Prehospital Provider Scope of Practice 5

Table of Contents 1-4

PREHOSPITAL PROVIDER SCOPE OF PRACTICE 5

Protocols

Universal Patient Care ………………………………………………………………………………………………...... 6

CARDIAC

Adult BLS Healthcare Providers...... 7

Cardiac Arrest.………………………...…………………………………………………………………………………...... … 8

V-Fib/Pulseless V-Tach/Pulseless Electrical Activity ……………………………………………………...... 8 Asystole………………………………………………………………………………………………………………………...…… 8

Cardiogenic Shock…………………………………………………………………………………………………………...… 9 Bradycardia…………………………………………………………………………………………………………………... 10 Adult Tachycardia...... ………………………………………………………………………………………………….…. 11

RESPIRATORY

Airway (Adult)……………………………………………………………………………………………………………...……12 Failed Airway (Adult)………………………………………………………………………………………………...……… 13

Reactive Airway Disease……………………………………………………………………………………………....……14 Pulmonary Edema…………………………………………………………………………………………………………...… 15 Post resuscitation Management……………………………………………………………………………………....… 16

Medical

Abdominal Pain…………………………………………………………………………………………………………….…… 17 Allergic Reaction……………………………………………………………………………………………………………..… 18 Altered Mental Status / Diabetic Emergency…………………………………………………………………..… 19 General Illness………………………………………………………………………………………………………………..… 20 Overdose / Poisoning……………………………………………………………………………………………………..… 21 Pain Management…………………………………………………………………………………………………………..… 22 Psychological / Emotional Emergencies…………………………………………………………………………… 23Seizure……………………………………………………………………………………………………………………………… 24 Stroke……………………………………………………………………………………………………………………………..… 25 OB/GYN

Eclampsia………………………………………………………………………………………………………………………..… 26 Postpartum……………………………………………………………………………………………………………………..… 27

Environmental

Environmental………………………………………………………………………………………………………………..… 28

Burns ……………………………………………………………………………………………………………………………..… 29Decompression Illness / SCUBA Diving Related……………………………………………………………..…. 30

Drowning / Near Drowning……………………………………………………………………………………………..… 31

Head Injury…………………………………………………………………………………………………………………..…… 32 Multi-system Trauma …………………………………………………………………………………………………..……. 33

Pediatric Protocols

Pediatric BLS Healthcare Provider...... 34

Pediatric Cardiac Arrest/Pediatric V-Fib /Pulseless V-Tach/Asystole/Pediatric PEA…… 35

Pediatric Bradycardia….……………………………………………………………………………………………………… 36

Pediatric Tachycardia...... …………………………………………………………… 37

Pediatric Airway…………………………………………………………………………………………………………..…… 38

Pediatric Allergic Reaction…………………………………………………………………………………………………. 39

Pediatric ALOC..…………………………………………………………………………………………………………………… 40

Pediatric Breathing Difficulty……………………………………………………………………………………………… 41

Pediatric Hypoglycemia………………………………………………………………………………………………………42

Pediatric Seizure .……………………………………………………………………………………………………………..…43

Pediatric Procedure

Pediatric Assessment…………………………………………………………………………………………………………… 44

Pediatric References…………………………………………………………………………………………………………….45 Airway Needle Cricothyrotomy (Pediatric)………………………………………………………………………… 46

APGAR Scale/AVPU Infant/Child/CUPS Pediatric……....………………………………………………………… 47

Neonatal Resuscitation…………………………………………………………………………………………………………48

Pain Assessment and Documentation – Pediatric…………………………………………………………………49

Rule of Nines Child………………………………………………………………………………………………………………50

Venous Access – Intraosseous Pediatric………………………………………………………………………………. 51Procedures

Adult Assessment……………………………………………………………………………………………………………..… 52-54

Airway Capnography………………………………………………………………………………………………………..…… 55

Airway Combitube….………………………………………………………………………………………………………..…… 56

Airway Difficult Airway Assessment (LEMON)………………………………………………………………....……57

Airway Intubation Confirmation End-Tidal Co2 Detector ………………………………………………..……58

Airway Intubation Orotracheal………………………………………………………………………………………….....59

Airway Intubation with Eschmann Catheter, Tracheal Tube introducer or Gum Elastic Boughie 60

Airway Laryngotracheal KING®...... 61-62

Airway Nasotracheal Intubation …………………………………………………………………………………………….. 63

Airway Nebulizer Inhalation Therapy …………………………………………………………………………………...64

Airway Needle Cricothyrotomy (Adult) …………………………………………………………………………………. 65

Airway Non-invasive Positive Pressure Ventilation (NIPPV)…………………………………………………. 66

Airway RSI………………………………………………………………………………………………………………………………..67

Airway Suctioning –Basic....…………………………………………………………………………………………………...... 68

Airway Suctioning – Advanced ………………………………………………………………………………………………..69

Airway Tracheostomy Tube Change………………………………………………………………………………………… 70

Airway Ventilator Operation…………………………………………………………………………………………………… 71

Cardiac 12 Lead ECG………………………………………………………………………………………………………………… 72

Cardiac Cardioversion……………………………………………………………………………………………………………… 73

Cardiac Defibrillation Automated……………………………………………………………………………………………74

Cardiac Defibrillation Manual…………………………………………………………………………………………………75

Cardiac Transcutaneous Pacing………………………………………………………………………………………………76

Chest Compression External Device…………………………………………………………………………………………77

Chest Decompression………………………………………………………………………………………………………………78 Childbirth………………………………………………………………………………………………………………………………… 79 Childbirth/Fundal Massage……………………………………………………………………………………………………… 80 Cincinnati Stroke Screen………………………………………………………………………………………………………….. 81 CPR…………………………………………………………………………………………………………………………………………… 82 Discontinuation of CPR / Do Not Attempt Resuscitation / Determination of Field Death………… 83 Glucometry……………………………………………………………………………………………………………………………… 84

Glasgow Coma Score…………………………………………………………………………………………………………………85 Hemorrhage Control………………………………………………………………………………………………………………… 86 Injections – Subcutaneous, Intramuscular………………………………………………………………………………… 87 Orthostatic Blood Pressure Measurement………………………………………………………………………………… 88

Pain Assessment and Documentation – Adult……………………………………………………………………………89

Pulse Oximetry………………………………………………………………………………………………………………………… 90 Restraints……………………………………………………………………………………………………………………………….… 91-92

Rule of Nines Adult……………………………………………………………………………………………………………………93

Spinal Clearance……………………………………………………………………………………………………………………….94

Spinal Immobilization……………………………………………………………………………………………………………… 95 Splinting…………………………………………………………………………………………………………………………………… 96

Taser Dart Removal………………………………………………………………………………………………………………… 97 Temperature Measurement……………………………………………………………………………………………………… 98 Thrombolytic Screen………………………………………………………………………………………………………………… 99

Venous Access – Blood Draw……………………………………………………………………………………………………… 100

Venous Access – External Jugular Access...... 101

Venous Access – Extremity ………………………………………………………………………………………………………… 102

Venous Access – Intraosseous Adult……………………………………………………………………………………………103

Wound Care………………………………………………………………………………………………………...…… 104 Drug Formulary

Acetaminophen (APAP)…………………………………………………………………………………………………………………105 Activated Charcoal ...... 106

Adenosine (Adenocard)…………………………………………………………………………………………………………………107

Afrin (Oxymetazoline)…………………………………………………………………………………………………………………… 108 Albuterol Sulfate (Proventil, Ventolin)………………………………………………………………………………………… 109

Amiodarone (Cordarone)...... 110

Aspirin (ASA, AcetylsalicylicAcid)…………………………………………………………………………………………………111

Atropine Sulfate…………………………………………………………………………………………………………………...... 112

Atrovent (Ipratropium Bromide)………………………………………………………………………………………………… 113 Calcium Chloride (CaCI2)……………………………………………………………………………………………………………… 114 Cardizem (Diltiazem)…………………………………………………………………………………………………………………… 115

Dextrose 50% in Water (D50W)…………………………………………………………………………………………………… 116

Dilaudid (Hydromorphone)…………………………………………………………………………………………………………117 Diphenhydramine (Benadryl)……………………………………………………………………………………………………… 118 Dopamine (Intropin)…………………………………………………………………………………………………………………… 119 Epinephrine Hydrochloride (Adrenaline)…………………………………………………………………………………… 120

Etomidate (Amidate)…………………………………………………………………………………………………………………… 121

Fentanyl (Sublimaze)……………………………………………………………………………………………………………………. 122 Furosemide (Lasix)………………………………………………………………………………………………………………………. 123 Glucagon……………………………………………………………………………………………………………………………………… 124

Glucose Oral (Glucose Gel)…………………………………………………………………………………………………………… 125

Hydroxocobalamin ...... 126 Lidocaine……………………………………………………………………………………………………………………………………… 127 Lorazepam (Ativan)……………………………………………………………………………………………………………………… 128 Magnesium Sulfate (MgSo4)………………………………………………………………………………………………………… 129 Methylprednisolone (Solu-Medrol)………………………………………………………………………………………………. 130 Midazolam (Versed)……………………………………………………………………………………………………………………… 131 Morphine………………………………………………………………………………………………………………………………………. 132 Naloxone (Narcan)………………………………………………………………………………………………………………………… 133 Nitroglycerine (NitroStat)……………………………………………………………………………………………………………… 134

Oxytocin (Pitocin)…………………………………………………………………………………………………………………………. 135

Promethazine (Phenergan)……………………………………………………………………………………………………………136 Rocuronium (Zemuron)………………………………………………………………………………………………………………… 137

Sodium Bicarbonate (NaHco3)………………………………………………………………………………………………………. 138 Succinylcholine (Anectine)………………………………………………………………………………………………… 139

Thiamine (Betalina, Biamine, Vitamin B1)...... …...... 140

Vasopressin (Pitressin)……………………………………………………………………………………………………...... … 141 Vecuronium (Norcuron)…………………………………………………………………………………………………...... … 142

Zofran (Ondansetron)……………………………………………………………………………………………………...... … 143

Drug Reference…………………………………………………………………………………………………………………………...... 144

Miscellaneous

Air Ambulance Transports……………………………………………………………………………………...... …………… 145

Physician on Scene…………………………………………………………………………………………………………...... … 145 Emergency at Physician’s Office……………………………………………………………………………………...... …… 146 Medical Incident Reports……………………………………………………………………………………………...... ……… 146

Law Enforcement Assists………………………………………………………………………………………………...... …… 146

10 Critical Steps for Handling Possible Bioterrorism Events…………………………………………...... 147-148 Medical Spanish……………………………………………………………………………………………………………...... 149-151 Mnemonic’s…………………………………………………………………………………………………………………...... … 152-153

State of WA Prehospital Trauma Triage Procedure...... 154-155

PCH Full and Modified Trauma Activation Criteria...... 156

State of WA Prehospital Cardiac Triage Destination Procedure…………………………………………………… 157-158

State of WA Prehospital Stroke Triage Destination Procedure…………………………………………………… 159-160

Prehospital Provider Conduct…………………………………………………………………………………………………… 161 Infection Control Standards……….……………………………………………………………………………………………… 161 Patient Refusal of Medical Evaluation………………………………………………………………………………………… 161

1e. Medical Control/Base station needs to be notified………………………………………………....……… 161

2e. Medical Control/Base Station needs to be notified...……………………………………………………… 161

PREHOSPITAL PROVIDER SCOPE OF PRACTICE

Level of
Certification / Medical control & Skills Capabilities / Medication Administration
First Responder / MPD protocols, patient assessment, CPR, AED, BVM, Bandaging, splinting, trauma, triage, medical, and pediatrics. / 02
Emergency Medical Technician / MPD protocols, patient assessment, CPR AED, BVM, Bandaging, splinting, trauma, triage, medical, pediatrics, OB/GYN / 02, Aspirin, Epinephrine auto-injector, Charcoal, Glucose, assist with patient’s own metered dose inhaler as well as other prescribed medication
Emergency Medical Technician-Advanced / MPD protocols, EMT skills and knowledge, IV Therapy skills, ET, Multi-lumen airway. / 02, IV Fluid Therapy, Nalonxone, Glucose, Aspirin, Dextrose 50/25, Albuterol Nebulizer, Nitroglycerin, Charcoal, Epinephrine for anaphylaxis by commercially preloaded measured-dose device.
Emergency Medical Technician- Paramedic / MPD protocols, EMT skills and knowledge, IV Therapy skills, ET, Multi-lumen airway, advanced airway control, ACLS w/manual defibrillation, and advanced patient assessment, trauma and medical skills. / 02, IV Fluid Therapy, Medications per MPD protocol.

UNIVERSAL PATIENT CARE PROTOCOL

Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
Notes:
● Any patient contact which does not result in an EMS transport should be documented.
● Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status, and location of
Injury or complaint.
● Required vital signs on every patient include blood pressure, pulse, respirations.
● Pulse oximetry and temperature documentation is dependent on the specific complaint.
● A pediatric patient is defined by the Broselow-Luten tape. If the patient does not fit on the tape, they are
Considered Adult.
● Timing of transport should be based on patient’s clinical condition and the Washington State Trauma Triage Tool.
Cardiac Arrest
Oxygen
Consider Pulse Oximetry
P / Consider
Cardiac Monitor 12 Lead ECG / P
M / Doesn’t fit protocol?
Contact Medical Control / M

Adult BLS Healthcare Providers

High-Quality CPR
* Rate at least 100/min
* Compression depth at least
2 inches (5cm)
* Allow complete chest recoil
after each compression
* Minimize interruptions in chest compressions
* Avoid excessive ventilation

Definite Pulse

No Pulse

Shockable Not Shockable

Adult Cardiac Arrest

Shout for Help/Activate Emergency Response

Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M

Yes No

2 9

Shock

A / CPR 2 min
* IV/IOaccess / A

5 Yes

Shock

P / CPR 2 min
*Epinephrine every3-5 min
*Consider advanced airway, capnography / P
P / CPR 2 min
*IV/IO access
*Epinephrine every 3-5 min
*Consider advanced airway, capnography / P

No Yes

7 Yes

P / CPR 2 min
*Amiodarone
*Treat reversible causes / P

Shock 11

P / CPR 2 min
*Amiodarone
*Treat reversible causes / P

NoYes

Cardiogenic Shock

History:

Cardiac ischemia (MI, CHF)
Medications
Allergic reaction

/ Signs/Symptoms:

Restlessness, confusion
Weakness, dizziness
Weak, rapid pulse
Pale, cook, clammy skin
Delayed capillary refill
Hypotension
Rates & pulmonary edema on exam

/ Differential:

Dysrhythmias
Vasovagal

Pearls:

Be cautious of impending pulmonary edema
Hypotension can be defined as systolic blood pressure of less than 100
Consider performing orthostatic vital signs on patients in nontrauma situations if suspected blood or fluid loss
250cc-500cc fluid bolus and reevaluate lung sounds

/ Meds:
Dopamine 5 – 20 mcg/kg/prn titrate SBP>100
Epinephrine mix 1mg 1:1000 in 250 NS titrate to SBP>100 drip 2-10 mcg/min
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
A / Obtain IV Access / A
A / Fluid Bolus NS / A
P / 12 lead ECG / P
P / Dopamine
Or
Epinephrine / P
M / Contact Medical Control / M

Adult Bradycardia

Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M

(With Pulse)

Persistent bradyarrhythmia causing:
* Hypotension?
* Acutely altered mental status?
* Signs of shock?
* Ischemic chest discomfort?
* Acute heart failure?

Doses/Details
Atropine IV Dose:
First dose: 0.5 mg bolus
Repeat every 3-5 minutes
Maximum: 3 mg
Dopamine IV Infusion:
2-10 mcg/kg per minute
Epinephrine IV Infusion:
2-10 mcg per minute

Yes

P / Atropine
If atropine ineffective:
* Transcutaneous pacing
OR
* Dopamine infusion
OR
* Epinephrine infusion / P

Adult Tachycardia

(With Pulse)

Doses/Details
Synchronized Cardioversion
Initial recommended doses:
* Narrow regular: 50-100 J
* Narrow irregular: 120-200 J biphasic or 200 J monophasic
* Wide regular: 100 J
* Wide irregular: defibrillation dose
(NOT synchronized)
Adenosine IV Dose:
First dose: 6 mg rapid IV push; follow with NS flush.
Second dose: 12 mg if requird
Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia
Procainamide IV Dose:
20-50 mg/min until arrhythmia suppressed, hypotension ensures, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF
Amiodarone IV Dose:
First dose: 150 mg over 10 minutes. Report as needed if VT recurs.
Follow by maintenance infusion of 1 mg/min for first 6 hours.
Sotalol IV Dose:
100 mg (1.5 mg/kg) over 5 minutes.
Avoid if prolonged QT.

Yes

Airway, Adult

Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
Notes:
● For this protocol, adult is defined any person who does not fit the Broselow-Luten tape
● EMT’s must have multi-lumen airway training to use Combitubes or King-LTD
● Capnometry or Capnography is mandatory with all methods of intubation. Document result.
● Maintain C-spine immobilization for patients with suspected spinal injury
● Paramedics should consider combitube or King-LTD when unable to intubate
● Reconfirm ETT placement each time patient is moved
● Continuous pulse oximetry should be utilized in all patients with compromised respiratory function
Pulse Oximetry
Pulse Oximetry
M / Contact Medical ontrol / M
Combitube/
King-LTD
P / Oral-tracheal
Intubation / P

Airway, Adult Failed

Continue BVM /
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
P / Surgical Airway / P
Combitube/ King-LTD

Reactive Airway Disease

History: Asthma COPD – Emphysema, chronic Bronchitis Congestive Heart Failure Home treatment (0₂, nebulizer) Medications, (Theophylline, Steroids, Inhalers) Toxic exposure Smoking / Signs and Symptoms: Shortness of breath Pursed-lip breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi Use of accessory muscles Fever, cough Tachycardia / Differential: Asthma Anaphylaxis Aspiration COPD (Emphysema, Bronchitis) Pleural effusion Pneumonia Pulmonary Embolus Pneumothorax Cardiac (MI or CHF) Pericardial Tamponade Hyperventilation Inhaled Toxin (Carbon monoxide, etc.)
Universal Patient Care Protocol
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
Pt’s MDI per prescription
A / Obtain IV access / A
Febrile or Hypotensive? ― Yes
A / Obtain IV access / A
P / ECG / P
A / Albuterol prn / A
p / And prn Atrovent / p
p / Methylprednisolone prn / p
p / Epinephrine / p
Pearls: Barotrauma is often caused by the over-ventilation of Reactive Airway Patients Consider NIPPV if available / Meds: Albuterol- 2.5 mg SVN Atrovent- 0.5 mg SVN Epinephrine- 1:1,000 0.1-03ml IM
Magnesium- 2 g/100mg IV over 10-15 min Methylprednisolone- 125 mg IV
p / Magnesium / p
M / Contact Medical Control / M

Pulmonary Edema

History: • Congestive Heart Failure • Past Medical history • Medications (Digoxin, Lasix) • Viagra, Levitra, Cialis • Cardiac history – past Myocardial Infarction / Signs/Symptoms: • Respiratory distress, rales • Apprehension, Orthopnea • Jugular vein distention • Pink, frothy sputum • Peripheral edema, Diaphoresis • Hypotension, shock • Chest pain / Differential: • Myocardial Infarction • Congestive Heart Failure • Asthma • Anaphylaxis • Aspiration • COPD • Pleural effusion • Pneumonia • Pulmonary Embolus • Pericardial Tamponade
Mild Moderate- able to speak sentences, crackles base only, 0₂ sat ≥ 92% Severe- respiratory distress, crackles throughout, 0₂ sat <92% Near Death- Decreased LOC, cyanosis, dropping sats, ineffective respiratory drive
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
Universal Patient Care Protocol
A / Obtain IV Access / A
P / ECG / 12 Lead / P
P / Consider Capnography / P
A / Nitroglycerin if SBP> 100 / A
P / And / or Furosemide / P
Pearls: • Consider Non-Invasive Positive Pressure Ventilation (NIPPV) if available • Avoid Nitroglycerin in any patient (man or woman) who have used sexual performance enhancement drugs (i.e. Viagra, Levitra, Cialis) In the past 48 hours due to possible severe hypotension. • If patient has taken Nitroglycerin without relief, consider potency of the medication • Consider Myocardial infarction in all these patients • Allow the patient to be in their position of comfort to maximize their breathing effort. / Meds: Furosemide- 0.5-1.0 mg/kg IV or double the patients single oral dose up to 160 mg IV Morphine- 2mg IV q 3-5 minutes to 20 max Diluadad- 0.5 mg IV increments total to 2mg. 1-2 mg IM Nitroglycerin- 0.4 mg SL may repeat q5 min up to 5 times if SBP>100 mmHg
P / Morphine / P
M / Contact Medical Control / M

Post Resuscitation Management

History: Respiratory arrest Cardiac arrest / Signs/Symptoms: Return of pulse / Differential: Continue to address specific differentials associated with the original dysrhythmia
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
Repeat Primary Assessment
A / Obtain IV Access / A

P / Monitor ECG/
ETCO2 if available / P
Vital Signs/Pulse oximetry
sHypotension ion

Hypotension Bradycardia

A / Consider fluid bolus / A
Treat per Bradycardia Protocol
P / Consider Dopamine or Ephinephrine / P
P / Midazolam or Lorazepam prn / p
M / Contact Medical Control / M
Notes:
*Sedate as needed / Meds: Lorazepam 1-2 mg IV/IN/IM May repeat PRN Midazolam 2.5-10mg IV/IO over 2 minutes Dopamine IV Start at 5-20mcg/kg/min and titrate to SBP of 90-100 mmHg Epinephrine mix 1mg 1:1000 in 250mL NS, titrate 2-10 mcg/min for SBP> 100mmHg

Abdominal Pain

History: Age Past Medical / Surgical history Medications Onset Palliation / Provocation Quality (crampy, constant, sharp, dull, etc.) Region / Radiation / Referred Severity (1-10) Time (duration / repetition) Fever Last meal eaten Last bowel movement / emesis Menstrual history (pregnancy) / Signs/Symptoms: Pain (location / migration) Tenderness Nausea Vomiting Diarrhea Dysuria Constipation Vaginal bleeding / discharge Pregnancy / Differential: AAA Ectopic pregnancy Bowel obstruction Cardiac Pregnancy (ectopic?) GI Bleed Appendicitis Cholecystitis Pancreatitis Kidney stones
Universal Patient Care Protocol
Signs/symptoms of shock

YesNo

A / Obtain IV Access / A
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
P / Diphenhydramine or
Zofran / P

Notes: Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise Antacids should be avoided in patients with renal disease The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50 Appendicitis presents with vague, peri-umbilical pain which migrates to the RLQ over time / Meds: Diphenhydramine- 25-50 mg IV/IM/PO Zofran – 4mg IV/IO/IM
M / Contact Medical Control / M

Allergic Reaction

History: • Onset and Location • Food Allergy • Insect bite/sting • Medication Allergy
• New Clothing, soap, detergent • Past history of reactions
• Past Medical History
• Medication history / Signs/Symptoms: • Itching or hives • Coughing/wheezing or respiratory distress • Chest or throat constriction • Difficulty swallowing • Hypotension or shock • Edema / Differential:
• Urticaria (rash only) • Anaphylaxis (systemic effect) • Shock (vascular effect) • Angioedema (drug induced) • Aspiration/airway obstruction • Vasovagal event • Asthma or COPD • CHF
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
Universal Patient Care Protocol

Evidence of impending

Epinephrine

Respiratory Distress or shock

Hives/Rash Only

A / Obtain IV/IO access / A

No Respiratory component

A / Fluid Bolus NS / A
P / Diphenhydramine / P
P / Diphenhydramine / P
Reassess patient
P / Methylprednisone / P

P / ECG /Consider 12 lead / P
P / Albuterol prn / P
P / And prn Atrovent / P
P / Epinephrine Drip 2-10 mcg/min / P
M / Contact Medical Control / M
Pearls:
· Signs of shock include SBP <90
· The shorter the onset from contact to symptoms, the more severe the reaction.
· A single dose of Epinephrine may not reverse the effects of Anaphylaxis.
Administer additional doses as needed.
· Obtain ECG tracing during pharmacological administrations.
· EMT may assist with patients own MDI / Meds:
Epinephrine 0.1=0.3 cc IM; 0.1-0.3mg SQ, SL Repeat Epinephrine PRN
Diphenhydramine 25-50 mg PO/IM/IV
Albuterol 2.5.mg Pt.’s MDI per prescription SVN
Albuterol 2.5 mg & Atrovent 0.5 mg SVN
Methylprednisolone 125 mg IV
History:

Known diabetic, medic alert tag
Drugs, drug paraphernalia
Report of illicit drug use or toxic ingestion
Past Medical history
Medications
History of Trauma
GI History
Syncope

/ Signs/Symptoms:

Decreased mental status
Change in baseline mental status
Bizarre behavior
Hypoglycemia (cool, diaphoretic skin)
Hyperglycemia (warm dry skin; fruity breath, Kussmal resps: signs of dehydration)
Diabetic
Syncope

/ Differential:

Head Trauma
CNS (stroke, tumor, seizure, infection
Cardiac (MI, CHF)
Thyroid (hyper/hypo)
Shock
Diabetes (Hyper/hypoglycemia)
Toxicologic
Acidosis / Alkalosis
Environmental exposure
Pulmonary (Hypoxia)
Electrolyte abnormality
Psychiatric disorder
Syncope

Altered Mental Status/Diabetic Emergency

Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
A / Obtain IV access / A
Blood Glucose check
A / Normal Saline / A
Administer Oral Glucose
A / Normal Saline / A
Yes
No
P / Thiamine / P
A / Dextrose / A
A / Naloxone prn / A
P / Glucagon prn / P
P / ECG / 12 lead / P
Pearls:
· Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety.
· It is safer to assume hypoglycemia than hyperglycemia if doubt exists.
· Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia
· Low glucose (,60), normal glucose (60 – 120), high glucose (>250).
· Consider Restraints if necessary for patient’s and/or personnel’s protection per the restraint procedure. / Meds:
Dextrose - D50% 25-50 g IV
Glucagon- 1 mg IM
Naloxone- 0.4-2 mg IV /IM (Start with lower dose)
M / Contact Medical Control / M

General Illness

Fever / Nausea / Vomiting / Unknown

History:
· Age
· Duration
· Past medical history
· Last Oral Intake
· Medications
· Immunocompromised
· Blood emesis/diarrhea
· Menstrual history
· Environmental exposure / Signs / Symptoms:
·Warm
·Sweaty
· Flushed
· Pain
· Radiation
· Abdominal distension
· Chills/Rigors
· Constipation
· Diarrhea / Differential:
· Infections / Sepsis
· Cancer / Tumors / Lymphomas
· GI or Renal disorders
· Heat Stroke
· Medication or drug reaction
· Vasculitis
· Hyperthyroid
· CNS disease/trauma
· Myocardial infarction
· Diabetic ketoacidosis
· Gynecologic disease (ovarian cyst, PID)
· Electrolyte abnormalities
· Pregnancy
· Psychologic
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M
Universal Patient Care Protocol
Check Blood Glucose *
Perform Cincinnati Stroke* Test
A / Obtain IV Access / A
A / Fluid Bolus NS prn / A
P / ECG / 12 lead prn / P
P / Zofranor Diphenhydramine / P
Nausea/Vomiting?

P / Acetaminophen / P
Fever?

Consider

Cooling measures

P / Lorazepam / P

Consider

M / Contact Medical Control / M
Notes:

Individual’s normal body temperature differ with 98.6°F (37°C) being average. Generally a temperature over 100°F (38°C) is considered a fever.
If shivering or hyperthermic give Lorazepam

*If indicated **Contact Medical Control / Meds:
Acetaminophen- 500-1000mg PO
Diphenhydramine- 25-50 mg IV/IM/PO
Zofran- 4mg / 2ml IV/IM

Overdose/Poisoning

History:
· Ingestion or suspected ingestion of a potentially toxic substance
· Substance ingested, route, quantity
· Time of ingestion
· Reason (Suicidal, accidental, criminal)
· Past medical history, medications / Signs / Symptoms:
·Mental status changes
· Hypotension / Hypertension
· Decreased respiratory rate
∙ Tachycardia, dysrhythmias
∙ Seizures / Differential:
· Tricyclic antidepressants (TCAs)
· Acetaminophen (Tylenol)
· Depressants
· Stimulants
· Anticholinergic
· Cardiac medications
· Solvents, Alcohol, Cleaning agents
· Insecticides (organophosphates)
Poison Control 800-222-1222
Universal Patient Care Protocol
Legend
EMT
A / EMT-A / A
P / EMT-P / P
M / MC Order / M