MESA COUNTY EMERGENCY MEDICAL SERVICES TREATMENT AND OPERATIONAL PROTOCOLS AND POLICIES Versions 10.10.2 and 10.10.3 Put into effect October 1, 2010 and approved by Bobby Dery, MD Medical Director Mesa County EMS System This set of protocols and policies supersedes all previous versions, copies, and/or printed material which may carry the same or similar name.
TABLE OF CONTENTS INTRODUCTION Authorization for Protocols/Website Intro 1 Forward.... Intro 2 Delegation of Practice Statement/How These Protocols Work Intro 4 Medication Administration. Intro 6 Mesa County EMS Formulary... Intro 7 Medication Administration Special Circumstances. Intro 8 Approved Medications. Intro 9 Formulary by Training Level... Intro 10 Inter-Facility Transfer Medications. Intro 11 Hazmat: Approved Medications. Intro 12 Best Practices Benchmarking. Intro 14 Age Cutoffs for These Protocols. Intro 15 Prehospital Patient Assessment Guidelines. Intro 16 AIRWAY/BREATHING PROTOCOLS Best-Practice Benchmarks. Airway/Breathing 1 MCEMS Statement on Intubation and Rescue Airways... Airway/Breathing 2 Confirmation/Monitoring of Tracheal Intubations... Airway/Breathing 3 Adult Airway Algorithm... Airway/Breathing 5 Pediatric Airway Algorithm. Airway/Breathing 6 CPAP Airway/Breathing 8 MCEMS Statement on Cricothyrotomy Airway/Breathing 9 Respiratory Distress Flowchart. Airway/Breathing 11 Shortness of Breath with Bronchospasm Airway/Breathing 12 Shortness of Breath with Pulmonary Edema.. Airway/Breathing 13 Respiratory Arrest... Airway/Breathing 15 CARDIAC PROTOCOLS Best-Practice Benchmarks. Cardiac 1 Chest Pain/Cardiac Alert Cardiac 2 Cardiac Arrest.. Cardiac 5 Therapeutically Induced Hypothermia. Cardiac 7 Adult Arrhythmias Cardiac 9 Cardiogenic Shock.. Cardiac 11 Approved Adult ACLS Medications.. Cardiac 13 Syncope Cardiac 15 Hypertension Cardiac 17 Continued on next page
TABLE OF CONTENTS MEDICAL PROTOCOLS Best-Practice Benchmarks Medical 1 Medical Triage Destination Guidelines Medical 2 Shock Medical 4 Altered Mental Status/Coma. Medical 6 Seizures/Status Epilepticus... Medical 7 CVA/TIA Medical 8 CVA/TIA Checklist.. Medical 10 Allergy/Anaphylaxis Medical 12 Glycemic Emergencies.. Medical 13 Toxins and Overdoses... Ingested Medical 15 Inhaled/Adsorbed/injected Medical 16 Tri-cyclic Antidepressants.. Medical 17 Narcotics.. Medical 18 Organophosphates Medical 19 Psychiatric/Behavioral Medical 21 Abdominal Pain... Medical 22 Vomiting Medical 24 OB/GYN Medical 26 TRAUMA PROTOCOLS Best-Practice Benchmarks.... Trauma 1 MCEMS Statement on Trauma Care/Scene Times... Trauma 2 SMH Trauma Activation Criteria...... Trauma 4 Adult Trauma Destination Guidelines..... Trauma 5 Pediatric Trauma Destination Guidelines..... Trauma 8 Glasgow Coma Scale.... Trauma 11 Traumatic Cardiac Arrest...... Trauma 12 Hypovolemic Shock.... Trauma 13 Hemorrhage..... Trauma 14 Spinal Immobilization Protocol..... Trauma 16 Spinal Trauma..... Trauma 17 Head Trauma...... Trauma 19 Chest Trauma..... Trauma 21 Abdominal Trauma..... Trauma 23 Face and Neck Trauma..... Trauma 25 Burns.... Trauma 27 Extremity Trauma....... Trauma 32 Eye Trauma..... Trauma 34 Continued on next page
TABLE OF CONTENTS PEDIATRIC PROTOCOLS Best-Practice Benchmarks.... Peds 1 Pediatric Medical Destination Guidelines... Peds 3 Pediatric Ages and General Guidelines. Peds 4 Pediatric Respiratory Arrest.. Peds 5 Cardiac Arrest/Dysrhythmia.. Peds 7 Pediatric Shock/Dehydration. Peds 9 Approved Pediatric ACLS Medications... Peds 11 Pediatric Respiratory Distress.. Peds 13 Pediatric Respiratory Distress with Wheezing.. Peds 15 Pediatric Respiratory Distress with Stridor. Peds 17 Allergic Reaction/Anaphylaxis.. Peds 19 Seizures/Status Epilepticus... Peds 21 Pediatric Glycemic Emergencies.. Peds 23 Pediatric AMS/Coma.. Peds 25 Childbirth.. Peds 27 APGAR Score. Peds 28 Neonatal Resuscitation.. Peds 29 Pediatric Vital Signs and Formulas.. Peds 31 ENVIRONMENTAL PROTOCOLS Best-Practice Benchmarks... Enviro 1 Hypothermia With Signs of Life Enviro 2 Hypothermia Without Signs of Life... Enviro 4 Heat Emergencies.. Enviro 7 Bites and Stings.. Enviro 8 Snakebite..... Enviro 9 Drowning/Near Drowning... Enviro 11 Altitude Illness..... Enviro 12 Continued on next page
TABLE OF CONTENTS TREATMENT POLICIES AND PROCEDURES PROTOCOLS Best-Practice Benchmarks..... Treatment P&P 1 Rescue Airways...... Treatment P&P 2 Chest Decompression.... Treatment P&P 4 Defibrillation..... Treatment P&P 6 Cardioversion...... Treatment P&P 8 Transcutaneous Pacing..... Treatment P&P 10 Intraosseus Access.... Treatment P&P 11 Venous Access....... Treatment P&P 14 Field Blood Samples...... Treatment P&P 16 Taser Patient Care..... Treatment P&P 17 Taser Wound Care Instructions... Treatment P&P 18 Non-Transport/Refusals.... Treatment P&P 19 Field Death Pronouncement.... Treatment P&P 22 Termination of Medical Resuscitation.. Treatment P&P 23 DNR/CPR Directives/Advance Directives... Treatment P&P 24 Death Situation Guidelines.... Treatment P&P 27 Hospice.... Treatment P&P 28 Restraint of Patients....... Treatment P&P 31 Non-EMS-System Providers On-Scene..... Treatment P&P 33 OPERATIONAL POLICIES AND PROCEDURES PROTOCOLS Delegation of Medical Direction..... Operational P&P 1 Consent....... Operational P&P 2 Confidentiality/Protected Health Information...... Operational P&P 5 Radio Report Procedures...... Operational P&P 6 Patient Care Reports..... Operational P&P 7 Documentation....... Operational P&P 10 Transfer of Care/ALS Backup...... Operational P&P 13 Continuous Quality Improvement/Quality Assurance... Operational P&P 14 Non-EMS-Agency Event Medicine...... Operational P&P 20 Disciplinary Procedures: Providers.. Operational P&P 21 Protocol Deviation Levels: Providers...... Operational P&P 23 Disciplinary Procedures: Agencies.. Operational P&P 24 New Provider Orientation...... Operational P&P 27 Probationary Procedure: Providers..... Operational P&P 30 Medical Director Agreement..... Operational P&P 32 Squad Review..... Operational P&P 33 Protocol and Skills Testing....... Operational P&P 36 Priority Dispatch..... Operational P&P 38 Medication Inventory...... Operational P&P 40 Agency Controlled-Substance Requirements Operational P&P 40.1 Direct Admit Patients..... Operational P&P 41 Provider Certifications and Record Keeping.. Operational P&P 42 Search and Rescue Relationship..... Operational P&P 44 Nurses Functioning in the Pre-Hospital Environment... Operational P&P 46 Hazardous Materials...... Operational P&P 48 Incident Command System...... Operational P&P 49 Infectious/Communicable Disease...... Operational P&P 50 Stress Management....... Operational P&P 51 Veterans Affairs...... Operational P&P 52
AUTHORIZATION FOR PROTOCOLS/WEBSITE These protocols are issued by the Mesa County EMS Medical Director (Medical Director or EMSMD), and govern the practices of all EMS entities in Mesa County via the authority of the Mesa County Emergency Medical Services Resolution, adopted by the Board of Mesa County Commissioners on December 6, 2004. (Mesa County Colorado Resolution No. MCM 2004-220-2). All providers and agencies were invited to participate in the review and adoption of these protocols through their Agency Quality Director and the Mesa County EMS CQI/QA Committee. These protocols will be regularly reviewed. New or revised protocols will be released via the Mesa County EMS website, and/or directly to the Agencies and Providers via each agencies Agency Quality Director (AQD). The Mesa County EMS website is the clearinghouse for all EMS communications, documents, educational materials, protocol updates and other important information. All interested parties are strongly encouraged to visit the site often, and to sign up for E-mail notifications on the site so the Medical Director and Mesa County EMS Coordinator can keep all providers and agencies up to date. Please visit: http://ems.mesacounty.us Intro 1 Intro 1 Intro 1
FORWARD Users of these protocols are assumed to have knowledge of more detailed and basic patient management principles found in EMS textbooks and literature appropriate to the EMS providers level of training, certification and licensure. These protocols are not an instruction manual, or a medical textbook. The Medical Director relies on the training you received in your EMT certification course, and the knowledge, experience and continuing education you have accumulated, to guide all of your decision making. The Medical Director requires that any treatment, intervention or action attempted by you is within the scope of your training, experience and level of licensure. The Medical Director requires that any treatment, intervention or action attempted by you is authorized for your level of certification by both these protocols AND State of Colorado Rule. These protocols are intended to be general guidelines regarding the expectations the Medical Director has concerning the medical treatment and care of patients. They also detail the operational competency expected of the agencies and personnel approved to act under the extension of the Medical Director s medical license. They are not intended to be a definitive list or guide of all possible injuries or treatments, but rather, the beginning of care for the majority of patients we see in our practice. The ultimate goal of our EMS system is to provide kind, compassionate care to the community we serve in a manner consistent with how we would want our own families treated. It is my wish to encourage independent thinking, so that you may, along with the physicians providing on-line medical control, arrive at the best treatment decisions for individual patients- whether or not their particular injury or illness is written down in these pages. But you must understand and follow the scope of practice set forth for you in these protocols, and in current State Rules. Best regards, Bobby Dery MD October 1, 2010 Intro 2 Intro 2 Intro 2
DELEGATION OF PRACTICE STATEMENT/ HOW THESE PROTOCOLS WORK All of the providers who operate under these protocols and policies do so by direct extension of the medical license granted by the State of Colorado, and the DEA license granted by the Drug Enforcement Agency, to the Medical Director. The providers are the eyes, ears, and hands of the Medical Director, who is responsible for oversight of all pre-hospital treatment rendered by Mesa County EMS System personnel. State of Colorado and Federal Rules give the ability to physicians to extend their licenses to cover prehospital provider s practice of medicine. These Rules also imposes oversight requirements for those physicians acting as Medical Directors. All of the operational components of this document are meant to satisfy those requirements, and must be followed without exception. State of Colorado First Responder or EMT Certification is required to participate in this system. However, State Certification does not confer a right to work in the Mesa County System. Proficiency must be demonstrated and maintained in order to function at the levels specified in this document. Therefore, the Medical Director maintains the absolute power to limit, restrict, or revoke any provider s system certification level solely at his/her discretion. How these protocols work: Each certification level builds on the preceding level, i.e. EMT-B-IV s are responsible for/allowed all skills/medications listed under EMT-B; EMT-I s are responsible for/allowed all skills/medications listed under EMT- B and EMT-B-IV; EMT-P s are responsible for/allowed all skills/medications listed under EMT- B, EMT-B-IV and EMT-I. First responders will perform and be responsible for those EMT-B skills for which they have been trained, and nothing above that. Whenever questions arise about the proper course of treatment or transport, On- Line Medical Control should be contacted. The Medical Director has delegated his authority to these licensed physicians to give direction to prehospital providers in accordance with this document. Providers will follow those directions given by On-Line Medical Control within their scope of practice for their system certification level. Intro 4 Intro 4 Intro 4
MEDICATION ADMINISTRATION See Intro 9- Approved Medications for Mesa County EMS as warranted. See Intro 10- Formulary Breakdown by Training Level as warranted. See Cardiac 13- Approved ACLS Medications as warranted. See Peds 11- Approved Pediatric ACLS Medications as warranted.. All EMT s and agencies shall take all possible actions to reduce the possibility of medication errors; including, but not limited to, following these protocols. All medication errors shall be reported to the Medical Director immediately- See Operational P&P 23- Protocol Deviation Levels. POLICY AND PROCEDURES 1. Once a medication has been chosen for use, the proper medication identification and concentration shall be confirmed, and reconfirmed, prior to administration. 2. Certain medications can be administered via one route only, others via several. Medications also come in different concentrations. Double check everything prior to administration. 3. If the patient has an unexpected response, or lack of response, to a medication- re-check vial or syringe to confirm what medication was given. Contact base if unsure how to treat any possible complications. 4. Any medication administration error shall be recorded in the PCR exactly as it happened, without explanations. If patient is awake, it should be explained to them what has occurred and what the possible complications might be. 5. Medication errors will also be explained directly to the accepting EDP at time of patient drop-off. 6. YOU MUST know the indications, contraindications, dosing, and common adverse effects of any medication you use- it is your obligation as an EMS provider to do so. 7. YOU MUST be completely familiar with Intro 9- Approved Medications for Mesa County EMS, and Intro 10- Formulary Breakdown by Training Level. 8. YOU MUST know which medications you are allowed to give by verbal vs. standing order for your level of certification. 9. If an EDP orders you to give a medication you are not allowed to administer, it is your job to inform the EDP of this fact, and NOT administer that medication. 10. You, not the EDP, are responsible for knowing your scope of practice. Intro 6 Intro 6 Intro 6
MEDICATION ADMINISTRATION MESA COUNTY EMS FORMULARY See Intro 9- Approved Medications for Mesa County EMS as warranted. See Intro 10- Formulary Breakdown by Training Level as warranted. See Cardiac 13- Approved ACLS Medications as warranted. See Peds 11- Approved Pediatric ACLS Medications as warranted.. 1. The State of Colorado is very progressive in the number and varieties of medications it allows physicians to delegate administration of to EMS providers. Some of these medications may not have been taught to the providers during their initial EMT training. a. It is the responsibility of each EMT, and each EMS Agency, to assure the Medical Director that all approved and/or required supplemental education has occurred prior to an EMT being allowed to administer any medication. i. Even if said medication is allowed for that EMT by State Rule or these protocols. 2. EMT Basics may administer specific medications by standing order as per State of Colorado Rules; see Intro 10- Formulary Breakdown by Training Level. a. EMT-B s must contact base prior to administration of any other medication; including assisting with patient s own nitroglycerin, patient s own measured dose inhalers, or administering an albuterol nebulization. b. See Intro 8- Medication Administration- Special Circumstances for exceptions which are allowed by State Rule. 3. EMT Intermediates may administer specific medications by standing order as per State of Colorado Rules see Intro 10- Formulary Breakdown by Training Level. a. EMT-I s must contact base prior to the administration of any other medication. b. Contact with base may be concurrent with administration of ACLS medications if patient is in cardiac arrest. c. See Intro 8- Medication Administration- Special Circumstances for exceptions which are allowed by State Rule. 4. EMT Paramedics a. May administer and monitor approved medications by standing order as per State of Colorado Rules and unless required to contact base as per each protocol. Intro 7 Intro 7 Intro 7
MEDICATION ADMINISTRATION SPECIAL CIRCUMSTANCES (PER STATE RULE) See Treatment P&P 10- Transcutaneous Pacing for EMT-I medications allowed. See Treatment P&P 11- Intraosseus Access for EMT-I medications allowed. 1. EMT-B-IV may administer and monitor medications beyond their approved level under the direct visual supervision of an on-protocol Mesa County EMS System approved EMT-I or EMT-P ifa. the patient is in extremis or cardiac arrest; AND b. the medication(s) are approved for the EMT-I or the EMT-P; AND c. neither EMT is in their probationary training period. d. the senior EMT is ultimately responsible for all decisions. e. The AQD and EMSMD must be notified ASAP when this occurs. 2. EMT-I may administer and monitor medications beyond their approved level under the direct visual supervision of an on-protocol Mesa County EMS System approved EMT-P ifa. the medication(s) are approved for the EMT-P; AND b. neither EMT is in their probationary training period. c. the senior EMT is ultimately responsible for all decisions. d. The AQD and EMSMD must be notified ASAP when this occurs. 3. EMT-I, when unable to make contact with an EDP to obtain a direct verbal order (despite adequate attempts), is allowed to administer the following medications under standing order: a. Cardiac arrest medications (atropine, epinephrine, lidocaine) may be administered in the case of cardiac arrest. b. Behavioral management medications (Haldol and midazolam) may be administered if the safety of the patient or EMT is at risk. c. In such special circumstances, when a direct verbal order has not been obtained, the AQD and EMSMD must be notified ASAP. 4. EMT-I and EMT-P may administer Versed (midazolam) for behavior control post intubation- EMT-I must call EDP for order. a. Dose: midazolam (Versed)- 3 mg IV/IO/IM/IN/ETT b. Pediatrics: midazolam (Versed)- 0.2mg/kg IV/IO/IM/IN/ETT. i. Max 3 mg. 5. EMT-P may administer Versed (midazolam) for pain control for muscle spasm. EMT-I is not allowed to administer Versed (midazolam) for pain per State Rule. a. Dose: midazolam (Versed)- 3 mg IV/IO/IM/IN b. Pediatrics: midazolam (Versed)- 0.2mg/kg IV/IO/IM/IN. i. Max 3 mg. See Treatment P&P 10- Transcutaneous Pacing for EMT-I medications allowed. See Treatment P&P 11- Intraosseus Access for EMT-I medications allowed. Intro 8 Intro 8 Intro 8
APPROVED MEDICATIONS FOR MESA COUNTY EMS Refer to specific protocols for additional details General: Oxygen Normal Saline Antidotes: Atropine Cyanide Antidote Kit Narcan (naloxone) Nerve Agent Antidote Kit Sodium Bicarbonate Behavioral Management: Haldol (haloperidol) Versed (midazolam) Cardiovascular: ACLS: see adult and pediatric Approved ACLS Medications Aspirin morphine sulfate nitroglycerin Endocrine and Metabolism: D50 D25 Oral Glucose Gastrointestinal: Zofran (ondansetron) Pain Management: Sublimaze (fentanyl) lidocaine (IO anesthetic) Versed (midazolam) EMT-P ONLY- for muscle spasm, cardioversion, cardiac pacing. Respiratory and Allergic Reaction: Albuterol Benadryl (diphenhydramine) Epinephrine and racemic epinephrine ipratropium Solu-medrol (methylprednisolone) Seizure Management: Versed (midazolam) magnesium sulfate Miscellaneous: lidocaine (pre-intubation) lidocaine jelly (tip of ET tube) Vaccines: Influenza Hepatitis B Tetanus PPD Intro 9 Intro 9 Intro 9
FORMULARY BREAKDOWN BY TRAINING LEVEL EMT-B, B-IV, I: ALLOWED MEDICATIONS (AS PER STATE RULES) If you are a: EMT-B EMT-B IV EMT-I May administer by: Standing Order - OTC medications - O2 - Aspirin - Oral Glucose - Epi Auto Injector - Nerve Agent Antidote - OTC medications - O2 - Aspirin - Oral Glucose - Epi Auto Injector - Nerve Agent Antidote - D50 and D25 - Normal Saline - Narcan - OTC medications - O2 - Aspirin - Oral Glucose - Epi Auto Injector - Nerve Agent Antidote - D50 and D25 - Normal Saline - Narcan - Cyanide Antidote - SL NTG, pts. own supply - SL NTG, sublingual - Vaccines - Lidocaine for IO anesthetic May administer by: EDP Order - SL NTG, pts. own supply - Albuterol - MDI; pts. own inhaler - SL NTG, pts. own supply - Albuterol - MDI; pts. own inhaler - Atropine - Haloperidol - Midazolam (Versed) - Adenosine - Epinephrine - Lidocaine - MDI s - NTG paste - Sodium bicarbonate - Ondansetron (Zofran) - Fentanyl - Diphenhydramine - Albuterol - Ipratropium - Methylprednisolone Intro 10 Intro 10 Intro 10
INTER-FACILITY TRANSPORT APPROVED MEDICATIONS (AS PER STATE RULES) 1. All infusion medications must be started at the source hospital/facility. 2. Patient must be stable on these drips prior to transport. 3. These medications shall not be titrated by EMS, unless by EDP order. 4. These medications shall not be discontinued by EMS unless by EDP order. 5. -You may, and should, decline to transport a patient you believe requires a level of care beyond your capabilities. EMT I Amiodarone Lidocaine Crystalloids Colloids (non-blood component, i.e. Mannitol, etc.) Total parenteral nutrition Antibiotics EMT P All off the above, plus Glycoprotien inhibitors Heparin Low molecular weight heparin Diltiazem max rate 15 mg/hr Dobutamine Nitroglycerin IV Magnesium sulfate max rate 4 g/hr Oxytocin Blood Components Sodium bicarbonate Potassium chloride max rate 10 meq/hr Insulin Mannitol Methylprednisolone PLEASE NOTE Thrombolytics and paralytics are NOT approved for inter-facility monitoring by EMT s in Mesa County. Intro 11 Intro 11 Intro 11
HAZMAT: APPROVED MEDICATIONS Approved HazMat Medications to be used only by approved HazMat trained Paramedics with base station approval. Alcaine ophthalmic drops Calcium gluconate Methylene blue Intro 12 Intro 12 Intro 12
BEST PRACTICES BENCHMARKING See Operational P&P 14- CQI/QA as warranted. Benchmarking is the process of comparing an organization s performance to national or industry benchmarks, or best practices. This process allows an organization to develop plans on how to make improvements, or adapt certain best practices, with the aim of increasing systemwide performance. Benchmarking is an integral part of the Continuous Quality Improvement (CQI) plan in place in the Mesa County EMS System. We will be continuously comparing our performance to EMS best practices, and targeting education, protocol development and discipline to help us improve our performance where needed. The spirit of Benchmarking and CQI are this: most problems are found in processes, not people. CQI does not seek to blame, but rather to improve. The intent is to look at our system as a whole, and gather objective data to analyze and thus improve processes. A simple example: for EMS patients with AMS, a best practice benchmark might be that 100% have their blood glucose measured in the field. If our system data shows that it is only occurring 80% of the time in Mesa County then we have a system-wide problem. Is it a charting issue (not using checkbox)?; a training issue (EMT-B s are not being taught how to use glucometer)?; an education issue (providers do not know they need to check BG in AMS)?; a protocol issue (protocols are not clear)? If individual providers are persistently deficient, then they will also be counseled/disciplined as needed. But the issue uncovered is undoubtedly a system problem, not an individual provider problem. Most sections of these protocols have a Best Practices Benchmarks protocol at the beginning of the section, which delineates some of the CQI benchmarks the Agency Quality Directors will be tracking for that group of protocols. Additionally, a Benchmarks Box has been added at the end of each individual protocol for which benchmarks will be tracked, in order to remind providers of the best practices we are shooting for as a System for that protocol. A Benchmark Box looks like this: Benchmark Box: Please see Cardiac 1 for EMS System best practice benchmarks for Chest Pain/Cardiac Alert- ntg, asa, ekg This is an important process in our system. Advancements in CQI are the next horizon for our EMS system. Please join the CQI/QA committee and the EMSMD in studying these portions of our protocols, and actively incorporating them into your EMS care and documentation. Intro 14 Intro 14 Intro 14
AGE CUTOFFS FOR THESE PROTOCOLS See Peds 4- Pediatric Ages and General Guidelines as warranted. See Cardiac 7- Therapeutically Induced Hypothermia as warranted. See Trauma 5- Adult Trauma Destination Guidelines as warranted. See Trauma 8- Pediatric Trauma Destination Guidelines as warranted. See Cardiac 13- Approved Adult ACLS Medications as warranted. See Peds 11- Approved Pediatric ACLS Medications as warranted. See Airway/Breathing 9- Cricothyrotomy as warranted. When using these protocols, the following age breakdowns are to be used, with several important exceptions as noted below: 1. Pediatrics : a. Neonate: birth to one month. b. Infant: one month to one year. c. Child: 11 years and younger. 2. Adults : 12 years or older 3. Exceptions: a. Therapeutically Induced Hypothermia- 16 and older. b. Adult Trauma Destination Guidelines- apply to 15 and older. c. Pediatric Trauma Destination Guidelines- apply to 14 and younger. d. Approved Adult ACLS Medications- apply to 15 and older. e. Approved Pediatric ACLS Medications- apply to 14 and younger. f. Surgical (open) cricothyrotomy- for 8 and older. g. Needle cricothyrotomy- for 7 and younger. h. Many protocols give age specific dosing of medications: Narcan, ipratropium, pain medications, Midazolam, Zofran, NS. OTHER AGE CONSIDERATIONS Judgment must be used in adult teenage dosing- small older teenagers may require pediatric doses. Judgment must be used in pediatric dosing- large young teenagers may require adult doses (especially of epinephrine). When in doubt, discuss dosing with the EDP if possible. The use of length-based tape guidelines for sizing equipment and medication dosages in pediatric patients is strongly encouraged. If you find any medication dosage in these protocols which you feel is inappropriate vis a vis these age breakdowns please contact the EMSMD. Intro 15 Intro 15 Intro 15
PREHOSPITAL PATIENT ASSESSMENT GUIDELINES The following guidelines are to be used with every patient encounter. SCENE SAFETY AND ASSESSMENT 1. The safety of the prehospital provider will take precedence over patient care. It is the ultimate responsibility of each provider to determine the safe time to enter a scene. 2. Do not enter an unsafe scene until cleared to do so by law enforcement or the fire department. This may mean waiting until the other agencies arrive and clear the scene. Examples include but are not limited to: structure fires, hazardous material scenes, scenes where violence has occurred (GSW, SW, assaults). 3. The providers must use all means at their disposal to ensure their own safety, health, and well being at all times including the use of personal protection equipment. 4. Determine number of patients and consider request for additional assistance or activation of MCI plan. 5. Make sure all possible patients have been located and assessed. INITIAL PATIENT ASSESSMENT 1. Commonly referred to as the ABCDE s. 2. Do not focus on other injuries or illness until airway, breathing, and circulatory integrity have been established. a. This may preclude any other history or exam in critical patients. 3. Do not forget to control c-spine when indicated. a. If airway or breathing problems preclude immediate c-spine stabilization it must be performed as soon as the airway or breathing problems have been addressed. b. This must be charted accordingly. 4. Consider air transport if the initial patient condition and circumstances dictate. Continued on next page Intro 16 Intro 16 Intro 16
PATIENT ASSESSMENT GUIDELINES, continued FOCUSED HISTORY AND PHYSICAL EXAM 1. Vital Signs a. Includes BP, pulse rate, respiratory rate, mental status, SaO 2, and end-tidal CO 2 when available. b. Apply oxygen therapy to all patients who may benefit, IDEALLY guided by pulse oximitry with SaO2 < 95%. c. Auscultated blood pressures are preferred over palpated BPs. d. Consider CO monitoring if available. 2. Medical patient a. Assess chief complaint with focused exam of systems involved. b. Get quick pertinent history related to chief complaint. c. Begin treatment according to protocol for the identified illness. 3. Trauma Patient a. Assess mechanism of injury and anticipate potential injuries. b. Quick head, chest, and abdominal (pelvis) exam for potentially lifethreatening injuries. c. Begin treatment according to protocol for identified injuries. d. Do not forget that trauma patients can also have medical illness. DETAILED PHYSICAL EXAM 1. Complete the physical exam (head to toe) looking for focal areas of injury, infection, or hypoperfusion. 2. Examine all wounds to determine nature and source of bleeding. ONGOING PATIENT ASSESSMENT 1. Reassess vital signs as outlined above and monitor per patient condition. a. Stable patients require at least two sets of vital signs if time with patient > 15 minutes, and reassessments at least every 15 minutes. b. Critical patients require vital sign assessments every 5 minutes. 2. Monitor patient for any changes in level of consciousness, airway or cardiopulmonary integrity and treat per protocol should deterioration be noted. a. NOTIFY RECEIVING HOSPITAL OF PATIENT DETERIORATION AS SOON AS POSSIBLE. 3. Reassess and record patient response to treatments, noting improvement, deterioration, or lack of change. 4. Reassess treatment regiment if patient is not improving. Consider other causes of patient illness and contact base physician if you have any questions. Intro 17 Intro 17 Intro 17