Contra Costa County

Prehospital Care Manual

January 2009


Contra Costa County Prehospital Care Manual – January 2009Page 1

Table of Contents

GENERAL NOTES SECTION

Communications

Radio Communications

Base Hospital Communications

Receiving Facility Report Format

Contra Costa County Hospitals

Notes on Dialysis Patients

Load And Go Procedures

Notes on Pain Assessment and Management

OPQRST Mnemonic

Pain Assessment Tools

FACES PainScale

Numeric Pain Scale

Pain Assessment In The Very Young

Notes On Pediatric Patients

Initial Approach

Age Definitions

Vital Signs

Abnormal Vital Signs For Age

Notes On OB/Gyn Emergencies

Vaginal Bleeding

Sexual Assault

Childbirth

Notes On Trauma

Glasgow Coma Scale

Helmet Removal

Cervical Collars

Spinal Immobilization

Head Injury

Amputations

Geriatric Patients

Notes On Hypothermia

Notes On Geriatrics

Notes On Burns

Regional Burn Centers

Rule of Nines

BLS NOTES SECTION

EMT Scope of Practice

BLS Management of Patients Encountered Prior to Activation of 9-1-1

Administration of Oral Glucose

Public Safety Defibrillation

Patient Assessment

Verbal Report

Defibrillator Cables/Pads

Patient Care Data

Spinal Immobilization

ALS NOTES SECTION

Paramedic Scope of Practice

Local Optional Scope of Practice

ALS Skills List

Airway Management

ALS Procedures

Oral Endotracheal Intubation

Tracheostomy Tube Replacement

Stomal Intubation

Endotracheal Tube Introducer (Bougie)

Esophageal Airway (King LTS-D)

Continuous Positive Airway Pressure (CPAP)

Needle Thoracostomy

Saline Lock

Intraosseous Infusion - Pediatric

Pulse Oximetry

Blood Glucose Testing

External Cardiac Pacing

12-Lead Electrocardiography

TREATMENT GUIDELINES

Cardiac Emergencies

Shock (Non-Traumatic) C1

Shock

Cardiogenic Shock

Public Safety Defibrillation C2

Ventricular Fibrillation/Pulseless Ventricular Tachycardia C3

Pulseless Electrical Activity C4

Asystole C5

Ventricular Tachycardia with Pulses C6

Ventricular Tachycardia With Pulses: Stable

Ventricular Tachycardia With Pulses: Unstable

Paroxysmal Supraventricular Tachycardias C7

Supraventricular Tachycardia: Stable

Supraventricular Tachycardia: Unstable

Bradycardia C8

Bradycardia: Unstable

Other Cardiac Dysrhythmias C9

Sinus Tachycardia

Atrial Fibrillation

Atrial Flutter

Chest Pain C10

Return of Spontaneous Circulation C11

Environmental Emergencies

Heat Illness/Hyperthermia E1

Heat Cramps/Heat Exhaustion

Heat Stroke

Hypothermia E2

Moderate Hypothermia

Severe Hypothermia

Burns E3

Envenomation E4

Snake Bites

Bees/Wasps

Hazardous Materials Emergencies

General Priorities and Treatment H1

Hydrofluoric Acid H2

Pesticides – Carbamates and Organophosphates H3

Medical Emergencies

Abdominal Pain M1

Systemic Allergic Reactions/Anaphylaxis M2

Systemic Allergic Reaction/Anaphylaxis

Anaphylactic Shock M3

Anaphylactic Shock

Dystonic Reaction M4

Poisons/Drugs M5

Ingestions

Tricyclic Antidepressants

Pain Management (Non-Traumatic) M6

Neurologic Emergencies

Coma/Altered Level of Consciousness N1

Seizures/Status Epilepticus N2

Acute Cerebrovascular Accident (Stroke) N3

Syncope/Near Syncope N4

OB-GYN Emergencies

Vaginal Hemorrhage O1

Shock

Vaginal Bleeding – Not In Shock

Imminent Delivery (Normal) O2

Imminent Delivery (Complications) O3

Breech Presentation

Prolapsed Cord

Pre-Eclampsia/Eclampsia O4

Pediatric Emergencies

Routine Medical Care P1

Neonatal Resuscitation P2

Cardiac Arrest – Non-Traumatic P3

Pediatric Cardiopulmonary Arrest – Primary Therapy

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

Asystole/Pulseless Electrical Activity (PEA)

Bradycardia P4

Tachycardia P5

Stable Tachycardia

Unstable Tachycardia

Unstable Supraventricular Tachycardia (SVT)

Unstable – Possible Ventricular Tachycardia

Hypotension/Shock P6

Altered Level of Consciousness P7

Seizures P8

Poisoning P9

Anaphylaxis/Allergic Reaction P10

Systemic Allergic Reaction

Anaphylactic Shock P11

Anaphylactic Shock

Airway Obstruction P12

Infant/Child With Complete Airway Obstruction

Conscious Patient – Able To Speak

Conscious Patient – Unable To Cough Or Speak

Patient Who Becomes Unconsious

Acute Respiratory Distress P13

Croup/Epiglotitis

Acute Asthma/Bronchospasm

Trauma Patients P14

Minor Trauma P15

Traumatic Arrest P16

Burns P17

Apparent Life-Threatening Event (ALTE) P18

Pain Management (Non-Traumatic) P19

Respiratory Emergencies

Airway Obstruction R1

Conscious Patient – Able To Speak

Conscious Adult Patient – Unable To Cough Or Speak

Adult Patient Who Becomes Unconsious

Acute Respiratory Distress R2

Respiratory Distress

Chronic Obstructive Pulmonary Disease

Acute Asthma/Bronchospasm

Respiratory Arrest R3

Acute Pulmonary Edema R4

Pneumothorax R5

Simple Pneumothorax

Tension Pneumothorax

Traumatic Emergencies

Critical Trauma T1

Minor Trauma T2

Crush Injury/Crush Syndrome T3

Dopamine Drip Rates

Adult ALS Drug List

Pediatric Dosage Charts

Gray – 3-5 kg

Pink – 6-7 kg

Red – 8-9 kg

Purple – 10-11 kg

Yellow – 12-14 kg

White – 15-18 kg

Blue – 19-22 kg

Orange – 24-28 kg

Green – 30-36 kg

40 kg

45 kg

Pain Evaluation/Treatment

Patient Reporting Guidelines

INDEX


Contra Costa County Prehospital Care Manual – January 2009Page 1

General NotesSection


Contra Costa County Prehospital Care Manual – January 2009Page 1

Communications

radio communications

Four radio channels are designated for communications with hospitals in Contra Costa County. Receiving hospital communications are done via XCC EMS 2, whereas paramedic base hospital communications may occur via XCC EMS 2 or XCC EMS 3, depending on location.

XCC EMS 1
(formerly L9) / T: 491.4375
R: 488.4375 / Use for Sheriff’s Dispatch-to-ambulance communication
XCC EMS 2
(formerly L19) / T: 491.9125
R: 488.9125 / Primary channel for base contact for West County paramedic units. Also used county-wide for BLS and helicopter radio traffic
XCC EMS 3 / T: 491.6125
R: 488.6125 / Primary channel for base contact for paramedic units operating south of Ygnacio Valley Road and west of I-680 along Highway 24
XCC EMS 4 / T: 491.6625
R: 488.6625 / Primary channel for base contact for paramedic units operating in East County and Central County north of Ygnacio Valley Road.

Whenever possible, paramedic personnel should use the XCC EMS channel assigned to the area in which they are responding, for ambulance-to-base hospital communications. XCC EMS 2 is the county-wide backup ALS channel and should be used if XCC EMS 3 or XCC EMS 4 is not available. Ambulance and helicopter personnel are to contact Sheriff’s Dispatch on XCC EMS 1 to request the use of XCC EMS 2 prior to utilizing the channel. The dispatcher shall be given unit identification and a description of current traffic (Code 2, Code 3 or trauma destination decision).

No request for use is necessary for XCC EMS 3 or XCC EMS 4. However, each unit must monitor the channel prior to use to ensure that other units are not already using the channel. Radio identification procedures must be strictly followed, as more than one call may be occurring at the same time. If traffic is in progress on a XCC EMS channel, other ambulance personnel may either wait until current traffic is finished or find an alternate means of contacting the desired hospital. Any unit may, in cases such as trauma destination decisions, request that Sheriff’s Dispatch break into current traffic on XCC EMS 2 to request temporary use of the channel. Units using XCC EMS 3 or XCC EMS 4 may request use of the channel from a unit that is currently on that channel. When making base contact for trauma destination only, the initial transmission should make the purpose of the call clear. Cellular phones may also be used as a means of communication.

base hospital communications

CONTRA COSTA COUNTY BASE HOSPITAL
HOSPITAL / ED PHONE / BASE PHONE/XCC EMS 2 CODE
John Muir Medical Center – Walnut Creek Campus
1601 Ygnacio Valley Road
Walnut Creek, CA 94598 / (925) 939-5800 / Taped: (925) 939-5804
Rec. Facility Notification: (925) 947-3379
XCC EMS 2 Code: 14524

The base hospital is on-call 24 hours per day.

Radio Contact and Patient Handoff Guidelines: SBAR

Situation / What is the situation? Urgent Issues? / Agency name & unit #.
State why calling: (eg: STEMI Alert, High Risk Criteria, ETA)
Pt age and gender.
Chief complaint. Urgent concerns & immediate needs up front.
Background / What happened up to this point? What past history would be important to others caring for the patient to know? / Presenting complaint and symptoms.
Pertinent past medical history.
High risk medications.
Assessment / How is the patient now? Improved or worse since on scene? Patient stable or unstable? / General impression.
Pertinent Findings.
Vital Signs.
Pain Level.
RX/Recap / What field care has been given? Was it effective? Repeat concerns as needed? / Prehospital treatments given & patient response.
Restate concerns.
Respond to questions.

SBAR is a evidenced-based communication model developed in the military and is widely used in many industries including aviation and health care to make sure the right information gets to the right people in the shortest timeframe. It is currently the communication standard of care in many emergency departments in the United States because it has been so effective in improving communication between health care providers.

  • These guidelines outline the priority information that needs to be related during patient care handoff to the receiving party so that information critical to patient care is not missed.
  • The format emphasizes urgent concerns be brought to the forefront and empowers the EMS provider to advocate for the patient
  • These guidelines are to be used in a flexible way that meets the needs of the situation encountered.
  • Although the format is split into separate sections (Situation, Background, Assessment and Rx Recap) the information is relayed as a conversation.
  • See addendum of PHCM for SBAR guidelines for trauma, STEMI, hospital contact & patient handoff.

Trauma Patient Report Format

This report is for personnel calling the base hospital either for destination or to inform the base of a patient who is being transported to the trauma center (meets criteria for direct transport).

S / What is the situation? Urgent Issues? / Agency name & unit #.
State “Trauma Destination Decision” or patient meeting “High Risk” criteria.
ETA to trauma center. Pt age and gender.
Urgent concerns & immediate needs up front.
If trauma destination request-state destination you believe is needed.
B / What happened up to this point? What past history would be important to others caring for the patient to know? /

Mechanism of Injury/Injuries Sustained

Chief Complaint. State patient’s major injuries and LOC
Basic scene information:
  • Seatbelt or helmet use
  • Airbag deployment
  • Prolonged extrication
  • Estimated MPH in known

A / How is the patient now? Improved or worse since on scene? Patient stable or unstable? / Primary Survey and pertinent positives: ABCD (can report as ABCD normal except….)

Report if abnormal

  • Airway (if not patent)
  • Breathing (labored, shallow, or rapid)
  • Circulation (altered perfusion, shock)
  • Estimated blood loss
  • Disability: AVPU include any changes
If pertinent VS, ALOC
R / What field care has been given? Was it effective? Repeat concerns as needed? / Treatment(s):
Prehospital treatments & patient response.
Restate concerns as needed.
Respond to questions.
Request direct online MD consultation as needed.

The following is a list of examples of positive findings on secondary survey that would be appropriate to report. This is not an exhaustive list and other important findings may need reporting:

HEENT: Blood, swelling anywhere on head around eyes, ears, mouth, nose. Inability to open mouth.

NECK: Midline tenderness to touch or crepitus.

CHEST: Visible wounds, breath sounds unequal, pain upon compression.

ABDOMEN: Visible wounds, tender to palpation, distention

PELVIS: Pain on compression. Stable or unstable.

EXTREMITIES: Deformity, tenderness, swelling.

NEUROLOGICAL: Presence of numbness or tingling. Abnormal motor exam or extremities (if non-tender/not splinted)

SPINE: Tenderness or pain to palpation.

Trauma Patient Handoff: MIVT

The MIVT (Mechanism, Injuries, Vital Signs, Treatment) report is given at the trauma center upon arrival. MIVT works with SBAR to efficiently relate the most critical prehospital information to the trauma physician or ED physician in the trauma room in a time frame of 30 seconds or less. The MIVT report puts urgent concerns & immediate needs of the trauma patient needs up front.

If there are major issues the paramedic feels are critical to the first minutes of care that needs to be relayed upfront. The paramedic should remain available to provide more detailed or additional information to the scribe in the trauma room.

S / What is the situation? Urgent Issues? / Pt identification, age and gender & MR # (if known)
(M) Mechanism of Injury:eg: MVA, rollover, ejection, GSW, blunt trauma
B / What happened up to this point? What past history would be important to others caring for the patient to know? / (I) Injuries Sustained/Level of Consciousness
  • Injuries: Major Anatomy involved, major patient complaints-does not have to be all inclusive
  • Level of Consciousness: AVPU format. Should include changes noted on scene and en route.

A / How is the patient now? Improved or worse since on scene? Patient stable or unstable? / (V) Vital Signs.
  • Blood Pressure: If known, otherwise quality/location of pulse
  • Pulse: Rate and quality
  • Respiratory Rate: Add abnormal lung sounds if noted
  • ECG rhythm: if anything other than NSR or sinus tachycardia
  • Pulse oximetry: If known

R / What field care has been given? Was it effective? Repeat concerns as needed? /

(T) Treatment

  • Patient response to treatment.
  • Respond to questions.
  • Repeat concern as needed.

Contra Costa County Hospitals

CONTRA COSTA COUNTY HOSPITALS
HOSPITAL / SERVICES / ED PHONE # / XCC EMS 2 Alert Code
Contra Costa Regional Medical Center
2500 Alhambra Avenue
Martinez, CA 94553 / Basic ED
OB/Neonatal /
(925) 370-5170 / 14574
Doctor’s Medical Center – San Pablo
2000 Vale Road
San Pablo, CA 94806 / Basic ED
STEMI Center
/
(510) 232-6622 / 13613
John Muir Medical Center – Walnut Creek Campus
1601 Ygnacio Valley Road
Walnut Creek, CA 94598 / Basic ED
OB/Neonatal
Trauma Center
STEMI Center / (925) 939-5800 / 14524
Kaiser Medical Center – Richmond
901 Nevin Avenue
Richmond, CA 94504 / Basic ED /
(510) 307-1566 / 13653
Kaiser Medical Center – Walnut Creek
1425 South Main Street
Walnut Creek, CA 94596 / Basic ED
OB/Neonatal
STEMI Center /
(925) 295-4820 / 14284
John Muir Medical Center – Concord Campus
2540 East Street
Concord, CA 94520 / Basic ED
STEMI Center /
(925) 674-2333 / 14214
San Ramon Regional Medical Center
6001 Norris Canyon Road
San Ramon, CA 94583 / Basic ED
OB/Neonatal
STEMI Center /
(925) 275-8338 / 13623
Sutter/Delta Medical Center
3901 Lone Tree Way
Antioch, CA 94509 / Basic ED
OB/Neonatal /
(925) 779-7273 / 14294
Kaiser Medical Center – Antioch
5001 Deer Valley Road
Antioch, CA 94531 / Basic ED / (925) 813-6500 (switchboard) / 14564

Notes on Dialysis Patients

Patients with advanced renal disease requiring dialysis have special medical needs that may deserve specific attention in the pre-hospital setting. Problems that may occur include fluid overload and electrolyte imbalances. Patients may be particularly prone to these problems if they should miss scheduled dialysis sessions.

Fluid overload may lead to pulmonary edema. The initial treatment of this is similar to other patients with pulmonary edema, and may include oxygen, nitroglycerin and morphine. Definitive treatment at a center that provides acute dialysis capabilities is often necessary. The preferable transport destination for this type of patient is the hospital at which the patient has received dialysis care. Patients in extremis will need transport to the closest emergency department.

Hyperkalemia is also common in renal failure patients, leading to arrhythmia or ventricular fibrillation. Treatment in the field may include sodium bicarbonate and calcium chloride.

Notes on Bariatric Patients

Bariatric patients are morbidly obese individuals who weigh 100 pounds or more than their ideal body weight. Severe obesity can result in patients having difficulty with walking or moving and special equipment may be necessary to transport the patient. AMR has a bariatric unit in Contra Costa County which, when needed, should be requested as soon as possible. When the decision is made to transport the bariatric patient, notify the receiving facility as they need time to prepare equipment for the patient’s arrival.

Obesity has many health care risks associated with it, including diabetes, cardiovascular respiratory and other problems. Special prehospital considerations are:

Airway Management / Obese patients are prone to respiratory insufficiency, airway obstruction and have difficult airways to intubate. Positioning to maintain their airway is very important. Obese patients should be transported in a seated position. CPAP may also be needed more often to support oxygenation and ventilation.
Vascular
Access / Increased subcutaneous tissue makes it difficult to obtain regular IV access. The IO proximal tibia site may be difficult to access due to difficulty in finding appropriate landmarks. In these cases the distal tibia (media malleolus) is a preferred IO site.
Proper Medication Dosage / Obesity may create a need for increased medication due to the patient’s body weight. Increases in medication beyond what is listed in the PHCM should be requested through the Base as needed.

Load and Go Procedures

Patients with severe medical conditions or traumatic injuries often need to be transported without delay. Field treatment is to be minimized to essential stabilization and the emphasis is placed on prompt transport to an appropriate receiving facility.

Conditions to be considered for "Load and Go" transport include:

  • unmanageable airways in any patient;
  • obstetrical emergencies including prolapsed cord, abnormal presentation, abnormal bleeding, or maternal seizures.
  • patients in shock
  • severe trauma, especially to the head, chest, or abdomen; for severe trauma, scene time should not exceed 15 minutes. Reasons for extended scene times should be documented on the patient care report

Notes on Pain Assessment and Management

Relief of pain and suffering is an important component of quality EMS field care. Pain assessment is the 5th vital sign and should be performed on each patient using an age appropriate pain scale. Pain is a subjective experience for the patient and should be treated following the appropriate pain treatment guideline. Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts should be made to alleviate pain using both pharmacologic (e.g, Morphine, Nitroglycerin for cardiac cases) and non-pharmacologic (e.g., splinting, immobilization) measures.

  • Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5 minutes after every medication administration.
  • Assess pain using the same pain scale before and after pain administration and document.
  • Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved. Administer medication cautiously and monitor patient.
  • Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional narcotic administration.

OPQRST mnemonic