Corvallis Mountain Rescue Unit

Corvallis Mountain Rescue Unit

Standing Orders

Field Guide

ROUTINE MEDICAL CARE

DOCUMENTATION

ASSESSMENT

AIRWAY

OXYGEN

ACUTE MOUNTAIN SICKNESS (AMS)

ALLERGY & ANAPHYLAXIS

CARDIAC CHEST PAIN

CPR & ACLS

ALTERED MENTAL STATUS

DEATH IN THE FIELD

HYPOTHERMIA

HYPERTHERMIA

PAIN / NAUSEA

RESPIRATORY

SEIZURE

SHOCK

SPINAL TRAUMA

FRACTURES/DISLOCATIONS

WOUND MANAGEMENT

The following are standing orders allowing care to be performed under the medical license of your physician advisor. These protocols are designed to increase the level of care provided to injured or ill persons. These protocols were created for situations when care, which is normally available in the front country, is not available or would be significantly delayed. Providers need to use their clinical judgment when applying these protocols in the front country. The majority of CMRU personnel have excellent knowledge but very little experience with patient care and contact. Procedures which are not time critical and could be performed at a higher standard or by a more experienced provider should be deferred to a professional health care provider. The risk of performing treatments for illnesses or injuries which are time sensitive should be evaluated based on the most likely estimate of transport time to definitive care. i.e. simple dislocations should be reduced within 2-4 hrs but after 12-30 hrs there may be little benefit gained by reduction. In addition, do to location, weather, and many other objective factors it may be in the best interest, of the patient and/or rescuers, to withhold/modify treatments until conditions may be controlled or have changed. CMRU personnel will make every attempt to be reasonably equipped to provide medical care, but due to the nature of mountain rescue, some equipment or resources may not be available requiring ingenuity and modification of protocols. Providers will need to use their best judgment.

Statement of purpose3

Providers should consider the following three points when making difficult ethical treatment decisions.

Is your decision consistent with the laws and policies that govern this region?

Does your decision promote a “winning” situation for as many parties as possible?

Are you willing to see this decision on the front page of a national newspaper?

Pediatrics are defined as: Infants ages < 1 yr, & Children ages 1-13

The BSA tape is the reference for pediatric patients.

Use PPE (gloves, masks, gowns, eye protection, etc.) as appropriate to avoid body fluid contact.

If any body fluid exposure occurs, personnel should contact the Medical Committee Chair as soon as possible.

Equipment, which has come in contact with body fluids, should be cleaned per the care instructions or with 10% bleach solution.

CPR/BLS Airway Procedures as per current AHA standards.

Basic vital signs include: pulse rate, respiratory rate, blood pressure, and mentation (GCS). Basic vital signs should be monitored and recorded for every patient.

Vital signs should be monitored and recorded as follows:

Unstable patients, every 30 min.

Stable patients, every 60 min.

Baseline vital signs should be measured and recorded before any medication or treatment is rendered.

IVs will be initiated with saline locks unless the patient needs fluid or is receiving medications which require IV flush.

Adult/pediatric IOs may be initiated in patients in extremis where other IV access is not possible in a timely manner; any med given by IV may be given by IO.

Texas (all providers) or Foley (EMT-P and PA only) catheters may be placed on patients receiving diuretics, those who are unconscious, and those undergoing long technical evacuations.

Acceptable form of valsalva: have the patient bear down.

Pain should be assessed using a 0-10 scale before and after every treatment of pain (chest pn, musculoskeletal, etc) and with every set of vital signs when appropriate.

In any patient where spinal immobilization was performed or considered, the presence or absence of the following should be assessed and recorded pre and post immobilization:

Sensation to light touch in all extremities.

Distal circulation in all extremities (radial pulse and dorsal pedal or posterior tibial pulse).

Motor function of all extremities

Sensation, circulation, and motor function should be assessed for all extremity injuries or complaints.

Contact of the hospital physician for any unusual or unfamiliar situations is encouraged.

Medical professional, with greater training, who offer their assistance or wish to take control of patient care will:

Identify themselves

Preferable show some proof of licensing authority

Be treated with professional courtesy

Be assisted as needed

Be informed that any care which is outside the scope of these protocols will require the medical professional to: solely accept responsibility of said care, stay with the patient and provide direct pass down to the receiving physician, and sign patient care documentation.

Routine medical care5

All Providers

All patient encounters will be documented in the S.O.A.P. format.

Subjective – Information related to the provider by the patient, bystanders, dispatch, other providers, etc.

Objective – Information directly observed by the provider including: condition of the scene, head to toe physical exam, assessment of the pt’s mental status, etc.

Assessment – The providers assimilation of subjective and objective information to create a statement summarizing patient injury. i.e. shoulder dislocation post ground level fall.

Plan – A flow chart recording pertinent patient interactions, the time they occurred, and any change in patient status at that time. i.e. 1830 shoulder reduced, pt reported decrease of pain from 9/10 to 2/10. 1830 sling and swath applied, CMS intact before and after.

Subjects encountered become patients and require documentation when they have received a “patient assessment” from a provider.

Requests for bandages, ice, etc. are not considered patient encounters unless the provider assesses the injury or illness.

Commercial SOAP notebooks are available in each medical kit, if a SOAP notebook is not available the provider may record his/her SOAP note by whatever means are available.

SOAP notes should be completed within 24 hrs of the end of the patient encounter. Do to the extended nature of our care, providers are encouraged to begin a SOAP note shortly after the initial assessment and continue to record patient information, interaction, and observations throughout contact.

Completed SOAP notes (original) should be forwarded to the unit secretary for storage. In the event of complicated patients, a copy of the SOAP note should be forwarded to the receiving hospital.

If patient care is to be transferred to another CMRU provider the original SOAP note may remain with the pt and be completed by the new CMRU provider.

If patient care is to be transferred to another agency, a copy of the SOAP note or a copy of the pertinent items on the SOAP note (flow chart) should be provided to the new provider during verbal patient care passdown.

Documentation1

ASSESSMENT

Assessment9

FR / WFR / OEC / EMT-B

If pt unable to maintain own airway then, manually open airway (head tilt or chin thrust)

Providers should use this protocol in conjunction with Oxygen Therapy protocol.

Complete Airway Obstruction

Utilize Foreign Body Airway Obstruction protocol per current AHA guidelines.

If gag reflex, NPA.

If no gag reflex, OPA

Emt-i

Assess airway support already in place, if adequate leave in place, if inadequate then remove and continue.

If aspiration risk AND no immediately reversible cause (hypoglycemia, opiate OD, etc.) AND no EMT-P available on scene then, Combitube.

If EMT-P available skip Combitube.

EMT-P / PA

Assess airway support already in place, if adequate leave in place, if inadequate then remove and continue.

If aspiration risk AND;

Not immediately reversible ( BG, opiate OD, etc.) OR;

Expected course dictates (airway burns) then, Intubate.

If no muscle tone expected (code situation) then, intubate via direct laryngoscopy w/o pharmacology.

Otherwise, RSI.

If ETI successful confirm via: direct cord visualization, EID, lung sounds, ETCO2, and SaO2.

If airway not maintainable via other means then; Crycothyrotomy

If required to maintain airway, sedate patient per RSI.

Consider NG or OG if gastric distention.

Complete Airway Obstruction

Remove foreign body with magill forceps.

If unable to remove foreign body, laryngeal trauma or epiglottitis, consider crycothyrotomy.

Considerations

Airway11

FR / WFR / OEC / EMT-B

Routine Medical Care,

Providers should use all tools available to assess the adequacy of oxygenation and ventilation including:

Visualization (rate, depth, rhythm, skin color, positioning)

Auscultation

Mental status

SaO2

Providers should use this protocol in conjunction with airway protocol.

If ventilation is inadequate then assist or control ventilations via Mouth to Mask or BVM to maintain adequate oxygenation and ventilation.

If oxygenation inadequate OR pt’s condition could benefit from additional O2 (cardiac, trauma, etc.) then provide supplemental O2 using a rate and method which provides the desired effect, measured as above.

In general providers should select methods which are less invasive and provide for greater communication first.

COPD patients should be managed to maintain SaO2 levels between 90 - 95%.

Head trauma patients should not be hyperventilated, maintain ETCO2 between 32-35 mmHg.

The following methods are acceptable for O2 administration.

Nasal cannula @ 2-6 lpm O2.

NRM @ 10-12 lpm O2.

BVM @ 10-12 lpm O2.

Emt-i

The following methods are acceptable for O2 administration.

Nebulizer @ 6 lpm O2. (for use with nebulized medications only)

EMT-P / PA

If unable to oxygenate adequately in the presence of  lung sound and hypotension consider needle thoracentesis.

Considerations

Caution should be observed when positive pressure ventilating pediatric, asthma/COPD, and geriatric patients.

Allow adequate exhalation.

Avoid hyperventilation.

Ventilate only until the chest begins to rise.

Oxygen13

FR / WFR / OEC / EMT-B

Recognition of Acute Mountain Sickness (AMS) in the field should be based on two factors; history of ascent and symptoms consistent with AMS. Although usually mild, many travelers have been afflicted with AMS after ascents of only 1500 meters above their baseline elevation. Many mountaineers and alpinist experience mild AMS during their summit attempts on Cascade peaks. Those who become injured or are forced to remain at high elevations may experience increasing symptoms during their unplanned stay at elevation. Providers should consider the possibility of AMS and watch for worsening symptoms in all patients at altitude.

Symptoms of AMS include:

Headache

SOB during exertion or at rest

Weakness

Ataxia

Nausea and Vomiting

Pulmonary edema

Routine Medical Care

AMS at all levels is best treated by rapid descent until symptoms recede.

Descent of 200-300 meters may resolve mild and moderate symptoms.

Pts whose symptoms are severe may require descents of 1000-1500 meters before symptoms resolve.

Encourage fluids and nutrition PO, if gag intact.

Oxygen per Oxygen Therapy Protocol

Emt-i

IV

NS per Shock Protocol

EMT-P / PA

If Mild AMS and unable to descend than,

If other causes can be reasonably ruled out, headache may be treated with APAP 650 mg PO q 4-6 hrs.

If Moderate AMS (severe headache, lassitude, weakness, ataxia, SOB at rest, reduced urinary output) and unable to descend than,

Diamox 125-250 mg PO q 12 hrs PRN.

If High Altitude Cerebral Edema (HACE) (ataxia,  mental status, confusion, vomiting) and unable to immediately descend than,

Decadron 10 mg IVP, repeat 6 mg q 6-8 hrs PRN.

If High Altitude Pulmonary Edema (HAPE) (tachypnea, peripheral edema, rales, cyanosis, copious sputum) and unable to immediately descend than,

Lasix 40 mg IVP q

Nifedipine 10 mg SL q 8 hrs.

Acute Mountain Sickness15

FR / WFR / OEC / EMT-B

Routine Medical Care

Oxygen per Oxygen Therapy Protocol

SYSTEMIC SEVERE ALLERGIC REACTION if patient displays:

Hypotension and one or more of the following:

Hives

Pediatric
Epi 1:1,000, 0.01 mg/kg IM; repeat PRN q 10 min.

Tongue/face swelling

Wheezing

Stridor

Than,

Epi 1:1,000, 0.3 mg IM; repeat PRN q 10 min.

Pediatric
Benadryl 1 mg/kg IVP/IM, max 50 mg.

Bronchodilators per Respiratory Distress Protocol

Diphenhydromine 25-50 mg IM; repeat PRN q 4-6 hrs.

Emt-i

IV

NS per Shock Protocol

If SYSTEMIC SEVERE ALLERGIC REACTION and no response to IM epinephrine and IV fluids: consider Epi 1:10,000 0.3 mg slow IV push over 3 minutes.

EMT-P / PA

Dexamethasone 10-20 mg IVP; repeat 2-4 mg IVP q 4 hrs PRN.

Acute Mountain Sickness15

FR / WFR / OEC

Routine Medical Care,

Oxygen per Oxygen Therapy Protocol.

ASA 324 mg PO.

Emt-b

May assist pt w/ Rx’d NTG, If SBP>90; repeat q 3-5 min max 3 doses.

Emt-i

IV

ECG

NTG 0.4 mg SL, If SBP>90 AND chest pain continues, repeat q 3-5 min max 3 doses.

EMT-P / PA

12 lead ECG

May continue NTG 0.4 mg SL PRN if SBP>90.

Considerations

MEDICATION WARNING: NTG is contraindicated if pt has taken any erectile dysfunction medication (Viagra, Levitra, or Cialis) within last 24 hours.

Cardiac17

ALL PROVIDERS

CPR and ACLS should be performed per provider level per the current AHA provider standards.

Cardiac17

FR / WFR / OEC

Altered Mental Status is a broad and general term for the alteration of a patient’s ability to mentate at their baseline level. Altered mental status complaints are complicated by the plethora of circumstances from which it originates and the fact that complaints are often lodged by persons other then the patient. If possible providers should attempt to identify the circumstances which lead to the current altered mental status complaint. Providers should be aware that, do to the complexity of causes, several protocols could be used in the treatment of altered mental status. Providers should use all tools available and the differential diagnoses below to identify an appropriate treatment plan.

Differential diagnosis for altered mental status should include:

Poisoning

Overdose

CVA

Alcohol/Drug Intoxication

Behavioral Emergency/Anxiety

Seizures/Postictal

Hypoglycemia

Metabolic disorders

Hypoxia

Trauma/TBI

Routine Medical Care,

Emphasize aggressive airway management

Oxygen per Oxygen Therapy Protocol.

If history or other scene clues suggest hypoglycemia and gag reflex intact/pt able to swallow than, Oral Glucose 25–50g or available sugar source (brown sugar / carbohydrate gel / gummy bears / etc.)

If LOC improves with administration of Glucose than continue administration until pt is GCS 15.

Emt-b

Check CBG, if <60 then, treat as above.



Emt-i

IV

ECG

Pediatric
Narcan 0.1mg IV/IM/SQ, max 2mg.

If hypoglycemia suspected than, D50W, 12.5 g IVP, repeat PRN for continued  CBG.

If constricted pupils then, Narcan 0.4mg IV/IM/SQ.

EMT-P / PA

If administering glucose or dextrose AND alcoholism or malnutrition is suspected then, Thiamine 100 mg slow IV push.

Pediatric
Thiamine 2 mg/kg slow IV push.

Considerations

Altered mental status19

All Responders

Any trauma patient who is pulseless and apneic may be considered dead.

Any patient who exhibits rigor, lividity, or obvious moral injury may be considered dead.

Any hypothermic patient who is frozen, who’s core temperature is the same as the ambient temperature or exhibits asystole via ECG may be considered dead.

Any patient who is pulseless and apneic and remains unresponsive to 30 min of available resuscitation may be considered dead.

Death in the Field21

FR / WFR / OEC / EMT-B

Routine Medical Care,

Oxygen per Oxygen Therapy Protocol

Consider concurrent use of Altered Mental Status protocol

Protect from environment.

Remove wet clothing.

If pt is able to warm self (shivering)

Provide for pt to warm self (insulation, activity, etc.)

Provide for adequate hydration (warm fluids preferred) and caloric fueling.

If pt is unable to warm self (no longer shivering) and has a pulse:

Provide warming to pt’s core, warm H20 bottles, charcoal heater, etc. (Skin to Skin contact not recommended)

Handle patient gently

Avoid the use of airway adjuncts

Assist ventilations as necessary

If pt shows no signs of life and,

Core temp >86 F – treat per current AHA guidelines

Core temp <86 F - Provide 30 min CPR and active warming (charcoal heater) before discontinuing resuscitation.

Emt-i /EMT-P / PA

If ECG is available than:

V-Fib - defib x1, @360 j.

If no conversion or patient reverts to V-Fib than CPR and active warming x 30 min or until rectal temp >86°F (standard ACLS applies above 86 F)

Asystole – CPR and active warming for 30 min.

Other than V-Fib or Asystole:

<3 hrs to definitive care than, transport without intervention.

>3 hrs to definitive care than, CPR and active warming for 30 min.

IV

If no contraindications (pulmonary edema, near drowning, etc.) than, NS 500 cc warmed to pt temp up to 108 F, repeatPRN.

Considerations

hypothermia23

FR / WFR / OEC / EMT-B

Routine Medical Care,

Oxygen per Oxygen Therapy Protocol

Consider concurrent use of Altered Mental Status protocol

Hyperthermia (rectal temperature >105 F):

Remove from environment.

If skin is hot, red and dry

Remove clothing.

Place ice packs in groin and axilla.

Mist patient with water.

If gag reflex intact, provide oral fluids.

Emt-i / EMT-P / PA

IV

NS per Shock Protocol

Considerations

hypothermia23

FR / WFR / OEC / EMT-B

Routine Medical Care,

Oxygen per Oxygen Therapy Protocol

Position patient to reduce pain and control nausea

Emt-i

IV

EMT-P / PA

Nausea:

Zofran 4 mg IVP/IM

OR

Phenergan 0.25 -0.5 mg/kg IVP/IM

Pain:

Tordol 60 mg IM or 30 mg IVP

Considerations

Pain / Nausea25

FR / WFR / OEC / EMT-B

Respiratory distress is a common and often life threatening complaint in the prehospital setting. Providers should use every tool available to select the appropriate treatment regime. Providers should also continually be aware that many conditions create a symptom of respiratory distress without any disease process of the lungs themselves. Consider assessing the following during a respiratory complaint: mentation, ability to speak/length of sentences, body position, respiratory rate, pulse rate, blood pressure, lung sounds, SaO2, ETCO2 (value and waveform), ECG, 12-lead, the patient’s medical history, and history of recent events.

Differential diagnosis for respiratory emergencies should include:

Bronchospasm (asthma, emphysema, bronchitis, COPD, )

Acute Mountain Sickness

Congestive Heart Failure

Pneumonia

Myocardial Infarction

Pulmonary Embolus

Psychosomatic / Anxiety

Metabolic

Anaphylaxis / Allergy