Formatted for DOUBLE SIDED printing

Berrien County Protocols

Adult and Pediatric Protocols Revised July 2007

These protocols have been prepared in accordance with the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Contingent upon adoption by the local Medical Control Authority, these protocols supersede all previous similar protocols.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYADULT TREATMENT PROTOCOLS INDEX

REVISED JULY 2007

CARDIACTable of ContentsGeneral Pre-Hospital CareAdult

Cardiac Arrest – General ProtocolAutomated External Defibrillator (AED)VF / Pulseless VTAsystole / PEA ProtocolChest Pain / Acute Coronary SyndromeAcute Pulmonary Edema / CHFCardiogenic ShockWide Complex TachycardiaNarrow Complex TachycardiaBradycardia Protocol

PediatricCardiac Protocols – General ProtocolPediatric - VF / Pulseless VTPediatric - Asystole / PEAPediatric - Wide Complex TachycardiaPediatric - Narrow Complex TachycardiaPediatric - Bradycardia

CBRNEGeneral CBRNE Identification of AgentsChemical ExposureCHEMPACKCommunicable DiseaseCyanide ExposureMass Causality IncidentMEDRUN

ENVIRONMENTALDrowning/ Near DrowningHyperthermiaHypothermia/Frostbite

MEDICALAbdominal ProblemsAllergic Reaction/ AnaphylaxisGeneral Weakness/ IllnessHemorrhage (Non-Traumatic)Hypertensive EmergencyPoisoning/ OverdoseRespiratory DistressSexual AssaultShock

NEUROLOGICALAcute Altered Mental StatusCerebrovascular Accident (CVA)SeizuresSyncope

OB/GYNObstetrical Emergencies

PSYCHPsychiatric Emergencies

TRAUMAAssessment/ StabilizationBurnsChest InjuryHead TraumaSoft Tissue InjuriesSpinal Injury

PEDIATRICSGeneral Pediatric Assessment & TreatmentAltered Mental StatusAnaphylaxis/Allergic ReactionBronchospasmBurnsDeath of a ChildForeign Body Airway ObstructionNear - DrowningNewborn ResuscitationNon-Traumatic ShockPain ManagementRespiratory Distress, Failure, or ArrestSeizuresToxic ExposureTrauma

GENERAL PROCEDURESTable of Contents

APPENDIX

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYADULT TREATMENT PROTOCOLS

REVISED JULY 2007

Cardiac

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYADULT CARDIAC TREATMENT PROTOCOLS

REVISED JULY 2007 Page: 1

Table of ContentsTable of Contents.................................................................................................................1General Pre-Hospital Care...................................................................................................2Adult Cardiac Arrest – General Protocol.............................................................................3

Automated External Defibrillator (AED) Procedure.....................................................4Ventricular Fibfillation / Pulseless Ventricular Tachycardia.........................................5Asystole / PEA Protocol................................................................................................6Chest Pain / Acute Coronary Syndrome Protocol..........................................................7Acute Pulmonary Edema / CHF Protocol......................................................................8Cardiogenic Shock.........................................................................................................9Wide Complex Tachycardia........................................................................................10Narrow Complex Tachycardia.....................................................................................11Bradycardia Protocol...................................................................................................12

Pediatric Cardiac Protocols – General Protocol.................................................................13Pediatric Ventricular Fibfillation / Pulseless Ventricular Tachycardia.......................14Pediatric Asystole / PEA Protocol...............................................................................15Pediatric Wide Complex Tachycardia.........................................................................16Pediatric Narrow Complex Tachycardia......................................................................17Pediatric Bradycardia...................................................................................................18



General Pre-Hospital Care

In most cases, the stabilization of patients presenting with medical conditions should be carried out at the patient’s side prior to patient movement or transport. Before attempting the following procedures, implement appropriate blood borne and/or airborne pathogen protective procedures. Contact medical control according to local protocol.

I. Pre-Medical Control

M B S P A. Assure ABCs while maintaining c-spine precautions where indicated.

B. Do airway intervention using appropriate airway adjuncts when necessary:

MFR EMT EMT-S EMT-POropharyngeal Airway X X X XNasopharyngeal Airway X X X XBag-Valve-Mask Ventilation X X X XSupraglottic Airway (per MCA approval) X X XOral / Nasal Endotracheal Intubation X XNeedle / Surgical Cricothyroidotomy XX: Approved Intervention

C. Administer oxygen and assist ventilations, as indicated in accordance with Airway / Oxygenation Procedure. Use 2-person BVM technique whenever possible.

D. Obtain a history and physical exam using the following as a guideline:

1. Age and sex

2. Present complaint

3. Pertinent medical history

4. Pertinent medications patient is taking

5. Medication allergies

E. Obtain vital signs approximately every 15 minutes, or as frequently as necessary to monitor the patient’s condition:

1. Blood pressure

2. Pulse rate

3. Respiratory rate

4. Lung sounds

5. Pupil reactions (as appropriate)

6. Skin condition and color

7. Level of consciousness

F. Follow specific protocol for patient condition.

S P G. Establish vascular access per Vascular Access Procedure in accordance with a specific protocol.

P H. Apply cardiac monitor and treat rhythm according to appropriate protocol. If available and applicable, obtain 12-lead EKG. A copy of the rhythm strip or 12-lead EKG should be attached to the patient care record and should be left at the receiving facility.



Adult Cardiac Arrest - General Protocol

This protocol should be followed for all adult cardiac arrests. Once arrest is confirmed emphasis should be on avoiding interruptions in CPR. When an ALS unit is present, follow this general cardiac arrest protocol until a rhythm is determined. Once this is done, see the appropriate rhythm specific protocol. CPR should be done in accordance with current guidelines established by the American Heart Association.


M B S A. If unwitnessed arrest perform 2 minutes of CPR or,

B. If witnessed or unwitnessed and bystander CPR in progress, apply AED if available and follow AED protocol.

P C. If unwitnessed arrest perform 2 minutes of CPR.

D. Apply cardiac monitor and treat rhythm according to appropriate protocol.

M B S P E. Confirm Arrest: If pulseless, continue CPR.

F. Establish a patent airway, maintaining C-Spine precaution if indicated, using appropriate airway adjuncts and high flow oxygen.

G. Reassess ABC’s as indicated by rhythm or patient condition change. Pulse checks should take no more than 10 seconds.

B S P H. Insert advanced airway as authorized by local MCA. Avoid significant interruptions in CPR.

S P I. Start an IV NS KVO at the most proximal location, with the largest appropriate size IV catheter. If IV is unsuccessful may start an IO line. Endotracheal administration of medication should be avoided unless other options do not exist.

II. Post-Medical Control

P J. Consider termination of resuscitation per local MCA protocol.



Automated External Defibrillator (AED) Procedure

The Automated External Defibrillator (AED) shall be applied only to patients found in cardiopulmonary arrest. Interruptions to CPR should be kept to a minimum. The AED should not be used on patients found lying on conductive surfaces or patients in moving vehicles. There are no age or weight limits for AED use. In pediatric patients, attenuated pads should be used, if available. If adult pads are used in pediatric patients, place in an anterior/posterior configuration.


M B S P A. Follow the General Cardiac Arrest protocol.

B. Stop CPR to analyze patient and shock once, if needed.

C. Continue CPR immediately after the shock, or immediately if no shock is indicated and continue for 2 minutes (5 cycles) or when AED initiates analysis.

D. If no pulse, analyze the patient and repeat one shock, if needed.

E. If patient converts to a non-shockable rhythm at any time, continue CPR until AED prompts to check the patient.

F. Should a patient who is successfully defibrillated arrest again, analyze the patient. If the AED indicates shockable rhythm then deliver shock as directed.

G. If ALS is not available and the patient is either in a non-shockable rhythm or the patient has received two cycles of CPR and shocks, the patient should be transported to the nearest appropriate facility with continued CPR and advanced airway (EMT/SPECIALIST).

P H. If ALS arrives and the AED allows for manual shocks, it may remain in place. If not, complete any shock you are administering, and then disconnect the AED. ALS should attach their ECG monitor and continue treating the patient per protocol. ALS does not need to repeat any of the AED shocks.

Note: Follow manufacturer’s instructions except age limits.



Ventricular Fibrillation / Pulseless Ventricular Tachycardia

If AED is applied prior to ALS arrival, perform CPR and reassess the rhythm as indicated. After each intervention resume CPR immediately and reassess the rhythm after each 2 minute interval.

All defibrillations will be at the device’s maximum recommended energy.


P A. Follow the Cardiac Arrest – General Protocol.

B. Defibrillate x1 and immediately resume compressions

C. Continue CPR for 2 minutes and reassess rhythm.

D. Establish an advanced airway. Avoid significant interruptions in CPR.

E. Defibrillate x1 and immediately resume compressions

1. Continue CPR for 2 minutes and reassess rhythm.

F. Start an IV NS KVO at the most proximal location.

G. If IV is unsuccessful, start an IO line. Endotracheal administration of medication should be avoided unless other options do not exist.

H. Administer Epinephrine 1 mg 1:10,000 IV/IO, (10 ml). Repeat every 3-5 minutes. May be administered before or after defibrillations.

I. Administer Vasopressin 40 units IV/IO in place of second dose of Epinephrine as approved by local medical control.

J. Defibrillate x1 and immediately resume compressions


K. For persistent or recurrent VF/Pulseless VT, administer Amiodarone 300 mg IV/IO. May be administered before or after defibrillations.

L. Administer Magnesium Sulfate 2 gm IV/IO for suspected torsades de pointes.

M. Defibrillate x1 and immediately resume compressions


N. For persistent or recurrent VF/Pulseless VT, administer Amiodarone 150 mg IV/IO. May be administered before or after defibrillations.

O. Defibrillate x1 and immediately resume compressions


P. Repeat defibrillation x1 every 2 minutes with CPR, as indicated.


P Q. Initiate transport.

R. Consider termination of arrest (if persistent fine VF)

* Need to choose between Vasopressin or epinephrine



Asystole / Pulseless Electrical Activity Protocol

During CPR, consider reversible causes of Asystole/PEA and treat as indicated. Causes and efforts to correct them include:

Hypovolemia – fluid bolusHypoxia – reassess airway and ventilate with high flow oxygenTension pneumothorax – pleural decompressionHypothermia – follow Hypothermia Protocol rapid transportHyperkalemia (history of renal failure) – Calcium Chloride per protocol

a. Hypoxia – reassess airway and ventilate with high flow oxygenb. Tension pneumothorax – pleural decompressionc. Hypothermia – warmingd. Hyperkalemia (history of renal failure) – Calcium chloride per Medical Control


P A. Follow the Cardiac Arrest - General Protocol.

B. Administer Epinephrine 1 mg 1:10,000 IV/IO (10 ml), repeat every 3-5 minutes.

C. Administer Vasopressin 40 units IV/IO in place of second dose of Epinephrine as approved by local medical control.

D. Administer Atropine Sulfate 1 mg IV/IO for asystole and PEA with a HR less than 60/minute, repeat every 3-5 minutes to a total dose of 3 mg.

E. If renal failure is suspected, administer Calcium Chloride 1gm IV/IO and Sodium Bicarbonate 1 mEq/kg IV/IO with flush in between medications.

F. Continue CPR and reassess rhythm every 2 minutes.


P G. Initiate transport

H. Consider termination of resuscitation



Chest Pain / Acute Coronary Syndrome Protocol

The goal is to reduce cardiac workload and to maximize myocardial oxygen delivery by reducing anxiety, appropriately oxygenating and relieving pain.


M B S P A. Follow General Pre-Hospital Care Protocol.

B. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar medications in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN.

C. Assist patient in the use of their own Nitroglycerin sublingual tabs or spray, (check expiration date) if available and if the patient’s systolic BP is above 120 mmHg, for a maximum of 3 doses.

D. Administer aspirin 324 mg (chew and swallow if no aspirin within 24 hours).

B S P E. Do not delay transport.

S P F. Start an IV NS KVO. If the patient has a systolic BP of less than 100 mmHg, administer a NS fluid bolus in 250 ml increments and reassess.

P G. Obtain 12-lead ECG if available. Follow local MCA transport protocol if ECG is positive for acute ST Segment Elevation Myocardial Infarction (STEMI) and alert hospital as soon as possible.

H. Administer nitroglycerin 0.4 mg sublingual if systolic BP is above 100 mmHg. Dose may be repeated at 3 to 5 minute intervals if chest pain persists and systolic BP remains above 100 mmHg or to a maximum of 3 doses. This may be done prior to IV placement if systolic BP is 120 mm Hg or above.

I. Administer aspirin 324 mg (chew and swallow if no aspirin within 24 hours).

J. If pain persists, administer pain medication per Pain Management Protocol if local MCA authorizes this Pre-Medical Control Contact.


P K. If pain persists, administer pain medication per Pain Management Protocol if local MCA authorizes this Pre-Medical Control Contact.

L. Continue nitroglycerin 0.4 mg sublingual every 3 to 5 minutes



Acute Pulmonary Edema / CHF Protocol

This protocol is to be followed for patients in acute respiratory distress situations, not chronic.



B. Initiate supplemental oxygen by non-rebreather mask.

C. Position patient upright with legs dependent, if possible.

B S P D. If indicated, establish an advanced airway in the patient to maintain an adequate airway.

S P E. Start an IV NS KVO.

P F. Apply cardiac monitor and treat rhythm according to appropriate protocol.

G. Obtain 12-lead ECG if available. Follow local MCA transport protocol if ECG is positive.

H. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or a similar medication in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN.

I. If BP above 100 mm Hg, administer Nitroglycerin 0.4 mg SL. Repeat every 5 minutes if BP above 100 mm Hg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mm Hg.

J. Consider CPAP / Bi-PAP, if available.


P K. Administer Furosemide (Lasix) 40 mg IV.

L. If systolic BP remains above 100 mm Hg, administer Morphine Sulfate 2 mg IV.



Cardiogenic Shock



B. Remove any transdermal nitroglycerin patches using gloves.

B S P C. Establish an advanced airway as authorized and as needed.

S P D. Start IV NS KVO.

E. Hypotensive patients should receive a fluid bolus, as indicated, by hemodynamic state in 250 cc increments and reassess.

F. Repeat 250 cc NS bolus x2 as needed for persistent hypotension.

P G. Apply cardiac monitor and treat rhythm according to appropriate protocol.

H. Obtain 12-lead ECG if available. Follow local MCA transport protocol.


P I. Consider continued fluid boluses, 250 cc NS for persistent hypotension

J. Consider Dopamine Drip (Inotropin) 400 mg in 250 ml of NS, 10-20 mcg/kg/min. Titrate to a systolic BP above 90 mmHg. Dopamine (Inotropin) is not indicated for hemorrhagic shock.



Wide Complex Tachycardia(Presumed Ventricular Tachycardia)

A guideline for patients with STABLE wide complex tachycardia. SYNCHRONIZED CARDIOVERSION PRECEEDS DRUG THERAPY FOR HEMODYNAMICALLY UNSTABLE PATIENTS. Unstable patients may be defined as those having a wide complex tachycardia with: significant chest pain, shortness of breath, decreased level of consciousness, hypotension, shock, or pulmonary edema.


P A. Follow the General Pre-Hospital Care Protocol.

B. If time and condition allow, consider sedation per Sedation Procedure prior to cardioversion.

C. If the patient is unstable, or becomes unstable, cardiovert immediately beginning at 100 J, increasing to 200 J, 300 J, 360 J. For a biphasic device start at 100J, increasing to 150 J, 200 J.

D. Start an IV NS KVO.

E. Administer Amiodarone (Cordarone) 150 mg IV over 10 minutes.

1. Alternate medical control authority intervention: Lidocaine 1 mg/kg IV push

F. Administer Magnesium Sulfate 2 gm IV/IO for suspected torsades de pointes.


P G. Administer additional Amiodarone (Cordarone) 150 mg IV over 10 minutes.

*Alternate medical control authority intervention: Lidocaine 1 mg /kg IV push.



Narrow Complex Tachycardia

A guideline for the care of patients with narrow complex tachycardia with a ventricular rate greater than 150/minute. SYNCHRONIZED CARDIOVERSION PRECEDES DRUG THERAPY FOR HEMODYNAMICALLY UNSTABLE PATIENTS. Unstable patients may be defined as those suffering a narrow complex tachycardia with: significant chest pain, shortness of breath, decreased level of consciousness, hypotension, shock, or pulmonary edema. Adenosine is only used for regular rhythm tachycardia.



B. If time and condition allow, consider sedation per Sedation Procedure prior to cardioversion.

C. If the patient is unstable, or becomes unstable, cardiovert immediately beginning at 100 J, increasing to 200 J, 300 J, 360 J. For a biphasic device start at 100J, increasing to 150 J, 200 J.

D. Start an IV NS KVO. A large bore antecubital IV should be secured whenever possible.

E. DO NOT USE CAROTID MASSAGE. Have the patient attempt a valsalva maneuver.

F. If the rhythm is regular, administer Adenosine (Adenocard) 6 mg rapid IV over 1-3 seconds through the most proximal injection site. This should be followed immediately with 20 ml NS flush. Fluids should be administered at wide-open rate during the administration of Adenocard (Adenosine).

G. If conversion does not occur, administer Adenosine (Adenocard) 12 mg IV using the same technique as stated above. May repeat 12 mg dose once.


P Optional medical control authority intervention: If the rhythm is irregular, administer Diltiazem (Cardizem) 0.25 mg/kg up to 20 mg IV slow push over approximately 5 minutes, titrated to heart rate less than 120/minute. May only be given with online medical direction. Use with caution in patients taking beta blockers.



Bradycardia Protocol

This is a protocol for patients with serious symptomatic bradycardia. Serious symptomatic bradycardia may be defined as patients with heart rate less than 60 and any of the following symptoms: chest pain, shortness of breath, decreased level of consciousness, hypotension, shock, or pulmonary edema. Titrate treatments to a heart rate above 60 bpm. If the patient remains hypotensive, refer to the cardiogenic shock protocol.



B. Start an IV NS KVO.

C. Administer Atropine Sulfate 0.5 mg IV repeating every 3-5 minutes to a total dose of 3 mg IV, until a heart rate of >60/minute is reached.

D. Transcutaneous pacing (TCP) when available may be initiated prior to establishment of IV access and/or before Atropine begins to take effect. Pacing may be the treatment of choice for high degree A-V block. Follow the External Pacing Protocol.

E. Provide sedation and analgesia as needed per Sedation and Pain Management Protocols


P F. Administer Dopamine Drip 2-10 mcg/kg/min. Mix drip by putting 400 mg in 250 ml NS.

G. Administer Epinephrine Drip 2-10 mcg/min. Mix drip by putting 1 mg of 1:1,000 in 250 NS.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC CARDIAC TREATMENT PROTOCOLS


Pediatric Cardiac Arrest – General Protocol

This protocol should be followed for all pediatric cardiac arrests. Once arrest is confirmed emphasis should be on avoiding interruptions in CPR. When an ALS unit is present follow this general cardiac arrest protocol until a rhythm is determined. Once this is done, see the appropriate rhythm specific protocol. CPR should be done in accordance with current guidelines established by the American Heart Association.

Note: Primary cardiac arrest in the pediatric patient is rare. Most arrests are secondary to respiratory failure. When transport time is short the airway may be maintained with basic airway management techniques. Advanced airway insertion attempts should be performed in such a manner as to keep CPR interruptions to a minimum. Medications given during arrest are best given IV or IO. Avoid endotracheal administration unless IV or IO access is unavailable.


M B S A. If unwitnessed arrest perform 2 minutes of CPR or,

B. If witnessed or unwitnessed and bystander CPR in progress, apply AED if available and follow AED protocol.

P C. If unwitnessed arrest perform 2 minutes of CPR.

D. Apply cardiac monitor and treat rhythm according to appropriate protocol.

M B S P E. Confirm Arrest: If pulseless, continue CPR.

F. Establish a patent airway, maintaining C-Spine precaution if indicated, using appropriate airway adjuncts and high flow oxygen.

G. Reassess ABC’s as indicated by rhythm or patient condition change. Pulse checks should take no more than 10 seconds.

B S P H. Insert advanced airway as authorized by local MCA. Minimize interruptions in CPR.

S P I. Start an IV NS KVO at the most proximal location, with the largest appropriate size IV catheter. If IV is unsuccessful (after a maximum of three attempts) start an IO line in both adult and pediatric patients. Endotracheal administration of medication should be avoided unless other options do not exist.


P J. Consider termination of resuscitation per local MCA protocol.



Pediatric Ventricular Fibrillation/Pulseless Ventricular Tachycardia


P A. Follow the Pediatric Cardiac Arrest – General Protocol.

B. Defibrillate at 2 joules/kg*.

C. Continue CPR for 2 minutes and reassess rhythm.

D. Repeat defibrillation at 4 joules/kg if VF/Pulseless VT persists*,

E. Continue CPR for 2 minutes and reassess rhythm.

F. Administer Epinephrine 0.01 mg/kg 1:10,000 (0.1 ml/kg) IV/IO, or Epinephrine 1:1000, 0.1 mg/kg (0.1 ml/kg) via ET if IV/IO unavailable. Repeat every 3-5 minutes. May be administered before or after defibrillation.

G. Continue CPR for 2 minute cycles and reassess rhythm after each cycle.

H. Repeat defibrillation at 4 joules/kg if VF/Pulseless VT persists*.

I. Continue CPR for 2 minute cycles and reassess rhythm.

J. Repeat defibrillation at 4 joules/kg if VF/Pulseless VT persists*.

*If calculated energy is less than the lowest available setting use the lowest available setting


P K. ** If VF/Pulseless VT persists, administer Amiodarone 5 mg/kg IV/IO (maximum 300 mg). Amiodarone may be repeated up to 15 mg/kg or 300 mg maximum total dose. May be administered before or after defibrillation.

L. Administer magnesium 50 mg/kg IV/IO, maximum 2 g for suspected torsades de pointes.

M. Contact Medical Control prior to transport for additional orders as appropriate.

** Alternate medical control authority intervention: Lidocaine 1 mg/kg IV push.



Pediatric Asystole/PEA

During CPR, consider reversible causes of Asystole/PEA and treat as indicated. Causes and efforts to correct them include:

a. Hypovolemia – 20 cc/kg NS fluid bolusb. Hypoxia – reassess airway and ventilate with high flow oxygenc. Tension pneumothorax – pleural decompressiond. Hypothermia – follow Hypothermia Protocol, rapid transporte. Hyperkalemia (history of renal failure) – Calcium Chloride per Medical Control


P A. Follow the General Cardiac Arrest Protocol.

B. Administer Epinephrine 1:10,000, 0.01 mg/kg (0.1 ml/kg) IV/IO, or Epinephrine 1:1000, 0.1 mg/kg (0.1 ml/kg) via ET if IV/IO unavailable. Repeat every 3-5 minutes.

C. Continue CPR for two minute cycles and reassess rhythm.


P D. With suspected hyperkalemia (history of renal failure) Calcium Chloride 20 mg/kg IV/IO.

E. Consult with Medical Control prior to transport for consideration of termination of resuscitation.



Pediatric Wide Complex Tachycardia



B. If patient is pulseless, treat as Ventricular Fibrillation/Pulseless Ventricular Tachycardia

C. If patient is stable, monitor the patient for changes in rhythm or vital signs.

D. If patient is unstable or becomes unstable, as evidenced by altered consciousness or hypotension, use synchronized cardioversion at 0.5 – 1 joule/kg.* If time and condition allow, consider sedation, per Sedation Procedure prior to cardioversion, but do not delay cardioversion.

E. If unsuccessful, repeat cardioversion at 2 joules/kg.


P F. ** Administer Amiodarone 5 mg/kg (maximum 150 mg) IV over 20 to 60 minutes.

*If calculated energy is less than the lowest available setting use the lowest available setting.

**Alternate medical control authority intervention: Lidocaine 1 mg /kg IV push.



Pediatric Narrow Complex Tachycardia

Narrow complex tachycardia in excess of 150 per minutes in pediatric patients may represent sinus tachycardia for which the underlying cause should be treated. Consult Medical Control early for uncertainty regarding rhythm.



B. If patient is unstable, as evidenced by either altered level of consciousness or hypotension, or IV access is not readily available consider cardioversion using 0.5 – 1 joules/kg*. Repeat using 2 joules/kg, as indicated. If time and condition allow, consider sedation, per Sedation Procedure prior to cardioversion, but do not delay cardioversion.

C. If infant rate is less than 220 bpm or child rate is less than 180 bpm consider sinus tachycardia. Treat with IV fluids, do not cardiovert or give adenosine if sinus tachycardia.

D. If history of abrupt rate change, infant rate greater than 220 bpm or child rate greater than 180 bpm consider supraventricular tachycardia.

E. If IV access is readily available: administer Adenosine 0.1mg/kg IV (maximum first dose 6 mg) rapid IV bolus. If not effective, administer Adenosine 0.2mg/kg IV (maximum second dose 12 mg) rapid IV bolus. May repeat Adenosine 0.2mg/kg IV (maximum dose 12 mg) rapid IV bolus once if needed.

*If calculated energy is less than the lowest available setting use the lowest available setting.


P F. Additional orders as appropriate.



Pediatric Bradycardia

Note: Bradycardia should be considered to be due to hypoxia until proven otherwise. For bradycardia with a pulse that causes cardiopulmonary compromise:


M B S P A. Follow the General Pre-Hospital Care Protocol and apply high flow oxygen.

B. Perform CPR if, despite oxygenation and ventilation, HR < 60/min with poor perfusion.

P C. If symptomatic bradycardia persists, administer Epinephrine 1:10,000, 0.01 mg/kg (0.1 ml/kg) IV/IO, or Epinephrine 1:1000, 0.1 mg/kg (0.1 ml/kg) via ET if IV/IO unavailable, repeat every 3-5 minutes.

D. If cardiac arrest develops, or the rhythm changes, go to the appropriate protocol.

E. Contact Medical Control.


P F. Administer Atropine Sulfate 0.02 mg/kg IV (minimum dose 0.1 mg). Maximum individual dose for children is 1 mg. Repeat every 3-5 minutes to a total dose of 3 mg.

G. Consider cardiac pacing.

H. Additional orders as appropriate.


REVISED JULY 2007

CBRNE

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYGENERAL CBRNE IDENTIFICATION OF AGENTS

REVISED JULY 2007 Page: 1 of 4

Purpose: This is written to provide general pre-arrival information for suspected HAZMAT and CBRNE (chemical, biological, radiological, nuclear, and explosive) incidents.

NOTE: This information is designed to augment other established protocols.

M B S P I. First Responder/ EMS Issues

A. Chemical agents pose a threat during every phase of their existence: production, packaging, storage and delivery to the intended target. Many common hazardous materials used in industry pose the same threat to emergency responders as the chemicals classified as nerve, blister, blood, and choking agents.

B. Biological threats may be intentional or natural. Either may affect large segments of the population and will not necessarily present immediately.

C. Radiological threats affecting a significant portion of the population will most likely be associated with the explosion of a nuclear device or with the intentional release of radioactive material, including associated with an explosion as in a “dirty bomb”.

D. Nuclear threats may be intentional or accidental. Either may affect large segments of the population. Immediate threat is results of explosion followed by devastation of radioactive isotopes.

E. Explosive threats may be intentional or accidental. Either may affect large segments of the population and will present immediately. Those not affected by initial device may risk threat from agents released. Awareness should be heightened for secondary incendiary devices in the event of an intentional explosive.

II. Signs and Symptoms of Attack

A. Unlike an attack with explosives, the fact that a terrorist has attacked with a chemical or biological agent may not always be obvious at first.

B. Many of the early signs and symptoms produced by chemical warfare agents may resemble those of a variety of disorders, including stress, psychological withdrawal, palpitations, gastrointestinal distress, headaches, dizziness, and inattentiveness.

C. The patient's clinical presentation will offer clues about the type of toxic substance used.

D. CHEMICAL INCIDENT (HAZMAT or CBRNE)

1. Responders should be alert for the following signs that a chemical agent may have been dispersed:

a. Explosions that dispense liquids, vapors or gases b. Explosions that seem only to destroy a package or bomb device c. Unscheduled and unusual spray being disseminated d. Abandoned spray devices e. Numerous dead animals, fish and birds f. Lack of insect life g. Mass casualties without obvious trauma h. Definite pattern of casualties and common symptoms i. Civilian panic in potential target areas (government buildings, public

assemblies, etc.)j. Any clustering of symptoms or unusual age distribution (e.g., chemical

exposure in children).



E. BIOLOGICAL INCIDENT (Natural or CBRNE)

1. Responders should be alert for the following signs that a biological agent may have been dispersed:

a. An unusual increase in the number of individuals seeking care, especially with similar symptoms such as respiratory, neurological, gastrointestinal or dermatological symptoms.

b. Any clustering of patients in time or location (e.g., persons who attended the same public event).

F. RADIOLOGICAL INCIDENT (CBRNE)

1. Notification of the detonation of a nuclear device.2. Dirty bomb

G. NUCLEAR INCIDENT (Natural or CBRNE)

1. Explosion with mushroom cloud and devastation of a large geographical area (atypically large for an incendiary device)

H. EXPLOSIVE INCIDENT (Natural or CBRNE)

1. Responders should be aware of the possibility of secondary incendiary devices and release of a threatening agent.

a. Obvious traumab. Panic in potential target areas.

III. MEDICAL RESPONSE

A. First responding units must approach with caution.

B. Approach upwind, uphill and upstream, as appropriate.

C. Utilize resource materials such as the Emergency Response Guidebook or Emergency Care for Hazardous Materials Exposure.

D. Utilize appropriate PPE.

E. Be aware of contaminated terrain and contaminated objects.

F. Hazmat response protocols must be initiated, as well as unified incident command.

G. Maintain a safe distance.

H. Attempt to identify the nature of the exposure by looking for placards, mode of dispersal (vehicle explosion, bomb, aerosolized gas, etc.)

I. Victims and potential victims must be evacuated rapidly from the contaminated area and decontaminated as quickly as possible, if appropriate. In certain situations, treatment may be initiated within the hot and/or warm zones of an incident by properly trained, protected and equipped personnel.

J. Be alert for secondary devices.

IV. Select Agents of Terrorism

A. Chemical Agents A chemical agent may be defined as a compound that, through its chemical properties, produces lethal or damaging effects in humans, animals, plants or materials. Chemical agents are usually man-made through the use of industrial chemical processes.

1. Chemical agents are classified by their effects:

a. Lethal agents are designed to kill, and are broken down into two subcategories:



i. Nerve agents

1. Nerve agents, the most deadly of all chemical agents, disrupt nerve transmission within organs and are quickly fatal in cases of severe exposure.

ii. Blood agents

1. Blood agents (cyanides) interfere with the blood's ability to transport oxygen throughout the body; often rapidly fatal.

b. Blister agents, or vesicants, cause a blistering of the skin and mucous membranes, especially the lungs.

c. Choking agents, or pulmonary agents, irritate the lungs, causing them to fill with fluid.

d. Incapacitating agents, cause an intense (but temporary) irritation of eyes and respiratory tract.

2. The potential of the agent to do damage is measured by how readily it disperses. Chemical agents are either persistent or non-persistent. Wind and rain will increase the dispersion rate of a chemical agent. Heavy rains act to dilute both persistent and non-persistent agents and facilitate penetration into the ground.

a. Persistent agents have low volatility, evaporate slowly and are particularly hazardous in liquid form. They stay around for long periods of time (24 hours or longer) and contaminate not only the air but objects and terrain as well. Mustard and the nerve agent VX are examples of persistent agents.

b. Non-persistent agents are volatile and evaporate quickly, within several hours. Gases, aerosols, and highly volatile liquids tend to disperse rapidly after release. Phosgene, cyanide and the G series of nerve agents (with the exception of GD-Soman) are non-persistent agents. Because of their volatility, they pose an immediate respiratory hazard but are not particularly hazardous in liquid form.

B. Biological Agents

Micro-organisms and toxins, generally, of microbial, plant or animal origin to produce disease and/or death in humans, livestock and crops

1. Biological agents

a. Bacterial Agentsi. Anthrax

ii. Choleraiii. Plagueiv. Tularemiav. Q-Fever

b. Viral Agentsi. Smallpox

ii. Venezuelan Equine Encephalitisiii. Viral Hemorrhagic Fevers

c. Biological Toxinsi. Botulinum Toxins

ii. Staphylococcal Enterotoxin Biii. Riciniv. Trichothecene Mycotoxins (T2)



2. Biological agents utilized as a CBRNE may not become evident until hours, days or weeks after the exposure due to the various incubation periods for each pathogen.

C. Radiological Agents

Isotope exposure with typically no immediate effect. The sooner the victim has symptoms the worse the exposure.

D. Nuclear Agents

Primary risk is massive trauma and devastation as the result of a large scale blast. Supportive care and treatment based upon exposure.

E. Explosives

Threats with explosive devices may be or large or small scale. Trauma and mass casualty care will be primary.

V. Personal Protective Equipment

A. NIOSH/OSHA/EPA classification system:

Level A: Fully encapsulating, chemical resistant suit, gloves and boots, and a pressure demand, self-contained breathing apparatus (SCBA) or a pressure-demand supplied air respirator (air hose) and escape SCBA. (Maximum protection against vapor and liquids)

Level B: Non-encapsulating, splash-protective, chemical-resistant suit that provides Level A protection against liquids but is not airtight. (Full respiratory protection is required but danger to skin from vapor is less)

Level C: Utilizes a splash suit along with a full-faced positive or negative pressure respirator (a filter type air purifying respirator or PAPR) rather than an SCBA or air line.

Level D: Limited to coveralls or other work clothing, boots and gloves

B. Universal Precautions:

1. Universal precautions: assume that all patients are potentially contagious and use appropriate barriers to prevent the transmission of pathogenic organisms. PPE include gloves, gowns, HEPA respirators, face shields and appropriate hand-washing.

2. If a chemical exposure is suspected, coated Tyvex suits, and respirators with Organic Vapor/HEPA cartridges are recommended.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYCHEMICAL EXPOSURE PROTOCOL


Purpose: To provide specific criteria for the treatment of chemical exposure of patients.

Note: This protocol may be used in conjunction with the General CBRNE/Identification of Agent Protocol .

VI. Assessment/Management – Chemical Agents

If there is a confirmation of, or symptoms indicative of, a chemical incident, utilize appropriate PPE as outlined in the General CBRNE Protocol.

M B S P A. Chemical Exposure

1. Nerve Agents & Cyanide Compounds – refer to appropriate protocol

2. Choking Agents

a. Phosgene, Chlorine, Chloropicrin

b. Routes: Inhalation

c. Signs and symptoms:i. Cough, dyspnea, irritation of mucous membranes, pulmonary edema

d. Patients should be immediately removed from the area to a clean atmosphere.

e. Treatmenti. Respiratory chemical PPE

ii. Assist ventilations, as necessaryiii. 100% Oxygeniv. Symptomatic treatment per protocolv. Eye irrigation

1. Remove contact lenses2. Flush with 1000cc of NS each eye3. Flush from nose-side outward

P 4. If available, use Tetracaine hydrochloride 1-2 drops in each eye.a. Ensure that patient does not rub eyes after administration of

Tetracaine as injury may result.vi. For severe exposure consider early intubation and aggressive

ventilatory support. (Evidence of non-cardiogenic pulmonary edema)

A. Albuterol 2.5mg via nebulizer or 2-3 puffs from metered dose inhaler, if wheezing (May repeat x 1).

M B S P 4. Vesicant Agents (Blister agents)

a. ExamplesSulfur Mustard (HD), Nitrogen Mustard (HN), Lewisite, Phosgene Oxime (CX) Vesicant agents are named for their tendency to cause blisters.

b. DecontaminationPatients suspected to be contaminated should be decontaminated by removing clothing and using soap (if available) and water. Medical providers will require the proper protective equipment as determined by unified command, for patient management. Decontaminate by blotting and cleansing with soap (if available) and water. Avoid scrubbing and the use of hot water.

Note: Latex and rubber will absorb Mustard. Remember that time is critical for effective mustard decontamination because blister agents become “fixed” to tissue components within two minutes after deposition.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYCHEMICAL EXPOSURE PROTOCOL


c. Management/Treatment

i. Immediate attention should be directed toward assisted ventilation, administration of 100 % oxygen, insertion of intravenous lines and institution of cardiac monitoring, if available.

ii. Symptomatic treatment per protocol.

5. Lacrimator Agents (Tear Gas)

a. Information

Lacrimator (tearing) agents are widely used by law enforcement, the military, and widely available to the public.

b. Signs and Symptoms

The most common effects are nasal and ocular discharges, photophobia, and burning sensations in the mucous membranes.

c. Decontamination

Patients suspected to be contaminated should be decontaminated with soap and water. Medical providers require protective masks and clothing for patient management since lacrimator agents are transmitted by physical contact. Decontaminate by blotting and cleansing with soap and water.

d. Treatment

i. High flow oxygen for all symptomatic patients.ii. Symptomatic treatment per protocol (no specific antidote).iii. Eye irrigation

A. Remove contact lensesB. Flush with 1000cc of NS each eyeC. Flush from nose-side outwardD. If available, use Tetracaine hydrochloride 1-2 drops in each eye.

1. Ensure that patient does not rub eyes after administration of Tetracine as injury may result.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYCHEMPACK


Purpose: The CHEMPACK Project provided the State of Michigan, in collaboration with the Center for Disease Control (CDC) and the U.S. Department of Homeland Security, with a sustainable, supplemental source of pre-positioned nerve agent/organophosphate antidotes and associated pharmaceuticals that will be readily available for use when local supplies become depleted. A large-scale event would rapidly overwhelm both the pre-hospital and hospital healthcare systems.

The CHEMPACK project is one component of the Michigan Emergency Preparedness Pharmaceutical Plan (MEPPP), a comprehensive statewide plan for coordinating timely application of pharmaceutical resources in the event of an act of terrorism or large-scale technological emergency/disaster.

ACTIVATION

I. EMS Identifies a need for Nerve Agent (NA) antidote support.

A. Notify Central Dispatch (911) or the Medical Control Authority/hospital (MCA) and provide the Essential Elements of Information (EEI).

B. Central Dispatch or MCA/Hospital

1. Submits EEI Report to the MEDDRUN/CHEMPACK Communications Agency.a. Primary: SURVIVAL FLIGHT: 877-633-7786 (877 MEDSRUN)b. Secondary: Aero Med: 616-391-5330

2. Informs Emergency Management that Nerve Agent Antidote Supplies have been requested.

1. CHEMPACK Communications Agency:

1. Conducts analysis & issues deployment orders to selected CHEMPACK storage sight, (CSS) Point of Contact (POC).

2. Contacts the state agency (OPHP) Point of Contact: BEEPER: 517-232-7297

2. CHEMPACK Storage site notifies the transport unit and moves cashe to designated loading area.

1. If confirmed, the Agency loads CHEMPACK supplies onto transport.

2. If deployed, MA Dispatch notifies the MCA regarding dispatching transport vehicle.

RESPONSIBILITIES

I. OPHP/POC follow-up will include:

A. Contacting the requesting agency to authenticate the request.

B. Contacting CHEMPACK Communications Agency to provide confirmation or initiate recall. If confirmed, advise if Alert Orders should be initiated.

C. Contacts Michigan State Police (MSP) East Lansing Operations Center (ELOP)

D. Coordinates potential Inter-Hospital Formulary Distribution.

E. Coordinates a MI-HAN Alert.

II. CHEMPACK Communications:

A. Provides Certificate Order/Recall Order.

B. Notifies CHEMPACK storage site Point of Contact of either a Certification Order or Recall Order.

C. If OPHP issues an alert, MEDDRUN/CHEMPACK Communications Agency issues an Alert Order to appropriate CHEMPACK storage site(s) for possible deployment.



III. CHEMMPACK Storage Site:

A. Once confirmed, the Agency loads the CHEMPACK Supplies into the transportation vehicle and transports to the specific location.

IV. Designated Transportation Agency:

A. Ensure adequate security of the cache materials while being transported to the delivery point.

B. Maintain communications with the ChemPack Storage site’s Point of Contact while en route to the delivery point, providing periodic updates regarding present location/circumstances that may impact time of delivery.

C. Follow the routes specified by the CSS POC and advise upon arrival to the delivery point.

DELIVERY OF CACHE

I. When the cache arrives at the delivery point the Incident Command (IC) will take receipt of the cache as the person in charge by completing the Transfer of Custody form that will accompany the cache. The IC will ensure accurate accounting of the antidote supplies in coordination with the senior medical/EMT at the scene.

A. If additional antidotes are required the IC will Inform Central Diapatch/911.

B. If it appears that the amount of antidote needed will be less than anticipated, the transport vehicle will remain in the area to take custody of the unused antidotes to return them to the CSS POC.

C. Advise the CSS POC when the mission is completed.



Essential Elements of Information (EEI) Report To Request CHEMPACK Deployments

Essential Elements of Information Report 1. Name, Position, and Contact Information for the Individual Requesting Deployment of the CHEMPACK Cache?

Name: ____________________________Position/Title:______________________Telephone/Other: _____________________________________________________

2. Name of Physician / Officer in Charge of Medical Management at the Scene (if different from “1.” above.)

Name: ____________________________Position/Title: ______________________Employer: _________________________Telephone/Other: ___________________

3. Location of Incident

Jurisdiction Name __________________Closest Intersection __________________

(or)Name of Site ___________________

4. Estimated Number of Casualties

None 5-10 100-300 1 10-20 300-500 2-3 20-40 500-1000 4-5 40-100 1000+

5. Symptoms of Casualties

Pin Pointed Pupils TwitchingDimness of Vision SeizuresSlurred Speech Chest TightnessDifficulty in Breathing Unconsciousness

6. Local Supplies of Antidotes and Pharmaceuticals are Exhausted, multiple lives remain at risk, and CHEMPACK supplies are needed to save lives?

Yes ________ No ________

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYCOMMUNICABLE DISEASE


7Purpose: This is written to provide general guidelines for the treatment and transport of a patient

with a known or suspected communicable disease.

NOTE: The EMS provider must recognize that any patient that presents with one of the following may be potentially infectious, and must take the necessary precautions to avoid secondary exposure. These precautions include following this protocol.

a skin rash open wounds blood or other body fluids a respiratory illness that produces cough and/or sputum

Exposure Defined:

An exposure is determined to be any breach of the skin by cut, needle stick, absorption or open wound, splash to the eyes, nose or mouth, inhaled, and any other parenteral route.

Reporting Exposures:

Police, Fire or EMS personnel who, in the performance of their duty, sustain a needle stick, mucous membrane or open wound exposure to blood or other potentially infectious material (OPIM) may request, under Public Act 368 or 419, that the patient be tested for HIV/Hepatitis B and C surface antigen. The exposed individual shall make the request on a Michigan Department of Community Health Form J427 (MDCII Form J427). The exposed individual should also report the exposure in accordance with their employer's policies and procedures.

Follow appropriate infection control procedures.

M B S P Pre-Radio

1. If a patient presents with one of the following symptom complexes, then follow the remainder of this protocol.

1. Fever > 100.5 F AND headache or malaise or myalgia, AND cough or shortness of breath or difficulty breathing.

2. Pustular, papular or vesicular rash distributed over the body in the same stage of development (trunk, face, arms or legs) preceded by fever AND rash progressing over days (not weeks or months) AND patient appears ill.

B. Consider the patient to be both airborne and contact contagious. Crew will don the following PPE:

1. N95 or higher protective mask/respiratory protection

2. Gloves

3. Goggles or face shield

DO NOT REMOVE protective equipment during patient transport.

3. Follow General Pre-Hospital Care Protocols(oxygen delivery with non-rebreather facemasks may be used for patient; however, nebulizer use should be avoided if possible because of increase spread of disease)

4. Positive pressure ventilation should be performed using a resuscitation bag-valve mask. If available, one equipped to provide HEPA or equivalent filtration of expired air should be used. Also see the section in this protocol “Mechanically Ventilated Patients".



5. Patient should wear a paper surgical mask to reduce droplet production, if tolerated.

6. Notify the receiving facility, prior to transport, of the patient's condition to facilitate preparation of the facility and institution of appropriate infection control procedures.

7. Hands must be washed or disinfected with a waterless hand sanitizer immediately after removal of gloves. Hand hygiene is of primary importance for all personnel working with patients.

8. Vehicles that have separate driver and patient compartments and can provide separate ventilation to these areas are preferred for patient transportation. If a vehicle without separate compartments and ventilation must be used, the outside air vents in the driver compartment should be turned on at the highest setting during transport of patient to provide relative negative pressure in the patient care compartment.

9. Patients should also be encouraged to use hand sanitizers.

10. Unless critical, do not allow additional passengers to travel with the patient in the ambulance.

11. All PPE and linens will be placed in an impervious biohazard plastic bag upon arrival at destination and disposed of in accordance with the direction from the hospital personnel.

MECHANICALLY VENTILATED PATIENTS B S P 1. Mechanical ventilators for potentially contagious patient transports must provide HEPA

filtration of airflow exhaust.

2. EMS providers should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive pressure ventilation.

3. BIPAP, CPAP and nebulizers should be avoided if possible because of increased spread of disease when used.

CLEANING AND DISINFECTION

Cleaning and Disinfection after transporting a potentially contagious patient must be done immediately and prior to transporting additional patients. Contaminated non-reusable equipment should be placed in biohazard bags and disposed of at hospital. Contaminated reusable patient care equipment should be placed in biohazard bags and labeled for cleaning and disinfection according to manufacture's instruction.

INTERFACILITY TRANSFERS

1. Follow the above precautions for inter-facility transfers.

2. Prior to transporting the patient, the receiving facility should be notified and given and ETA for patient arrival allowing them time to prepare to receive this patient.

3. Clarify with receiving facility the appropriate entrance and route inside the hospital to be used once crew has arrived at the receiving facility.

4. All unnecessary equipment items should be removed from the vehicle to avoid contamination.



5. All transport personnel will wear the following PPE:

a. Gloves

b. Gown

c. Shoe Covers

d. N-95 (or higher) protective mask

6. Drape/cover interior of patient compartment and stretcher (utilizing plastic or disposable sheets with plastic backing)

7. Isolate the patient:

a. Place disposable surgical mask on patient

b. Cover patient with linen sheet to reduce chance of contaminating objects in area.

8. All PPE and linens will be placed in an impervious biohazard plastic bag upon arrival the receiving destination and disposed of in accordance with the direction from the hospital personnel.

9. The ambulance(s)/transport vehicle will not be used to transport other patients (or for any other use) until it is decontaminated using the CDC guidelines for decontamination.

A. Patient cohorting may occur if resources are exhausted and patients are grouped with same disease. Cohorting should only be utilized as a last resort.

NOTE: All non-vaccinated EMS personnel should be vaccinated (when applicable) within 24 hours following potential exposure

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYCYANIDE EXPOSURE


Purpose: This Protocol is intended for EMS personnel at all levels to assess and treat patients exposed to cyanide. The protocol includes the use of inhaled amyl nitrite by trained personnel who are authorized by their local medical control authority. Additionally, the protocol allows trained and authorized paramedics to administer sodium nitrite and sodium thiosulfate when these medications are available.

M B S P I. Chemical Agents

A. Agents of Concern.

1. Cyanide

2. Hydrogen Cyanide

3. Potassium/Sodium Cyanide

4. Cyanogen Chloride

B. Detection: The presence of these agents can be detected through specialized environmental monitoring equipment available to hazardous materials response teams.

C. Modes of Exposure

1. Inhalation (including smoke inhalation)

2. Ingestion

3. Skin Absorbtion (unlikely)

II. Assessment

A. Shortness of Breath1. Possibly accompanied by chest pain2. Generally not associated with cyanosis (blue skin/membranes)3. Pulse oximetry levels usually normal4. Usually associated with increased respiratory rate and depth5. Potential for rapid respiratory arrest

B. Confusion, decreased level of consciousness, comaC. SeizuresD. Headache, dizziness, vertigo (sense of things spinning)E. Pupils dilate (late)

III. Personal Protection A. Be Alert for secondary device in potential terrorist incidentB. Personal Protective Equipment (PPE) as directed by Incident Commander. C. Assure EMS personnel are operating outside of Hot ZoneD. Avoid contact with vomit if ingestion suspected – off gassing possibleE. Decontamination of victims usually not indicated unless additional unknown

chemical(s) suspected

M B S P IV. Patient Management (After Evacuation)

A. Evaluate and maintain the airway, provide oxygenation and support ventilation as needed.B. Note: Patients in respiratory arrest (i.e., not breathing but still having a pulse) have

been found to respond to antidote therapy and should receive positive pressure ventilation when operationally feasible. This is in contrast to most triage systems that would categorize non-breathing patients as non-survivable.

CONTACT MEDICAL CONTROL





C. Amyl Nitrite Per Amyl Nitrite Procedure*1. Requires symptomatic patient(s) and2. Positive evidence of cyanide exposure through environmental monitoring or credible

operational intelligence. B S P D. Alert receiving hospital ASAP to prepare additional antidotes

S P E. Establish vascular access P F. Cardiac monitoring P G. Sodium Nitrite 10 ml (300 mg) IV over 5 minutes if available and cyanide exposure

confirmed and with medical control order* for critical patients1. For pediatric patients: 0.27 - 0.31 ml/kg IV over >5 minutes. Reference the

BROSELOW Pediatric Antidotes for Chemical Warfare Tape. 2. Monitor BP carefully and slow administration for hypotension

H. Sodium Thiosulfate 50 ml (12.5 g) IV over 10 minutes if available and cyanide exposure confirmed and with medical control order* for critical patients

1. For pediatric patients: 1.65 ml/kg (12.5 g/50 ml solution) IV over 10 minutes2. Generally administered after sodium nitrite3. If cyanide exposure not confirmed, may receive order for Sodium Thiosulfate

without Sodium NitriteI. Reference the BROSELOW Pediatric Antidotes for Chemical Warfare Tape.

* NOTE: A single medical control order in a mass casualty incident may be applied to all symptomatic patients.

These medications are not required to be carried on EMS vehicles and may be available through special response units.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYMASS CASUALTY INCIDENTS


Purpose: To provide a uniform initial response to a Mass Casualty Incident (MCI) to facilitate a common understanding in terminology, procedures and participation.

Pre-hospital care providers will operate in accordance with medical control authority standard operating procedures.

Definitions:

Incident Commander (IC):

The IC is the individual responsible for all incident activities, including the development of strategies and tactics and the ordering and the release of resources. The IC has overall authority and responsibility for conducting incident operations and is responsible for the management of all incident operations at the incident site. EMS will typically fall under the IC through a subordinate Branch, Division or Group.

Section Chief:

A Section Chief may be assigned to Operations, Logistics, Planning, or Administration/Finance depending on the size of the incident. Not all incidents will require all 4 sections to be assigned.

Branch Director:

A Branch Director may be assigned under the Operations Section Chief. Branch Directors are responsible for managing a specific discipline including Fire, EMS, Law Enforcement, Public Works, Public Health, etc.

Division Supervisor:

A Division Supervisor is assigned to an area that is separated by a barrier. Examples of a Division would be a multi level structure, include separated by a river, etc. Numbers are primarily used to identify divisions.

Group Supervisor:

A Group Supervisor functions within the Operation Section and is assigned to a specific group. Letters of the alphabet are primarily used to identify groups.

Unit Leaders:

Units can be assigned to the Command and General Staff or within a Group or Division.

Medical Unit Officer:

The Medical Unit Officer is the individual responsible for the management of incident responder medical treatment and rehab.

Safety Officer:

The IC shall appoint a Safety Officer who will ensure safety of responders and victims during the incident operations. With the concept of Unified Incident Command there is valid reasoning to have Assistant Safety Officers to include all disciplines involved in the operation. The Safety Officer appointed by the IC shall have the authority designed within the Incident Command System with the input and advice of all Assistant Safety Officers.

Deputies:

Deputies are used within the Command and General Staff or Sections of the ICS. A Deputy may be a higher-ranking responder that assists the IC or Section Chief however does not assume Command.

Coordinating Resource:

The entity within the local EMS system responsible for the notification and coordination of the mass casualty response. Examples include: medcom, resource hospital, MCA, medical control, dispatch



Regional Medical Coordination Center:

The MCC serves as a regional multi-agency coordination entity as defined by the National Incident Management System (NIMS). The MCC serves as a single regional point of contact for the coordination of healthcare resources. The MCC is intended to optimize resource coordination among hospitals, EMS agencies, medical control authorities and other resources. The MCC serves as a link to the State Health Operations Center (SHOC).

State Health Operations Center:

The SHOC serves as a statewide multi-agency coordination entity as defined by NIMS. SHOC is intended to coordinate state-level healthcare and public health resources, to serve as a central point of contact for regional MCC’s, and to serve as a resource to the State EOC. SHOC is expected to be activated following a major disaster or other public health emergency and should be operational within hours of activation.

Incident Command System:

The ICS organizational structure develops in a top-down fashion that is based on the size and complexity of the incident, as well as the specific hazard environment created by the incident.

Unified Command:

In incidents involving multiple jurisdictions, a single jurisdiction with multi-agency involvement, or multiple jurisdictions with multi-agency involvement, unified command can be implemented. Unified command allows agencies to work together effectively without affecting individual agency authority, responsibility, or accountability

An Incident Command System (ICS) or Unified Incident Command System (UICS) will evolve in an MCI. The ICS/UICS is a dynamic way to bring a management structure to a disaster situation. The first EMS responder shall assume the role of EMS Branch Director/Group Supervisor and will identify him/herself to the Incident Commander and become liaison with ICS/UICS and medical elements in the Triage, Treatment, and Transportation areas as EMS personnel converge and are assigned these roles. The Incident Commander will assume command and secure the MCI. The Incident Commander will have access to special equipment, expertise and communications to support the medical aspects of an MCI. Implement the ICS/UICS as soon as possible and utilize it.

All Levels of Pre-hospital Providers

I. EMS Branch Director/Group Supervisor

The first pre-hospital emergency medical services provider (MFR, EMT, EMT-Specialist, or Paramedic) on scene takes charge of medical care. This position may only be relinquished to another pre-hospital care EMS provider when:

A. MCI is more appropriately within their jurisdiction; and

B. Same or higher qualifications of current EMS Branch Director/Group Supervisor.

C. Responsibilities

1. Survey the scene

2. Call for back-up

3. Notify the “coordinating resource” of the nature and scope of the MCI and identify any potentially hazardous materials

4. Begin primary triage and tag patients for priority evacuation to treatment.

5. Status update to the “Coordinating Resource” when initial triage is complete.



6 The first licensed pre-hospital EMS provider on the scene is the EMS Branch Director/Group Supervisor in charge of the Medical Operations, and

a. Designates staging, triage, treatment and transport areas consistent with the ICS, or UICS if implemented, design

b. Assigns responding EMS and other health care personnel to designated functional areas as needed.

c. Establish Medical Communications with coordinating resource

d. Will transfer charge to:

1) A pre-hospital EMS provider of higher license level within the medical control authority

2) Pre-hospital EMS provider in whose jurisdiction the MCI occurs and who is at least the same level of licensure

SCENE MANAGEMENT

EMS personnel should accomplish the following actions upon arrival.

I. Survey the scene

IV. If Incident Command has not been established the senior EMS personnel shall assume the role of IC. The IC shall assume to role of all other elements of the ICS until she/he as assigned other personnel to their roles.

V. Advise dispatch who has assumed command and who has EMS Branch Director/Group Supervisor and their exact location.

VI. Organize the scene and ensure an effective response including:

A. Securing the area and limiting access to nonessential personnel

B. Determining whether the incident scene is safe to enter and whether decontamination is required

C. Assigning personnel to the necessary tasks and roles

D. Establishing staging, triage, treatment, and transportation areas

E. Establishing communication between areas

F. Establishing traffic pattern that provided for the smooth flow of patients and vehicles

G. Ensure that appropriate record-keeping takes place

VII. Call for additional resources

A. EMS personnel

B. Any specialized equipment

C. MEDDRUN

D. CHEMPACK

E. Regional Medical Coordination Center (MCC)

F. Other available resources

VIII. Inform the “Coordinating Resource” of nature and scope of incident

IX. Begin primary triage

A. START Triage (JUMPSTART for pediatrics)





X. Assign roles to arriving EMS personnel

A. Triage Leader Role

1. Report to EMS Branch Director / Group Supervisor

2. Coordinates rapid triage process

B. Treatment Leader Role

1. Within EMS Branch Operations, establish treatment areas

2. Assigns personnel to treatment areas

3. Supervise care in treatment areas

4. Document care given

5. Requests additional personnel needs to EMS Branch Director/Group Supervisor

C. Transportation Leader Role

1. Prioritize transportation of patients from scene

2. With information from coordinating resource, assigns destination hospital

3. Maintains log of patients transported

PATIENT MANAGEMENT

J. Primary Triage

A. Identify and manage immediate life threats. Necessary care will be limited to:

1. Positioning airway

2. Attempt hemorrhage control

B. Identify patients for priority evacuation to treatment area.

1. Priority Red (one): Life-threatening

2. Priority Yellow (two): Life or limb threat but no immediate danger. Care might be delayed 1-2 hours.

3. Priority Green (three): Medical treatment can be

delayed

4. Priority Black (four): Dead or expectant injuries

C. The triage information (e.g. tag or colored strip) should be attached to the body and the appropriate section removed to indicate priority by the last remaining section.

D. Triaged patients (except black category) are taken or directed to corresponding treatment area

E. Notify the”coordinating resource” of number, general injury type, and priority of patients when primary triage information is available.

1. Updating the “coordinating resource” as primary triage information is updated is imperative.



II. Treatment

A. Perform secondary triage within each treatment area

B. Identify and treat potential life-threatening injuries / illnesses in treatment area in accordance with established patient care protocols.

C. Do the most good for the greatest number of patients as resources permit

D. Stabilize and prepare for transport on a priority basis to hospital(s).

III. Transport

A. EMS personnel assigned to transport activities should report to the transport group leader

B. Transport personnel will be assigned patients and destination hospitals.

PERSONNEL ACCOUNTABILITY

I. EMS personnel responding to an incident should report to the designated staging area unless otherwise directed while en route to the incident.

A. Off duty personnel should report to their own agency for assignment and not to the scene.

B. Personnel Identification badges should be worn so they are visible at all times.

II. It is the IC’s responsibility to establish a personnel accountability system and maintain the ability to account for all personnel at all times



III. Personnel should have their credentials validated prior to utilization in a disaster. Credentialing may be accomplished through pre-designated local response plans.

REGIONAL MEDICAL COORDINATION CENTER (MCC)

I. MCC Responsibilities

A. Maintain communications with all involved entities

1. EMS Branch Directors

2. EMS Division/Group Supervisors

3. EMS Unit Leaders

4. Hospitals

5. Local EOCs (when activated)

6. SHOC (when activated)

7. MEMS sites (when activated)

8. Other Regional MCCs (as appropriate)

B. Provide initial and update alerts via available communications resources

C. Provide frequent updates to on-scene EMS Branch Directors / Group Supervisors regarding hospital casualty care capacity

D. May relay casualty transport information to receiving facilities

E. May relay urgent and routine communications to appropriate entities

F. May assist in coordination and distribution of resources

G. Other appropriate tasks as necessary for an effective regional medical response

STATE HEALTH OPERATIONS CENTER

I. Operated by MDCH Office of Public Health Preparedness

II. EMS Personnel should be aware of the existence of SHOC but are not expected to directly interface with SHOC.

DEMOBILIZATION

I. The IC should remain cognizant of the resources available and needed. An assessment must be performed for each operational period. Review of the Incident Action Plan (IAP) must be performed to determine the necessary resources. Resources that are in staging and not needed should be demobilized until it is later determined they are needed.

CISM

I. Critical Incident Stress Management may be utilized as necessary both during and post event.



Example organizational chart

INCIDENT/UNIFIED COMMANDFireEMS

INCIDENT/UNIFIED COMMANDFireEMS

Law Enforcement

OperationsOperations PlanningPlanning LogisticsLogisticsFinance

AdministrationFinance

Administration

StagingStaging

LawEnforcement

Branch

FireBranch

Public WorksBranch

EMSBranch

LawEnforcement

Branch

FireBranch

Public WorksBranch

EMSBranch

Medical SafetyAssistant

Medical SafetyAssistant

TriageGroup

Triage Units

Litter BearerTeams

MedicalExaminerPersonnel

TriageGroup

Triage Units

Litter BearerTeams

MedicalExaminerPersonnel

TreatmentGroup

TreatmentGroup

TreatmentTeams

TreatmentTeams

Red TeamImmediateRed TeamImmediate

Yellow TeamDelayed

Yellow TeamDelayed

Green TeamMinor

Green TeamMinor

TransportGroup

MedicalCommunications

Coordinator

Air AmbulanceCoordinator

GroundAmbulanceCoordinator

TransportGroup

MedicalCommunications

Coordinator

Air AmbulanceCoordinator

GroundAmbulanceCoordinator

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYMEDDRUN


Purpose: The Michigan Emergency Drug Delivery and Resource Utilization Network (MEDDRUN) established standardized cashes of medications and supplies strategically located throughout the State of Michigan. In the event of a terrorist incident or other catastrophic event resulting in mass casualties, MEDDRUN is intended to rapidly deliver medications and medical supplies, when local supplies are not adequate or become exhausted. The goal is to deploy MedPack within 15 minutes of the request.

AUTHORIZATION

E. Only authorized agencies and officials can request MEDDRUN. These agencies include any Michigan Hospital, local public health agency, or emergency management program. Authorized officials include designated representatives from the Office of Public Health Preparedness (OPHP), the Michigan State Police (MSP) and the Regional Bioterrorism Preparedness projects.

ACTIVATION

I. There are two modes for activating MEDDRUN, depending on the location and who is making the request. The first may be any EMS personal that identifies the need; the second may be a hospital, public health, EOC or Emergency Management that identifies a need for activation.

II. EMS

A. Identifies need

B. Contact Central Dispatch, a hospital or MCA

C. Central Dispatch contacts MEDDRUN Communications Agency

1. Primary: Survival Flight 877-633-7786 (877 MEDSRUN)

2. Secondary: Aero Med: 616-391-5330

III. Hospital, Public Health, EOC or Emergency Management

A. Identifies need

B. Contact MEDDRUN Communications Agency

1. Primary: Survival Flight 877-633-7786 (877 MEDSRUN)

2. Secondary: Aero Med: 616-391-5330

RESPONSIBILITIES

I. MEDDRUN Communications Agency

A. Contact MEDDRUN Agency Dispatch who then dispatches the closest MEDDRUN MedPack to the requesting location.

*Dispatch and response should not be delayed while waiting for confirmation from OPHP.

B. Contacts OPHP Point of Contact 517-232-7297 (beeper)

C. Will notify/alert the next closest MEDDRUN Agency for possible deployment.

D. Contact dispatched MEDDRUN Agency to either confirm/recall deployment after OPHP Point of Contact (POC) has confirmed the request with the affected agency.

E. Communicate updates with requesting agency.

F. OPHP POC will contact the requesting agency to authenticate the request.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYMEDDRUN


II. OPHP POC

A. Contact the MEDDRUN Communications Agency to provide confirmation and determine the need for any additional MedPacks or/ to recall the dispatch.

B. Contact the Michigan State Police East Lansing Operations Center (ELOP).

C. Contact the Regional Medical Coordination Center.

D. Will coordinate a MI-HAN alert.

E. Once MedPack reaches its destination the MEDDRUN response vehicle and crew will have completed their primary mission. They will either return to service or assume other operational responsibilities as requested by incident management officials and coordinate with their dispatch center.

1. The person in charge of the scene will receive the MedPack. The MEDDRUN Controlled Substance Transfer Form must be completed. (See attachment) The Controlled Substance Form must be issued, Submitted, and received by the Regional Bioterrorism Preparedness Medical Director, within 24 hours.

POST MEDDRUN DEPLOYMENT

I. Within 72 hours of a MedPack deployment, the MEDDRUN Agencies, OPHP and MEDDRUN Communications will prepare a Preliminary after Action Report (AAR) using the format prescribed by OPHP. (See AAR attachment) OPHP will review each AAR with the intent of improving future MEDDRUN responses.

Re-STOCKING MEDPACKS

I. It is important that a MedPack be restocked and placed back in service as quickly as possible. The MEDDRUN Agency may be returned to service on a limited basis with a partially depleted MedPack. Depending on the availability of federal funds, the Regional Preparedness Bioterrorism Coordinator, in Collaboration with OPHP will be responsible for ordering the supplies to re-stock the MedPack(s) used.

II. OPHP and MEDDRUN Communications will be notified upon the MedPack being returned to FULL SERVICE.

*MEDDRUN may also be pre-deployed for special events, designated by the State and Regional Leadership.

*Should non-authorized agencies, officials or another state request MEDDRUN an authorized OPHP official must approve this request.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYNERVE AGENT/ORGANOPHOSPHATE PESTICIDE EXPOSURE TREATMENT PROTOCOL


Purpose: This Protocol is intended for EMS personnel at all levels to assess and treat patients exposed to nerve agents and organophosphate pesticides. The protocol includes the use of the Mark I Antidote Kits and the Atropen auto-injector for personnel trained in the use of these devices and authorized by the local medical control authority.

M B S P I. Chemical Agents

A. Agents of Concern.

1. Military Nerve Agents including: Sarin (GB), Soman (GD), Tabun (GA), VX2. Organophosphate Pesticides (OPP) including Glutathione, Malathion, Parathion, etc.

B. Detection: The presence of these agents can be detected through a variety of monitoring devices available to most hazardous materials response teams and other public safety agencies.

II. Patient Assessment A. SLUDGEM Syndrome

1. S Salivation / Sweating / Seizures2. L Lacrimation (Tearing)3. U Urination4. D Defecation / Diarrhea 5. G Gastric Emptying (Vomiting) / GI Upset (Cramps)6. E Emesis7. M Muscle Twitching or Spasm

B. Threshold Symptoms : These are symptoms that may allow rescuers to recognize that they may have been exposed to one of these agents and include:

1. Dim vision2. Increased tearing / drooling3. Runny nose4. Nausea/vomiting5. Abdominal cramps6. Shortness of breath

NOTE: Many of the above may also be associated with heat related illness.C. Mild Symptoms and Signs:

1. Threshold Symptoms plus:2. Constricted Pupils*3. Muscle Twitching4. Increased Tearing, Drooling, Runny Nose5. Diaphoresis

D. Moderate Symptoms and Signs: 1. Any or All of Above plus2. Constricted Pupils*3. Urinary Incontinence 4. Respiratory Distress with Wheezing5. Severe Vomiting

E. Severe Signs 1. Any or All of Above plus

a. Constricted Pupils*b. Unconsciousnessc. Seizuresd. Severe Respiratory Distress

*NOTE: Pupil constriction is a relatively unique finding, occurs early and persists after antidote treatment. The presence of constricted pupils with SLUDGEM findings indicates nerve agent / OPP toxicity.



M B S P III. Personal Protection

A. Be Alert for secondary device in potential terrorist incidentB. Personal Protective Equipment (PPE)

1. Don appropriate PPE as directed by Incident Commander. 2. Minimum PPE for Non-Hot Zone (i.e., DECON Zone)

a. Powered Air Purifying Respirator or Air Purifying Respiratory with proper filter

b. Chemical resistant suit with bootsc. Double chemical resistant gloves (butyl or nitrile)d. Duct tape glove suit interface and other vulnerable areas

C. Assure EMS personnel are operating outside of Hot ZoneD. Avoid contact with vomit if ingestion suspected – off gassing possibleE. Assure patients are adequately decontaminated prior to transport

1. Per Decontamination Protocol2. Removal of outer clothing provides significant decontamination. 3. Clothing should be removed before transport4. Do NOT transport clothing with patient

F. Alert hospital(s) as early as possible

M B S P IV. Patient Management (After Evacuation and Decontamination)

A. Evaluate and maintain the airway, provide oxygenation and support ventilation as needed.NOTE: Anticipate need for extensive suctioning

B. Antidote administration per Mark I Kit Dosing Directive – See Chart S P C. Establish vascular access

P D. Atropine 2-6 mg IV/IM per Mark I Kit Dosing Directive if Mark I Kit is not available (each Mark I Kit contains 2 mg of atropine)

E. Treat seizures per Seizure Protocol1. Adult:

a. Administer diazepam 2-10 mg IVP OR b. Midazolam 0.05 mg/kg to max 5 IVP c. Administer Midazolam 0.1 mg/kg to max 10 mg IMd. If available, Valium auto-injector

2. Pediatrics:a. Diazepam 0.2 mg/kg (maximum individual dose 10 mg) via intravenous

route or 0.5 mg/kg (maximum individual dose 10 mg) via rectal routeb. Midazolam 0.15 mg/kg (maximum individual dose 5 mg) via intravenous or

intramuscular routec. Reference the BROSELOW Pediatric Antidotes for Chemical Warfare

Tape. F. Monitor EKG

P V. Post Medical Control

A. Additional Atropine 2 mg IV/IM for continued secretions (0.05 mg/kg for pediatrics)




B. Seizure Prophylaxis per Seizure Protocol for patients with severe signs



M B S P

Mark I Kit Dosing Directive

Clinical Findings Signs/SymptomsRequired

ConditionsMark I Kits To

Be Delivered

SE

LF

-RE

SC

UE

Threshold Symptoms

Dim vision Increased tearing Runny nose Nausea/vomiting Abdominal cramps Shortness of breath

ThresholdSymptoms

-and-Positive evidenceof nerve agent or

OPP on site

1 Mark I Kit(self-rescue)

AD

UL

T P

AT

IEN

T

Mild Symptoms and Signs

Increased tearing Increased salivation Dim Vision Runny nose Sweating Nausea/vomiting Abdominal cramps Diarrhea

Medical ControlOrder 1 Mark I Kit

Moderate Symptoms and Signs

Constricted pupils Difficulty breathing Severe vomiting

Constricted Pupils

2 Mark I Kits

Severe Symptoms and Signs

Constricted pupils Unconsciousness Seizures Severe difficulty

breathing

Constricted Pupils

3 Mark I Kits(If 3 Mark I Kits are used, administer 1st dose of available benzodiazepine)

PE

DIA

TR

IC

Pediatric Patient with Non-Severe

Signs/Symptoms

Mild or moderate symptoms as above

Positive evidence of nerve agent or

OPP on site

Age >8 years old: As Above

Age <8 years old Per Medical Control

Pediatric Patient with Severe

Signs/Symptoms

Constricted pupils Unconsciousness Seizures Severe difficulty

breathing

Severe breathing difficulty

Weakness

Age > 8 years old: 3 Mark I Kits

Age < 8 years old: 1 Mark I Kit

Contact Medical Control as needed


REVISED JULY 2007

Environmental

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYDROWNING NEAR-DROWNING PROTOCOL

REVISED JULY 2007 Page 1 of 1

Purpose: To provide a process for the assessment and management of drowning or near drowning incidents.

I. Management

A. Establish and maintain the airway with spinal stabilization. Provide oxygenation and support ventilations as needed. Establish IV access in route.

B. If pulse is absent, initiate CPR.

1. If submersion time is greater than 2 hours refer to the Dead On Scene Policy, unless hypothermia is present.

P 2. Monitor EKG.

M B S P a. If monitor or AED indicates defibrillation warranted, defibrillate up to three shocks.

M B S P 3. If patient is hypothermic, go to Hypothermia/Frostbite protocol

4. Prevent further heat loss by transport in a warm environment. Patient should be dry.

M B S P C. If pulse is present:

P 1. Monitor EKG.

M B S P 2. Obtain patient's temperature:

M B S P 3. If patient is hypothermic (temperature <86o F or 34-36oC), go to Hypothermia/Frostbite Protocol.

4. Prevent further heat loss by transport in a warm environment. Patient should be dry.

5. Continued support of oxygenation and ventilation.

D. Possible orders post-radio contact (pulse absent):

1. Medications or further defibrillation as ordered by Medical Control.

S P E. Possible orders post radio contact (pulse present):

1. Medications as ordered

II. Special Considerations

M B S P A. Patient suspected of hypothermia should receive gentle handling, as movement may precipitate VF.

B. Maintain horizontal position if possible.


Date of Revision: Date of BCMCA Approval:

Date of State Approval: Signature of BCMCA MD:

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYENVIRONMENTAL HYPERTHERMIA PROTOCOL


Purpose: To provide a process for the assessment and management of hyperthermia.

I. Management

A. General Management:

M B S P 1. Establish and maintain airway, provide oxygenation and support ventilation.

2. Move patient to a cool area.

3. Remove restrictive clothing.

4. If possible, give responsive patient oral fluids.

M B S P B. Management of unstable patient with (Heat Stroke)

(skin is red, hot and dry, temp > 102o):

1. Immediately initiate aggressive cooling:

a. Cold/wet sheet

b. Air conditioning with good ventilation

c. Misting of cool water

d. Ice packs in axilla, neck and groin

e. Do NOT use alcohol to attempt cooling.

P 2. Monitor EKG.

S P 3. Obtain vascular access.

a. Administer fluid bolus, with repeat as needed, titrating to signs of adequate perfusion.

M B S P 4. If patient experiences seizures, refer to Seizure Protocol.

M B S P C. Management of patient with signs of heat exhaustion: (pallor, diaphoresis, generalized weakness and patient remaining alert)

1. If possible, give patient oral fluids.

2. Allow patient to rest.

D. Management of patient with heat cramps: (sudden development of severe cramps of the abdominal or skeletal muscles)

1. Move patient to cool area to rest.

2. If possible, give oral fluids.

E. Possible orders post radio contact:


BERRIEN COUNTY MEDICAL CONTROL AUTHORITYENVIRONMENTAL HYPERTHERMIA PROTOCOL


1. Additional IV fluids



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYHYPOTHERMIA/FROSTBITE PROTOCOL


Purpose: To provide for the process of assessment and management of the patient experiencing hypothermia or frostbite.

I. Management of Systemic Hypothermia

M B S P A. Ensure careful, gentle handling of the patient.

B. If respirations are absent or inadequate, establish and maintain the airway, provide oxygenation and support ventilation.

C. If respirations are adequate, provide oxygenation.

D. If pulse is absent, refer to appropriate Cardiac Arrest Protocol.

1. If frozen solid and no signs of life, immediately contact Medical Control for possible referral to Dead on Scene Protocol.

E. If pulse is present, continue with this protocol.

F. Remove wet or constrictive clothes from patient. Wrap in blankets and protect from wind exposure.

G. Transport in warmed patient compartment, monitoring patient closely.

S P H. Obtain vascular access.

1. Use warm IV fluids if possible.

I. If altered mental status, refer to Altered Mental Status Protocol.

P J. Monitor EKG.

B. Management of Frostbite

M B S P A. Remove wet or constricting clothing. Keep skin dry and protected from wind.

B. Do not allow the limb to thaw if there is a chance that limb may re-freeze before evacuation is complete or if patient must walk to transportation.

C. Dress injured areas lightly in clean cloth to protect from pressure, trauma or friction. Do not rub. Do not break blisters.

D. Keep patient warm.

E. Frostbitten areas should be supported and elevated during transport.

F. Pain management per procedure.





REVISED JULY 2007

Medical

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYABDOMINAL PROBLEMS PROTOCOL


Purpose: To provide a process for the assessment and management of the patient experiencing abdominal pain.

I. Management

M B S P A. Evaluate and maintain airway, provide oxygenation and support ventilation as needed.

B. Position patient in a position of comfort if pain is non-traumatic. If trauma related, refer to Trauma protocol.

C. Do not allow patient to take anything by mouth.

D. Severe abdominal pain


P 2. Monitor EKG.

3. If symptoms of shock develop, see Non-Cardiogenic Shock Protocol.

E. Non-severe abdominal pain (stable vitals, no trauma, mild pain):

B S P 1. Transport

F. Possible orders post radio contact (severe abdominal pain):

S P 1. Consider Pain Management (see pain management protocol)

2. Consider fluid bolus

G. Possible orders post radio contact (non-severe abdominal pain):

S P 1. Consider vascular access




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYALLERGIC REACTION/ANAPHYLAXIS PROTOCOL


Purpose: To provide a process for the assessment and management of the patient experiencing an allergic or anaphylactic reaction.

I. Assessment Information

M B S P A. Specific Objective Findings:

1. Respirations: respiratory distress, wheezing, stridor, retractions

2. Swelling: facial, tongue, upper airway

3. Vital signs: hypotension, tachycardia

4. Skin: itching, hives, swelling, flushing, rash

5. General: nausea, weakness

6. Medications

C. Management

M B S P A. Establish and maintain airway, provide oxygenation and support ventilation as needed.

1. Upright position if not hypotensive

S P 2. Consider early intubation before laryngeal swelling becomes severe.

M B S P B. Determine substance or source of exposure, remove patient from source if known.

P C. Monitor EKG.

S P D. Obtain vascular access.

1. If patient is hypotensive, administer fluid bolus with repeat as needed, titrating to signs of adequate perfusion.

P E. If patient is symptomatic, consider administration of Diphenhydramine 50 mg IM or IV.

F. In cases of severe allergic reaction with hypotension and profound distress:

P 1. Administer epinephrine 1:1000 0.3 mg (0.3 ml) IM

P G. Administer albuterol aerosol 5 mg, repeated at 5 mg if no improvement.

H. Possible orders post radio contact:

P 1. Additional Epinephrine 1:1,000 0.3 mg (0.3 ml) IM

B S P 2. If available, administer epinephrine auto-injector (EpiPen): 0.3 mg SQ in adult.

P 3. Epinephrine 1:10,000 0.3 mg (3 ml of 1:10,000 solution) slow IV for profound anaphylactic shock (near cardiac arrest) with laryngeal edema.

B S P 4. If available, consider albuterol aerosol (5 mg), repeated as ordered.



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYGENERALIZED WEAKNESS/ILLNESS PROTOCOL


Purpose: To provide a process for the assessment and management of the patient experiencing a general weakness or illness.

I. Management:

M B S P A. Position patient on either side if vomiting; otherwise supine.

B. Evaluate and maintain airway, provide oxygenation and support ventilation as needed.

C. Do not allow patient to take anything by mouth.

P D. If patient is Bradycardic or Tachycardic-refer to the appropriate protocol.

B S P E. Monitor vital signs during transport.

F. Be alert for other signs and symptoms and refer to appropriate protocol.

S P G. Possible orders post radio contact:

1. Obtain vascular access

a. Possible administration of additional IV fluids




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYHEMORRHAGE (NON-TRAUMATIC) PROTOCOL


Purpose: To provide a process for the assessment and management of the patient hemorrhaging from non-traumatic causes.

I. Management

M B S P A. Establish and maintain airway, provide oxygen and support ventilation as needed.

B. GI Bleeding:

S P 1. With vital signs stable, consider vascular access.

M B S P 2. If vital signs are unstable, refer to Shock Protocol.

C. Vaginal Bleeding:

1. If vaginal bleeding and signs of shock, refer to Shock Protocol.

S P 2. If vaginal bleeding and late term pregnancy, place in left lateral recumbent position, obtain vascular access.

S P 3. If vaginal bleeding and no signs of shock (not pregnant)

a. Consider vascular access.

D. Possible orders post radio contact:

1. Possible administration of additional IV fluids

D. Special Considerations

M B S P A. Products of conception passed by patient with vaginal bleeding should be brought to Emergency Department




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYHYPERTENSIVE EMERGENCY PROTOCOL


Purpose: This protocol is for the purpose of assessment and treatment of the patient with a Hypertensive Emergency.

Note: This is characterized by rapid increase in blood pressure in patients presenting with neurologic abnormalities*.



1. Diastolic blood pressure > 130 mmHg

2. *Presence of Neurological Abnormalities; (confusion, seizures, transient or persistent focal neurological signs, altered mental status)

3. If patient is pregnant, go to Obstetrical Emergencies Protocol.

E. Management

A. Evaluate and maintain the airway, provide oxygenation and support ventilation as needed.

B. Keep patient quiet.

S P C. Obtain vascular access.

M B S P D. Reassess vital signs frequently.

E. Consider elevation of the head, if not contraindicated.

F. Possible orders post-radio contact:

1. Medication administration by physician order only.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPOISONING/OVERDOSE PROTOCOL


Purpose: To provide a process for the assessment and management of the patient that may have ingested or received an exposure to a toxic substance, including bites and stings.

I. Management of Toxic Exposure (including ingestion)

M B S P A. Use proper protective equipment and prepare for decontamination if necessary. (Refer to decontamination protocol.)

B. Identification of the substance (patient has been exposed to).

1. Sample of drug or substance and any medication or poison containers should be brought in with patient if it does NOT pose a risk to rescuers.

C. Establish and maintain the airway, provide oxygenation and support ventilation as needed.

S P 1. Consider early intubation if signs of airway compromise or altered level of consciousness.

M B S P D. Remove clothing exposed to chemical.

E. Dilute toxic substances:

1. Noxious gas inhaled (including carbon monoxide & smoke):

a. Ensure high concentration of oxygen is provided

b. If suspected cyanide gas exposure, contact medical direction immediately.

2. Eye contamination:

a. Irrigate continuously with Normal Saline or tap water for 15 minutes (attempt to continue en route) or as directed by Medical Control.

b. For alkali exposure, maintain continuous irrigation.

3. Skin absorption:

a. Irrigate continuously with Normal Saline, or tap water for 15 minutes or as directed by Medical Control.

4. Ingestion:

a. As directed by Medical Control.

F. If altered mental status, refer to Altered Mental Status Protocol.

G. If cardiac dysrhythmia, refer to appropriate dysrhythmia protocol.

H. If respiratory distress, refer to Respiratory Distress Protocol.

I. If the patient is seizing, refer to Seizure Protocol.

J. Monitor vital signs and EKG and obtain vascular access.




K. Possible orders post radio contact per specific exposure:

M B S P 1. Drug, Chemical, Plant, Mushroom Ingestion:

a. Use protective eye equipment.

b. In situations of potential ingestion or inhalation of petroleum distillates, do NOT induce vomiting. Monitor the patient's respiratory and mental status very closely.

B S P c. If patient is alert and oriented:

1) Administer activated charcoal 50 gm of premixed solution (Peds: 1 gm/kg).

2) Prepare for emesis; recover and save emesis. Use appropriate barriers according to universal precautions guidelines.

P d. For symptomatic antidepressant ingestions (tachycardia, wide complex QRS),

1) Consider administration of sodium bicarbonate 50 mEq IVP

e. For extrapyramidal dystonic reactions,

1) Consider administration of Diphenhydramine 50 mg IVP

f. For symptomatic calcium channel blocker overdose,

1) Consider calcium chloride 500mg IVP.

g. For respiratory compromise or hemodynamic instability with narcotic overdose,

1) Consider naloxone 2 mg IVP

h. Organophosphate Exposure (Malathion, Parathion)

i. Consider Atropine 2 mg IVP, repeated every 5 minutes until "SLUDGE" symptoms improve or as directed. (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal hypermotility, Emesis)

2. Other specific poisonings may be managed per specific medical control protocol.

F. Management of Bites and Stings

A. Establish and maintain the airway, provide oxygenation and support ventilation as needed.

S P B. Obtain vascular access as needed per patient condition.

C. Human Bites:

1. Provide appropriate wound care management.

2. Consider splinting of extremity.

D. Spiders, Snakes and Scorpions:

1. Protect rescuers. Bring in spider, snake or scorpion if captured and contained or if dead for accurate identification.

2. Indirect ice for comfort on spider or scorpion bite.

3. Consider splinting of extremity. For snake bite, consider applying venous constricting band.



E. Bees and Wasps:

1. Remove sting mechanism from honey bees only by scraping out. Do not squeeze venom sac if this remains on stinger.

2. Provide wound care.

3. Observe patient for signs of systemic allergic reaction.

4. Treat anaphylaxis per Allergic Reaction/Anaphylaxis Protocol.

F. Possible orders post radio contact:

S P 1. Pain management per procedure as needed.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYRESPIRATORY DISTRESS PROTOCOL


Purpose: To provide the process for the assessment and management of patients experiencing respiratory distress.

I. Management

M B S P A. Allow patient a position of comfort.

B. Establish and maintain airway, provide oxygenation and support ventilation as needed.

C. Auscultate breath sounds

D. Determine the type of respiratory problem involved:

1. Upper Airway Obstruction

a. Complete Obstruction:

1) Go to Obstructed Airway Procedure.

2) Transport

b. Partial Obstruction: epiglottitis, foreign body, anaphylaxis:

1) Also see Obstructed Airway Protocol.

2) Consider anaphylaxis (see Allergic Reaction/ Anaphylaxis Protocol).

B S P 3) Transport in position of comfort.

M B S P 2. Clear Breath Sounds:

a. Hyperventilation, metabolic problems, MI, pulmonary embolus

P 1) Monitor EKG

B S P 2) Transport

3. Crackles (rales):

a. Suspected cardiac (i.e., pulmonary edema)

M B S P 1) Sit patient upright.

P 2) Monitor EKG.

S P 3) Obtain vascular access.

P 4) NTG 1/150 gr (0.4 mg) SL

i) May repeat every three to five minutes, to a total of 3 doses.

ii) Do not administer if patient is, or becomes hypotensive (systolic BP <90), or has taken Viagra®, Levitra, or Cialis (or

similar medications) within previous 24 hours.

P 5) Consider Furosemide 40 mg slow IVP after medical control

6) Consider Morphine 2-6 mg IVP after medical control.

7) Transport

b. Suspected non-cardiac (i.e., pneumonia)

1) Sit patient upright.

P 2) Monitor EKG.

S P 3) Obtain vascular access.

B S P 4) Transport

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYRESPIRATORY DISTRESS PROTOCOL


M B S P 4. Wheezes (i.e., asthma, COPD):

a. Consider anaphylactic reaction: see Allergic Reaction/ Anaphylaxis Protocol.

b. Sit patient upright.

B S P c. Albuterol 5 mg nebulized, may be repeated at 5 mg if no improvement.

P d. For severe respiratory distress, consider epinephrine 1:1,000 IM. (0.3 mg).

B S P e. Transport

P f. Monitor EKG

S P g. Consider vascular access

5. Asymmetrical breath sounds:

S P a. Obtain vascular access.

B S P b. Transport

P c. If evidence of tension pneumothorax and patient unstable, consider decompression (refer to Pleural Decompression Procedure)

P E. Possible orders post radio contact (for suspected CHF; crackles, rales):

1. Additional NTG SL 0.4 mg every 3 to 5 minutes

2. Additional Furosemide repeat up to 1 mg/kg up to total dose

3. Consider morphine 2-5mg IVP

B S P 4. Albuterol 5 mg nebulized, may be repeated at 5 mg nebulized if no improvement

F. Possible orders post radio contact (asthma):

P 1. Consider epinephrine 1:1,000 SQ/IM. (0.3 mg).

2. Consider magnesium sulfate 2gms slow IVP in refractory Status Asthmaticus.

B S P 3. Consider albuterol nebulized 2.5 to 5 mg

P G. Possible orders post radio contact (COPD):

B S P 1. Albuterol 5 mg

*Optional intervention for Basic and Specialist

1. Albuterol 5 mg nebulized for Asthma or COPD




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSEXUAL ASSAULT PROTOCOL


Purpose: To provide the process for evaluation and management of situations involving alleged sexual assault.

I. Assessment and Management Information

M B S P A. Preserve evidence whenever possible.

1. Advise patient to not shower, change clothes, or dispose of pertinent objects.

B. Assess patient for injury and treat according to protocol.

C. Assure appropriate police agency has been notified.

D. Use sensitivity in asking victim for historical information.

E. Thoroughly document all injuries and voluntary statements of patient.

F. Transport

B S P G. Possible orders post radio contact:

1. If transport is refused,

a. Refer patient to support agency and/or hospital whenever possible.

G. Special Considerations

M B S P A. The investigation of the circumstances surrounding the incident is the responsibility of the law enforcement agency.

B. Red marks may disappear and your documentation may be the only witness that the victim was choked or struck, even though he/she stated it. Be alert for torn clothing, fragments of cloth, blood, or body fluids, etc. for they need to be preserved as evidence. Police are responsible for the disposition of this evidence.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSHOCK PROTOCOL


Purpose: To provide the process for the assessment and management of the patient who potentially or currently is experiencing shock due to any cause other than cardiogenic.

I. Assessment: Consider multiple etiologies of shock (hypovolemic, neurogenic, septic and cardiogenic)

H. Management

M B S P A. Establish and maintain an airway, provide oxygenation and support ventilations as needed.

B. Control major bleeding

C. Position patient:

1. Left lateral recumbent if 3rd trimester pregnancy.

2. Elevate legs 10-12 inches.

D. Immediate load and transport for unstable patients.

S P E. Obtain vascular access (in a manner that will not delay transport).

1. Administer fluid bolus (300 ml – adult) unless patient in pulmonary edema

F. Consider second large bore IV of Normal Saline en route to hospital.

G. Monitor EKG.

S P H. Possible orders post radio contact:

1. Additional IV fluid bolus

P 2. Consider dopamine IV Drip 400 mg/250 cc (1600 mcg/1 ml) begin at 5 mcg/kg/min titrated up to 20 mcg/kg/min to maintain BP of 90mmHg for non-hypovolemic shock.





REVISED APRIL 2007

Neurological

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYACUTE ALTERED MENTAL STATUS PROTOCOL


Purpose: To provide a process for the assessment and management of the patient with an altered mental status.



1. Vital Signs, pupil changes, EKG

2. Mental and neurologic status: Baseline vs. current

3. Characteristic odor to breath (ketones, alcohol)

4. Medical Alert tags

5. Environmental clues

6. Determine if signs of hypoglycemia are present

I. Management

M B S P A. Restrain patient if necessary.

M B S P B. If the patient is alert but demonstrating signs of hypoglycemia, administer oral high caloric fluid if available.

C. If patient is not alert or vital signs are unstable:

1. Evaluate and maintain airway, provide oxygenation and support ventilations as needed.

2. If no concern regarding spinal injury, place the patient on either side.


B S P 4. Measure blood glucose level:

P a. If blood glucose is less than 70 mg/dl, administer dextrose 50% 25 grams (50 cc) IVP

M B S P b. Carefully administer small amounts of oral glucose paste, buccal or sublingual, if there is a delay in providing advanced level care.

P 5. If no response to the 50% dextrose, or 50% dextrose not indicated, and respiratory depression is present, give naloxone 2 mg IVP.

6. If unable to start IV, when D50 indicated:

a. Administer glucagon 1 mg IM.

M B S P D. Consider re-check of blood glucose level 10 minutes after glucose administration.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYCARDIOVASCULER ACCIDNET (CVA/STROKE) PROTOCOL


Purpose: To provide a process for the assessment and management of suspected CVA. This protocol may be used in conjunction with the altered mental status protocol.

I. Assessment

M B S P A. Try to elicit signs (suggestive of stroke) utilizing the Cincinnati Prehospital Stroke Scale

B. Measure blood glucose

J. Management

M B S P A. ABC’s with Supplemental Oxygen

B. Minimize scene time and begin transport

(Perform IV start and EKG after going en route)

C. Make contact with destination hospital

S PD. IV NS KVO

P F Monitor EKG.

G. IF blood glucose <70 mg/dl treat per Acute Altered Mental Status Protocol




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSEIZURES PROTOCOL


Purpose: To provide the process for the assessment and management of the seizure patient.

I. Management

M B S P A. Establish and maintain airway, provide oxygenation and support ventilation.

B. IF PATIENT IS ACTIVELY SEIZING:1. Protect patient from injury.2. Do not force anything between teeth.

S P 3. Obtain vascular access.P 4. If IV is successful:

a. Administer diazepam 2-10 mg IVP ORb. Midazolam 0.05 mg/kg to max 5 IVP in 2 mg increments if seizure

uncontrolledB S P c. Measure blood glucose level.

S P 1). If blood glucose is less than 70 g/dl, administer dextrose 50% 25 grams (50 cc) IVP.

5. If IV is unsuccessful or delayed:P a. Administer Midazolam 0.1 mg/kg to max 10 mg IM

6. If blood glucose is found to be less than 70 or hypoglycemia is suspected:S P a. Administer dextrose 50% 25 grams (50cc) IVP

B S P b. If no IV access, administer glucagon 1 mg 7. Monitor EKG.

B S P 8. Transport

C. IF PATIENT IS NOT SEIZING, BUT HAS ALTERED MENTAL STATUSP 1. Monitor EKG.

S P 2. Obtain vascular access.3. If blood glucose is found to be less than 70 or hypoglycemia is suspected;

P a. Administer dextrose 50% 25 grams (50cc) IVP.b. If no IV access, administer glucagon 1 mg IM

B S P 4. Transport patient

D. IF PATIENT IS ALERT:S P 1. Obtain vascular access.

B S P 2. Transport patient

E. Possible orders post radio contact (actively seizing): P 1. Additional dextrose 50% 25 grams (50cc) IVP

2. Possible diazepam 2-10mg IVP, rectal




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSYNCOPY PROTOCOL


Purpose: To provide the process for assessment and management of the syncopal, or near syncopal patient.

I. Management

M B S P A. Establish and maintain airway, provide oxygenation and support ventilation.

B. Keep the patient flat, DO NOT try to sit patient up.

1. If third trimester pregnancy, position patient left lateral recumbent.

C. Evaluate and maintain the airway, provide oxygenation and support ventilation as needed.

D. If patient’s mental status remains altered, refer to Altered Mental Status Protocol.

P E. Monitor EKG. Recommend 12-lead EKG when available

S P F. Consider vascular access.

B S P G. Transport

S P H. Possible orders post radio contact:

1. Additional IV fluids as ordered





REVISED APRIL 2007

OB/ GYN

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYOBSTETRICAL EMERGENCIES PROTOCOL


Purpose: To provide the process for the assessment and management of the patient with an obstetrical related emergency.


M B S P A. History:1. Past Medical History: previous births, previous complications2. Current History: duration of gestation (weeks), whether single or multiple births are

expected.3. Assess contractions for duration and frequency.

B. Determine whether to transport or remain at scene due to imminent delivery (need to push or bear down, crowning). If question on whether to transport, contact Medical Control.

K. General Management

A. Evaluate and maintain airway, provide oxygen and support ventilation as needed.S P B. Obtain vascular access, if time permits.

L. Management of Normal Delivery

M B S P A. Have oxygen and suction readily available for care of the newborn.B. If signs of newborn delivery are imminent, and there is no time to transport, prepare for

delivery.1. As baby's head begins to emerge from vagina, support it gently with hand and towel to

prevent an explosive delivery.a. If practical, mouth and nose should be suctioned.

2. After head is delivered, look and feel to see if cord is wrapped around baby's necka. If the cord is around neck and loose, slide it gently - over the head - Do

Not Tug.b. If the cord is around neck and snug, clamp the cord with 2 clamps and cut

between the clamps.3. As the shoulders deliver, carefully hold and support the head and shoulders as the body

delivers, usually very suddenly - and the baby is very slippery! Note the time of delivery.

M B S P 4. Prevent heat lossa. Dry baby off and remove all wet linen.b. Place baby in warm environment.

5. Place the baby on its side with head lower than the body and gently suction mouth and then nose making sure the airway is clear.

a. If evidence of meconium, suction immediately. Contact Medical Control.b. Additional stimulation

6. When infant is delivered and breathing normally, cord should be tied or clamped. 7. Score APGAR at one minute and five minutes after delivery. (See Appendix C)8. Prepare and transport.9. Following placental delivery, massage the uterus to aid in contraction of the uterus.10. Place placenta in basin or plastic bag and transport with mother.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYOBSTETRICAL EMERGENCIES PROTOCOL


11. Do not pull forcefully to remove placenta, only gentle, slow, steady traction may be applied to the cord.

M. Abnormal Deliveries (breech position, prolapsed cord, etc.)

M B S P A. Immediately transport and contact Medical Control as soon as appropriate.B. Administer oxygen

B S P C. Immediate transportD. Possible

orders post-radio contact:

P 1. For persistent seizure, consider:a. Magnesium sulfate 2gms IVP over 1-2 mins. with IV running wide open.

Additional 2 gms IVP repeated if seizure continues.b. Diazepam 2 - 10 mg IVP slowly, if no response to Magnesium Sulfate

N. Special Considerations

A. For vaginal bleeding, refer to hemorrhage (non-traumatic) protocol.B. Breech Position

1. Transport immediately and contact medical control.2. Buttocks/trunk may deliver spontaneously. Do not pull or attempt to accelerate delivery

unless legs and buttocks are delivered to the level of umbilicus on their own.3. Once legs clear, support body on palm of your had and surface of your arm allowing

head to deliver.4. If head doesn’t deliver immediately, transport rapidly to the hospital with mother’s

buttocks elevated on pillows with baby’s airway maintained throughout transfer.a. Place gloved hand in vagina with your fingers on either side of baby’s nose

and push the vaginal wall away from baby’s face until head is delivered C. Prolapsed Cord – Life Threatening Condition

1. Place mother in supine position with hips supported on pillow2. Evaluate and maintain airway, provide oxygen3. With sterile gloved hand, gently push baby up the vagina several inches to release

pressure on the cord.4. Do not attempt to push cord back5. Transport. Maintain pressure on baby’s head.

D. Arm or Limb Presentation1. Immediate transport2. Position of comfort

Delivery should not be attempted outside hospital





REVISED APRIL 2007

Psychiatric

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPSYCHIATRIC EMERGENCIES PROTOCOL


Purpose: To provide a process for the assessment and management of the patient experiencing a psychiatric problem.


M B S P A. History:

1. Current History: head injury, overdose/intoxication, central nervous system disease or infection, hypoglycemia, post-ictal state, or hypoxia.

O. Management

M B S P A. Assure scene is secure.

1. Assure law enforcement agency has been notified.

2. All rescue personnel shall exit the scene until secure.

3. If physical violence has occurred or there is a likelihood that the patient has access to a weapon, do not intervene.

B. Evaluate airway and maintain, provide oxygenation and support ventilation as needed.

C. If patient becomes violent or actions present a threat to patient's safety or that of others, restraint may be necessary. Refer to “Physical Patient Restraint Procedure”.

D. If medical emergency, follow appropriate protocol.

E. Possible orders post radio:

1. If chemical restraint necessary, administer Midazolam 0.1 mg/kg to maximum of 10 mg IM.

P. Special Considerations

A. Definitions:

1. Protective Custody - The temporary custody of an individual by a law enforcement officer with or without the individual's consent for the purpose of protecting that individual's health and safety, or the health and safety of the public and for the purpose of transporting the individual if the individual appears, in the judgment of the law enforcement officer, to be a person requiring treatment. Protective custody is civil in nature and is not to be construed as an arrest. (330.401, Sec. 410, Michigan Mental Health Code)

2. Authority to Restrain - EMS personnel are able to restrain and treat and transport an individual under authority of Sec 20969 of Public Act 179, which states: "This part and the rules promulgated under this part do not authorize medical treatment for or transportation to a hospital of an individual who objects to the treatment or transportation. However, if emergency medical services personnel, exercising professional judgment, determine that the individual's condition makes the individual incapable of competently objecting to treatment or transportation, emergency medical services may provide treatment or transportation despite the individual's objections unless the objection is expressly based on the individual's religious beliefs."


BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPSYCHIATRIC EMERGENCIES PROTOCOL


B. Communication Skills:

1. Keep calm; do not get angry with the patient.

2. Talk slowly and clearly to the patient; do not shout or threaten.

3. Identify yourself and keep the patient constantly informed of what you are doing and why.

4. Use speech that is very simple, in short statements.

5. You may have to repeat yourself since the patient's comprehension abilities may be reduced. "You are safe with us. We are taking you to the hospital where you will be safe."




REVISED APRIL 2007

Trauma

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYTRAUMA ASSESSMENT/STABILIZATION PROTOCOL


Purpose: To provide the process for assessment and management of the trauma patient.

I. Management

M B S P A. Evaluate and maintain the airway, provide oxygenation and support ventilation as needed.

B. Stabilize spinal column while opening the airway, determine level of consciousness. Refer to Spinal Immobilization Procedure.

C. Control major external bleeding.

D. If shock present, refer to Shock Protocol.

E. Initiate transport and consider vascular access.

F. Alert receiving hospital as soon as appropriate.

G. Note mechanism of injury.

H. Refer to Mass Casualty Policy, if appropriate.

I. Scene time of 10 minutes or less is desirable for the major trauma patient with uncomplicated extrication. Minimize scene time.



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYBURNS PROTOCOLREVISED JULY 2007 Page 1 of 2

Purpose: To provide a process for assessment and management of the burned patient, regardless of the cause.

I. Management

M B S P A. Evaluate and maintain the airway, provide oxygenation and support ventilation as needed.

S P B. Obtain vascular access if indicated for pain management or fluid therapy. (See pain management protocol)

M B S P C. THERMAL BURNS:

1. Stop the burning process. Remove smoldering and non-adherent clothing.

2. Assess and treat associated trauma. Protect c-spine.

3. Remove any constricting items.

4. If partial/full burn is moderate-to-severe (more than 10% or 10 palm-sizes), cover wounds with dry clean dressings.

5. Use cool, wet dressings in smaller burns (less than 10%) for patient comfort.

S P 6. If partial or full thickness burn is greater than 10% body surface area or if there is evidence of hypovolemic shock, administer fluid bolus.

M B S P D. THERMAL INHALATION INJURY:

1. Monitor closely for airway deterioration. If evidence of airway involvement or inhalation injury, administer high flow O2 via NRB. Intubate if indicated.

P 2. Monitor EKG.

3. Rapid Transport

E. CHEMICAL BURNS: (Consider Hazmat; Poison Control)

M B S P 1. Protect personnel from contamination and decontaminate prior to transport

2. Remove all clothing and constricting items.

3. Assess and treat for associated injuries.

4. Check eyes for exposure and irrigate as needed.

5. Evaluate for systemic symptoms, which might be caused by chemical contamination. Contact medical control for possible treatment.

6. Wrap burned area in clean, dry dressing for transport. After decontamination, preserve body heat.

a. If partial or full thickness burn is greater than 10% body surface area, or if there is evidence of hypovolemic shock, administer fluid bolus.

F. ELECTRICAL INJURY:

M B S P 1. Protect rescuers from live electric wires.

2. Remove patient from electrical source when safe.

3. Treat associated injuries, provide spinal immobilization when indicated.

P 4. Monitor patient EKG for possible arrhythmias. Treat as per specific arrhythmia protocol.

M B S P 5. Assess and treat entrance and exit wounds.

P G. For all types of burns when indicated, see pain management procedure.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYBURNS PROTOCOLREVISED JULY 2007 Page 2 of 2

H. Possible orders post-radio contact (thermal burns):

P 1. Pain management per procedure.

S P 2. Additional IV fluid bolus

I. Possible orders post-radio contact (thermal inhalation, chemical burns):

P 1. Intubation per procedure.

2. Pain management per procedure.

NOTE: For a non-thermal toxic inhalation, see Poisoning Protocol.

J. Possible orders post-radio contact (electrical injury):

P 1. Pain management per procedure.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYCHEST INJURY PROTOCOL


Purpose: To provide the process for the assessment and management of the patient who may have a chest injury.

I. Management

M B S P A. Establish and maintain airway with spine stabilization (refer to Spinal Immobilization Procedure), provide oxygenation and ventilation as needed.

B. Control hemorrhage.

C. For patient with diminished or absent breath sounds:

1. Look for life-threatening respiratory problems and stabilize:

a. Open or sucking chest wound 3-sided seal or similar.

b. Large flail segment: stabilize

2. If patient is exhibiting signs of respiratory distress/ hypoxia, tachycardia, and lung sounds are diminished, consider tension pneumothorax. If decompression is indicated, refer to pleural decompression procedure

D. Transport as soon as possible.

S P E. Obtain vascular access.

P F. Monitor EKG.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYHEAD TRAUMA PROTOCOL


Purpose: Proper early assessment and management of patients with head injuries is important in obtaining optimal outcome.


M B S P A. Assess level of consciousness1. Determine AVPU2. Measure Glasgow Coma Scale (GCS-See Appendix D)

B. Assess pupils for size, equality, and reactivityC. Signs of cerebral herniation

1. Extensor posturing2. Unequal or unreactive pupils3. Progressive neurologic deterioration

a. Decrease in GCS of >= 2 in patient with initial GCS of <9D. Consider Altered Mental Status Protocol if mechanism of injury and/or obvious injuries

are inconsistent with level of consciousness.

Q. Management

M B S P A. Evaluate and maintain the airway, provide oxygenation and support ventilation as needed.1. Routine hyperventilation is not recommended2. Hyperventilate only for signs of cerebral herniation (see above)

a. Adult hyperventilation=16-20 per minuteb. Child hyperventilation=20-24 per minutec. Infant hyperventilation=24-28 per minute

B. Control bleedingC. Follow Spinal Injury Protocol.

B S P D. Transport as soon as possible if GCS <15S P E. Obtain vascular access

1. If SBP <90a. Administer fluid bolusb. Repeat fluid bolus to maintain SBP >90

2. If SBP >90a. Keep IV TKO

P F. Monitor cardiac rhythmM B S P G. Reassess vital signs, GCS, and pupils as able

I. Possible orders post radio contact:1. Diversion to trauma center/CT equipped hospital, if available.

S P 2. Increase or decrease IV fluid infusion.


BERRIEN COUNTY MEDICAL CONTROL AUTHORITYHEAD TRAUMA PROTOCOL


P 3. Sedation for intubated patient, follow Patient Sedation Procedure.



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSOFT TISSUE & ORTHOPEDIC INJURIES PROTOCOL


Purpose: To provide the process for assessment and management of the patient with potential soft tissue and/or orthopedic injuries.

I. Management

M B S P A. If appropriate, stabilize cervical spine and immobilize patient (per procedure).

B. Evaluate and maintain airway, provide for oxygenation and support ventilation as needed.

C. Assess and maintain adequacy of neurovascular function before and after immobilization.

1. Control all bleeding.

a. Utilize direct pressure.

b. Use dressing and bandaging as needed.

c. Elevate and immobilize for additional control.

d. Utilize pressure points only if direct pressure fails to control hemorrhage.

e. The use of tourniquet should only be considered as an absolute last resort to control hemorrhage.

2. Monitor vital signs for presence of hypotension (eg. hypovolemia).

3. Recoverable amputated parts should be brought to hospital as soon as possible.

D. If patient is unstable, immobilize major orthopedic injuries.

B S P 1. Transport without delay


a. Administer fluid bolus with repeat as needed, titrating to signs of adequate perfusion.

M B S P E. If patient is stable, immobilize orthopedic injuries.

B S P 1. Transport

S P 2. Obtain vascular access, in-patient with major injury or per Medical Control.

P 3. Pain management as indicated. Perform per pain management procedure.

F. Partial/complete amputations and/or severe crush injuries

B S P 1. Cover wounds with sterile gauze dressings moistened with normal saline.

G. Align in anatomical position if indicated. Splint and elevate extremity.

H. Wrap amputated part in sterile gauze dressing moistened with normal saline. Seal in a plastic bag and, if available, place bag in container of ice and water. DO NOT place part directly on ice or dry ice.

I. Continuous monitoring of circulation, sensation, and motion distal to the injury during transport.




J. Possible orders post radio contact:

S P 1. Additional IV fluid bolus

P 2. For analgesia, refer to Pain Management Procedure



R. Special Considerations

M B S P A. All trauma patients need priority assessment and treatment for life-threatening and other injuries per trauma protocol.

B. Treat the patient not the part.

C. Impaled objects are left in place. Removal of impaled objects is with approval of medical control ONLY



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSPINAL INJURIES PROTOCOL


Purpose: Spinal immobilization should occur whenever there is a risk of injury in the trauma patient.

I. Indications for Spinal Immobilization

M B S P A. Mechanism of injury with one or more Specific Objective Findings:

1. Altered Mental Status

(Patient not oriented to person, place and time, history of confusion, memory deficits or loss of consciousness)

2. Use of intoxicants or illicit drugs

(Indicated by history, smell or behavior)

3. Motor and/or sensory deficits present

(Patient unable to appropriately move all extremities, numbness, tingling or shooting pains, decrease or loss of sensation in extremities)

4. Patient complaint of spinal column pain or tenderness on palpation

5. Painful distracting injury or circumstances

6. Long bone fracture proximal to wrist or ankle

7. Priapism

8. Mechanism of injury including fall from more than 5 stairs, axial load, scene fatality, high velocity accident, ejection or rollover, recreational vehicle, auto-pedestrian, other high risk mechanism.

9. Multisystem trauma or blunt or high velocity penetrating trauma above level of clavicle.

B. High risk mechanism of injury

II. Management

M B S P A. Establish and maintain airway with spine stabilization, provide oxygenation and support ventilation as needed.

1. Use modified jaw thrust to open airway.

2. Manual immobilization with hands on bony prominences MUST be done while attempting intubation, even if immobilization equipment is in place, OR during other patient movement procedures.

B. Maintain manual immobilization of the spine.

M B S P C. Immobilize and extricate per spinal immobilization procedure.

D. Transport

S P E. Consider vascular access if indicated.

P F. If patient is Bradycardic or Tachycardic-refer to the appropriate protocol.

Note: High-risk mechanism of Injury is defined as violent impact forces that are clearly capable of damaging the spinal column. Examples include high velocity crashes, a fall from >20 feet, a gunshot wound to the torso or neck




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC TREATMENT PROTOCOLS

REVISED APRIL 2007

Pediatrics

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC TREATMENT PROTOCOLS TABLE OF CONTENTS

REVISED APRIL 2007

1.) General Pediatric Assessment & Treatment

2.) Altered Mental Status

3.) Anaphylaxis/Allergic Reaction

4.) Bronchospasm

5.) Burns

6.) Death of a Child

7.) Foreign Body Airway Obstruction

8.) Near-Drowning

9.) Newborn Resuscitation

10.)Non-Traumatic Shock

11.)Pain Management

12.)Respiratory Distress, Failure, or Arrest

13.)Seizures

14.)Toxic Exposure

15.)Trauma

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC ALTERED MENTAL STATUS PROTOCOL


Purpose: This protocol is intended for patients with an altered mental status of unknown etiology.

I. Management

M B S P 1. Refer to General Pediatric Assessment and Treatment Protocol.2. Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway cannot be

maintained with positioning and the patient is unconscious. 3. Assess breathing. 4. If breathing is inadequate, assist ventilation using a bag-valve-mask device with high-flow,

100% concentration oxygen.S P 5. If the airway cannot be maintained by other means, including attempts at assisted ventilation,

or if prolonged assisted ventilation is anticipated, consider endotracheal intubation. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per medical direction.

B S P 6. If breathing is adequate, place the child in a position of comfort and administer high-flow, 100% concentration oxygen as necessary. Use a non-rebreather mask or blow-by as tolerated.

7. If signs of respiratory distress, respiratory failure, or respiratory arrest are present, refer to the appropriate protocol for treatment options.

8. Assess circulation and perfusion.P 9. Initiate cardiac monitoring.

S P 10. Obtain vascular access. If intravenous access cannot be obtained, proceed with intraosseous access.

P 11. If hypoglycemia suspected and blood sugar less than 70, administer Dextrose:a. 0.5 g/kg of D25 IV/IO (max. dose 2-4 ml/kg of 25% solution

P b. If vascular access is unavailable, administer 0.025 mg/kg glucagon via intramuscular injection. (max. dose 1 mg.)

P 12. Dextrose may be repeated IV at the same dose if hypoglycemia is still suspected and no change in patient’s mental status.

P 13 Administer naloxone at 0.1 mg/kg (maximum individual dose 2 mg) via intravenous or intraosseous route. Naloxone may be given via endotracheal tube or intramuscular injection at the same dose if vascular access is not available.

S P 14. If there is evidence of shock or suspected dehydration, administer a fluid bolus of normal saline at 20 ml/kg set to maximum flow rate. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.

B S P 15. Re-assess mental status.16. Expose the child only as necessary to perform further assessments.17. Keep child as warm as possible.18. If the child’s condition is critical or unstable, initiate transport. Perform focused history and

detailed physical examination enroute to the hospital if patient status and management of resources permit.

19. Reassess the patient frequently.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC ANAPHYLAXIS/ALLERGIC REACTION PROTOCOL


Purpose: To provide a method for assessment and treatment of the patient having an allergic reaction.

I. Assessment

The patient with an allergic reaction will have:

generalized allergic manifestations, such as urticaria (hives)

a history of allergic exposure

To meet the criteria for anaphylactic shock, the patient must have the findings listed above plus one of the following:

partial or complete airway obstruction (wheezing, stridor)

signs of shock, such as altered mental status, respiratory distress, weak or absent peripheral pulses, cyanosis

II. Management

M B S P 1. Refer to General Pediatric Assessment and Treatment Protocol.

P 2. If patient meets criteria for anaphylactic shock, administer epinephrine 1:1000 solution at 0.0l mg/kg (maximum individual dose 0.3 mg) via IM injection. Massage the injection site vigorously for 30 to 60 seconds.

M B S P 3. Assess breathing.

4. If breathing is inadequate, assist ventilation using a bag-valve-mask device with high-flow, 100% concentration oxygen.

S P 5. If the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated, consider endotracheal intubation. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per regional medical direction.

M B S P 6. If breathing is adequate, place the child in a position of comfort and administer high-flow, 100% concentration oxygen as necessary. Use a nonrebreather mask or blow-by as tolerated.

B S P 7. If wheezing is present in a patient with adequate ventilation, administer 2.5 mg albuterol via nebulizer. If wheezing persists, repeat 2.5 mg albuterol via nebulizer.

8. Assess circulation and perfusion.

P 9. Reassess patient for signs of anaphylactic shock. If criteria are still present, repeat epinephrine 1:1000 solution at 0.0l mg/kg (maximum individual dose 0.3 mg) via IM injection.

10. Initiate cardiac monitoring.

S P 11. If the patient meets criteria for anaphylactic shock, establish vascular access using an age-appropriate large-bore catheter. If intravenous access cannot be obtained, proceed with intraosseous access. Do not delay transport to obtain vascular access.

12. If evidence of shock persists, administer a fluid bolus of normal saline at 20 ml/kg set to maximum flow rate. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC ANAPHYLAXIS/ALLERGIC REACTION PROTOCOL


P 13. Administer diphenhydramine at 1 mg/kg (maximum individual dose 50 mg) via intravenous route or deep intramuscular injection if no vascular access.

M B S P 14. Assess mental status.

15. Expose the child only as necessary to perform further assessments. Keep child as warm as possible.

16. If the child’s condition is critical or unstable, initiate transport. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit.


18. Possible orders post contact:

B S Epi-pen Jr




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC ASSESSMENT & TREATMENT PROTOCOL


Purpose: This protocol provides general guidelines for pediatric patient management. Refer to additional protocols as appropriate for treatment of specific conditions.

I. Assessment

M B S P 1. Ensure scene safety.

2. Form a general impression of the patient’s condition.

3. Observe standard precautions.

4. Establish patient responsiveness. If cervical spine trauma is suspected, manually stabilize the spine.

III. Management

1. Assess the patient’s airway for patency, protective reflexes and the possible need for advanced airway management. Look for signs of airway obstruction.

2. Open the airway using head tilt/chin lift if no spinal trauma is suspected, or modified jaw thrust if spinal trauma is suspected.

3. Suction as necessary.

4. Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway cannot be maintained with positioning and the patient is unconscious.

5. Assess the patient’s breathing, including rate, bilateral auscultation, inspection, effort, and adequacy of ventilation as indicated by chest rise. Inspect chest for trauma.

6. If chest rise indicates inadequate ventilation, reposition airway and reassess.

7. If inadequate chest rise is noted after repositioning airway, suspect a foreign body obstruction of the airway. Refer to the appropriate protocol for treatment options.

8. Assess for signs of respiratory distress, failure, or arrest. If present, refer to the appropriate protocol for treatment options.

9. If the child is not breathing or breathing is inadequate, initiate assisted ventilation using a bag-valve-mask device with high-flow, 100% concentration oxygen. Begin with two slow, deep breaths of about 1-1/2 seconds’ duration, then ventilate at 20 breaths/minute for all ages.

S P 10. ONLY if the airway cannot be maintained by other means, including attempts at assisted ventilation, consider endotracheal intubation. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per medical direction.

M B S P 11. If breathing is adequate, place the child in a position of comfort and administer high-flow, 100% concentration oxygen as necessary. Use a non-rebreather mask or blow-by as tolerated.

12. Control hemorrhage using direct pressure or a pressure dressing.

13. Assess circulation and perfusion by measuring heart rate and observing skin color and temperature, capillary refill time, and the quality of central and peripheral pulses.

14. If pulse absent, initiate cardiopulmonary resuscitation per appropriate protocol.

P 15. Initiate cardiac monitoring.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC ASSESSMENT & TREATMENT PROTOCOL


S P 16. If there is evidence of shock, obtain vascular access using an age-appropriate large-bore catheter. If intravenous access cannot be obtained, proceed with intraosseous access. Administer a fluid bolus of normal saline at 20 ml/kg set to maximum flow rate. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.

M B S P 17. Evaluate mental status, including papillary reaction, distal function and sensation.

18. If spinal trauma is suspected, continue manual stabilization, place a sized appropriately rigid cervical collar, and immobilize the patient on long backboard or similar device.




22. Contact medical direction for additional instructions




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC BRONCHOSPASM PROTOCOL


Purpose: To provide a means of assessment and treatment for the patient with bronchospasms.

I. Assessment

1. Bronchospasm is usually accompanied by respiratory distress with the following findings:

Wheezing

prolonged expiration

increased respiratory effort (decreased effort may be noted as patient’s condition approaches respiratory failure)

severe agitation, lethargy

suprasternal and substernal retractions

tripod positioning

IV. Management


B S P 2. If the patient shows signs of respiratory distress or respiratory failure together with clinical evidence of bronchospasm or a history of asthma, administer 2.5 mg albuterol via nebulizer. If these respiratory findings persist, repeat 2.5 mg albuterol via nebulizer. Do not delay transport to administer medications.

If BVM or intubation is necessary, allow extended expiratory phase and low ventilation/ min. rate to prevent air trapping and pneumothorax.

P 3. If no response to nebulizer, administer epinephrine 1:1000 at 0.01 mg/kg IM (maximum individual dose 0.3 mg).

M B S P 4. Assess circulation and perfusion.


S P 6. If the patient shows signs of severe respiratory distress, respiratory failure, or respiratory arrest, establish vascular access and administer normal saline to keep the vein open. If intravenous access cannot be obtained in a patient with respiratory arrest, proceed with intraosseous access. Do not delay transport to obtain vascular access.


8. Expose the child only as necessary to perform further assessments. Keep the child as warm as possible.

9. Initiate transport. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit.


11. Contact medical direction for additional instructions.

V. Special Consideration

A silent chest is an ominous sign indicating that respiratory failure or arrest is imminent .



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC BURNS PROTOCOL


Purpose: To provide a means of assessment and treatment of the patient with burns.

I. Management


2. Stop the burning process. If a dry chemical is involved, brush it off, then flush with copious amounts of water. If a caustic liquid is involved, flush with copious amounts of water. Remove all of patient’s clothing prior to irrigation. Be prepared to treat hypothermia, which may arise secondary to these interventions. For chemical burns with eye involvement, immediately begin flushing the eye with normal saline. Continue flushing throughout assessment and transport.

3. Establish patient responsiveness. If cervical spine trauma is suspected, manually stabilize the spine. Remove the patient’s clothing and jewelry in any affected area.





8. Assess breathing. Refer to the appropriate protocol for management of respiratory distress.


S P 10. ONLY if the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated, consider endotracheal intubation. This step should also be undertaken if inhalation injury is suspected. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per medical direction.

If BVM or intubation is necessary, allow extended expiratory phase and low ventilation/ min. rate to prevent air trapping and pneumothorax.

M B S P 11. If breathing is adequate, place the child in a position of comfort and administer high-flow, 100% concentration oxygen as necessary. Use a non-rebreather mask for potential inhalation injury or any serious thermal burn.


P 13. For electrical burns, initiate cardiac monitoring and determine rhythm. If a dysrhythmia is present, refer to the appropriate protocol for treatment options.

S P 14. If there is evidence of shock in a patient with major thermal burns, obtain vascular access using an age-appropriate large-bore catheter. If intravenous access cannot be obtained, proceed with intraosseous access. Administer a fluid bolus of normal saline at 20 ml/kg set to maximum flow rate. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.


16. If spinal trauma is suspected, continue manual stabilization, place an appropriate sized rigid cervical collar, and immobilize the patient on a long backboard or similar device.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC BURNS PROTOCOL



18. Apply a clean burn sheet or dry sterile dressings to burned areas. To prevent hypothermia, avoid moist or cool dressings over large surface area and do not leave wounds or skin exposed.


P 20. Pain management may be indicated. Refer to the appropriate protocol for treatment options.

M B S P 21. Reassess the patient frequently.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC DEATH OF A CHILD PROTOCOL


Purpose: There is no normal parental reaction to the death of a child. Individual responses may range from emotional outbursts to apparent withdrawal. Rescuers should not make any assumptions or judgments. Maintain a professional demeanor at all times. Perform the initial assessment, environmental assessment, and focused history as part of the clinical process. Observe, assess, and document accurately and objectively.

I. Management


2. Assess airway and breathing. Confirm apnea.


P 4. Initiate cardiac monitoring. Confirm absent pulse.

B S P 5. Determine whether to resuscitate:

If patient does not exhibit lividity or rigor, proceed with cardiopulmonary resuscitation, following the protocol for non-traumatic cardiac arrest. Initiate transport.

If patient exhibits lividity and rigor, shows no signs of life, contact medical control and appropriate law enforcement and refer to dead on scene protocol. Note: Lividity can be mistaken for bruising and evidence of abuse.

VI. Special Considerations (as appropriate)

A. Provide supportive measures for parents and siblings:

Explain the resuscitation process, transport decision, and further actions to be taken by hospital personnel or the medical examiner.

Reassure parents that there was nothing they could have done to prevent death.

Allow the parents to see the child and say goodbye.

Maintain a supportive, professional attitude no matter how the parents react.

Whenever possible, be responsive to parental requests. Be sensitive to ethnic and religious needs or responses and make allowances for them.

B. Obtain patient history using a nonjudgmental approach. Ask open-ended questions as follows:

Has the child been sick?

Can you describe what happened?

Who found the child? Where?

What actions were taken after the child was discovered?

Has the child been moved?

When was the child last seen before this occurred, and by whom?

How did the child seem when last seen?

When was the last feeding provided?

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC DEATH OF A CHILD PROTOCOL


C. Reassess the environment. Document findings, noting the following:

Where the child was located upon arrival

Description of objects located near the child upon arrival

Unusual environmental conditions, such as a high temperature in the room, abnormal odors, or other significant findings

D. If the parents interfere with treatment or attempt to alter the scene, initiate the following actions:

Remain supportive, sympathetic, and professional

Avoid arguing with the parents or exhibiting anger

Do not restrain the parents or request that they be restrained unless scene safety is clearly threatened

E. Document the emergency call, including the following information:

Time of arrival

Initial assessment findings and basis for resuscitation decision

Time of resuscitation decision

Time of arrival at hospital if resuscitation and transport were initiated

Parental support measures provided if resuscitation was not initiated

History obtained (note who provided the information)

Environmental conditions

Time law enforcement personnel arrived on scene

Time that scene responsibility was turned over to law enforcement personnel



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC FOREIGN BODY AIRWAY OBSTRUCTION PROTOCOL


Purpose: To provide a means of assessment and treatment of the patient with an airway obstruction.

I. Management


2. Use age-appropriate techniques to dislodge the obstruction (for infants younger than one year, apply back blows with chest thrusts; for children one year and older, use abdominal thrusts).

S P 3. If unsuccessful, establish a direct view of the object and attempt to remove it with Magill forceps.

4. If unsuccessful, attempt endotracheal intubation and ventilate the patient, once patient is unconscious.

M B S P 5. Assess circulation and perfusion.

6. Assess mental status.







BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC NEAR DROWNING PROTOCOL


Purpose: To provide a means of assessment and treatment of the near drowning patient.

I. Management


2. Assess and manage airway and breathing as per General Pediatrics Assessment and Treatment Protocol.

P 3. Initiate cardiac monitoring and determine rhythm. Consult the appropriate protocol for treatment of specific dysrhythmias.

S P 4. Obtain vascular access. Administer normal saline


6. If spinal trauma is suspected, continue manual stabilization, apply an appropriate sized rigid cervical collar, and immobilize the patient on a long backboard or similar device.

7. Expose the child only as necessary to perform further assessments. Keep child as warm as possible. Remove wet clothing.

8. If the child’s condition is critical or unstable, initiate transport as quickly as possible. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit.

9. Reassess patient frequently.




BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC NEWBORN RESUSCITATION PROTOCOL


Purpose: To provide a method of assessment and treatment of newborn resuscitation.

I. Management


2. Suction the infant’s airway using a bulb syringe as soon as the infant’s head is delivered and before delivery of the body. Suction the mouth first, then the nose.

3. Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the baby in a thermal blanket or dry towel. Cover the infant’s scalp to preserve warmth.

4. Open and position the airway. Suction the infant’s airway again using a bulb syringe. Suction the mouth first, then the nose.

S P 5. If thick meconium is present, initiate endotracheal intubation before the infant takes a first breath. Suction the airway using an appropriate suction adapter while withdrawing the endotracheal tube. Repeat this procedure until the endotracheal tube is clear of meconium. If the infant’s heart rate slows, discontinue suctioning immediately and provide ventilation until the infant recovers. Note: If the infant is already breathing or crying, this step may be omitted.

M B S P 6. Assess breathing and adequacy of ventilation.

7. If ventilation is inadequate, stimulate the infant by gently rubbing the back and flicking the soles of the feet.

8. If ventilation is still inadequate after brief stimulation, begin assisted ventilation at 40 to 60 breaths per minute using a bag-valve-mask device with high-flow, 100% concentration oxygen.

9. If ventilation is adequate and the infant displays central cyanosis, administer high-flow, 100% concentration oxygen via blow-by. Hold the tubing 1 to 1-1/2 inches from the infant’s mouth and nose and cup a hand around the end of the tubing to help direct the oxygen flow toward the infant’s face.

10. Assess heart rate by auscultation.

11. If the heart rate is slower than 60 beats per minute after 30 seconds of assisted ventilation with high-flow, 100% concentration oxygen, initiate the following actions:

A. Continue assisted ventilation.

B. Begin chest compressions at a combined rate of 120/minute (three compressions to each ventilation).

S P C. If there is no improvement in heart rate after 30 seconds, perform endotracheal intubation.

P D. If there is no improvement in heart rate after intubation and ventilation, administer 1:10,000 epinephrine solution at 0.01 mg/kg (maximum individual dose 1 mg) via endotracheal tube, or establish vascular access and administer the same dose. In the neonate, vascular access may be obtained intraosseously, or intravenously. Repeat epinephrine at the same dose every 3 to 5 minutes as needed.

E. Initiate transport. Reassess heart rate and respirations en route.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC NEWBORN RESUSCITATION PROTOCOL


12. If the heart rate is between 60 and 80 beats per minute, initiate the following actions:

Continue assisted ventilation with high-flow, 100% concentration oxygen.

If there is no improvement in heart rate after 30 seconds, initiate management sequence described in step 11, beginning with chest compressions.

Initiate transport. Reassess heart rate and respirations en route.

13. If the heart rate is between 80 and 100 beats per minute, initiate the following actions:

Continue assisted ventilation with high-flow, 100% concentration oxygen.

Stimulate as previously described.

Initiate transport. Reassess heart rate after 15 to 30 seconds.

14. If the heart rate is faster than 100 beats per minute, initiate the following actions:

Assess skin color. If central cyanosis is still present, continue blow-by oxygen.

Initiate transport. Reassess heart rate and respirations en route.





BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC NON-TRAUMATIC SHOCK PROTOCOL


Purpose: To provide a method of assessment and treatment of the patient in non-traumatic shock.

I. Assessment

Shock may be categorized as hypovolemic, distributive, or cardiogenic. Manifestations of shock include:

altered mental status

tachypnea

tachycardia

absent peripheral pulses

cool, clammy, mottled skin

capillary refill time longer than 2 seconds

hypotension and/or bradycardia (late findings)

VII. Management



S P 3. Establish vascular access using an age-appropriate large-bore catheter. If intravenous access cannot be obtained, proceed with intraosseous access. Do not delay transport to obtain

vascular access.

4. If evidence of shock, administer a fluid bolus of normal saline at 20 ml/kg set to maximum flow rate. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.

B S P 5. Assess mental status.







BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC PAIN MANAGEMENT PROTOCOL


Purpose: To provide a method of assessment and management of a patient with pain.

I. Management


S P 2. Obtain vascular access. Administer normal saline to keep the vein open.


P 4. Contact medical control for altered mental status prior to administering pain management.

M B S P 5. Expose the child only as necessary to perform further assessments. Keep child as warm as possible.


P 7. Assess the patient’s pain using a numerical scale or visual analogue scale as appropriate to child’s abilities.

8. Administer Morphine: 0.1 mg/kg (maximum individual dose 10 mg) via intravenous or subcutaneous route

9. After drug administration, assess the patient’s response. Note adequacy of ventilation and perfusion.


11. Contact medical direction for further instructions.



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC RESPIRATORY DISTRESS, FAILURE or ARREST PROTOCOL


Purpose: To provide a method of assessment and treatment of the patient in respiratory distress, failure or arrest.

I. Assessment

A. Respiratory distress is indicated by the following findings: alert, irritable, anxious stridor audible wheezing respiratory rate faster than normal for age intercostal retractions nasal flaring neck muscle use central cyanosis that resolves with oxygen administration mild tachycardia able to maintain sitting position (children older than four months)

B. Respiratory failure involves the findings above with any of the following additions or modifications: sleepy, intermittently combative, or agitated increased respiratory effort at sternal notch marked use of accessory muscles retractions, head bobbing, grunting central cyanosis marked tachycardia poor peripheral perfusion decreased muscle tone Respiratory arrest involves the findings above with any of the following additions or

modifications: unresponsive to voice or touch absent or shallow chest wall motion absent breath sounds respiratory rate slower than 10 breaths per minute weak to absent pulses bradycardia or asystole limp muscle tone unable to maintain sitting position (children older than four months)

II. Management


2. Assess the patient’s airway for patency, protective reflexes and the possible need for advanced airway management. Look for signs of airway obstruction. Signs include: absent breath sounds tachypnea intercostal retractions stridor or drooling (See III. Special Considerations below before treatment). choking bradycardia cyanosis

3. If foreign body obstruction of the airway is suspected, refer to the appropriate protocol for treatment options.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC RESPIRATORY DISTRESS, FAILURE or ARREST PROTOCOL





7. Assess the patient’s breathing, including rate, auscultation, inspection, effort, and adequacy of ventilation as indicated by chest rise.

8. If chest rise indicates inadequate ventilation, reposition airway and reassess.

9. If inadequate chest rise is noted after repositioning airway, suspect a foreign body obstruction of the airway. Refer to the appropriate protocol for treatment options.

10. Assess for signs of respiratory distress, failure, or arrest. If signs of respiratory failure or arrest are present, assist ventilation using a bag-valve-mask device with high-flow, 100% concentration oxygen.

S P 11. ONLY if the airway cannot be maintained by other means, including attempts at assisted ventilation, consider endotracheal intubation. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per medical direction.

M B S P 12. If breathing is adequate and patient exhibits signs of respiratory distress, administer high-flow, 100% concentration oxygen as necessary. Use a non-rebreather mask or blow-by as tolerated.

13. If wheezing is present, refer to the appropriate protocol for treatment options.



S P 16. If the patient shows signs of severe respiratory failure or respiratory arrest, establish vascular access and administer normal saline to keep the vein open. If intravenous access cannot be obtained, proceed with intraosseous access. Do not delay transport to obtain vascular access.



19. Initiate transport. Perform focused history and detailed physical en route to the hospital if patient status and management of resources permit.



III. Special Considerations

A patient who presents with acute respiratory distress of sudden onset accompanied by fever, drooling, hoarseness, stridor, and tripod positioning may have a partial airway obstruction. Do nothing to upset the child. Perform critical assessments only. Enlist the parent to administer blow-by oxygen. Place the patient in a position of comfort. Do not attempt vascular access.

TRANSPORT IMMEDIATELY!



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC SEIZURE PROTOCOL


Purpose: This protocol is intended for patients who are experiencing status epilepticus. To manage seizures in patients who are not experiencing status epilepticus, contact on-line medical control for instructions.

I. Assessment

Status epilepticus:

a single episode of seizure activity lasting longer than 5 minutes, or

two or more episodes of seizure activity between which the patient does not regain consciousness

II. Management


2. Protect the patient from injury during involuntary muscular movements.





7. Assess breathing.


S P 9. ONLY if the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated, consider endotracheal intubation. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per regional medical direction.

M B S P 10. If breathing is adequate, place the child in a position of comfort and administer high-flow, 100% concentration oxygen as necessary. Use a non-rebreather mask or blow-by as tolerated.



S P 13. Establish vascular access. Administer normal saline at a sufficient rate to keep the vein open.

P 14. Check blood sugar. If <70 mg/dl, administer intravenous dextrose as follows:

0.5 g/kg of D25 IVP

If vascular access is unavailable, administer 0.025 mg/kg glucagon via intramuscular injection. (max. 1 mg)

P 15. Dextrose may be repeated at same dosage if hypoglycemia is still suspected and patient is still in status epilepticus.

16. Intravenous anticonvulsants should be given slowly (over 1-2 minutes) to avoid apnea. Administer one of the following anticonvulsants:

Diazepam 0.2 mg/kg (maximum individual dose 10 mg) via intravenous route or 0.5 mg/kg (maximum individual dose 10 mg) via rectal route

Midazolam 0.05-0.1 mg/kg (maximum individual dose 5 mg) via intravenous or intramuscular route

17. If seizures persist, repeat Diazepam or Midazolam at the same dose or medical control for further instructions.


BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC SEIZURE PROTOCOL








BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC TOXIC EXPOSURE PROTOCOL


Purpose: To provide a method of assessment to treat the patient exposed to toxins.

I. Management


2. Look for the source of the toxic exposure. Initiate decontamination prior to transport. If ocular exposure, irrigate with copious amounts of water or saline, continuing during transport. Remove any contaminated objects or clothing. Collect any containers or medication bottles to transport with the patient to the hospital. Refer to decontamination procedure.


S P 4. Obtain vascular access as indicated.

P 5. If respiratory depression is present and a narcotic overdose is suspected, administer naloxone at 0.1 mg/kg (maximum individual dose 2 mg) via intravenous, intraosseous, or intramuscular route.

M B S P 6. Contact medical control for other toxic exposures.

7. Assess mental status.





II. Special Considerations

Treatment for other toxic exposures may be instituted as permitted by medical control. Other treatments include the following and if medical control chooses to implement treatments, must identify dosages:

High-dose atropine for organophosphates

Sodium bicarbonate for tricyclic antidepressants

Glucagon for calcium channel blockers or beta-blockers

Diphenhydramine for dystonic reactions

Dextrose for insulin overdose



BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPEDIATRIC TRAUMA PROTOCOL


Purpose: The priorities in pediatric trauma management are to prevent further injury, provide rapid transport, notify the receiving facility, and initiate definitive treatment. On-scene time for a traumatic injury should be less than 10 minutes unless there are extenuating circumstances, such as extrication, hazardous conditions, or multiple victims.

I. Management


2. If breathing is adequate, 100% concentration oxygen as necessary. Use a non rebreather mask or blow-by as tolerated.

P 3. If breath sounds are absent or signs of severe respiratory distress are noted together with a mechanism of injury that could cause a tension pneumothorax, perform needle decompression. Use an 18- or 20-gauge over-the-needle catheter. Insert the needle in the mid-clavicular line at the second intercostal space, just above the third rib.

M B S P 4. Control hemorrhage using direct pressure or a pressure dressing.




8. Continue manual stabilization while placing an appropriate sized rigid cervical collar. Immobilize the patient on a long backboard or similar device.

B S P 9. Initiate transport to an appropriate facility.

S P 10. Obtain vascular access using an age-appropriate large-bore catheter and administer normal saline to keep the vein open. If extenuating circumstances delay transport, obtain vascular access on the scene, but do not delay transport to obtain vascular access.

11. If there is evidence of shock, initiate vascular access. If intravenous access cannot be obtained, proceed with intraosseous access. Administer a fluid bolus of normal saline at 20 ml/kg set to maximum flow rate. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg.

M B S P 12. Splint obvious fractures of long bones.

13. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit.






BERRIEN COUNTY MEDICAL CONTROL AUTHORITYGENERAL PROCEDURES

REVISED JULY 2007

General Procedures

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYGENERAL PROCEDURES INDEX

REVISED JULY 2007

Airway Management Albuterol Nebulizer DecontaminationElectrical Therapy (as appropriate for level of care in system) Epi-Pen Helmet Removal Medication Administration MCA – Mutual Aid AgreementObstructed Airway Pain Management Patient Assessment Patient Restraint Patient Sedation Pleural decompression Spinal Immobilization Taser/Stun GunVagal Maneuvers Vascular Access

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYAIRWAY/OXYGENATION PROCEDURE


Purpose: To define and describe the procedure for evaluating, establishing, and maintaining an airway, providing oxygenation and ventilation.

M B S P I. Evaluate adequacy of airway, oxygenation and ventilation A. Verify patent airway (i.e., clear, free of foreign substances, stridor) B. Assess for impaired oxygenation (i.e., cyanosis, altered LOC, dyspnea) C. Assess for insufficient ventilation (i.e., rate, depth, abnormal breath sounds) D. Patients with chest pain, altered level of consciousness, significant trauma, or other

conditions at risk for hypoxia should receive supplemental oxygen

II. Establish and maintain patent airway A. Manually open airway:

1. Medical patient: use Head Tilt-Chin Lift, or Head tilt- Jaw Thrust 2. Trauma patient: use Modified Jaw Thrust

B. If unable to establish open airway, proceed to Obstructed Airway Procedure. C. Clear airway of secretions or emesis:

1. Turn patient to side, if possible, maintaining spinal immobilization in trauma patient.

2. Suction the oropharynx with a large bore catheter. a. In general, 15 seconds should be used for the maximum time suctioning

between assessments and oxygenation. b. Suctioning must continue until airway established.

D. Insert basic airway adjunct: 1. Oropharyngeal airway (without gag reflex). 2. Nasopharyngeal airway (with gag reflex).

S P E. To secure a definitive airway: 1. Establish endotracheal tube placement

a. Maximum of 2 attempts per provider/ 4 total attempts maximum. Each attempt should generally be limited to 30 seconds.

1) Oxygenate between attempts.2) An appropriate alternative to ET intubation is to insert a dual lumen

airway or LMA. S P F. Orotracheal Intubation Procedure

1. Indications a. Unconscious and unable to maintain airway with absence of gag

reflex. 2. Contraindications

a. Unable to open mouth 3. Procedure:

a. Assemble and inspect equipment. 1) Use of stylet recommended.

b. Pre-oxygenate and hyperventilate. 1) Avoid excessive hyperventilation. 2) Monitor pulse ox continuously .

c. Use assistant as appropriate.d. Position patient’s head.

1) Slight hyperextension if no trauma. 2) Neutral position with manual immobilization if trauma suspected.



e. Suction may be necessary before intubation. f. Use Selleck's maneuver to prevent aspiration. This may also facilitate

cord visualization. g. Perform laryngoscopy. h. Perform intubation

1) If possible, visualize tube pass between cords. i. Without releasing tube, inflate cuff. j. Utilize Esophageal Detection Device (EDD) to confirm tube placement. k. Ventilate and auscultate for tube placement

1) Epigastrium (positive gastric sounds indicate esophageal tube placement).

2) Chest (asymmetric breath sounds may indicate mainstem intubation).

l. Apply end tidal CO2 device for a perfusing patient. m. Repeat laryngoscopy if tube placement questionable. n. Secure ET tube and re-evaluate prior to any patient movement. o. Consider immobilization of patient’s head to maintain tube position. p. Assure adequate oxygenation and ventilation. q. Re-evaluate for tube location following any patient movement and while

performing patient care. S P G. Nasotracheal Intubation Procedure

1. Indications: a. Breathing patient in need of airway support.

1) Comatose patient unable to open the mouth2) Respiratory failure with gag reflex.

2. Contraindications (relative): a. Patient with mid-face instability/facial trauma (consider dual lumen

airway device). 3. Procedure:

a. Assemble and inspect equipment. 1) Consider tip controlled endotracheal tube.

b. Pre-oxygenate and hyperventilate. 1) Avoid excessive hyperventilation.

c. Use assistant as appropriate. d. Administer neosyphnephrine spray. e. Lubricate tip of ET tube with lidocaine jelly if available. f. Use Selleck’s maneuver to facilitate cord stabilization. g. Insert tube into nare without a stylet (consider right nare first with bevel

against septum). h. Advance tube along floor of nose. i. If resistance is met, rotate tube slightly. j. Listen for breathing, advance tube during inspiration.

1) Observe for fogging. No sound means tube is not in the trachea. k. Without releasing tube, inflate cuff. l. Ventilate and auscultate for tube placement

1) Epigastrium (positive gastric sounds indicate esophageal tube placement).

2) Chest (asymmetric breath sounds may indicate mainstem intubation).



m. Apply end tidal CO2 device for a perfusing patient. n. Secure ET tube and re-evaluate prior to any patient movement. o. Consider immobilization of patient’s head to maintain tube position. p. Assure adequate oxygenation and ventilation. q. Re-evaluate for tube location following any patient movement and

regularly throughout patient care.

B S P H. CombiTube Insertion Procedure

1. Indications

a. Unconscious and unable to maintain airway with absence of gag reflex.

2. Contraindications:

a. Patient under 5 feet tall and over 6 feet 7 inches

1) Patient between 4 and 5 ½ feet tall use CombiTube SA.

b. History of caustic ingestion.c. History of esophageal varices. d. Known or suspected foreign body obstruction of the larynx or trachea. e. Presence of a tracheostomy

3. Procedure for CombiTube Insertion

f. Assemble and inspect equipment. g. Pre-oxygenate and hyperventilate.

1) Avoid excessive hyperventilation.

h. Use assistant as appropriate. i. Suction may be needed. j. Position head in neutral alignment k. Lift tongue and lower jaw upward with one hand. l. With other hand, hold CombiTube so that it curves in the same direction

as curve of pharynx. Insert the tip into the mouth and advance gently until the printed ring is aligned with the teeth/gums.

m. Inflate oropharyngeal cuff (blue port/#1)

1) CombiTube 100 ml of air. 2) CombiTube SA 85 ml of air.

n. Inflate distal cuff (white port/#2)

1) CombiTube 15 ml of air. 2) CombiTube SA 12 ml of air.

o. Begin ventilation through blue tube. Auscultate for gastric and breath sounds.

1) If gastric sounds are absent and breath sounds are present, continue ventilation through this tube.

2) If gastric sounds are present, immediately begin ventilation through the other clear tube. Re-auscultate to confirm tracheal tube placement.

p. Remove syringes and monitor that cuffs remain inflated. q. Listen for air leak. If needed for good seal, up to 40 ml additional air may

be added to blue port. r. Consider passing orogastric tube through tube 2 to relieve gastric

distention. Only if tube is in esophageal position.



III. Tracheal Suctioning

A. Indications: excessive secretions that compromise ventilations/oxygenation

S P B. Via Endotracheal or Tracheostomy Tube:

1. Pre-oxygenate and hyperventilate. 2. Use sterile flexible catheter down ET tube for less than 15 sec. 3. Suction only on way out. 4. Consider use of up to 10 ml of normal saline solution if thick secretions present. 5. Aseptic technique should be used.

M B S P IV. When airway is patent, support oxygenation and ventilation.

B. If ventilation is inadequate begin positive pressure ventilations:

1. Pocket mask with one-way valve with supplemental oxygen, if available. 2. Bag-Valve-Mask (BVM) with supplemental oxygen, if available 3. Use two rescuer technique, if available. 4. The use of manually triggered high positive pressure breathing devices (Demand

Valve) is prohibited.

C. If patient is breathing adequately and needs supplemental oxygen:

1. Use non-rebreathing mask at 12-15 lpm. 2. A nasal cannula may be used at 2-6 lpm, for patients with little or no respiratory

distress or unable to tolerate a non-rebreathing mask.

M B S P V. Pediatric Considerations:

A. If chest rise is inadequate, reposition airway and reassess. If no improvement, consider foreign body obstruction and go to appropriate protocol.

B. If child is breathing with no signs of respiratory distress, administer supplemental oxygen (100 %) by mask, blow-by, or nasal cannula as needed.

C. If child is breathing with signs of respiratory distress, administer high flow oxygen (100%) as necessary. Initiate cardiac monitoring and pulse oximetry. If bronchospasm is present, refer to appropriate protocol.

D. If child is not breathing or breathing is inadequate, initiate ventilation using a bag-valve-mask device with high flow (100%) oxygen. Begin with two slow, deep breaths of 1 ½ seconds duration. Then ventilate at 20 breaths/minute. Initiate cardiac monitoring and pulse oximetry, if available.

S P E. If a child in respiratory failure cannot be adequately ventilated using BMV, or if prolonged ventilation is anticipated, consider endotracheal intubation as permitted by medical control.

1. Confirm tube placement using clinical assessment and end-tidal CO2 monitoring device.

2. Esophageal Detection Device (EDD) is not recommended.

VI. Asthma Considerations:

D. If asthma is suspected as cause of respiratory failure, adjust respiratory rate to allow prolonged expiration. Normal respiratory rate used via BVM or in an intubated patient will lead to air trapping, failed ventilation and possible pneumothorax

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYALBUTEROL/NEBULIZER PROCEDURE


Purpose: Proper administration of nebulized medications.

I. Indication

A. Patient with respiratory distress and wheezing.

B S*P

II. Management

A. Obtain vital signs and lung sounds.

B. Place the appropriate volume of medication in the lower half of the nebulizer unit. Then screw the upper half of the unit in place.

C. Attach the nebulizer to the base of the T-piece. Then attach the mouthpiece to the T-piece or connect neb chamber to NRB mask.

D. Attach one end of the oxygen tubing to the base of the nebulizer and the other end of the oxygen tubing to the oxygen source.

E. Set the oxygen liter flow at 6-7 L/min.

F. Instruct the patient to breathe normally through the mouthpiece, taking a deep inspiration every 4 or 5 breaths.

G. Continue the treatment until all the medication has been delivered through the nebulizer. You may need to gently tap the reservoir once or twice during the treatment to re-disburse the medication.

H. Obtain and record another complete set of vital signs and lung sounds after completion of the treatment.

III. Pediatric Considerations

A. Infants and small children may not be able to use adult mouth piece and may need to use blow-by.

*Optional Intervention for Basic and Specialist:

Albuterol 2.5mg-5mg nebulized

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYDECONTAMINATION PROCEDURE


Purpose: To reduce patient exposure and prevent personnel and equipment exposure/contamination.

M B S PI. Indications

A. Suspect exposure to radiation or chemical toxin.

B. Consider gasoline exposure in motor vehicle accidents.

C. Do not enter scene until properly cleared and protected with appropriate personal protective equipment.

D. Alert medical control and local health authorities as appropriate.

II. Chemical Decontamination

A. Wear proper personal protective equipment. Consider possible fumes given off by chemical agents.

B. Remove all clothing. Cut off clothing – do not pull over head. Provide privacy when possible.

C. Decontaminate skin and hair with copious water and soap when available. Irrigate eyes with copious water or normal saline and remove contact lenses when possible. Use heated enclosure when possible. Water used to decontaminate should be contained when possible without delaying transport.

D. Transport patient. Keep patient warm. Do not transport clothing or contaminated articles.

III. Radiation Decontamination

A. Secure safety of accident scene

B. Wear proper personal protective equipment and radiation exposure monitoring device.

C. Remove patient’s clothes.

D. Irrigate wounds, eyes, skin and hair with copious water. Contain water drainage.

E. Keep patient warm and transport.

IV. Transport to designated isolation/decontamination area when appropriate and as per medical control.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYELECTRICAL THERAPY PROCEDURE


Purpose: To perform appropriate electrical therapy.

I. Automated External Defibrillation – See separate Protocol

II. Manual Defibrillation

Note: This procedure is to be used in conjunction with the appropriate protocol by Paramedics only.

A. Indications: ventricular fibrillation, pulseless ventricular tachycardia

B. Technique: See treatment protocol

III. Synchronized Cardioversion


A. Indications: unstable patient with a pulse requiring cardioversion

B. Contraindication: heart rate <150 unless ordered by medical control

C. Technique:

1. Consider IV and sedation per protocol. 2. Turn synchronizer switch "on". Assure QRS complex is marked. 3. Apply defibrillator paddles/pads according to manufacturer specifications. 4. Charge defibrillator to energy level specified in appropriate protocol or according

to manufacturer specifications. 5. Check rhythm. 6. Cardiovert patient. 7. Recheck pulse and rhythm 8. If rhythm does not convert, re-cardiovert according to the appropriate protocol. 9. If ventricular fibrillation occurs, deactivate synchronized mode and defibrillate.

IV. Transcutaneous Pacing


A. Indications: bradycardias/heartblock with inadequate perfusion

B. Technique:

1. Monitor EKG. 2. Consider sedation per protocol. 3. Apply Pacing Electrodes (anterior - posterior preferred).

a. One pad to left anterior chest and one pad beneath left scapula or per manufacturer specifications.

b. Pads may also go on antero-lateral (lead II position)

4. Assure adequate amplitude of QRS complexes 5. Set external pacemaker rate to 70 B.P.M. 6. Rapidly dial up at increments of 10-20 MA until capture occurs.

a. Use only minimal MA needed for mechanical capture.

7. Assure adequate electrical/mechanical capture.

a. Electrical: Visible pacer spike immediately followed by wide QRS and T-wave.

b. Mechanical: improved pulses, LOC, BP

8. If mechanical capture is not obtained, contact medical control. Perform CPR if appropriate.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYELECTRICAL THERAPY PROCEDURE


V. Special Considerations for Electrical Therapy:

A. Early defibrillation is a high priority goal.

B. Dry the chest wall if wet or diaphoretic.

C. Remove medication patches.

D. Avoid placing the paddles/pads over a pacemaker or internal defibrillator.

E. If visible muscle contraction of the patient did not occur, defibrillation did not occur, inspect equipment.

F. Avoid physical contact with patient during defibrillation/ cardioversion.

G. Electrical therapy may not be successful in hypothermic patients; refer to hypothermia protocol.

H. If a sinus rhythm is achieved by cardioversion and reverts to the previous rhythm, repeat the cardioversion at the same setting as was initially successful.

I. Clip/shave hair (if pads won't adhere).

J. Transcutaneous pacing may be performed in pulseless electrical activity.

VI. Pediatric Considerations:

A. Infant paddles are to be used until 1 year of age or up to 10 kilograms.

B. Defibrillation may be performed pre medical control contact.

C. Cardioversion and transcutaneous pacing post medical control contact.

.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYEPI-PEN PROCEDURE


Purpose: To allow use of Epi-pen/Epi-Pen Jr. for life-threatening anaphylaxis by authorized prehospital providers licensed at or above the Medical First Responder level.

B S P

I. Indications

A. Life-threatening allergic/anaphylactic reactions

B. Use with Allergic Reaction/Anaphylaxis Protocol

II. Contraindications

A. No absolute contraindications to life-threatening anaphylaxis

Caution: Use with caution in patients with heart disease, high blood pressure, and stroke.

III. Technique

A. Use of Epi-Pen only allowed after contact with Medical Control

B. Epi-Pen is an auto-injector that injects medication into the subcutaneous tissue when the device is pushed against the skin. Injection is to be done at the anterolateral portion of the thigh.

C. Dosing: Epi-Pen (0.3 mg) is used for patients weighing over 32 kg and between the ages of 11 and 70. Epi-Pen Jr. (0.15 mg) is used for patients from age 2 to 11, and weighing at least 10 kg.

IV. Documentation

A. EMS providers will note any changes in the patient’s condition and report those changes to on-line medical control and document changes on the run form and complete the Epi-Pen Utilization Form.

V. Accountability

Epi-Pens will be stored in a securely locked compartment in a temperature controlled area of the EMS vehicle. They will be furnished by the hospital and replaced according to the “Pharmacy Procedure”

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYEPI-PEN PROCEDURE


Epi-Pen Utilization Form(To be used by Hospital)

Drug Standard Quantity Count Expiration Date Epi-Pen 0.3 mg 2 ______ _____________ Epi-Pen Jr. 0.15 mg 2 ______ _____________ Run Date _________________________________________________ Patient Name ______________________________________________ Physician _________________________________________________ EMT _____________________________________________________ Receiving Hospital __________________________________________

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYHELMET REMOVAL PROCEDURE


Purpose: To insure proper handling of patients suspected of sustaining a head, neck or back injury while wearing a protective helmet.

Policy: In the event that an individual is injured while wearing a protective helmet, the initial assessment should proceed as outlined in the primary assessment protocol with concern for assessing airway, breathing and circulation while addressing the potential for cervical spine injury. The goal is to appropriately treat the patient in terms of cervical spine immobilization and manage the patient's airway.

M B S P

I. High Impact Helmets (i.e. motorcycle, car racing)

A. Whether the helmet is a closed or open faced style helmet, the helmet must always be removed prior to immobilization because it interferes with a proper assessment of possible head injury and will cause the cervical spine into a flexion position while the patient is supine.

M B S P

II. Low Impact Helmets with Shoulder Pads (i.e. football, ice hockey, etc.)

A. In those patients wearing a well-fitted helmet which conforms closely to the patient's head, it is generally preferable to leave the helmet in place:

1. A well-fitted helmet can be determined by trying to place the first and second fingers between the forehead of the patient and the frontal pad of the helmet. If this cannot be achieved, the helmet is well-fitted.

2. If the patient is awake and able to protect his/her airway, the helmet should be left in place and the patient immobilized using the helmet to assist with immobilization. The face shield must be removed prior to transport.

3. If the patient has an altered level of consciousness or, for any other reason, is unable to protect his/her airway, the helmet should be left in place and the patient immobilized using the helmet to assist with immobilization. The face shield should be immediately removed to allow access to the airway.

a. If the face shield cannot easily be removed, the helmet must be removed using in-line immobilization.

B. If the airway cannot be controlled for any reason with the helmet in place, the helmet should immediately be removed, using in-line immobilization.

C. In the event that the helmet must be removed, the patient’s shoulder pads must be removed to maintain neutral alignment of the cervical spine for immobilization.

D. It is common that in these types of sports the athlete will wear a well-fitted helmet without shoulder pads in the pre-season. If this is the case, the helmet must be removed prior to immobilization because it will cause the cervical spine into a flexion position while the patient is supine

M B S P

III. Low Impact Helmets without Shoulder Pads (ie. baseball, bicycle, rollerblade, etc.)

A. Whether the helmet is a closed or open faced style helmet, the helmet must always be removed prior to immobilization because it will cause the cervical spine into a flexion position while the patient is supine.

NOTE: When immobilizing patients with the helmet in place, the cervical immobilization portion of most immobilization devices will cause the neck to flex forward when the patient's head is placed on it. For that reason, head immobilization devices should generally not be used in these patients. The helmet should rest directly on the backboard with towel rolls used to provide lateral support to the helmet. EMS crews should work closely with sports medicine personnel (team trainers and physicians) for organized team sports. When providing scheduled standbys at sporting events, EMS personnel should introduce themselves to the sports medicine personnel of the teams prior to the game.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYMEDICATION ADMINISTRATION PROCEDURE


I. Indications for Administration

A. Need for medication identified by on-scene paramedic or as ordered by on-line medical control.

B. Establish allergies.

C. Paramedic is familiar with the medication, actions, and side effects

II. Preparation for Administration

A. Medication is checked for:

1. Right medication 2. Right dose /amount 3. Right time 4. Right route for administration 5. Expiration date

III. Administration

A. Oral Medications

1. Provide medications to patient with direction on the administration (i.e.: to be chewed, swallowed, held under the tongue, or buccal, etc.)

B. Rectal Medications

1. Attach a Teflon catheter (from an angiocath) to the end of a syringe that contains medication to be administered. Gently insert catheter into rectum and instill medication.

C. Nebulizer Therapy refer to Albuterol Nebulizer Procedure

D. Endotracheal Administration

1. When vascular access is delayed and an endotracheal tube is in place, specific medications can be administered down the ET tube.

2. The medication is rapidly injected down the tube in a bolus that is diluted or followed by normal saline to flush the tube. Do not exceed 10 ml in one fluid bolus.

3. The medications that may be given down the ET tube are:

a. epinephrine b. atropine c. naloxone (Narcan) d. lidocaine

E. Subcutaneous Injections

1. Medication is prepared in syringe 1 ml or less with needle 25-27ga., 1/2 - 5/8 inch.

2. A site is selected and cleansed with alcohol (upper outer arm, front of the thigh, or abdomen).

3. Pinch skin up into a fat fold of at least 1 inch. 4. Insert needle at 45-degree angle, aspirate. 5. If no blood appears in syringe, inject medication slowly. 6. Gently massage site with alcohol wipe. 7. Dispose of syringe in sharps container.

F. Intramuscular Injections

1. Medication is prepared in syringe of less than 5 cc with needle 18-22ga., 1 1/2-2 inches. 0.2 ml of air may be added to syringe.

2. Site is selected and cleansed with alcohol (deltoid, dorsal gluteal, ventro-gluteal, or vastus lateralis).

3. Spread skin taut, insert needle at 90 degree angle, aspirate.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYMEDICATION ADMINISTRATION PROCEDURE


4. If no blood appears in syringe, inject medication slowly. 5. Apply slight pressure to site with alcohol wipe. 6. Dispose of syringe in sharps container.

G. Intravenous Medications: Bolus Dose

1. Medication is prepared in syringe with Luer-lock connector or protected-needle. (A needle to insert into a port should only be used as a last resort.)

2. All air is cleared from syringe and excess medication expelled. 3. Site is cleansed and syringe is attached via luer-lock to stop-cock, other luer-lock

connector, or protected needle is inserted into capped port of IV line. 4. Patency of IV is checked by aspirating blood or by monitoring flow with no signs

of infiltrate. 5. IV line is clamped or flow is controlled to flush medication, as medication is

pushed into IV port. 6. Time taken to administer medication is specific to medication. Flush IV line to

assure medication administration. 7. Monitor IV catheter site for signs of infiltration. 8. Dispose of syringe in sharps container.

H. Intravenous Medications: Continuous Drip

1. Pre-mixed intravenous medications are selected or appropriate dose of medication is added to intravenous fluid bag. Affix label to fluid container.

2. Calculations of drip rates are completed prior to administration of medication. 3. Shake bag to distribute medication, add administration line and flush. 4. Connect medication bag to closest port possible. Main-line fluid will be turned off

during piggyback drip administration. 5. Control flow rate for desired drops per minute and monitor for consistency.

IV. Post Medication Assessment

A. Assess patient for change in condition following medication administration.

1. Medications are discontinued when possible if untoward effects occur or as directed by physician.

V. Documentation

A. Documentation on patient care record will include:

1. Name of medication 2. Dose and concentration of medication 3. Time of administration 4. Route/site of administration 5. Documentation of narcotic waste with witness signature. 6. Document response to medication.

B. Patient care record is signed by a medical control physician.

VI. Pediatric Considerations:

A. When actual weight is unknown, a length based/color coded resuscitation tape (i.e., Broselow) should be used for pediatric dosing.

1. Medications for tracheal doses should be diluted to a volume of 3 to 5 ml

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPRE-HOSPITAL (EMS) MCA MUTUAL AID AGREEMENT PROCEDURE


Purpose: Establish a mechanism allowing EMS agencies/Medical Control Authorities to give prehospital care across jurisdictional boundaries during “disaster” conditions.

This agreement between the Medical Control Authorities (MCA) demonstrates the intention to assist and support each other during a disaster situation. It provides an approved/authorized process allowing EMS agencies to function within a MCA during a disaster.

During “disaster” conditions, whether natural or otherwise, MCA’s may need assistance from other MCA’s. For the purpose of this agreement, a “disaster” is considered to be an emergency event where a “declared” emergency and/or disaster condition as defined by local, state, or federal statutory laws, exists in which the responding MCA and EMS resources may be unable to handle the patient care needs without additional resources from outside it’s own Medical Control area.

Requests for support may be made to the MCA or EMS agencies within the jurisdiction. It is agreed that mutual aid response is dependent on the availability of equipment and personnel.

It is in the best interests of participating MCA’s to include each other in disaster in planning efforts. It is expected that upon request, participating MCA’s will extend any relevant information on emergency planning to other MCA’s as deemed reasonably appropriate by the participating MCA distributing the information.

Participating MCA’s agree to adopt, as a minimum, the State Model Protocols for responding to a disaster event, and those agencies/EMS personnel will follow these when responding outside their own MCA, unless prior arrangements with that MCA.

It is agreed that signatories may terminate this agreement without cause by providing a 30 day written notice to all other participating MCA’s

.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYOBSTRUCTED AIRWAY PROCEDURE


M B S P I. Indications A. Complete or partial obstruction of the airway due to a foreign body. B. Complete or partial obstruction of the airway due to airway swelling from anaphylaxis,

croup, or epiglottitis; refer to Respiratory Distress Protocol. C. Patient with unknown illness or injury who cannot be ventilated after the airway has

been properly opened. II. Technique

A. Complete Foreign Body Airway Obstruction for Adult Patient 1. In conscious patient greater than 1 year of age perform continuous

abdominal thrusts until object is dislodged or patient goes unconscious. P 2. For the unconscious patient, after two unsuccessful sets of abdominal thrusts,

perform direct laryngoscopy and attempt removal using Magill forceps. a. Removal may be facilitated with simultaneous abdominal thrusts. b. If unsuccessful then attempt intubation. If intubation is successful

but unable to ventilate then gently advance endotracheal tube beyond carina to attempt to push foreign body into one lung and then draw endotracheal tube to normal position to ventilate free lung (always assess for other causes of ventilation failure such as esophageal placement)

M B S P B. Partial Foreign Body Airway Obstruction for Adult Patient 1. Have patient assume a position of comfort. 2. Refer to Airway/Oxygenation Procedure. 3. As long as the patient is moving air or coughing, support airway attempts. 4. If patient demonstrates evidence of deterioration (change in mental status,

inability to ventilate), treat as complete airway obstruction. C. When the Foreign Body Obstruction is relieved for Adult Patient:

1. Place in recovery position. 2. Refer to Airway/Oxygenation Procedure.

D. Suspected Anatomical Obstruction for Adult Patient 1. See Allergic Reaction/Anaphylactic Protocol as appropriate. 2. Refer to Airway/Oxygenation Procedure. 3. Initiate rapid transport.

III. Special Considerations A. No attempts should be made to relieve a partial airway obstruction. However, be ready

to intervene immediately if complete airway obstruction develops. B. Vomiting and aspiration commonly occur after relief of an airway obstruction. Be

prepared to quickly and aggressively suction the patientIV. Pediatric Considerations

A. Use age appropriate techniques to dislodge the obstruction (for infants younger than 1 year, apply back blows with chest thrusts; for children 1 year and older use only abdominal thrusts).

S P B. If unsuccessful, establish a direct view of the object and attempt removal with Magill forceps.

C. If unsuccessful, attempt endotracheal intubation and ventilate. If unable to ventilate and confident of correct positioning, gently advance endotracheal tube beyond carina to attempt to move foreign body into one bronchus. Then withdraw endotracheal tube to normal positioning and attempt ventilation.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPAIN MANAGEMENT PROCEDURE


Purpose: Paramedic management for pain. This procedure is to be followed when directed by the individual medical treatment protocol, or after online Medical Control contact.

I. Indications For Pain Management

A. Relief of moderate to severe pain.


A. Known allergy to medicine.

III. Procedure

A. Maintain airway, provide oxygenation and support ventilation as needed.

B. Obtain vascular access.

C. Administration:

1. Titrate administration of medication to a level where pain is reduced or relieved.

a. Administer morphine sulfate 2-8 mg slow IVP with reassessments after each 2-4 mg. (for peds 0.1 mg/kg IVP, max 4 mg) or as ordered.

b. If allergic to morphine sulfate, consider Patient Sedation Procedure.

c. If IV is not obtained, consider morphine IM.

IV. Pediatric Considerations

A. Administer morphine sulfate 0.1 mg/kg IVP, maximum 4mg, or as ordered.

B. If allergic to morphine sulfate, consider Patient Sedation Procedure.

C. If IV is not obtained, consider morphine IM.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPLERAL DECOMPRESSION PROCEDURE


Purpose: Decompression of a tension pneumothorax. This procedure is for Paramedic use only.

I. Indications

A. Suspected Tension Pneumothorax

1. In PEA (per medical control)

2. In perfusing patient, in significant distress (post medical control)

II. Technique

A. Evaluate and maintain the airway, provide oxygenation and support ventilations.

B. Decompression procedure:

1. Assemble equipment

a. Large bore IV catheter - 16 ga or 14 ga. x 2”

b. Betadine swabs

c. Dressing and tape

2. Identify landmarks

a. Insert needle in the mid-clavicular line at the second intercostal space just above the third rib or fifth intercostals space just above the sixth rib.

3. Prep the area with Betadine

4. Remove flash chamber cap from IV catheter

5. Insert the catheter over the top of the rib until air rushes out. Advance catheter over the needle. Remove needle leaving catheter in place.

6. Reassess breath sounds and patient's condition (patient's condition should improve almost immediately).

7. Secure catheter with tape.

8. Remember, the patient may need to have both sides of chest decompressed due to bilateral pneumothoraces.

III. Possible complications of procedure

A. Pneumothorax

B. Hemothorax

C. Vascular Injury

NOTE:*REMEMBER to go just above the rib due to all of the major structures (arteries, veins, and nerves) which lie below the rib. The closer you stay to the top of the rib, the less chance of complication.

IV. Pediatric Considerations

A. To perform needle decompression use an 18 or 20 gauge over the needle catheter inserting the needle in the mid-clavicular line at the second intercostal space, just above the third rib.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPATIENT ASSESSMENT PROCEDURE


M B S P I. Scene Evaluation A. Recognize environmental hazards to rescuers, and secure area for treatment. Do not

enter scene until secured.B. Recognize hazard for patient, and protect from further injury. C. Identify number of patients. Initiate a MCI/disaster plan if appropriate. D. Observe position of patient, mechanism of injury, surroundings. E. Identify self. F. Utilize universal precautions in all protocols. G. Determine if patient has a valid Do-not-resuscitate bracelet/order.

II. Primary Survey A. Airway:

1. Protect spine from movement in trauma victims. Provide continuous spinal stabilization.

2. Observe the mouth and upper airway for air movement. 3. Establish and maintain the airway. 4. Look for evidence of upper airway problems such as vomitus, bleeding, facial

trauma, absent gag reflex. 5. Clear upper airway of mechanical obstruction as needed.

B. Breathing: Look, Listen and Feel 1. Note respiratory rate, noise, and effort. 2. Treat respiratory distress or arrest with oxygenation and ventilation. 3. Observe skin color and mentation for signs of hypoxia. 4. Expose chest and observe chest wall movement, as appropriate. 5. Look for life-threatening respiratory problems and stabilize:

a. Open or sucking chest wound: 3-sided seal or similar. b. Large flail segment: stabilize.

P c. Tension pneumothorax: transport promptly and consider pleural decompression.

M B S P C. Circulation: 1. Check pulse and begin CPR if no central pulse. 2. Note pulse quality and rate; compare distal to central pulses as appropriate. 3. Control hemorrhage by direct pressure. (If needed, use elevation, pressure points.) 4. Check capillary refill time in fingertips. 5. If evidence of shock or hypovolemia begin treatment according to shock

protocols.M B S P D. Level of consciousness:

1. Note mental status (AVPU) a. Alert b. Verbal stimuli response c. Painful stimuli response d. Unresponsive

B S P 2. Measure Glasgow Coma Scale a. Eye opening: Spontaneous 4

To speech 3 To pain 2 No response 1

b. Verbal response: Oriented and talking 5 Disoriented and talking 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPATIENT ASSESSMENT PROCEDURE


c. Motor response: Obeys command 6 Localizes pain 5 Withdraws to pain 4 Flexion to pain 3 Extension to pain 2 No response 1

M B S P III. The secondary survey is performed in a systematic manner. (Steps listed are not necessarily sequential.)

A. Vital Signs: 1. Frequent monitoring of blood pressure, pulse, and respirations 2. Temperature as indicated in protocol.

B S P 3. Blood glucose measurement as available and appropriate. 4. Pulse oximetry as available and appropriate

P 5. *EKG monitoring as indicated in protocol. (Recommend obtaining 12 lead EKG without delay of patient transport when applicable.)

M B S P B. Head and Face: 1. Observe and palpate for deformities, asymmetry, bleeding, tenderness, or crepitus. 2. Recheck airway for potential obstruction: upper airway noises, dentures, bleeding,

loose or avulsed teeth, vomitus, or absent gag reflex. 3. Eyes: pupils (equal or unequal, responsiveness to light), foreign bodies, contact

lenses, or raccoon eyes 4. Ears: bleeding, discharge, or bruising behind ears

B. Neck: 1. Maintain immobilization, if appropriate. 2. Check for deformity, tenderness, wounds, jugular vein distention, use of neck

muscles for respiration, altered voice, and medical alert tags. C. Chest:

1. Observe for wounds, air leak from wounds, and symmetry of chest wall movement and use of accessory muscles.

2. Palpate for tenderness, wounds, crepitus, or unequal rise of chest. 3. Auscultate for bilateral breath sounds.

D. Abdomen: 1. Observe for wounds, bruising, distention, or pregnancy. 2. Palpation.

E. Pelvis: 1. Palpate pelvis for tenderness and stability.

F. Extremities: 1. Observe for deformity, wounds, open fractures, and symmetry. 2. Palpate for tenderness and crepitus. 3. Note distal pulses, skin color, and medical alert/DNR tags. 4. Check sensation. 5. Test for motor strength if no obvious fracture present.

G. Back: 1. Observe and palpate for tenderness and wounds.

M B S P IV. Special Considerations: A. Trauma patient assessment may require spinal immobilization based on Spinal Injury

Protocol. *Optional intervention (state approved local medical control protocol)

1. Acquire 12 lead EKG when available without delay of patient transport.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPHYSICAL PATIENT RESTRAINT PROCEDURE


Purpose: To ensure appropriate restrain of patients.

MB S P I. Indications:

A. When an ill or injured person who is behaving in such a manner as to interfere with their examination, care and treatment to the extent they endanger their life or the safety of others.

II. Procedure

A. Ensure that enough personnel are available to properly control the patient and establish the restraints. Do not place personnel or patient at risk of physical harm. Involve police to secure scene and patient.

B. Explain the purpose of the restraints.

C. Physically control the patient and apply restraints.

D. Complete Primary and Secondary Assessments.

1. Restrained extremities should be evaluated for pulse quality, capillary refill time, color, sensory and motor function continuously

a. Restraints must be adjusted if any of these functions are compromised.

2. Restraints must not interfere with medical treatment.

E. Attempt to identify common physical causes for patient’s abnormal behavior.

Hypoxia Hypoglycemia Head Trauma ETOH/ Substances use/ abuse

F. If risk of vomiting, keep patient in lateral-recumbent position, preferably left. If this is not possible, the patient should be placed in the prone or supine position, with one arm restrained along the patient's side and the other arm restrained above the head.

G. Patient should be secured to a backboard or stretcher only. Patients must never be secured directly to a vehicle or immovable object.

H. Transport patient.


I. Inform hospital that restraints are in place and assistance will be necessary at the hospital to continue restraint of the patient.

III. Special Considerations

A. Restraints should be of a soft nature (e.g. leather cuffs, cravats, sheets, etc.) applied to the wrists and ankles. A restraint may also be needed across the chest and/or pelvis.

B. Make a plan before any attempt at restraint, assigning specific duties to each member of the team. Designate a team leader.

C. A show of force may initially be sufficient to gain the cooperation of the patient and is preferable to the actual use of force as a first step.

D. Use only as much force as is required.

E. Once restraints have been applied, they should never be removed until the patient is safely in the hospital.

F. Stay with a restrained patient at all times, be observant for possible vomiting and be prepared to turn the patient and suction if necessary.

G. Document the time that restraints are applied and the rationale for use.

H. Remain calm and alert. Attempt to calm the patient.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPHYSICAL PATIENT RESTRAINT PROCEDURE


I. Documentation must include:

1. A description of the circumstance / behavior which precipitated the use of restraints.

2. A statement that no other less restrictive measure appeared appropriate and / or other measures were tried and failed.

3. Time of application of the restraints.

4. Type of restraint used.

5. The positions in which the patient was restrained.

J. Restraint devices applied by law enforcement officers:

1. An officer must be present with the patient at all times at the scene, as well as in the ambulance during transport.

2. The restraint and position must not be so restrictive that the patient is in a position that compromise patient care.

K. EMS Personnel may NOT use:

1. Hard plastic ties or any restraint devices that require a key to remove.

2. Backboards to “sandwich” the patient.

3. Restraints which secures the patient’s hands and feet behind the back.

4. Restraints that “hog tie” the patient.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYPATIENT SEDATION PROCEDURE


Purpose: Proper sedation of patients requiring a painful medical procedure. This procedure is for Paramedic use only and is to be used only after Medical Control approval except in the case of critical airway management.

I. Indications For Sedation

A. Electrical cardioversion

B. Transcutaneous pacing

C. Moderate to severe pain with morphine allergy


A. Probable inability to control the patient's airway

B. Known allergy to sedation medications

III. Assessment

A. Evaluate adequacy of airway.

B. Evaluate presence of adequate ventilation with oxygenation.

C. Monitor vital signs and level of consciousness.

D. Monitor EKG.

E. Pulse oximetry, if available.

IV. Procedure

A. Maintain airway, provide oxygenation and support ventilation.

B. Obtain vascular access.

C. For Electrical cardioversion, transcutaneous pacing, and post intubation sedation, sedate patient to a level of consciousness where procedure can be performed.

1. Administer morphine sulfate 2-10 mg slow IVP (for peds 0.1 mg/kg IVP) or as ordered, titrating until sedation occurs, AND/OR

2. Administer midazolam 0.5 mg-5 mg slow IVP, in 2mg increments (for peds 0.1 mg/kg slow IVP) or as ordered, titrating until sedation occurs, OR

3. Administer diazepam 2.5-5 mg slow IVP

RECONTACT MEDICAL CONTROL AS NEEDED

D. Possible orders post radio contact:

1. If additional sedation medication becomes necessary enroute, additional meds as follows:

a. morphine sulfate 2-10 mg slow IVP

b. midazolam 0.5 mg-5 mg slow IVP

c. diazepam 2.5-5 mg slow IV

2. For pain management in a morphine allergic patient administer midazolam 0.5 mg-5 mg slow IVP.

V. Pediatric Considerations

A. Pediatric sedation is to occur post medical control ONLY.

1. Administer midazolam 0.1 mg/kg slow IVP to max dose of 2.0 mg or as ordered, titrating until sedation occurs.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSPINAL IMMOBILIZATION PROCEDURE


M B S P I. Indications A. Mechanism of injury with one or more Specific Objective Findings:

1. Altered Mental Status (Patient not oriented to person, place and time, history of confusion, memory deficits or loss of consciousness)

2. Use of Intoxicants or Illicit drugs (Use of drugs or intoxicants by history, smell of potential intoxicants, behavior may indicate intoxication)

3. Motor and/or sensory deficits present (Patient unable to appropriately move all extremities, numbness, tingling or shooting pains, decrease or loss of sensation in extremities)

4. Patient complaint of spinal column pain or tenderness 5. Painful distracting injury 6. Long bone fracture proximal to wrist or ankle 7. Priapism 8. Spinal Shock 9. Mechanism of injury including fall from more than 5 stairs, axial load, scene

fatality, high velocity accident, ejection or rollover, recreational vehicle, auto-pedestrian, other high risk mechanism.

10. Multisystem trauma, or blunt or high velocity penetrating trauma above level of clavicle.

M B S P II. Specific Techniques A. Cervical Immobilization Devices

1. Cervical collar should be placed on patient prior to patient movement, unless absolutely impossible.

2. If no collar can be made to fit patient, towel or blanket rolls may be used to support neutral head alignment.

M B S P 3. Extrication Device/Short Backboard Procedure a. May be indicated when patient condition is stable, and patient is in more

of a sitting position than horizontal position. b. Patient's head and cervical spine should be manually immobilized from an

anterior or posterior location. c. Rescuers place patient in stable, neutral position where space is created to

place extrication device/backboard behind patient. d. While patient is supported, extrication device/backboard is placed behind

patient, and patient moved back into secure position if necessary.e. Extrication device/short blackboard device is secured to patient, with

torso straps applied before head immobilization. 1) Head immobilization material is used without compromising

movement of lower jaw (to assure possible airway management especially after patient placed in supine position).

f. Patient is moved to supine position on long backboard. g. Patient is further immobilized on Long backboard.

M B S P 4. Emergency Patient Removal a. Indicated when scene poses an imminent, life -threatening danger to

patient and/or rescuers, (i.e.; vehicle or structure fire).

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYSPINAL IMMOBILIZATION PROCEDURE


b. Patient is pulled from danger while best attempt is made to immobilize c-spine.

c. Rapid Extrication removal without short spinal immobilization indicated when patient condition is unstable (i.e.: airway-breathing compromise, shock, unconsciousness).

M B S P 5. Long Backboard Immobilization

a. Indicated when patient requires spinal immobilization.

b. Cervical immobilization device should be in place.

c. Patient is log rolled, maintaining neutral alignment of spine and extremities, to the long backboard (Log roll is preferred method). If log roll is not possible, patient should be moved to board while maintaining neutral alignment.

d. Patient is strapped to the board in a manner to prevent lateral or axial slide.

e. Head immobilization materials such as foam pads, blanket rolls mat be used to prevent lateral, flexion or extension movements.

M B S P III. Special Considerations

A. Hypoventilation is likely to occur with spinal cord injury above the diaphragm. Quality of ventilation should be monitored closely with support offered early.

B. Spinal/neurogenic shock may result from high spinal cord injury.

1. Monitor patient for bradycardia and hypotension. The typical sympathetic nervous system response to trauma can not occur because of interruption of nerve impulses.

C. Neurologic impairment will complicate assessment of abdomen and extremities (pain, guarding, etc., may not be present).

D. Immobilization of the patient wearing a helmet should be according to the Helmet Removal Procedure.

E. Manual ("hands-on") immobilization must be initiated and continue until additional immobilization equipment is in place.

1. During patient movement or during rough transport, manual immobilization may need to be added again to stabilize patient.

2. Manual immobilization must be used during any procedure that risks head or neck movement, such as endotracheal intubation.

3. Be suspicious of a spinal injury with patient’s who are unconscious.

4. Documentation must include: Mechanism of Injury, Patients level of consciousness, Neurological deficits, Spinal column pain or tenderness, suspicion of use of drugs or intoxicants, painful distracting injuries, or any other specific objective findings.

5. The use of sandbags to assist with head stabilization is NOT acceptable.

Note: Mechanism of Injury is defined as violent impact forces that are clearly capable of damaging the spinal column. Examples include: high velocity crashes, a fall from >20 feet, a gunshot wound to the torso or neck, axial load to neck

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYTASER/STUN GUN PROCEDURE


EMS may be requested to respond to an incident where law enforcement officers used a Taser/Stun Gun to subdue an individual. When responding to this type of call it is important, the EMS providers gather information from law enforcement about the reason the stun gun was used. If the individuals behavior was noted as “bizarre or crazy”, keep in mind that there may be an underlying cause for this behavior, i.e., drugs, alcohol, or other medical conditions.

M B S P 1. ABC’s

2. Vital Signs

3. Find location of barb, treat as impaled object

4. Check for injuries that may have occurred after use of Taser/Stun gun if patient was in an upright position.

P 5. Monitor EKG, (consider 12 lead if available)

M B S P 6. Contact on line medical control

7. All patients who have received electrical shock though the use of the Taser/stun gun shall be transported to the emergency department for evaluation.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYVAGAL MANEUVERS PROCEDURE


Purpose: Outline purpose of Valsalva maneuver. This procedure is for Paramedic use only.

I. Indications

A. Narrow complex tachycardia/Stable SVT


A. Patient < 8 years old.

III. Equipment Needed

A. EKG Monitor

B. Patent vascular access

C. Oxygen

IV. Procedure

A. Ensure that patient has oxygen, a patent IV, and is on a cardiac monitor.

B. Run EKG strip during procedure.

C. Instruct the patient to cough forcefully several times.

If this is ineffective:

3. Explain Valsalva’s Maneuver to the patient.

4. Instruct the patient to perform Valsalva's Maneuver as defined in AHA ACLS guidelines:

a. Have patient take a deep breath and bear down.

b. Maintain this maneuver for as long as possible.

II. Documentation

A. Results of initial assessment and indications for procedure

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYVASCULAR ACCESS PROCEDURE


Purpose: To outline the process in patients requiring vascular access. This policy applies to EMT-Specialists and Paramedics.

I. Indications

A. For the purpose of fluid or medication administration.

B. External jugular cannulation should be initiated in patients in whom access is necessary and other peripheral vascular access is not accessible or is contraindicated.

C. Intraosseous placement should be initiated in those patients, pediatric or adult, in whom vascular access is necessary and peripheral or external jugular vascular access is not accessible or is contraindicated.

D. Umbilical vein catheterization is indicated in newborn resuscitation, when unable to access peripheral IV.

II. Saline Lock may be initiated in patients in which IV access for medication administration may be necessary but IV fluid therapy unlikely.

III. IVs will be initiated in those situations in which fluid resuscitation may be indicated.

IV. Contraindications

A. To peripheral vascular access:

1. No peripheral sites available 2. Burns overlying available peripheral sites unless no other sites available 3. Infection overlying available peripheral sites

B. To intraosseous infusion and placement:

1. If infiltration occurs (rare), do not reuse the same bone as fluid will leak out of the original hole; select another site.

2. Do not place in a fractured extremity. If the femur is fractured, use the opposite leg.

C. To umbilical vein catheterization:

1. Inability to identify the umbilical vein or place the catheter.

III. Special Considerations (Side effects/Complications)

A. Initiation of vascular access generally should not delay patient transport to the hospital.

B. General side effects or complications: infection, air embolism, catheter shear, hematoma, arterial puncture, fluid overload

C. Intraosseous placement:

1. Complications include subperiosteal infusion, osteomyelitis, sepsis, fat embolism, bone marrow damage.

D. Umbilical vein catheterization:

1. Should not be attempted unless the single, large umbilical vein can easily be identified.

2. To be initiated after transport has begun.

IV. Standards for IV attempts

A. Two (2) attempts per provider, maximum 4 attempts.

B. Additional attempts per medical control.

C. Document any reasons for deviation.

V. Needle size for IV placement

A. Adult TKO 18 ga - 20 ga Angiocath

B. Adult trauma/internal bleeding/C-arrest 14 ga - 18 ga.

C. Child 20 ga - 24 ga Angiocath



VI. Flow Rates

A. Flow rates for all IV's are to be at rates TKO or saline lock unless otherwise indicated by specific protocol or Medical Control.

1. 25 ml/hr is TKO rate for adults. 2. The use of saline locks is encouraged in place of prophylactic TKO IV lines.

B. The amount of fluid infused along with the IV rate is to be noted on the EMS Medical Record.

C. Any reason for variation from standard flow rates must be documented on the EMS Medical Record.

D. The standard fluid bolus volume will be 1 liter normal saline with repeat as necessary, unless otherwise noted by protocol. The bolus would be contraindicated in patients with pulmonary edema. Volume for pediatric patient will be 20 ml/kg, unless otherwise noted by protocol.

E. Medicated drips should be piggybacked to main IV line or saline lock.

VII. Solutions - Protocol or Medical Control dictates choice of solution

A. Normal Saline – macro-drip; micro-drip.

B. Children – micro-drip

VIII. Procedures

A. Utilize universal precautions

B. Procedure for Peripheral Vascular Cannulation:

1. Gather and prepare equipment 2. Place the tourniquet on the extremity 3. Cleanse the skin 4. Make your puncture while maintaining vein stability 5. Watch for flashback. Once you have a blood return, advance the catheter as per

normal IV technique and attach the IV tubing or Normal saline lock cap. If you have no blood return and you are in the vein, remove the needle hub and attach your syringe to assist in aspirating for blood.

6. Remove tourniquet. 7. Instill 2-3 ml of normal saline if normal saline lock placed8. Secure catheter and IV tubing

C. Procedure for External Jugular Cannulation: (per Medical Control Approval only)

1. Gather and prepare equipment 2. Position patient supine (trendelenburg, if possible) 3. Turn head to opposite side of venipuncture (if no C-spine injury is suspected) 4. Cleanse the skin 5. Occlude the vein by using the side of your finger above the clavicle to facilitate

filling the vein. 6. Make your puncture midway between the angle of the jaw and the middle of the

clavicle with insertion of the needle toward the heart. Do not attempt if vein is not visualized.

7. Watch for flashback. Once you have a blood return, advance the catheter as per normal IV technique and attach the IV solution or normal saline lock cap, covering catheter with gloved finger while preparing to attach the IV tubing. If you have no blood return and you are in the vein, remove the needle hub and attach your syringe to assist in aspirating for blood.

8. Instill 2-3 ml of normal saline if normal saline lock placed. 9. Secure IV catheter and tubing.



D. Procedure for Intraosseous Placement: 1. Placement of the IO line by the following technique:

a. Have all IO equipment ready prior to bone penetration b. Expose the lower extremity c. Stabilize the lower extremity to minimize motion d. Selection of site

1) In children less than six years of age, the preferred order of insertion sites is proximal tibia.

e. Scrub the insertion site with alcohol prep. Strict adherence to aseptic technique is essential.

f. Insert the IO needle Proximal Tibial Technique. Place sand bags or rolled towels under the knee. Insert the needle, one finger's breadth below the tibial tuberosity and slightly medial to midline, perpendicular to the skin directed away from the epiphyseal plate (i.e. direct toward the foot), and advance to the periosteum. The bone is penetrated with a slow boring or twisting motion until you feel sudden "give" (decrease in resistance) as the needle enters the marrow cavity.

g. Attempt to confirm marrow placement by removing the stylet and aspirating blood and/or bone marrow.

1)If unable to aspirate, attach 12 ml syringe with normal saline and gently infuse normal saline.

2)Observe for normal saline leakage or SQ tissue swelling a) If neither occur, proceed b) If either occur, select a different site

h. Connect the appropriate IV equipment (normal saline locks not indicated in IO placement)

i. Administer the appropriate fluids and/or drugs j. Stabilize the entire intraosseous set-up as if to secure an impaled

object k. Notify Medical Control of the IO placement

2. If the IO is unsuccessful after 2 attempts, contact Medical Control. E. Procedure for Umbilical Vein Catheterization:

1. Prepare sterile field, sterile prep umbilical stump.2. Prepare equipment

a. 20ga. IV catheter with needle removed b. Stopcock flushed, with normal saline extension set attached to IV

catheter c. 12 ml syringe filled with normal saline

3. Trim umbilical cord down to 1/2 - 1 inch from abdomen 4. Identify umbilical vein

a. The cord has two arteries and one vein, with the vein being larger and having a thinner wall.

5. Insert IV catheter into vein until tip would be just below abdominal skin. a. Observe for free flow of blood b. Gently aspirate on syringe slowly to confirm lack of resistance c. If no "flashback" of blood is noted, catheter may be inserted too far;

withdraw catheter slightly and check for flashback. d. Inject normal saline

6. Secure umbilical tape around cord tightening around catheter to prevent any blood loss and tape catheter and extension to umbilicus.

7. Administer medications or fluids per Neonatal Resuscitation Protocol.

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYAPPENDIX

REVISED APRIL 2007

APPENDIX B

CINCINNATI PREHOSPITAL STROKE SCALE

FACIAL DROOP

Normal: Both sides of face move equally

Abnormal: One side of face does not move at all

ARM DRIFT

Normal: Both arms move equally or not at all

Abnormal: One arm drifts compared to the other

SPEECH

Normal: Patient uses correct words with no slurring

Abnormal: Slurred or inappropriate words or mute

References

Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.”

Ann Emerg Med 1999 Apr;33(4):373-8

BERRIEN COUNTY MEDICAL CONTROL AUTHORITYAPPENDIX

REVISED APRIL 2007

APPENDIX C

APGAR SCALE

The test is administered at one minute and five minutes after birth. If there are problems with the infant, an additional score may be repeated at a 10-minute interval. For a Cesarean section the baby is additionally assessed at 15 minutes after delivery. The chart below displays the criteria used in the APGAR scale.

Test 0 Points 1 Point 2 Points

Activity (Muscle Tone)

Absent Arms & legs extended

Active movement with flexed arms & legs

Pulse (Heart Rate)

Absent Below 100 bpm Above 100 bpm

Grimace (Response Stimulation or Reflex Irritability)

No Response Facial grimace Sneeze, cough, pulls away

Appearance (Skin Color)

Blue-gray, pale all over

Pink body and blue extremities

Normal over entire body – Completely pink

Respiration (Breathing)

Absent Slow, irregular Good, crying

After the infant is examined, the scores are totaled. A score of 7-10 is considered normal. A newborn with a score of 4-7 may require additional resuscitative measures while a score of 3 and below necessitates immediate medical attention. It is important to remember that the APGAR score is strictly used to determine the newborn’s immediate condition at birth and does not necessarily reflect the future health of your baby.

APPENDIX D

GLASCOW COMA SCALE

Glasgow Coma Score

The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below :

Best Eye Response. (4) 1. No eye opening.

2. Eye opening to pain.

3. Eye opening to verbal command.

4. Eyes open spontaneously.

Best Verbal Response. (5) 1. No verbal response

2. Incomprehensible sounds.

3. Inappropriate words.

4. Confused

5. Orientated

Best Motor Response. (6) 1. No motor response.

2. Extension to pain.

3. Flexion to pain.

4. Withdrawal from pain.

5. Localizing pain.

6. Obeys Commands.

Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to break the figure down into its components, such as:

E3V3M5 = GCS 11.

A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.

Teasdale G., Jennett B., LANCET (ii) 81-83, 19

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