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Home My WebLink Aboutalco-fm-2025-draft-07-31-20241000 SAN LEANDRO BLVD. | SUITE 200 | SAN LEANDRO, CA 94577 PHONE: 510.618.2050 | WEB: ems.acgov.org | Email: alcoems@acgov.org 2025 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 ..................................................................VI EMERGENCY MEDICAL SERVICES - STAFF DIRECTORY .................................VII GENERAL POLiCiES TAB GENERAL POLICIES TOC .....................................................................................1 AN OVERVIEW OF PATIENT CARE POLICIES .....................................................2 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ...............3 BURN PATIENT CARE ............................................................................................7 BURN PATIENT CRITERIA .....................................................................................9 CARDIOPULMONARY RESUSCITATION (CPR) ...................................................10 ADDITIONAL INFORMATION: ..........................................................................11 MECHANICAL CPR DEVICES: .........................................................................11 PIT CREW ROLES: ...........................................................................................12 CRUSH INJURY SYNDROME ................................................................................13 EXTREMITY INJURY ..............................................................................................14 HYPERKALEMIA .....................................................................................................15 HYPERTHERMIA / HEAT ILLNESS ........................................................................16 HYPOTHERMIA .......................................................................................................17 INFECTION CONTROL AND SCREENING CRITERIA ..........................................19 OB/GYN EMERGENCIES .......................................................................................20 SCOPE OF PRACTICE - LOCAL OPTIONAL .........................................................21 SMOKE INHALATION / CO MONITORING ............................................................22 TRANSPORT GUIDELINES ....................................................................................24 TRAUMA PATIENT CARE .......................................................................................25 TRAUMA PATIENT CRITERIA ................................................................................26 ADULT POLiCiES TAB ADULT POLICIES TOC ...........................................................................................29 AIRWAY OBSTRUCTION ........................................................................................30 ALTERED LEVEL OF CONSCIOUSNESS .............................................................31 ANAPHYLAXIS / ALLERGIC REACTION ...............................................................32 BRADYCARDIA .......................................................................................................33 CARDIAC ARREST - GENERAL GUIDELINES ......................................................34 CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA ..............................................35 ii CARDIAC ARREST - MEDICAL - VF/PVT ..............................................................36 CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT ....................................37 CARDIAC ARREST - TRAUMATIC .........................................................................38 CHEST PAIN - SUSPECTED CARDIAC/STEMI .....................................................39 DYSTONIC REACTION...........................................................................................40 MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE .............................41 PAIN MANAGEMENT ..............................................................................................43 POISONING | INGESTION | OVERDOSE ..............................................................44 PULMONARY EDEMA / CHF ..................................................................................45 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) .......46 RESPIRATORY DISTRESS ....................................................................................47 RETURN OF SPONTANEOUS CIRCULATION - ROSC ........................................48 ROUTINE MEDICAL CARE - ADULT ......................................................................49 SEIZURE .................................................................................................................51 SEPSIS ....................................................................................................................52 SEVERE NAUSEA ...................................................................................................53 SHOCK: HYPOVOLEMIC/CARDIOGENIC .............................................................54 SICKLE CELL PAIN EMERGENCY ........................................................................55 STROKE / CVA ........................................................................................................56 SUBMERSION .........................................................................................................57 SUSPECTED OPIOID WITHDRAWAL ....................................................................58 TACHYCARDIA .......................................................................................................59 VENTRICULAR ASSIST DEVICES -VAD ...............................................................60 PEDiATRiC POLiCiES TAB PEDIATRIC POLICIES TOC ...................................................................................63 AIRWAY OBSTRUCTION ........................................................................................64 ANAPHYLAXIS / ALLERGIC REACTION ...............................................................65 ALTERED LEVEL OF CONSCIOUSNESS .............................................................66 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE .............................................67 BRADYCARDIA .......................................................................................................68 CARDIAC ARREST - GENERAL GUIDELINES ......................................................69 CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA ................................................70 CARDIAC ARREST - MEDICAL - VF/PVT ..............................................................71 CARDIAC ARREST - TRAUMATIC .........................................................................72 NEONATAL RESUSCITATION ................................................................................73 iii PAIN MANAGEMENT ..............................................................................................74 POISONING | INGESTION | OVERDOSE ..............................................................76 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) .......77 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY .................................78 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY .............................79 ROUTINE MEDICAL CARE - PEDIATRIC ..............................................................80 SEIZURE .................................................................................................................81 SEIZURE - MIDAZOLAM DOSE CHART ................................................................82 SEVERE NAUSEA ...................................................................................................83 SHOCK AND HYPOTENSION ................................................................................84 SICKLE CELL PAIN EMERGENCY ........................................................................85 SUBMERSION .........................................................................................................86 TACHYCARDIA .......................................................................................................87 OPERATiONAL POLiCiES TAB OPERATIONAL POLICIES TOC .............................................................................89 ALS RESPONDER ..................................................................................................90 BLS/FIRST RESPONDER .......................................................................................91 DETERMINATION OF DEATH IN THE FIELD ........................................................92 DEATH IN THE FIELD - GRIEF SUPPORT ............................................................94 END OF LIFE CARE................................................................................................95 EMS AIRCRAFT TRANSPORT ...............................................................................96 EMS EVENT REPORTING ......................................................................................100 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION ......................101 INTERFACILITY TRANSFERS ...............................................................................102 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 103 MEDICAL PERSONNEL ON THE SCENE ..............................................................104 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE ..........................106 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS ................107 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING ............108 RESTRAINTS ..........................................................................................................109 PROCEDURES TAB PROCEDURE POLICIES TOC ...............................................................................111 ADVANCED AIRWAY MANAGEMENT ....................................................................112 CONSENT AND REFUSAL GUIDELINES ..............................................................114 iv CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP ......................................118 ECG - 12 LEAD ........................................................................................................120 HEMORRHAGE CONTROL ....................................................................................122 INTRANASAL (IN) MEDICATION ADMINISTRATION ............................................124 INTRAOSSEOUS ACCESS PROCEDURE ...........................................................125 PLEURAL DECOMPRESSION ...............................................................................126 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES.............................................127 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE ...................128 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS.............................................129 REPORTING FORMAT ............................................................................................130 SEDATION ...............................................................................................................131 SPINAL INJURY ASSESSMENT.............................................................................132 SPINAL MOTION RESTRICTION (SMR) ...............................................................134 STOMA AND TRACHEOSTOMY .............................................................................135 TRANSCUTANEOUS PACING - TCP .....................................................................137 TRANSFER OF CARE ............................................................................................138 TRIAGE TO WAITING ROOM .................................................................................139 TXA - TRANEXAMIC ACID ......................................................................................140 STROKE ASSESSMENT SCALES (CPSS AND PSS) ..........................................141 MCi/ DiSASTER/ WMD TAB MCI/ DISASTER/ WMD TOC ...................................................................................142 BIOLOGICAL ATTACK ............................................................................................143 ACTIVE SHOOTER RESPONSE ............................................................................143 BIOLOGICAL ATTACK ............................................................................................144 CHEMICAL ATTACK ................................................................................................146 CHEMPACK DEPLOYMENT ...................................................................................147 CYANIDE POISONING ...........................................................................................148 DECONTAMINATION INCIDENT ............................................................................149 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” ..................150 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE ................................152 MULTI-CASUALTY INCIDENT - EMS RESPONSE ................................................154 NERVE AGENT AUTOINJECTOR ADMINISTRATION...........................................157 NERVE AGENT TREATMENT .................................................................................159 SUSPICIOUS POWDER PROCESS .......................................................................161 *SEE THE EMS MOBILE FIELD APP FOR A KEYWORD SEARCH OF THIS BOOK* AMBULANCE REROUTING CRITERIA 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 - Certified 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., fire, 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 thefacility during this type of incident. The hospital must come off Physical Plant diversion immediately upon resolution of the issue Reasons for Rerouting Maximumtimeallowed 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, fire, etc.)All Closest appropriate facility AREA iNTENTiONALLY BLANK AMBULANCE REROUTING CRITERIA vi EMERGENCY MEDiCAL SERviCES - STAFF DiRECTORY EMS Office 510-618-2050 (main number)510-618-2099 (fax #) On-call EMS Staff 925-422-7595 – ACRECC EMS Website - http://ems.acgov.org | EMS Email- alcoems@acgov.org EMS Event Reporting - go to https://ems.acgov.org and select the “EMS Event Report” link to submit a report EMS DIRECTOR Lauri McFadden 510-618-2055 lauri.mcfadden@acgov.org DEPUTY EMS DIRECTOR William McClurg 510-618-2030 william.mcclurg@acgov.org MEDICAL DIRECTOR Zita Konik, MD, FAEMS 510-618-2086 zita.konik@acgov.org DEPUTY MEDICAL DIRECTOR Nicole D’Arcy, MD 510-618-3302 nicole.darcy@acgov.org EMS COORDINATORS Naila FranciesClinical Quality Improvment | Data | EHR 510-208-9061 naila.francies@acgov.org Cynthia FrankelEMS for Children | ReddiNet | AED/PAD Prog. | EMS System Plan 510-618-2031 cynthia.frankel@acgov.org Kreig HarmonClinical Quality Improvement | Field Protocols & App | CCT-P | Trauma 510-667-7984 kreig.harmon@acgov.org Mike JacobsSpecialty Systems of Care - Cardiac Arrest Care | STEMI | Stroke 510-618-2047 michael.jacobs@acgov.org Elsie KuselSpecialty Programs 510-481-4197 elsie.kusel@acgov.org Jim Morrissey - SupervisorMHOAC | Emergency Preparedness and Response 510-618-2036 jim.morrissey@acgov.org Ryan PrestonCA OES Region II Regional Disaster Medical Health Specialist (RDMHS)510-618-2033 ryan.preston@acgov.org Scott SalterProfessional Standards | Compliance 510-618-2022 scott.salter@acgov.org Leslie SimmonsReceiving Facility Liaison | Ambulance Ordinance | Compliance 510-667-7412 leslie.simmons@acgov.org Carolina SnypesSpecial Projects | Procurement Management | BLS Clinical Quality Improvement 510-618-2011 carolinae.snypes@acgov.org Andrew SulymaDispatch Liaison | Fire Department Liaison | CA OES Region II Regional Disaster Medical Health Specialist (RDMHS)510-667-7533 andrew.sulyma@acgov.org Gerald TakahashiEducational Programs | EMS Orientation | Paramedic Accreditation 510-667-7588 gerald.takahashi@acgov.org Yolanda TakahashiCATT Project Manager | 911 EOA Transport Provider Liaison | Unusual Occurences | Compliance 510-618-2003 yolanda.takahashi@acgov.org EMERGENCY MEDICAL SERVICES - STAFF DIRECTORY vii ADMINISTRATIVE SERVICES AND SUPPORT TEAM Michelle Barrientos - EMS Secretary 510-618-2024 michelle.barrientos@acgov.org Ashley Gutierrez - Financial Services Specialist II 510-618-2337 ashley.gutierrez@acgov.org Erica Campos - Administrative Specialist II 510-618-2008 erica.campos@acgov.org Elise Harris - Specialist Clerk I 510-618-2059 elise.harris@acgov.org Sonya Lee - Specialist Clerk I 510-618-2034 sonya.lee@acgov.org Victor Pires - Data Analyst 510-618-3315 victor.pires@acgov.org Maria Ramos - Specialist Clerk I 510-618-2096 maria.ramos@acgov.org Shant’e Williams - Specialist Clerk I 510-618-2050 Shante.Williams2@acgov.org EMS CORPS Michael Gibson - EMS Corps Program Director 510-618-2099 michael.gibson@acgov.org Lucretia Bobo - Community Outreach Worker II 510-667-7413 lucretia.bobo@acgov.org Martha Lemus - Clerk II 510-667-2135 martha.lemus@acgov.org HEALTHCARE EMERGENCY PREPAREDNESS & RESPONSE (HEPR) Ron Seitz - Supervising Program Specialist 510-268-2139 ron.seitz@acgov.org Bev Chu - CRI Program Specialist 510-567-8216 beverly.chu@acgov.org Teelee Garvin - Specialist Clerk II 510-268-2385 teelee.garvin@acgov.org Preston Lam - HPP Program Specialist 510-268-2384 preston.lam@acgov.org Emma Olenberger - Program Services Coordinator 925-307-6633 emma.olenberger@acgov.org Hunter Park - Supply Clerk II 510-418-0576 hunter.park2@acgov.org Todd Stephenson - PHEP Program Specialist 510-567-8241 todd.stephenson@acgov.org INJURY PREVENTION Kat Woolbright - Program Manager 510-618-1990 kathryn.woolbright@acgov.org Laura Fultz - Program Specialist 510-618-2028 laura.fultz@acgov.org Ysela Jimenez-Patino - Community Health Outreach 510-618-2045 ysela.jimenez-patino@acgov.org Carol Powers - Senior Injury Prevention Program Coordinator 510-667-3055 carol.powers@acgov.org Follow us on our social media channels @alcoems on Facebook, Instagram, and X Download the Alameda County EMS Field Manual App for free in the Apple App Store or the Google Play Store viii THIS PAGE INTENTIONALLY LEFT BLANK GENERAL POLICIES TABGENERAL POLICIES TOCPatient Care Policy (General) Patient Care Policy (General)Modified On: December 1, 2011 1 GENERAL POLICIES TOC GENERAL POLICIES TOC GENERAL POLICIES TOC .........................................................................................1 AN OVERVIEW OF PATIENT CARE POLICIES ........................................................2 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ..................3 BURN PATIENT CARE ...............................................................................................7 BURN PATIENT CRITERIA ........................................................................................9 CARDIOPULMONARY RESUSCITATION (CPR) ......................................................10 ADDITIONAL INFORMATION: ..........................................................................11 MECHANICAL CPR DEVICES: .........................................................................11 PIT CREW ROLES: ...........................................................................................12 CRUSH INJURY SYNDROME ....................................................................................13 EXTREMITY INJURY..................................................................................................14 HYPERKALEMIA ........................................................................................................15 HYPERTHERMIA / HEAT ILLNESS ...........................................................................16 HYPOTHERMIA ..........................................................................................................17 INFECTION CONTROL AND SCREENING CRITERIA .............................................19 OB/GYN EMERGENCIES ...........................................................................................20 SCOPE OF PRACTICE - LOCAL OPTIONAL ............................................................21 SMOKE INHALATION / CO MONITORING ................................................................22 TRANSPORT GUIDELINES .......................................................................................24 TRAUMA PATIENT CARE ..........................................................................................25 TRAUMA PATIENT CRITERIA ...................................................................................26 AN OVERVIEW OF PATIENT CARE POLICIES Patient Care Policy (General)Modified 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 field personnel and Base Hospital Physicians. All procedures and/or medications must be within the scope of practice for field 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 104) 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 difference between policies exists, the policy with the most recent date prevails ASSAULT | ABUSE | HU-MAN TRAFFICKING | DOMES-TIC VIOLENCE Patient Care Policy (General)Modified On: June 15, 2023 3 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 1.UNIVERSAL CARE PRINCIPALS: In any situation where EMS personnel knows or reasonably suspects a person suffering from any wound or other physical injury inflicted 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 effort will be made to transport the patient to a receiving hospital for evaluation. Immediately inform hospital staff of your findings. 1.3 Document all pertinent observations on the electronic health record. 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 filed within 36 hours ÎTO REPORT CHILD ABUSE: ►Immediate verbal report to: Alameda County Children and Family Services at: 510-259-1800- 24 hour number, follow the appropriate prompts. Make sure to note the name and title of the individual that you gave your report to. ►Complete the written report found at: http://tinyurl.com/SCAreportform and fax to 510-780-8620 within 36 hours of the incident ►ALL responding agencies at a scene must complete their own report - no single agency can report in behalf of another agency. ÎTO 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: Alameda County Adult Protective Services - 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 suffered serious neglect contact local law enforcement. ►A written report can be completed online by going to: https://reporttoaps.org/ and then clicking on "Alameda County Intake Form" and completing the displayed form 2.SEXUAL ASSAULT: This involves any form of non-consensual conduct/contact with another person, or the inability of the victim to give consent due to age, cognitive disability, or voluntary/involuntary incapacitation by substances. Substances are involved in the majority of sexual assaults, keep a high index of suspicion on these patients. When EMS responds to a victim of sexual assault: 2.1 Use best judgement when assigning the primary-care provider noting the gender could be triggering to the victim 2.2 Explain in advance each treatment/procedure and offer the patient simple choices (e.g. to sit up or recline on the gurney) empowering them to feel in control. 2.3 Mirror the patient’s language (e.g., do not say “rape” or “sexual assault” if the patient has not used those words) • 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 Patient Care Policy (General)Modified On: June 15, 2023 4 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 2.4 Keep the assessment brief and injury-focused: ►Do not interview the patient about the assault ►In the absence of hemorrhage, there is rarely a need to visualize genitalia ►Assess the patient for strangulation injuries, as this is common with sexual assault 2.5 Preserve the physical evidence: ►Transport the patient “as found.” Discourage showering, removing/changing clothes, brushing teeth, using mouthwash, smoking, eating or drinking. Do not allow the patient to wash or clean their hands. ►If clothes have been removed, place clothing in a paper bag. Do not use plastic bags; they collect moisture, which degrades important organic material. If it is necessary to cut off the patient’s clothes, cut around soiled, torn, or damaged areas by 6 inches. ►Do not clean, irrigate, or apply ointment to wounds. If necessary, apply dry sterile gauze to wounds. ►If the patient needs to urinate, or vomit, preserve in a clean container (e.g. urinal, emesis basin). This evidence especially important with drug-facilitated sexual assaults. ►Chain of custody must be maintained for each item to be valuable in the forensic process. This is best accomplished by having the patient keep all evidence collected at scene in their possession or law enforcement maintaining possession.. 2.6 Transport the patient to a facility capable of performing the sexual assault forensic exam regardless of the hospital's diversion status. This exam can be performed up to 21 days post assault. ►Adult patients: Wilma Chan Highland Hospital or Washington Hospital ►Pediatric patients: Children’s Hospital (≤13 y.o.) 3.SUSPECTED HUMAN TRAFFICKING: Human trafficking involves labor or services, by means of force, fraud or coercion for the purposes of subjection into commercial sex acts or other involuntary servitude. If the person is under 18 years of age, no force, fraud or coercion is required. 3.1 Warning signs of human trafficking include: ►Individuals, who are isolated/segregated from contact with responders, are physically or emotionally bullied by others, or who don’t have control of their own ID/documents. ►Manifest signs of physical neglect – malnourished, unreasonable workplace injuries ►Live or work in locations with unsuitable living conditions or unreasonable safety working environments. ►Incidents where responders are approached and asked for protection/asylum from other individuals at a scene 3.2 Reporting requirements: ►EMS personnel should send an Unusual Occurrence report to Alameda County EMS at alco.uo@acgov.org for any suspected human trafficking cases. The information provided will be relayed directly to the Northern California Regional Intelligence Center for Human Trafficking. ►For suspected human trafficking offer the patient the 24/7 Human Trafficking Resource Center hotline number 888-373-7888 if doing so does not compromise patient safety. 4.DOMESTIC VIOLENCE and (DV) LETHALITY SCREEN 4.1 DEFINITION: Domestic violence is 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. Patient Care Policy (General)Modified On: June 15, 2023 5 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 4.1.1 Notify Law Enforcement and Receiving Facility staff (as needed) 4.1.2 Perform Domestic Violence Lethality Screen in Section 4.2 4.2 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 (see questions below in Section 4.3) Î If patient screens HIGH RISK, refer patient to the Family Violence Law Center (FVLC) by calling the FVLC 24/7 hotline # 800-947-8301 Î Briefly describe the DV circumstances to the FVLC advocate without providing any patient identifying information Î If patient consents to speaking with FVLC advocate, hand patient the phone Î 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 Î 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 4.3 Questions used in the Domestic Violence Lethality Screen for First Responders ÎA “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? ÎNegative 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/she 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 first responder may trigger the protocol referral to FVLC if not already triggered above, as a result of the victim’s response to the question below, or whenever the first responder believes the victim is in a potentially lethal situation ÎIs there anything else that worries you about your safety? (If “yes”) What worries you? Patient Care Policy (General)Modified On: May 10, 2019 6 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE DV Incident suspected? Notify Law Enforcement Transport Continue routine care Notify receiving facility of suspected abuse Is it safe, appropriate, and feasible to perform LAP and call FVLC? Perform DV Lethality Assessment Patient screens as HIGH RISK? Call FVLC 800-947-8301 and briefly describe circumstances without providing any identifying patient information Patient consents to speaking with a FVLC advocate? Repeat basic safety plan from advocate to patientandProvide discreet DV resource information Hand phone to patientandProvide discreet DV resource information Yes Yes Continue routine evaluation/careNo No Provide discreet DV resource informationNoYes Yes Provide discreet DV resource informationNo Yes No BURN PATIENT CARE Patient Care Policy (General)Modified On: July 1, 2014 7 BURN PATIENT CARE BURN PATIENT CARE A. BASIC ASSESSMENT AND MANAGEMENT 1. Assess Airway and Breathing 1.1 Assess for thermal airway injury and smoke inhalation - quick list of S/S here 1.2 High flow oxygen is critical - ??? for all burns 1.3 Be prepared for intubation 2. Assess and expose 2.1 Perform a mini neurological exam - level of consciousness 2.2 Expose and examine the patient for other areas of burn 2.3 Remove jewelry, but do not remove stuck clothing 3. Obtain vascular access 3.1 Obtain at least one IV access point for pain management and fluid resuscitation and if possible a second IV for major burns 4. Administer IV fluids – See 5. Document burn severity and treat the pain 5.1 Estimate the severity of the burns using the ABA Classification or the “Rule of 9s or "Rule of 1s"” 5.2 Treat pain. Pain management should be considered mandatory for moderate to severe burns. See Pain Management Policies – Adult (page 43) and Pediatric (page 74) 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 first responder defibrillation protocol if patient is unconscious and pulseless C. TAR BURNS 1. Do not attempt to remove the tar • 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)Modified On: May 10, 2019 8 BURN PATIENT CARE BURN PATIENT CARE 2.Cool with water 3.Maintain body temperature and observe for hypothermia D.CHEMICAL BURNS 1.Remove clothing 2.Liquid chemicals: ÎFlush immediately with copious amounts of tepid water for 10 - 15 minutes 3.Dry chemicals: ÎBrush off as much as possible, then flush with copious amount of tepid water for 10 - 15 minutes 4.Identify chemical 5.Assess for associated respiratory burns BURNPATIENTCRITERIA Patient Care Policy (General)Modified On: July 21, 2017 9 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 staffed 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 affect 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 Potentially 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 first contact out-of-county hospital to confirm bed availability. This can be done through the appropriate dispatch center or via land-line from the field 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 5.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 CARDIOPULMONARY RE-SUSCITATION (CPR) Patient Care Policy (General)Modified On: July 21, 2017 10 CARDIOPULMONARY RESUSCITATION (CPR) CARDIOPULMONARY RESUSCITATION (CPR) 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 thebreastbone (sternum) 1 rescuer2 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. Patient Care Policy (General)Modified On: May 27, 2021 11 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 specific 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 defibrillation 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. Defibrillation: Device specific. While both monophasic and biphasic wave form defibrillators 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 48) MECHANICAL CPR DEVICES: 12. PURPOSE: Effective and uninterrupted compressions are important for survival; AHA/ERC Guidelines for CPR (Cardio-Pulmonary Resuscitation) 2005 emphasize the significance of compressions to provide critical blood flow 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 effectiveness 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 ÎHypovolemia ÎHypoxia ÎHydrogen Ion (acidosis) ÎHypo-/Hyperkalemia ÎHypothermia ÎHypoglycemia (pediatric only) ÎTension pneumothorax ÎTamponade, cardiac ÎToxins ÎThrombosis, pulmonary ÎThrombosis, coronary AutoPulse Contraindications Î≤ 17 years of age ÎPatients with traumatic injury (wounds resulting from sudden physical injury or violence) LUCAS Contraindications ÎIf it is not possible to position LUCAS safely or correctly on the patient’s chest ÎToo 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 ÎToo 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)Modified On: December 1, 2011 12 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 (field 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 confirmatory adjuncts• Completes EHR at hospital (if appropriate) (with med leader)• Communicates with law/family as needed• Defibrillates if medication leader not available• Inserts advanced airway (see page 110) * (NOTE: Do not interrupt chest compressions to place an advanced airway) Medication Leader:• Defibrillates• Initiates IV or IO• Administers (or supervises) medications• Tracks and notifies team of all monitor changes• Completes EHR (with airway leader)• Communicates with family/law as needed• Terminates resuscitative efforts (with team leader)• Sets up mechanical CPR device* (see page 11)• Monitors mechanical CPR device* (see page 11) 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 CRUSH INJURY SYNDROME Patient Care Policy (General)Modified On: July 21, 2017 13 CRUSH INJURY SYNDROME CRUSH INJURY SYNDROME ÎCrush Injury syndrome Definition: 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 25)• 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: 4 and/  Cardiac Monitor  12 Lead EKG  Albuterol 10-20  Fluid resuscitation 20 ml/  see pain Adult: 41Pediatric: 66  Calcium Chloride 1 (2 min.) Note: flush IV tubing after administering CaCl to avoid precipitation  Sodium Bicarbonate 1 /60 seconds Note: . suspected(see note)Yes Reassess as needed No patient (prior to release) EXTREMITY INJURY Patient Care Policy (General)Modified On: December 1, 2011 14 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 43 (Adult) or page 74 (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 fluid 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 Definition: 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 definitive treatment is achieved in the hospital, and aims to stabilize patients with the potential to arrest or become unstable HYPERKALEMIA Patient Care Policy (General)Modified On: July 24, 2018 15 HYPERKALEMIA HYPERKALEMIA Definition: 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 definitive treatment is achieved in the hospital, and aims to stabilize patients with the potential to arrest or become unstable (s) : 1. 2. Flattened-3. 4. Sinusoidal pattern5. Ventricular Fibrillation  Cardiac Monitor  12 Lead ECG /:  / Nausea/  Palpitations  Numbness/ (s) Reassess as needed Calcium Chloride 1 (2 min.) Note: flush IV tubing after administering CaCl to avoid precipitation  Sodium Bicarbonate 1 / 60 seconds  Albuterol (only) 10-20by nebulizer or BVM Note: compatible. Yes No Cautions:u u HYPERTHERMIA / HEAT ILLNESS Patient Care Policy (General)Modified On: December 1, 2011 16 HYPERTHERMIA / HEAT ILLNESS HYPERTHERMIA / HEAT ILLNESS 1. SIGNS AND SYMPTOMS OF A HEAT EMERGENCY ÎWeakness or exhaustion ÎDizziness ÎHeadache ÎSweating may or may not be present ÎFainting or feeling faint ÎRapid heart rate ÎMuscle cramps ÎAltered 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 O23.1.5 Fan the patient 3.1.6 Water may be given if patient is alert, has a gag reflex, 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 fluid 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 fluid intake or sweating) ►Medications HYPOTHERMIA Patient Care Policy (General)Modified On: May 6, 2013 17 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 ÎNote: 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 difficulties. The patient’s judgment may be affecting 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 humidified is preferred) 3.1.5 Closely monitor cardiac rhythm 3.1.6 Check blood glucose levels. Administer glucose as needed (see ALOC page 31 – adult or page 66 - 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 find an unresponsive, hypothermic patient, take time (30-45 seconds) to try and find 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, defibrillation 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)Modified On: December 1, 2011 18 HYPOTHERMIA HYPOTHERMIA 3.3 ALS: 3.3.1 Give fluid 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 efforts 3.3.3 Defer ACLS medications until rewarming occurs (> 30° C / 86° F) INFECTION CONTROL AND SCREENING CRITERIA Patient Care Policy (General)Modified On: May 27, 2021 19 INFECTION CONTROL AND SCREENING CRITERIA INFECTION CONTROL AND SCREENING CRITERIA 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 fit testing. 2.2 Ensure availability and familiarity with appropriate PPE and proper donning/doffing procedures for all types of PPE. 2.3 Ensure availability 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 filter 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 findings and treatments appropriately. OB/GYN EMERGENCIES Patient Care Policy (General)Modified On: June 15, 2023 20 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 73). 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 fingers on each side of the neonate’s nose and mouth, split fingers 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 Defined 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: ÎEstimate blood loss (if any) ÎIs the patient in shock? If yes, Go to page 54 “Shock” protocol • Consider immediate transport or prepare for delivery • Determine stage (trimester) of pregnancy • Any patient that is ≥ 20 weeks pregnant who has sign(s)/symptom(s) that may be pregnancy related (e.g. ABD pain), should be preferentially triaged to a receiving facility with a Labor and Delivery department. SCOPE OF PRACTICE -LOCAL OPTIONAL Patient Care Policy (General)Modified On: June 15, 2023 21 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 Blood Glucose Testing 1.1.3 Epinephrine 1.1.4 Narcan 2.Local Optional Scope of Practice – requires authorization from State EMS Authority and additional training 2.1 ALS PERSONNEL: 2.1.1 Buprenorphine (optional) 2.1.2 Hydroxocobalamin (optional) 2.1.3 Ketamine (Ketalar) 2.1.4 Ketorolac (Toradol) 2.1.5 Olanzapine (Zyprexa) 2.1.6 Sodium Thiosulfate 2.1.7 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 Officer 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 SMOKE INHALATION / CO MONITORING Patient Care Policy (General)Modified On: July 21, 2017 22 SMOKE INHALATION / CO MONITORING SMOKE INHALATION / CO MONITORING • Routine Medical Care • Symptoms of Carbon Monoxide (CO) poisoning: ÎInitial symptoms are similar to the flu 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 fire. 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 fires 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 fluid 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: ÎUnconsciousness, non-responsiveness ÎHypotension ÎSeverely 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)Modified On: July 21, 2017 23 SMOKE INHALATION / CO MONITORING SMOKE INHALATION / CO MONITORING Measure SpCO(if available) ü Transport on 100% O2 ü Consider 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 poisoningSodium 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.OxygenIV/IO NSAdminister Sodium Thiosulfate 12.5 g/ 50 ml over 10 minutes Yes No *Signs and symptoms of smoke inhalation: ü Unconsciousness, non-responsiveness ü Hypotension ü Severely altered level of consciousness with soot in the mouth or nose TRANSPORT GUIDELINES Patient Care Policy (General)Modified On: July 21, 2017 24 TRANSPORT GUIDELINES TRANSPORT GUIDELINES Note: In addition, see “Trauma Patient Criteria” page 26, “Burn Patient Criteria” page 9, “Stroke / CVA” page 56, “Chest Pain/MI” page 39, and “12-lead ECG” page 120 for specific 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 specified 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 field personnel to provide field 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 significant, inherent risks for the public and the patient. If Code 3 transport of an acute patient does NOT significantly decrease transport time to the hospital, the acute patient should be transported Code 2 (no lights and siren). The hospital must be notified of the patient's Code 3 acuity even if transported Code 2 2.2 Scene assessment and/or potential extrication difficulties 2.3 ETA to the destination facility including traffic delays 2.4 Instructions within specific algorithms to “initiate early transport” 2.5 Hospital diversion status - See “Ambulance Rerouting” page vi 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 104 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 TRAUMA PATIENT CARE Patient Care Policy (General)Modified On: May 27, 2021 25 TRAUMA PATIENT CARE TRAUMA PATIENT CARE CRITICAL/TIME SENSITIVE INTERVENTIONS: ►Control major external hemorrhage (see page 122) ►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 26): Meets Physiologic and/or Anatomic Factors Meets Mechanism of Injury Criteria ÎTransport to the Trauma Center In accordance with Transport Guidelines (page 22). ÎADULT - Establish one (1) large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). Establish 2nd IV if appropriate. ÎPEDIATRIC- Establish one (1) appropriate large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). ÎTransport to the Trauma Center code 2. ÎADULT/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 26) for additional judgment decisions on code 2 transports ►Consider spinal motion restriction (SMR) for blunt trauma (see page 134) ►Administer Oxygen - Titrate SpO2 to 94-99% ►IV fluid resuscitation: ÎSBP < 90 mmHg, NS IV/IO 250 – 500ml bolus Î> 90 mmHg, IV/IO TKO or Saline Lock ÎReassess BP q 5 minutes ►Consider TXA for patients with signs of shock or uncontrolled bleeding (see page 140) ►Care of the patient with a closed head injury (GCS < 8): ÎAdvanced airway (ETT or SGA) ÎEnd-tidal CO2 should be between 30-35 mmHg ÎTrack respirations or ventilate to a rate of approx 12 times/minute with 100% O2 (AVOID HYPERVENTILATION) ÎIV/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 TRAUMA PATIENT CRITERIA Patient Care Policy (General)Modified On: June 15, 2023 26 TRAUMA PATIENT CRITERIA TRAUMA PATIENT CRITERIA 1. INTRODUCTION: The goal of the Alameda County trauma system is to transport confirmed patients meeting the various criteria below to a designated trauma center in a timely manner, bypassing non-trauma centers 2. RED CRITERIA TRAUMA PATIENTS (High Risk for Serious Injury): 2.1 A patient is identified as at high risk for serious injury when any of the following injury patterns or mental status/vitals signs listed below are present. These patients should be transported to a designated Trauma Center rapidly. Injury Patterns Mental Status & Vitals Signs • Penetrating injuries to head, neck, torso,and proximal extremities • Skull deformity, suspected skull fracture • Suspected spinal injury with new motor or sensory loss • Chest wall instability, deformity, or suspected flail chest • Suspected pelvic fracture • Suspected fracture of two or more proximal long bones • Crushed, degloved, mangled, or pulseless extremity • Amputation proximal to wrist or ankle • Active bleeding requiring a tourniquet or wound packing with continuous pressure All Patients • Total Glasgow Coma Scale ≤ 13 or; Motor GCS < 6 (Unable to follow commands) • RR < 10 or > 29 breaths/min • Respiratory distress or need for respiratory support • Room-air pulse oximetry < 90% Age 0–9 years • SBP < 70mm Hg + (2 x age in years) Age 10–64 years • SBP < 90 mmHg or • HR > SBP Age ≥ 65 years • SBP < 110 mmHg or • HR > SBP 3. YELLOW CRITERIA TRAUMA PATIENTS (Moderate Risk for Serious Injury): 3.1 In addition to above criteria, the following mechanisms of injury and EMS provider judgment of risk factors can be utilized to preferentially triage a patient to a trauma center. In general, these patients are transported code 2, however, differing field circumstances and/or patient condition may require a code 3 transport Mechanism of Injury EMS Judgment • High-Risk Auto Crash – Partial or complete ejection – Significant intrusion (including roof) • >12 inches occupant site OR • >18 inches any site OR • Need for extrication for entrapped patient – Death in passenger compartment – Child (age 0–9 years) unrestrained or in unsecured child safety seat – Vehicle telemetry data consistent with severe injury • Rider separated from transport vehicle with significant impact (eg, motorcycle, ATV, horse, etc.) • Pedestrian/bicycle rider thrown, run over, or with significant impact • Fall from height > 10 feet (all ages) Consider risk factors, including: • Low-level falls in young children (age ≤ 5 years) or older adult (age ≥ 65 years) with significant head impact • Anticoagulant use • Suspicion of child abuse • Special, high-resource healthcare needs • Pregnancy > 20 weeks • Burns in conjunction with trauma • Children should be triaged preferentially to pediatric capable centers • EMS Provider judgment - If concerned, take to a trauma center Patient Care Policy (General)Modified On: January 1, 2025 27 TRAUMA PATIENT CRITERIA TRAUMA PATIENT CRITERIA 4. TRANSPORT: Patients that meet Red or Yellow trauma criteria in the prior sections will be transported to the closest, most appropriate, designated Trauma Center 4.1 Adult trauma patients are defined as being 15 years of age or older 4.2 Pediatric trauma patients are defined as being 14 years of age or younger 5. Exceptions: The patient is identified as meeting Red or Yellow trauma criteria, but presents with one of the following: PATIENT PRESENTATION ACTION UNMANAGEABLE AIRWAY: The patient requires advanced airway management, and the paramedic is unable to manage the patient's airway through basic or advanced interven-tions. Closest Basic E.D. ADULT TRAUMATIC ARREST:Proceed to Adult Cardiac Arrest - Traumatic protocol orDetermination of Death in the Field protocol PEDIATRIC TRAUMATIC ARREST Proceed to Pediatric - Cardiac Arrest - Traumatic protocol or Determination of Death in the Field protocol ÎETA to the Pediatric Trauma Center ≤ 20 minutes Pediatric Trauma Center ÎETA to the Pediatric Trauma Center ≥ 20 minutes Closest Adult Trauma Center 6. PATIENT TURNOVER REPORTING FORMAT: EMS Clinicians should use the following DMIST format when turning over patient care to the Trauma Center medical team: ÎDemographics ÎMechanism ÎInjuries ÎSigns - Vital signs ÎTreatments Patient Care Policy (General)Modified On: January 1, 2025 28 TRAUMA PATIENT CRITERIA TRAUMA PATIENT CRITERIA 7. BASE HOSPITAL CONTACT: Varying field 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 Base Hospital contact made during transport 7.1 Contact the Base Hospital Physician if: ►The patient meets the criteria listed in the "Yellow Criteria" but the provider is requesting transport to a basic ED ►The patient requires medical treatment not covered in the Trauma Patient Care protocol ►The patient would benefit from consultation with the Base Hospital Physician 8. OUT-OF-COUNTY TRANSPORT 8.1 Patients who meet Trauma Patient Criteria may be transported directly to an out of county Trauma Center if it is the closest, most appropriate destination for the patient 8.2 Prior to transporting to an out-of-county Trauma Center, the transporting provider must: ►Contact the out-of-county Trauma Center by land line to determine if they can accept the patient ►Give a brief report including E.T.A. (See Reporting Format Protocol) ►Contact the Alameda County Base Hospital if medical consultation is required (see #5 above) 8.3 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 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 ADULT POLICIES TABAdult Policies TOCPatient Care Policy (Adult) Patient Care Policy (Adult)Modified On: December 1, 2011 29ADULT POLICIES TOC ADULT POLICIES TOC ADULT POLICIES TOC ...........................................................................................29 AIRWAY OBSTRUCTION ........................................................................................30 ALTERED LEVEL OF CONSCIOUSNESS .............................................................31 ANAPHYLAXIS / ALLERGIC REACTION ...............................................................32 BRADYCARDIA .......................................................................................................33 CARDIAC ARREST - GENERAL GUIDELINES ......................................................34 CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA ..............................................35 CARDIAC ARREST - MEDICAL - VF/PVT ..............................................................36 CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT ....................................37 CARDIAC ARREST - TRAUMATIC .........................................................................38 CHEST PAIN - SUSPECTED CARDIAC/STEMI .....................................................39 DYSTONIC REACTION...........................................................................................40 MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE .............................41 PAIN MANAGEMENT ..............................................................................................43 POISONING | INGESTION | OVERDOSE ..............................................................44 PULMONARY EDEMA / CHF ..................................................................................45 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) .......46 RESPIRATORY DISTRESS ....................................................................................47 RETURN OF SPONTANEOUS CIRCULATION - ROSC ........................................48 ROUTINE MEDICAL CARE - ADULT ......................................................................49 SEIZURE .................................................................................................................51 SEPSIS ....................................................................................................................52 SEVERE NAUSEA ...................................................................................................53 SHOCK: HYPOVOLEMIC/CARDIOGENIC .............................................................54 SICKLE CELL PAIN EMERGENCY ........................................................................55 STROKE / CVA ........................................................................................................56 SUBMERSION .........................................................................................................57 SUSPECTED OPIOID WITHDRAWAL ....................................................................58 TACHYCARDIA .......................................................................................................59 VENTRICULAR ASSIST DEVICES -VAD ...............................................................60 ALTERED LEVEL OF CONSCIOUSNESSAIRWAY OBSTRUC-TION Patient Care Policy (Adult)Modified On: April 10, 2012 30 AIRWAY OBSTRUCTION AIRWAY OBSTRUCTION • Routine Medical Care• If obstruction due to laryngeal trauma, see page 25 "Trauma Patient Care"• Obstruction due to epiglottitis: ÎDo not attempt to visualize the throat or insert anything into the mouth ÎMinimize outside stimulation. Keep the patient calm. Position of comfort. • Do not use a tongue/jaw lift or perform blind finger sweeps• Rapid Transport *Severe signs of obstruction? Suspect epiglottitis? or with Bag-Valve-Mask Able to ventilate adequately? Yes No Yes Maintain airway and Oxygen Yes ✓ Poor air exchange ✓ Increased breathing difficulty ✓ Silent cough ✓ Cyanosis ✓ Inability to speak or breathe ✓ Ask the patient “Are you choking”? If patient nods yes, act Maintain airwayand Oxygen If the patient deteriorates, or becomes completely obstructed, via -- should be attempted first. If airway can not be maintained with BVM Consider: (see page 108) Continue abdominal and chest thrusts. If the patient becomes unresponsive: Check mouth for F.B. No Apply in rapid sequence. If ineffective, or the patient is obese or in the late stages of pregnancy, consider . abdominal thrusts (FBO) cricothyrotomy choking ALTERED LEVEL OF CONSCIOUSNESS Patient Care Policy (Adult)Modified On: July 1, 2014 31 ALTERED LEVEL OF CONSCIOUSNESS ALTERED LEVEL OF CONSCIOUSNESS • Routine Medical Care• Obtain a complete patient history including current medications• Identify and document neurological deficits• 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 46)• Note: Glucose paste may be administered if the patient: 1) is able to hold head upright; 2) has a gag reflex; 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 ECG, as appropriate, and transport to a STEMI Receiving Center if STEMI is identified. (See page 120 - ECG 12-Lead) for STEMI Receiving Center information• SMR for trauma or suspicion of trauma (see page 134)• Contact the Base Physician if: Îthe Blood Glucose reading is > 60 mg/dL but hypoglycemia is suspected O2 – titrate to 94-99% SpO2IV/IO NS Check blood glucoseDextrose 10%First dose10g (100 ml) IV/IOorGlucagon 1 mg IM(if unable to start IV or IO) orOral 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/dlGive additionalDextrose 10%15g (150 ml) IV/IO Consider AEIOU – TIPS ALOC blood glucose hypoglycemia dextrose glucagon glucose paste naloxone ANAPHYLAXIS / ALLERGIC REACTION Patient Care Policy (Adult)Modified On: May 10, 2019 32 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, difficulty 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 fluid 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 OXYGENIf 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 discomfort from rash/itching but is not an essential treatment of ana-phylaxis. Consider reduced dosage if patient has taken diphenhydramine in the past 1-2 hrs. angioedema anaphylaxis anaphylactic shock allergic reaction handheld nebulizer diphenhydramine epinephrine albuterol BRADYCARDIAANAPHYLAXIS / ALLERGIC REACTION Patient Care Policy (Adult)Modified On: May 27, 2021 33 BRADYCARDIA BRADYCARDIA Maintain airway, assist breathing as needed02 – titrate to 94-99% SpO2MonitorIV/ IO NSConsider 12-lead if stable **Signs or symptoms of poor perfusion caused by bradycardia? Observe/Monitor √ 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 136)√ Consider: Sedation (see note above & sedation policy)√ Consider: Pain Management – titrate to effect √ Consider: Atropine 1 mg IV/ IO while waiting for TCP. May repeat q 3-5 minutes to a total dose of 3 mg.√ 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:√ Increase rate by 10 bpm to a max of 100bpm√ Fluid challenge, particularly if evidence of right ventricular MI 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 0.01 mg/ ml (10 mcg/ml) concentration 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 0.01 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 **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: ÎAcute altered mental status ÎHypotension ÎOn-going chest pain ÎOther signs of shock • Note: ÎIf utilizing Transcutaneous Pacing (TCP), verify mechanical capture and patient tolerance (see page 137) ÎUse sedation with caution in the hypotensive patient (see page 131) ÎIf patient symptomatic and pacing not available, consider rapid transport ÎConsider Hyperkalemia bradycardia TCP - Transcutaneous Pacing sedation atropine epinephrine fluid challenge fentanyl CARDIAC ARREST - General Guidelines Assess cause of arrest (medical vs. trauma Proceed to Cardiac Arrest- Trauma protocol Patient Disposition Go to appropriate cardiac arrest protocol for guidance on patient dispositions TraumaMedical For Cardiac Arrests of all causes: Initiate and maintain manual chest compressions until a mCPR device is available and appropriate to place Minimize interruptions to chest compressions at all times Immediately initiate timekeeping Consider advanced airway placement if persistent hypoxia/hypercarbia is present with BLS airway (OPA with BVM) Do not interrupt chest compressions for airway management Proceed to appropriate Cardiac Arrest- Medical protocol Special Considerations: ● BLS and ALS prehospital personnel are not required to initiate resuscitative measures in circumstances of obvious death, signed DNR/POLST form, or upon meeting Family Discretion Criteria as outlined in Determination of Death in the Field protocol ● Consider strangulation/hanging as causes of arrest and treat as a Medical Cardiac Arrest with SMR if suspected spinal cord injury Patient Care Policy (Adult)Modified On: January 1, 2025 34 CARDIAC ARREST - GENERAL GUIDELINES CARDIAC ARREST - GENERAL GUIDELINES CARDIAC Arrest - Medical - Asystole / PEA Patient Care Policy (Adult)Modified On: January 1, 2025 35 CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA CPR ECG / AEDBLS Airway (OPA)BVM ventilation with 10-15 lpm O2 ETCO2 Monitoring IV / IO NS Epinephrine 0.1mg/mL1 mg IV/IOq 5 minutes, up to 3 doses (1st dose ASAP – preferably within 5 min from start of CPR) Consider Advanced Airway Organized rhythm and pulse present?NoYes Proceed to Cardiac Arrest – Medical – VF/pVT protocol Shockable rhythm? 2 minutes or 5 cycles of CPRCheck rhythmYes No Proceed to:Return of Spontaneous Circulation protocol orBradycardia protocolorTachycardia protocol Consider: Determination of Death Criteria – Medical Arrest Resuscitation or Continue CPRTransport Important Considerations: ■ Do not interrupt CPR to administer medications or perform airway management ■ Use of a mechanical CPR device is required whenever it is available and appropriate ■ Consider and treat reversible causes as appropriate: • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary / coronary ■ If renal failure or hyperkalemia suspected, you may consider administering the following: 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 10• If patient presents with signs of obvious death or a valid DNR is presented - See Determination of Death in the Field Procedure asystole ITD - Impedance Threshold Device mechanical CPR epinephrine atropine CARDIAC ARREST - Medical - Refractory VF/pVTCardiac Arrest - Medical - VF/PVT Patient Care Policy (Adult)Modified On: January 1, 2025 36 CARDIAC ARREST - MEDICAL - VF/PVT CARDIAC ARREST - MEDICAL - VF/PVT • Routine Medical Care• Note: Use of a mechanical CPR device is required whenever available and appropriate *Manual chest compressionsPlace defibrillator pads in the anterior / posterior configuration Apply mechanical CPR (mCPR) device if available **Defibrillate (see note) Resume CPR immediately BLS Airway (OPA) BVM ventilation at rate of 10-12 with 10-15 lpm O2 ETCO2 Monitoring IV/IO NS 2 minutes or 5 cycles of CPR Check Rhythm Shockable rhythm? CPR while defibrillator charging**Defibrillate (see note)Resume CPR***Epinephrine 0.1mg/mL 1 mg IV/IO2 minutes or 5 cycles of CPR Check Rhythm Shockable Rhythm? CPR while defibrillator charging**Defibrillate (see note)Resume CPRAmiodarone 300 mg IV/IOConsider Advanced Airway Yes No Yes Shockable rhythm? Yes No VF/Pulseless VT notes: *Chest compressions:CPR/mCPR must be minimally interrupted (<10 secs) and should not be paused for airway placement. mCPR does not need to be paused for defibrillation(s). Manual chest compressors must be rotated at every rhythm check. **Defibrillation: Refer to manufacturer’s documentation for energy dose recommendations ***Epinephrine May be repeated q 5mins to a max of 3 doses No Proceed to Cardiac Arrest – Medical – Asystole/PEA protocol or Return of Spontaneous Circulation protocol Initiate transport to the closest STEMI centerProceed to Cardiac Arrest – Medical – VF/pVT protocol Anterior/Posterior pad placement illustration: VF - Ventricular Fibrillation VT - Ventricular Tachycardia mechanical CPR device ROSC - Return of Spontaneous Circulation defibrillate epinephrine amiodarone STEMI Receiving Center CARDIAC ARREST - Medical - Refractory VF/pVTCardiac Arrest - Medical - VF/PVT Patient Care Policy (Adult)Modified On: January 1, 2025 37 CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT Shockable rhythm? Yes If patient meets the above indications, prepare a second defibrillator and place the second defibrillator’s pads in the anterior/lateral position as pictured Double-sequential defibrillation steps: 1. Charge both defibrillators to recommended energy level 2. Deliver shock using defibrillator placed in A/P position first 3. Deliver shock with A/L placed defibrillator 1 second after the first defibrillation DO NOT DELIVER SHOCKS SIMULTANEOUSLY Go to Policy: Asystole/PEA page 37 Return of Spontaneous Circulation page 48 No CPR while defibrillators are charging Double-sequential Defibrillation (see note) Resume CPR Amiodarone 150mg IV/IO 3-5 minutes after 1st dose 2 minutes or 5 cycles of CPR Check Rhythm Shockable rhythm? Yes No CPR while defibrillators are charging Double-sequential Defibrillation (see note) Resume CPR Prepare for patient transport to STEMI Center Notify receiving STEMI center of pt inbound with refractory VF/VT as early as possible ***Epinephrine 0.1mg/mL 1mg IV/IO 2 minutes or 5 cycles of CPR Check Rhythm Shockable rhythm?No Yes CPR while defibrillators are charging Double-sequential Defibrillation (see note) Resume CPR ***Epinephrine 0.1mg/mL 1mg IV/IO 2 minutes or 5 cycles of CPR Check Rhythm Continue Double-sequential Defibrillation (see note) as appropriate every 2 minutes or 5 cycles of CPR or move to appropriate protocol VF/Pulseless VT notes: *Chest compressions:CPR/mCPR must be minimally interrupted (<10 secs) and should not be paused for airway placement. mCPR does not need to be paused for defibrillation(s). Manual chest compressors must be rotated at every rhythm check. **Defibrillation: Refer to manufacturer’s documentation for energy dose recommendations ***Epinephrine May be repeated q 5mins to a max of 3 doses • Routine Medical Care• Note: Use of a mechanical CPR device is required whenever available and appropriate• Indications: VF/Pulseless VT is considered refractory if 3 defibrillations have been delivered and additional defibrillation(s) are required at any point in a resuscitation. CARDIAC ARREST - TRAUMATIC Patient Care Policy (Adult)Modified On: January 1, 2025 38 CARDIAC ARREST - TRAUMATIC CARDIAC ARREST - TRAUMATIC • Do not resuscitate in the setting of obvious death as outlined in Determination of Death in the Field protocol, mass casualty incidents, or if staging, extrication (without resuscitation) and/or transport exceeds 20 minutes. Initiate CPR BLS Airway (OPA and BVM)Control major bleeding (tourniquet/wound packing)SMR as indicated by MOI (see note #4)Initiate Transport to Trauma Center (see note #6) During transport:→ Initiate ECG, SpO2 and ETCO2 monitoring → Consider advanced airway management if persistent hypoxia/hypercarbia with BLS airway → Bilateral needle thoracostomy if tension pneumothorax is suspected (see Pleural Decompression procedure)→ IV access x 2 (large bore) – IO access if unable to obtain IV access → IV/IO bolus of 1 liter NS Special Considerations: 1. Prioritize rapid transport 2. Consider strangulation/hanging causes of arrest and treat as a Medical Cardiac Arrest with SMR if suspected spinal cord injury and proceed to appropriate medical cardiac arrest protocol 3. ALS procedures in the field do not significantly improve outcomes for traumatic arrest patients 4. Prioritize airway placement with technique that is fastest with highest chance of first pass success (e.g. SGA) 5. Provide spinal motion restriction if indicated by mechanism or signs of blunt head/neck trauma. A backboard may be helpful to support chest compressions and transport 6. Epinephrine administration: -Do not administer if arrest was caused by hypovolemia from exsanguination -Do administer for arrests caused by hanging, strangulation, submersion/drowning, or blunt cardiac trauma (commotio cordis – likely minimal signs of external chest trauma but VF/VT rhythm) 7. Destination choice: Patient to Trauma Center: -Penetrating or Blunt trauma with significant hypovolemia from exsanguination -Submersion or Mechanical Asphyxiation (drowning, hanging, strangulation) with suspected head or spinal injury Patient to closest hospital: -Submersion or Mechanical Asphyxiation (drowning, hanging, strangulation) without suspected head or spinal injury 8. Trauma is not a contraindication for the use of mechanical CPR device as long as it does not delay transport Shockable rhythm identified?Yes No Continuously reassess airway and need for suction, hemorrhage control (efficacy of tourniquet, place pelvic binder for suspected pelvic fracture) Consider TXA administration if hemorrhagic shock is suspected ROSC Continue to destination and transfer patient care Defibrillate and proceed to Cardiac Arrest – Medical – VF/pVT protocol CHEST PAIN - SUSPECTED CARDIAC/STEMICARDIAC ARREST - TRAUMATIC Patient Care Policy (Adult)Modified On: May 27, 2021 39 CHEST PAIN - SUSPECTED CARDIAC/STEMI CHEST PAIN - SUSPECTED CARDIAC/STEMI • Routine Medical Care• Signs of Shock - 2 or more of the following: ÎPulse > 120/minute ÎPale, cool and/or diaphoretic skin signs ÎBP < 90/systolic ÎAltered 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 ECG, as appropriate, and transport to a STEMI Receiving Center if STEMI is identified. See page 120 - ECG 12-Lead for ECG 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 MonitorAssess ABC’sO2 – titrate to 94-99%Aspirin 162-324 mgIV/IO NS * NTG 0.4 mgup to 3 doses, q 3-5 minutes for continuing pain/discomfort If unresponsive to nitrates:Pain Management(see page 42) (^^see note) 12-lead EKG STEMI? Transmit EKG to STEMI Receiving Center (SRC) (see page 118) Transport to SRC Establish 2nd IV en-route Yes If cardiogenic shock, tachycardia, or life threatening dysrhythmia go to appropriate policy No Do not delay transport if technical difficulties impede EKG transmisison. Attempt to send en-route whenever possible. ^^ Note: If B/P drops below 90 systolic or drops > 30 mm/Hg from baseline at any point; or, heart rate is < 50 or > 120 bpm, contact the base physician before administering/continuing NTG and/or Pain Management Patients who have oxygen saturations of greater than 94% without signs or symptoms of hypoxia or impending airway compromise should not receive oxygen. chest pain AMI - Acute Myocardial Infarction erectile dysfunction STEMI STEMI Receiving Center CRC12-Lead EKG nitroglycerine aspirinfentanyl DYSTONIC REACTION Patient Care Policy (Adult)Modified On: December 1, 2011 40 DYSTONIC REACTION DYSTONIC REACTION • Routine Medical Care• History includes ingestion of phenothiazines: ÎChlorpromazine (Thorazine, Largactil) ÎPromazine (Compazine) ÎTriflupromazine (Vesprin) ÎLevomepromazine (Nozinan) ÎPiperidines (Haloperidol, Risperidone) ÎPromethazine (Phenergan)• Signs and Symptoms (often mistaken for a seizure disorder or tetany): ÎAgitated/frightened appearance ÎSmall pupils ÎHypotension ÎFacial grimaces ÎProtruding tongue ÎJaw muscle spasm ÎOculogyric crisis (circular movement of the eyeballs) ÎTorticollis (twisting of the neck) ÎSpasms of the back muscles, causing the head and legs to bend backward and the trunk to arch up O2 – titrate to 94-99% SpO2Maintain airway IV NS Diphenhydramine 1 mg/kg IV, IO or IMup to 50 mg If initial dose given IV/IO: May repeat dose in 15 minutes for continuing signs/symptoms. Reassess as needed Yes No dystonic reaction phenothiazines torticollis diphenhydramine MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE Patient Care Policy (Adult)Modified On: June 21, 2023 41 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 mins VF/VT: 1st dose: 300 mg IV/IO; 2nd dose: 150 mg IV/IOFollow each dose with 20mL NS flush. (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) Buprenophrine 16mg Sublingual (SL) 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/IO Cardiogenic/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 infused over 10 min Ketorolac (Toradol)15 mg IM/IV/IO Midazolam (Versed)Sedation: IV/IO (slowly) 1-2 mg, IM/IN: 2-5 mgSeizure: IM/IN: 10 mg, IV/IO: 5 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 fluid 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 Sodium thiosulfate 12.5 grams IV/IO over 10 minutes Adult medications - initial dose Patient Care Policy (Adult)Modified On: May 27, 2021 42 MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE 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: ÎPatient: 2 mg IV/IM(for use only by Paramedics or specially-trained EMTs) ÎAutoinjector 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: ÎPatient: 1 - 2 grams IV/IM(for use only by Paramedics or specially-trained EMTs) ÎAutoinjector antidote kit: 600 mg in 2 ml’s 1 - 3 kits depending on exposure (given with atropine) PAIN MANAGEMENT Patient Care Policy (Adult)Modified On: May 27, 2021 43 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 BLS Interventions:→ Positioning → Cold Pack(s)→ Splinting → Coaching Minor‐Moderate Pain: Ketorolac ‐ IM/IV/IO 15 mg x 1 ‐ (No repeat dose) Preferred first‐line medication for minor‐moderate 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) Moderate‐Severe Pain: FentanylIV/IO: 1 mcg/kg (50‐100 mcg) Slow push. Repeat q 5min PRN to a max. cumulative dosage of 200 mcg IM/IN: 1 mcg/kg (50‐100 mcg) Repeat q 10min PRN to a max. cumulative dosage of 200 mcg Base contact required if contraindications are present or >200 mcg is needed OR KetamineIV/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) Ketorolac Considerations: Contraindications: ■ Patients who meet Trauma Criteria ■ NSAID Allergy (e.g. Ibuprofen, Naproxen, Aspirin) ■ Pregnancy ■ History of: GI Bleed, Ulcers, Renal disease ■ Current anticoagulant use Note: Standards doses of Fentanyl OR Ketamine may be administered if Ketorolac is ineffective Fentanyl & Ketamine Considerations: DO NOT CO‐ADMINISTER FENTANYL AND KETAMINE Patient Monitoring Continuous monitoring of the patient’s LOC and respiratory status via direct observation/ETCO2/SpO2, etc is required. Contraindications: ■ Decreased respiratory rate ■ Altered mental status/LOC ■ Suspected Traumatic Brain Injury Notes: 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 pain management visual analog scale naloxone fentanyl POISONING | INGESTION | OVERDOSE Patient Care Policy (Adult)Modified On: August 1, 2016 44 POISONING | INGESTION | OVERDOSE POISONING | INGESTION | OVERDOSE • Routine Medical Care• Protect Yourself! - See Hazardous Materials Incidents - EMS Response page 152• 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: ÎIf organophosphate poisoning suspected* ÎIf calcium channel or beta blocker OD suspected* ÎFor treatment options for specific 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 IV/ IO NS TKO Charcoal Max dose of 50 grams Fluid Challenge Sodium Bicarbonate For patients with suspected narcotic OD go to Respiratory Depression page 45Seizure page 50 poisoning ingestion overdose organophosphate poisoning beta blocker OD calcium channel blocker OD tricyclic antidepressant OD widened QRS activated charcoal sodium bicarbonate fluid challenge naloxone PULMONARY EDEMA / CHF Patient Care Policy (Adult)Modified On: May 27, 2021 45 PULMONARY EDEMA / CHF PULMONARY EDEMA / CHF • Routine Medical Care• Consider ASA, 162 – 324 mg po, for acute coronary syndrome patients• Perform 12-Lead ECG, and transport to a STEMI Receiving Center if STEMI is identified. (See page 120 - ECG 12-Lead) for STEMI Receiving Center information• Rapid transport if on scene stabilization is unlikely O2 – titrate to 94-99% SpO2IV NS * CPAP page 116 NTG ^NTG *Note #1:Consult the base physician at any point ^ Note #2: ✓ ✓ NTG ✓ Cardiogenic Shock page 53 Reassess as needed pulmonary edema CHF sedation aspirin nitroglycerine CPAP Continuous Positive Airway Pressure RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) Maintain airway patency and adequate respirations with BLS airway adjuncts and BVM as needed Oxygen- titrate to SpO2 of 94-99% Consider vascular access 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 108) Monitor/Reassess NoYes 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)Modified On: May 10, 2019 46 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 effects (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 RESPIRATORY DISTRESS Patient Care Policy (Adult)Modified On: May 27, 2021 47 RESPIRATORY DISTRESS RESPIRATORY DISTRESS • Routine Medical Care ÎAsthma ÎCOPD ÎBronchospasm ÎPulmonary edema (see page 45)• Limit physical exertion, reduce patient anxiety O2 – titrate to 94-99% SpO2IV NS Mild Respiratory Distress- Mild wheezing/SOB- Cough Moderate to Severe Distressany 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 Albuterol5 mg in 6 mL NSandIpratropium500 mcg (2.5 mL)by nebulizer, CPAP, or BVM Epinephrine 1mg/mL0.01 mg/kg IMmax dose 0.5 mgPt must have no history of coronary artery disease or hypertension If respiratory distress continuesAlbuterol (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. respiratory distress asthma bronchospasm COPD handheld nebulizer albuterol ipratropium epinephrine atrovent Return of Spontaneous Circulation - ROSC Patient Care Policy (Adult)Modified On: May 27, 2021 48 RETURN OF SPONTANEOUS CIRCULATION - ROSC RETURN OF SPONTANEOUS CIRCULATION - ROSC Monitor and support ABCs Confirm Palpable pulse and auscultated BP Monitor EtCO2 (maintain 35‐40 mmHg with PPV) O2 titrate to 94‐99% Perform 12‐LEAD Check blood glucose B/P < 90 systolic B/P ≥ 90 systolic Pulse < 60 BPM Pulse ≥ 60 BPM Atropine 1 mg IV/IORepeat q 5 min as needed Max. dose is 3 mg Transcutaneous Pacing if indicated(see note above) B/P < 90 SystolicandHR ≤ 60 bpm? Go to appropriate arm of this algorithm Fluid Challenge500ml Consider:Epinephrine0.5ml (5 mcg) SIVP every 3 minutes, titrate to a SBP of ≥ 90 Monitor Push Dose Epinephrine Mixing Instructions:→ Take Epinephrine 1 mg of 0.1 mg/ml preparation (Cardiac Epinephrine) and waste 9ml 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 0.01 mg/ml (10 mcg/ml) concentration Yes No Consider:Epinephrine0.5ml (5 mcg) SIVP every 3 minutes, titrate to a SBP of ≥ 90 • Routine Medical Care• 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 137): 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 ROSC - Return of Spontaneous Circulation TCP - Transcutaneous Pacing atropine epinephrine amiodarone fluid challenge STEMI Center ROUTINE MEDICAL CARE - ADULT Patient Care Policy (Adult)Modified On: June 10, 2013 49 ROUTINE MEDICAL CARE - ADULT ROUTINE MEDICAL CARE - ADULT 1. DEFINITIONS: Baseline vital signs: ÎPulse rate ÎBlood pressure ÎRespiratory rate ÎPulse Oximetry ÎConsider temperature SAMPLE History: S = Signs & symptomsA = AllergiesM = MedicationsP = Pertinent past historyL = Last oral intakeE = Events leading to the injury/illnessAdapted from Emergency Care and Transportation of the Sick and Injured, 8th Edition 2. SCENE SIZE-UP: ÎSubstance isolation ÎScene safety ÎDetermine mechanism of injury | nature of illness ÎDetermine number of patients ÎRequest additional assistance 3. INITIAL ASSESSMENT: ÎForm general impression of the patient ÎAssess mental status ÎAssess the airway ÎAssess breathing ÎAssess circulation ÎIdentify priority patients 4. TRAUMA PATIENTS: Focused History and Physical Exam - Reconsider mechanism of injury Significant Mechanism of Injury: ÎRapid trauma assessment ÎBaseline vital ÎSAMPLE History ÎTransport ÎDetailed physical exam No Significant Mechanism of Injury: ÎFocused assessment based on chief complaint ÎBaseline vital signs ÎSAMPLE History ÎTransport ÎDetailed physical exam 5. MEDICAL PATIENTS - Focused History and Physical Exam - Evaluate responsiveness Responsive: ÎHistory of illness ÎSAMPLE history ÎFocused physical exam based on ÎChief complaint ÎBaseline vital signs ÎRe-evaluate transport decision ÎDetailed physical exam Unresponsive: ÎRapid medical assessment ÎBaseline vital signs ÎSAMPLE history ÎRe-evaluate transport decision ÎDetailed physical exam 6. ONGOING ASSESSMENT ÎRepeat initial vitals signs Î Reassess vital signs ÎRepeat focused assessment Î Reassess interventions Patient Care Policy (Adult)Modified On: May 10, 2019 50 ROUTINE MEDICAL CARE - ADULT ROUTINE MEDICAL CARE - ADULT 7. TREAT AS APPROPRIATE, WITHIN SCOPE OF PRACTICE (See specific 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 118) 7.2.4 ETI or SGA (see Advanced Airway Management see page 112) 7.3 Circulation: ►Initiate CPR, as needed.(see page 10) 7.4 Fluid Administration: ►Start an intravenous/intraosseous line as needed ►When IV access is needed, most of the time a saline lock is sufficient. 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 reflex: Position of comfort 8.2 Depressed Level of Consciousness, no trauma, decreased gag reflex: Left lateral position 8.3 Trauma: Spinal Motion Restriction (SMR), as needed. (see Spinal Motion Restriction (SMR) Procedure page 134). Make sure the patient can be rolled to the side in the event of vomiting 8.4 Pregnancy: Do not lay the patient flat 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 first 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 SEIZURE Patient Care Policy (Adult)Modified On: June 21, 2023 51 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 Maintain airway and adequate respirationsOxygen Actively seizing? Check Blood Glucose Result < 60 mg/ dL? If patient continues to seize consider:- Additional Midazolam Reassess as needed If ALOC considered,Go to page 35 Yes No Yes No Midazolam: IM: 10 mg (preferred route) ORIN: 10 mg (5 mg in each nare) ORIV/IO 5 mg, may repeat x 1 in 10 minutes Maximum dosage of 10 mg per patient regardless of route Go to ALOC page 35 seizure cooling measures blood glucose midazolam glucose paste dextrose glucagon SEVERE NAUSEASEPSIS Patient Care Policy (Adult)Modified On: August 18, 2017 52 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 tothe 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 fluid boluses to SBP > 90 or to 30 ml/kg total fluid dose If patient continues to have signs and symptoms of shock after 30ml/kg total fluid 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 inflammatory response can be overwhelmed leading to SIRS (Systemic Inflammatory Re-sponse 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 andmonitor Initiate Fluids IV/IO sepsis sepsis alert systemic inflammatory response syndrome (SIRS) epinephrine SEVERE NAUSEA Patient Care Policy (Adult)Modified On: May 13, 2015 53 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 first 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% SpO2Maintain airwayIV NS Zofran (ondansetron) 4 mg IV/ IM/ POSlowly (over 30 sec.) if given IV Reassess as needed Yes No If no improvement of symptoms May repeat x1 q 15 minutes nausea vomiting ondansetron Zofran SHOCK: HYPOVOLEMIC/CAR-DIOGENIC Patient Care Policy (Adult)Modified On: August 18, 2017 54 SHOCK: HYPOVOLEMIC/CARDIOGENIC SHOCK: HYPOVOLEMIC/CARDIOGENIC • Routine Medical Care• Shock - 2 or more of the following: ÎPulse > 120/minute Î Altered Mental Status ÎBP < 90/systolic Î Pale, cool and/or diaphoretic skin signs• Initiate early transport and treat en route, if appropriate.• NOTE: A fluid 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 32 • If trauma suspected, see page 24• If sepsis suspected, see page 52 -Assist respirations as needed with Bag-Valve-maskMonitor enroute Ischemic chest pain with signs and symptoms of shock If lung sounds clear 250-500 ml IV/ IO(see note) 0.5 mL (5 mcg) IV/ IO every 3 minutes, titrate to a SBP > 90 Go to appropriate dysrhythmia protocol Dysrhythmia Present? Control run IV to maintain B/P > 90/systolic Consider:if extremity bleeding is uncontrolled Yes No Consider: 12-Lead EKG Consider: 500 ml IV/ IO 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 epinephrine shock hypovolemic shock cardiogenic shock fluid challenge Sickle Cell Pain Emergency Patient Care Policy (Adult)Modified On: January 1, 2025 55 SICKLE CELL PAIN EMERGENCY SICKLE CELL PAIN EMERGENCY • Early and aggressive pain management is key to stopping the progression of ischemic processes associated with Sickle Cell emergencies.• Patients with Sickle Cell Disease (SCD) are at higher risk for other serious conditions including ACS, CVA, pulmonary embolism, and sepsis. A high index of suspicion should be maintained for other serious etiologies to symptoms especially in the setting of patient reporting abnormal pain or S/S patterns. Pt c/o pain and/or S/S consistent with prior SCD episode per pt. Pain Management BLS Interventions(Do not delay ALS interventions while waiting for BLS interventions to improve patient pain) → Heat packs/blankets/warming measures → Distraction (Screen/phone use) ALS Interventions Fentanyl IV: 1 mcg/kg (50-100 mcg) Slow push. Repeat q 5min PRN to a max. cumulative dosage of 200 mcg IM/IN: 1 mcg/kg (50-100 mcg) Repeat q 10min PRN to a max. cumulative dosage of 200 mcg OR Ketamine IV: 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) Additional Interventions/Adjuncts PRN: → IV fluids only if hypovolemic/dehydrated → Oxygen if SpO2 is ≤ 95%→ Ondansetron PRN for N/V → Diphenhydramine for allergic reaction S/S→ Consider Ketorolac if the above interventions are contraindicated, declined, or ineffective (see pain management protocol) Special Considerations: Absence of tachycardia/hypertension does not rule out sickle cell emergencies. Prompt and aggressive analgesia is always recommended for patients reporting pain Triggers for sickle cell emergencies can be infection, temperature changes, dehydration, stress/lack of sleep Priapism can be a presentation of sickle cell emergencies and should be treated with aggressive pain control Pregnancy is not a contraindication to opioid use in patients with sickle cell pain emergencies Yes No Transport per Transport Guidelines Protocol Assess for other serious conditions such as ACS, CVA, pulmonary embolus and utilize appropriate protocol(s) for patient presentation STROKE / CVA Patient Care Policy (Adult)Modified On: January 1, 2025 56 STROKE / CVA STROKE / CVA • Routine Medical Care• Rapidly identify signs of a stroke using the Cincinnati Prehospital Stroke Scale (CPSS) and Posterior Stroke Scale (PSS)• For detailed information on obtaining a CPSS / PSS - See the Procedures Section - Stroke Assessment Scales• Last Known Well Time (LKWT) must be obtained from a reliable patient or bystander. See note • Limit on scene time to <15 minutes and initiate rapid transport for ‘Stroke Alerts’ to a designated Stroke Receiving Center Patient is considered a ‘Stroke Alert’ Initiate Transport to a Stroke Receiving Center Special Considerations: The LKWT information must be provided by a reliable party or reported by a reliable patient. If the reliable party cannot accompany the patient to the receiving facility, a phone number for that party must be obtained The patient may be transported to their designated Stroke Receiving Center of choice, as long as this does not add more than 10 minutes to the transport time Determine if the patient has recently taken blood thinner medications and report this finding to the receiving facility For patients whose onset of S/S is between 6-24 hrs, consider not utilizing red lights and siren during transport Early Notification of Receiving Hospital Perform CPSS Perform Posterior Stroke ScaleNegative Positive LKWT ≤24 hrs? Negative Proceed to appropriate protocol Positive O2 – titrate to 94-99% SpO2 Obtain IV access NoBlood glucose >60 mg/dL? Yes Proceed to: Altered Level of Consciousness protocol and reassess SUBMERSION Patient Care Policy (Adult)Modified On: December 1, 2011 57SUBMERSION 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 17)• Consider CPAP - see CPAP procedure (page 118) for indications O2 – titrate to 94-99% SpO2Spinal Immobilization Trauma Patient Care page 25 CPAPspinal motion restriction (SMR) hypothermia Suspected Opioid withdrawal Patient Care Policy (Adult)Modified On: January 1, 2025 58 SUSPECTED OPIOID WITHDRAWAL SUSPECTED OPIOID WITHDRAWAL • Routine Medical Care• Indications: ÎPost Naloxone Administration with signs/symptoms of opiate withdrawal ÎPatient stated complaint of opioid withdrawal or seeking assistance for Opioid Use Disorder (OUD) ÎPatient presenting with signs/symptoms consistent with any positive score on the Clinical Opiate Withdrawal Scale (COWS)• Goals:ÎReduce patient suffering and;ÎPatient entry into a CA Bridge Program (www.cabridge.org) for treating Opioid Use Disorder Patient meets indication(s) listed above? Proceed to appropriate protocol Treat sign(s)/symptom(s) as appropriate to reduce patient suffering: Dehydration – IV Fluids Pain Management – non-opioids are preferred N/V – Ondansetron Persistent Itching - Diphenhydramine Evaluate severity of S/S utilizing COWS Score on ALCO EMS App or via EHR prior to medication administration Encourage transport to CA Bridge facility This is not required, but encouraged and preferred regardless of insurance Patient may refuse further treatment/transport with completion of AMA procedure – Base MD contact is not required if only Buprenorphine was administered → Report findings including COWS Score to Receiving Facility→ Provide patient with MAT brochure→ Document findings and treatment(s) including a working phonenumber that the patient can be contacted on for follow-up NoYes Clinical Opioid Withdrawal Scale (COWS) of ≥ 7 ? Give patient water to moisten oral mucosaAdminister 16mg of Buprenophine SL Reassess after 10 mins including COWS Score Yes No → Continue with supportive treatment→ Provide patient with MAT brochure→ Encourage transport to CA Bridge facility→ Document findings and treatment(s) Signs/Symptoms of Opioid Withdrawal: TachycardiaSweating/diaphoresisRestlessness and/or agitationDilated pupilsChills/body or joint achesRhinorrhea/lacrimationYawningTremorsNausea/Vomiting/Diarrhea/ABD painPiloerection If signs/symptoms persist/worsen an additional 8mg Buprenorphine SL (max. total dose of 24mg) may be administered Alameda County CA Bridge Facilities: Alta BatesEden Medical CenterHighlandKaiser FremontKaiser OaklandSan Leandro HospitalUCSF Benioff Children’sWashington Hospital Buprenorphine administration exclusion criteria:→ < 16 years old → Methadone use within the last 10 days→ Altered mental status/unable to give consent→ Current/recent intoxication and/or recent use of benzodiazepines or other intoxicants→ Unable to comprehend potential risks/benefits of treatment To locate the COWS Scoring Tool in the ALCO EMS App, Open the App > Adult > Suspected Opioid Withdrawal > Click the icon In the upper right-hand corner TACHYCARDIA Patient Care Policy (Adult)Modified On: June 10, 2013 59 TACHYCARDIA TACHYCARDIA • Routine Medical Care• Serious Signs and Symptoms: ÎChest Pain Î Acute MI Î BP < 90/systolic Î Shortness of Breath ÎShock Î CHF Î Decreased LOC Î 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 131 – -Monitor ** Is patient stable? ✓ ✓ Consider: precardioversion sedation with ✓ Consider titrate to effect (see ) ✓ 100 J, 200 J, 300 J, 360 Jmonophasic 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 No Regular rhythm? - ✓ ✓ If no conversion: Regular rhythm? ✓ Monitor ✓ If patient becomes unstable go to appropriate arm of this algorithm Rhythm converts?? If V-tach or uncertain: 150 mg in 100 ml D5Wgive over 10 mins. (= 100 gtts/min with 10 gtts/ml tubing) NarrowQRS WideQRS> 0.12 sec Yes Yes No Yes No Yes No ✓ 6 mg rapid IV ✓ 12 mg rapid IV ++Both monphasic andbiphasic waveformsare acceptable tachycardia wide QRS synchronized cardioversion sedation midazolam amiodarone adenosine fentanyl VENTRICULAR ASSIST DEVICES -VAD Patient Care Policy (Adult)Modified On: July 17, 2014 60 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 flow (non-pulsatile/pulseless). They are further divided into: ÎLeft Ventricular Assist Devices (LVAD), The more common continuous flow pump located in the patient’s thorax attached to the patients’ left ventricle and aorta ÎRight Ventricular Assist Devices (RVAD), ÎBiventricular Assist Devices (BiVAD). ASSESSMENT: 3. Assess for presence of a DNR, POLST or Advance Directive. 4. First ASSESS THE PATIENT, not the device. ÎThe reason for the call may or may not be a problem with the VAD. VAD patients can and frequently do have other medical conditions. ÎPatients with a continuous flow 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 refill, etc.) ►Pulse oximetry may be unreliable. ÎUtilize the American Heart Association’s C-A-B recommendations, with one addition: ►C = Circulation / Connections and Function (device) ►A = Airway ►B = Breathing ÎETCO2 will read accurately and be useful in assessment. 5. Assess the device to see if it is working. ÎInformation 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. ÎIf 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. ÎThe 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. ÎIf the patient has a continuous flow 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. ÎDetermine 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 flow. ÎCheck 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. LVAD VAD Ventricular Assist Device Left Ventricular Assist Device RVAD BVAD Right Ventricular Assist Device Biventricular Assist Device VENTRICULAR ASSIST DEVICES -VAD Patient Care Policy (Adult)Modified On: May 10, 2019 61 VENTRICULAR ASSIST DEVICES -VAD VENTRICULAR ASSIST DEVICES -VAD ÎIf the pump is pumping then the problem is usually with the patient, not the device. ÎDo ABCs in conjunction with your VAD assessment. TREATMENT/TRANSPORT: 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 Pacific 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 62 THIS PAGE INTENTIONALLY LEFT BLANK PEDIATRIC POLICIES TABPediatric Policies TOCPatient Care Policy (Pediatric) Patient Care Policy (Pediatric)Modified On: December 1, 2011 63 PEDIATRIC POLICIES TOC PEDIATRIC POLICIES TOC PEDIATRIC POLICIES TOC ...................................................................................63 AIRWAY OBSTRUCTION ........................................................................................64 ANAPHYLAXIS / ALLERGIC REACTION ...............................................................65 ALTERED LEVEL OF CONSCIOUSNESS .............................................................66 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE .............................................67 BRADYCARDIA .......................................................................................................68 CARDIAC ARREST - GENERAL GUIDELINES ......................................................69 CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA ................................................70 CARDIAC ARREST - MEDICAL - VF/PVT ..............................................................71 CARDIAC ARREST - TRAUMATIC .........................................................................72 NEONATAL RESUSCITATION ................................................................................73 PAIN MANAGEMENT ..............................................................................................74 POISONING | INGESTION | OVERDOSE ..............................................................76 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) .......77 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY .................................78 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY .............................79 ROUTINE MEDICAL CARE - PEDIATRIC ..............................................................80 SEIZURE .................................................................................................................81 SEIZURE - MIDAZOLAM DOSE CHART ................................................................82 SEVERE NAUSEA ...................................................................................................83 SHOCK AND HYPOTENSION ................................................................................84 SICKLE CELL PAIN EMERGENCY ........................................................................85 SUBMERSION .........................................................................................................86 TACHYCARDIA .......................................................................................................87 AIRWAY OBSTRUC-TION Patient Care Policy (Pediatric)Modified On: May 10, 2019 64 AIRWAY OBSTRUCTION AIRWAY OBSTRUCTION • Pediatric Routine Medical Care• If airway obstruction is caused by laryngeal trauma, see page 25 "Trauma Patient Care"• Do not use a tongue/jaw lift or perform blind finger sweeps• Obstruction due to suspected epiglottitis: ÎDo not attempt to visualize the throat or insert anything into the mouth ÎMinimize outside stimulation. Keep the patient calm. Position of comfort. • Rapid Transport• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 112) if BVM ventilation is not adequate. *Severe signs of obstruction? Ableto ventilate adequately? Maintain airwayand Oxygen Transport to the closest ED *Signs of severe obstruction Poor air exchange Increased breathing difficulty Silent cough CyanosisInability to speak or breathe Ask the patient “Are you choking”?If patient nods yes, act Observe Assist Ventilationwith Bag Valve Mask(see note) If the patient becomes unresponsive: Begin CPR Check for F.B.Only remove if seen in the pharynx If the patient is < 1 year old:- Deliver 5 back blowsfollowed by 5 chest thrusts. If the patient is > 1 year old:- Apply abdominal thrusts in rapid sequence . - If ineffective, consider chest thrusts. NoYes Yes No abdominal thrusts (FBO) cricothyrotomy choking back blows ANAPHYLAXIS / ALLERGIC REACTION Patient Care Policy (Pediatric)Modified On: June 29, 2023 ANAPHYLAXIS / ALLERGIC REACTION 65ANAPHYLAXIS / 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, difficulty 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 medication dosages and fluid 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 See LBRT for IV/IM/IO dose Max. dose: 50mg Reassess 5-10 mins. after IM Epi. If V/S not improved with fluid bolus: EPINEPHRINE 0.1mg/mL IV/IO slow push*** See LBRT for IV/IO dose • Max single dose 0.1 mg• May repeat q 5 minutes IV/IO AccessFLUID BOLUS NS See LRBT for dose - may repeat x 1 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 See LBRT for IV/IM/IO dose Max. dose: 50mg YESYES NO** SIGNS OF SHOCK? If no responseBase Physician consult NOTES* If patient develops signs of anaphylaxis, go to other arm of this algorithm **Shock in children may be subtle and hard to recognize. BP readings may be difficult to determine or inaccurate 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 IM BLS Providers: 0.15mg IM ALS Providers: See LRBT for IM dose- may repeat LBRT dose x 1 in 5 min angioedema anaphylaxis anaphylactic shock allergic reaction handheld nebulizer diphenhydramine epinephrine albuterol ALTERED LEVEL OF CONSCIOUSNESS Patient Care Policy (Pediatric)Modified On: June 29, 2023 66 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 77)• 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)• Note: Oral Glucose may be administered if the patient: 1) is able to hold head upright; 2) has a gag reflex; and, 3) can self-administer the medication• Note: A newborn in this protocol is considered such for the first 30 minutes after being born. Check Blood Glucose Results< 60 mg mg/dL? (<40 mg/dL fornewly born) Adequate response? ReassessAs needed Yes No NoYes IV/ IO Access?Yes No Consider AEIOU – TIPS Maintain airway and adequate respirations.O2 – titrate to 94‐99% SpO2IV/ IO NS Dextrose 10% IV / IOSee LBRT for dose May repeat LBRT dose until FSBS is >60 mg/dL or >40 mg/dL in newborns Oral Glucose(see note above)See LBRT for dose OrGlucagonSee LRBT for dose ALOC blood glucose hypoglycemia dextrose glucagon glucose paste naloxone dextrose 25% (D25) dextrose 10% (D10) BRIEF RESOLVED UNEXPLAINED EVENT - BRUE Patient Care Policy (Pediatric)Modified On: September 5, 2017 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE 67BRIEF 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 field personnel 1.5 50–60% have no known etiology 1.6 40–50% have an identifiable etiology (e.g. Child abuse, SIDS, swallowing dysfunction, infection, bronchiolitis, seizures, CNS anomalies, 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 reflux ►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 66 if B.S. < 60mg/ dL) 2.6 Treat any identifiable 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 Brief Resolved Unexplained Event - BRUE blood glucose Cardiac Arrest - General GuidelinesBRADYCARDIA Patient Care Policy (Pediatric)Modified On: January 1, 2025 68 BRADYCARDIA BRADYCARDIA • Pediatric Routine Medical Care• Consider and treat other possible causes: ÎHypoxia (most common) ÎHypothermia ÎHead Injury ÎHeart Block ÎToxins/ drugs ÎBeta Blockers or calcium channel blockers • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• Note: TCP reserved for children with symptomatic bradycardia refractory to BLS and ALS interventions. Use pediatric electrodes if child weighs < 15 kg bradycardia TCP - Transcutaneous Pacing sedation atropine epinephrine Maintain patent airway, assist breathing as needed02 – titrate to 94-99% SpO2Monitor Signs/ symptoms of symptomatic bradycardia? Consider obtaining 12-lead ECGOngoing assessment and transportYesNoHR = <60? Start CPR Maintain continuous CPR until patient condition improves or interventions below are effective No Ensure that airway and breathing are being effectively managed Obtain IV/IO access Epinephrine 0.1mg/mL IV/IOSee LBRT for doseRepeat Epinephrine q 3-5 min If increased vagal tone or primary AV block:Atropine 0.1mg/mL IV/IOSee LBRT for doseMay repeat q 3-5 minutes Consider TCP Continue CPR during TCP until electrical and mechanical capture is obtained Consider Sedation procedure and Pain Management protocol If asystole/PEA develops, proceed to:Cardiac Arrest – Medical – Asystole/PEA Yes Abbreviated TCP Steps 1. Apply pacer pads in A/P configuration 2. Set pacer rate to 100 bpm 3. Increase pacer current to secure electrical capture 4. Check for mechanical capture by palpation of femoral pulse 5. Increase pacer current by 5-10mA See TCP Procedure for additional information Signs/Symptoms of Symptomatic bradycardia:  Acute ALOC Weak pulses  Hypotension Central Cyanosis Example of ECG with electrical capture Cardiac Arrest - General Guidelines Assess cause of arrest (medical vs. trauma Proceed to Cardiac Arrest- Trauma protocol Patient Disposition Go to appropriate cardiac arrest protocol for guidance on patient dispositions TraumaMedical For Cardiac Arrests of all causes: Initiate and maintain manual chest compressions until a mCPR device is available and appropriate to place Minimize interruptions to chest compressions at all times Immediately initiate timekeeping Consider SGA placement if persistent hypoxia/hypercarbia is present with BLS airway (OPA with BVM)Do not interrupt chest compressions for airway management Proceed to appropriate Cardiac Arrest- Medical protocol Special Considerations: ● BLS and ALS prehospital personnel are not required to initiate resuscitative measures in circumstances of obvious death, signed DNR/POLST form, or upon meeting Family Discretion Criteria as outlined in Determination of Death in the Field protocol. ● Consider strangulation/hanging as causes of arrest and treat as a Medical Cardiac Arrest with SMR if suspected spinal cord injury. Patient Care Policy (Pediatric)Modified On: January 1, 2025 CARDIAC ARREST - GENERAL GUIDELINES 69CARDIAC ARREST - GENERAL GUIDELINES CARDIAC ARREST - Medical - Asystole/PEA Patient Care Policy (Pediatric)Modified On: January 1, 2025 70 CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA • Pediatric Routine Medical Care• In PEA, identify other causes and treat (See CPR page 10)• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 112) if BVM ventilation is not adequate. Resume CPRIV / IO NS Epinephrine 0.1mg/mL IV/IOSee LBRT for dose (1st dose ASAP – preferably within 5 min from start of CPR)q 5 minutes, up to 3 doses Non-shockable rhythm continues? No Continue CPRand medication administration Transport Shockable rhythm? No Proceed to: Cardiac Arrest – Medical – VF/pVT protocol Yes Shockable rhythm? 2 minutes CPR 30:2 5 cycles 1 rescuer 15:2 10 cycles 2 rescuersCheck rhythm Yes No Do not interruptCPR to administer medications Consider Determination of Death Criteria – Medical Arrest Resuscitation Proceed to Bradycardia protocol or Tachycardia protocol Yes If pulse present - post resuscitation care REVERSIBLE CAUSES• Hypovolemia• Hypoxia• Hydrogen ion (acidosis)• Hypoglycemia• Hypo-/hyperkalemia• Hypothermia• Tension pneumothorax• Tamponade, cardiac• Toxins• Thrombosis, pulmonary• Thrombosis, coronary Immediate and uninterrupted chest compressionsPlace ECG / AED BLS Airway (OPA) BVM ventilation with 10-15 lpm O2 ETCO2 Monitoring pulseless arrest asystole PEA - pulseless electrical activity epinephrine CARDIAC ARREST - Medical - VF/PVT Patient Care Policy (Pediatric)Modified On: January 1, 2025 CARDIAC ARREST - MEDICAL - VF/PVT 71CARDIAC ARREST - MEDICAL - VF/PVT • Pediatric Routine Medical Care• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 112) if BVM ventilation is not adequate Defibrillate (see LBRT for dose) Resume CPR IV / IO NS Shockable rhythm? CPR while defibrillator charging Defibrillate (see LBRT for dose) Resume CPR Epinephrine 0.1mg/mL IV/IO: See LBRT for dose q 5 minutes, up to 3 doses Shockable Rhythm? CPR while defibrillator charging Defibrillate (see LBRT for dose) Resume CPR Amiodarone IV/IO – See LBRT for dose. q 5 minutes, up to 2 doses Prepare for transport Proceed to: Cardiac Arrest – Medical – Asystole/PEA protocol If pulse present - post resuscitation care Yes No No Yes 2 minutes CPR 30:2 5 cycles 1 rescuer 15:2 10 cycles 2 recuersCheck rhythm Do not interruptCPR to administer medications Shockable rhythm? Yes No Immediate and uninterrupted chest compressionsPlace ECG / AED BLS Airway (OPA)BVM ventilation with 10-15 lpm O2 ETCO2 MonitoringDo not delay defibrillation for completion of these interventions. pulseless arrest VF - Ventricular Fibrillation VT - Ventricular Tachycardia defibrillate epinephrine amiodarone Cardiac Arrest - Traumatic • Do not resuscitate in the setting of obvious death as outlined in Determination of Death in the Field protocol, mass casualty incidents, or if staging, extrication (without resuscitation) and/or transport exceeds 20 minutes. Initiate CPR BLS Airway (OPA and BVM)Control major bleeding (tourniquet/wound packing)SMR as indicated by MOI (see note #4)Initiate Transport to Trauma Center (see note #6) During transport: → Initiate ECG, SpO2 and ETCO2 monitoring → Consider SGA placement if persistent hypoxia/hypercarbia with BLS airway → Bilateral needle thoracostomy if tension pneumothorax is suspected (see Pleural Decompression procedure) → IV access x 2 (large bore) – IO access if unable to obtain IV access → IV/IO bolus of 1 liter NS Special Considerations: 1. Prioritize rapid transport 2. Consider strangulation/hanging as causes of arrest and treat as a Medical Cardiac Arrest with SMR if suspected spinal cord injury and proceed to appropriate medical cardiac arrest protocol 3. ALS procedures in the field do not significantly improve outcomes for traumatic arrest patients 4. Provide spinal motion restriction if indicated by mechanism or signs of blunt head/neck trauma. A backboard may be helpful to support chest compressions and transport 5. Epinephrine administration: -Do not administer if arrest was caused by hypovolemia from exsanguination -Do administer for arrests caused by hanging, strangulation, submersion/drowning, or blunt cardiac trauma (commotio cordis – likely minimal signs of external chest trauma but VF/VT rhythm) 6. Destination choice: Patient to Trauma Center: -Penetrating or Blunt trauma with significant hypovolemia from exsanguination -Submersion or Mechanical Asphyxiation (drowning, hanging, strangulation) with suspected head or spinal injury Patient to closest hospital: -Submersion or Mechanical Asphyxiation (drowning, hanging, strangulation) without suspected head or spinal injury 7. Trauma is not a contraindication for the use of mechanical CPR device as long as it does not delay transport Shockable rhythm identified?Yes No Continuously reassess airway and need for suction, hemorrhage control (efficacy of tourniquet, place pelvic binder for suspected pelvic fracture) Defibrillate and proceed to Cardiac Arrest – Medical – VF/pVT protocol Continue to destination and transfer patient care Patient Care Policy (Pediatric)Modified On: January 1, 2025 72 CARDIAC ARREST - TRAUMATIC CARDIAC ARREST - TRAUMATIC NEONATAL RESUSCITATIONCardiac Arrest - Traumatic Patient Care Policy (Pediatric)Modified On: June 29, 2023 NEONATAL RESUSCITATION 73NEONATAL 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 first be restored• Avoid naloxone for neonates whose mothers are suspected of long-term exposure to opioids• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation asnecessary. Consider Advanced Airway Management (page 112) if BVM ventilation is not adequate. Term Gestation?Amniotic fluid clear?Breathing or crying?Good muscle tone? Provide warmth Clear airway if needed Dry off Assess color Provide warmth Position - Clear airway if needed Dry, stimulate, reposition Breathing &HR > 100? MonitorPink? Supplemental O2Cyanotic? Pink? Positive pressure ventilation 40-60 breaths/minute Yes PersistentCyanosis? No Apneic orHR < 100 HR < 60? Continue ventilation Administer chest compressionscompression:ventilation ratio 3:1 (90:30 for a total of 120 combined events/minute) No Epinephrine 0.1mg/mL See LRBT for dose Fluid bolus See LBRT fordose - may repeat LBRT dose x 1 as needed Yes No Yes PostResuscitationcareYes HR < 60? No Effectiveventilation,HR > 100 &color pink NOTE: Routine suctioning of vigorous, full term newborns at birth is not indicated. Wiping the face, nose, mouth is preferred gestational age premature infants epinephrine fluid challenge fluid bolus naloxone PAIN MANAGEMENT Patient Care Policy (Pediatric)Modified On: May 10, 2019 74 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 0No particular expressionor smile 1Occasional grimace orFrown, withdrawn, disinterested 2Frequent to constant frownClenched jaw, quivering chin Legs 0Normal or relaxed position 1Uneasy, restless, tense 2Kicking, or legs drawn up Activity 0Lying quietly, normalposition, moves easily 1Squirming, tense, shiftingBack and forth 2Arched, rigid or jerking Cry 0No cry (awake or asleep)1Moans or whimpers;occasional complaint 2Cries steadily, screams,sobs, frequent complaints Consolability 0Content, relaxed 1Reassured by “talking to,hugging; distractible 2Difficult to consoleor 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 ÎFace 0 is very happy because he doesn't hurt at all ÎFace 2 hurts just a little bit ÎFace 4 hurts a little more ÎFace 6 hurts even more ÎFace 8 hurts a whole lot ÎFace 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 administered, 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 10No Pain Worst Pain Ever pain management behavioral tool naloxone fentanyl Patient Care Policy (Pediatric)Modified On: June 29, 2023 PAIN MANAGEMENT 75PAIN MANAGEMENT • Pediatric Routine Medical Care. If oxygen is administered, 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)• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) BLS Interventions:Positioning Cold Pack(s)Splinting Coaching ALS Intervention: Fentanyl IN (preferred)/IM/IV/IOSee LBRT for dose May repeat dose on LBRT q 5 min, to a max. of 3 total doses via all routes Base Physician consult if patient requires > 200 mcg or if contraindication(s) are present Fentanyl Considerations: Contraindications: Age‐adjusted hypotension Decreased respiratory rate Altered mental status Suspected Traumatic Brain Injury Notes: Capnography monitoring is recommended Burn patients may require higher doses Have Naloxone readily available Monitor/Reassess FACES Scale visual analog scale POISONING | INGESTION | OVERDOSE Patient Care Policy (Pediatric)Modified On: June 29, 2023 76 POISONING | INGESTION | OVERDOSE POISONING | INGESTION | OVERDOSE • Pediatric Routine Medical Care• Protect Yourself! - See page 152 "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)• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 112) if BVM ventilation is not adequate. Ventilating adequately, alert with a good gag reflex? If non-acid, non-caustic, non-petroleum, and within one hour of ingestion consider:Activated Charcoal PO See LBRT for dose Max dose of 50 grams If tricyclic antidepressant suspected: Sodium Bicarbonate IV/IOSee LBRT for dose Assist respiration with BVM (see note above) NoYes Base Physician order For late stage seizure go to: Seizure page 79 For patients with suspected narcotic OD go to Respiratory Depression page 75 poisoning ingestion overdose organophosphate poisoning beta blocker OD calcium channel blocker OD tricyclic antidepressant OD activated charcoal sodium bicarbonate naloxone RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) Patient Care Policy (Pediatric)Modified On: June 29, 2023 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) 77RESPIRATORY 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 effects (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• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) Maintain airway patency and adequate respirations with BLS airway adjuncts and BVM as needed Oxygen- titrate to SpO2 of 94-99% Consider vascular access Respiratory rate ≤ 12 Monitor/Reassess Monitor/Reassess NoYes Naloxone 1 mg/mL IN/IM/IV: See LBRT for dose Titrate dose 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 108) 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 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY Patient Care Policy (Pediatric)Modified On: May 10, 2019 78 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY • Pediatric Routine Medical Care• CROUP/EPIGLOTTITIS: ÎIf the patient deteriorates, or becomes completely obstructed, positive pressure ventilation via bag-valve-mask should be attempted ÎDo not attempt to visualize the throat or insert anything into the mouth if epiglottitis suspected ÎAllow a parent to hold the child or the O2 mask if the presence of the parent calms the child ÎMinimize outside stimulation. Keep the patient calm ÎPosition of comfort• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 112) if BVM ventilation is not adequate. Airway Obstruction page 64 Allergic Reactionpage 65 Maintain airway and Oxygen BVM Ventilation O2 – titrate to 94-99% SpO2 airway oxygen BVM Ventilation respiratory distress (stridor) croup epiglottitis cricothyrotomy stridor RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY Patient Care Policy (Pediatric)Modified On: June 29, 2023 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY 79RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY • Pediatric Routine Medical Care• Position of comfort• Use an LBRT to determine pediatric medication doses - (Shown underlined on the algorithm)• Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 112) if BVM ventilation is not adequate O2 – titrate to 94‐99% SpO2via blowby or non‐rebreather mask Moderate to Severe DistressAny 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) Albuterol5 mg in 6 ml NS andIpratropium500 mcg (2.5 ml)by nebulizer or via BVM If response inadequate:Epinephrine 1mg/mL See LBRT for dose If respiratory distress continuesAlbuterol (only)5 mg in 6 ml NSby nebulizer or via BVMMay repeat x1 if respiratory distress continues Maintain airwayand oxygen If decreased LOC or apnea Consider: BVM Ventilation (see note) Albuterol 5 mg in 6 ml NSvia hand‐held nebulizer, mask or BVMMay repeat x1 respiratory distress (wheezing) wheezing albuterol epinephrine ipratropium ROUTINE MEDICAL CARE - PEDIATRIC Patient Care Policy (Pediatric)Modified On: January 1, 2025 80 ROUTINE MEDICAL CARE - PEDIATRIC ROUTINE MEDICAL CARE - PEDIATRIC The defined age of a pediatric patient is 14 years old or less, and unless specified 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. Specified ages for transport or treatment other than 14 years old include: TRANSPORT 5150 Psych Evaluation (page 128: ÎChildren ( ≤ 11 y.o.) – Children’s Hospital ÎAdolescents ( ≥ 12 y.o. & ≤ 17 y.o.) – ALCO Youth CSU Trauma Destination (page 26): Î≤ 14 y.o. – Children’s Hospital Î≥ 15 y.o. – Closest Adult Trauma Center Sexual Assault (page 3): ÎChildren ( ≤ 13 y.o.) – Children’s Hospital ÎAll Others ( ≥ 14 y.o.) – Highland or Washington TREATMENT Advanced Airway Management (page 112): Î<40kg- authorized airway is OPA/NPA, BVM, or SGA CPAP (page 118): Î< 8 y.o. – Absolute Contraindication IO Access (page 125): Refusal of Care (page 114): Î≤ 17 y.o. may not refuse transport or treatment unless legally emancipated An approved Alameda County-specific, pediatric LBRT shall be used to determine appropriate medication dosages, fluid volumes, defibrillation settings and equipment sizes. The tape is designed to estimate a child’s weight based on length (head to heel). When the child's height exceeds the length of the tape, refer to the adult dose. PRIMARY SURVEY SPECIAL CONSIDERATIONS Establish level of responsiveness ►AVPU: Alert, Verbal, Painful, Unresponsive Evaluate airway and protective airway reflexes ►Identify signs of airway obstruction and respiratory distress, including: Îcyanosis Î intercostal retractions Î choking Îstridor Î absent breath sounds Î grunting Îdrooling Î apnea or bradypnea Î nasal flaring Îtachypnea 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 134Consider 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 10) ►Assess perfusion using the following indicators: Îheart rate Î mental status Î skin signs Îquality of pulse Î capillary refill Î 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 ►An approved Alameda County-specific, pediatric LBRT shall be used to determine appropriate medication dosages, fluid volumes, defibrillation settings and equipment sizes. ►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 fluid, 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 pediatric destination decisions Seizure Patient Care Policy (Pediatric)Modified On: June 29, 2023 SEIZURE 81SEIZURE • 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 an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) Activelyseizing? Midazolam Preferred route is IN – See LBRT for dose (half of dose in each nare)ORIM: See LBRT for dose OR IV/IO: See LBRT for dose For all routes ‐ may repeat LBRT dose x 1 in 10 minutes if still actively seizing Continues to seize? Check Blood Glucose Results < 60 mg/dL? Go to ALOC page 62 If patient continues to seize consider:‐ Additional Midazolam Base Physician order Yes Yes Yes No If febrile: Cooling measures Reassess as needed No No seizure cooling measures blood glucose midazolam glucose paste dextrose Seizure - MIDAZOLAM DOSE CHART Patient Care Policy (Pediatric)Modified On: May 10, 2019 82 SEIZURE - MIDAZOLAM DOSE CHART SEIZURE - MIDAZOLAM DOSE 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 PI N K RE D PU R P L E YE L L O W WH I T E BL U E OR A N G E GR E E N OT H E R OT H E R kg 3 – 5 6– 7 8– 9 10 – 1 1 12 – 1 4 15 – 1 8 19 – 2 2 24 – 2 8 30 – 3 6 40 45 lb s 6– 1 1 13 – 1 5 17 – 2 0 22 – 2 5 27 – 3 1 33 – 4 0 42 – 4 9 53 – 6 2 65 – 8 0 90 10 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 3ml 0. 1 7ml 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 5ml 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 SEVERE NAUSEA Patient Care Policy (Pediatric)Modified On: June 29, 2023 SEVERE NAUSEA 83SEVERE NAUSEA nausea vomiting ondansetron Zofran • 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)• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• 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% SpO2Maintain airwayIV NS Is the patient severely nauseous and/ or vomiting?* Ondansetron (Zofran) PO (preferred route) ‐ 4 mg IV/IM – See LBRT for dose Slowly (over 30 sec.) if given IVMax single dose 4 mg IV/ IM Reassessas needed Yes No If symptoms do not improve Is the patient> 40kg? Repeat x1q 15 minutes Contact Base Hospital Yes No Sickle Cell Pain EmergencySHOCK AND HYPOTENSION Patient Care Policy (Pediatric)Modified On: June 29, 2023 84 SHOCK AND HYPOTENSION SHOCK AND HYPOTENSION • Pediatric Routine Medical Care• IMPORTANT SIGNS OF SHOCK: ÎCool, clammy, mottled skin ÎPallor - due to decreased skin perfusion ÎAltered level of consciousness - due to decreased perfusion to the brain ÎBP < 70 systolic• Initiate early transport and treat en route, if appropriate ÎGo to Trauma Patient Care (page 25) if trauma suspected ÎGo to Allergic Reaction (page 65) if anaphylaxis suspected• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm)• NOTE: Shock in children may be subtle and hard to recognize. Determining BP may be difficult and readings may be inaccurate Cardiogenic Shock Hypovolemic ShockSeptic Shock Spinal Shock Contact base physician Control Hemorrhage, if appropriate IV/ IO access Fluid Bolus – See LBRT for dose May repeat LBRT dose x 1 if needed Continuing signs of shock? Repeat Fluid Bolus Reassess as needed Base physician consult Yes No shock hypovolemic shock cardiogenic shock septic shock spinal shock fluid challenge Sickle Cell Pain Emergency Patient Care Policy (Pediatric)Modified On: January 1, 2025 SICKLE CELL PAIN EMERGENCY 85SICKLE CELL PAIN EMERGENCY • Pediatric Routine Medical Care• Early and aggressive pain management is key to stopping the progression of ischemic processes associated with Sickle Cell emergencies• Patients with Sickle Cell Disease (SCD) are at higher risk for other serious conditions including ACS, CVA, pulmonary embolism, and sepsis. A high index of suspicion should be maintained for other serious etiologies to symptoms especially in the setting of patient reporting abnormal pain or S/S patterns Pt c/o pain and/or S/S consistent with prior SCD episodes perpt. or guardian Pain Management BLS Interventions (Do not delay ALS interventions while waiting for BLS interventions to improve patient pain) → Heat packs/blankets/warming measures → Distraction (Screen/phone use) ALS Interventions Fentanyl IN (preferred)/IM/IV - May repeat dose on LBRT q 5 min, to a max. of 3 total doses via all routes Non-opioid medications (Ketorolac, Tylenol) See LBRT for dosing Additional Interventions/Adjuncts PRN: → IV fluids only if hypovolemic/dehydrated → Oxygen if SpO2 is ≤ 95% → Diphenhydramine for allergic reaction S/S → Ondansetron PRN for N/V Special Considerations: Absence of tachycardia/hypertension does not rule out sickle cell emergencies. Prompt and aggressive analgesia is always recommended for patients reporting pain Triggers for sickle cell emergencies can be infection, temperature changes, dehydration, stress/lack of sleep Priapism can be a presentation of sickle cell emergencies and should be treated with aggressive pain control Pregnancy is not a contraindication to opioid use in patients with sickle cell pain emergencies Yes No Transport per Transport Guidelines Protocol Assess for other serious conditions such as ACS, CVA*, and pulmonary embolus and utilize appropriate protocol(s) for patient presentation *Pediatrics with SCD are at riskof CVA SUBMERSION Patient Care Policy (Pediatric)Modified On: April 10, 2012 86 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 118 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• Initiate rapid transport to the closest most appropriate receiving hospital• Note: If hypothermia is suspected and the patient is in ventricular fibrillation, rewarming is essential. Remove wet clothing, wrap in warm blankets and place in warm ambulance hypothermia O2 – titrate to 94-99% SpO2 ✓ Spinal Immobilization ✓ ✓ Trauma Patient Care page 25 CPAP Spinal Motion Restriction (SMR) hypothermia TACHYCARDIA Patient Care Policy (Pediatric)Modified On: June 29, 2023 TACHYCARDIA 87TACHYCARDIA • Pediatric Routine Medical Care• Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) Sinus Tachycardia< 220/min ‐ infant< 180/min ‐ child P waves ‐ present/normal R to R ‐ variable PR ‐ constant Supraventricular Tachycardia (SVT)> 220/min ‐ infant > 180/min ‐ child P waves ‐ absent/abnormal Heart rate ‐ constant Treat underlying cause(s) Consider: Fluid bolus – See LBRT for dose May repeat LBRT dose x 1 Consider: VagalManeuver Adenosine Rapid IVP See LBRT initial dose (max. 1st dose 6 mg) See LBRT repeat dose (max. 2nd dose 12 mg) Consult with Base Physician forAmiodarone IV/IO infusion (over 20‐60 mins)See LBRT for dose Synchronized Cardioversion See LBRT for dose If not effective, increase to the next dose listed on LBRT Consider Sedationbut do not delay cardioversionSee Sedation page 138 Support ABCs if needed O2 – titrate to 94‐99% SpO2Attach monitor Evaluate QRS duration Wide QRS>0.08 secNarrow QRS< 0.08sec Evaluate rhythmConsider 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 88 THIS PAGE INTENTIONALLY LEFT BLANK OPERATIONAL POLICIES TABOPERATIONAL POLICIES TOCOperations Operations Modified On: May 27, 2021 89 OPERATIONAL POLICIES TOC OPERATIONAL POLICIES TOC OPERATIONAL POLICIES TOC ................................................................................89 ALS RESPONDER ......................................................................................................90 BLS/FIRST RESPONDER ..........................................................................................91 DETERMINATION OF DEATH IN THE FIELD ...........................................................92 DEATH IN THE FIELD - GRIEF SUPPORT ...............................................................94 END OF LIFE CARE ...................................................................................................95 EMS AIRCRAFT TRANSPORT ..................................................................................96 EMS EVENT REPORTING .........................................................................................100 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION .........................101 INTERFACILITY TRANSFERS ...................................................................................102 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT ...103 MEDICAL PERSONNEL ON THE SCENE .................................................................104 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE .............................106 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS ....................107 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING ...............108 RESTRAINTS .............................................................................................................109 ALS RESPONDER Operations Modified On: September 10, 2017 90 ALS RESPONDER ALS RESPONDER 1.ALS PERSONNEL - In Alameda County, an "ALS responder" is defined 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 first 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 153 "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 96 "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: ÎMulti-Casualty Incident – EMS Response (MCI) page 153 ÎRefusal of Service page 114 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 first 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 CPR & Basic Life Support for Healthcare Providers course (AHA or approved equivalent) that includes in-person skills testing of the following: ÎSingle and multiple responder CPR for adult, child, and infant; ÎAED utilization; ÎRelief of foreign-body airway obstruction (choking) and ventilation techniques for adult, child, and infant 3.2.2 Advanced Cardiac Life Support 3.2.3 PEPP (Pediatric Education for Prehospital Personnel), or Pediatric Advanced Life Support (PALS), or Emergency Pediatric Care (EPC), or an approved equivalent 3.2.4 "START" or "JumpSTART" Triage for MCI. 3.2.5 OSHA and CAL-OSHA for infection control 3.2.6 International Trauma Life Support (ITLS), PreHospital Trauma Life Support (PHTLS), Assessment and Treatment of Trauma (ATT) or an approved equivalent 3.2.7 Alameda County EMS policies for patient care not covered by, or in addition to the above ALS Responder BLS/FIRST RESPONDER Operations Modified On: July 24, 2018 91 BLS/FIRST RESPONDER BLS/FIRST RESPONDER 1. FIRST RESPONDER PERSONNEL - In Alameda County, First Responder personnel are: 1.1 Public Safety personnel (life guard, firefighter or peace officer) trained in "First Aid and CPR Standards for Public Safety Personnel", according to the standards defined in Title 22, Chapter 1.5 1.2 Individuals who are certified as an EMT by a California local EMS agency, the California State Fire Marshall's Office, 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 108 "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 96 "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 153 "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 first aid or basic life support as necessary (see page 49 "Routine Medical Care"). 3.1.2 A First Responder form must be completed for every patient (exception: see page 153 “Multi-Casualty Incident - EMS Response” and page 114 “Refusal of Service”). 3.2 BLS/First Responders are held to the following standards during patient care: 3.2.1 CPR & BLS for Healthcare Provider Course (AHA or approved equivalent) that includes in-person skills testing of the following: ÎSingle and multiple responder CPR for adult, child, and infant; ÎAED utilization; ÎRelief of foreign-body airway obstruction (choking) and ventilation techniques for adult, child, and infant 3.2.2 Approved training program curriculum for emergency first aid. 3.2.3 "START" or "JumpSTART" Triage for MCI. 3.2.4 Alameda County Policy “Multi-Casualty Incident - EMS Response” page 153 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 BLS/ALS First Responder DETERMINATION OF DEATH IN THE FIELD Operations Modified On: January 1, 2025 92 DETERMINATION OF DEATH IN THE FIELD DETERMINATION OF DEATH IN THE FIELD 1. INTRODUCTION 1.1 BLS and ALS prehospital personnel are not required to initiate resuscitative measures in any of the following circumstances: ►Signs of obvious death are present: ÎTotal decapitation ÎTotal incineration ÎTotal separation or destruction of the heart or brain ÎDecomposition of body tissues ÎIn cases of traumatic arrest, if the staging and extrication time (without resuscitation) exceeds 20 minutes ALS clinicians only: For the signs below, an ECG reading of asystole in two or more leads must be observed for one minute in conjunction with these signs ÎDependent pooling of blood resulting in skin discoloration indicating lividity ÎRigidity throughout the entire body, including the limbs, indicating rigor mortis ● Isolated tightness in the jaw is not sufficient for determining rigor mortis ►During multi-casualty incidents (MCIs); follow MCI triage principles ►Presence of a signed Do Not Resuscitate (DNR) order, or Physician Order for Life- Sustaining Treatment (POLST), an approved medical medallion inscribed with the words, “Do Not Resuscitate-EMS", or family discretion criteria ÎFamily discretion criteria: • In the absence of a valid DNR/POLST directive, if an identifiable immediate family member or spouse requests no resuscitation, with the unanimous agreement of others present, resuscitation efforts may be withheld or ceased if already initiated ÎCopies or original forms of the signed DNR/POLST directives are acceptable • All forms require the patient's signature (or signature of appropriate surrogate) and the signature of the patient's physician to be valid ÎFor additional DNR/POLST special considerations see Section 5 of this policy 1.2 If any doubt exists, begin CPR immediately, and continue resuscitation efforts until it is determined the patient has signs of obvious death, meets determination of death criteria as outlined in this policy, a valid DNR/POLST is presented, or family discretion criteria 1.3 Contacting base should be reserved for cases of determining death in situations not addressed by this policy 2. Determination of Death Criteria – Medical Arrest Resuscitation 2.1 In the absence of obvious death, an MCI, a valid DNR/POLST, or family discretion criteria, adult and pediatric medical arrest resuscitation efforts may be terminated by ALS prehospital personnel after resuscitation efforts have continued for at least 20 minutes, and all of the following are present: ÎApnea ÎNo palpable carotid or femoral pulse for 10 seconds ÎECG reading of Asystole or PEA < 40 bpm ÎETC02 < 20 mmHg; advanced airway preferred ÎROSC never achieved (ROSC defined as consecutive 5 minutes of palpable pulses at any point) ÎPatient has received ≤ 2 defibrillations ÎHypothermia is not suspected as the cause of arrest death in the field determination of death obviously dead Operations Modified On: January 1, 2025 93 DETERMINATION OF DEATH IN THE FIELD DETERMINATION OF DEATH IN THE FIELD 2.2 If any of the Determination of Death Criteria for Medical Arrest Resuscitation are not met, continue resuscitation and contact base hospital 3. Procedure After Determination of Death in the Field 3.1 Reference the Death in the Field – Grief Support guidelines 3.2 Request the coroner and local public safety agency and remain with the deceased until either agency arrives 3.3 The public safety agency with local jurisdiction is responsible for the deceased. The deceased’s body may not be moved or disturbed until a disposition is determined by the Alameda County Coroner’s Bureau 3.4 Complete an EHR and attach a one-minute ECG rhythm strip of the final cardiac rhythm in two leads 4. DNR/POLST Special Considerations 4.1 If the patient is in cardiac arrest, the DNR/POLST directive should be honored, and resuscitation withheld ÎWhile family can reverse a DNR/POLST encouragement should be given to honor patient wishes 4.2 Correct identification of the patient is essential. After a good faith effort to identify the patient, the presumption should be that the identity is correct if proper documentation is present, and the circumstances are consistent. When available, a reliable witness may be used to identify the patient 4.3 If the patient is transported, a copy of the DNR/POLST directive should stay with the patient ÎIf the patient arrests while in transit, do not start resuscitation. Continue transporting to the original destination 4.4 A copy of the DNR directive should be attached to the EHR. If a copy is unavailable, document the type of DNR directive, date the order was issued, and the name of the physician 4.5 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 4.6 There are other valid forms of directives including Advanced Health Care Directive (AHCD), the California Natural Death Act, and living wills ÎThe AHCD contains a “Health Care Instructions” section with the patient’s resuscitation preferences 4.7 When a patient is not in cardiac arrest, has a DNR/POLST, and requests treatment, up to and including resuscitation, the request should be honored hypothermia DNR - Do Not Resuscitate POLST - Physician Orders for Life-Sustaining Treatment DEATH IN THE FIELD - GRIEF SUPPORT END OF LIFE CARE Operations Modified On: May 27, 2021 94 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 field. 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 field. 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 "Determination of Death in the Field" page 92). ►assist with the notification 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 difficult time, it is OK to cry” ►"You may not remember all I have said rightnow and that's OK.” ►“I will be available later to talk to you” ►"I don't know but I will find out"• Remember: You cannot fix 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 notified (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 specific 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 office.• 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 Ican do?"• Go through the grief support brochure, point out referral numbers. Give them your card or how they can reach you.• Offer your condolences shake hands or touch if appropriate.• Leave grief support coroner DEATH IN THE FIELD - GRIEF SUPPORT END OF LIFE CARE Operations Modified On: May 27, 2021 95 END OF LIFE CARE END OF LIFE CARE • Routine Medical Care• Indications: ÎPatient has a life limiting or terminal illness, prefers comfort-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: ÎReduce patient symptom distress and; ÎMaintain patient dignity by aligning care with stated end-of-life preferences All interventions should be minimally invasive with the goal to maintain patient comfort Airway – Position/Suction PRN Breathing – Oxygen PRN Circulation – Control hemorrhage Position of comfort Review and verify POLST/DNAR Documentation Is the patient on hospice care? Contact hospice service and discuss care plan along with the patient/family Pain Management – Opioids are preferredSee Pain Management Protocol Yes No Naloxone administration is not advised Discuss home care and/or transport options with patient or person holding legal authority to make medical decisions for the patient Initiate Assess and Refer to Hospice Care/Primary Care Provider if transport is declined or transport per agreed upon care plan If there are any unresolvable issues regarding an appropriate care plan – contact the Base MD EMS AIRCRAFT TRANSPORT Operations Modified On: December 1, 2011 96 EMS AIRCRAFT TRANSPORT EMS AIRCRAFT TRANSPORT NOTE: EMS Aircraft utilized in Alameda County for prehospital emergency care will meet the qualifica-tions specified 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 notified 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 traffic, 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 significant 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 confirm radio frequency and ground contact/incident identifier ►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 EMS aircraft air ambulance EMS AIRCRAFT TRANSPORT Operations Modified On: December 1, 2011 97EMS 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 classified 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 flat ►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 fire 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 final 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 LZ - Landing Zone Operations Modified On: December 1, 2011 98 EMS 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 identified 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 first 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 139, "Transfer of Care" 9.2 The EMS Aircraft crew may release the patient to an ALS ground transport unit if ground transport is Operations Modified On: December 1, 2011 99EMS 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 Notification 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: ÎState OES Law Division at (800) 852-7550 for approval ÎCoast Guard dispatch (415) 556-2103 to give the Coast Guard helicopter flight crew an advanced notification. 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. EMS EVENT REPORTING Operations Modified On: January 1, 2025 100 EMS EVENT REPORTING EMS EVENT REPORTING 1. EMS EVENT REPORTING CRITERIA: 1.1 Events shall be reported to the Alameda County EMS Agency within twenty-four (24) hours from time of discovery if the event resulted in harm, had the potential to result in harm, or was deemed to be a potential threat to public health and safety within any of the following areas: 1.1.1 Deviations from Alameda County EMS Administrative Policies or the Field Manual 1.1.2 Medication, or clinical treatment errors 1.1.3 Deviation from authorized list of supplies or equipment 1.1.4 Equipment failures 1.1.5 Unintentional patient harm or injury during care 1.1.6 Communication failures, e.g., radios, phones, technological challenges 1.1.7 Base hospital communication and/or guidance 1.1.8 Specialty systems of care destination errors, e.g., Stroke, STEMI, Cardiac Arrest, Trauma, Sexual Assault, Psychiatric receiving 1.1.9 Collision of any EMS vehicle that resulted in injury 1.2 Any EMS clinician act or omission pursuant to Division 2.5, Chapter 7, Section 1798.200, of the Health and Safety Code, including but not limited to the following: 1.2.1 Diversion of controlled substances 1.2.2 Substance-related impairment while on duty 1.2.3 Gross negligence 1.2.4 Mistreatment or physical/sexual abuse of a patient 1.3 Events where exceptional EMS care was provided are strongly encouraged to be submitted for commendation and recognition 1.3.1 A nomination for the Alameda County EMS Award can be submitted in addition to the EMS Event Report 2. EMS EVENT REPORTING - HOW-TO: ►All EMS Event Reports must by submitted digitally. To submit a EMS Event Report: ►Scan the QR code on this page with any mobile device ►Go to https://tinyurl.com/alcoems-eventreport Link to EMS Event Reporting Form EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION Operations Modified On: January 1, 2025 101 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 specified in Alameda County EMS Agency's "Minimum Equipment and Supply Specifications Policy. 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 sufficient 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 file 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 identified standards for equipment and personnel. ►Deficiencies may result in the unit's removal from service until the deficiencies are remedied ►The Alameda County EMS Agency will notify the service provider agency's designated management representative immediately of the infraction 5. EQUIPMENT AND SUPPLIES LIST: See the EMS Agency's website for the latest copy of the Equipment and Supplies List at: https://ems.acgov.org or by scanning the QR code below Link to Equipment and Supplies List INTERFACILITY TRANSFERS Operations Modified On: July 24, 2018 102 INTERFACILITY TRANSFERS INTERFACILITY TRANSFERS Note: This policy pertains to emergency transfers to a higher level of care that come through the9-1-1 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 defined 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 office 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 interfacility transfers IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT Operations Modified On: December 1, 2011 103IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 1. PURPOSE: To define the scope of practice of the EMT and paramedic with respect to the management of patients during emergency or routine transport from the field or during an interfacility transfer 2. Certified 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 flow and turn off the flow of intravenous fluid; ►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 fluids 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 fluid 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 office 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 infusion devices ventilators thoracostomy tubes MEDICAL PERSONNEL ON THE SCENE Operations Modified On: December 1, 2011 104 MEDICAL 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 identifies 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 offer 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 identifies 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 Office 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 cmaCALIFORNIAMEDICAL 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. Offer 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 offer 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 PARAMEDICSA 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 offer 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 offer suggestions only (alternative #1); or, 3.2 retain medical control but consider suggestions offered by the physician on scene (alternative #2); or, 3.3 delegate medical control to the physician on scene (alternative #3) physician on scene Operations Modified On: December 1, 2011 105MEDICAL 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. Offer 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) ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE Operations Modified On: December 1, 2011 106 ON 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 first 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, fire) but no Ambulance Personnel 3.1 Stop to ascertain if assistance is required. The crew should notify the officer 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 qualified responder. The decision to wait for an emergency ALS ambulance or to authorize transport by the ambulance is the responsibility of the most medically qualified 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 130) 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 on-view an accident PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS Operations Modified On: December 1, 2011 107PARAMEDIC 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 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING Operations Modified On: July 24, 2018 108 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 first on the scene of an incident: 2.1 shall cancel a responding ambulance unit upon determination that, in the best judgment ofthe first 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 92) 2.3 Ambulance personnel arriving first 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 first on the scene of an incident should upgrade a responding unit to a "non-divertible" response status: 3.1 If it is determined by first 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 findings of an active CVA within the current time treatment window 3.1.3 Patients who meet “Trauma Patient Criteria” as defined on page 25 of this book 3.1.4 Patients who have significant 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 first 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 first medical personnel on-scene, the illness or injury is not immediately life threatening or that the difference in Code 3 and Code 2 response time would not likely have an impact on patient outcome. RESTRAINTS Operations Modified On: January 1, 2025 109 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 field 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 specifically 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 handcuffs are applied by law enforcement officers: 2.1 The patient will not be cuffed to the stretcher and a law enforcement officer shall accompany the patient in the ambulance, if the handcuffs are to remain applied 2.2 A law enforcement officer 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 or soft restraints 110 THIS PAGE INTENTIONALLY LEFT BLANK PROCEDURES TABPROCEDURE Policies TOCProcedures Procedures Modified On: December 1, 2011 111PROCEDURE POliCiES TOC PROCEDURE POliCiES TOC PROCEDURE POLICIES TOC ...............................................................................111 ADVANCED AIRWAY MANAGEMENT ....................................................................112 CONSENT AND REFUSAL GUIDELINES ..............................................................114 CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP ......................................118 ECG - 12 LEAD ........................................................................................................120 HEMORRHAGE CONTROL ....................................................................................122 INTRANASAL (IN) MEDICATION ADMINISTRATION ............................................124 INTRAOSSEOUS ACCESS PROCEDURE ...........................................................125 PLEURAL DECOMPRESSION ...............................................................................126 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES.............................................127 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE ...................128 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS.............................................129 REPORTING FORMAT ............................................................................................130 SEDATION ...............................................................................................................131 SPINAL INJURY ASSESSMENT.............................................................................132 SPINAL MOTION RESTRICTION (SMR) ...............................................................134 STOMA AND TRACHEOSTOMY .............................................................................135 TRANSCUTANEOUS PACING - TCP .....................................................................137 TRANSFER OF CARE ............................................................................................138 TRIAGE TO WAITING ROOM .................................................................................139 TXA - TRANEXAMIC ACID ......................................................................................140 STROKE ASSESSMENT SCALES (CPSS AND PSS) ..........................................141 ADVANCED AIRWAY MANAGEMENT Procedures Modified On: June 21, 2023 112 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 defibrillation or demonstrates ROSC (2015 AHA Guidelines) 1.5 Personnel must confirm 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 Definition: An intubation attempt is defined as the insertion of the laryngoscope blade into the patient's mouth. 3.1.2 All ETI attempts should be performed with two providers. 3.1.3 All ETI attempts must utilize a gum elastic bougie device when direct laryngoscopy (DL) or non-channeled video laryngoscopy (VL) is utilized. Channeled VL does not require bougie utilization. 3.1.4 The maximum ETT size that can be utilized for ETI is 7.0mm. 3.1.5 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. 3.1.6 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. Procedures Modified On: May 10, 2019 113 ADVANCED AiRWAY MANAGEMENT ADVANCED AiRWAY MANAGEMENT 3.2 Supraglottic Airway Device (i-gel®) 3.2.1 Definition: A supraglottic airway attempt is defined 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 sniffing 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 definitive 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 fields 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 confirm ETT/SGA placement should be electronically uploaded into and documented on the patient's EHR. 4.4.1 Describe waveform (e.g. box, shark fin, 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, deflate 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 131) 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 CONSENT AND REFUSAL GUIDELINES Procedures Modified On: January 1, 2025 114 CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES 1. PATIENT DEFINITION: 1.1 A 'patient' is an individual meeting anyone one of the following criteria: ►Requests evaluation for potential illness or injury ► Medical assistance has been requested for the individual by another person ►Has obvious evidence of illness or 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 ► A person who is deceased ► A person who demonstrates impaired psychiatric function or suicidal intent ►An assessment was performed (V/S, history, diagnostic, physical exam) 2. DOCUMENTATION OF NON-PATIENT / PATIENT CONTACTS 2.1 If a person does not meet the definition of a patient in Section 1, detailed patient information is not required to be entered into the EHR. 2.2 If a person meets the definition of a patient in Section 1, they shall be offered a treatment and/or transport after a complete assessment which shall include a full set of vital signs. Patients/Designated Decision Makers (DDM) with mental capacity have the right to refuse any or all treatment(s) and/or transport as long as EMS personnel have explained the care and the patient/DDM demonstrates capacity as defined below. 3. PATIENTS WHO MAY LEGALLY GIVE CONSENT OR REFUSE MEDICAL TREATMENT ARE AS FOLLOWS: 3.1 Is an adult (18 years old or older) with mental capacity 3.2 A minor who is: 3.2.1 Legally emancipated 3.2.2 Lawfully married 3.2.3 On Active Duty with the Armed Forces 3.2.4 >12 years old seeking prevention or treatment of pregnancy or sexual assault 3.2.5 >12 years old seeking treatment of rape, contagious diseases, alcohol, or drug abuse 3.3 A patient who has a Designated Decisions Maker (DDM) 3.3.1 A Designated Decision Maker (DDM) is defined as: An individual to whom the patient or a court has given legal authority to make medical decisions concerning the patient’s healthcare (a parent or Durable Power of Attorney DPOA) 4. ASSESS AND RELEASE (AAR) FROM EMS CARE DEFINITION: 4.1 A patient who, after assessment by EMS personnel, does not desire treatment and/or transport to an emergency department 5. ASSESS AND RELEASE (AAR) FROM EMS CARE CRITERIA: 5.1 EMS clinician and the patient or DDM agree that the illness/injury does not require immediate treatment/transport via emergency/911 services 5.2 In order to release care, a patient, parent, or guardian must have legal and mental decision-making capacity by meeting all of the following criteria: 5.2.1 Understands the nature of the medical condition, and the risks and consequences of not seeking treatment now 5.2.2 Exhibits evidence of decision-making capacity sufficient to understand the nature of the medical condition as well as the risks and potential consequences of not seeking additional medical care/transport 5.2.3 Exhibits no evidence of: ►Altered level of consciousness ►Alcohol or drug ingestion that impairs decision-making capacity consent and refusal guidelines patient definition refusal of care refusal of service Procedures Modified On: January 1, 2025 115 CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES 5.3 EMS personnel should advise the patient/DDM of alternative care and transport options, which may include directing them to other services: 5.3.1 Private transport to a clinic, physician’s office, or an Emergency Department 5.3.2 Telephone consultation with a physician 6. ASSESS AND RELEASE (AAR) FROM EMS CARE DOCUMENTATION ESSENTIALS: 6.1 What the patient is refusing (i.e. medical care, transport) 6.2 Why the patient is refusing care and their plan for follow up care 6.3 The apparent capacity of the patient to refuse care 6.4 The presence or absence of impairment (i.e. drugs, alcohol, or significant head trauma) 6.5 Risk and consequence of refusing care as explained to the patient or legal representative 6.6 Statement that the patient understands the risks and consequences of refusing care 6.7 The patient understanding that they may re-access 911 if needed 6.8 Signature of patient or legal representative refusing care 6.9 Documentation that interpreter was used, when appropriate 6.10 Under “Reason for Refusal or Release” choose "Patient/Guardian states intent to transport by other means" or "Released following protocol guidelines” as disposition category in EHR 7. AGAINST MEDICAL ADVICE (AMA) DEFINITION: 7.1 A patient who after assessment by ALS personnel is recommended to accept treatment and/or transport, but refuses 8. AGAINST MEDICAL ADVICE (AMA) CRITERIA: 8.1 EMS clinician advises the patient or DDM to receive treatment and transport. The patient or DDM refuse medical care against the advice of the EMS clinician 8.2 In order to refuse care, a patient, parent, guardian, or DDM must have legal and mental decision-making capacity by meeting ALL of the following criteria: 8.2.1 Understands the nature of the medical condition, and the risks and consequences of refusing care 8.2.2 Exhibits evidence of decision-making capacity sufficient to understand the nature of the medical condition as well as the risks and potential consequences of not seeking additional medical care/transport 8.2.3 Exhibits no evidence of: ►Altered level of consciousness; ►Alcohol or drug ingestion that impairs decision-making capacity; ►Danger to self or others 9. AGAINST MEDICAL ADVICE (AMA) DOCUMENTATION ESSENTIALS: 9.1 What the patient is refusing (i.e. medical care, transport) 9.2 Why the patient is refusing care and their plan for follow up care 9.3 The apparent capacity of the patient to refuse care 9.4 The presence or absence of impairment (i.e. drugs or alcohol) 9.5 Risk and consequence of refusing care as explained to the patient or legal representative 9.6 Statement that the patient understands the risks and consequences of refusing care 9.7 The patient understanding that they may re-access 911 if needed 9.8 Signature of patient or legal representative refusing care 9.9 Documentation that interpreter was used, when appropriate 9.10 Under “Reason for Refusal or Release” choose AMA as disposition category in EHR Procedures Modified On: January 1, 2025 116 CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES 10. BASE CONTACT: Can be made to help convince the patient to receive treatment and/or transport when the refusal would cause potential harm or death to the patient 11. PEDIATRIC CONSIDERATIONS: Parents or guardians who refuse treatment and/or transport for pediatric patients whom the clinician feels should receive treatment and/or transport deserve specials consideration 11.1 Base contact should be made, as well as considering law enforcement involvement to encourage treatment and/or transport. 11.2 Consider potential abuse or neglect of the child in the parent or guardian’s refusal. 12. SPECIAL CONSIDERATIONS: 12.1 Consider early involvement of law enforcement if there is any threat to self, others or grave disability. 12.2 If the patient cannot legally refuse care or is mentally incapable of refusing care, document on the PCR that the patient required immediate treatment and/or transport, and lacked the mental capacity to understand the risks/consequences of the refusal (implied consent) 12.3 At no time are field personnel to put themselves in danger by attempting to transport or treat a patient who refuses. At all times, good judgment should be used, appropriate assistance obtained, and supporting documentation completed 12.4 An individual under arrest or incarcerated, or on a 5150 is legally capable of consenting or refusing medical care but cannot refuse transport. 12.5 If you cannot complete the refusal of service log due to scene safety issues or upon the insistence of another agency, complete an EMS Event form and send it to the EMS Agency Procedures Modified On: January 1, 2025 117 CONSENT AND REFUSAl GUiDEliNES CONSENT AND REFUSAl GUiDEliNES 13. CONSENT AND REFUSAL GUIDELINES WORKFLOW: Is this person a patient? A patient is defined as any one of the following: Requests evaluation for potential illness or injury Medical assistance has been requested for the individual by another person 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 A person who is deceased A person who demonstrates impaired psychiatric function or suicidal intent An assessment was performed (v/s, history, diagnostic, physical exam) Yes Transport to receiving center Does the patient agree to transport? Does the patient need emergent treatment or transport? AMA Involve DPOA for Assess and Release Against Medical Advice Definition (AMA): A patient who, after assessment and recommendation from Advanced Life Support EMS clinicians for treatment and/or transport, the patient who has decision-making capacity or the legal representative, declines treatment and/or transport. Against Medical Advice Criteria: EMS clinician advises the patient or designated decision maker (DDM) to receive treatment and transport. The patient or DDM refuse medical care against the advice of the EMS clinician. Base Contact Considerations: Pediatric Consideration See Consent and Refusal Guidelines Section 11.0 Special Consideration See Consent and Refusal Guidelines Section 12.1 -12.5 Assessment Assess and Release (AAR) From EMS Care Definition: A patient or who, after assessment by EMS clinicians, does not desire treatment and/or transport to an emergency department and does not meet protocol criteria for an emergency medical condition for treatment and/or transport to an emergency department. Assess and Release from EMS Care Criteria: EMS clinician and the patient or designated decision maker (DDM) agree that the illness/injury does not require immediate treatment /transport via emergency /911 services and the patient and/or DDM does not want to be transported. Assess and Release Who can consent or refuse treatment and transport? Patients who are ≥ 18 years of age with mental capacity A minor who is either: o Legally emancipated, or o Lawfully married, or o On Active Duty with the Armed Forces Yes Yes Involve DPOA or LE Can the person consent to refusal of care or transport? No No Yes Does the patient request transport? Transport to receiving center Can the person consent to refusal of care or transport? No Yes No Yes No CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP Procedures Modified On: December 1, 2011 118 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 significant 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 first 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. CPAP Procedures Modified On: December 1, 2011 119CONTiNUOUS 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 must 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 12-Lead ECG STEMI SRC intercostal space limb leads precordial leads ACS - Acute Coronary Syndrome ST segment ECG - 12 LEAD Procedures Modified On: May 26, 2016 120 ECG - 12 lEAD ECG - 12 lEAD 1. INTRODUCTION: 12-lead electrocardiograms (ECGs) are used with a variety of patients and should be used with a number of patient care policies (e.g., ALOC (page 31), Chest Pain/MI (page 39), and CHF/Pulmonary Edema (page 45). Treatment under these policies should proceed in conjunction with the application of the 12-lead ECG. Our goal is to incorporate the 12-lead ECG 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 ECG program and who have received the required training may perform a 12-lead ECG. [see 12-LEAD ECG PROGRAM (#4210) in the Administrative Manual for training and program requirements]. 12-lead ECG 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. ECG CRITERIA FOR STEMI: convex, “tombstone,” or flat 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 Modified On: June 6, 2012 121 ECG - 12 lEAD ECG - 12 lEAD 4.PROCEDURE: 4.1 Attach ECG leads to the patient (limb leads to the upper arms and ankles, and six chest leads). Perform an ECG 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 suspectedinferior MIs) 4.2 If the ECG machine is reading “Acute MI” or the equivalent, or definite new left bundle branch block, immediately transmit the ECG 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 ECG (leads, amount of ST elevation in millimeters, “confidence” 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 branchblock, left ventricular hypertrophy, pericarditis or paced rhythms). ►Significant vital signs and physical findings ►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 traffic and weather conditions, as well as the patient’s choice of facility or physician 4.5 Any 12-lead ECGs obtain should attached to the EHR 4.6 Serial 12-lead ECGs, 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 Hemorrhage Control Procedures Modified On: May 10, 2019 122 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 effectively 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 difficult or dangerous situation for responding caregivers ►Mass casualty event ►Significant 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• Significant bleeding from multiple locations 3. TOURNIQUET: Place County-approved tourniquet according to manufacturer's instructions 4. WOUND PACKING: Significant 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 tourniquet C.A.T. - Combat Application Tourniquet hemorrhage control Procedures Modified On: May 6, 2013 123 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 INTRANASAL (IN) MEDICATION ADMINISTRATION INTRAOSSEOUS ACCESS PROCEDURE Procedures Modified On: May 13, 2015 124 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 specific treatment algorithms: ►Pain Management – Adult page 43 | Pediatric page 74 ►Respiratory Depression or Apnea – Adult page 46 | Pediatric page 77 ►Sedation – page 131 ►Seizure – Adult page 51 | Pediatric page 81 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 intranasal IN INTRAOSSEOUS ACCESS PROCEDURE Procedures Modified On: May 27, 2021 125 iNTRAOSSEOUS ACCESS PROCEDURE iNTRAOSSEOUS ACCESS PROCEDURE 1.PURPOSE: To obtain rapid circulatory access to provide necessary intravenous fluids or medications 2.INDICATIONS: ►Consider for use in any unconscious or seriously ill or injured patient in whom IV access cannot beestablished in a very timely fashion ►Any medications or fluids that can be given in a peripheral vein can be given intraosseous 3.CONTRAINDICATIONS: ►Fracture in target bone ►Previous, significant 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 addtional references below): 4.1 Proximal Tibial Tuberosity 4.2 Proximal Humerus 4.3 Distal Femur (≤10 y/o) 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 43, Pediatric page 74. Also,consider use of 2% Lidocaine for anesthetic effect. 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. Flushwith 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) IOover 60 seconds. Repeat PRN Proximal Tibia Proximal Humerus Distal Femur (≤10 y/o) intraosseous infusion EZ-IO (Proximal Tibia) PLEURAL DECOMPRESSION Procedures Modified On: May 10, 2019 126 PlEURAl DECOMPRESSiON PlEURAl DECOMPRESSiON 1. INDICATIONS: When clinical findings reveal a tension pneumothorax (severe respiratory distress, diminished breath sounds on the affected 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 pleural decompression intercostal space pneumothorax tension pneumothorax PSYCHIATRIC AND BEHAVIORAL EMERGENCIES Procedures Modified On: January 1, 2025 127 PSYCHiATRiC AND BEHAViORAl EMERGENCiES PSYCHiATRiC AND BEHAViORAl EMERGENCiES Severe Agitation with Altered Mental Status that endangers the patient, healthcare providers, or bystanders and has failed attempts at verbal de-escalation ► Paranoia► Disorientation► Extremely aggressive or violent► Tachycardia► Increased strength► Hyperthermia► Clear danger to self/others Calm/Cooperative? Consider Olanzapine administration (pg.127) Attempt de-escalation(if possible) Consider Restraints protocol Consider Sedation protocol Yes No Behavioral Crisis ► Aural/Visual hallucinations► Anxiety► Depression► Manic behavior► Suicidal ideation► Disorganized thoughts► Unpredictable behavior Cognitive Impairment/Developmental Disability ► Alzheimer’s disease► Dementia► Autism► Down Syndrome► Intellectual disability► Developmental delays► Traumatic Brain Injury Continuous monitoring after: Immediate and continuous visual airway monitoring As soon as it is safe to do so: Continuous SpO2 and ETCO2 monitoring Vitals signs and ECG monitoring Consider Hyperthermia/Heat Illness protocol IV access/consider fluid bolus 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 Guidelines protocol Calm/Cooperative? Yes If transport is necessary, transport to the closest, most appropriate receiving hospital *If possible, allow caregiver to accompany the patient Attempt de-escalation (if possible) Consider Restraints protocol Consider Sedation protocol No Transport all of these patients to the closest, most appropriate Emergency Department Treatment Never use prone positioning Consider Restraints protocol Consider Sedation protocol Psychiatric and Behavioral Emergencies- OLANZAPINE Procedures Modified On: May 10, 2019 128 PSYCHiATRiC AND BEHAViORAl EMERGENCiES- OlANZAPiNE PSYCHiATRiC AND BEHAViORAl EMERGENCiES- OlANZAPiNE 1. iNTRODUCTiON: Olanzapine (Zyprexa) 10 mg sublingual is an atypical antipsychotic with minimal sideeffects. The major side effect would be minimal sedation that can be worsened by alcohol or other sedatives. Orally disintegrating Olanzapine sublingual allows for rapid absorption, with effects occurring within 10-15 minutes of administration. 2. iNDiCATiONS: 2.1 Olanzapine is indicated for the cooperative, anxious adult patient with a primarily behavioralhealth 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: ÎAge less than 18 or over 65 ÎClinical intoxication with other substances ÎPregnant patients 4. POSSiBlE ADVERSE EFFECTS: ►Dystonic Reaction ►Anticholinergic Effects ►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. Psychiatric and Behavioral Emergencies- OLANZAPINE PSYCHIATRIC EVALUATION - 5150 TRANSPORTS Procedures Modified On: December 5, 2012 129 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 psychiatricevaluation shall be assessed and transported according to this policy. For minors (age below 18) the hold is called a 5585 holdand 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 mostappropriate 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: ÎPatients “in extremis” (those with a potential life-threatening illness or injury) ÎPatients who are unconscious, unresponsive, have chest or abdominal pain, significant bleeding, or suspected shock ÎPatients who shows signs of potential significant toxicity from illicit drugs or alcohol, which may include the following findings: ►depressed mental status ►inability to ambulate ►diaphoresis, agitation ÎPatients with combative behavior who require field sedation with Midazolam or whose combativeness prevents assessment (vital signs or examination) ÎPatients with abnormal vital signs or findings: ►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/dLÎPatients 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: ÎPatients with history of use of drugs or alcohol who do not show signs of significant toxicity ÎPatients with abnormalities in vital signs, but without other significant physical findings or history suggesting an acute medical problem (systolic BP up to 190, diastolic BP upto 110 and pulse up to 120) ÎPatients with minor abrasions or contusions (not needing laceration repair or othercomplex care or evaluation) ÎPatients 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 findings should also be transported to receiving hospitals: ÎPatients who have been outside of adult supervision/control for more than 24 hours ÎPatients with recent vomiting over a prolonged period or who report no food or fluid intake for 16 hours or more ÎPatients 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 ALCO Youth CSU, San Leandro. Notify ALCO Youth CSU en route (510) 483-3030 2.4 Children Age 11 and Under ÎAll 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 REPORTING FORMAT Procedures Modified On: July 1 2014 130 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 inorder to make sound treatment or triage decisions. Occasionally pause briefly to confirm 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 withoutcompromising patient safety and care) ►Physical assessment 9Vital signs / Glasgow Coma Scale 9Pertinent positives and pertinent negatives, as needed 9For STEMI patients see "ECG 12-Lead" policy (page 120, 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 9Vital signs / Glasgow Coma Scale 9Pertinent positives and pertinent negatives to support the general assessment. ►Treatment rendered prior to contact and patient response, if applicable ►Specific 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 9Vital signs/Glasgow Coma Scale 9Pertinent 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 9Vital signs, if available / Glasgow Coma Scale 9Pertinent positives and pertinent negatives radio report reporting format base contact SEDATION Procedures Modified On: May 27, 2023 131 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 significant 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 9To reduce combative behavior that endangers patient or caregivers 9Anticipated: • Cardioversion in the conscious patient • Cardiac pacing in the conscious patient MIDAZOLAM: Adult: 9IV/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 9IM/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) 9IN / IM: See LBRT for dosage - May repeat LBRT dosage x 1 - 15 minutes after the initial dose if needed sedation procedure SPINAL INJURY ASSESSMENT Procedures Modified On: June 6, 2012 132 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 highindex 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 deficit to the extremities ►Significant 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 childmay 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 efforts to decrease unnecessary immobilizations in the field 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 bestcourse of action ►Studies show that immobilizing trauma victims may cause more harm than good to the patient. Penetrating trauma victimsbenefit most from rapid assessment and transport to a trauma center without spinal motion restriction (SMR) spinal injury assessment spinal motion restriction (SMR) Procedures Modified On: June 6, 2012 133 SPiNAl iNJURY ASSESSMENT SPiNAl iNJURY ASSESSMENT A Reliable Patient is cooperative, sober and alert without: ÎSignificant Distracting Injuries ÎLanguage Barrier SPiNAl PAiN/TENDERNESS ÎPalpate vertebral columnthoroughly MOTOR/SENSORY EXAM: ÎWrist or finger extension (both hands) ÎPlantarflexion (both feet) ÎDorsiflexion (both feet) ÎCheck gross sensation in all extremities ÎCheck for abnormal sensations toextremities(e.g. parathesias) POTENTIAL FOR UNSTABLE SPINAL INJURY? ►RELIABLE PATIENT? ►NORMAL SPINE EXAM? ►NORMAL MOTOR/SENSORY? OMIT 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 spine injury criteria SPINAL MOTION RESTRICTION (SMR) Procedures Modified On: June 6, 2012 134 SPiNAl MOTiON RESTRiCTiON (SMR) SPiNAl MOTiON RESTRiCTiON (SMR) 1.INTRODUCTION: The term spinal motion restriction (SMR) better describes the procedure used to care forpatients 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 effects caused by traditional spinal immobilization while still providing appropriate care to patients with possible spinal injury by implementing alternative methods toachieve SMR 3.INDICATIONS: Any patient identified 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 effects 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 flexion, 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 flexible 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 finger abduction, wrist/finger extension, plantar/dorsal flexion 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 difficulty breathing: SMR has been found to limit respiratoryfunction an average of 17% with the greatest effect 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 spinal motion restriction (SMR) STOMA AND TRACHEOSTOMY Procedures Modified On: December 1, 2011 135STOMA 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 filled 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 humidified 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 reflex. 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 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 sufficient flow rate to produce misting stoma tracheostomy Procedures Modified On: December 1, 2011 136 STOMA AND TRACHEOSTOMY STOMA AND TRACHEOSTOMY 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 cuffed and uncuffed 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 fit through the stoma without force. Check the cuff, unless an uncuffed 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 fitted 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 inflate 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 fields. Check the neck for subcutaneous emphysema, indicating false passage 4.3.9 Allow no longer than 30 seconds for the procedure TRANSCUTANEOUS PACING - TCP Procedures Modified On: January 1, 2025 137 TRANSCUTANEOUS PACiNG - TCP TRANSCUTANEOUS PACiNG - TCP 1. INDICATIONS: This procedure should be used on patients experiencing symptomatic bradycardia (see Adult Bradycardia or Pediatric Bradycardia protocols. This includes patients with “failed” pacemakers. Note: Bradycardia in children is 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 field setting) ►Hypothermia 2. CONTRAINDICATIONS: 2.1 Asystole 2.2 Bradyasystolic arrest 2.3 Hypothermia 3. PROCEDURE: 3.1 Consider sedation with midazolam (See Sedation procedure) and/or appropriate Pain Management protocol for all conscious patients undergoing pacing. Hypotension is not an absolute contraindication in this setting. If unable to start IV, consider administering IM or IN 3.2 Place pads on the patient in anterior/posterior (A/P) position. If unable to place posterior pad, the pads can be placed in the anterior/lateral (A/L) position. Do not place pads over pre-existing implanted devices such as pacemakers or AICDs 3.3 Set pacing rate to: 3.3.1 Adults (≥15 y/o): 60-80 bpm (goal of >30 bpm above patient's initial rate) 3.3.2 Pediatrics (≤14 y/o) set pacing rate at 100 bpm 3.4 Start pacer current output at 0 milliamps (mA). Increase milliamps until electrical captured is obtained on the ECG (Max 120mA) 3.5 Confirm mechanical pacer capture by palpation of a femoral pulse. A pulse should be associated with at least every paced QRS complex. (Note: assessment of carotid pulse is not recommended as pacing can cause muscle contractions that are difficult to distinguish from pulse) 3.6 If electrical/mechanical capture cannot be achieved at 120mA, change vector of pads and repeat above steps. 3.7 Pediatric patients: Continue CPR until able to achieve electrical/mechanical capture 3.8 Once both electrical and mechanical capture obtained, increase the pacer current by 5-10mA 3.9 Once electrical and mechanical capture is obtained, the pacing rate may be increased slowly to relieve patient's symptoms (acute ALOC, hypotension, weak pulses, or central cyanosis) from bradycardia 4. SPECIAL CONSIDERATIONS: 4.1 TCP should not be delayed for IV access, 12-lead ECG, or while waiting for atropine to take effect in an unstable patient 4.2 CPR is safe during TCP and should be performed in pediatric population 4.3 Electrical capture can occur without mechanical capture. Electrical capture can be assessed on the monitor with identification of QRS complexes after every pacer spike. Mechanical capture is evaluated with palpation of a femoral pulse with every QRS complex 4.4 TCP is safe to perform in pregnant patients Example of ECG with electrical capture TRANSFER OF CARE Triage to waiting room Procedures Modified On: December 1, 2011 138 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 certified health care profes-sional, which may include any paramedic or other prehospital emergency personnel at the scene of the emergency, who is most medically qualified specific to the provision of rendering emergency medical care. If no licensed or certified health care professional is available, the authority shall be vested in the most appropriate medically qualified 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 officials 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 field 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 Triage to waiting room Procedures Modified On: May 27, 2023 139 TRiAGE TO WAiTiNG ROOM TRiAGE TO WAiTiNG ROOM 1. PURPOSE: To provide guidelines for field providers to identify which patients are appropriate to bring directly to ER waiting rooms.2.NOTES: ÎAll decisions on where the patient is brought to must be patient centered; ÎWork with ER staff to ensure that they are informed of the patient's eligibility for placement in the waiting room; ÎDocument pt's final disposition (ER Bed, waiting room, etc.) Follow standard intake process Does the patient have any of the following? ■ Has a complaint or assessment finding that is suggestive of the need for time-sensitive intervention ■ Requires continuous cardiac monitoring ■ IV access in place (may be discontinued if appropriate) ■ Any medications were administered (except for Ondansetron or Ketorolac) ■ Patient has an acute psychiatric complaint ■ Alcohol or drug consumption that has impaired the patient’s decision-making capacity No Yes Does the patient fit all of the criteria below? ■ Pt is 18 y/o or is a minor accompanied by a parent/guardian ■ Pt. is A&Ox4 and has appropriate decision-making capacity ■ If pt. is a minor, the parent/guardian must be A&OX4 and have appropriate decision-making capacity ■ Pt. has the ability to ambulate at their baseline capacity without assistance and is able to maintain a seated position ■ Vital Signs – should be within normal limits for the pt’s age, for example: • HR: 60-110• RR: 10-20 • SBP: 100-180 mmHg• DBP: 60-100 mmHg • SpO2: >94% on room air Bring patient to ER waiting room Follow standard intake process No Yes TXA - TRANEXAMIC ACID Stroke Assessment Scales (CPSS and PSS) Procedures Modified On: June 21, 2023 140 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 amolecule 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 intrauma patients meeting specific 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 deficits ►SBP < 90 mmHg ►Significant hemorrhage with a HR > 120 ►Bleeding not controlled by direct pressure or tourniquet ►Major amputation of any extremity abovethe 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 notified that TXA was administered. 3.4 Follow IV fluid resuscitation guidelines on page 25, “Trauma Patient Care” Stroke Assessment Scales (CPSS and PSS) Cincinnati Prehospital Stroke Scale (CPSS) Sign/Symptom Testing Procedure 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 compared 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 Posterior Stroke Scale (PSS) Sign/Symptom Testing Procedure Normal Abnormal Visual Fields Face the patient, ask them to look straight at your nose, move your fingers in each of the four visual quadrants (upper right/left, lower right/left), and ask the patient to state the side they see the fingers moving Vision intact in all of the four quadrants Missing vision in any of the four quadrants Finger-to-Nose Patient holds arms at their shoulder to 90 degrees with elbows flexed to 90 degrees, place your index finger at various locations in front of the patient at a dis-tance that requires patient to extend their elbow to reach your finger, ask patient to use their index finger on one hand to touch their index finger to your finger, then touch their index finger to their own nose, then to your finger. Repeat several times moving their target finger each time. Patient repeats the process using the oppo-site hand's index finger No weakness, wobbling, or shaking in either arm while attempting to make contact with your finger Weakness, wobbling, or shaking in either arm while attempting to make contact with your finger ***When both arms are equally shaking or weak, this is not considered an abnormal finding*** Procedures Modified On: January 1, 2025 141 STROkE ASSESSMENT SCAlES (CPSS AND PSS) STROkE ASSESSMENT SCAlES (CPSS AND PSS) 1. PURPOSE: To be used in conjunction with the STROKE / CVA Protocol for the assessment of suspected stroke / CVA 142 THIS PAGE INTENTIONALLY LEFT BLANK MCI/ DISASTER/ WMD TABMCI/ Disaster/ WMD TOCMCI/ DISASTER/ WMD MCI/ Disaster/ WMD Modified On: December 1, 2011 143MCI/ DISASTER/ WMD TOC MCI/ DISASTER/ WMD TOC MCI/ DISASTER/ WMD TOC ...................................................................................143 ACTIVE SHOOTER RESPONSE ............................................................................144 BIOLOGICAL ATTACK ............................................................................................145 CHEMICAL ATTACK ................................................................................................147 CHEMPACK DEPLOYMENT ...................................................................................148 CYANIDE POISONING ...........................................................................................149 DECONTAMINATION INCIDENT ............................................................................150 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” ..................151 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE ................................153 MULTI-CASUALTY INCIDENT - EMS RESPONSE ................................................155 NERVE AGENT AUTOINJECTOR ADMINISTRATION...........................................158 NERVE AGENT TREATMENT .................................................................................160 SUSPICIOUS POWDER PROCESS .......................................................................162 ACTIVE SHOOTER RESPONSE MCI/ Disaster/ WMD Modified On: April 10, 2012 144 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, fire 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 identified ►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 suffering only from penetrating trauma ►Once the threat is eliminated, law enforcement may be available to help evacuate the injured Biological attack MCI/ Disaster/ WMD Modified On: April 10, 2012 145 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 SI 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 : fe 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 wid 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 ) , blo o d y p l e u r a l e f f 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 ulc 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 Sta 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 (in h a l a t i o n ) Ci p r o f l 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 Cip r o f l 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 ) Dif f i 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 Dil 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 ) Slu 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 f l 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 Sta 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 Tri 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 , c h e s t pa 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 f l 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 f l 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 Cip r o f l 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 wit 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 Air b o r n e p r e c a u t i o n s Sta 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 biological attack botulism anthrax plague ricin MCI/ Disaster/ WMD Modified On: December 1, 2011 146 BIOlOgICAl ATTACk BIOlOgICAl ATTACk146BIOlOgICAl 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 SI 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 hil a r a d e n o p a t h y ( p l e u r a l ef f u s i o n s l i k e T B ) Dif f 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 Sta 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 f l o x a c i n p o s s i b l y ef f 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 cli n i c a l i m p r o v e m e n t ) x 10 - 1 4 d a y Cip r o f l 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 ) Hig 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 - - f i r s t o n e x t r e m i t i e s (fa 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 , f i 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 Air 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 Clo 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 tularemia smallpox CHEMICAL ATTACK MCI/ Disaster/ WMD Modified On: December 1, 2011 147 CHEMICAl ATTACk CHEMICAl ATTACk 147CHEMICAl ATTACk CHEMICAl ATTACk CH E M I C A L PR O P E R T I E S IM M E D I A T E A C T I O N S SY 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 f f 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 f f i 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 o u t s i d e , yo u s h o u l d g e t i n 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 clo 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 clo 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 f f 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 f l 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 / f i 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 , dif f i 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 , f l 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 f i 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 f f 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 ►Bli 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 f l 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 f i c ch e m i c a l a g e n t s HY D R O G E N C Y A N I D E Ex t r e m e l y f l 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 f i 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 , blu r r e d v i s i o n , d i f f i 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 f i 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 chemical attack nerve agents sulfur mustards hydrogen cyanide chlorine CHEMPACK DEPLOYMENT MCI/ Disaster/ WMD Modified On: December 1, 2011 148 CHEMPACk DEPlOYMENT CHEMPACk DEPlOYMENT ON-SCENEIncident 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 DISPATCHDispatch (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 CHEMPACKSTORAGE SITEFire/EMS Chempack site opens (break seals), loads up and transports unit to site location (staging, medical, etc.) REQUEST MADE TO DISPATCH ON-SCENE MEDICALMedical unit utilizes Chempack assets on-scene and en-route to hospitals HOSPITALTreatment continues in hospital with on-site Chempack assets INCIDENT chempack CYANIDE POISONING MCI/ Disaster/ WMD Modified On: December 1, 2011 149CYANIDE POISONINg CYANIDE POISONINg • This policy is to be used in conjunction with Smoke Inhalation page 21 and HazMat page 153• 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 MonitorIV 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 cyanide poisoning sodium thiosulfate hot zone warm zone DECONTAMINATION INCIDENT MCI/ Disaster/ WMD Modified On: December 1, 2011 150 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 identification, 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 notified 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 decontamination incident Radiological DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” MCI/ Disaster/ WMD Modified On: December 1, 2011 151RADIOlOgICAl 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 sufficiently 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 affected 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 3.4 Turn to radio/TV channels for advisories from: ►Emergency response ►Health authorities radiological dispersion device dirty bomb MCI/ Disaster/ WMD Modified On: December 1, 2011 152 DECONTAMINATION INCIDENT DECONTAMINATION INCIDENT 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 offers no protection to other parts of the body or against other radioactive isotopes hazardous materials incident exclusion zone hot zone contamination reduction zone warm zone HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE MCI/ Disaster/ WMD Modified On: December 1, 2011 153HAZARDOUS 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 Medical 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 identified in OSHA 29 CFR 1910.120 and California OSHA as defined 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. Definitions 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 hazardous materials incident exclusion zone hot zone contamination reduction zone warm zone ICS - Incident Command System contamination reduction corridor support zone cold zone MCI/ Disaster/ WMD Modified On: December 1, 2011 154 HAZARDOUS MATERIAlS INCIDENTS - EMS RESPONSE HAZARDOUS MATERIAlS INCIDENTS - EMS RESPONSE 4. Patient Management 4.1 Follow the Multi-casualty Incident (MCI) Plan – page 155, if appropriate 4.2 For nerve gas/cyanide exposure: ►Patient exposure: Cyanide Poisoning – page 149 Nerve Agent Treatment - page 160, (HazMat trained paramedics only) ►Rescuer exposure: Nerve Agent Autoinjector Administration – page 158 4.3 Paramedics should contact the Base Physician early in the incident regarding treatment for other specific exposures 4.4 EMTs and paramedics may only render care within their scope of practice 5. Scene Management Responsibilities Specific to HazMat Incidents 5.1 Police Responsibilities 5.1.1 Evacuations ahead of hazard area. Evacuation plans developed under unified command 5.1.2 Traffic control in and around effected 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.) MULTI-CASUALTY INCIDENT - EMS RESPONSE MCI/ Disaster/ WMD Modified On: May 29, 2019 155 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 different for each incident based on time of day, location, resources available, etc. 2. NOTIFICATIONS: Incident Commanders shall make notifications through ACRECC. Organizations should have internal notification procedures 3. MCI RESOURCE ORDERING, INITIATION AND TERMINATION: 3.1 The first 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 specific 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 4. RESOURCE ORDERING PRIORITY LIST 4.1 ALCO 911 Ambulances 4.2 ALCO BLS Permitted Ambulances MCI RESOURCE ORDERING MCI RESPONSE MCI RESOURCE RESPONSE PACKAGE MCI NOTIFICATIONS MCI Response 1 Î5 Closest 911 Ambulances Î1 EMS Supervisor ÎEMS TAC channel assignedNote: Immediately cancel assigned resource(s) when no longer required ÎJurisdictional Fire Battalion Chief ÎCounty EOA Provider Operations Supervisor ÎLEMSA Duty Officer MCI Response 2 Î5 Closest Ambulances Î1 EMS Supervisor Î1 DMSUNote: Immediately cancel assigned resource(s) when no longer required ÎAll County Fire Duty Chiefs Resources in MCI Response 2 are in addition to resources assigned in MCI Response 1 MCI Response 3 Î5 Closest Ambulances Î1 EMS Supervisor ÎConsider 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: Î5 Closest Ambulances Î1 EMS Supervisor multi-casualty incident SEMS - Standard Emergency Management System ICS - Incident Command System MCI advisory MCI alert MCI/ Disaster/ WMD Modified On: May 29, 2019 156 MUlTI-CASUAlTY INCIDENT - EMS RESPONSE MUlTI-CASUAlTY INCIDENT - EMS RESPONSE 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 notified and will “Initiate an MCI” under the Reddinet MCI module. ACRECC will immediately send an “ED Capacity poll and general notification” to the hospitals in Alameda County 5.2 For MCI Levels II & III, ACRECC will notify the EMS Duty Officer 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 confirm 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 effort 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 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” MCI LEVELS MCI Level Approximate Patient Count I 5-14 Patients II 15-50 Patients III > 50 Patients MCI/ Disaster/ WMD Modified On: May 29, 2019 157 MUlTI-CASUAlTY INCIDENT - EMS RESPONSE MUlTI-CASUAlTY INCIDENT - EMS RESPONSE 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 reunification. On scene EMS Supervisors may also have the ability to enter information into ReddiNet 5.9 Verbal notification 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 traffic 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 identification vests. At a minimum the IC, Medical Group Supervisor, Triage and Treatment, and Transportation Unit Leader should be clearly identified with vests NERVE AGENT AUTOINJECTOR ADMINISTRATION MCI/ Disaster/ WMD Modified On: December 1, 2011 158 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 160 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 first two fingers. DO NOT cover or hold the needle end with your hand, thumb, or fingers-you might accidentally inject your self. An accidental injection into the hand WILL NOT deliver an effective 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 fingers (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 firm, 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 firmly 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 ►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 Figure 1 - Thigh injection site Figure 2 - Buttocks injection site nerve agent autoinjector autoinjector Pralidoxime chloride 2-Pam atropine MCI/ Disaster/ WMD Modified On: December 1, 2011 159NERVE AgENT AUTOINJECTOR ADMINISTRATION NERVE AgENT AUTOINJECTOR ADMINISTRATION ►After administering the first 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)Atropinedose range (mg/kg)2-PAMdose 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. 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 160 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 first two fingers. DO NOT cover or hold the needle end with your hand, thumb, or fingers-you might accidentally inject your self. An accidental injection into the hand WILL NOT deliver an effective 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 fingers (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 firm, 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 firmly 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 ►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 MARK I antidote kit NERVE AGENT TREATMENT MCI/ Disaster/ WMD Modified On: July 24, 2018 160 NERVE AgENT TREATMENT NERVE AgENT TREATMENT ►ALS and specially trained BLS personnel may administer nerve agent antidote medications to patients. (See page 158 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 153 (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 ►Difficulty 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 nerve agent treatment MCI/ Disaster/ WMD Modified On: December 1, 2011 161NERVE 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 ZoneMild 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 IMAdult:1-2 gramsChild:20-40 mg/kgmaximum 1 gram May repeat in severe exposures Hot ZoneSevere 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 gramsChild:20 mg/kg maximum 1 gram May repeat in severe exposures Note: In a moderateto severe exposure – repeat as neededuntil 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 withDiazepamAdult: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 onlyAdult/Adolescent: 5 mg Child:0.1 mg/kg (maximum 5 mg) Note: MMRS providers may use Diazepam Autoinjector 10 mg IM - ADULTS ONLY See applicable Table of Contents to locate protocols or utilize the EMS Mobile App for keyword searches SUSPICIOUS POWDER PROCESS MCI/ Disaster/ WMD Modified On: December 1, 2011 162 SUSPICIOUS POWDER PROCESS SUSPICIOUS POWDER PROCESS Initial notification to 9-1-1 Police Response,Possible Haz-Mat Response Assessmentbased on initial information/ impression Immediate rule-out(e.g. sugar spilled on counter, detergent spilled on grocery store floor) Haz-MatEvaluation needed Possible Anthrax or other threatSubstance still suspicious, (or overt threat) Unlikely to be Anthraxor other threatSubstance unknown, still needs to be identified Notify FBI FBIProtocols Notify Environmental Health Alameda County LabTEST CADHSState LabTEST Positive Negative Notification via Law Enforcement FBI may direct No ornegative Notification via Public Health Yes StillSuspicious? AL A M E D A C O U N T Y AP P R O V E D RE C E I V I N G HO S P I T A L S (5 1 0 ) a r e a c o d e u n l e s s o t h e r w i s e s p e c i f i e d (R e v . 0 7 / 2 0 2 4 ) Ho s p i t a l Ma i n N u m b e r ED N u m b e r 51 5 0 Me d i c a l Ev a l . Ad u l t s / 51 5 0 Ps y c h E v a l . He l i p a d CA Br i d g e L& D ST E M I St r o k e Se x u a l As s a u l t Tr a u m a Al a m e d a 52 2 - 81 4 - x x AL C O Yo u t h C S U - -- - - 48 3 - Ad o l e s c e n t s Ag e 12 -17 Al t a B a t e s 20 4 - 20 4 - x x x Ch i l d r e n ’ s 42 8 - 42 8 - Ag e < 11 Ag e < 11 x x Ag e < 1 3 Ag e < 1 4 Ed e n 53 7 - 72 7 - x x x x x Ag e > 1 5 Hi g h l a n d ( A C M C ) 43 7 - (b a s e M D ) x x x x x Age > 14 Ag e > 1 5 Jo h n G e o r g e 34 6 -13 34 6 - Age > 18 Ka i s e r - An t i o c h (92 5 ) 8 1 3 - (92 5 ) 81 3 - x x Ka i s e r - Fr e m o n t 24 8 - 24 8 -72 0 x Ka i s e r - Oa k l a n d 75 2 - 75 2 - x x x x x Ka i s e r – Sa n L e a n d r o 45 4 - 45 4 - x x x Ka i s e r – Wa l n u t C r e e k (9 2 5 ) 2 9 5 - (9 2 5 ) 9 3 9 - x x x Sa n L e a n d r o 35 7 - 66 7 - x x Sa n R a m o n (9 2 5 ) 2 7 5 - (9 2 5 ) 2 7 5 - x x x St . R o s e 26 4 - 26 4 - x x x Su m m i t 65 5 - 86 9 - x x x Va l l e y C a r e (9 2 5 ) 8 4 7 - (9 2 5 ) 4 1 6 - x x x x x Wa s h i n g t o n 79 7 - 81 8 - x x x x x Age > 14 Ag e > 1 5 OU T -OF -CO U N T Y R E S O U R C E S Jo h n M u i r M e d i c a l C e n t e r x x x x x Re g i o n a l M e d i c a l C e n t e r (4 0 8 ) 7 2 9 -28 x x Sa n F r a n c i s c o G e n e r a l (62 8 ) 2 0 6 - (62 8 ) 6 4 7 - x x x x Sa n J o a q u i n G e n e r a l (20 9 ) 4 6 8 - (20 9 ) 9 8 2 - x x x x Sa n t a C l a r a V a l l e y ( V M C ) (4 0 8 ) 8 8 5 - (4 0 8 ) 8 8 5 - x x x x (A d u l t & P e d ) (4 0 8 ) 8 8 5 -66 6 6 St a n f o r d (6 5 0 ) 7 2 3 - x x x x x St . F r a n c i s M e m o r i a l (4 1 5 ) 3 5 3 -63 0 0 x (4 1 5 ) 3 5 3 -62 5 5 UC D a v i s M e d i c a l C e n t e r x x x x x (9 1 6 ) 7 3 4 -36 3 6 Base Physician Contact Template ituation  Identify yourself/unit number  State purpose of call: (e.g. AMA consult, destination decision, etc.)  Provide basic patient demographics (e.g. age/gender)  Reason for patient contact/EMS activation Background  Provide history of present illness/injury Medical history Assessment   Physical findings  Treatment provided Recommendation/Request  State your recommendation/request Confirm Base Physician’s recommendation/orders Hospital Notification Template Basic Notifications 1. Unit Number 2. Transport code 3. Age & Gender 4. Chief Complaint 5. V/S stable or detailed V/S if abnormal 7. Treatment(s) 8. Repeat ETA 9. Check for questions Specialty care patient notifications For each category below, include info from the basic notification template plus the appropriate category below 1. Mechanism of Injury 2. Injuries 3. GCS – each category of E/V/M + total 4. Detailed Vital Signs 1. Airway – non-patent, patent, airway placed/not-placed 2. Breathing – absent/spontaneous 5. Summary of treatment(s) given Stroke Alert Sepsis STEMI Pediatric Patients