICATION ADMINISTRATION ...............................................131 INTRAOSSEOUS ACCESS PROCEDURE ................................................................132 PLEURAL DECOMPRESSION ...................................................................................133 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES ................................................134 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE .......................135 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS ................................................136 REPORTING FORMAT ...............................................................................................137 SEDATION ..................................................................................................................138 SPINAL INJURY ASSESSMENT ................................................................................140 SPINAL MOTION RESTRICTION (SMR) ...................................................................142 STOMA AND TRACHEOSTOMY ................................................................................143 TRANSCUTANEOUS PACING - TCP .........................................................................145 TRANSFER OF CARE ................................................................................................146 Procedures Modiﬁ ed On: May 10, 2019 116 ADVANCED AIRWAY MANAGEMENT ADVANCED AIRWAY MANAGEMENT 1. INTRODUCTION: The approved airway management procedure consists of endotracheal intubation (ETI) or insertion of a supraglottic airway (SGA) device. ***Nasotracheal intubation is NOT an approved skill in Alameda County*** 1.1 Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary with all patients. 1.2 For patients ≥ 40kg, personnel are authorized to perform the skill of endotracheal intubation or placement of an SGA. 1.3 For patients < 40kg, BVM ventilation is the preferred method of ventilatory management. If BVM ventilation is unsuccessful or impossible, a SGA device may be placed. 1.4 If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to responds to initial CPR and deﬁ brillation or demonstrates ROSC (2015 AHA Guidelines) 1.5 Personnel must conﬁ rm tube placement (ETI or SGA) with capnography / capnometry, auscultation and physical assessment (auscultation, observation of chest rise, visualization of the tube passing through the cords, etc.). See Section #4. 2. INDICATIONS: 2.1 Non-traumatic cardiac and/or respiratory arrest. 2.2 Traumatic cardiac and/or respiratory arrest or severe ventilatory compromise where the airway cannot be adequately maintained by BLS techniques. 3. APPROVED ADVANCED AIRWAY MANAGEMENT PROCEDURE: 3.1 Endotracheal intubation 3.1.1 Deﬁ nition: An intubation attempt is deﬁ ned as the insertion of the laryngoscope blade into the patient's mouth. 3.1.2 Make no more than 2 total intubation attempts per patient. Each attempt should not last longer than 30 seconds. Ventilate with 100% oxygen for one minute prior to each attempt. 3.1.3 If patient has a Cormack-Lehane* grade of 3 or 4 (epiglottis is not or is barely visible), consider primary use of a supraglottic airway. *Cormack-Lehane scale Grade 1 Grade 2 Grade 3 Grade 4 Procedures Modiﬁ ed On: May 10, 2019 117 ADVANCED AIRWAY MANAGEMENT ADVANCED AIRWAY MANAGEMENT 3.2 Supraglottic Airway Device (i-gel®) 3.2.1 Deﬁ nition: A supraglottic airway attempt is deﬁ ned as the insertion of the supraglottic airway device into the patient's mouth. 3.2.2 For patients ≥ 40kg, a supraglottic airway (i-gel®) device may be placed as a primary airway (if Cormack-Lehane grade is 3 or 4) or after unsuccessful attempt(s) at endotracheal intubation. 3.2.3 For patients < 40kg, BVM ventilation is the preferred method of ventilatory management. If BVM ventilation is unsuccessful or impossible, an SGA device may be placed 3.2.4 The i-gel® SGA device comes in seven sizes determined by the patient's weight: Size 5 4 3 2.5 2.0 1.5 1.0 Weight (kg) >90kg 50-90kg 30-60kg 25-35kg 10-25kg 5-12kg 2-5kg 3.2.5 The patient should be in the sniﬃ ng position. The chin should be gently pressed down/ inferior before proceeding to insert the i-gel device. 3.2.6 Introduce the leading soft tip into the mouth of the patient in a direction toward the hard palate. 3.2.7 Glide the i-gel device downwards and backwards along the hard palate with a continuous, but gentle push until deﬁ nitive resistance is felt. 3.2.8 Do not apply excessive force during insertion. 3.2.9 If unexpected resistance is met during insertion, apply jaw-thrust and slightly rotate the device. 4. CONFIRM TUBE PLACEMENT: To be used on an endotracheal tube or the i-gel® device in the order listed below 4.1 Visualize the ETT passing through the vocal cords and look for chest rise with ventilation. 4.2 Auscultate both lung ﬁ elds for breath sounds. Listen over left upper quadrant of the abdomen for air in the stomach 4.3 Waveform capnography/capnometry must be continuously monitored. 4.4 Document. All devices used to conﬁ rm ETT/SGA placement should be electronically uploaded into and documented on the patient's EHR. 4.4.1 Describe waveform (e.g. box, shark ﬁ n, straight line, bumpy line, etc.) 4.4.2 Capnometry number in mmHg (e.g.15 mmHg) should be, at a minimum, documented at the initiation of monitoring, after every patient movement, and at transfer of patient care. 4.5 If there is any doubt as to proper placement of the endotracheal tube, visualize the pharynx and vocal cords with laryngoscope and use capnographic waveform to make a decision. If still in doubt, suction the patient, deﬂ ate the cuﬀ , remove the endotracheal tube and replace with a supraglottic airway. (Be prepared - removal of an ET tube may induce vomiting). Ventilate between attempts with 100% oxygen 5. If the patient regains consciousness while intubated, do not extubate. Use restraints as necessary to prevent uncontrolled extubation. Consider Sedation (see Sedation page 138) 6. If the patient has a suspected spinal injury: ►Open the airway using a jaw-thrust without head extension ►If airway cannot be maintained with jaw thrust use a head-tilt/chin-lift maneuver ►Manually stabilize the head & neck rather than using an immobilization device during CPR Procedures Modiﬁ ed On: August 21, 2018 118 ASSESS AND REFER GUIDELINES ASSESS AND REFER GUIDELINES The Assess and Refer process identiﬁ es patients whose condition does not require transport by 911 emergency ambulance. All 911 calls for EMS will receive an appropriate response, timely assessment, and appropriate patient care. 1. Paramedic Assess and Refer Decision Making Principles ►Does the patient, guardian, or parent have Decision Making Capacity? ►How concerned are you with the patient's current medical issue? ►How likely is the patient to successfully navigate the provided referral? 2. Assess and Refer Criteria The patient, guardian, or parent should meet all of the following criteria: ►Is an adult (18 years of age or over), or legally emancipated if under 18 years of age ►Is oriented to Person, Place, Time, and Situation ►Exhibits no evidence of: Altered level of consciousness Alcohol or drug ingestion that impairs Decision Making Capacity ►Exhibits evidence of Decision Making Capacity suﬃ cient to understand the nature of the medical condition as well as the risks and potential consequences of not seeking additional medical care/transport from the provided referral ►The patient would beneﬁ t from the provided referral ►The patient is likely to successfully navigate the provided referral 3. Documentation Requirements ►Physical exam ►Evidence that the patient, parent, or guardian is alert, oriented, and acting appropriately for their age ►Indications that there were no signs of signiﬁ cant impairment due to drugs, alcohol, organic causes, or mental illness ►Any other observations that indicate that the patient, guardian, or parent had unimpaired Decision Making Capacity ►The fact that you oﬀ ered care/treatment and provided a referral ►What you told the patient, guardian, or parent about the nature of the illness/injury and the speciﬁ c risks accepting the provided referral for the medical condition (utilize "quotes" as appropriate) ►The indicators that the patient, guardian, or parent understands the above risks ►What the patient, guardian, or parent speciﬁ cally stated about why he/she is accepting the provided referral (utilize "quotes" as appropriate) ►Your eﬀ orts to encourage the patient, guardian, or parent to seek care via the provided referral ►The person(s), if any, who remained to look after the patient (the patient's "support system") ►The name of the interpreter utilized, if applicable Procedures Modiﬁ ed On: July 24, 2018 119 CONSENT AND REFUSAL GUIDELINES CONSENT AND REFUSAL GUIDELINES 1. INTRODUCTION: 1.1 Adults with Decision-Making Capacity may refuse EMS care and/or transportation 1.2 All potential patients at the scene of an EMS system call must be oﬀ ered medical care 1.3 Consent to treat and/or transport may be actual, expressed, or implied (the patient is unable to give consent but is in need of medical attention - e.g., an unconscious patient) 1.4 If the individual consents, treat only according to the scope of the consent. Adults with Decision- Making Capacity can give partial consent, (e.g., transportation without treatment). There is no legal duty to provide unwanted treatment or transportation 2. PATIENT DEFINITION: 2.1 The deﬁ nition of 'patient' is any individual that: ►Has a complaint suggestive of potential illness or injury ►Requests evaluation for potential illness or injury ►Has obvious evidence of illness of injury ►Has experienced an acute event that could reasonably lead to illness or injury ►Is in a circumstance or situation that could reasonably lead to illness or injury Is the individual deﬁ ned as a patient? (Refer to 2.1 above)YES NO Continue to Section 3: Refusal of Care Note: ALS Personnel only Skip to Section 7 Refusal of Service Note: BLS and ALS personnel may honor a Refusal of Service NOTE TO BLS PERSONNEL: If the individual is deﬁ ned as a patient and is refus-ing care, the patient requires an assessment by an ALS provider. Treat as nec-essary while awaiting the arrival of ALS personnel. Continue to page 23: Transport Guidelines Continue to page 118: Assess and Refer Guidelines Note: ALS Personnel only Procedures Modiﬁ ed On: July 24, 2018 120 CONSENT AND REFUSAL GUIDELINES CONSENT AND REFUSAL GUIDELINES 3. REFUSAL OF CARE - applies to patients who by direct examination, mechanism of injury, or by initiating a patient relationship by dialing 9-1-1 for medical care for themselves, are refusing medical care/transportation. Only ALS personnel may honor a refusal of care 3.1 In order to refuse care, a patient, parent, or guardian must have legal and mental Decision- Making Capacity by meeting all of the following criteria: 3.1.1 Is an adult (18 or over), or if under 18 legally emancipated 3.1.2 Understands the nature of the medical condition, and the risks and consequences of refusing care 3.1.3 Exhibits no evidence of: ►Altered level of consciousness ►Alcohol or drug ingestion that impairs judgment 3.1.4 Is oriented to Person, Place, Time, and Situation 3.2 Actions: 3.2.1 If the patient has the legal and mental Decision-Making Capacity for refusing care: ►Honor the refusal ►Document thoroughly. Complete a EHR and a “Refusal of Care” form 3.2.2 If the patient does not have the legal or mental Decision-Making Capacity to refuse care: ►Document on the EHR to show that the patient required immediate treatment and/or transport, and lacked the legal or mental Decision-Making Capacity to understand the risks/ consequences of refusal. (implied consent) ►Treat only as necessary to prevent death or serious disability and transport ►Do not request a 5150 hold unless the patient requires a psychiatric evaluation 4. BASE CONTACT: A refusal of care may be against the advice of the EMS responders and/or the base hospital physician (AMA); however, an adult with Decision-Making Capacity has the legal right to refuse care. For patients with acute conditions (see 4.1.2 and 4.1.3 below) every eﬀ ort should be made to convince the patient to be transported. Be persuasive - get help from: ►Family members, friends, etc. ►The Base Physician ►Consider calling law enforcement especially if the patient is a child 4.1 Paramedics should contact the Base Physician: 4.1.1 For any patient being treated and/or transported involuntarily 4.1.2 Whenever the refusal of care and/or transport poses a threat to the patient’s well-being 4.1.3 Additional examples of situations where Base Physician contact should be made include, but are not limited to: ►Markedly abnormal vital sign ►Uncontrolled hemorrhage ►Suspected ischemic chest pain ►Suspected new onset Acute Stroke ►Any patient meeting critical trauma criteria ►Any condition for which ﬁ eld personnel believe that admission to an emergency department/hospital may be necessary ►Any time medical treatment is begun and then the patient refuses transport Procedures Modiﬁ ed On: February 15, 2012 121CONSENT AND REFUSAL GUIDELINES CONSENT AND REFUSAL GUIDELINES 5. REQUIRED DOCUMENTATION FOR THE PATIENT REFUSING CARE: ►Physical exam ►Evidence that the patient was alert, oriented and appropriate for their age ►Indications that there were no signs of signiﬁ cant impairment due to drugs, alcohol, organic causes, or mental illness ►Anything else that made you believe that the patient was mentally capable ►The fact that you oﬀ ered treatment and transportation ►What you told the patient about the nature of the illness/injury and the speciﬁ c risks of refusal for the medical condition. (Use “quotes” as appropriate) ►The indications that the patient understood these risks ►What the patient speciﬁ cally said about why he/she is refusing treatment/transport. (Use “quotes” as appropriate) ►Your eﬀ orts to encourage the patient to seek care ►The person(s), if any, who remained to look after the patient (the patient's "support system") ►The name of the interpreter, if applicable 6. OTHER THINGS TO CONSIDER: 6.1 Other situations where a minor may consent to but may not refuse medical care include: ►A minor who is 12 years of age or older, for the treatment of drug or alcohol problems, or infectious, contagious or communicable diseases ►A minor of any age who is pregnant, for medical care related to the pregnancy ►At least 15 years old, living separate and apart from the parent/guardian and managing his or her own ﬁ nancial aﬀ airs 6.2 If the parent/guardian is unavailable consent/refusal of care may be obtained over the telephone. Document exactly as you would if the parent/guardian was present on scene. Verify the name and relationship of the individual to the patient. Attempt to have another person validate the consent/refusal with the parent/guardian. Document exactly what was said, use “quotes” as appropriate 6.3 If the patient is 18 or older but there is reason to suspect that the patient has been judged incompetent by a court and placed under a legal conservatorship, seek consent from the designated guardian 6.4 If the parent/guardian is unavailable and treatment can be safely delayed: ►Document thoroughly ►Attempt to reach the parent/guardian by phone. Do not release the child in the custody of a relative or friend unless that individual has been authorized by the parent/guardian to make medical decisions for that child ►Transport to a hospital or leave in the custody of a law enforcement oﬃ cer. 6.5 If the parent/guardian is unavailable and treatment cannot be safely delayed: ►Treat and transport as necessary to prevent death or serious disability (implied consent) ►Document on the EHR to show that your treatment was reasonable and necessary under the circumstances 6.6 If the parent/guardian is available but refuses to consent for necessary, emergency treatment: ►Explain the risks of refusal ►Be persuasive and/or get help from family members, Base Physician or law enforcement ►Document the situation/statements by parent/guardian thoroughly on the EHR and complete an Alameda County EMS Refusal of Care form Procedures Modiﬁ ed On: February 15, 2012 122 CONSENT AND REFUSAL GUIDELINES CONSENT AND REFUSAL GUIDELINES 6.7 An individual under arrest or incarcerated is legally capable of consenting or refusing medical care 6.8 The law presumes that an individual is competent to consent or refuse. The party alleging a lack of capacity has the legal burden of proving it. Document accordingly; anyone forcing treatment on an unwilling patient must be able to prove both the necessity of the treatment and the incapacity of the patient 6.9 If you cannot complete the refusal of service log due to scene safety issues or upon the insistence of another agency, complete an unusual occurrence form and send it to the EMS Agency 7. REFUSAL OF SERVICE - applies to those persons who do not meet (see 2.1) the deﬁ nition of a patient and are refusing all EMS services. The oﬀ er of an assessment and transport must be made and refused by the individual. BLS and ALS personnel may honor a refusal of service 7.1 The individual must meet all of the following criteria: ►Does not have a complaint suggestive of potential illness or injury ►Does not request evaluation for potential illness or injury ►Does not have obvious evidence of illness of injury ►Has not experienced an acute event that could reasonably lead to illness or injury ►Is not in a circumstance or situation that could reasonably lead to illness or injury 7.2 Actions: ►Honor the refusal ►Enter the individual’s name on the “Refusal of Service log” and obtain a signature ►Complete a EHR detailing circumstances of refusal of service ►In an event where multiple people sign a Refusal of Service log, complete one EHR detailing the circumstances of that event (not one for each patient) Procedures Modiﬁ ed On: July 24, 2018 123 CONSENT AND REFUSAL GUIDELINES CONSENT AND REFUSAL GUIDELINES DI S P O S I T I O N O F M I N O R S ( s e e s e c t i o n 6 ) • M i n o r s m u s t b e l e f t i n t h e c u s t o d y o f a p a r e n t , gu a r d i a n , c o n s e r v a t o r o r l a w e n f o r c e m e n t • C o n s e n t t o l e a v e a m i n o r o n - s c e n e c a n b e ob t a i n e d f r o m a p a r e n t , g u a r d i a n o r c o n s e r v a t o r vi a t e l e p h o n e » M a k e b a s e c o n t a c t i t a p p r o p r i a t e » D o c u m e n t t h e c o n v e r s a t i o n o n t h e ap p r o p r i a t e R O C o r R O S f o r m » T h o r o u g h l y d o c u m e n t t h e c o n v e r s a t i o n an d c i r c u m s t a n c e s o f t h e e n c o u n t e r o n t h e PC R . P a y s p e c i a l a t t e n t i o n t o i n c l u d e mi n i m u m d o c u m e n t a t i o n r e q u i r e m e n t s i n se c t i o n 5 a b o v e ME N T A L C A P A C I T Y • U n d e r s t a n d s : » N a t u r e o f t h e m e d i c a l co n d i t i o n » R i s k s a n d c o n s e q u e n c e s o f re f u s i n g c a r e • E x h i b i t s no ev i d e n c e o f : » A L O C » A l c o h o l o r d r u g i n g e s t i o n t h a t im p a i r s j u d g m e n t • O r i e n t e d t o P e r s o n , P l a c e , T i m e , a n d E v e n t LE G A L C A P A C I T Y • 1 8 o r o v e r • E m a n c i p a t e d m i n o r : » D e c l a r a t i o n o f e m a n c i p a t i o n » M a r r i e d » O n a c t i v e m i l i t a r y d u t y YE S YE S YE S NO NO NO Do e s t h e pe r s o n h a v e le g a l ca p a c i t y ? Do e s t h e pe r s o n h a v e me n t a l ca p a c i t y ? Is a p a r e n t , gu a r d i a n , co n s e r v a t o r , o r PD a v a i l a b l e ? Is t h e p e r s o n de f i n e d a s a p a t i e n t ? (s e e 2 . 1 a b o v e ) Go t o S e c t i o n 3 Re f u s a l o f C a r e No t e : A L S P e r s o n n e l o n l y Go t o S e c t i o n 7 Re f u s a l o f S e r v i c e No t e : B L S a n d A L S p e r s o n n e l ma y h o n o r a R e f u s a l o f S e r v i c e YE S NO Tr a n s p o r t CO N S I D E R B A S E CO N T A C T F O R P A T I E N T S WH O R E F U S E TR A N S P O R T (s e e s e c t i o n 4 a b o v e ) NO T E T O B L S P E R S O N N E L : I f t h e i n d i v i d u a l i s d e f i n e d a s a pa t i e n t a n d i s r e f u s i n g c a r e , t h e p a t i e n t r e q u i r e s a n as s e s s m e n t b y a n A L S p r o v i d e r . T r e a t a s n e c e s s a r y w h i l e aw a i t i n g t h e a r r i v a l o f A L S p e r s o n n e l . Go t o P a g e 2 3 : Tr a n s p o r t G u i d e l i n e s Go t o P a g e 1 1 6 : As s e s s a n d R e f e r Gu i d e l i n e s No t e : A L S P e r s o n n e l o n l y Procedures Modiﬁ ed On: December 1, 2011 124 CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP 1. PURPOSE: To improve ventilation and oxygenation, and avoid intubation. CPAP is required for all ALS providers. 2. INDICATIONS: Patients age 8 or older in severe respiratory distress and: ►CHF with pulmonary edema ►Near-drowning ►Other causes of severe respiratory distress 3. CONTRAINDICATIONS - Bag-valve-mask ventilation or endotracheal intubation should be considered for any patient who exhibits one or more of the following contraindications 3.1 Absolute Contraindications (DO NOT USE): ►Age < 8 ►Respiratory or cardiac arrest ►Agonal respirations ►Severely depressed level of consciousness ►Systolic blood pressure < 90 ►Signs and symptoms of pneumothorax ►Inability to maintain airway patency ►Major trauma, especially head injury with increased ICP or signiﬁ cant chest trauma ►Facial anomalies or trauma (e.g., burns, fractures) ►Vomiting 3.2 Relative Contraindications (USE CAUTIOUSLY): ►History of Pulmonary Fibrosis ►Decreased LOC ►Claustrophobia or unable to tolerate mask (after ﬁ rst 1-2 minutes trial) 4. COMPLICATIONS: ►Hypotension ►Pneumothorax ►Corneal Drying 5. GOALS OF CPAP: ►Elimination of dyspnea ►Decreased respiratory rate ►Decreased heart rate ►Increased Sp02 ►Stabilized blood pressure Bag-valve-mask ventilation or endotracheal intubation should be considered if the patient fails to show improvement based on the above goals. Procedures Modiﬁ ed On: December 1, 2011 125CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP For all CPAP patients: 6. FAILURE TO IMPROVE: Should the patient fail to show improvement with CPAP (as evidenced by the following) remove the CPAP device and assist ventilations with BVM, as needed 6.1 Sustained or increased heart rate, 6.2 Sustained or increased respiratory rate, 6.3 Sustained or increased blood pressure, 6.4 Sustained or decreasing pulse oximetry readings, and/or 6.5 Decrease in level of consciousness 7. DOCUMENTATION: 7.1 The use of CPAP rnust be documented on the EHR 7.2 Vital signs (BP, HR, RR, Sp02) must be documented every 5 minutes. 7.3 Narrative documentation should include a description of the patient's response to CPAP. Refer to "Goals of CPAP" for descriptive terms that may be useful 7.4 Additional narrative documentation should include if the patient does not respond to CPAP and endotracheal intubation is required Procedures Modiﬁ ed On: May 26, 2016 126 EKG - 12 LEAD EKG - 12 LEAD 1. INTRODUCTION: 12-lead electrocardiograms (EKGs) are used with a variety of patients and should be used with a number of patient care policies (e.g., ALOC (page 33), Chest Pain/MI (page 37), and CHF/ Pulmonary Edema (page 43). Treatment under these policies should proceed in conjunction with the application of the 12-lead EKG. Our goal is to incorporate the 12-lead EKG into our destination decision making process with regard to the ST-elevation MI (STEMI) patient. The transmission or reporting of the ST- elevation MI should decrease “door-to-intervention” times in our communities’ hospitals Approved STEMI Centers are: STEMI Centers ED Phone Number Kaiser Walnut Creek (Out of County) (925) 939-1788 Kaiser Fremont (510) 248-5011 Kaiser Oakland (510) 752-8869 Alameda County Medical Center - Highland (510) 535-6000 San Ramon Medical Center (Out of County) (925) 275-8338 St. Rose Hospital (510) 264-4251 Summit Medical Center (510) 869-8797 Valley Care Medical Center (925) 416-6518 Washington Hospital (510) 608-1367 Only ALS personnel who are employed by an agency with an approved 12-lead EKG program and who have received the required training may perform a 12-lead EKG. [see 12-LEAD EKG PROGRAM (#4210) in the Administrative Manual for training and program requirements]. 12-lead EKG is required for ALS transport providers. 2. INDICATIONS: Any patient with known or suspected Acute Coronary Syndrome (ACS) ►chest pain ►discomfort or tightness radiating to the jaw, shoulders or arms ►nausea ►ROSC ►diaphoresis ►dyspnea ►anxiety ►syncope/dizziness ►other “suspicious symptoms” ►known treatment for ACS 3. EKG CRITERIA FOR STEMI: convex, “tombstone,” or ﬂ at ST segment elevation in two or more contiguous leads. Use the machine reading “acute MI” or the equivalent, as the principal determinant for STEMI assessment Procedures Modiﬁ ed On: June 6, 2012 127 EKG - 12 LEAD EKG - 12 LEAD 4. PROCEDURE: 4.1 Attach EKG leads to the patient (limb leads to the upper arms and ankles, and six chest leads). Perform an EKG as indicated in #3 above ►V1: right 4th intercostal space ►V2: left 4th intercostal space ►V3: halfway between V2 and V4 ►V4: left 5th intercostal space, mid-clavicular line ►V5: horizontal to V4, anterior axillary line ►V6: horizontal to V5, mid-axillary line ►V4R: right 5th intercostal space, mid-clavicular line (use in all suspected inferior MIs) 4.2 If the EKG machine is reading “Acute MI” or the equivalent, or deﬁ nite new left bundle branch block, immediately transmit the EKG and notify the STEMI Receiving Center. Use the machine reading as the principal determinant for STEMI assessment. Use your clinical judgment for situations outside of those listed above 4.3 Include the following information in your report: ►Age and sex ►Interpretation of the 12-lead EKG (leads, amount of ST elevation in millimeters, “conﬁ dence” in your 12-lead assessment) ►Location of reciprocal changes (if applicable) ►Symptoms (including presence or absence of chest pain) ►Presence of new left bundle branch block. Presence of imposters (early repolarization left bundle branch block, left ventricular hypertrophy, pericarditis or paced rhythms). ►Signiﬁ cant vital signs and physical ﬁ ndings ►Time of onset ►Estimated time of arrival to receiving STEMI Receiving Center 4.4 Transport patients with ST elevation in two or more contiguous leads and symptoms of ACS to the closest, most appropriate STEMI Receiving Center. Personnel should consider traﬃ c and weather conditions, as well as the patient’s choice of facility or physician 4.5 Any 12-lead EKGs obtain should attached to the EHR 4.6 Serial 12-lead EKGs, en route, are required in patients with strong symptomology and are encouraged in all other patients 4.7 Follow your agency’s procedure for QI purposes Procedures Modiﬁ ed On: May 10, 2019 128 HEMORRHAGE CONTROL HEMORRHAGE CONTROL 1. INTRODUCTION: Controlling severe bleeding from an extremity injury can be challenging (especially in the lower limbs). Use of a County-approved tourniquet can assist in the care of patients with uncontrollable bleeding in the extremities safely and eﬀ ectively when the appropriate precautions are taken. Approved for both ALS and BLS. 2. INDICATIONS: ►Amputation ►Failure to stop bleeding with pressure dressing(s) ►Injury does not allow control of bleeding with pressure dressing(s) ►Impaled foreign body with ongoing extremity bleeding ►Under diﬃ cult or dangerous situation for responding caregivers ►Mass casualty event ►Signiﬁ cant extremity hemorrhage in the face of any or all of: • Need for airway management • Need for breathing support • Circulatory shock • Need for other emergent interventions or assessment • Signiﬁ cant bleeding from multiple locations 3. TOURNIQUET: Place County-approved tourniquet according to manufacturer's instructions 4. WOUND PACKING: Signiﬁ cant uncontrolled bleeding from extremity and junctional (shoulder or groin) wounds may be packed with standard or hemostatic gauze. Wounds to the chest, abdomen, or pelvis should not be packed. 5. HEMOSTATIC AGENT: After tourniquet placement, and to aid in severe arterial bleeding; or to control severe bleeding where tourniquets are not indicated (trunk, head, neck, etc), use of a hemostatic gauze is indicated. Use of hemostatic gauze is optional. 6. PROCEDURE: Any standard gauze or County-approved hemostatic gauze may be utilized Procedures Modiﬁ ed On: May 6, 2013 129 HEMORRHAGE CONTROL HEMORRHAGE CONTROL Tourniquet Reassessment Algorithm Patient in circulatory shock?Yes No Unstable clinical situation? Yes No Limited personnel or resources? Yes No Go to tourniquet removal algorithm Leave on and transport Tourniquet Removal Algorithm§ Amputated extremity?Yes No Significant Bleeding from site? Yes No Reassess as needed Leave on and transport Yes Apply tourniquet to bleeding limb(s) on proximal segment Significant Extremity Bleeding with need for other interventions?* Transport time > 30 minutes expected? Go to appropriate protocol No Yes No Leave on and transportGo to tourniquet reassessment algorithm Apply pressure dressing before loosening tourniquet. After applying pressure dressing, loosen tourniquet (leave it in place) Retighten tourniquet and transport Before applying a tourniquet, and if time permits, attempt to control bleeding via direct pressure * §NOTE: Do not go to the Tourniquet Removal Algorithm unless transport time is greater than 30 minutes AND criteria have been met in the Tourniquet Reassessment Algorithm for removal Procedures Modiﬁ ed On: December 1, 2011 130 IMPEDANCE THRESHOLD DEVICE (ITD) IMPEDANCE THRESHOLD DEVICE (ITD) 1. INTRODUCTION: ResQPOD® is an impedance threshold device (ITD) that enhances the vacuum in the chest that forms during the chest recoil phase of CPR. Studies have shown that this process draws more blood back to the heart (increases preload), and increases cardiac output, blood pressure, perfusion to vital organs and survival rates 2. WARNINGS: Contraindicated in patients where cardiopulmonary resuscitation (CPR) is not indicated. Never use on patients with pulse or spontaneous breathing. Remove immediately from ventilation circuit once CPR is discontinued 3. INDICATIONS: To be used on all patients ≥ 8 years of age in cardiac arrest 4. CONTRAINDICATIONS: 4.1 Patients under the age of eight (8) 4.2 Patients with a ﬂ ail chest 5. PROCEDURE: The ResQPOD can be used for either basic or advanced life support during cardiac arrest, with a bag-valve mask attached to a face mask, an endotracheal (ET) tube, or other airway devices (e.g. - SGA) 5.1 Select airway adjunct (tube or mask) 5.2 Attach bag-valve to air intake port on ResQPOD 5.3 Slide the Ventilation Timing Assist Light switch to on when using the ResQPOD in an intubated patient 5.4 Begin CPR (page 9): ►Allow for complete chest release/recoil after each compression ►Follow recommended ventilation rates ►DO NOT hyperventilate 5.5 Use 30:2 compressions:ventilation ratio (15:2 for infants and children with 2 rescuers) for basic life support when using a face mask. Ventilate intubated patients 8-10 breaths/minute with each breath lasting 1.5 seconds (maximum) to optimize CPR and ResQPOD eﬃ cacy. Excessive ventilation rates will reduce the eﬀ ectiveness of the ResQPOD 5.6 Clean or suction vomit or secretions from the ResQPOD by removing from airway adjunct and shaking or blowing out debris using ventilation source. NOTE: Discontinue use if correct function cannot be assured. After pulse and/ or spontaneous respirations have been restored, immediately remove ResQPOD from ventilation circuit and help patient breathe as needed ResQPOD© Impedance Threshold Device Timing Light Switch *Note: the timing light ensures that ven- tilations do not exceed 8 - 10 per minute Procedures Modiﬁ ed On: May 13, 2015 131 INTRANASAL (IN) MEDICATION ADMINISTRATION INTRANASAL (IN) MEDICATION ADMINISTRATION 1. INDICATIONS: ►Fentanyl for pain management ►Naloxone for suspected opiate overdose on patients who are apneic or near-apneic with a pulse -or- ►Midazolam for seizures or sedation 2. PROCEDURE: 2.1 Assess ABC’s (Airway, Breathing, Circulation) 2.2 For pulseless patient, go to appropriate cardiac arrest protocol 2.3 Establish airway and begin bag-valve-mask ventilation with 100% O2 if appropriate 2.4 Load syringe with the appropriate dose.. See speciﬁ c treatment algorithms: ►Pain Management – Adult page 41 | Pediatric page 66 ►Respiratory Depression or Apnea – Adult page 44 | Pediatric page 72 ►Sedation – page 138 ►Seizure – Adult page 49 | Pediatric page 76 2.5 Attach MAD nasal atomizer 2.6 Place atomizer 1.5 cm into the nostril 2.7 Briskly compress the syringe to administer 1/2 of the medication 2.8 Remove and repeat into the other nostril until all the medication has been administered. ►Continue ventilating the patient as needed ►If no appropriate response within 3 minutes, go to appropriate policy Procedures Modiﬁ ed On: May 27, 2021 132 INTRAOSSEOUS ACCESS PROCEDURE INTRAOSSEOUS ACCESS PROCEDURE 1. PURPOSE: To obtain rapid circulatory access to provide necessary intravenous ﬂ uids or medications 2. INDICATIONS: ►Consider for use in any unconscious or seriously ill or injured patient in whom IV access cannot be established in a timely fashion ►Any medications or ﬂ uids that can be given in a peripheral vein can be given intraosseous 3. CONTRAINDICATIONS: ►Fracture in target bone ►Previous, signiﬁ cant orthopedic procedure at the site, prosthetic limb or joint ►IO catheter use in past 48 hours of the target bone ►Infection at the area of insertion ►Excessive tissue (severe obesity) and/or absence of adequate anatomical landmarks 4. APPROVED IO ACCESS SITES (see additional references below): 4.1 Proximal Tibial Tuberosity 4.2 Proximal Humerus 4.3 Distal Femur (<10 y/o unconscious patient only) 5. NEEDLE SIZING REFERENCE: ►15 mm Needle Set (pink hub, 3kg-39kg) ►25 mm Needle Set (blue hub, >3kg) ►45 mm Needle Set (yellow hub, >40kg with excessive tissue) 6. IO ACCESS SITE PAIN MANAGEMENT 6.1 If the patient is responsive to pain, consider Pain Management Adult page 41, Pediatric page 66. Also, consider use of 2% Lidocaine for anesthetic eﬀ ect. Prime EZ-Connect extension set with lidocaine Note that the priming volume of the EZ-Connect is approximately 1.0mL ►ADULT - 40mg (2 mL) 2% Lidocaine slowly over 120 seconds. Let Lidocaine dwell for 60 seconds. Flush with 5 to 10ml NS. Slowly administer an additional 20mg of lidocaine IO over 60 seconds. Repeat PRN ►PEDIATRIC - 0.5mg/kg (not to exceed 40mg) 2% Lidocaine slowly over 120 seconds. Let Lidocaine dwell for 60 seconds. Flush with 2 to 5ml NS. Slowly administer subsequent lidocaine (half the initial dose) IO over 60 seconds. Repeat PRN Proximal Tibia Proximal Humerus Distal Femur (<10 y/o unconscious pt only) Procedures Modiﬁ ed On: May 10, 2019 133 PLEURAL DECOMPRESSION PLEURAL DECOMPRESSION 1. INDICATIONS: When clinical ﬁ ndings reveal a tension pneumothorax (severe respiratory distress, diminished breath sounds on the aﬀ ected side, tracheal deviation) with rapidly deteriorating vital signs 2. EQUIPMENT: 2.1 County-approved decompression needle/kit 3. PROCEDURE: 3.1 Preferred Site: ►2nd or 3rd intercostal space, mid-clavicular line 3.2 Prep site with chlorhexidine 3.3 Firmly but carefully insert the needle at a 90 degree angle just over the superior aspect (superior border) of the rib, through the skin and pleura until air escapes or a distinct "give" is felt. The undersurface of the rib should be avoided to limit injury to the neurovascular bundle. Air should be freely aspirated (if not, you are not in the pleural space) 3.4 Remove the needle 3.5 Attach a one-way valve (if necessary). 3.6 Recheck breath sounds and continuously monitor cardio-respiratory status. 4. COMPLICATIONS: 4.1 Lung laceration 4.2 Pneumothorax 4.3 Hemorrhage secondary to damage to the intercostal artery or vein Procedures Modiﬁ ed On: May 10, 2019 134 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES PSYCHIATRIC AND BEHAVIORAL EMERGENCIES Treatment IV access/consider fluid bolus Consider Restraints (pg. 112) Consider Sedation (pg. 138) Excited Delirium Ź Paranoia Ź Disorientation Ź Extremely aggressive or violent Ź Tachycardia Ź Increased strength Ź Hyperthermia Ź Clear danger to self/others Calm/ Cooperative? Consider Olanzapine administration (pg.135) Attempt de-escalation (if possible) Consider Restraints (pg. 112) Consider Sedation (pg. 138) Yes No Behavioral Crisis Ź Aural/Visual hallucinations Ź Anxiety Ź Depression Ź Manic behavior Ź Suicidal ideation Ź Disorganized thoughts Ź Unpredictable behavior Cognitive Impairment/ Developmental Disability Ź Alzheimer’s disease Ź Dementia Ź Autism Ź Down Syndrome Ź Intellectual disability Ź Developmental delays Ź Traumatic Brain Injury Assessment Consider potential medical causes ECG monitoring/12-lead ECG (pg. 126) ETCO2 monitoring Assess for Hyperthermia (pg. 15) Attempt to determine triggering event Involve caregivers (unless they are the trigger) Determine level of language and communication ability Full medical assessment Utilize simple language, be mindful of vocal tone and body language Transport to closest, most appropriate psychiatric facility or receiving hospital per transport policy (pg. 23 & pg.136) Calm/ Cooperative? Yes If transport is necessary, transport to the closest, most appropriate receiving hospital (pg. 23) *If possible, allow caregiver to accompany the patient Attempt de-escalation (if possible) Consider Restraints (pg. 112) Consider Sedation (pg. 138) No Transport to the closest, most appropriate receiving hospital ( pg.23) Procedures Modiﬁ ed On: May 10, 2019 135 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE 1. INTRODUCTION: Olanzapine (Zyprexa) 10 mg sublingual is an atypical antipsychotic with minimal side eﬀ ects. The major side eﬀ ect would be minimal sedation that can be worsened by alcohol or other sedatives. Orally disintegrating Olanzapine sublingual allows for rapid absorption, with eﬀ ects occurring within 10-15 minutes of administration. 2. INDICATIONS: 2.1 Olanzapine is indicated for the cooperative, anxious adult patient with a primarily behavioral health presentation and a history of psychiatric disorder. These patients will commonly be hearing voices or having paranoid thoughts after not taking their usual psychiatric medications. 2.2 In accordance with Restraint Policy (P.111), restraints may be utilized after patient self- administers Olanzapine. 3. CONTRAINDICATIONS: Age less than 18 or over 65 Clinical intoxication with other substances Pregnant patients 4. POSSIBLE ADVERSE EFFECTS: ►Dystonic Reaction ►Anticholinergic Eﬀ ects ►CNS Depression 5. ADMINISTRATION: Olanzapine (Zyprexa) 10mg, should be handed to the patient for sublingual self- administration. No water is needed for the orally disintegrating tablet. Procedures Modiﬁ ed On: December 5, 2012 136 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS PSYCHIATRIC EVALUATION - 5150 TRANSPORTS 1. GENERAL INFORMATION: Any patient who has been, or will be (e.g. - self-committal) placed on a 5150 hold for psychiatric evaluation shall be assessed and transported according to this policy. For minors (age below 18) the hold is called a 5585 hold and is similar to 5150 hold 2. MEDICAL CLEARANCE CRITERIA: 2.1 Age 65 and Above: Patients with or without acute medical issues, should be transported to the closest most appropriate receiving hospital for evaluation 2.2 Age 12 to 64: 2.2.1 Transport patients to a closest most appropriate receiving hospital* if there is a suspected acute medical or traumatic condition requiring emergent or urgent attention in an Emergency Department. Patients with these conditions include: Patients “in extremis” (those with a potential life-threatening illness or injury) Patients who are unconscious, unresponsive, have chest or abdominal pain, signiﬁ cant bleeding, or suspected shock Patients who shows signs of potential signiﬁ cant toxicity from illicit drugs or alcohol, which may include the following ﬁ ndings: ►depressed mental status ►inability to ambulate ►diaphoresis, agitation Patients with combative behavior who require ﬁ eld sedation with Midazolam or whose combativeness prevents assessment (vital signs or examination) Patients with abnormal vital signs or ﬁ ndings: ►Systolic blood pressure over 190 mmHg or diastolic blood pressure over 110 mm/Hg ►Pulse rate sustained over 120 ►Blood glucose under 60 mg/dL or over 250 mg/dL Patients with a suspected overdose of medication 2.2.2 Adult patients on 5150 who do not meet medical clearance criteria (see 2.1 and 2.2) should be transported to John George Pavilion, San Leandro. These include: Patients with history of use of drugs or alcohol who do not show signs of signiﬁ cant toxicity Patients with abnormalities in vital signs, but without other signiﬁ cant physical ﬁ ndings or history suggesting an acute medical problem (systolic BP up to 190, diastolic BP up to 110 and pulse up to 120) Patients with minor abrasions or contusions (not needing laceration repair or other complex care or evaluation) Patients who otherwise appear healthy but have communication barriers due to language or developmental disability, or are unwilling to answer questions 2.3 Adolescents Age 12 to 17 2.3.1 Criteria for transport to the closest most appropriate receiving hospital for medical clearance listed above (2.2.1) for adults also apply to adolescent patients on 5585 (5150) holds 2.3.2 Additionally, adolescent patients with the following ﬁ ndings should also be transported to receiving hospitals: Patients who have been outside of adult supervision/control for more than 24 hours Patients with recent vomiting over a prolonged period or who report no food or ﬂ uid intake for 16 hours or more Patients with known severe chronic medical conditions 2.3.3 Adolescent patients who do not meet medical clearance criteria (see 2.2) should be transported to Willow Rock Center, San Leandro. Notify Willow Rock en route (510) 895-5502 2.4 Children Age 11 and Under All children age 11 and under on a 5585 (5150) hold should be transported to Children's Hospital Oakland unless there is a need to divert to another hospital because of medical instability NOTE: Additional considerations for most appropriate facility are listed in the Transport Guidelines and Abuse/Assault Policies Procedures Modiﬁ ed On: July 1, 2014 137 REPORTING FORMAT REPORTING FORMAT 1. INTRODUCTION: Patient reports to a Base Hospital, Trauma Center or Receiving Hospital should be brief and to the point. Only pertinent information should be presented initially, however the Base Physician may need to request additional information in order to make sound treatment or triage decisions. Occasionally pause brieﬂ y to conﬁ rm reception and allow for questions or orders 2. MEDICAL PATIENTS: 2.1 Receiving Hospital Report ►ETA ►General patient information - For emergent patients, include medical record number (if available without compromising patient safety and care) ►Physical assessment Vital signs / Glasgow Coma Scale Pertinent positives and pertinent negatives, as needed For STEMI patients see "EKG 12-Lead" policy (page 127, section 4.3) for reporting information ►Interventions made and patient response, if applicable ►Problems encountered, if applicable (e.g. unable to intubate) 2.2 Base Contact ►General patient information ►Chief complaint and general assessment ►Patient destination and ETA ►Physical assessment Vital signs / Glasgow Coma Scale Pertinent positives and pertinent negatives to support the general assessment. ►Treatment rendered prior to contact and patient response, if applicable ►Speciﬁ c requests for medications/procedures 3. TRAUMA PATIENTS: 3.1 Receiving Hospital Report ►ETA ►General patient information ►Triage criteria met, including mechanism of injury ►Physical assessment Vital signs/Glasgow Coma Scale Pertinent positives and pertinent negatives, as needed ►Interventions made and patient response, if applicable ►Problems encountered, if applicable (e.g. unable to intubate) 3.2 Trauma Destination (60 seconds) ►ETA to the closest appropriate ED vs. TC ►General patient information ►Triage criteria met ►Mechanism of injury ►Physical assessment Vital signs, if available / Glasgow Coma Scale Pertinent positives and pertinent negatives Procedures Modiﬁ ed On: May 10, 2019 138 SEDATION SEDATION 1. GENERAL INDICATIONS: 1.1 To reduce combative behavior that endangers patient or caregivers 1.2 As an adjunct to pain relief for ALS procedures such as cardioversion and/or cardiac pacing 1.3 Use CAUTION with: ►Concomitant use of an opiate and midazolam can cause signiﬁ cant respiratory depression, hypotension and decreased level of consciousness. Administer concomitantly only when absolutely indicated. Administer lower doses of one or both agents ►Elderly patients are especially sensitive to the effects of midazolam. They should receive a lower dose and especially close monitoring ►A very small proportion of patients may have a paradoxical effect (i.e. - increased agitation) 2. CONTRAINDICATIONS: 2.1 Absolute: ►Sensitivity to Midazolam ►Systolic BP < 90 mmHg (adult) - except for patients who need TCP or cardioversion 2.2 Relative: ►Nausea/vomiting ►Depressed mentation ►Suspected drug/alcohol intoxication ►Multiple systems trauma ►Head injury ►Concomitant narcotic administration - (this is a RELATIVE contraindication and is not intended to prevent the use of necessary narcotic analgesia, when indicated)(These MAY be the most likely cause for the condition that requires proposed sedation. The best judgment of the paramedic is necessary to evaluate the need for sedation) 3. PROCEDURE: 3.1 Give supplemental oxygen (titrate to 94-99% SpO2) 3.2 Institute continuous cardiac monitoring 3.3 Continuously monitor the patient using the Airway Checklist, including ETCO2 3.4 Establish IV access if possible 3.5 Be prepared to provide airway/ventilation management 3.6 Ensure that receiving hospital personnel are aware that patient has been sedated INDICATIONS: MEDICATION – DOSE/ROUTE: SEDATION INDICATIONS To reduce combative behavior that endangers patient or caregivers Anticipated: • Cardioversion in the conscious patient • Cardiac pacing in the conscious patient MIDAZOLAM: (refer to weight-based chart for dosing guidance)Adult: IV/IO (slowly): 1-2 mg increments- titrated to desired degree of sedation. May repeat, q 5 min, to a total max dose of 10 mg IM/IN: 2-5 mg increments- titrated to desired degree of sedation. May repeat q 5 min, to a total max dose of 10 mg Pediatric (> 5kg or <40kg) IV (slowly) / IN (briskly): 0.05 mg/kg - loading dose. Titrate to desired degree of sedation. May repeat x 2, q 5 minutes, to total max dose of 3 mg IM: 0.1 mg/kg - if unable to establish IV access. May repeat x 1, q 30 minutes Procedures Modiﬁ ed On: May 6, 2013 139 SEDATION SEDATION MIDAZOLAM - WEIGHT- BASED CHART PEDIATRIC > 5 kg or < 40 kg Weight Dose kg lbs IV0.05 mg/kg IM0.1 mg/kg 5 11 .25 mg .5 mg 10 22 .5 1 15 33 .75 1.5 20 44 1 2 25 55 1.25 2.5 35 77 1.75 3.5 ADULT > 40 kg Weight Dose kg lbs 0.1 mg/kg 40 88 4 mg 45 99 4.5 mg 50 110 5 mg 55 121 5.5 mg 60 132 6 mg 65 142 6.5 mg 70 154 7 mg 75 165 7.5 mg 80 176 8 mg 90 198 9 mg >100 >220 10 mg Procedures Modiﬁ ed On: June 6, 2012 140 SPINAL INJURY ASSESSMENT SPINAL INJURY ASSESSMENT 1. INTRODUCTION: 1.1 Omit SMR if all assessment criteria are safely assessed and normal 1.2 Consider SMR for a patient who is suspected of having a traumatic unstable spinal column injury. Have high index of suspicion for pediatrics and patients with degenerative skeletal/ connective tissue disorders (i.e. osteoporosis, elderly, previous spinal fractures, etc) 1.3 Victims of penetrating trauma (stabbings, gunshot wounds) to the head, neck, and/or torso SHOULD NOT receive SMR unless there is one or more of the following: ►Obvious neurologic deﬁ cit to the extremities ►Signiﬁ cant secondary blunt mechanism of injury (e.g.- fell down stairs after getting shot) ►Priapism ►Neurogenic shock ►Anatomic deformity to the spine secondary to injury 2. Pediatric Patients and Car Seats: 2.1 Infants restrained in a rear-facing car seat may be immobilized and extricated in the car seat. The child may remain in the car seat if the immobilization is secure and his/her condition allows (no signs of respiratory distress or shock) 2.2 Children restrained in a car seat (with a high back) may be immobilized and extricated in the car seat; however, once removed from the vehicle, the child should be placed in SMR 2.3 Children restrained in a booster seat (without a back) need to be extricated and immobilized following standard SMR procedures 3. Helmet removal: Safe and proper removal of the helmet should be done by two people following steps outlined in an approved trauma curriculum ►Alameda County EMS is supporting eﬀ orts to decrease unnecessary immobilizations in the ﬁ eld and reduce the risks and complications associated with this procedure ►If the immobilization process is initiated prior to assessment, STOP and perform spine injury assessment to determine best course of action ►Studies show that immobilizing trauma victims may cause more harm than good to the patient. Penetrating trauma victims beneﬁ t most from rapid assessment and transport to a trauma center without spinal motion restriction (SMR) Procedures Modiﬁ ed On: June 6, 2012 141 SPINAL INJURY ASSESSMENT SPINAL INJURY ASSESSMENT A Reliable Patient is cooperative, sober and alert without: Signiﬁ cant Distracting Injuries Language Barrier SPINAL PAIN/TENDERNESS Palpate vertebral column thoroughly MOTOR/SENSORY EXAM: Wrist or ﬁ nger extension (both hands) Plantarﬂ exion (both feet) Dorsiﬂ exion (both feet) Check gross sensation in all extremities Check for abnormal sensations to extremities(e.g. parathesias) POTENTIAL FOR UNSTABLE SPINAL INJURY? ►RELIABLE PATIENT? ►NORMAL SPINE EXAM? ►NORMAL MOTOR/SENSORY? OMIT SMROMIT SMR POSSIBLE SPINE INJURY APPLY SMRAPPLY SMR YES High-Risk Factors: • Age ≥ 65 • Meets Trauma Patient Criteria for Mechanism of Injury (Section 3) • Axial load to the head (e.g. - diving injury) • Numbness or tingling in extremities If any one of the high-risk factors above are present, strongly consider SMR Low-Risk Factors: • Simple rear-end MVC • Ambulatory at any time on scene • No neck pain at scene • Absence of midline cervical spine tenderness The low-risk factors above allow safe omission of SMR NO YES Procedures Modiﬁ ed On: June 6, 2012 142 SPINAL MOTION RESTRICTION (SMR) SPINAL MOTION RESTRICTION (SMR) 1. INTRODUCTION: The term spinal motion restriction (SMR) better describes the procedure used to care for patients with possible unstable spinal injuries. SMR includes: ►Reduction of gross movement by patient ►Prevention of duplicating the damaging mechanism to spine ►Regular reassessment of motor/sensory function 2. PURPOSE: To decrease the risk of negative eﬀ ects caused by traditional spinal immobilization while still providing appropriate care to patients with possible spinal injury by implementing alternative methods to achieve SMR 3. INDICATIONS: Any patient identiﬁ ed by Alameda County’s Spinal Injury Assessment to warrant spinal motion restriction. The spinal injury assessment should be performed prior to application of SMR. 4. PROCEDURE: If patient experiences negative eﬀ ects of SMR methods used, alternative measures should be implemented. 4.1 Methods/tools to achieve SMR that are allowable: (less invasive to more invasive) lateral, semi-fowler’s or fowler’s position with cervical collar only, soft collars, pillows, vacuum splint or mattress, children’s car seats, KED, backboards with adequate padding, head immobilizers and straps 4.2 Provide manual stabilization restricting gross motion. Alert and cooperative patients may be allowed to self-limit motion if appropriate with or without cervical collar 4.3 Apply cervical collar 4.4 If needed, extricate patient limiting ﬂ exion, extension, rotation and distraction of spine 4.5 Considerations for patient movement when decision to SMR has been made: ►Keeping with the goals of restricting gross movement of spine and preventing increased pain and discomfort, self-extrication by patient is allowable ►Pull sheets, other ﬂ exible devices, scoops and scoop-like devices can be employed if necessary. Hard backboards should only have limited utilization 4.6 Apply adequate padding or vacuum mattress to prevent tissue ischemia and increase comfort 4.7 Place patient in position best suited to protect airway 4.8 Regularly reassess motor/sensory function (include ﬁ nger abduction, wrist/ﬁ nger extension, plantar/dorsal ﬂ exion and sharp/dull exam if possible) 4.9 Consider the use of SpO2 and EtCO2 to monitor respiratory function 5. SPECIAL CONSIDERATIONS 5.1 Patients with acute or chronic diﬃ culty breathing: SMR has been found to limit respiratory function an average of 17% with the greatest eﬀ ect experienced by geriatric and pediatric subjects restricted to a hard backboard. ►Use SMR with caution with patients presenting with dyspnea and position appropriately 5.2 Pediatric patients: 5.2.1 Consider use of padded pediatric motion restricting board 5.2.2 Avoid methods that provoke increased spinal movement 5.2.3 If choosing to apply SMR to patient in car seat, ensure that proper assessment of patient posterior is performed 5.3 Combative patients: Avoid methods that provoke increased spinal movement and/or combativeness Procedures Modiﬁ ed On: December 1, 2011 143STOMA AND TRACHEOSTOMY STOMA AND TRACHEOSTOMY 1. INTRODUCTION: 1.1 Temporary or permanent placement of a tracheostomy tube is often necessary to maintain an open airway. Patients with tracheostomy tubes or stomas should not be intubated orally. Suctioning of surgical airways is often required to attempt to clear and maintain an open airway. Administration of inhaled medications will need to be given via the stomas or tracheostomy tubes 1.2 Tracheostomy tube replacement: A dislodged tracheostomy tube should not be replaced unless the paramedic has the skill and training to do so. Training should be consistent with the material contained in “Pediatric Education for Prehospital Personnel – 2000” pages 300-302. (See #4 below for stoma intubation technique.) 2. SUCTIONING: 2.1 Equipment: 2.1.1 Appropriate sized suction catheter (Pediatrics use 8-10F) 2.1.2 Suction unit with adjustable suction capacity 2.1.3 Bag-valve-mask with oxygen supply 2.1.4 5 mL syringe ﬁ lled with sterile saline 2.2 Contraindication: Use of demand valve 2.3 Procedure: 2.3.1 Adjust suction to 120 - 150 mmHg for adults; decrease suction to 80 - 100 mmHg for pediatrics 2.3.2 Apply sterile gloves 2.3.3 Flush suction catheter with saline to lubricate tip and establish patency of suction catheter 2.3.4 Remove the T tube if a tracheostomy patient is on humidiﬁ ed oxygen 2.3.5 Ventilate the patient with 100% oxygen several times 2.3.6 Insert the suction catheter into the stoma or tracheostomy opening with the suction oﬀ (the thumb hole open). The short length of the tracheostomy tube facilitates suctioning. The catheter may be directed through the right or left bronchus by having the patient turn his/her head to the opposite side 2.3.7 Apply suction by occluding the thumb hole while slowly withdrawing the catheter in a twisting motion. Suction of a tracheostomy tube should take no longer than 10 seconds for the adult patient and 3-4 seconds for the pediatric patient 2.3.8 If mucus plugs or thick secretions are present, the instillation of 3 - 5 mL of sterile saline may be helpful 2.3.9 Pre-oxygenate with 100% O2 2.3.10 Check breath sounds 2.3.11 Suctioning can stimulate a cough reﬂ ex. Allow the patient to cough. Be prepared to suction or catch secretions from the tracheal opening. Recheck breath sounds 3. ALBUTEROL MEDICATION ADMINISTRATION: 3.1 Equipment 3.1.1 Albuterol 3.1.2 Sterile Normal Saline Procedures Modiﬁ ed On: December 1, 2011 144 STOMA AND TRACHEOSTOMY STOMA AND TRACHEOSTOMY 3.1.3 Hand Held Nebulizer 3.1.4 Oxygen tubing and supply 3.1.5 Additional reservoir tubing (optional) 3.2 Procedure: 3.2.1 Assure clear airway. Suction if necessary 3.2.2 Assemble hand held nebulizer as for patient with intact upper respiratory track 3.2.3 Attach trach collar to reservoir tubing 3.2.4 Connect oxygen delivery tubing to oxygen source at suﬃ cient ﬂ ow rate to produce misting 3.2.5 Fit trach collar over stoma or tracheostomy tube 3.2.6 Instruct patient to breathe slowly and deeply 3.2.7 Optional: Mouthpiece may be replaced by additional reservoir tubing. 4. STOMA INTUBATION: 4.1 Equipment: 4.1.1 appropriate sized cuﬀ ed and uncuﬀ ed ET tubes 4.1.2 bag-valve-mask 4.1.3 appropriate sized suction catheters 4.1.4 oxygen supply 4.1.5 suction equipment with adjustable suction capacity 4.2 Contraindication: Use of demand valve 4.3 Procedure: 4.3.1 Select the largest endotracheal tube that will ﬁ t through the stoma without force. Check the cuﬀ , unless an uncuﬀ ed tube is being used on a pediatric patient 4.3.2 Pre-oxygenate with 100% oxygen using a bag valve mask device with the face mask ﬁ tted over the stoma. Do not use demand valve 4.3.3 Wear sterile gloves. Do not use a stylet. It is not necessary to lubricate the tube 4.3.4 Suction, if necessary 4.3.5 Pass the endotracheal tube and inﬂ ate the cuﬀ . The pharynx has been bypassed, so the tube will protrude from the neck several inches 4.3.6 Hold the tube in place, watch for chest rise with ventilation 4.3.7 Secure the tube and ventilate with 100% O2 4.3.8 Auscultate the lung ﬁ elds. Check the neck for subcutaneous emphysema, indicating false passage 4.3.9 Allow no longer than 30 seconds for the procedure Procedures Modiﬁ ed On: August 20, 2017 145 TRANSCUTANEOUS PACING - TCP TRANSCUTANEOUS PACING - TCP 1. INDICATIONS: This procedure should be used on patients experiencing symptomatic bradycardia (see Adult and Pediatric Bradycardia - page 36 and page 64). This includes patients with “failed” pacemakers. Note: Bradydysrhymias in children are usually due to respiratory causes Consider alternate causes of the dysrhythmia and treat appropriately prior to initiation of TCP: ►Hypoxia ►Trauma ►Drug overdose ►Electrolyte imbalance (not treatable in the ﬁ eld setting) ►Hypothermia 2. CONTRAINDICATIONS: 2.1 Asystole 2.2 Bradyasystolic arrest TCP should not be delayed pending IV access or while waiting for atropine to take eﬀ ect in an unstable patient. TCP should be initiated simultaneously with atropine in this setting 3. PROCEDURE: 3.1 Consider administering midazolam (see sedation procedure) and/or Pain Management (Adult page 41 - Pediatric page 66). Decrease dose of one or both agents with concomitant midazolam administration or age > 65 3.2 If unable to start IV, consider administering IM 3.3 Place pads on the patient 3.4 Set initial TCP rate at 80 beats per minute (bpm) 3.5 Begin output at 0 milliamps (mA). Increase by 10 mA until capture/pulses are noted. Once capture is conﬁ rmed, continue pacing at a slightly higher output level (10%) 3.6 If capture is maintained but the patient remains symptomatic of inadequate tissue perfusion (BP < 90 systolic, altered level of consciousness) consider increasing the rate by 10 bpm until 100 bpm is reached 3.7 If perfusion remains a problem, consider Consider: Epinephrine 0.5mL (5 mcg) slow IV, every 3 minutes, titrate to a SBP > 90 3.8 Contact the Base Physician for consultation if perfusion remains a problem and/or alteration of TCP settings Procedures Modiﬁ ed On: December 1, 2011 146 TRANSFER OF CARE TRANSFER OF CARE AUTHORITY: Division 2.5 of the California Health and Safety Code, Section 1798.6 "Authority for patient health care management in an emergency shall be vested in that licensed or certiﬁ ed health care professional, which may include any paramedic or other prehospital emergency personnel at the scene of the emergency, who is most medically qualiﬁ ed speciﬁ c to the provision of render-ing emergency medical care. If no licensed or certiﬁ ed health care professional is available, the authority shall be vested in the most appropriate medically qualiﬁ ed representative of public safety agencies who may have responded to the scene of an emergency." "Notwithstanding ... authority for the management of the scene of an emergency shall be vested in the appropriate public safety agency having primary investigative authority. The scene of an emergency shall be managed in a manner designed to minimize the risk of death or health impairment to the patient and to other persons who may be exposed to the risks as a result of the emergency condition, and priority shall be placed upon the interests of those persons exposed to the more serious and immediate risks to life and health. Public safety oﬃ cials shall consult emergency medical services personnel or other authoritative health care professionals at the scene in the determination of relevant risks." 1. Medical personnel will not enter an unsafe emergency/crime scene, or continue to render care until released by the incident commander. Public safety personnel shall secure the scene to make entry reasonably safe 2. Components of the transfer of care at the scene of an emergency include: 2.1 Evaluation of the scene 2.2 Medical aspects of extrication and all movement of the patient(s) 2.3 Assessment 2.4 Treatment rendered 2.5 Destination 3. If a disagreement occurs between medical personnel at the scene on any aspects of the transfer of care: 3.1 If time permits, contact the Base Physician to determine the appropriate treatment/ destination. Otherwise, the more conservative patient-based decision will prevail (e.g. if ﬁ eld personnel disagree on transport vs. non-transport, the patient will be transported) 3.2 If necessary, involved personnel will immediately notify the EMS on-call representative through ALCO-CMED. The EMS on-call representative will notify the EMS Medical Director 3.3 If appropriate, the EMS Medical Director will organize a meeting with the involved personnel to resolve the issues within two (2) business days MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 147MCI/ DISASTER/ WMD TOC MCI/ DISASTER/ WMD TOC MCI/ DISASTER/ WMD TOC ......................................................................................147 ACTIVE SHOOTER RESPONSE ...............................................................................148 BIOLOGICAL ATTACK ................................................................................................149 CHEMICAL ATTACK ...................................................................................................151 CHEMPACK DEPLOYMENT ......................................................................................152 CYANIDE POISONING ...............................................................................................153 DECONTAMINATION INCIDENT ...............................................................................154 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” .....................155 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE ...................................157 MULTI-CASUALTY INCIDENT - EMS RESPONSE ...................................................159 NERVE AGENT AUTOINJECTOR ADMINISTRATION ..............................................162 NERVE AGENT TREATMENT ....................................................................................164 SUSPICIOUS POWDER PROCESS ..........................................................................166 MCI/ Disaster/ WMD Modiﬁ ed On: April 10, 2012 148 ACTIVE SHOOTER RESPONSE ACTIVE SHOOTER RESPONSE 1. INTRODUCTION 1.1 ACTIVE SHOOTER RESPONSE- The EMS response to Active Shooter Incidents needs to be coordinated with on scene law enforcement. 1.2 EMS providers need to be ready to enter a secured scene quickly and aggressively 1.3 EMS providers should be “forward leaning” and have trauma focused medical gear and triage tools available 1.4 Working closely with law enforcement is critical in getting life saving medical assets to the injured as soon as the threat has been mitigated or neutralized. The UNIFIED COMMAND model is best for these types of incidents 1.5 Make sure law enforcement command knows that an EMS team is ready, staged and awaiting direction. Most SWAT teams have an imbedded tactical medic that would be the logical liaison to EMS assets on scene 1.6 Concepts applied are based on the Tactical Combat Casualty Care (TCCC) and the International School of Tactical Medicine (ISTM) 2. Consider the following items during an EMS response to an Active Shooter Incident: ►Communication must be maintained throughout the incident with respective dispatch centers and on scene medical, ﬁ re and law enforcement ►Law enforcement is in charge of the event. While in a warm zone environment, EMS should follow the direction of law enforcement ►Law enforcement may provide a protective envelope (force protection model) around EMS providers and escort them into “warm zone” areas to treat or evacuate victims. (No active threat in the area) ►Make sure to have emergency egress routes and casualty collection points (CCP), as well as evacuation rally points identiﬁ ed ►If EMS team is brought in to extricate patient, only minimal equipment should be carried. Roll up evacuation stretchers should be considered ►EMS teams need to be prepared to split up if law enforcement requires it ►EMS providers should use individual medical packs with life saving bleeding and airway tools so they can work “independently” on trauma victims ►Spinal motion restriction is not indicated for patients suﬀ ering only from penetrating trauma ►Once the threat is eliminated, law enforcement may be available to help evacuate the injured MCI/ Disaster/ WMD Modiﬁ ed On: April 10, 2012 149 BIOLOGICAL ATTACK BIOLOGICAL ATTACK DI S E A S E / AG E N T In c u b a t i o n SY M P T O M S S I G N S TR A N S M I S S I O N & PR E C A U T I O N S TR E A T M E N T (A d u l t d o s a g e ) PR O P H Y L A X I S AN T H R A X 2- 6 d a y s Ra n g e : 1 d a y t o 8 we e k s (B a c i l l u s a n t h r a c i s ) ba c t e r i a In h a l a t i o n : F l u - l i k e sy m p t o m s , n a u s e a , vo m i t i n g , a b d o m i n a l p a i n , fe v e r , r e s p i r a t o r y d i s t r e s s Cu t a n e o u s : i n i t i a l i t c h i n g pa p u l e ; f e v e r In h a l a t i o n : f e v e r , f o l l o w e d by ab r u p t o n s e t o f re s p i r a t o r y f a i l u r e , c o n f u s i o n wi d e n e d m e d i a s t i n u m o n ch e s t X - r a y ( a d e n o p a t h y ) , bl o o d y p l e u r a l e ﬀ u s i o n s , at y p i c a l p n e u m o n i a Cu t a n e o u s : i n i t i a l i t c h i n g pa p u l e , 1 - 3 c m p a i n l e s s ul c e r , t h e n n e c r o t i c c e n t e r ; ly m p h a d e n o p a t h y Ae r o s o l i n h a l a t i o n No p e r s o n - t o - p e r s o n tr a n s m i s s i o n St a n d a r d p r e c a u t i o n s Me c h a n i c a l v e n t i l a t i o n An t i b i o t i c t h e r a p y (i n h a l a t i o n ) Ci p r o ﬂ o x a c i n 4 0 0 mg I V q 8 - 1 2 h r OR Do x y c y c l i n e 2 0 0 m g I V in i t i a l , t h e n 1 0 0 m g I V q 8- 1 2 h r PL U S Ri f a m p i n 1 0 m g / k g / d p o (u p t o 6 0 0 m g d a y ) OR Cl i n d a m y c i n 1 2 0 0 - 2 4 0 0 mg / d a y I M o r I V Ci p r o ﬂ o x a c i n 5 0 0 mg o r Do x y c y c l i n e 10 0 m g p o q 1 2 h r ~ 8 w e e k s Am o x i c i l l i n i n pr e g n a n c y a n d c h i l d r e n (i f s u s c e p t i b l e ) Va c c i n e i f a v a i l a b l e BO T U L I S M 12 - 7 2 h o u r s Ra n g e : 2 h r s – 8 d a y s to x i n c a u s e d b y th e b a c t e r i u m (C l o s t r i d i u m bo t u l i n u m ) Di ﬃ c u l t y s w a l l o w i n g o r sp e a k i n g ( s y m m e t r i c a l cr a n i a l n e u r o p a t h i e s ) Sy m m e t r i c d e s c e n d i n g we a k n e s s Re s p i r a t o r y d y s f u n c t i o n No s e n s o r y d y s f u n c t i o n No f e v e r Di l a t e d o r u n - r e a c t i v e p u p i l s Dr o o p i n g e y e l i d s ( p t o s i s ) Do u b l e v i s i o n ( d i p l o p i a ) Sl u r r e d s p e e c h ( d y s a r t h r i a ) De s c e n d i n g ﬂ a c c i d p a r a l y s i s In t a c t m e n t a l s t a t e Ae r o s o l i n h a l a t i o n Fo o d i n g e s t i o n No p e r s o n - t o - p e r s o n tr a n s m i s s i o n St a n d a r d p r e c a u t i o n s Me c h a n i c a l v e n t i l a t i o n Pa r e n t e r a l n u t r i t i o n Tr i v a l e n t b o t u l i n u m an t i t o x i n a v a i l a b l e fr o m S t a t e H e a l t h De p a r t m e n t s a n d C D C Ex p e r i m e n t a l v a c c i n e ha s b e e n u s e d i n la b o r a t o r y w o r k e r s PL A G U E 1- 3 d a y s b y in h a l a t i o n (Y e r s i n i a p e s t i s ) ba c t e r i a Su d d e n o n s e t o f f e v e r , ch i l l s , h e a d a c h e , m y a l g i a Pn e u m o n i c : c o u g h , ch e s t p a i n , d y s p n e a , f e v e r Bu b o n i c : p a i n f u l l y m p h no d e s Pn e u m o n i c : H e m o p t y s i s ; ra d i o g r a p h i c p n e u m o n i a - - pa t c h y , c a v i t i e s , c o n ﬂ u e n t co n s o l i d a t i o n , h e m o p t y s i s , cy a n o s i s Bu b o n i c : t y p i c a l l y p a i n f u l , en l a r g e d l y m p h n o d e s i n gr o i n , a x i l l a , a n d n e c k Pe r s o n - t o - p e r s o n tr a n s m i s s i o n i n pn e u m o n i c f o r m s Dr o p l e t p r e c a u t i o n s u n t i l pa t i e n t t r e a t e d f o r a t le a s t t h r e e d a y s St r e p t o m y c i n 3 0 m g / k g / da y i n t w o d i v i d e d d o s e s x 1 4 d a y s Ge n t a m i c i n 3 - 5 m g / kg / d a y I V / I M i n q 8 h r do s a g e Te t r a c y c l i n e 2 - 4 g p e r da y Ci p r o ﬂ o x a c i n 4 0 0 m g I V q 1 2 h r As y m p t o m a t i c c o n t a c t s or p o t e n t i a l l y e x p o s e d pa t i e n t s Do x y c y c l i n e 10 0 m g p o q 1 2 h Ci p r o ﬂ o x a c i n 50 0 m g p o q 1 2 h Te t r a c y c l i n e 25 0 m g p o q 6 h r Va c c i n e : n o t a v a i l a b l e RI C I N If i n h a l e d , S / S x wi t h i n 4 - 8 h o u r Pr o t e i n t o x i n pr o d u c e d f r o m ca s t o r b e a n s (R i c i n u s c o m m u n i s ) Fe v e r , S O B , n a u s e a , c h e s t ti g h t n e s s Sw e a t i n g , p u l m o n a r y e d e m a , cy a n o s i s , h y p o t e n s i o n , pu l m o n a r y a n d c i r c u l a t o r y co l l a p s e No p e r s o n t o p e r s o n tr a n s m i s s i o n Ai r b o r n e p r e c a u t i o n s St a n d a r d p r e c a u t i o n s Su p p o r t i v e c a r e GI d e c o n t a m i n a t i o n i f in g e s t e d Va c c i n e u n d e r de v e l o p m e n t No t e : t h e s e a r e f o r r e f e r e n c e o n l y , a n d a r e n o t i n AL C O E M S p r o t o c o l MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 150 BIOLOGICAL ATTACK BIOLOGICAL ATTACK150BIOLOGICAL ATTACK BIOLOGICAL ATTACK DI S E A S E / AG E N T In c u b a t i o n SY M P T O M S S I G N S TR A N S M I S S I O N & PR E C A U T I O N S TR E A T M E N T (A d u l t d o s a g e ) PR O P H Y L A X I S TU L A R E M I A 2- 5 d a y s Ra n g e : 1 - 2 1 da y s “p n e u m o n i c ” (F r a n c i s e l l a tu l a r e n s i s ) ba c t e r i a Fe v e r , c o u g h , c h e s t ti g h t n e s s , p l e u r i t i c p a i n He m o p t y s i s r a r e Co m m u n i t y - a c q u i r e d , at y p i c a l p n e u m o n i a Ra d i o g r a p h i c : b i l a t e r a l pa t c h y p n e u m o n i a w i t h hi l a r a d e n o p a t h y ( p l e u r a l eﬀ u s i o n s l i k e T B ) Di ﬀ u s e , v a r i e d s k i n r a s h Ma y b e r a p i d l y f a t a l In h a l a t i o n o f a g e n t s No p e r s o n - t o - p e r s o n tr a n s m i s s i o n b u t la b o r a t o r y p e r s o n n e l at r i s k St a n d a r d p r e c a u t i o n s St r e p t o m y c i n 3 0 m g / k g / da y I M d i v i d e d b i d f o r 14 d a y s Ge n t a m i c i n 3 - 5 m g / k g / da y I V i n t h r e e e q u a l di v i d e d d o s e s x 1 0 - 1 4 da y s Ci p r o ﬂ o x a c i n p o s s i b l y eﬀ e c t i v e 4 0 0 m g I V q 1 2 hr ( c h a n g e t o p o a f t e r cl i n i c a l i m p r o v e m e n t ) x 10 - 1 4 d a y Ci p r o ﬂ o x a c i n 50 0 m g p o q 1 2 h r Do x y c y c l i n e 10 0 m g p o q 1 2 h r Te t r a c y c l i n e 25 0 m g p o q 6 h r Ex p e r i m e n t a l l i v e va c c i n e SM A L L P O X 12 - 1 4 d a y s Ra n g e : 7 - 1 7 d a y s (V a r i o l a v i r u s ) Hi g h f e v e r a n d m y a l g i a ; it c h i n g ; a b d o m i n a l p a i n ; de l i r i u m Ra s h o n f a c e , e x t r e m i t i e s , ha n d s , f e e t ; c o n f u s e d w i t h ch i c k e n p o x w h i c h h a s l e s s un i f o r m r a s h Ma c u l o p a p u l a r t h e n v e s i c u l a r ra s h - - ﬁ r s t o n e x t r e m i t i e s (f a c e , a r m s , p a l m s , s o l e s , or a l m u c o s a ) Ra s h w i t h h a r d , ﬁ r m p u s t u l e s (“ i n t r a d e r m a l b l i s t e r s ” ) Ra s h i s s y n c h r o n o u s o n va r i o u s s e g m e n t s o f t h e bo d y Pe r s o n - t o - p e r s o n tr a n s m i s s i o n Ai r b o r n e p r e c a u t i o n s Ne g a t i v e p r e s s u r e Cl o t h i n g a n d s u r f a c e de c o n t a m i n a t i o n Su p p o r t i v e c a r e Va c c i n a t e c a r e g i v e r s Ex p e r i m e n t a l : c i d o f o v i r (u s e f u l i n a n i m a l s t u d i e s ) Va c c i n a t i o n ( v a c c i n e av a i l a b l e f r o m C D C ) No t e : t h e s e a r e f o r r e f e r e n c e o n l y , a n d a r e n o t i n AL C O E M S p r o t o c o l MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 151 CHEMICAL ATTACK CHEMICAL ATTACK 151CHEMICAL ATTACK CHEMICAL ATTACK CH E M I C A L P R O P E R T I E S I M M E D I A T E A C T I O N S S Y M P T O M S TR E A T M E N T NE R V E A G E N T S • VX • Sa r i n • Ta b u n Ca n b e l i q u i d o r g a s En t e r s t h e b o d y t h r o u g h : ►Sk i n a n d e y e s ►In h a l a t i o n ►In g e s t e d ►If y o u a r e e x p o s e d , th e e ﬀ e c t s w i l l a p p e a r fa i r l y r a p i d l y ►Pe o p l e a r o u n d y o u m a y be g i n f a i n t i n g , v o m i t i n g o r ha v e d i ﬃ c u l t y b r e a t h i n g ►Bi r d s a n d i n s e c t s ma y d i e q u i c k l y a n d fa l l f r o m t h e s k y ►IM M E D I A T E L Y le a v e t h e a r e a ►Av o i d p u d d l e s o f l i q u i d ►If t h e a t t a c k w a s ou t s i d e , y o u s h o u l d g e t in t o a b u i l d i n g o r c a r ►If t h e a t t a c k w a s i n s i d e , ge t t o t h e o u t s i d e ►If y o u w e r e d i r e c t l y ex p o s e d , r e m o v e cl o t h i n g ( p l a c e i n p l a s t i c ba g s , i f p o s s i b l e ) ►Re m o v i n g c o n t a m i n a t e d cl o t h i n g i s m o r e im p o r t a n t t h a n m o d e s t y ►Do n o t r e m o v e co n t a m i n a t e d c l o t h i n g ov e r y o u r h e a d ; c u t o r t e a r it o ﬀ t o a v o i d c o n t a c t w i t h th e e y e s , n o s e , a n d m o u t h ►Th o r o u g h l y ﬂ u s h a l l ar e a s w h e r e a g e n t co n t a c t e d y o u r s k i n , u s i n g ne a r e s t w a t e r a v a i l a b l e ►Ha z m a t / ﬁ r e c r e w s a r e tr a i n e d f o r i m m e d i a t e re s p o n s e a n d m e d i c a l tr e a t m e n t i s a v a i l a b l e at m o s t h o s p i t a l s ►Pu p i l s s h r i n k t o p i n p o i n t s an d v i c t i m b e g i n s s w e a t i n g an d t w i t c h i n g ►Ru n n y n o s e , w a t e r y ey e s , d r o o l i n g , i n c r e a s e d re s p i r a t o r y s e c r e t i o n s , ex c e s s i v e s w e a t i n g , di ﬃ c u l t b r e a t h i n g , d i m n e s s of v i s i o n , n a u s e a , v o m i t i n g ►Re m o v e c l o t h i n g , ﬂ u s h ey e s / s k i n w i t h p l e n t y o f wa t e r ►Ge t m e d i c a l a t t e n t i o n im m e d i a t e l y ; t h e r e a r e an t i d o t e s f o r s p e c i ﬁ c ch e m i c a l a g e n t s ►At r o p i n e i s a n e ﬀ e c t i v e an t i d o t e SU L F U R M U S T A R D S Ge n e r a l l y t h i c k l i q u i d , y e l l o w or b r o w n i n c o l o r , w i t h a s l i g h t ga r l i c o r m u s t a r d o d o r . E n t e r s th e b o d y t h r o u g h : ►Sk i n a n d e y e s ►In h a l a t i o n ►In g e s t e d ►Bl i s t e r i n g a g e n t , b u r n i n g ex p o s e d e y e s a n d s k i n ; an d l u n g s , m o u t h a n d th r o a t i f i t i s b r e a t h e d i n (i n h a l e d ) . No t u s u a l l y n o t i c e d u n t i l 1 - 6 ho u r s a f t e r e x p o s u r e ►Re m o v e c l o t h i n g a n d ﬂ u s h e y e s / s k i n w i t h p l e n t y of w a t e r ►Ge t m e d i c a l a t t e n t i o n im m e d i a t e l y , t h e r e a r e an t i d o t e s f o r s p e c i ﬁ c ch e m i c a l a g e n t s HY D R O G E N CY A N I D E Ex t r e m e l y ﬂ a m m a b l e , c o l o r l e s s ga s o r l i q u i d En t e r s t h e b o d y t h r o u g h : ►Sk i n a n d e y e s ►In h a l a t i o n ►In g e s t e d ►Bu r n i n g a n d r e d n e s s o f th e s k i n a n d e y e s ►In h a l a t i o n c a u s e s co n f u s i o n , d r o w s i n e s s , sh o r t n e s s o f b r e a t h , le a d i n g t o c o l l a p s e Ge t f r e s h a i r i m m e d i a t e l y Fl u s h s k i n / e y e s w i t h p l e n t y of w a t e r Ge t m e d i c a l a t t e n t i o n im m e d i a t e l y ; t h e r e a r e an t i d o t e s f o r s p e c i ﬁ c c h e m i c a l ag e n t s CH L O R I N E Gr e e n i s h - y e l l o w g a s w i t h st i n g i n g o d o r . H e a v i e r t h a n a i r , so i t w i l l s e t t l e i n l o w s p o t s En t e r s t h e b o d y t h r o u g h : ►Sk i n a n d e y e s ►In h a l a t i o n ►In g e s t e d Ve r y h a r m f u l t o t h e e y e s a n d sk i n a n d c a n c a u s e t e a r i n g , bl u r r e d v i s i o n , d i ﬃ c u l t y br e a t h i n g , a n d b u r n s Ge t f r e s h a i r i m m e d i a t e l y Fl u s h s k i n / e y e s w i t h p l e n t y of w a t e r Se e k m e d i c a l a t t e n t i o n im m e d i a t e l y ; t h e r e a r e an t i d o t e s f o r s p e c i ﬁ c c h e m i c a l ag e n t s No t e : t h e s e a r e f o r r e f e r e n c e o n l y , a n d ar e n o t i n A L C O E M S p r o t o c o l MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 152 CHEMPACK DEPLOYMENT CHEMPACK DEPLOYMENT ON-SCENE Incident Commander (IC) has authority to request Chempack(s) based on medical personnel (Fire/EMS) assessment of presenting symptoms of patients and other field specific information (detectors, intelligence) LLNL DISPATCH Dispatch (CAD) determines best (closest) Chempack and automatically dispatches request to housing facility. Fire/ EMS Unit transports Chempack to the scene and reports to appropriate destination (i.e. staging, medical) FIRE/EMS CHEMPACK STORAGE SITE Fire/EMS Chempack site opens (break seals), loads up and transports unit to site location (staging, medical, etc.) REQUEST MADE TO DISPATCH ON-SCENE MEDICAL Medical unit utilizes Chempack assets on- scene and en-route to hospitals HOSPITAL Treatment continues in hospital with on-site Chempack assets INCIDENT MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 153CYANIDE POISONING CYANIDE POISONING • This policy is to be used in conjunction with Smoke Inhalation page 21 and HazMat page 157• Medications are only given if the patient is showing signs and symptoms of cyanide poisoning. THEY ARE NOT TO BE GIVEN PROPHYLACTICALLY Symptoms: ►Exposure to a vapor or liquid that may smell like “bitter almonds” ►Upper airway and/or eye irritation ►Flushing ►Headache ►Anxiety ►Agitation ►Vertigo ►Weakness ►Nausea ►Muscular trembling Signs: ►Transient hyperpnea, followed by seizures, apnea and cardiac collapse ►Tremor ►Normal pupils ►Diaphoresis ►Cyanosis Signs and/or symptoms of cyanide exposure Warm Zone Hot Zone Monitor IV NS Sodium Thiosulfate IV over 10 minutes Adult: 12.5 grams Child: 0.4 gm/kg (max dose 12.5 grams) High flow O2 (if available Intubate if apneic MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 154 DECONTAMINATION INCIDENT DECONTAMINATION INCIDENT ►This policy is for instances where a patient presents to EMS personnel without forewarning of a possible hazardous materials incident ►All patients exposed or contaminated by suspected hazardous materials should be decontaminated prior to transportation to the emergency department e.g. - Industrial Response Team, Fire Hazardous Materials Response 1. Paramedics will advise the base hospital of the following: 1.1 Nature of the emergency (i.e.,describe the incident) 1.2 Total number of suspected patients exposed or contaminated 1.3 Number of patients exposed and exhibiting symptoms 1.4 Chemical identiﬁ cation, if known 1.5 Patient status 1.6 Treatment prior to transport 1.7 Describe decontamination provided on scene 1.8 ALS, BLS 2. Base will acknowledge report and advise on further treatment as necessary. If, while enroute to the hospital, the crew inadvertently discovers a potentially contaminated individual, the following instructions will be followed: 2.1 Crew should ensure that receiving hospital has clear understanding of the potential for a hazardous materials incident 2.2 Stage the ambulance away from the receiving hospital ED until notiﬁ ed where the decontamination area will be located 2.3 Keep the patient and ambulance personnel in or near the ambulance until the decontamination area is ready to receive the patient(s) 2.4 Ambulance personnel should remain in or near their vehicle until the decontamination team is ready to decontaminate EMS personnel, if necessary MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 155RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” Adapted from: Nuclear Regulatory Commission http://www.nrc.gov 1. Background: 1.1 Principal type of “dirty bomb” combines a conventional explosive such as Dynamite/Explosives with radioactive material 1.2 A conventional explosive itself would have more immediate lethality than dirty bombs 1.3 Most probably, not enough radiation would be present in a dirty bomb to: ►Kill people ►Cause severe illness 1.4 Most radioactive material employed in hospitals is suﬃ ciently benign 1.5 About 100,000 patients a day are released with this material in their bodies 1.6 Certain other radioactive materials could contaminate up to several city blocks 1.7 It could create fear and possibly panic and requiring potentially costly cleanup 1.8 A second type of RDD might involve a powerful radioactive source hidden in a public place 1.9 Hiding places may include such places as : ►Trash receptacles ►Latrines ►Delivery vehicles ►Vending machines ►Parked vehicles 1.10 A dirty bomb is in no way similar to a nuclear weapon 1.11 The presumed purpose of its use would be as a Weapon of Mass Disruption 1.12 Not as a Weapon of Mass Destruction 2. Impact of a Dirty Bomb: 2.1 The extent of local contamination would depend on a number of factors 2.2 Factors includes: ►The size of the explosive ►The amount and type of radioactive material used ►The weather conditions 2.3 Prompt detection of the kind of radioactive material employed would greatly assist local authorities 2.4 It would assist in advising the community on protective measures, such as: ►Quickly leaving the immediate area or ►Going inside until being further advised 2.5 Subsequent decontamination of the aﬀ ected area could involve considerable: ►Time ►Expense 3. What Should You Do Following an Explosion 3.1 Move away from the immediate area--at least several blocks from the explosion 3.2 Head inside and establish shelter-in-place 3.3 This to reduce exposure to radioactive dust MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 156 DECONTAMINATION INCIDENT DECONTAMINATION INCIDENT 3.4 Turn to radio/TV channels for advisories from: ►Emergency response ►Health authorities 3.5 If facilities are available, remove clothes and place them in a sealed plastic bag 3.6 Save contaminated clothing to allow for testing for radiation exposure 3.7 Take a shower to wash oﬀ dust and dirt, or to reduce radiation exposure, if the explosive device is radioactive 3.8 If radiation was released, local news will advise people where to report for: ►Radiation monitoring ►Blood tests ►Other tests 3.9 Test to determine if in fact exposed and what steps to take to protect health. 4. Risk of Cancer 4.1 Short time or small doses of radioactive dust does not mean a person will get cancer 4.2 The additional risk will likely be very small 4.3 Potassium Iodide (KI) will not be protective except in the unlikely event that the dirty bomb contained radioactive iodine isotopes 4.4 The iodine isotopes would have to be in large quantities 4.5 Radioactive iodine isotopes are not particularly attractive for use in an RDD 4.6 KI only protects the thyroid from radioactive iodine 4.7 KI oﬀ ers no protection to other parts of the body or against other radioactive isotopes MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 157HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE The information contained in this policy is based on guidelines contained in EMSA #231 - Hazardous Materials Medi- cal Management Protocol 1. INTRODUCTION: Individuals who respond to and function within the Exclusion Zone (Hot Zone) or Contamination Reduction Zone (Warm Zone) must be members of specially trained HazMat teams, trained in the use of self contained breathing apparatus, selection of appropriate chemical protective suits and how to function in them. Other rescuers should be trained in accordance with Federal OSHA standards identiﬁ ed in OSHA 29 CFR 1910.120 and California OSHA as deﬁ ned in the California Code of Regulations, Title 8, Section 5192 2. EMS interface with HazMat teams 2.1 The Incident Command System (ICS) shall be used for on scene management 2.2 The Medical Branch Supervisor shall make contact with the Incident Commander, face-to-face or by radio, who will direct the Medical Branch Supervisor to the Hazardous Materials Group Supervisor 2.3 Pertinent information will be relayed to the Medical Branch Supervisor including, patient information (number requiring transport and injuries) and the type of exposure (chemical name and information about the chemical [SPELL CHEMICAL NAME]) 2.4 The Medical Branch Supervisor shall make Base contact in order to obtain recommendations regarding decontamination and patient treatment 2.5 Once cleared by the Site Access Leader, EMS personnel may proceed to the end of the "Contamination Reduction Corridor" to receive patients. Any secondary treatment by EMS personnel should be done in the "Support Area" 3. Deﬁ nitions 3.1 Exclusion Zone (Hot Zone) - Area that encompasses all known or suspected hazardous materials 3.2 Contamination Reduction Zone (Warm Zone) - Area between the "Exclusion Zone" and the "Support Area". "Safe Refuge Area" and "Contamination Reduction Corridor" are set up within this area 3.3 Contamination Reduction Corridor - An area within the "Contamination Reduction Zone" where the actual decontamination takes place. EMS personnel, once cleared, receive patients at the end of the "Contamination Reduction Corridor" and move them to the "Support Area" for secondary treatment 3.4 Support Zone (Cold Zone) - Clean area outside "Contamination Reduction Zone" where equipment and rescue personnel are staged to receive and treat decontaminated patients. Secondary exposure to hazardous materials is not expected in this area and special clothing is not required MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 158 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE 4. Patient Management 4.1 Follow the Multi-casualty Incident (MCI) Plan – page 159, if appropriate 4.2 For nerve gas/cyanide exposure: ►Patient exposure: Cyanide Poisoning – page 153 Nerve Agent Treatment - page 164, (HazMat trained paramedics only) ►Rescuer exposure: Nerve Agent Autoinjector Administration – page 162 4.3 Paramedics should contact the Base Physician early in the incident regarding treatment for other speciﬁ c exposures 4.4 EMTs and paramedics may only render care within their scope of practice 5. Scene Management Responsibilities Speciﬁ c to HazMat Incidents 5.1 Police Responsibilities 5.1.1 Evacuations ahead of hazard area. Evacuation plans developed under uniﬁ ed command 5.1.2 Traﬃ c control in and around eﬀ ected area(s) 5.1.3 Incidents on State/Federal Highways joint command is with CHP 5.2 Fire Department Responsibilities 5.2.1 Incident Stabilization 5.2.2 Rescue and medical treatment (all paramedics may provide treatment in Cold Zone) 5.2.3 Assistance to responsible party or agency with development of appropriate cleanup/ disposal plan. May include the assistance of other agencies, (i.e. environmental health, etc.) MCI/ Disaster/ WMD Modiﬁ ed On: May 29, 2019 159 MULTI-CASUALTY INCIDENT - EMS RESPONSE MULTI-CASUALTY INCIDENT - EMS RESPONSE 1. INTRODUCTION: A Multi-Casualty Incident (MCI) is any incident where the number of injured persons exceeds the day-to-day operating capabilities; requiring additional resources and/or the distribution of patients to multiple hospitals. This may be diﬀ erent for each incident based on time of day, location, resources available, etc. 2. NOTIFICATIONS: Incident Commanders shall make notiﬁ cations through ACRECC. Organizations should have internal notiﬁ cation procedures 3. MCI RESOURCE ORDERING, INITIATION AND TERMINATION: 3.1 The ﬁ rst arriving unit should initiate an MCI through ACRECC 3.2 Inform ACRECC of the Incident Type (Medical, Trauma, MVC, Haz-Mat etc.) 3.3 Responders should order MCI Resource Response (MCI Response) as soon as possible in order to get resources responding. This resource ordering can occur before an exact patient count is obtained. 3.4 Patient count approximations should be used as guidelines for initiating a speciﬁ c MCI LEVEL and are not intended as a substitute for sound scene judgment 3.5 As soon as there is an approximate number of patients determined, the MCI Level should be declared 3.6 Immediately cancel assigned resource(s) when no longer required 3.7 Terminate the MCI through ACRECC when the MCI has been mitigated MCI RESOURCE ORDERING MCI RESPONSE MCI RESOURCE RESPONSE PACKAGE MCI NOTIFICATIONS MCI Response 1 5 Closest 911 Ambulances 1 EMS Supervisor EMS TAC channel assigned Note: Immediately cancel assigned resource(s) when no longer required Jurisdictional Fire Battalion Chief County EOA Provider Operations Supervisor LEMSA Duty Oﬃ cer MCI Response 2 5 Closest Ambulances 1 EMS Supervisor 1 DMSU Note: Immediately cancel assigned resource(s) when no longer required All County Fire Duty Chiefs Resources in MCI Response 2 are in addition to resources assigned in MCI Response 1 MCI Response 3 5 Closest Ambulances 1 EMS Supervisor Consider Air Assets Note: Immediately cancel assigned resource(s) when no longer required Resources in MCI Response 3 are in addition to resources assigned in MCI Response 2 Additional Levels For Each Additional level: 5 Closest Ambulances 1 EMS Supervisor MCI/ Disaster/ WMD Modiﬁ ed On: May 29, 2019 160 MULTI-CASUALTY INCIDENT - EMS RESPONSE MULTI-CASUALTY INCIDENT - EMS RESPONSE 4. RESOURCE ORDERING PRIORITY LIST 4.1 ALCO 911 Ambulances 4.2 ALCO BLS Permitted Ambulances 4.3 Mutual Aid from contiguous county(ies) 5. MANAGEMENT OF MCI INCIDENTS AND PATIENT DISTRIBUTION 5.1 Once an MCI alert is determined by prehospital personnel, ACRECC will be notiﬁ ed and will “Initiate an MCI” under the Reddinet MCI module. ACRECC will immediately send an “ED Capacity poll and general notiﬁ cation” to the hospitals in Alameda County 5.2 For MCI Levels II & III, ACRECC will notify the EMS Duty Oﬃ cer of the incident 5.3 Emergency responders shall perform triage using one of the following triage methods: ►The Simple Triage and Rapid Treatment (START) algorithm for adults and JumpSTART for pediatrics ►The Sort, Assess, Lifesaving Interventions, Treatment / Transport (SALT) algorithm for patients in all age groups 5.3.1 Acuity based Triage colors for both Triage Tape and Triage Tags are universally accepted as Black (expectant / deceased), Red (immediate / life threatening,), Yellow (delayed / serious not life threatening), and Green (minor / walking wounded). Only Black, Red, Yellow, and green are acceptable triage colors 5.3.2 The use of colored “Triage Tape” upon initial contact with victims at the crisis site is preferred over Triage Tags to identify initial acuity. Triage tags should be used at the external Casualty Collection Point (CCP) outside the crisis site or applied to patients during transport. Acuity-guided transport of all patients shall occur in a coordinated and expedient manner 5.4 Hospital Poll: For MCI incidents involving 15+ patients, ACRECC will send a “bed capacity” poll to all hospitals in Alameda County to conﬁ rm bed availability 5.5 For the duration of the MCI, the Transportation Unit Leader under ICS will determine transportation methods and destinations 5.6 Whenever possible, patients should be transported to the most appropriate hospital without overloading one particular facility. Every eﬀ ort will be made to transport trauma patients to a designated trauma hospital. In a Level II or III MCI, transport to a designated trauma center may not always be possible MCI LEVELS MCI Level Approximate Patient Count I 5-14 Patients II 15-50 Patients III > 50 Patients MCI/ Disaster/ WMD Modiﬁ ed On: May 29, 2019 161 MULTI-CASUALTY INCIDENT - EMS RESPONSE MULTI-CASUALTY INCIDENT - EMS RESPONSE 5.7 First Round Destination Procedure may be implemented without prior authorization. All Alameda County receiving hospitals should prepare to receive patients, especially those in close proximity to the incident First Round Destination Procedure Non-Trauma patients** to each Alameda County receiving hospital (for a total of 6): Two (2) “Immediate” Four (4) “Delayed” and/or “Minor” ** e.g.: Medical incident, HazMat Trauma patients to each Alameda County Trauma Center (for a total of 7): Three “Immediate” Four (4) “Delayed” and/or “Minor” 5.8 ACRECC in conjunction with the incident command structure will track patient numbers, acuity and destinations in ReddiNet in as close to real-time as possible. ReddiNet will serve as the primary mechanism notifying receiving facilities of the number and acuity of incoming patients. Receiving hospitals will enter patient names and other relevant information into ReddiNet. This will facilitate patient accountability and reuniﬁ cation. On scene EMS Supervisors may also have the ability to enter information into ReddiNet 5.9 Verbal notiﬁ cation to hospitals: In a Level I MCI, transporting units should contact the receiving hospital enroute to give an abbreviated report on the patient(s) status and ETA. In a Level II or III MCI, if ReddiNet is unavailable or non-functional, a medical communications coordinator should be designated to notify receiving facilities of the number and acuity of incoming patients. 5.10 Incident Log - The Transportation Unit Leader should maintain an incident log 5.11 The on-scene Incident Commander or designee (ie. Medical Group Supervisor or Transportation Unit Leader) should contact ACRECC during and at the conclusion of the MCI to provide and reconcile patient tracking information to ensure accountability 6. RESOURCE MANAGEMENT - The Incident Commander has the overall responsibility for developing objectives and requesting the necessary resources required to mitigate the incident. There will be no self- dispatching. Clear communications between all involved agencies is imperative 6.1 The following items are MCI Management points to consider ►The three “T’s” ensure that Triage, Treatment and Transport have been addressed ►Request resources through the Incident Commander in the early stages of the incident. Ensure adequate personnel and equipment ►Establish staging areas. Transport Units and/or other units that do not immediately have an assignment should report to the designated staging area and wait for instructions ►Use a one-way traﬃ c pattern. Transport units should be staged to assure good access and egress from Loading Area ►All incoming units drop oﬀ required EMS equipment at a designated location ►County Disaster Trailers shall be requested through ACRECC 6.2 Use ICS identiﬁ cation vests. At a minimum the IC, Medical Group Supervisor, Triage and Treatment, and Transportation Unit Leader should be clearly identiﬁ ed with vests MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 162 NERVE AGENT AUTOINJECTOR ADMINISTRATION NERVE AGENT AUTOINJECTOR ADMINISTRATION 1. INTRODUCTION: Nerve agent auto-injectors are to be used when EMS personnel are exposed to nerve agents (Sarin, Soman, Tabun, VX) and have signs and symptoms of nerve agent exposure, or when ALS/ specially trained BLS personnel treat victims in an MCI situation in the hot zone 2. EQUIPMENT: 2.1 Mark I autoinjector antidote kit containing: ►Atropine autoinjector (2 mg in 0.7 mL) ►Pralidoxime chloride autoinjector - 2-PAM (600 mg in 2 mL) 2.2 Additional atropine (2 mg) autoinjectors 3. PROCEDURE: If you experience any or all of the nerve agent poisoning symptoms, you must IMMEDIATELY self-administer the nerve agent antidote (see “Nerve Agent Treatment” - page 164 for signs and symptoms) 3.1 Injection Site Selection: ►The injection site for administration is normally in the outer thigh muscle (Figure 1). It is important that the injections be given into a large muscle area ►If the individual is thinly-built, then the injections should be administered into the upper outer quadrant of the buttocks (Figure 2) 3.2 Arming The Autoinjector: ►Immediately put on your protective mask ►Remove the antidote kit ►With your non-dominant hand, hold the autoinjectors by the plastic clip so that the larger autoinjector is on top and both are positioned in front of you at eye level ►With your dominant hand grasp the atropine autoinjector (the smaller of the two) with the thumb and ﬁ rst two ﬁ ngers. DO NOT cover or hold the needle end with your hand, thumb, or ﬁ ngers-you might accidentally inject your self. An accidental injection into the hand WILL NOT deliver an eﬀ ective dose of the antidote, especially if the needle goes through the hand ►Pull the injector out of the clip with a smooth motion. The autoinjector is now armed 3.3 Administering the antidote to yourself: ►Hold the autoinjector with your thumb and two ﬁ ngers (pencil writing position). Be careful not to inject yourself in the hand! ►Position the green (needle) end of the injector against the injection site (thigh or buttock). DO NOT inject into areas close to the hip, knee, or thigh bone ►Apply ﬁ rm, even pressure (not jabbing motion) to the injector until it pushes the needle into your thigh (or buttocks). Using a jabbing motion may result in an improper injection or injury to the thigh or buttocks ►Hold the injector ﬁ rmly in place for at least 10 seconds. Firm pressure automatically triggers the coiled spring mechanism. This plunges the needle through the clothing into the muscle and at the same time injects the antidote into the muscle tissue ►Carefully remove the autoinjector from your injection site MARK I antidote kit Figure 1 - Thigh injection site Figure 2 - Buttocks injection site MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 163NERVE AGENT AUTOINJECTOR ADMINISTRATION NERVE AGENT AUTOINJECTOR ADMINISTRATION ►Next, pull the 2 PAM injector (the larger of the two) out of the clip ►Inject yourself in the same manner as the steps above, holding the black (needle) end against your outer thigh (or buttocks) ►Massage the injection sites, if time permits ►After administering the ﬁ rst set of injections, wait 5 to 10 minutes ►After administering one set of injections, you should initiate decontamination procedures, as necessary, and put on any additional protective clothing ►Atropine only may be repeated every 10 - 15 minutes as needed. (Note: multiple doses of atropine may be needed.) 3.4 Administering the antidote to another in the Hot Zone: ►Squat, DO NOT kneel, when masking the casualty or administering the nerve agent antidotes to the casualty. Kneeling may force the chemical agent into or through your protective clothing ►Mask the casualty ►Position the casualty on his or her side (swimmer’s position) ►Position yourself near the casualty's thigh ►The procedure for site selection and medication administration is the same as 3.1 – 3.3 ►Atropine only should be repeated as needed- multiple doses may be needed 4. DOSAGE SCHEME FOR MARK I ADMINISTRATION - via autoinjector Additional atropine may be needed until a positive response is achieved (decrease in bronchospasm and/or respiratory secretions) AD U L T Signs & Symptoms Onset # of autoinjectors to use: Vapor: small exposure Pinpoint pupils Runny nose Mild SOB Seconds MARK I autoinjector antidote kit – 1 dose initially (containing atropine and 2-PAM) May repeat x1 in 10 minutes Liquid: small exposure Sweating Twitching Vomiting Feeling weak Minutes to Hours MARK I autoinjector antidote kit – 1 dose initially (containing atropine and 2-PAM) May repeat x1 in 10 minutes Both: large exposure Convulsions Apnea Copious secretions Seconds to Hours MARK I autoinjector antidote kit – 3 doses initially (containing atropine and 2-PAM) May repeat x1 in 10 minutes PE D I A T R I C Age (approx.) Weight (approx.) Autoinjectors (#) (each type) Atropine dose range (mg/kg) 2-PAM dose range (mg/kg) 3-7 13-25 kg 1 0.08-0.13 24-46 8-14 26-50 kg 2 0.08-0.13 24-46 >14 > 51 kg 3 0.11 or less 35 or less NOTE: While not approved for pediatric use, autoinjectors should be used as initial treatment in children with severe, life-threatening nerve agent toxicity where IV treatment is not possible or available, or a more precise IM dosing would be logistically impossible. MCI/ Disaster/ WMD Modiﬁ ed On: July 24, 2018 164 NERVE AGENT TREATMENT NERVE AGENT TREATMENT ►ALS and specially trained BLS personnel may administer nerve agent antidote medications to patients. (See page 162 for auto-injector procedure) ►Nerve agent antidote medications are only given if the patient is showing signs and symptoms of nerve agent poisoning. THEY ARE NOT TO BE GIVEN PROPHYLACTICALLY ►This policy is to be used in conjunction with page 157 (HazMat) ►Note: A decrease in bronchospasm and respiratory secretions are the best indicators of a positive response to atropine and 2-PAM therapy Signs and Symptoms of Nerve Agent Exposure (from mild to severe) Exposure Signs & Symptoms ►Unexplained runny nose ►Tightness in the chest ►Diﬃ culty breathing ►Bronchospasm ►Pinpoint pupils resulting in blurred vision ►Drooling ►Excessive sweating ►Nausea and/or vomiting ►Abdominal cramps ►Involuntary urination and/or defecation ►Jerking, twitching and staggering ►Headache ►Drowsiness ►Coma ►Convulsions ►Apnea MNEMONIC FOR NERVE AGENT EXPOSURE Muscarinic Effects: Nicotinic Effects: D iarrhea M ydriasis U rination T achycardia M iosis W eakness B radycaria, bronchorrhea H ypertension E mesis F asciculations L acrimation S alivation SE V E R E M O D E R A T E M I L D MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 165NERVE AGENT TREATMENT NERVE AGENT TREATMENT If patient exposed: ● Strip off clothing ● Blot off the agent ● Flush area with large amounts of water ● Cover affected area Warm Zone Mild to Severe Exposures IV/ IO NS Atropine IV/ IO or IM: Adult:2mg Child:0.02 mg/kg - minimum dose 0.1 mg (see note) ^Pralidoxime (2-PAM) IV/ IO or IM Adult:1-2 grams Child:20-40 mg/kg maximum 1 gram May repeat in severe exposures Hot Zone Severe Exposures Only *Atropine IM only: Adult/Adolescent - 2 mg Child:< 2 years 0.5 mg 2-10 years 1 mg (see note) *^Pralidoxime (2-PAM) IM only: Adult/Adolescent: 1-2 grams Child:20 mg/kg maximum 1 gram May repeat in severe exposures Note: In a moderate to severe exposure – repeat as needed until a positive reponse is achieved *See page 162 for autoinjector use in the hot zone. Document the number of autoinjectors administered to the victim ^Administer 2-PAM as soon as possible, especially for agents that ‘age’ quickly Treat seizures with Diazepam Adult:5-10 mg IV/ IO as needed Child:0.1-0.3 mg/kg – repeat at 0.05 - 0.1 mg/kg in 10 minutes if needed Treat seizures with Midazolam IM only Adult/Adolescent: 5 mg Child:0.1 mg/kg (maximum 5 mg) Note: MMRS providers may use Diazepam Autoinjector 10 mg IM - ADULTS ONLY MCI/ Disaster/ WMD Modiﬁ ed On: December 1, 2011 166 SUSPICIOUS POWDER PROCESS SUSPICIOUS POWDER PROCESS Initial notification to 9-1-1 Police Response, Possible Haz-Mat Response Assessment based on initial information/ impression Immediate rule-out (e.g. sugar spilled on counter, detergent spilled on grocery store floor) Haz-Mat Evaluation needed Possible Anthrax or other threat Substance still suspicious, (or overt threat) Unlikely to be Anthrax or other threat Substance unknown, still needs to be identified Notify FBI FBI Protocols Notify Environmental Health Alameda County Lab TEST CADHS State Lab TEST Positive Negative Notification via Law Enforcement FBI may direct No or negative Notification via Public Health Yes Still Suspicious? 167 POLICY LOCATOR INDEX ACTIVE SHOOTER RESPONSE ..............................................................................148 ACUTE STROKE .........................................................................................................30 ADULT POLICIES TOC ...............................................................................................29 ADVANCED AIRWAY MANAGEMENT ......................................................................116 AIRWAY OBSTRUCTION ............................................................................................32 AIRWAY OBSTRUCTION ............................................................................................60 ALS RESPONDER .......................................................................................................84 ALTERED LEVEL OF CONSCIOUSNESS ..................................................................33 ALTERED LEVEL OF CONSCIOUSNESS ..................................................................62 AMBULANCE REROUTING CRITERIA .......................................................................V ANAPHYLAXIS / ALLERGIC REACTION ...................................................................34 ANAPHYLAXIS / ALLERGIC REACTION ...................................................................61 AN OVERVIEW OF PATIENT CARE POLICIES ...........................................................2 APPROVED ABBREVIATIONS .................................................................................VIII ASSAULT | ABUSE | DOMESTIC VIOLENCE...............................................................3 ASSESS AND REFER GUIDELINES ........................................................................118 ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY .................................................35 BIOLOGICAL ATTACK ...............................................................................................149 BIOLOGICAL ATTACK ...............................................................................................150 BLS/ALS FIRST RESPONDER ...................................................................................85 BRADYCARDIA ...........................................................................................................36 BRADYCARDIA ...........................................................................................................64 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE .................................................63 BURN PATIENT CARE ..................................................................................................6 BURN PATIENT CRITERIA ...........................................................................................8 CARDIOPULMONARY RESUSCITATION (CPR) .........................................................9 CERTIFICATION | RECERTIFICATION | ACCREDITATION CHECKLIST ...............VII CHEMICAL ATTACK ..................................................................................................151 CHEMPACK DEPLOYMENT .....................................................................................152 CHEST PAIN - SUSPECTED CARDIAC/STEMI .........................................................37 168 CONSENT AND REFUSAL GUIDELINES.................................................................119 CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP ........................................124 CRUSH INJURY SYNDROME .....................................................................................12 CYANIDE POISONING ..............................................................................................153 DEATH IN THE FIELD .................................................................................................87 DEATH IN THE FIELD - GRIEF SUPPORT ................................................................92 DECONTAMINATION INCIDENT ..............................................................................154 DYSTONIC REACTION ...............................................................................................38 EKG - 12 LEAD ..........................................................................................................126 EMERGENCY MEDICAL SERVICES - STAFF DIRECTORY .....................................VI EMS AIRCRAFT TRANSPORT ...................................................................................93 END OF LIFE CARE ....................................................................................................86 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION ..........................97 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS .......................................98 EXTREMITY INJURY...................................................................................................13 GENERAL POLICIES TOC ............................................................................................1 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE ..................................157 HEMORRHAGE CONTROL .......................................................................................128 HYPERKALEMIA .........................................................................................................14 HYPERTHERMIA / HEAT ILLNESS ............................................................................15 HYPOTHERMIA ...........................................................................................................16 IMPEDANCE THRESHOLD DEVICE (ITD) ...............................................................130 INFECTION CONTROL ...............................................................................................18 INTERFACILITY TRANSFERS ..................................................................................105 INTRANASAL (IN) MEDICATION ADMINISTRATION ..............................................131 INTRAOSSEOUS ACCESS PROCEDURE ...............................................................132 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT ..106 KEYWORD INDEX .....................................................................................................171 MCI/ DISASTER/ WMD TOC .....................................................................................147 MEDICAL PERSONNEL ON THE SCENE ................................................................107 MEDICATIONS – AUTHORIZED | STANDARD INITIAL DOSE .................................39 MULTI-CASUALTY INCIDENT - EMS RESPONSE ..................................................159 NEONATAL RESUSCITATION ....................................................................................65 169 NERVE AGENT AUTOINJECTOR ADMINISTRATION .............................................162 NERVE AGENT TREATMENT ...................................................................................164 OB/GYN EMERGENCIES ............................................................................................19 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE ............................109 OPERATIONAL POLICIES TOC .................................................................................83 PAIN MANAGEMENT ..................................................................................................41 PAIN MANAGEMENT ..................................................................................................66 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS ...................110 PEDIATRIC DRUG CHART - (DRUGS NOT ON THE LBRT) .....................................68 PEDIATRIC POLICIES TOC ........................................................................................59 PLEURAL DECOMPRESSION ..................................................................................133 POISONING | INGESTION | OVERDOSE ..................................................................42 POISONING | INGESTION | OVERDOSE ..................................................................69 POLICY LOCATOR INDEX ........................................................................................167 PROCEDURE POLICIES TOC ..................................................................................115 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES ...............................................134 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE ......................135 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS ...............................................136 PULMONARY EDEMA / CHF.......................................................................................43 PULSELESS ARREST: ASYSTOLE, PEA ...................................................................70 PULSELESS ARREST: VF/ VT ....................................................................................71 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” ....................155 REPORTING FORMAT ..............................................................................................137 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) ............44 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) ............72 RESPIRATORY DISTRESS.........................................................................................45 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY ......................................73 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY ..................................74 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING .............. 111 RESTRAINTS ............................................................................................................112 RETURN OF SPONTANEOUS CIRCULATION - ROSC .............................................46 ROUTINE MEDICAL CARE – ADULT..........................................................................47 ROUTINE MEDICAL CARE - PEDIATRIC ..................................................................75 170 SCOPE OF PRACTICE - LOCAL OPTIONAL .............................................................20 SEDATION .................................................................................................................138 SEIZURE ......................................................................................................................76 SEIZURE ......................................................................................................................49 SEIZURE - MIDAZOLAM DRUG CHART ....................................................................77 SEPSIS ........................................................................................................................50 SEVERE NAUSEA .......................................................................................................51 SEVERE NAUSEA .......................................................................................................78 SHOCK AND HYPOTENSION .....................................................................................79 SHOCK: HYPOVOLEMIC/CARDIOGENIC .................................................................52 SMOKE INHALATION / CO MONITORING .................................................................21 SPINAL INJURY ASSESSMENT ...............................................................................140 SPINAL MOTION RESTRICTION (SMR) ..................................................................142 STOMA AND TRACHEOSTOMY ...............................................................................143 SUBMERSION .............................................................................................................53 SUBMERSION .............................................................................................................80 SUSPECTED OPIOID WITHDRAWAL ........................................................................54 SUSPICIOUS POWDER PROCESS .........................................................................166 TACHYCARDIA ............................................................................................................55 TACHYCARDIA ............................................................................................................81 TRANSCUTANEOUS PACING - TCP ........................................................................145 TRANSFER OF CARE ...............................................................................................146 TRANSPORT GUIDELINES ........................................................................................23 TRAUMA PATIENT CARE ...........................................................................................24 TRAUMA PATIENT CRITERIA ....................................................................................25 TXA - TRANEXAMIC ACID ..........................................................................................28 UNUSUAL OCCURENCES........................................................................................113 VENTRICULAR ASSIST DEVICES -VAD ...................................................................56 VENTRICULAR FIBRILLATION | VENTRICULAR TACHYCARDIA: PULSELESS ...58 171 Keyword Index Symbols 2-Pam - 162 12-Lead EKG - 126 Chest Pain - 37 Pulmonary Edema / CHF - 43 Return Of Spontaneous Circulation (ROSC) - 46 Tachycardia - 55 A abbreviations: See also approved abbreviations - VIII abdominal thrusts (FBO) - 32, 60 accreditation: See also paramedic accreditation - VII activated charcoal Poisoning | Ingestion | Overdose (Adult) - 42 Poisoning | Ingestion | Overdose (Pedi) - 69 adenosine Tachycardia (Adult) - 55 Tachycardia (Pedi) - 81 Adult medications - initial dose - 39 adult protective services - 3 adult trauma arrest - 26 advanced airway management - 116 air ambulance - 93 albuterol - 12 Allergic Reaction/ Anaphylaxis - 34 Allergic Reaction / Anaphylaxis (Pedi) - 61 Respiratory Distress (Adult) - 45 Respiratory Distress (Pedi) - 74 allergic reaction - 34, 61 ALOC - 33, 62 ALS Responder - 84 AMI - Acute Myocardial Infarction - 37 amiodarone ROSC - 46 Tachycardia (Adult) - 55 VF/ VT (Adult) - 58 Pulseless Arrest: VF/ VT (Pedi) - 71 amputation - 13 anaphylactic shock - 34, 61 anaphylaxis - 34, 61 anatomic criteria (trauma) - 25: 172 angioedema - 34, 61 anthrax - 149 aspirin Chest Pain - 37 Pulmonary Edema / CHF - 43 assess and refer - 118 asthma - 45, (Pedi) 71 asystole - 35, 70 atropine Asystole (Adult) - 35 Bradycardia (Adult) - 36 ROSC - 46 Bradycardia (Pedi) - 64 Nerve Agent Autoinjector Administration - 162 atrovent: 45, (Pedi) 74 See also ipratropium autoinjector: See also nerve agent autoinjector B back blows - 60 base contact - 2, 137 base contact (trauma) - 27 base physician - 2 behavioral assessment tool - 134 beta blocker OD - 42, 69 biological attack - 149 blood glucose - 31, 33, 49, 62, 63, 76 BLS Responder - 85 botulism - 149 bradycardia - 36, 64 breech delivery - 19 bronchospasm - 45, (Pedi) 74 Broselow Tape: 68 See LBRT - Length Based Resuscitation Tape burns - 6-8 C calcium channel blocker OD - 42, 69 calcium chloride - 12, 35 California Bridge Program - 54 capnography - 116-117 capnometry - 116-117 carbon monoxide - 21 cardiogenic shock - 52, 79 Cardiopulmonary resuscitation: - 9-11See also CPR certiﬁ ed stroke centers - 30 chemical attack - 151 chempack - 152 173 chest pain - 37 CHF - 43 child abuse - 3 child protective services - 3 chlorine - 151 choking - 32, 60 closed head injury - 24 cold zone - 157 complete diversion: - V See also diversion consent and refusal guidelines - 119 contamination reduction corridor - 157 contamination reduction zone - 157 Continuous Positive Airway Pressure: - 124 See also CPAP cooling measures - 15, 76 COPD - 45 Cormack-Lehane scale - 116 coroner - 103 clinical opioid withdrawal score/scale - 54 CPAP - 124 Pulmonary Edema / CHF - 43 Submersion (Adult) - 53 Submersion (Pedi) - 80 CPAP procedure - 12 CPR - 9 Additional Information - 10 Pit Crew Roles - 11 CPSS - Cincinnati Prehospital Stroke Scale - 31 croup - 73 Crush Injury - 12 CVA - Cerbral Vascular Accident - 31 cyanide - 21 cyanide poisoning - 153 D death in the ﬁ eld - 87 criteria (for determination of) - 87 donor card - 90 decontamination incident - 154 deﬁ brillate - 58, 71 determination of death: - 87 See also death in the ﬁ eld dextrose ALOC (Adult) - 33 ALOC (Pedi) - 62 dextrose 10% (D10) - 33, 62: See also dextrose diphenhydramine Allergic Reaction/ Anaphylaxis - 34 Dystonic Reaction - 38 174 Allergic Reaction / Anaphylaxis (Pedi) - 61 dirty bomb - 155 dislocation - 13 DNR - Do Not Resuscitate - 87 domestic violence - 3 donor card - 90 dressing burns - 6 dystonic reaction - 38 E eclampsia - 19 elder abuse - 3 EMS aircraft - 91 endotracheal intubation - 116 endotracheal tube - 116 end of life care - 86 epiglottitis - 73 epinephrine Allergic Reaction/ Anaphylaxis - 34 Allergic Reaction / Anaphylaxis (Pedi) - 61 Asystole (Adult) - 35 Bradycardia (Adult) - 36 Bradycardia (Pedi) - 64 Neonatal Resus - 65 Pulseless Arrest: Asystole, PEA (Pedi) - 70 Pulseless Arrest: VF/ VT (Pedi) - 71 Respiratory Distress (Adult) - 45 Respiratory Distress (Pedi) - 74 Return of Spontanous Circulation - 46 VF/ VT (Adult) - 58 equipment and supply speciﬁ cations - ALS/ BLS - 98 EtCO2 - 116 exclusion zone - 157 EZ-IO - 102, 132 F FACES Scale - 66 fentanyl - 41, 67 ﬂ uid bolus: See also ﬂ uid challenge ﬂ uid challenge Anaphylaxis / Allergic Reaction (Adult) - 34 Anaphylaxis / Allergic Reaction (Adult) - 61 Bradycardia (Adult) - 36 Neonatal Resus - 65 Poisoning | Ingestion | Overdose (Adult) - 42 ROSC - 46 175 Sepsis - 50 Shock (Adult) - 52 Shock (Pedi) - 79 ﬂ uid resuscitation - 12 ﬂ uid resuscitation (burns) - 6 fracture - 13 G gestational age - 65 glucagon ALOC (Adult) - 33 ALOC (Pedi) - 62 glucose paste ALOC (Adult) - 33 ALOC (Pedi) - 62 grief support - 103 H handheld nebulizer - 34, 45, 61, 74 hazardous materials incident - 157 head-tilt/ chin-lift - heat emergency - 15 Heimlich Maneuver: See also CPR: Abdominal thrusts high-pressure injury - 13 hot zone - 153, 157 hydrogen cyanide - 151 Hyperkalemia - 14 hypoglycemia - 33, 62 hypothermia - 16, 53, 80, 87 treatment - 16 hypovolemic shock - 52, 79 I ICS - Incident Command System - 157, 159 IN: 131 See also intranasal infection control - 18 infusion devices - 106 ingestion - 42, 69 inhalation injury - 6, 8 initial certiﬁ cation: VII intercostal space - 123, 132 interfacility transfers - 105 intranasal - 131 intraosseous infusion - 132 intubation - 116 ipratropium 176 Respiratory Distress (Adult) - 45 Respiratory Distress (Pedi) - 74 ITD - Impedance Threshold Device - 35, 57 ITD - Impedance Threshold Device - procedure - 130 K Ketamine - 41 Ketorolac - 41 L laryngoscope - 116 LBRT - Length Based Resuscitation Tape - 68 limb leads - 127 LZ - Landing Zone - 92 M MCI - 159 mechanical CPR - 10, 11, 35, 57 midazolam Sedation - 138 Seizure (Adult) - 49 Seizure (Pedi) - 76 Tachycardia (Adult) - 54 multi-casualty incident - 159 N naloxone Neonatal Resus - 65 Pain Management (Adult) - 41 Pain Management (Pedi) - 66 Poisoning | Ingestion | Overdose (Adult) - 42 Poisoning | Ingestion | Overdose (Pedi) - 69 Respiratory Depression or Apnea (Adult) - 44 Respiratory Depression or Apnea (Pedi) - 72 nausea - 51, 78 nerve agent autoinjector - 162 nerve agents sarin - 151 tabun - 151 VX - 151 nerve agent treatment - 164 nitroglycerine Chest Pain - 37 Pulmonary Edema / CHF - 43 177 novel inﬂ uenza A: See also infection control O OB/GYN - 19 obviously dead - 87 olanzapine - 135 ondansetron Severe Nausea - 51, 78 on-view an accident - 109 opioid use disorder (OUD) - 54 organ donor - 90 organophosphate poisoning - 42, 69 out-of-county trauma centers - 27 overdose - 42, 69 P pain management - 41, 66 paramedic consideration (trauma) - 25: See also trauma criteria partial diversion: V See also diversion PEA - pulseless electrical activity - 35, 70 Pediatric Drug Chart (non LBRT) - 68 pediatric trauma arrest - 26 pediatric destination decisions - 75 phenothiazines - 38 physician on scene - 107 physiologic criteria (trauma) - 25: See also trauma criteria plague - 149 pleural decompression - 133 pneumothorax - 133 poisoning - 42, 69 POLST - Physician Orders for Life-Sustaining Treatment - 86-91 Pralidoxime chloride: See also 2-Pam precordial leads - 126 pre-eclampsia - 19 premature infants - 65 prolapsed cord - 19 pulmonary edema - 43 pulseless arrest - 35, 58, 70, 71 R radiological dispersion device - 155 radio report: 136 See also reporting format recertiﬁ cation: VII See also EMT initial certiﬁ cation reporting format - 136 respiratory distress - 45 respiratory distress (stridor) - 73 178 respiratory distress (wheezing) - 74 ResQPOD - 130 ricin - 149 ROSC - Return of Spontaneous Circulation - 10, 46, 57 S scope of practice - 20 sedation Bradycardia (Adult) - 36 Bradycardia (Pedi) - 64 Tachycardia (Adult) - 55 Psychiatric and Behavioral Emergencies - 134 sedation procedure - 138 seizure - 49, 76 SEMS - Standard Emergency Management System - 159 sepsis - 50 sepsis alert - 50 septic shock - 79 sexual assault - 3 shark-ﬁ n - 117 shock - 52, 79 smallpox - 150 smoke inhalation - 21 snake bite - 13 sodium bicarbonate - 12, 35 Poisoning | Ingestion | Overdose (Adult) - 42 Poisoning | Ingestion | Overdose (Pedi) - 69 sodium thiosulfate - 21, 22, 153 spinal immobilization: See spinal motion restriction (SMR) spinal motion restriction (SMR) - 53, 80, 140-142 spinal shock - 79 spine injury criteria - 140-142 spontaneous abortion - 19 SRC - 23, 126: See also STEMI receving center State of Maine Criteria: See also spine injury criteria STEMI - 37, 126 STEMI Center - 23, 46, 56: See also STEMI Receiving Center STEMI Receiving Center - 33, 37, 43, 58, 126 stoma - 142 stridor - 73 stroke centers - 30 ST segment - 126 sulfur mustards - 151 support zone - 157 supraglottic airway - 116 suspicious powder - 166 179 synchronized cardioversion Tachycardia (Adult) - 54 Tachycardia (Pedi) - 81 systemic inﬂ ammatory response syndrome (SIRS) - 50 T tachycardia - 54, 81 TCP - Transcutaneous Pacing - 36, 46, 64 procedure - 145 tension pneumothorax - 133 thoracostomy tubes - 106 thrombolysis - 31 torticollis - 38 tracheostomy - 143 Tranexamic Acid - 24, 28 transport guidelines - 23 trauma criteria - 25 anatomic criteria - 25 paramedic consideration - 25 physiologic criteria - 25 trauma patient - 24 trauma patients with burns - 26 tricyclic antidepressant OD - 42, 69 tularemia - 150 TXA - 24, 28 V vaginal bleeding - 19 ventilators - 105 VF - Ventricular Fibrillation VF (Adult) - 58 VF (Pedi) - 71 visual analog scale - 66 vomiting - 51, 78 VT - Ventricular Tachycardia VT (Adult) - 58 VT (Pedi) - 71 W warm zone - 153, 157 waveform capnography - wheezing - 74 widened QRS - 42, 55 180 wide QRS - 42, 55 X Y Z Zofran: 39, See also ondansetron Severe Nausea (Adult) - 51 Severe Nausea (Adult) - 78 ALAMEDA COUNTY APPROVED RECEIVING HOSPITALS (510) area code unless otherwise specified (Rev. 10/21) Hospital Main Number ED Number 5150 Medical Eval. Adults / Adolescents 5150 Psych Eval. Helipad CA Bridge L&D STEMI Stroke Sexual Assault Trauma Alameda 522-3700 814-4095 814-3336 x x Alta Bates 204-4444 204-1303 x x Children’s 428-3000 428-3240 Age < 11 Age < 11 x Age < 13 Age < 14 Eden 537-1234 889-5015 x x x x Age > 15 Highland (ACMC) 437-4800 437-4559 (base MD) 535-6000 x x x x Age > 14 Age > 15 John George 346-7500 346-1421 Age > 18 Kaiser - Fremont 248-3000 248-7206 x x x Kaiser - Oakland 752-1000 752-7667 x x x x Kaiser – San Leandro 454-1000 454-4348 x x x Kaiser – Walnut Creek (925) 295-4000 (925) 939-1788 x x x San Leandro 357-6500 667-4545 x x San Ramon (925) 275-9200 (925) 275-8280 x x x St. Rose 264-4000 264-4026 x x x Summit 655-4000 869-8700 x x x x Valley Care (925) 847-3000 (925) 416-6525 x x x x x Washington 797-1111 818-8531 x x x x Age > 14 Willow Rock 895-5502 895-5502 Adolescents Age 12-17 OUT-OF-COUNTY RESOURCES Hospital ED Number Base Number Helipad L & D STEMI Stroke Trauma Burn John Muir Medical Center (925) 947-4444 (925) 939-5804 x x x x x Regional Medical Center (408) 729-2841 x x x x San Francisco General (628) 206-8111 (628) 647-4747 x x x x San Joaquin General (209) 982-1975 x x x x Santa Clara Valley (VMC) (408) 885-6912 (408) 885-6937 x x x x x (408) 885-6666 Stanford (650) 723-7337 x x x x x St. Francis Memorial (415) 353 6300 x (415) 353-6255 UC Davis Medical Center x x x x x (916) 734-3636 Weight kg lbs Amiodarone Drip - Pediatric Tachycardia dose amount Mix dose in 100cc NS/DW 5 11 25mg 0.5cc Give over 20 to 60 minutes (50 to 17gtts/min) with 10gtts/cc tubing Requires base physician consult 10 22 50mg 1.0cc 15 33 75mg 1.5cc 20 44 100mg 2.0cc 25 55 125mg 2.5cc 35 77 150mg 3.0cc Amiodarone Drip - Adult Mix 150 mg in 100cc NS/DW Adult Tachycardia: give over 10 minutes (100 gtts/minute with 10gtts/cc tubing) Push Dose Epinephrine mixing instructions: »Take Epinephrine 1 mg of 0.1 mg/ml preparation (Cardiac Epinephrine) and waste 9 ml of Epinephrine »In that syringe, draw 9 ml of normal saline from the patient's IV bag and shake well »Mixture now provides 10 ml of Epinephrine at a 0.01mg/ml (10 mcg/ml) concentration