Patient Care Protocols - Government of Newfoundland and

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ALS Patient Care Protocols

FIELD GUIDE \

Provincial Medical Oversight Version 4.1 January, 2020 Newfoundland & Labrador

Advanced Life Support Patient Care Protocols

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ACKNOWLEDGEMENT

OFFICE OF THE PROVINCIAL MEDICAL OVERSIGHT PROGRAM

Paramedicine & Medical Transport - Eastern Health

St. Clare's Mercy Hospital RM SM340

154 LeMarchant Road St. John's NL, Canada, A1C 5B8

TEL: 709 – 777 – 5209 FAX: 709 – 777 – 5940

www.pmtnl.ca [email protected]

© All Rights Reserved: No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the Provincial Medical Oversight Program.

If found, please return to address above.

OLMC 1-877-709-3535

This OLMC line is only to be used for medical advice when actively engaged in patient care

mailto:[email protected]

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AUTHORIZATION FOR PROTOCOLS

OVERVIEW

These protocols were developed for the following reasons:

1. To provide the EMS provider with a quick field reference2. As written standards of care which are consistent throughout the Province of Newfoundland &

Labrador. Users of these protocols are to have knowledge of more detailed and basic patientmanagement principles found in EMS textbooks and literature appropriate to the EMS provider’slevel of training and licensure.

3. All users must have strict adherence to these protocols.

POLICY

Practitioners will work within their scope of practice specifically guided by procedures and protocols as authorized by the Provincial Medical Director or the Assistant Provincial Medical Director.

SCOPE

Advanced Care Paramedics, Critical Care Paramedics, and Medical Flight Specialists actively medically certified with the Provincial Medical Oversight Program (PMO) and who are on duty with a public ALS ambulance service that is recognized by the Department of Health and Community Services.

PURPOSE

The Procedures and Protocols are based on current best practice and evidence. These protocols are issued by the Provincial Medical Director and will be supported by Regional Medical Advisor and On-Line Medical Control physicians. These protocols govern the practice of EMS Providers who are registered and certified with the Provincial Medical Oversight Program by the authority of Department of Health and Community Services.

REVIEW

These protocols will be subject to annual review. New or revised protocols will be issued as applicable changes occur. If there are errors or omissions, please contact PMO.

Dr. Brian Metcalfe BSc, MD, CCFP(EM) Provincial Medical Director Provincial Medical Oversight Paramedicine & Medical Transport

Dr. Chrystal Horwood BSc(hons), MD, CCFP(EM) Assistant Provincial Medical Director Provincial Medical Oversight Paramedicine & Medical Transport

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CONTENTS

GENERAL STANDARDS OF CARE 7

MEDICAL AUTHORITY 9

PART I: ADULT EMERGENCY PROTOCOLS 10

AIRWAY MANAGEMENT 11

ADVANCED AIRWAY ALGORITHM 13

ENDOTRACHEAL INTUBATION 14

FAILED INTUBATION 16

RESCUE AIRWAY (EXTRAGLOTTIC DEVICE / CRICOTHYROIDOTOMY) 17

POST INTUBATION MANAGEMENT 18

RESPIRATORY DISTRESS WITH BRONCHOSPASM 20

NON-INVASIVE POSITIVE PRESSURE VENTILATION (NIPPV) 21

ALLERGY AND ANAPHYLAXIS 22

UNCONTROLLED TRAUMATIC BLEEDING 24

CARDIAC ARREST 26

VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA 28

PULSELESS ELECTRICAL ACTIVITY (PEA) / ASYSTOLE 29

POST CARDIAC ARREST CARE (RETURN OF SPONTANEOUS CIRCULATION) 30

TERMINATION OF RESUSCITATION (TOR) 31

OBVIOUS DEATH 32

DO NOT RESUSCITATE (DNR) 33

MANAGEMENT OF DEATH (RESUSCITATION TERMINATED OR NOT INDICATED) 34

SHOCK 36

SEPSIS 37

CARDIOGENIC SHOCK 38

PULMONARY EDEMA 39

ISCHEMIC CHEST PAIN 40

ADULT SYMPTOMATIC BRADYCARDIA (WITH PULSE) 42

UNSTABLE TACHYCARDIA 43

STABLE NARROW COMPLEX TACHYCARDIA 44

STABLE WIDE COMPLEX TACHYCARDIA 45

ACUTE STROKE 46

PARAMEDIC PROMPT CARD FOR ACUTE STROKE PROTOCOL 47

SYMPTOMATIC HYPOGLYCEMIA 48

TREAT AND RELEASE PROTOCOL FOR HYPOGLYCEMIA 49

SYMPTOMATIC HYPERGLYCEMIA 51

CONVULSIVE SEIZURES 52

ADULT NAUSEA AND VOMITING 53

PAIN MANAGEMENT 54

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PROCEDURAL SEDATION 56

AGITATED / COMBATIVE 57

ALCOHOL WITHDRAWAL EMERGENCIES 59

GENERAL APPROACH TO TOXIN MANAGEMENT 60

SPECIFIC TOXIN MANAGEMENT 61

TRAUMA ALERT 67

C-SPINE ASSESSMENT 68

SPINE ASSESSMENT FOR BACKBOARD 69

BURNS 70

HEAT RELATED ILLNESS 71

HYPOTHERMIA 72

TENSION PNEUMOTHORAX 73

BLUNT TRAUMATIC CARDIAC ARREST 75

PENETRATING TRAUMATIC CARDIAC ARREST 76

ADULT FLUID THERAPY 78

OXYGEN THERAPY 79

LESS THAN LETHAL FORCE 81

ADRENAL INSUFFICIENCY 83

PART II: PEDIATRIC EMERGENCY PROTOCOLS 86

PEDIATRIC RESPIRATORY DISTRESS WITH BRONCHOSPASM 87

PEDIATRIC RESPIRATORY DISTRESS WITH INSPIRATORY STRIDOR 89

PEDIATRIC ALLERGY AND ANAPHYLAXIS 90

PEDIATRIC CARDIAC ARREST 92

PEDIATRIC VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA 94

PEDIATRIC PULSELESS ELECTRICAL ACTIVITY (PEA) / ASYSTOLE 95

PEDIATRIC POST CARDIAC ARREST CARE (RETURN OF SPONTANEOUS CIRCULATION) 96

PEDIATRIC SHOCK 97

PEDIATRIC SEPTIC SHOCK 99

PEDIATRIC SYMPTOMATIC BRADYCARDIA 100

PEDIATRIC BRADYCARDIA 101

PEDIATRIC NARROW COMPLEX TACHYCARDIA 102

PEDIATRIC NARROW COMPLEX TACHYCARDIA ALGORITHM 103

PEDIATRIC NARROW COMPLEX TACHYCARDIA Cont’d 104

PEDIATRIC WIDE COMPLEX TACHYCARDIA 105

PEDIATRIC SYMPTOMATIC HYPOGLYCEMIA 106

PEDIATRIC SYMPTOMATIC HYPERGLYCEMIA 108

PEDIATRIC CONVULSIVE SEIZURES 110

PEDIATRIC NAUSEA AND VOMITING 111

PEDIATRIC PAIN MANAGEMENT 112

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PEDIATRIC PROCEDURAL SEDATION 113

PEDIATRIC AGITATED / COMBATIVE 114

PEDIATRIC GENERAL APPROACH TO TOXINS MANAGEMENT 116

PEDIATRIC SPECIFIC TOXIN MANAGEMENT 117

PEDIATRIC HEAT RELATED ILLNESS 123

PEDIATRIC HYPOTHERMIA 124

PEDIATRIC FLUID THERAPY 125

PEDIATRIC ADRENAL INSUFFICIENCY 127

PART III: OBSTETRICAL EMERGENCY PROTOCOLS 130

ECLAMPSIA (PREECLAMPSIA WITH SEIZURE) 131

CHILDBIRTH 132

POST-PARTUM HEMORRHAGE 134

COMPLICATIONS OF DELIVERY 135

NEONATAL ASSESSMENT AND RESUSCITATION 136

NEONATAL RESUSCITATION 137

PART IV: REFERENCES 142

12 LEAD ECG GUIDELINES 143

12 LEAD ECG ACQUISITION TECHNIQUE 144

15 LEAD ECG GUIDELINES 145

15 LEAD ECG ACQUISITION TECHNIQUE 145

SYNCHRONIZED CARDIOVERSION GUIDELINES 147

NON-EMS MEDICAL PERSONNEL ON SCENE 148

REFUSAL OF CARE 150

POTENTIAL COMMUNICABLE/QUARANTINABLE DISEASE 152

MASS CASUALTY INCIDENT MANAGEMENT 153

SIMPLE TRIAGE AND RAPID TREATMENT (START) TRIAGE SYSTEM 154

JUMP SIMPLE TRIAGE AND RAPID TREATMENT (JumpSTART) TRIAGE SYSTEM 155

COMMUNICATIONS REFERENCE 156

AGITATED COMBATIVE / PHYSICAL RESTRAINT 158

AIRWAY REFERENCE 160

PEDIATRIC REFERENCE 162

PEDIATRIC DEVICE REFERENCE 164

PAIN SCALES 165

DEFINITIONS SURROUNDING DNR, TOR, AND DETERMINATION OF DEATH 166

BURN REFERENCES 167

GLASGOW COMA SCALE 168

OXYGEN TANK DURATION CHARTS 169

IV RATE CONVERSION CHART 172

METRIC CONVERSION CHARTS 173

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ACRONYMS / ABBREVIATIONS 174

PART V: MEDICATION FORMULARY 178

ACETAMINOPHEN 179

ACETYLSALACYLIC ACID (ASA) 179

ADENOSINE 180

AMIODARONE 181

AMIODARONE INFUSIONS 183

ATROPINE 184

CALCIUM CHLORIDE 10% 186

CHARCOAL 187

DEXTROSE 188

DIMENHYDRINATE (GRAVOL) 189

DIPHENHYDRAMINE (BENADRYL) 190

DOPAMINE 191

DOPAMINE INFUSION TABLE 192

EPINEPHRINE 1:1000 193

EPINEPHRINE 1:10 000 195

FENTANYL 196

FUROSEMIDE 197

GLUCAGON 198

GLUCOSE (ORAL) 199

HYDROCORTISONE 200

IPRATROPIUM BROMIDE 201

KETOROLAC 202

LIDOCAINE SPRAY 10% (10 MG/SPRAY) 203

MAGNESIUM SULFATE 204

MAGNESIUM INFUSIONS 206

METOCLOPRAMIDE 208

MIDAZOLAM 209

NALOXONE HYDROCHLORIDE 212

NITROGLYCERIN 214

OLANZAPINE 215

OXYTOCIN 216

SALBUTAMOL 217

SODIUM BICARBONATE (4.2% AND 8.4%) 219

TETRACAINE 0.5% 221

THIAMINE 222

TRANEXAMIC ACID (TXA) 222

MEDFLIGHT NL – AUTO LAUNCH CRITERIA 223

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GENERAL STANDARDS OF CARE General standards of care should be performed as necessary with all patients based on your scope of practice • Scene assessment (Safety issues, MOI, # of patients, need for additional resources) • Use of PPE and universal precautions • Assessment of LOC, Airway, Breathing, and Circulation • C-spine immobilization • Airway management • Administration of oxygen • Assisted ventilation • Obtained detailed history • Perform physical examination • Obtain vital signs • Measure blood glucose level • Monitor and interpret 12 lead and 15 lead ECG • Establish vascular access (IV considered preferred route of administration unless otherwise

noted) • Spinal immobilization • Perform CPR, ACLS, and PALS as per Heart & Stroke guidelines; NRP as per Canadian Pediatric

Society • Standards of trauma care to follow guidelines of International Trauma Life Support (ITLS) • Consider differential diagnosis • Frequent reassessment, particularly after intervention • Radio and verbal report to receiving facility • Completion of Patient Care Record

DOCUMENTATION Ensure complete, thorough and timely documentation of patient care activities. Patient care reports should contain enough detail so that it is easily apparent why specific treatments were offered or decisions were made. Careful documentation is especially important when documenting cases including but not limited to: • Traumatic Cardiac Arrest • Obvious Death • Do-Not-Resuscitate (DNR) • Termination of Resuscitation (TOR) • Determination of Death • Spinal Assessment • Refusal of Care If a patient care report is reviewed, your documentation should present a logical train of thought that is easily followed through the appropriate protocol or algorithm.

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GENERAL STANDARDS OF CARE Cont’d To use these protocols as they were intended, it is necessary to know the philosophy, treatment principles, and definitions, which guided the physicians and paramedics who drafted these protocols:

1. Assessment and treatment should very RARELY delay transport.

IVs should be started en route except in those situations where treatment at the scene of an out-of-hospital emergency is in the patient’s best interest such as shock with prolonged extrication, or a cardiac patient when full ACLS care is available. Delays in transport should be discussed with OLMC.

2. Inability to establish voice contact with OLMC

There are rare situations where the patient is unstable and delay in treatment threatens the patient’s life or limb. If, after good-faith attempts, the practitioner cannot contact OLMC, then the practitioner is authorized to use any appropriate treatment protocols as standing orders. Continue attempts to contact OLMC and document these attempts on the patient care report. See Communication Failure in Communications Reference (Pg 156).

3. Treatments/drugs should be given in the order specified

PMO recognizes that often treatments are delivered simultaneously and more than one protocol may be used. OLMC may request treatments/drugs out of sequence for medical reasons.

4. Teamwork in patient care

Partnered crew members are required to collaborate throughout the duration of the patient encounter and discuss clinical findings and management of the patient. Crew members are jointly responsible for the overall care of the patient. In the event of disagreement surrounding appropriate management approach, contact OLMC as per Medical Authority directive (Pg 9).

5. Variation in clinical practice Practitioners are expected to utilize their best clinical judgement with paramount consideration to the most reasonable and prudent care of the patient. It is not reasonable to expect a protocol compilation to cover every possible clinical situation and/or patient need. Protocols are expected to cover most time-dependent emergencies, and practitioners are reminded that deviation from protocol may be required in rare circumstances. In the event of deviation from treatment protocol, the reasoning behind the treatment management decisions made must be outlined in the patient care record and the event must be reported to PMO immediately, or if the variation occurs outside of business hours by the next business day, to ensure sufficient review of the case, as well as to determine if a new protocol is warranted.

6. Duty to report in cases of medical error or adverse events Reporting of medical error assists in mitigating future error by permitting an avenue of education and remediation for involved practitioners and is essential to ensure appropriate patient follow-up. Reporting of medical error is mandatory and represents an essential component of professional paramedicine practice. Any medical error or adverse events made by any crew member during the care of a patient must be reported to PMO immediately, or if the error occurs outside of business hours by the next business day.

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MEDICAL AUTHORITY

The ultimate responsibility for the decisions made in patient care are hereinafter referred to as medical authority. Despite the following hierarchy for patient care decisions, partnered crew members are required to collaborate throughout the duration of the patient encounter and discuss clinical findings and management of the patient. Crew members are jointly responsible for the overall care of the patient. Medical authority is determined by the individual’s level of training. Personnel with the highest level of training shall have medical authority during ambulance responses. Personnel with the same level of training shall have medical authority determined by the amount of experience at that training level. The person with the most experience performing at that training level shall be granted medical authority. Personnel who have the same training level and same experience at that training level shall determine the course of treatment for the patient by mutual agreement. If persons with the same training level and experience cannot mutually agree on the course of treatment they must contact OLMC for direction. Failing the above, if there is disagreement regarding course of management at any time, regardless of training level or experience, practitioners must contact OLMC for direction.

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PART I: ADULT EMERGENCY PROTOCOLS

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AIRWAY MANAGEMENT 1. Manage airway as needed (airway maneuver and/or suction and/or adjunct)

• Follow current Heart & Stroke guidelines for management of respiratory arrest • If severe respiratory distress or respiratory depression, assist ventilation with positive pressure

ventilation: o Perform bag mask ventilation via BVM using 100% O2 as needed and PEEP at 5 cm H2O Consider Predictors of Difficult BVM1 Optimize BVM utilizing Optimal BVM2 techniques Observe for Signs of Effective Bag Mask Ventilation3

o Consider intubation as per Advanced Airway Algorithm (Pg 13) Optimize intubation attempts as outlined under Optimal Laryngoscopy (Pg 14)

o Proceed with Failed Intubation (Pg 16) and Rescue Airway Protocol (Pg 17) as indicated. • If airway obstructed follow current Heart & Stroke guidelines for management of foreign body

obstructed airway procedures as necessary o Utilize Magill forceps if indicated

2. Continuous cardiac, SpO2, ETCO2 (if EGD or ETT), and BP monitoring 3. IV access 4. Maintain adequate tidal volume and respiratory rate by monitoring chest rise and ETCO2 (if EGD

or ETT) 5. Titrate PEEP to optimize oxygenation if needed per Non-Invasive Positive Pressure Ventilation

Protocol (Pg 21)

1PREDICTORS OF DIFFICULT BAG MASK VENTILATION – “BOOTS” B O O T S

Beard Obese Older Toothless Snore / Stridor

2OPTIMAL BAG MASK VENTILATION / APPROACH TO DIFFICULT BAG MASK VENTILATION

1) Reposition airway – exaggerated head tilt or exaggerated jaw thrust 2) Position ear level with sternum (Ramp4 patient if obese) 3) Consider foreign body 4) Consider alternative mask size 5) Insert oral and/or nasal airway 6) Perform two-person bag mask ventilation with compression of cheeks into lateral mask

3SIGNS OF EFFECTIVE BAG MASK VENTILATION 1) Rising SpO2 2) Visible chest rise 3) Audible breath sounds 4) Good seal (no air leak) and good compliance

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AIRWAY MANAGEMENT Cont’d

4RAMPING FOR PATIENTS WITH OBESITY

Figure A: Patient positioned without ramping

Figure B Patient ramped so that the sternum and ear line up. This position should improve ventilation

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ADVANCED AIRWAY ALGORITHM Consider endotracheal intubation if any ONE OR MORE Indications for Endotracheal Intubation are present.1

NOTES 1 If you are able to oxygenate with BVM then ETI or EGD insertion is not mandatory. Be

prepared to suction the airway in the event that secretions accumulate or vomiting occurs. 2 Semi-responsive – Refers to patients with preserved muscular tone, including intact gag reflex,

coughing, clenching (trismus), or biting.

CAUTION

• Attempted laryngoscopy of the semi-responsive head or brain injured patient is contraindicated unless necessary due to inability to oxygenate or ventilate by optimal BVM.

Indications for Endotracheal Intubation: 1) To obtain and maintain an airway 2) To protect the airway 3) To correct for inadequate oxygenation and/or ventilation 4) To intervene early in presence of poor predicted clinical course

Unresponsive or moribund Semi-responsive2

Proceed with Endotracheal Intubation Protocol (Pg 14)

Limit to single trial of laryngoscopy as outlined in Endotracheal Intubation Protocol (Pg 14) AND using Airway Pharmacology (Pg 15)

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ENDOTRACHEAL INTUBATION 1. Perform optimal BVM with 100% O2 while preparing to intubate 2. Initiate Apneic Oxygenation in unconscious patient via nasal cannula, 15 L/min, if second oxygen

source available 3. Continuous cardiac, SpO2, and BP monitoring 4. Consider Predictors of Difficult Laryngoscopy1 and, if present, consider alternative airway

management strategies including continued optimal BVM AND / OR EGD insertion 5. Prepare equipment (STOP IC BARS)

S: Suction T: Tubes (For pediatric ET tube sizes see Pg 164) O: Oxygen P: Pharmacology as indicated [Airway Pharmacology (Pg 15) or Post Intubation

Management (Pg 18)]

I: IV access and fluid administration as indicated C: Confirmatory devices (colorimetric ETCO2 and waveform capnography)

B: Bougie A: Alternative intubation technique R: Rescue oxygenation device (EGD) S: Surgical airway

6. Attempt intubation using Optimal Laryngoscopy2:

• If unsuccessful 1st look Optimal Laryngoscopy (with or without intubation attempt) proceed with Failed Intubation Algorithm (Pg 16)

• If successful 1st look laryngoscopy and endotracheal intubation proceed with Post Intubation Management Protocol (Pg 18)

1 PREDICTORS OF DIFFICULT LARYNGOSCOPY – “MMAP” (Pg 160) M M A P

Measure “3-3-1” (finger breadths) Mallampati Class III and IV Atlanto-Occipital extension (Poor neck extension < 90º) Pathology (Throat or neck tumor, radiation, etc.)

2 OPTIMAL LARYNGOSCOPY / APPROACH TO DIFFICULT LARYNGOSCOPY

1) Undo C-collar to free the mandible (maintain manual C-spine immobilization but do not hold the mandible!)

2) Position ear level with sternum (Ramp patient if obese) 3) Head lift with free hand 4) External Laryngeal Manipulation (ELM) 5) Two-handed laryngoscopy 6) Blade change 7) Bougie

CAUTION

• Attempted laryngoscopy of the semi-responsive head or brain injured patient is contraindicated unless necessary due to inability to oxygenate or ventilate by optimal BVM.

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ENDOTRACHEAL INTUBATION Cont’d

AIRWAY PHARMACOLOGY Intended for use only in patients with an intact gag reflex Parenteral Should the patient require anxiolysis:

• Adult: midazolam 2.5 mg SIVP/IO o Consider reduced dose in patients over age 65

• Pediatric: midazolam 0.05 mg/kg SIVP/IO, maximum 2.5 mg Topical 1) Open mouth 2) Administer topical lidocaine 10% (10 mg/spray) as outlined in steps 3 and 4 while adhering to

dosing guidelines below: • Adult: Up to 20 sprays (Not to exceed a maximum total dose of 5 mg/kg)

o Reduce dose by half if age greater than 65 years

• Pediatric: Up to 10 sprays (Not to exceed a maximum total dose of 5 mg/kg)

3) First spray lidocaine 10% on the tongue, from front to the back targeting especially the posterior 1/3 of the tongue

4) Follow with gentle partial insertion of the laryngoscope or tongue depressor and continue to administer lidocaine 10% in a “spray as you go” manner to the pharynx – proceeding from the soft palate, posterior pharynx, tonsillar pillars and finally to the hypopharynx

5) If patient condition permits, allow a minimum of 2 minutes to reach maximal effect before proceeding with Optimal Laryngoscopy (Pg 14). Assist ventilation as needed with Optimal BVM (Pg 11) or proceed with immediate attempt at intubation if unable to adequately oxygenate with BVM

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FAILED INTUBATION

NOTES 1 If you are able to oxygenate with BVM then ETI or EGD insertion is not mandatory. Be prepared

to suction the airway in the event that secretions accumulate or vomiting occurs. If at any time you are unable to oxygenate with BVM (even after only one attempt at laryngoscopy) YOU HAVE NO TIME for further laryngoscopy attempts – move directly to the Failed Oxygenation limb of the algorithm.

2 If proceeding with a 2nd attempt at laryngoscopy ensure uninterrupted oxygenation with BVM and consider cause of unsuccessful 1st look. With 2nd attempt use strategies of the Approach to Difficult Laryngoscopy (Pg 14), not already attempted, to improve likelihood of 2nd look success.

• This algorithm is intended for the live patient where SpO2 is available to guide decision-making. • SpO2 is not accurate in cardiac arrest, and should not be used to assess adequacy of

oxygenation or ventilation. Ventilation by BVM, EGD or ETT is acceptable in cardiac arrest provided that sufficient chest rise is achieved. Inability to achieve chest rise should prompt consideration of alternatives proposed in the sequence above.

Unsuccessful 1st look laryngoscopy (with or without intubation attempt)

Revert immediately to BVM

Can you ventilate and oxygenate with BVM? 1 • Sustained SpO2 greater than 90%

OR • SpO2 less than 90% but increasing

Consider 2nd attempt of laryngoscopy2

• Sequentially perform the Approach to Difficult Laryngoscopy (Pg 14)

• Use Bougie for any intubation attempt

Sequentially perform the Approach to Difficult BVM: 1) Reposition airway 2) Consider foreign body 3) Consider alternative mask size 4) Insert OPA and/or NPA 5) Perform two-person BVM

If 2nd attempt of laryngoscopy is not made OR has been unsuccessful (with or without intubation attempt): • Revert immediately to BVM • Consider EGD insertion

If persistent SpO2 less than 90%: • Continue two-person BVM with OPA

and/or NPA • Add PEEP valve with 5 cm H2O and high

flow O2 (15 L/min by nasal cannula) • Consider EGD insertion

YES NO – “FAILED OXYGENATION”

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RESCUE AIRWAY (EXTRAGLOTTIC DEVICE / CRICOTHYROIDOTOMY) EXTRAGLOTTIC DEVICE (EGD)

To be utilized as outlined in the Airway Management (Pg 11), Endotracheal Intubation (Pg 14) and Failed Intubation Algorithm (Pg 16) Protocols

PREDICTORS OF DIFFICULT EGD PLACEMENT AND VENTILATION – “MOODS” M / O O D S

Mouth Opening limitation Obstruction at or below the glottis opening Disruption or Distortion or Displacement of the airway Stiff lungs (e.g. bronchospasm)

CRICOTHYROIDOTOMY

To be utilized as a last resort in the rare event of failed oxygenation AND inability to ventilate by any other means – “Can’t Ventilate & Can’t Oxygenate”

PREDICTORS OF DIFFICULT CRICOTHYROIDOTOMY – “DART” D A R T

Distortion from expanding neck hematoma, infection, or other pathology Access problems from obesity or neck flexion Prior neck Radiation Tumors

QUICK TRACH® CRICOTHYROIDOTOMY

1) Assemble equipment and fill syringe half full with 0.9% NaCl • Adult size – suitable for weight greater than 35 kg • Pediatric size – suitable for children from 10 – 40 kg

2) Position the patient supine with the head slightly extended (contraindicated if C-spine trauma suspected)

3) Locate the cricothyroid membrane between the thyroid cartilage and cricoid cartilage 4) Clean the area with alcohol 5) Stabilize the larynx by placing your thumb and index finger of your non-dominant hand on both

sides of the larynx. Anchor / stretch the skin slightly 6) Pierce the skin overlying the cricothyroid membrane with the needle/catheter/syringe assembly

with the tip directed 45% caudally while maintaining negative pressure on the syringe. Advance the needle until air is aspirated and bubbles are observed in the syringe.

7) Upon aspiration of air stop advancing the needle and slide the catheter over the needle until the hub of the catheter is flush with the skin

8) Retract the needle and syringe as a single unit and leave the catheter in place 9) Attach flex tube extender 10) Confirm correct placement 11) Secure catheter in place using pre-attached strap

NOTES • Upon successful placement of EGD or performance of a cricothyroidotomy, proceed with Post

Intubation Management Protocol (Pg 18)

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POST INTUBATION MANAGEMENT 1. Confirm and document1 the presence of the following confirmatory findings:

1) Presence of exhaled CO2 by colorimetric CO2 device or waveform capnography2 AND

2) 3 OR MORE of the following: • Presence of breath sounds over bilateral lungs and absence of breath sounds over the

epigastrium • Visualization of ETT passing through vocal cords • Negative Esophageal Detector Device (EDD) test3 • Symmetric chest rise • Improving SpO2

If esophageal placement is suspected, extubate immediately and proceed with Failed Intubation Protocol (Pg 16) 2. Secure endotracheal tube 3. Apply cervical collar to minimize neck mobility 4. Monitor vital signs every 2-5 minutes at least for 15 minutes or until hemodynamics have

stabilized 5. Continuous waveform capnography (ETCO2) 6. Consider gastric decompression (OG or NG) 7. Administer midazolam and fentanyl as outlined below for tolerance of ETT:

FEN

TAN

YL Adult • 1 mcg/kg SIVP/IO

• Repeat every 5 to 10 minutes if indicated

Pediatric • 1 mcg/kg SIVP/IO (not to exceed a single maximum dose of 200 mcg) • Repeat every 5 to 10 minutes if indicated

MID

AZO

LAM

Adult • 1-2 mg SIVP/IO • Repeat every 5 to 10 minutes if indicated Not to exceed a maximum total dose of 10 mg without OLMC direction

Pediatric • 0.05-0.1 mg/kg SIVP/IO (Not to exceed a maximum single dose of 2 mg) • Repeat every 5 to 10 minutes if indicated Not to exceed a maximum total dose of 5 mg without OLMC direction

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POST INTUBATION MANAGEMENT Cont’d

SUDDEN DETERIORATION IN THE INTUBATED PATIENT – “DOPE”

Consider any one or more of the following reversible complications: D O P E

Displacement of endotracheal tube Obstruction of endotracheal tube Pneumothorax Equipment failure

NOTES 1 Document the elements of confirmation of ETT placement with initial placement. Periodic

reconfirmation must be performed and documented every 10 minutes or after any significant patient movement.

2 Detection of CO2 is unreliable in cardiac arrest for purposes of confirmation of ETT placement. 3 EDD is contraindicated for age less than 5 years or in late pregnancy.

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RESPIRATORY DISTRESS WITH BRONCHOSPASM (COPD, Emphysema, Chronic Bronchitis, Asthma) 1. Manage airway 2. O2 via NRB during acute distress

• If needed, assist ventilations with BVM

3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access, initiate second IV during transport 6. Administer a combination of both salbutamol and ipratropium bromide as per dosing guidelines

below:

MDI + aerochamber1

OR

Nebulized with O2

Salbutamol 4-8 puffs (100 mcg/puff) 5 mg

Ipratropium bromide 4-8 puffs (20 mcg/puff) 500 mcg Repeat every 5 minutes if indicated (Not to exceed a maximum total of 3 administrations) If severe respiratory distress, there is no maximum number of salbutamol administrations

1 Each puff must be followed by at least 4 breaths 7. Non-Invasive Positive Pressure Ventilation (Pg 21) if continued and severe respiratory distress 8. Consider epinephrine 1:1000 0.3 mg IM, ideally in the anterolateral thigh, if severe refractory

bronchospasm with unstable vital signs 9. Magnesium sulfate 2 g IV in 100 mL 0.9% NaCl by IV infusion over 20 minutes (See

Pg 206 for magnesium infusion instructions) – to be considered only in cases of severe or refractory asthma or COPD when systolic blood pressure is greater than 100 mmHg

10. If confirmed COPD (Emphysema or Chronic Bronchitis) only and respiratory status has improved to patient’s baseline after treatment: • Consider replacing NRB with nasal cannula to maintain SpO2 90-92% • If there is continued respiratory distress continue O2 via NRB

Contact OLMC for patients that are unrelieved by salbutamol and/or ipratropium bromide and condition is deteriorating for consideration of the following:

• Repeat IM epinephrine • Hydrocortisone 100 mg SIVP

NOTES • Patients should be treated with MDI and aerochamber unless it is deemed inappropriate,

ineffective, or patient cannot tolerate. • Salbutamol or ipratropium bromide may be administered singularly if the patient has a

hypersensitivity to one or the other medications. • Salbutamol is contraindicated in the setting of suspected ischemic chest pain.

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NON-INVASIVE POSITIVE PRESSURE VENTILATION (NIPPV) Indications for NIPPV may include any of the following pathologies WITH associated physical findings:

SUSPECTED PATHOLOGY PHYSICAL FINDINGS • Acute Respiratory Distress Syndrome

(ARDS) • Pulmonary Edema • Near drowning • Asthma • COPD

• Severe respiratory distress • Respiratory fatigue (decreasing tidal volume

or respiratory rate, or rising ETCO2)

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) If indications are met, administer CPAP at 5-10 cmH20 pressure and reassess vital signs every 5 minutes. If condition deteriorates, remove CPAP, reassess breath sounds and vital signs (including BP) and initiate BVM if needed. Contraindications: • Unable to follow commands (not alert, unable to swallow secretions, or cough) • Apnea • Active vomiting or upper GI bleed • Major trauma or upper airway trauma • Suspected or unresolved pneumothorax1 • Unable to fit mask to face • Systolic blood pressure less than 90 mmHg or age specific hypotension (Pg 163) Discontinue if patient develops a contraindication to CPAP

Positive End Expiratory Pressure (PEEP)

If patient requires BVM or advanced airway, administer PEEP by setting PEEP valve initially at 5 cm H2O. If ineffective, titrate PEEP up to 10 cm H2O. Contact OLMC if additional PEEP required. Discontinue if patient develops systolic blood pressure less than 90 mmHg

22

ALLERGY AND ANAPHYLAXIS

FINDINGS OF ANAPHYLAXIS 1) Acute onset (minutes to hours) of TWO OR MORE of the following after exposure to a LIKELY

ALLERGEN:

• Skin symptoms (hives, itching, flushing) • Oropharyngeal edema (lips, tongue, uvula) • Respiratory compromise (dyspnea, wheeze, stridor, hypoxemia) • Gastrointestinal symptoms (crampy abdominal pain, vomiting, diarrhea) • Reduced blood pressure or associated symptoms (hypotonia, collapse, syncope) OR

2) Hypotension alone after exposure to a KNOWN ALLERGEN for patient

1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access 5. If shock present, administer a fluid bolus as per Adult Fluid Therapy Protocol (Pg 78) 6. If Findings of Anaphylaxis present administer:

• Epinephrine 1:1000 – 0.3 mg IM, ideally in the anterolateral thigh

o Repeat once in 5 minutes if no improvement AND

• DiphenhydrAMINE1 50 mg IV 7. If respiratory distress present (including wheezing), administer salbutamol:

MDI + aerochamber2 OR

Nebulized with O2

Salbutamol 4-8 puffs (100 mcg/puff) 5 mg Repeat every 5 minutes if indicated (Not to exceed a maximum total of 3 administrations) If severe respiratory distress, there is no maximum number of salbutamol administrations

2 Each puff must be followed by at least 4 breaths

8. Consider early intubation with Airway Pharmacology (Pg 15) if epinephrine not rapidly improving cardiorespiratory status with evidence of progressive oropharyngeal edema

23

ALLERGY AND ANAPHYLAXIS Cont’d

Contact OLMC if severe and refractory airway compromise, respiratory failure, or shock for consideration of:

• Additional IV fluid administration for refractory hypotension • For refractory airway compromise, respiratory failure, or hypotension administer

epinephrine 1:10 000 – 0.1 mg (1 mL) in 100 mL NaCl 0.9% over 5 minutes o Repeat every 5 to 15 minutes if indicated [Not to exceed a maximum total dose of

1 mg (10 mL)] • Dopamine 5 mcg/kg/min for refractory hypotension. Titrate by 5 mcg/kg/min, every 5 to

10 minutes, up to a maximum of 20 mcg/kg/min until MAP greater than 65 mmHg (See Pg 192 for dopamine infusion instructions)

1 NOTES • May give diphenhydrAMINE 25-50 mg IV/IM alone for isolated hives. • May administer diphenhydrAMINE 50 mg IM if anaphylaxis AND unable to establish an IV. • There is NO absolute contraindication to epinephrine in a patient with anaphylaxis. • DiphenhydrAMINE DOES NOT improve angioedema or respiratory symptoms in

anaphylaxis.

24

UNCONTROLLED TRAUMATIC BLEEDING 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg. 76) 3. Control Bleeding:

• Compressible site: Apply direct pressure to site of active bleeding. If hemostasis achieved, apply pressure dressing and monitor for re-bleeding.

• Non-compressible site OR Hemostasis not achieved at a compressible site: Insert hemostatic gauze into the wound and apply direct pressure for a minimum of three

(3) minutes. Release manual pressure only when hemostasis is achieved, then apply pressure dressing over the hemostatic gauze. Monitor for re-bleeding.

• Catastrophic extremity injury with massive hemorrhage: Rapidly apply a tourniquet at least 5 cm proximal to the injury, tighten until bleeding is

controlled. • Suspected pelvic fracture:

Apply a pelvic sling (Pg. 81) and tighten until reasonably stabilized. • Femur fracture:

Apply a traction splint to mid-shaft femur fractures. 4. Spinal immobilization, if indicated as per C-spine Assessment Protocol (Pg. 65) or if suspected

pelvic injury. 5. Continuous cardiac, SpO2, and BP monitoring. 6. Measure temperature AND blood glucose. 7. Two large bore IVs (initiate second IV during transport). 8. If unable to control bleeding through step 3 above, evaluate the patient for Tranexamic Acid

(TXA) Administration Criteria1. If criteria met, administer:

• Tranexamic Acid (TXA) 1g in 100 mL 0.9% NaCl by IV infusion over 10 minutes. (See Pg. 226 for Infusion Instructions)

1TRANEXAMIC ACID (TXA) ADMINISTRATION CRITERIA:

1. TXA Inclusion Criteria (Must have ALL): • Uncontrolled, life threatening bleeding • Confirmed less than three (3) hours since injury • Well established IV access • Evidence of shock, including any one or more of the following:

o Cool, pale, diaphoretic skin o Delayed capillary refill o Narrowing pulse pressure

o Altered LOC o Tachycardia

2. TXA EXCLUSION CRITERIA (Must have NONE):

• Known allergy to TXA • Isolated or obvious significant head injury • Active intravascular clotting disorder (i.e.: DVT or PE) • Less than 16 years of age

Contact OLMC prior to administration of TXA if patient is on chronic anticoagulants or if unsure of severe internal bleeding

25

UNCONTROLLED TRAUMATIC BLEEDING Contd.

Pelvic Sling

• Place a sheet, folded lengthwise, across the spine board at the level of the patient’s pelvis • Place patient on spine board, on top of the sheet. • Grab each end of the sheet and cross sheet ends across patient’s pelvis in opposing

directions. • Apply traction on each sheet end to increase tightness of sling without over compressing the

pelvis. The goal is to provide reasonable stability to the pelvis and reduce internal bleeding. • Hold traction on sheet ends until created sling is secured with a knot. Alternately, large surgical

clamps can be used by clamping the sheet ends to the opposing sides of the created sling. • Ensure sling is tight and prevent loosening of the sling.

NOTES

• It is essential to pre-alert the receiving health care facility as early as possible when transporting a patient with an uncontrolled, life threatening bleed. Ensure a Trauma Alert is called when performing a radio report.

• Do not remove a hemostatic dressing once applied. • Record time of tourniquet application. Assess and document neurological status in the distal

limb every 15 minutes. Ensure the medical staff at the emergency room are fully informed of the location and time of tourniquet application.

• If transport time exceeds two (2) hours, reassess the site of injury and if bleeding has stopped, slowly release pressure on the tourniquet. If bleeding recurs, immediately reapply the tourniquet and do not re-attempt removal.

• If pelvic injury suspected, avoid log rolling the patient if at all possible and use a scoop stretcher, if able, to transfer the patient to the long spine board.

• There is risk of harm if TXA is administered beyond the three (3) hour limit post-injury. • Patients who receive a TXA bolus in the prehospital environment must also receive a

maintenance infusion of TXA in the hospital environment. It is essential that the TXA Administration Form be completed and promptly submitted to the receiving physician upon patient arrival at the emergency department.

CAUTION

• Assess for both the entry and exit wounds in penetrating trauma. Application of direct pressure on an entry wound while neglecting the exit wound can permit exsanguination. Remember to always assess the back of the trauma patient.

26

CARDIAC ARREST If patient meets DNR Protocol (Pg 33) or Obvious Death Protocol (Pg 32) do not proceed with resuscitation 1. Confirm Vital Signs Absent (VSA) and initiate chest compressions 2. 100% O2 via BVM with PEEP 5 cm H2O 3. Continuous cardiac monitoring 4. Proceed with appropriate algorithm 5. Treat Reversible Causes1 6. IV/IO access2 (DO NOT delay or interrupt CPR) 7. Consider advanced airway (DO NOT delay or interrupt CPR) 8. Continuous waveform capnography3 (if EGD or ETT) for evaluation of CPR quality and detection

of ROSC

GENERAL GUIDELINES

• Initiate compressions immediately: C-A-B Sequence • Begin CPR (5 cycles of 30 compressions : 2 ventilations) and immediately attach defibrillator –

defibrillate without delay if indicated • Ensure high quality CPR

o Minimize interruptions in CPR o Allow full recoil of the chest between compressions o Rotate rescuers every 2 minutes (if resources allow) concurrent with pulse checks

• Proceed to appropriate algorithm • If return of spontaneous circulation (ROSC) proceed immediately with Post Cardiac Arrest

Care Protocol (Pg 30) • Determine if patient meets Termination of Resuscitation (TOR) Protocol (Pg 31) prior to

initiating transport • If re-arrest occurs during transport, resume Cardiac Arrest Protocol

HYPOTHERMIC CARDIAC ARREST (CORE TEMPERATURE LESS THAN 32ºC) • Hypothermic patients are to be resuscitated as per normal with defibrillation and up to three

doses of epinephrine. Do not administer any other medications. • Resuscitation will be continued until active re-warming has returned core temperature to

normal or there has been ROSC

1 REVERSIBLE CAUSES OF CARDIAC ARREST H’s Hypovolemia Hypoxia Hypothermia Hypo / Hyperkalemia Hypoglycemia Hydrogen Ion (acidosis)

T’s Tension Pneumothorax Tamponade Toxins Thrombosis Trauma

27

CARDIAC ARREST Cont’d

2 NOTES

• Peripheral IV, including external jugular vein, should be a first line attempt for vascular access.

• Intraosseous access should be limited to a single attempt after peripheral access fails after 3rd attempt OR is otherwise unattainable.

3 ROLE OF ETCO2 MONITORING IN CARDIAC ARREST

1) Detection of ROSC – abrupt and sustained rise in ETCO2 (greater than 35 mmHg) 2) Monitoring of CPR quality – if ETCO2 is less than 10 mmHg during CPR, try to improve CPR

quality by optimizing chest compressions

28

VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA

Contact OLMC for consideration of:

1) Sodium bicarbonate 8.4% 1 mEq/kg IVP/IO if suspected metabolic acidosis or hyperkalemia (Dialysis patient, ECG findings of hyperkalemia), or TCA overdose

2) Calcium chloride 10% 1 g SIVP (Over 2 to 5 minutes) if suspected hyperkalemia (Dialysis patient, ECG findings of hyperkalemia) • Repeat once in 10 minutes if indicated

Initiate CPR immediately • Attach defibrillator • O2 via BVM

Shockable rhythm?

Continue CPR while defibrillator charging • Defibrillate once at 200 J • Resume CPR immediately for 2 minutes • IV access • Epinephrine 1:10 000 1 mg IV

o Repeat every 3 to 5 minutes if indicated

Check pulse • If pulse present, proceed with Post

Cardiac Arrest Care Protocol (Pg 30) • If Asystole or PEA proceed with Asystole

/ PEA Protocol (Pg 29)

Shockable rhythm?

Continue CPR while defibrillator charging • Defibrillate once at 200 J • Resume CPR immediately for 2 minutes • Amiodarone 300 mg IVP/IO

o Administer amiodarone 150 mg IVP/IO in 3 to 5 minutes if indicated

• Consider advanced airway placement Perform rhythm check every 2 minutes and shock as indicated

Continue resuscitation until: • ROSC (Pg 30)

OR • Patient meets Termination of

Resuscitation requirements (Pg 31)

Pulseless Torsades de Pointes • Defibrillate as per VF/VT Protocol • Administer magnesium sulfate 2 g diluted

in 10 mL 0.9% NaCl IVP/IO

YES NO

YES

NO

29

PULSELESS ELECTRICAL ACTIVITY (PEA) / ASYSTOLE


1) Sodium bicarbonate 8.4% 1 mEq/kg IVP/IO if suspected metabolic acidosis or hyperkalemia (Dialysis patient, ECG findings of hyperkalemia), or TCA overdose

2) Calcium chloride 10% 1 g SIVP (Over 2 to 5 minutes) if suspected hyperkalemia (Dialysis patient, ECG findings of hyperkalemia) • Repeat once in 10 minutes if indicated

Shockable rhythm?

NO

Continue CPR and proceed with VF / Pulseless VT Protocol (Pg 28)

Resume CPR immediately for 2 minutes • IV access • Epinephrine 1:10 000 1 mg IV

o Repeat every 3 to 5 minutes if indicated

Shockable rhythm?


OR • Patient meets Termination of

Resuscitation requirements (Pg 31)

Resume CPR immediately for 2 minutes • Consider advanced airway placement • Treat Reversible Causes1 • Perform rhythm check every 2 minutes

YES

YES

NO

Initiate CPR immediately • Attach defibrillator • O2 via BVM • Confirm asystole in two leads

1Reversible Causes: Hypovolemia Tension Pneumothorax Hypoxia Tamponade Hypothermia Toxins Hypo/Hyperkalemia Thrombosis Hypoglycemia Trauma Hydrogen Ion (acidosis)

30

POST CARDIAC ARREST CARE (RETURN OF SPONTANEOUS CIRCULATION) 1. Manage airway and assist ventilations as necessary 2. O2 100% 3. If defibrillator was used, leave pads in place 4. Continuous cardiac, SpO2, ETCO2 (waveform capnography) and BP monitoring 5. Perform 12 Lead ECG – follow with 15 lead ECG if inferior and/or posterior MI suspected 6. Two large bore IVs (initiate second IV during transport)3 7. Treat Reversible Causes1 8. Adjust ventilation oxygenation, and fluid resuscitation to target values of:

• MAP – greater than or equal to 65 mmHg2,3 • ETCO2 – 35-45 mmHg • SpO2 – greater than or equal to 95%

o Utilize PEEP to optimize oxygenation if needed

9. If re-arrest occurs, resume Cardiac Arrest Protocol (Pg 26) and appropriate algorithm 10. If persistent hypotension (MAP less than 65 mmHg) proceed with Cardiogenic Shock Protocol

(Pg 38)



2 CALCULATION OF MEAN ARTERIAL PRESSURE (MAP):

MAP = [(2 x diastolic BP) + systolic BP] 3

NOTES 3 Hemodynamic instability and ectopy are common immediately post-ROSC. Monitor patient

carefully and administer IV fluid bolus, 1000 – 2000 mL NaCl 0.9% if hypotensive. For refractory hypotension after fluid bolus, administer dopamine as per Cardiogenic Shock Protocol (Pg 38).

A copy of the code summary and PCR must be left with the receiving facility

31

TERMINATION OF RESUSCITATION (TOR) This TOR Protocol CANNOT be utilized in situations related to:

1) Age less than 18 years 2) Pregnancy 3) Hypothermia 4) Electrocution including lightning strike 5) Trauma (Blunt or Penetrating Traumatic Cardiac Arrest Protocol Pg 75-76) 6) Poisoning or drug overdose 7) Sudden reversible event (anaphylaxis, choking, drowning with submersion less than 60 minutes,

asphyxia) In these cases resuscitation and transport must proceed as per usual cardiac arrest protocols.

CRITERIA FOR TERMINATION OF RESUSCITATION Termination of resuscitation is to be applied when resuscitation of cardiac arrest has been initiated and prior to transport The ACP or CCP can terminate resuscitative efforts when ALL of the following criteria are met: 1) At least 20 continuous minutes of ALS resuscitative efforts have been provided 2) No ROSC has occurred 3) The end of any cardiac arrest protocol has been reached If ALL requirements are met, proceed with the Management of Death Protocol (Pg 34)

32

OBVIOUS DEATH The ACP or CCP will NOT start resuscitation of a patient of any age that has suffered cardiac arrest (not breathing and no palpable pulse) if any of the following signs of obvious death are present:

1) Rigor mortis 2) Dependent lividity 3) Decapitation 4) Transection of the torso 5) Decomposition 6) Confirmed submersion greater than 60 minutes 7) Obvious destruction of brain, heart, or lungs that is incompatible with life 8) Other catastrophic injury that is incompatible with life

NOTES • Proceed with Management of Death Protocol (Pg 34) upon recognition of cardiac arrest

meeting Obvious Death criteria.

33

DO NOT RESUSCITATE (DNR) This DNR Protocol CANNOT be implemented in situations related to: 1) Trauma (See Blunt or Penetrating Cardiac Arrest Protocol Pg 75-76) 2) Suicide attempt 3) Sudden reversible events: choking, asphyxia, anaphylaxis, drowning, hypothermia, electrocution,

toxic ingestion or overdose 4) Pregnancy The ACP or CCP will NOT start or may terminate resuscitation of a patient of any age that has suffered from cardiac arrest (not breathing and no palpable pulse) in either of the following circumstances: 1. A Valid DNR Order or Advance Health Care Directive (Pg 166) is presented AND a reasonable

effort has been made to verify the identity of the patient named on the document

OR 2. A legally recognized Substitute Health Care Decision Maker (SHCDM) (Pg 166) is present and

states that the patient expressed a desire not to be resuscitated in this type of circumstance OR presents reasons why the patient should not be resuscitated while maintaining the patient’s best interest

AND

The ACP or CCP must NOT have any concerns about the appropriateness of withholding resuscitation based on:

1) Doubts about the patients best interest 2) The validity of the DNR order or Advance Health Care Directive 3) The identity of the person making the request as a SHCDM 4) The patients family that are present being unable to reach an agreement about withholding

resuscitation

NOTES • If the ACP or CCP has any concerns regarding the validity of the DNR request – full

resuscitative efforts should be initiated and contact made with OLMC if necessary. • If a request for DNR is made prior to the patient suffering complete cardiac arrest – provide

supportive care (oxygen, airway support, and comfort measures) and contact OLMC with transport to hospital as appropriate.

• Proceed with Management of Death Protocol (Pg 34) upon recognition of cardiac arrest with valid DNR request.

34

MANAGEMENT OF DEATH (RESUSCITATION TERMINATED OR NOT INDICATED) CAUTION

This protocol is NOT to be utilized as the initial assessment of the unconscious patient to determine if they are in cardiac arrest. The initial assessment to determine if cardiac arrest is present should be conducted in accordance with the standards outlined in the Cardiac Arrest Protocol, with a pulse check not exceeding 10 seconds duration. This protocol outlines the criteria that must be evaluated and documented in the PCR AFTER it has been determined that resuscitation from cardiac arrest is not indicated, or should be terminated when directed to do so by the Blunt or Penetrating Cardiac Arrest (Pg 75-76), DNR (Pg 33), Obvious Death (Pg 32), or Termination of Resuscitation (Pg 31) Protocol(s).

Once it is determined that resuscitation from cardiac arrest is not indicated OR should be terminated proceed with the following steps: 1. Evaluate for, confirm, and document the presence of all the Documentation of Death Criteria1 2. Determine if the death meets criteria for Reportable Death2 or Expected Death3

• If the death was an Expected Death inquire whether the patient is enrolled in the “End of Life Program” and proceed as follows: o If patient enrolled in the End of Life Program, contact the health care professional that has

been identified to the family for purposes of notification of death o If the patient is not enrolled in the End of Life Program, notify the family physician or

designate. If the family physician or designate is unavailable, contact the police

• If the death meets the criteria of a Reportable Death proceed as follows: 1) Do not disturb the scene – limit access only to essential responders 2) Leave ALL disposable medical equipment and supplies used in the resuscitation in place –

do not remove from the scene 3) Leave defibrillation pads, and airway adjuncts in position 4) Leave the deceased in position – do NOT move or cover the body 5) Exit the scene of the death immediately using the same pathway as was used to enter 6) Do not permit anyone entrance into the scene 7) Notify police

3. Provide comfort to the bereaved

• Disclose death simply and directly with warmth and compassion • Listen and empathize • Assist locating support – relative, friend, clergy, etc.

35

MANAGEMENT OF DEATH (RESUSCITATION TERMINATED OR NOT INDICATED) Cont’d 4. Allow the bereaved to see the body if they wish:

• If not a reportable death, prepare the deceased – clean up medical supplies, cover with blanket, place pillow under head, close eyes, wipe up body fluids, etc.

• Prepare the bereaved for what they will see and answer any questions • Do not rush the bereaved

5. Remain on-scene until appropriate supports arrive for the bereaved, and/or:

• Family physician, police, medical examiner, or funeral home arrive and assume control of the deceased

• Crew is requested to respond to another life-threatening time-dependent emergency call

1DOCUMENTATION OF DEATH CRITERIA Assess and document ALL of the following criteria: 1) No palpable carotid pulse (Assess for 60 seconds) 2) No spontaneous respiratory effort (Assess for 60 seconds) 3) No heart sounds (Assess for 60 seconds) 4) Non-reactive pupils

2REPORTABLE DEATH CRITERIA When ANY ONE OR MORE of the following criteria present: 1) Death as a result of violence, accident, or suicide 2) An unexpected death when the person was in good health 3) Where the person was not under the care of a physician 4) The death is obviously suspicious in nature 5) Where the cause of death is undetermined 6) Death is the result of improper or suspected negligent treatment by another person

3EXPECTED DEATH Any death that does not meet Reportable Death Criteria

NOTE • Transport of the deceased must be completed by a licensed funeral director. • An ambulance may transport the deceased only if the deceased is in a public place and the

funeral director will be extensively delayed (greater than 1 hour), or as directed by police or OLMC.

36

SHOCK 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Control bleeding (if applicable) 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure temperature AND blood glucose 6. Two large bore IVs (initiate second IV during transport) 7. Perform 12 lead ECG – follow with 15 lead ECG if inferior and/or posterior MI suspected 8. Consider causes of shock and treat accordingly:

• If shock due to anaphylaxis, proceed with Allergy and Anaphylaxis Protocol (Pg 22) • If shock due to sepsis, proceed with Sepsis Protocol (Pg 37) • If shock due to cardiac etiology, proceed with Cardiogenic Shock Protocol (Pg 38) • If cardiac dysrhythmia identified, proceed with appropriate dysrhythmia protocol (Pg 42-45) • If shock due to toxic ingestion, proceed with appropriate Specific Toxin Management Protocol

(Pg 61) 9. For all other causes of shock, or when the cause of shock is unknown, administer a fluid bolus as

per Adult Fluid Therapy Protocol (Pg 78)

Contact OLMC if MAP remains less than 65 mmHg after initial fluid bolus for consideration of:

• Additional IV fluid administration • Dopamine 5 mcg/kg/min for refractory hypotension. Titrate by 5 mcg/kg/min, every 5 to


NOTE • Trendelenberg positioning is not indicated in the treatment of shock, and is not to be utilized as

a treatment option.

37

SEPSIS 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. Two large bore IVs (initiate second IV during transport) 6. Perform 12 Lead ECG 7. If patient meets Sepsis Inclusion Criteria administer a fluid bolus of 20 mL/kg 0.9% NaCl

regardless of blood pressure

SEPSIS INCLUSION CRITERIA 1) History suspicious for infection OR confirmed infection

AND 2) Any TWO OR MORE of the following clinical findings:

• Temperature less than 36ºC or greater than 38ºC • Tachypnea (Respiratory rate greater than 20) • Heart rate greater than 90

8. If MAP remains below 65 mmHg patient is considered to be in Septic Shock, repeat fluid bolus to

achieve a MAP of greater than 65 mmHg

Contact OLMC if MAP remains less than 65 mmHg after second fluid bolus for consideration of:



DEFINITIONS Severe Sepsis Sepsis Inclusion Criteria + Any evidence of end-organ dysfunction

• Altered mental status, confusion, or coma • Renal dysfunction, or poor urine output • Respiratory distress, or hypoxia • Myocardial ischemia

Septic Shock Sepsis Inclusion Criteria + MAP less than 65 mmHg despite administration of 20 mL/kg 0.9%

NaCl

38

CARDIOGENIC SHOCK

CRITERIA FOR TREATMENT OF CARDIOGENIC SHOCK 1) Hypotension (SBP less than 90 and MAP less than 65 mmHg)

AND 2) Chest pain OR severe pulmonary edema OR cardiac dysrhythmia OR known cardiomyopathy

AND

3) No history of trauma OR infection OR dehydration

1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. Perform 12 lead ECG – follow with 15 lead ECG if inferior and/or posterior MI suspected

• If cardiac dysrhythmia identified, proceed with appropriate dysrhythmia protocol (Pg 42-45)

6. IV access 7. Administer a fluid bolus as per Adult Fluid Therapy Protocol (Pg 78)

• Do not administer if evidence of pulmonary edema • Reassess patient after each 250 mL of 0.9% NaCl and reduce IV fluid administration rate to

TKVO if MAP is greater than 65 mmHg • Discontinue IV fluids if pulmonary edema develops




SIGNS AND SYMPTOMS OF CARDIOGENIC SHOCK • Altered level of consciousness • Cool, pale, or mottled skin • Diaphoresis • Hypotension • Severe pulmonary edema (left heart failure) • Decreased urine output

39

PULMONARY EDEMA (Intended for patients with SEVERE and ACUTE pulmonary edema) 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Position patient upright if tolerated 5. Perform 12 lead ECG pre and post intervention – follow with 15 lead ECG if inferior and/or

posterior MI suspected1 6. IV access 7. Administer nitroglycerin as outlined below:

• SBP greater than 140 mmHg: 0.8 mg SL • SBP greater than 100 and less than 140 mmHg: 0.4 mg SL

Repeat every 5 minutes if indicated May give a maximum of nitroglycerin 0.4 mg SL if unable to establish IV and SBP greater than or equal to 120 mmHg

8. Early NIPPV (Pg 21) if severe and acute respiratory distress 9. Administer furosemide 40 mg SIVP if ALL of the following criteria are met:

• Clear signs of severe pulmonary edema • No suggestion of sepsis or pneumonia • No fever • No evidence of right ventricular MI1 • Verify urination within past 12 hours

10. If hypotension develops following the administration of nitroglycerin, and/or furosemide,

discontinue further administration of any of these medications.

1 INFERIOR WALL MYOCARDIAL INFARCTION WITH RIGHT VENTRICULAR INVOLVEMENT Caution is advised in patients with suspected inferior myocardial infarction. Right ventricular (RV) infarction may occur in up to 50% of patient with inferior MI. A right sided ECG must be performed in the presence of inferior ST elevation to evaluate for RV infarction (greater than or equal to 1 mm ST elevation in V4R)

If RV ST elevation: • Do not administer nitroglycerin or furosemide • Do not administer fentanyl without OLMC approval • Treat hypotension with IV fluid bolus as per Adult Fluid Therapy Protocol (Pg 78)

40

ISCHEMIC CHEST PAIN 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Perform 12 lead ECG pre and post intervention – follow with 15 lead ECG if inferior and/or

posterior MI suspected1 5. IV access 6. Administer ASA 160–162 mg PO chewed 7. Administer Nitroglycerin 0.4 mg SL

• Repeat every 5 minutes if indicated, until chest pain is relieved or SBP falls below 100 mmHg • If after 3 doses patient has no response to nitroglycerin, discontinue nitroglycerin and consider

fentanyl 8. If severe and acute pain unresponsive to nitroglycerin administer:

• Fentanyl 25-50 mcg IV o Repeat every 5 minutes if indicated until reasonable control of pain (Not to exceed a

maximum total dose of 300 mcg) 9. If hypotension develops following the administration of nitroglycerin and/or fentanyl, discontinue

further administration of any of these medications

1 INFERIOR WALL MYOCARDIAL INFARCTION WITH RIGHT VENTRICULAR INVOLVEMENT Caution is advised in patients with suspected inferior myocardial infarction. Right ventricular (RV) infarction may occur in up to 50% of patient with inferior MI. A right sided ECG must be performed in the presence of inferior ST elevation to evaluate for RV infarction (greater than or equal to 1 mm ST elevation in V4R)

If RV ST elevation: • Do not administer nitroglycerin or furosemide • Do not administer fentanyl without discussion without OLMC approval • Treat hypotension with IV fluid bolus as per Adult Fluid Therapy Protocol (Pg 78)

STEMI ALERT Notify receiving facility of “STEMI Alert” if any one of the following ECG findings are noted in a patient experiencing chest pain: 1) ECG printout that reads *****Acute MI***** or Left Bundle Branch Block 2) Greater than or equal to 1 mm ST elevation in two or more contiguous limb leads 3) Greater than or equal to 2 mm ST elevation in two or more contiguous precordial leads Complete Thrombolytic Checklist for STEMI during transport and establish 2nd IV during transport

41

ISCHEMIC CHEST PAIN Cont’d

SERIAL 12 LEAD ECGs If the initial 12 lead does not show evidence of ST elevation in a patient experiencing chest pain serial 12 lead ECGs must be performed as outlined below: 1) In ambulance just prior to transport 2) Every 15 minutes during transport (if transport time > 30 minutes) 3) Just prior to arrival to receiving health care facility 4) Any time patient condition or ECG rhythm changes If the initial 12 lead demonstrates evidence of ST elevation MI, serial 12 leads are not required unless there is a change in patient condition or ECG rhythm changes

42

ADULT SYMPTOMATIC BRADYCARDIA (WITH PULSE) 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Perform 12 lead ECG – follow with 15 lead ECG if inferior and/or posterior MI suspected 5. IV access 6. Consider and treat underlying cause 7. If Signs of Poor Perfusion1 present administer:

• Atropine2 0.5 mg IV push o Repeat every 3 to 5 minutes if indicated (Not to exceed a maximum total dose of 3 mg)

while considering further interventions as outlined below 8. If atropine ineffective after two doses, or 3rd degree AV Block with persistent Signs of Poor

Perfusion1 proceed to one or more of the following options:

• Transcutaneous pacing • Dopamine 5 mcg/kg/min for refractory hypotension. Titrate by 5 mcg/kg/min, every 5 to 10

minutes, up to a maximum of 20 mcg/kg/min until MAP greater than 65 mmHg (See Pg 192 for dopamine infusion instructions)

Contact OLMC if you are uncertain as to whether the patient meets criteria for intervention OR if normotensive with bradycardia and suspected cardiac ischemia.

1 SIGNS OF POOR PERFUSION

1) Hypotension 2) Acutely altered mental status 3) Signs of shock 4) Ischemic chest discomfort 5) Acute congestive heart failure with severe pulmonary edema

• A slow heart rate may be normal for some patients, whereas a heart rate of less than 60 beats per minute may be inadequate for others. This protocol is intended for management of clinically significant bradycardia with significant signs of poor perfusion. Poor perfusion is normally not evident unless heart rate is less than 50 beats per minute.

• Patients taking beta blockers, calcium channel blockers, and digoxin may have a normal resting heart rate less than 60.

2 NOTE • Atropine is likely to be ineffective in wide complex bradycardia or 3rd degree AV block (unless

junctional narrow complex escape rhythm).

43

UNSTABLE TACHYCARDIA (Sustained HR greater than 150 with suspected cardiac origin) 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Perform 12 Lead ECG – follow with 15 lead ECG if inferior and/or posterior MI suspected 5. IV access 6. Consider and treat underlying causes 7. If Signs of Poor Perfusion1 present proceed with immediate synchronized cardioversion as

per Synchronized Cardioversion Guidelines (Pg 147)

1 SIGNS OF POOR PERFUSION 1) Hypotension 2) Acutely altered mental status 3) Signs of shock 4) Acute congestive heart failure with severe pulmonary edema

If the patient is in atrial fibrillation or flutter and experiencing isolated ischemic chest pain, contact OLMC to discuss management prior to electrical cardioversion.

44

STABLE NARROW COMPLEX TACHYCARDIA (QRS less than 120 ms and sustained HR greater than 150 with suspected cardiac origin)

1 Modified VALSALVA MANEUVER

• Place patient upright on stretcher and instruct them to blow on the end of a 10 mL syringe (without needle) with maximum force for 15 seconds. Immediately follow this by simultaneously placing their head flat and elevating legs to 45 degrees for 15 seconds. Allow up to one minute for cardioversion.

• Modified Valsalva maneuver is 43% effective at cardioversion of SVT compared to 17% for standard Valsalva maneuver.

• Do not attempt carotid sinus massage.


• Synchronized cardioversion (Pg 147)

Is the rhythm regular or irregular?

• Attempt modified Valsalva maneuver1 • Administer adenosine 6 mg rapid IVP • If no conversion, give adenosine 12 mg

rapid IVP Each dose of adenosine must be followed immediately by a 20 mL bolus of 0.9% NaCl

• Continuous cardiac, SpO2, and BP monitoring

• Transport

REGULAR IRREGULAR

If no conversion

45

STABLE WIDE COMPLEX TACHYCARDIA (QRS greater than 120 ms and sustained HR greater than 150 with suspected cardiac origin)


• Repeat amiodarone 150 mg IV loading dose by infusion over 10 minutes o See Pg 183 for amiodarone infusion

instructions • Synchronized cardioversion (Pg 147)

Is the rhythm regular or irregular?

• Amiodarone 150 mg IV loading dose in 100 mL of D5W by infusion over 10 minutes

• If successful conversion AND transport time greater than 30 minutes follow loading dose with a maintenance infusion of amiodarone 1 mg/min

See Pg 183 for amiodarone infusion instructions

• Continuous cardiac, SpO2, and BP monitoring

• Transport

REGULAR IRREGULAR

If no conversion

46

ACUTE STROKE 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Establish and document Last Seen Normal (LSN) Time1 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure temperature AND blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 48)

6. Determine if patient is candidate for direct transport to a Stroke Centre using Paramedic Prompt

Card (Pg 47) 7. IV during transport

1 LAST SEEN NORMAL (LSN) TIME • The last time the patient was witnessed or confirmed in their usual state of health and

completely without signs or symptoms of stroke.

CAUTION

• If at any time during your patient contact there is airway compromise or patient condition becomes unstable, transport to the closest Emergency Department, even if it is not a designated Stroke Centre.

47

PARAMEDIC PROMPT CARD FOR ACUTE STROKE PROTOCOL Indications for Direct Transport to a Stroke Centre Direct transport to a designated Stroke Centre will be considered for patient who meet BOTH of the following requirements: 1) New onset of ANY ONE OR MORE of the following symptoms suggestive of the onset of an

acute stroke: • Unilateral arm AND / OR leg weakness or drift • Slurred speech OR inappropriate words OR unable to speak • Unilateral facial weakness or droop AND

2) Can be transported to arrive at a designated Stroke Centre within 4 hours of a clearly

determined Last Seen Normal Time or time of symptom onset Contraindications for Direct Transport to a Stroke Centre The presence of ANY ONE OR MORE of the following conditions excludes a patient from being transported directly to a Stroke Centre when there is a closer health care facility available:

• Uncorrected airway, breathing, or circulatory problem • GCS less than 10 • Blood glucose remains less than 4 mmol/L despite treatment as per Symptomatic

Hypoglycemia Protocol • Seizure at onset of symptoms or observed by paramedics • Terminally ill or palliative care patient • Pregnancy • Symptoms of stroke completely resolved prior to paramedic arrival or assessment1 • No Stroke Centre within 4 hours of LSN time in your area • Any history of:

o Brain hemorrhage in the past 6 months o Brain tumor, arteriovenous malformation (AVM), or brain aneurysm o Stroke or brain surgery within last 3 months o Anticoagulation with any of the following medications: Xarelto (Rivaroxaban) Eliquis (Apixaban) Pradaxa (Dabigatran) Lixiana (Edoxaban) Warfarin (Coumadin)

1 If symptoms improve significantly or completely resolve during transport, continue transport to

designated Stroke Centre

48

SYMPTOMATIC HYPOGLYCEMIA 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access 6. If blood glucose is less than 4 mmol/L, administer ONE of the following medications and recheck

blood glucose in accordance with table below: Patient able to maintain own airway (Awake and able to cough and swallow)

IV established Unable to establish IV

Oral glucose options: 1) Dex 4® tablets 20 g (5 tablets) 2) Insta-glucose® 1 tube (30 g) 3) 1 cup of juice or pop (Non-diet) 4) 4 teaspoons (20 mL) or 4 packets of

table sugar dissolved in water

Dextrose 50% (D50%) 25 g (50 mL) IVP

Glucagon1 1 mg IM

Recheck BGL in 15 minutes Recheck BGL in 10 minutes Recheck BGL in 20 minutes

7. Repeat Step 6 once if necessary 8. Thiamine 100 mg IV/IM if history of alcoholism OR evidence of malnourishment or starvation 9. If the patient expresses a wish to remain home rather than continue care to hospital evaluate for

Treat and Release inclusion and exclusion criteria (Pg 49)

Contact OLMC of blood glucose remains below 4 mmol/L after 2nd dose of dextrose or glucagon.

1 NOTES • Anticipate that it could take up to 20 minutes to observe an effect from glucagon. • While waiting for glucagon to take effect, manage patient’s airway as indicated and initiate

transport.

CAUTION

• If head injury or stroke suspected administer half of the usual dose of dextrose, recheck BGL, and then administer the second half dose if necessary.

• The goal is to correct hypoglycemia while avoiding transient hyperglycemia that may lead to cerebral edema.

49

TREAT AND RELEASE PROTOCOL FOR HYPOGLYCEMIA The Treat and Release Protocol is intended to be a patient initiated request for non-transport after resolution of hypoglycemia and return to normal level of consciousness. In all cases, transport to hospital should be presumed to be the usual outcome following treatment of hypoglycemia unless the patient requests non-transport or to remain at home. If upon resolution of hypoglycemia and return to normal level of consciousness the patient requests non-transport proceed as follows:

1. Does the patient meet ALL inclusion criteria? INCLUSION CRITERIA

Alert and cooperative

Capacity to refuse transport

In usual state of health before the hypoglycemic episode (No new medical concerns)

Competent adult bystander present to remain with patient

Patient is able to eat and monitor own blood sugar

If YES – Evaluate for Exclusion Criteria

If NO – Patient not eligible for Treat and Release – proceed with transport or contact OLMC if patient refuses transport

2. Does the patient have ANY ONE OR MORE exclusion criteria? EXCLUSION CRITERIA

Patient was compliant with all medications and nutritional intake

Symptoms developed over days

Hypoglycemia is in a non-diabetic patient

History of hepatic or renal insufficiency

Diabetes treated with oral hypoglycemics

Insulin overdose

If YES – Patient not eligible for Treat and Release – proceed with transport or contact OLMC if patient refuses transport

If NO – Proceed with Treat and Release (including completion of Patient Refusal Form) and

document presence of all inclusion criteria and absence of all Exclusion Criteria on PCR

50

TREAT AND RELEASE PROTOCOL FOR HYPOGLYCEMIA Cont’d

NOTES • If the patient meets all Inclusion Criteria and no Exclusion Criteria are identified contact with

OLMC is NOT required. You are required to document the presence of all Inclusion Criteria and absence of all Exclusion criteria on the PCR.

• In all Treat and Release circumstances the patient must be advised to contact his or her family physician to arrange follow-up within 24-48 hours. Document this and all advice given on the PCR.

• Contact with OLMC is mandatory if the patient does not meet all Inclusion Criteria or any Exclusion Criteria are identified and the patient is refusing transport.

51

SYMPTOMATIC HYPERGLYCEMIA This protocol is intended for patients who demonstrate findings of significant dehydration and presentations suggestive of diabetic ketoacidosis of hyperosmolar hyperglycemic state. Many diabetic patients may have blood glucose levels greater than 15 mmol/L during times of physiologic stress in the absence of dehydration and will NOT require fluid administration. 1. Manage airway and assist ventilations as necessary 2. O2 as appropriate 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access 6. If blood glucose is greater than 15 mmol/L, AND patient shows signs of dehydration administer a

fluid bolus as per Adult Fluid Therapy Protocol (Pg 78)

Contact OLMC if you are uncertain as to whether the patient meets criteria for fluid administration

52

CONVULSIVE SEIZURES 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Spinal immobilization if unprotected fall to ground and seizure has stopped if indicated by C-Spine

Assessment (Pg 68) and Spinal Immobilization Tool (Pg 68) 4. Position patient

• Actively seizing – place supine and protect from injury • Postictal – place left lateral recumbent and maintain airway

5. Continuous cardiac, SpO2, and BP monitoring 6. Measure temperature AND blood glucose


7. IV access, initiate second IV en route 8. If the patient is actively seizing administer:

• Midazolam 5 mg IV OR

• Midazolam 5 mg IN if unable to establish IV access

Repeat in 5 minutes if seizure continues or recurs (Not to exceed a maximum total dose of 10 mg by any route)

Contact OLMC if status epilepticus for consideration of additional midazolam

NOTES • Consider eclamptic seizure if the patient is pregnant without a history of seizures. If Criteria for

Eclampsia present proceed with Eclampsia Protocol (Pg 131). • If seizure is suspected to be the result of a toxin exposure, treat as per Specific Toxin

Management Protocol (Pg 61). • In the event you are unable to establish IV access and contraindications to intranasal

administration of midazolam are present, administer midazolam 10 mg IM. Repeat once in 15 minutes if seizure continues or recurs.

53

ADULT NAUSEA AND VOMITING 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose: 5. IV access 6. Position the patient in a position of comfort 7. If severe nausea and vomiting administer:

• DimenhyDRINATE 25-50mg IV

o Repeat once in 15 minutes if indicated (Not to exceed a maximum total dose of 50 mg) Administer lower dose in elderly patients Contraindicated in the setting of heat exhaustion or heat stroke

OR

• Metoclopramide 10 mg SIVP over 2 to 5 minutes if any of the following criteria apply:

o Severe nausea and vomiting refractory to dimenhyDRINATE after 15 minutes since last

dose o Allergy or contraindication to dimenhyDRINATE o Altered LOC or head injury

8. If metoclopramide has been administered and acute extrapyramidal1 signs or symptoms develop, reassure patient and administer diphenhydrAMINE 50 mg IV

1 EXTRAPYRAMIDAL SIGNS AND SYMPTOMS • Akathisia – a severe and unpleasant sensation of restlessness in patients causing them

severe anxiety and inability to sit still • Dystonia – increased rigidity or muscle contraction that may result in twisting or abnormal

postures • Dyskinesia – abnormal or repetitive movements (e.g.: lip smacking, eye twitching, etc.)

Administration of diphenhydrAMINE is not indicated for treatment of chronic extrapyramidal signs and symptoms

NOTES • DimenhyDRINATE OR metoclopramide may be administered by IM route if indications are

present AND you are unable to establish an IV.

54

PAIN MANAGEMENT 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access 5. If severe pain1, 2 administer:

• Fentanyl 25-50 mcg IV

o Repeat every 5 minutes if indicated until reasonable control of pain (Not to exceed a maximum total dose of 300 mcg)

OR

• Ketorolac 15 mg SIVP/IM if severe pain due to one of the following: o Acute musculoskeletal trauma o Uncomplicated renal or biliary colic if the presentation is consistent with previous episodes o Mechanical back pain o Burns

6. If ocular pain due to ocular foreign body, chemical exposure, or minor trauma administer:

• Tetracaine 0.5% 1-2 drops to affected eye(s) o Repeat every 5 to 10 minutes as needed o DO NOT administer tetracaine if suspected globe rupture3, instead administer fentanyl

and administer metoclopramide as per Nausea and Vomiting Protocol (Pg 53)

7. If severe headache4 and patient meets the Criteria for Metoclopramide in Migraine5, administer: • Metoclopramide 10 mg SIVP

o May administer 10 mg IM if indications are present AND you are unable to establish an IV o If metoclopramide has been administered and acute extrapyramidal signs and

symptoms6 develop, reassure patient and administer diphenhydrAMINE 50 mg IV 8. If patient develops nausea or vomiting proceed with Nausea and Vomiting Protocol (Pg 53)

5CRITERIA FOR METOCLOPRAMIDE IN MIGRAINE

1) Patient has all of the following: • Acute and severe unilateral headache • History of diagnosed migraine • Presentation of current migraine is consistent with previous migraines

o Any aura is consistent with previous auras

AND

2) Patient has none of the following: • Recent head trauma • New onset of fever greater than 38◦C • New neurological abnormality, including acute seizure

55




Administration of diphenhydrAMINE is not indicated for treatment of chronic extrapyramidal signs and symptoms

Contact OLMC if severe pain and unable to establish IV for consideration of:

• Fentanyl 50-100 mcg IN

NOTES 1 Document pain severity pre and post intervention. 2 Treatment of pain with parenteral opioids should be reserved for cases of severe pain only. 3 If globe rupture suspected DO NOT administer tetracaine – instead, do not touch the eye.

Administer systemic analgesia and anti-emetic(s) to avoid vomiting and increased intra-ocular pressure.

Signs of Globe Rupture 1) Irregular pupil 2) Large subconjunctival hematoma (blood collection on surface of globe) 3) Eye swollen closed 4) Hyphema - blood pooling in front of the iris (colored portion of eye) 5) Loss of globe integrity or shape

4 Consider migraine mimics, including stroke and pre-eclampsia.

56

PROCEDURAL SEDATION (For pacing or cardioversion) 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access 5. Administer:

• Fentanyl 25-50 mcg IV

o Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum total dose of 300 mcg) AND

• Midazolam 1-2 mg IV o Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum total dose of 10 mg)

Contact OLMC IV for consideration of:

• Repeat fentanyl administration • Repeat midazolam administration

CAUTION

• Be sure to actively monitor and manage the airway and breathing of a sedated patient at all times.

• Administer smaller doses of midazolam if the SBP is near, but above 100 mmHg prior to intervention.

57

AGITATED / COMBATIVE 1. Contact police and request that they attend the scene immediately 2. Manage airway and assist ventilation as necessary 3. O2 as per Oxygen Therapy Protocol (Pg 79) 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure temperature AND blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 48) 6. Consider and treat Reversible or Treatable Causes of Altered Mental Status1 7. IV access 8. Attempt verbal management techniques for crisis intervention to de-escalate the situation and

calm the patient 9. If severe agitation or imminent risk of harm to self and/or bystanders administer one of the

following depending on degree of risk to provider:

• Olanzapine 10 mg PO (DO NOT administer if age greater than 65 years AND history of dementia) OR

• Midazolam as outlined below:

o Midazolam 2.5-5 mg IV Repeat every 5 minutes if indicated until reasonable cooperativeness is achieved OR

o Midazolam 5-10 mg IM/IN if unable to establish an IV Repeat every 15 minutes if indicated until reasonable cooperativeness is achieved

Not to exceed a maximum total dose of 10 mg by any route

10. If Indications for Physical Restraint2 present, apply the least amount of physical restraint necessary to protect the patient from harming themselves or bystanders until police arrive as per Agitated Combative / Physical Restraint Reference (Pg 158)

11. If cocaine or other sympathomimetics are suspected as the cause of agitation or combativeness, proceed with Specific Toxin Management Protocol (Pg 61)


• Repeat midazolam administration

58

AGITATED / COMBATIVE Cont’d

1 REVERSIBLE OR TREATABLE CAUSES OF ALTERED MENTAL STATUS • Hypoxia • Hypotension • Hypoglycemia • Medications or Toxins • Sepsis

2 INDICATIONS FOR PHYSICAL RESTRAINT 1) Imminent danger3 to life OR threat of physical harm to patient and/or bystanders

AND

2) Attempts at verbal de-escalation have failed

AND

3) Attempts to restrain do NOT place the practitioner(s) at significant risk of harm to themselves

NOTES 3 Imminent Danger – an immediate threat of significant harm to one’s self or others, up to and

including death

Examples of Imminent Danger: • Actively attempting suicide • Actively attempting to cause serious bodily injury to others • Attempting to jump from a building or moving vehicle

CAUTION

• There is a high risk of positional asphyxia and/or aspiration in patients undergoing chemical or physical restraint. Close and continuous monitoring of these patients, including airway patency and adequacy of respirations is mandatory

• At NO TIME should the patient be restrained in the prone (face or chest-down) position • Always maintain an ability to escape the scene. Position yourself between the patient and the

exit at all times to maintain a safe exit should the situation escalate • Be alert for potential weapons and hazards. If the patient has a weapon, do not attempt to

disarm them. Instead, leave the scene and stage until the police declare the scene safe to re-enter

• Be aware of signs of increased agitation or aggression including, but not limited to: o Tense posture o Loud speech o Pacing o Threatening statements o Clenched hands o Hostile or aggressive body language

59

ALCOHOL WITHDRAWAL EMERGENCIES 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access 6. Thiamine 100 mg IV/IM 7. If history of frequent alcohol use with recent cessation1 AND signs of severe Alcohol Withdrawal2

or Delirium Tremens3 administer:

o 20 mL/kg bolus of 0.9% NaCl IV AND

• Midazolam 2.5-5 mg IV o Repeat every 5 minutes if indicated (Not to exceed a maximum total dose of 10 mg)

8. If unable to establish an IV and severe agitation or combativeness is present proceed with

the Agitated / Combative Protocol (Pg 57) 9. If seizure occurs proceed with Convulsive Seizure Protocol (Pg 52)

Contact OLMC if symptoms persist despite administration of maximum dose of midazolam for consideration of:

• Repeat midazolam administration - severe alcohol withdrawal may require very large doses of benzodiazepines

NOTES 1 Withdrawal syndrome usually develops in 6 to 24 hours after reduction or cessation of alcohol

intake and can last up to one week, peaking at 48 hours.

2 ALCOHOL WITHDRAWAL 3 DELIRIUM TREMENS 1) Agitation 2) Tremor 3) Tachycardia 4) Hypertension 5) Hyperthermia 6) Diaphoresis

1) Signs of Alcohol Withdrawal2 AND

2) ANY ONE OR MORE of the following: • Hallucinations • Delusions • Altered LOC • Confusion

60

GENERAL APPROACH TO TOXIN MANAGEMENT 1. Scene safety: protect rescuers and patients from immediate danger and contamination

• Toxic exposures might require special precautions, including CBRNE precautions or

decontamination, before patient treatment begins 2. Manage airway and assist ventilations as necessary 3. O2 as per Oxygen Therapy Protocol (Pg 79) 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure temperature AND blood glucose 6. IV access, initiate second IV en route 7. Perform 12 Lead ECG 8. If seizure occurs administer midazolam as per Convulsive Seizure Protocol (Pg 52) 9. Consider administration of charcoal as outlined below:

Contact OLMC for consideration of charcoal 1 g/kg PO if oral ingestion of an agent likely to produce significant toxicity AND ALL of the following criteria are met:

1) Alert 2) Able to cough and swallow 3) Ingested substance known to adsorb charcoal1 4) Less than 60 minutes elapsed since time of ingestion 5) Hemodynamically stable

1 SUBSTANCES THAT DO NOT ADSORB CHARCOAL

1) Lithium 2) Metals (Iron) 3) Alcohols (ethanol, methanol, ethylene glycol, and isopropyl alcohol) 4) Organophosphates and carbamates 5) Hydrocarbons 6) Borate 7) Bromide 8) Acids and alkalis

61

SPECIFIC TOXIN MANAGEMENT

CAUTION The following protocols are intended to be used as guides in the management of severely symptomatic patients with suspected ingestion or use of the specific toxin indicated. Contact with OLMC is mandatory for initiation of the management options indicated. • Do not delay transport in cases of severely symptomatic patients • Contact with OLMC should be made while preparing for or initiating transport • The goal of prehospital management is to initiate life-saving therapies and to sustain life until

arrival to hospital • Toxicity is unlikely to resolve completely with isolated prehospital management • Do not delay transport in favor of completion of all management options presented in the

prehospital setting

ANTIPSYCHOTIC-INDUCED DYSTONIC REACTION

This protocol is intended for management of acute dystonic reactions in patients confirmed to be taking antipsychotic medication.

• Administer diphenhydrAMINE 50 mg IV/IM

NOTES • Dystonia – state of increased muscle rigidity or muscle contraction that may result in twisting

or abnormal postures. • Acute dystonic reactions usually develop within the first several doses or after a large increase

in dose of antipsychotic medications. • It is possible to have an acute dystonic reaction in the absence of overdose.

62

SPECIFIC TOXIN MANAGEMENT Cont’d

OPIOIDS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of an opioid agent. Therapy is not intended to return patient to a normal level of consciousness. The goal of treatment is a respiratory rate greater than 10 with adequate ventilation. If ALL of the following criteria are met proceed with naloxone administration as outlined:

• Impaired consciousness • Respiratory rate less than 10 per minute • Pupil constriction (except in suspected meperidine (Demerol) or tramadol ingestion) • Requiring assisted ventilation

Administer naloxone1 as outlined below (See Pg 212 for naloxone instructions):

• 0.2-0.5 mg IV/IM

o Repeat every 2-3 minutes if indicated, titrated to improved respiratory drive o In opioid dependent patients start with a lower dose of naloxone (0.05 to 0.1 mg

IV/IM) to avoid precipitating acute withdrawal and titrate to sufficient respiratory drive

OR

• 2mg IN in each nare of a 1 mg/mL solution o Repeat every 2-3 minutes if indicated, titrated to improved respiratory drive

In the event of a cardiac arrest in the setting of suspected or confirmed opioid ingestion, administer:

• Naloxone 6 mg IV/IO 1 NOTES • IV route is preferred for pre-hospital naloxone administration. IN route is not considered first

line therapy and should only be considered if unable to establish IV access. IN route is unlikely to be effective without spontaneous respirations.

• Return to normal alertness is not a required outcome following naloxone administration. • If no response after 2 doses, initiate transport and continue treatment en route to hospital. • Opioid dependent patients include recreational users and patients receiving chronic or

palliative pain management. • Meperidine (Demerol) or tramadol are opioids that do not cause pupil constriction. • Examples of shorter acting opioids include, but are not limited to: fentanyl, hydromorphone

(Dilaudid), morphine (Morphine-IR), meperidine (Demerol), codeine, heroin, sufentanyl, Darvon, oxycodone.

• Examples of longer acting opioids include, but are not limited to: methadone, MS-Contin, OxyNEO, OxyContin, Hydromorph-Contin, morphine-SR.

63


Contact with OLMC is mandatory for initiation of the Specific Toxin Management guidelines presented in Pages 63-66.

COCAINE OR OTHER SYMPATHOMIMETICS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of a sympathomimetic agent. Findings suggestive of severe toxicity include:

1) Severe agitation or combativeness 2) Tachydysrhythmias 3) Severe hypertension 4) Hyperthermia 5) Ischemic chest pain

1. Administer midazolam 2.5-5 mg IV. Repeat every 5 minutes if indicated (Not to exceed a

maximum total dose of 10 mg unless otherwise directed by OLMC)

2. Administer 20 mL/kg 0.9% NaCl IV bolus

3. If wide complex dysrhythmia (QRS greater than 120 ms) administer sodium bicarbonate 8.4% 1 mEq/kg IV (1 mL/kg) (Over 1 to 2 minutes). Repeat once in 5 to 10 minutes if indicated.

4. If ischemic chest pain present concurrently manage with ischemic chest pain protocol, including:

• Administer midazolam as outlined above • O2 as per Oxygen Therapy Protocol (Pg 79) • 12 lead ECG pre and post intervention – follow with 15 lead ECG if inferior and/or posterior

MI suspected • ASA 160-162 mg PO • Nitroglycerin and/or fentanyl as per Ischemic Chest Pain Protocol (Pg 40) if pain is

refractory to O2 and midazolam 5. If unable to establish an IV and severe agitation or combativeness is present proceed with the

Agitated / Combative Protocol (Pg 57)

64


TRICYCLIC ANTIDEPRESSANTS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of a tricyclic antidepressant. 1. Perform 12 Lead ECG

• Determine rhythm and assess for findings suggestive of TCA toxicity (QTc prolongation and

wide QRS)

2. If hypotension administer 20 mL/kg 0.9% NaCl IV bolus

3. Treat seizures with midazolam as per Convulsive Seizure Protocol (Pg 52)

4. Assess for Indications for Sodium Bicarbonate administration:

1) QRS duration greater than 120 ms (as indicated on 12 lead ECG printout) AND

2) Hypotension OR Life-threatening dysrhythmia OR Seizure has occurred 5. If Indications for Sodium Bicarbonate present administer:

• Sodium bicarbonate 8.4% 1 mEq/kg IV (Over 1 to 2 minutes)

o Repeat once in 5 to 10 minutes if indicated

6. If corrected QT interval (QTc) is greater than 500 ms (as indicated on 12 Lead ECG printout) administer magnesium sulfate 1 g in 100 mL 0.9% NaCl by IV infusion over 20 minutes (See Pg 206 for magnesium infusion instructions)

7. If hypotension persists despite 0.9% IV fluid boluses and administration of sodium bicarbonate consider dopamine 5 mcg/kg/min for refractory hypotension. Titrate by 5 mcg/kg/min, every 5 to 10 minutes, up to a maximum of 20 mcg/kg/min until MAP greater than 65 mmHg (See Pg 192 for dopamine infusion instructions)

NOTES • Examples of TCAs include, but are not limited to: amitriptyline (Elavil), amoxapine (Asendin),

clomipramine (Anafranil), doxepin (Adapin / Sinequan), and imitramine (Tofranil)

65


ORGANOPHOSPHATES, CARBAMATES AND OTHER ANTICHOLINESTERASES

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of an organophosphate, carbamate, or anticholinesterase agent resulting in cholinergic toxicity.

Signs of Cholinergic Toxicity

Muscarinic Cholinergic Toxicity Nicotinic Cholinergic Toxicity S L U D G E B

Salivation Lacrimation Urination Defecation Gastrointestinal cramps Emesis Bronchorrhea

Seizures Coma Fasciculations Muscle weakness Paralysis Mydriasis (dilated pupils)

If ANY of the following criteria are met proceed as outlined :

1) Severe respiratory distress 2) Paralysis

OR 3) Impaired consciousness

1. Manage airway and provide positive pressure ventilation as needed

2. Administer atropine 1-2 mg IVP • If no response, double the previous dose every 5 to 10 minutes until decreased bronchial

secretions and improved ability to ventilate and oxygenate

66


BETA BLOCKERS AND CALCIUM CHANNEL BLOCKERS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of a beta blocker or calcium channel blocker. In the presence of life threatening signs and symptoms, including profound bradycardia AND hypotension, proceed as outlined.

1. Administer 500 mL 0.9% NaCl IV bolus. Repeat once if hypotension persists. 2. Administer atropine 0.5 mg IV. Repeat every 5 minutes as indicated (Not to exceed a

maximum total dose of 3 mg). 3. If no improvement after two doses of atropine, consider further intervention(s) as outlined

below:

• Calcium chloride 10% solution 1 g SIVP (Over 10 minutes). Repeat once in 10 minutes if indicated.

• Glucagon 5 mg IV (Over 1 to 2 minutes) if indicated • Dopamine 5 mcg/kg/min for refractory hypotension. Titrate by 5 mcg/kg/min, every 5 to 10

minutes, up to a maximum of 20 mcg/kg/min until age-specific hypotension resolved (Pg 162) (See Pg 192 for dopamine infusion instructions)

• External pacing if bradycardia refractory to all other interventions

The sequence of management in cases of beta blocker or calcium channel blockers may be modified based on advice received from OLMC

67

TRAUMA ALERT Trauma Alert allows for the highest state of readiness and preparation prior to the trauma patient’s arrival to hospital. It is important that the ambulance crew identify that the situation warrants a “Trauma Alert” and notifies the receiving hospital as soon as possible. Trauma Alert Criteria Mechanism of Injury

Death occurs in same compartment of a MVC

Fall greater than 5 meters (15 feet)

Vehicle vs. pedestrian collision

Patient ejected from the vehicle

MVC greater than 100 km/hr

Motorcycle or ATV collision

Vehicle roll-over

Any time the practitioner judges the mechanism of injury to constitute a major trauma

Physical Findings

Tachycardia or bradycardia

Hypotension

Respiratory distress

Glasgow Coma Scale less than 14

Paralysis or suspected spinal cord injury

Penetrating injury

Amputation proximal to wrist or ankle

Two or more proximal long bone fractures

Suspected pelvis fracture

Burns greater than 15% of total BSA or involving face or airway

Multi-system trauma (Involves two or more body systems)

Any time the practitioner judges the physical finding(s) to constitute a major trauma

Co-Morbidities

Age less than 5

Pregnancy

Morbid obesity

Coagulopathy

68

C-SPINE ASSESSMENT Spine assessment consists of two different decisions:

1. Does the patient require a cervical collar?

And if yes, 2. Does the patient require a backboard?

The following decision rule is based on the Canadian C-Spine Rule and will be used to determine if a cervical collar is required. It is only applicable in alert, cooperative patients with no recent history of drug or alcohol ingestion. If there is uncertainty in the interpretation of this tool or the practitioner judges the patient to be high risk for cervical spine injury, the practitioner must default towards application of a cervical collar.

Yes

Yes

Cervical Spine Decision Rule

Any high-risk feature? • Age greater than 65 or • Age less than 16 or • Dangerous Mechanism* or • Paresthesia in extremities

Any low-risk feature? • Simple rear-end MVC or • Ambulatory at any time or • Delayed onset of neck pain or • Absence of midline c-spine

tenderness

Able to rotate neck? • 45° left and right

Do not apply cervical collar

Apply cervical collar

Immobilization mandatory if: • GCS less than 15 • Acute paralysis • Unstable vitals • Known vertebral disease • Previous c-spine surgery

*Dangerous mechanism: • Fall from greater than 1m/5 stairs • Axial load to head (ie. diving) • MVC greater than 100 km/h • Rollover MVC or ejection • Motorized recreational vehicle • Bicycle struck/collision

Simple rear-end MVC excludes:

• Pushed into oncoming traffic • Hit by bus/large truck • Rollover MVC or ejection • MVC greater than 100 km/h

Adapted from the Canadian C-Spine Rule

Yes

No

No

No

69

SPINE ASSESSMENT FOR BACKBOARD

Most patients requiring a cervical collar will not require transport on a backboard. If a backboard is required to transfer a patient to a stretcher, it should be promptly removed once they are placed on the stretcher. If the patient can ambulate, they should be encouraged to lie down on the stretcher on their own. Patients must be secured using the stretcher’s five-point restraints.

Precautions should be taken to minimize movement of the spine during patient transfers. Scoop stretchers are an excellent option for transferring patients to a stretcher but must also be removed.

Patients must remain on a backboard during transport to hospital if: • Backboard is part of a larger splinting strategy (pelvic or multiple long bone fractures)• Significant trauma with altered LOC• New neurologic complaint (paralysis or paresthesia)• Obvious spinal deformity• Patient is agitated or otherwise unable to cooperate with their own spinal motion restriction• Patient is at risk of vomiting and may need to be turned on their side• Backboard removal would unacceptably delay transport in a critical patient• Practitioner feels there are extenuating circumstances requiring transport on a backboard

At the receiving facility, patient transfer devices such as sliding boards, scoop stretchers or roller devices should be used to minimize motion of the spine.

NOTES • If there are any concerns regarding the application of this protocol, contact OLMC• If a sending physician is requesting a patient be transferred on a backboard, it must be

discussed with OLMC• Backboards do not have a role in inter-facility transfers, even if a spine injury has been

diagnosed.

70

BURNS (Thermal and Chemical) 1. Manage airway and assist ventilations as necessary

• If impending airway collapse consider intubation with Airway Pharmacology (Pg 15) and rapid transport

2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Two large bore IVs if inhalation injury1 OR greater than 20% Total Body Surface Area (TBSA)

(Initiate 2nd IV during transport) 5. Stop the burning process:

• Remove involved clothing • Brush off powdered chemicals and copious irrigation of any other chemical exposure

6. Warm ambient temperature to avoid hypothermia 7. Estimate %TBSA affected using Rule of Nines (Pg 167) and provide wound care as outlined

below: Less than 5% TBSA • Cover with moist or saline soaked (10-25ºC) dressing

• Analgesia as per Pain Management Protocol (Pg 54) 5 – 20% TBSA • Cover with clean, dry sheet, or commercial dressing

• Analgesia as per Pain Management Protocol (Pg 54) Greater than 20% TBSA • Cover with clean, dry sheet, or commercial dressing

• IV fluid administration as per Parkland Formula (Pg 167) • Analgesia as per Pain Management Protocol (Pg 54)

8. Remove all items including jewelry that have the potential to become constrictive to the neck,

extremities or digits

SIGNS AND SYMPTOMS OF INHALATION INJURY • Inability to swallow • Sensation of throat swelling • Hypoxemia • Closed space fire victim • Respiratory distress

• Facial burns • Singed nasal hairs • Carbonaceous sputum • Wheezing or crackles • Voice changes

CAUTION

• Cooling with ice or ice water is contraindicated as this may increase severity of injury and lead to hypothermia.

71

HEAT RELATED ILLNESS This protocol is intended for the management of patients with exposure to high temperatures or high levels of exertion and without history of recent infection 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 48) 5. IV access

• If signs of dehydration present administer fluid bolus as per Fluid Therapy Protocol (Pg 78) 6. Begin cooling measures1 if signs of heat exhaustion or stroke present2. Continue until temperature

is less than 39°C or patient starts shivering. 7. If severe agitation or combativeness is present, concurrently manage as per Agitated /

Combative Protocol (Pg 57) 8. If seizure occurs, proceed with Convulsive Seizure Protocol (Pg 52). Continue cooling. 9. If severe nausea and vomiting, administer:

• Metoclopramide 10mg SIVP over 2-5 mins.

1COOLING MEASURES (STOP if patient starts shivering) 1) Remove the patient from hot environment and cool ambient temperature in the ambulance. 2) Remove patient’s clothing and apply cool water to patient’s skin. 3) Promote evaporation by using a fan or open window. 4) Apply ice packs to the groin, neck and axilla. DO NOT APPLY DIRECTLY TO SKIN

NOTES: • Patients may have normal to slightly elevated temperature with heat exhaustion. • Lack of perspiration is a late sign of heat stroke. • Patients with exertional heat illness may have profound sinus tachycardia as a normal physiological

response.

2SIGNS OF HEAT EXHAUSTION and HEAT STROKE Patients with heat related illness may exhibit one or more of the following:

Heat Exhaustion

• Decreased Coordination • Sweating • Tachycardia and Hypotension

• Hyperventilation • Headache • Abdominal pain and/or nausea and vomiting

Heat Stroke 1) Temperature greater than 40°C AND 2) Altered mental status or CNS dysfunction

72

HYPOTHERMIA This protocol is intended for the management of patients with exposure to environmental conditions consistent with hypothermia. 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 48) 5. IV access

• Treat hypotension as per Adult Fluid Therapy Protocol (Pg 78) 6. If signs of frostbite present:

• Splint or pad effected area to minimize injury • Remove jewelry if required • Pad between effected digits and bandage effected tissue loosely with a soft, sterile dressing. Do

not put pressure on the effected parts. 7. If signs of hypothermia proceed with steps for rewarming1 8. If Cardiac Arrest occurs proceed to Adult Cardiac Arrest Protocol (Pg 26)

1STEPS FOR REWARMING • Remove patient from cold environment • Remove wet clothing (cutting preferred) • Cover with blankets • Increase ambient temperature in ambulance • Apply radiant heat and/or warm blankets to core • Use warmed IV fluids for resuscitation

Mild Hypothermia Severe Hypothermia 1) 32°C-35°C 2) Normal Mental Status 3) Shivering 4) Normal to slightly elevated vital signs

1) Temperature less than 32°C 2) Decreased LOC, slurred speech and ataxia 3) Decreased Heart rate and respiratory rate 4) Shivering absent below 30°C

CAUTION

• Patients in severe hypothermia often become extremely bradycardic. Transcutaneous pacing is not indicated unless patient is warmed to greater than 32°C.

• Hypothermic patients are at a high risk for VF if handled roughly. Patient movement should be limited and a horizontal position maintained whenever possible.

• Severely hypothermic patients should have their core areas warmed first. Warming extremities before core can precipitate a secondary drop in temperature.

• DO NOT attempt to thaw frostbitten areas. • DO NOT ambulate patients with hypothermia.

73

TENSION PNEUMOTHORAX INDICATIONS FOR NEEDLE THORACENTESIS 1) Severe and worsening shortness of breath or respiratory distress

AND 2) Absent or markedly decreased breath sounds on affected side

AND 3) Clinical signs of shock

1. Manage airway and assist ventilations as necessary 2. O2 100% 3. Spinal immobilization if indicated 4. Continuous cardiac, SpO2 and BP monitoring 5. Perform needle thoracentesis as outlined below 6. Two large bore IVs (Initiate 2nd IV during transport) 7. Analgesia as needed per Pain Management Protocol (Pg 54)

NEEDLE THORACENTESIS 1) Pre-oxygenate 2) Landmark – 2nd intercostal space (above 3rd rib) on the anterior chest wall in the mid-clavicular

line on the affected side (alternate location is the mid-axillary line, 4th intercostal space – above 5th rib)

3) Clean area with alcohol 4) Insert 3 inch 14 gauge catheter- over-needle attached to a syringe along the upper border of

the rib at a 90º angle with skin while maintaining negative pressure on the syringe 5) Upon aspiration of air, STOP advancing needle and slide catheter over the needle until

catheter hub is flush with the skin 6) Retract the needle and syringe as a single unit and leave the catheter in position 7) Secure the catheter in place and attach flutter valve to the hub of the catheter if the patient is

spontaneously breathing 8) Continually monitor patient for recurrence (additional decompressions may be necessary)

NOTES • Decompression should be completed prior to intubation or artificial ventilation if indicated. • Jugular venous distension (JVD) and tracheal deviation are late signs of tension pneumothorax

and may not be observed.

74

PAGE INTENTIONALLY LEFT BLANK FOR FUTURE PROTOCOL

75

BLUNT TRAUMATIC CARDIAC ARREST UNWITNESSED BLUNT CARDIAC ARREST If the following two criteria are met on arrival to patient side then no resuscitation indicated: 1) Obvious external signs of major blunt trauma consistent with Trauma Alert Activation Criteria in

the Trauma Alert Protocol (Pg 67) AND

2) Confirmed cardiac arrest by absence of spontaneous respiration and palpable pulse WITNESSED BLUNT CARDIAC ARREST

ON-SCENE • Begin CPR (30 compressions : 2 ventilations) while attaching defibrillator • If VF / Pulseless VT – Proceed with VF/Pulseless VT Protocol while initiating transport • If PEA or asystole - Perform immediate bilateral chest decompression and administer 20 mL/kg

0.9% NaCl IV fluid bolus o If patient remains in cardiac arrest, terminate resuscitation

ENROUTE TO HOSPITAL • Begin CPR (30 compressions : 2 ventilations) while attaching defibrillator • If VF / Pulseless VT – Proceed with VF/Pulseless VT Protocol and continue transport • If PEA or asystole - Perform immediate bilateral chest decompression and administer 20 mL/kg

0.9% NaCl IV fluid bolus while continuing transport • Notify receiving Emergency Department without delay that cardiac arrest has occurred and

continue transport

NOTES • If no obvious external signs of significant trauma or if unsure of mechanism of injury, consider

medical cardiac arrest and treat according to appropriate medical cardiac arrest protocol. • Do not delay transport for any interventions or medications in traumatic cardiac arrest. All

interventions must be performed en route to the hospital. • Life-saving procedures (i.e.: decompression of tension pneumothorax or IV fluid boluses etc.)

take priority over ACLS medications in traumatic cardiac arrest. • Notify receiving Emergency Department without delay of actual or impending cardiac arrest

(From the scene if possible).

76

PENETRATING TRAUMATIC CARDIAC ARREST

Initiate CPR immediately • Attach defibrillator while preparing for transport • O2 via BVM • If penetrating injury to chest perform immediate chest

decompression on side(s) of injury • Determine rhythm

Shockable rhythm?

• Continue CPR and proceed with VF / Pulseless VT Protocol (Pg 28) and initiate rapid transport while defibrillator charging

• Limit to ONLY ONE SHOCK ON SCENE (unless patient entrapped or other unforeseen circumstance)

Assess for Signs of Life: 1) Pupillary response 2) Spontaneous movement 3) Organized ECG activity

If ALL Signs of Life absent: • Determine transport time to nearest

hospital

YES NO

PRESENT ABSENT

If ANY Signs of Life present: • Continue resuscitation • Initiate rapid transport • Administer 20 mL/kg 0.9% NaCl IV fluid

bolus • Proceed with Asystole / PEA Protocol

(Pg 29)

If transport time less than or equal to 20 minutes: • Continue resuscitation • Initiate rapid transport • Administer 20 mL/kg 0.9% NaCl IV fluid

bolus • Proceed with Asystole / PEA Protocol

(Pg 29)

If transport time greater than 20 minutes: • Terminate resuscitation and proceed with

Management of Death Protocol (Pg 34)

≤ 20 minutes > 20 minutes

77

PENETRATING TRAUMATIC CARDIAC ARREST Cont’d

NOTES

• If no obvious external signs of significant trauma or if unsure of mechanism of injury, consider medical cardiac arrest and treat according to appropriate medical cardiac arrest protocol.

• Do not delay transport for any interventions or medications in traumatic cardiac arrest. All interventions must be performed en route to the hospital.

• Life-saving procedures (i.e.: decompression of tension pneumothorax or IV fluid boluses etc.) take priority over ACLS medications in traumatic cardiac arrest.

• Notify receiving Emergency Department without delay of actual or impending cardiac arrest (From the scene if possible).

78

ADULT FLUID THERAPY When IV medication or fluid therapy may be required, start a peripheral IV line or lock using 0.9% NaCl solution. Unless otherwise directed by protocol or OLMC the drip rate will be set at TKVO at 30-60 mL/hr Fluid bolus should be initiated as follows unless otherwise specified by a specific treatment protocol.

FLUID ADMINISTRATION IN TRAUMA CASES Bolus administration of IV fluid is to be reserved for cases of hypotension with evidence of poor perfusion. When indicated, administer IV 0.9% NaCl as outlined below: • 20 mL/kg bolus until SBP 90 mmHg achieved • If brain and/or spinal cord injury is suspected, maintain an optimal SBP of 110-120 mmHg • There is no limit to the amount of fluid a paramedic may administer to achieve the desired

target SBP Routine administration of bolus IV fluids in the absence of hypotension is CONTRAINDICATED in the trauma patient.

FLUID ADMINISTRATION IN MEDICAL CASES (NON-TRAUMA) When indicated as per protocol administer IV 0.9% NaCl as outlined below: • 20 mL/kg bolus until MAP of greater than or equal to 65 mmHg is achieved • May repeat bolus administration while indications persist up to maximum 2000 mL unless

otherwise directed by protocol • If indications for additional IV fluid persist despite administration of 2000 mL IV fluids, contact

OLMC

NOTES: • Carefully observe for signs of pulmonary edema. Auscultate chest for crackles after every 250

mL If crackles present, stop bolus. • Peripheral IV, including external jugular vein, should be a first line attempt for vascular access. • Intraosseous access should be limited to a single attempt after peripheral access fails, after 3rd

attempt OR is otherwise unattainable.

79

OXYGEN THERAPY Oxygen therapy should be initiated as follows unless otherwise specified by a specific treatment protocol: A. Administer high flow oxygen without delay if any of the following critical findings are

present, regardless of SpO2. Be prepared to initiate PPV without delay if the patient displays signs of inadequate ventilation1: • Apnea • Respiratory distress or failure • Cyanosis or ashen colored skin • Loss of consciousness • Toxin or smoke inhalation • Suspected or confirmed carbon monoxide exposure • Hypotension with accompanied signs and symptoms of shock or impending shock • Complications of pregnancy or high risk childbirth:

o Hemorrhage o Labour with multiple fetuses o Premature labor (less than 37 weeks gestation) o Trauma extending beyond an isolated extremity o Complications of delivery o Eclampsia

B. Administer high flow oxygen if SpO2 less than 95% AND any of the following chief

complaints are present: • Ischemic chest pain • Cardiac arrhythmia, including STEMI • Acute stroke • Decreasing level of consciousness • Altered mental status • Uncomplicated pregnancy / childbirth • Traumatic injury • Sepsis

• Toxin ingestion • Hypo / Hyperglycemia • Convulsive seizures • Agitation or combative behavior • Electrocution • Vision and/or hearing changes • Near drowning • Acute severe pain

C. Once hypoxia has been corrected, titrate oxygen delivery to achieve a target SpO2 of 95%

80

OXYGEN THERAPY Cont’d

COPD If confirmed COPD (Emphysema or Chronic Bronchitis) only, administer oxygen according to the following guidelines: • If the patient is in moderate to severe respiratory distress or has critical findings, administer high

flow oxygen. Be prepared to initiate PPV without delay if the patient displays signs of inadequate ventilation1. o If respiratory status has improved to patient’s baseline after treatment, consider replacing

NRB with nasal cannula to maintain SpO2 90-92% • If the patient is in mild distress, administer low flow oxygen 1 to 2 liters per minute above home

oxygen levels, titrated to a target SpO2 of 90-92% NOTES 1. If you experience any difficulty obtaining a reliable SpO2, or if at any time you obtain a low

SpO2 reading, you must administer high flow oxygen and assume the patient is hypoxic and that any low reading is accurate.

2. There may be additional circumstances beyond those contained in this protocol which will require oxygen therapy. Clinicians are advised to use sound clinical judgement to titrate oxygen therapy to balance the risk of hypoxia with concerns about hyperoxia.

1CAUTION

In order for supplementary oxygen to be effective, the patient must have adequate respiratory effort, rate, and volume to ensure oxygen is delivered to the lungs. If the patient’s respiratory effort, rate, or volume is inadequate to maintain oxygenation, the patient is considered to be in respiratory failure, and PPV with high flow oxygen must be delivered without delay. The following signs of inadequate ventilation may be observed in patients with respiratory failure:

• Abnormal sounds with breathing, such as snoring, gurgling, or stridor • Fatigue with respiratory effort • Gasping • Irregular breathing pattern with periods of apnea • Little or no chest rise • Decreased or absent breath sounds (“Silent chest”) • Rate and/or depth of breathing grossly insufficient for age • Apnea

If there are findings of airway obstruction, such as stridor, snoring, or gurgling, proceed with basic airway maneuvers to open and/or clear the airway.

81

LESS THAN LETHAL FORCE Conducted Energy Weapons (CEW) 1. If cardiac arrest present, start CPR immediately and proceed with Cardiac Arrest Protocol

(Pg 26) without delay 2. Manage airway and assist ventilation as necessary 3. Administer O2 as per Oxygen Therapy Protocol (Pg 79) 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 48) 6. Assess for secondary injuries (burns, pathological fractures, etc.) 7. If altered mental status consider the following:

• If signs of hypoglycemia, treat as per Symptomatic Hypoglycemia Protocol (Pg 48) • If severe agitation or combativeness is present proceed with Agitated/Combative Protocol

(Pg 57) o If cocaine or other sympathomimetics are suspected as the cause of agitation or

combativeness, proceed with Specific Toxin Management Protocol (Pg 61) • If signs of hyperthermia and Excited Delirium1 are present, initiate external cooling measures

8. Determine the event(s) preceding the use of the CEW and how many “5-second cycles of energy” were delivered to the patient

9. Inspect the impact site of the probe dart(s). If necessary, cut away clothing to view the probe darts • Do NOT remove any probe dart(s) • Treat dart(s) as impaled object(s) and secure in place

10. Initiate IV access • If signs of hyperthermia and Excited Delirium1 are present, initiate a second IV en route to

hospital

1 EXCITED DELIRIUM A state of excessive agitation and psychosis often brought on by overdose, drug withdrawal, or non-compliance with medications used in the treatment of mental health disorders. These patients are at heightened risk of adverse outcome (cardiac and respiratory demise) and death, which is exacerbated in situations of physical restraint.

Assess the patient for the following signs of excited delirium: • Aggressive and bizarre behaviour • Dilated pupils • Extreme agitation • Shivering • Shouting • Excessive physical strength • Decreased sensitivity to pain

82

LESS THAN LETHAL FORCE Cont’d

CAUTION • Maintain police presence at all times while on-scene and request police escort during

transport. • Ensure that there is no electricity flowing through the CEW before approaching the patient. • Assume spinal precautions. All patients exposed to CEW are considered to have fallen until

proven otherwise. • Exercise caution when approaching a patient exposed to CEW energy as they may display

violent tendencies post-deployment. Always maintain an ability to escape the scene. Position yourself between the patient and the exit at all times to maintain a safe exit, should the situation escalate.

• At NO TIME should the patient be restrained in the prone (face or chest-down) position. • There is a high risk of positional asphyxia and/or aspiration in patients in excessively agitated

states. Close and continuous monitoring of these patients, including airway patency and adequacy of respiration, is mandatory.

• Patients with a weakened cardiac system may not tolerate exposure to CEW. Complaints of chest pain or shortness of breath must be taken seriously, evaluated, and treated as appropriate.

• All patients exposed to CEW must be transported to the closest medical facility for evaluation. If police determine transport by ambulance is too dangerous, ensure that the police are clearly informed of the need for medical evaluation at a hospital and document the badge number of the police officer informed.

• Be alert for the possibility of soft tissue burns after the use of a push stun feature on the CEW.

• Be alert for the possibility of blunt force trauma after the use of a bean bag deployment device

83

ADRENAL INSUFFICIENCY 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND closely monitor blood glucose


5. IV access • Administer 20 mL/kg bolus NaCl 0.9% if signs or symptoms of adrenal crisis1 present

6. If patient meets Criteria for Hydrocortisone Administration2, administer: • Hydrocortisone 100 mg IV, OR IM may be administered if IV delayed or unattainable

7. Perform 12 lead ECG

2CRITERIA FOR HYDROCORTISONE ADMINISTRATION 3) Patient has any one of the following:

• Trauma or significant physical stressor • Significant emotional crisis • Vomiting or diarrhea • Signs/symptoms of acute adrenal crisis1 • Fever of greater than or equal to 38ºC or signs of infection

AND 4) Medical history of any one of the following:

• 3 weeks or more of chronic glucocorticoid use • Malcompliance or cessation of chronic glucocorticoid medication within 3 months • Addison’s Disease • Congenital Adrenal Hyperplasia • Pituitary insufficiency/hypopituitarism (i.e.: tumors, previous radiation, hypopituitary

disorders) • Bilateral adrenalectomy (removal of adrenal glands) • Patient presents a home adrenal insufficiency kit containing a glucocorticoid medication • Patient is wearing a Medic-Alert stating the patient has adrenal insufficiency

1SIGNS AND SYMPTOMS OF ADRENAL CRISIS

• Nausea/Vomiting • Hypoglycemia • Abdominal pain • Arrhythmia • Hypotension (less than 100 SBP or drop of

20 mmHg from baseline)

• Weakness • Dizziness • Pallor • Confusion • Lethargy • Altered LOC

84

ADRENAL INSUFFICIENCY Cont’d

NOTES

• PMO maintains a low therapeutic threshold to administer hydrocortisone in the acutely ill or injured patient suspected to have adrenal insufficiency. There is little to no risk from a single stat dose of hydrocortisone. The risk of a low glucocorticoid level during crisis far outweighs the risk of unnecessary hydrocortisone administration.

• IV route is preferred for the administration of hydrocortisone. IM route via lateral thigh may be used if an IV is unsuccessful or otherwise delayed.

• Stress is defined as a circumstance that changes the physiological norm for the patient, and includes illness, trauma, and mental health crisis.

• Administer hydrocortisone regardless of any recent self-administration prior to EMS arrival • Glucocorticoids are used to support treatment of a multitude of medical conditions, including

but not limited to: autoimmune disorders, inflammatory bowel disease, asthma, cancer, autism, chronic allergies, and genetic enzyme deficiencies.

• Commonly prescribed glucocorticoids include, but are not limited to: prednisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, triamclinolone, cortisone acetate, hydrocortisone (cortisol).

• Past history of adrenal crisis presents increased risk for repeat adrenal crisis.

CAUTION • It is preferable to administer hydrocortisone prior to transport, as some patients in adrenal

crisis may not have sufficient adrenal reserves to manage movement, even to the ambulance. These patients may deteriorate rapidly.

• Do not ambulate these patients to the ambulance. • In the rare event that a patient with adrenal insufficiency presents with anaphylaxis,

administer epinephrine first, followed immediately by hydrocortisone.

85


86

PART II: PEDIATRIC EMERGENCY PROTOCOLS

87

PEDIATRIC RESPIRATORY DISTRESS WITH BRONCHOSPASM 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access 6. Administer salbutamol based on dosing below:

Age MDI + aerochamber 1

OR

Nebulized with O2

Less than 5 years 5 puffs (100 mcg/puff) 2.5 mg

Greater than or equal to 5 years 10 puffs (100 mcg/puff) 5 mg

Repeat every 5 minutes if indicated (Not to exceed a maximum total of 3 administrations) 1 Each puff must be followed by at least 4 breaths

7. Consider ipratropium bromide administration with 2nd and 3rd doses of salbutamol as per

dosing guidelines below:

Age MDI + aerochamber 1 OR

Nebulized with O2

All ages 3 puffs (20 mcg/puff) following dose of salbutamol 500 mcg (mix with salbutamol)

Repeat once in 5 minutes if indicated (Not to exceed a maximum total of 2 administrations) 1 Each puff must be followed by at least 4 breaths

8. If symptoms unrelieved by salbutamol and ipratropium bromide and or respiratory status is deteriorating, administer:

• Epinephrine 1:1000 0.01 mg/kg (0.01 mL/kg) IM in the anterolateral thigh [Not to exceed a

maximum single dose of 0.3 mg (0.3 mL)] AND • Magnesium sulfate 25 mg/kg IV [Not to exceed a maximum single dose of 2g (2000 mg)] by IV

infusion over 20 minutes (See Pg 206 for magnesium infusion instructions) – to be considered only in cases of severe or refractory asthma

Contact OLMC for patients that are unrelieved by salbutamol and/or ipratropium bromide and condition is deteriorating for consideration of the following:

• Continued administration of salbutamol • Continued administration of epinephrine • NIPPV (Pg 21) • Hydrocortisone 1mg/kg SIVP

88

PEDIATRIC RESPIRATORY DISTRESS WITH BRONCHOSPASM Cont’d

NOTES • Patients should be treated with MDI and aerochamber unless it is deemed inappropriate,

ineffective, or patient cannot tolerate. • Salbutamol or ipratropium bromide may be administered singularly if the patient has

hypersensitivity to one or the other medications. • If respiratory failure is refractory to all interventions consider a trial of NIPPV. Attempt BVM

assisted ventilations followed by intubation, if necessary.

89

PEDIATRIC RESPIRATORY DISTRESS WITH INSPIRATORY STRIDOR (Laryngotracheitis / Croup) 1. Manage airway and assist ventilations as necessary 2. Humidified O2 (Blow-by O2 acceptable if child refuses mask) 3. Continuous cardiac, SpO2, and BP monitoring 4. Keep child as comfortable as possible as agitation may worsen condition 5. Consider nebulized epinephrine 1:1000 in accordance with dosing guidelines below if

Indications for Nebulized Epinephrine1 present:

Nebulized Epinephrine 1:1000

Age Dose

Less than 1 year AND less than 5 kg 0.5 mg (0.5 mL) in 2 mL 0.9% NaCl

Less than 1 year AND greater than or equal to 5 kg 2.5 mg (2.5 mL)

Greater than or equal to 1 year 5 mg (5 mL)

Contact OLMC for refractory stridor and respiratory distress for consideration of:

• Repeat administration of nebulized epinephrine 1:1000

1 INDICATIONS FOR NEBULIZED EPINEPHRINE 1:1000

1) Current history of upper respiratory infection with a “barking cough”

AND

2) Significant respiratory distress

AND

3) Stridor at rest

90

PEDIATRIC ALLERGY AND ANAPHYLAXIS

FINDINGS OF ANAPHYLAXIS 1) Acute onset (minutes to hours) of TWO OR MORE of the following after exposure to a LIKELY

ALLERGEN:

• Skin symptoms (hives, itching, flushing) • Oropharyngeal edema (lips, tongue, uvula) • Respiratory compromise (dyspnea, wheeze, stridor, hypoxemia) • Gastrointestinal symptoms (crampy abdominal pain, vomiting, diarrhea) • Reduced blood pressure or associated symptoms (hypotonia, collapse, syncope) OR

2) Hypotension alone after exposure to a KNOWN ALLERGEN for patient

1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access 5. If age-specific hypotension (Pg 163) present, administer a fluid bolus as per Pediatric Fluid

Therapy Protocol (Pg 125) 6. If Findings of Anaphylaxis present administer:

• Epinephrine 1:1000 0.01 mg/kg (0.01 mL/kg) IM, ideally in the anterolateral thigh [Not to

exceed a maximum single dose of 0.3 mg (0.3 mL)] o Repeat once in 5 minutes if no improvement AND

• DiphenhydrAMINE1 1 mg/kg IV (Not to exceed a maximum single dose of 50 mg)

7. If respiratory distress present (including wheezing), administer salbutamol:

Age MDI + aerochamber 2

OR

Nebulized with O2

Less than 5 years 5 puffs (100 mcg/puff) 2.5 mg

Greater than or equal to 5 years 10 puffs (100 mcg/puff) 5 mg

Repeat every 5 minutes if indicated (Not to exceed a maximum total of 3 administrations) 2Each puff must be followed by at least 4 breaths 8. Consider early intubation with topical anesthesia (Pg 15) if epinephrine not rapidly improving

cardiorespiratory status with evidence of progressive oropharyngeal edema

91

PEDIATRIC ALLERGY AND ANAPHYLAXIS Cont’d

Contact OLMC if severe and refractory airway compromise, respiratory failure, or shock for consideration of:

• Additional IV fluid administration for refractory hypotension • For refractory airway compromise, respiratory failure, or hypotension administer

epinephrine 1:10 000 – 0.01 mg/kg (0.1 mL/kg) SIVP/IO (Over 5 minutes) [Not to exceed a maximum single dose of 0.1 mg (1 mL)] o Repeat every 5 to 15 minutes if indicated [Not to exceed a maximum total dose of 1

mg (10 mL)] • Dopamine 5 mcg/kg/min for refractory hypotension. Titrate by 5 mcg/kg/min, every 5 to

10 minutes, up to a maximum of 20 mcg/kg/min until age-specific hypotension resolved (Pg 163) (See Pg 192 for dopamine infusion instructions)

1 NOTE • May give diphenhydrAMINE 1 mg/kg PO (Not to exceed a maximum single dose of 50 mg)

alone for isolated hives. • May administer diphenhydrAMINE 1 mg/kg IM (Not to exceed a maximum single dose of 50

mg) if anaphylaxis AND unable to establish an IV. • There is NO absolute contraindication to epinephrine in a patient with anaphylaxis. • DiphenhydrAMINE DOES NOT improve angioedema or respiratory symptoms in

anaphylaxis.

92

PEDIATRIC CARDIAC ARREST If patient meets DNR Protocol (Pg 33) or Obvious Death Protocol (Pg 32) do not proceed with resuscitation

1. Confirm Vital Signs Absent (VSA) and initiate chest compressions 2. 100% O2 via BVM 3. Continuous cardiac and SpO2 monitoring 4. Proceed with appropriate algorithm 5. Treat Reversible Causes1 6. IV/IO access (DO NOT delay or interrupt CPR) 7. Consider advanced airway (DO NOT delay or interrupt CPR) 8. Continuous waveform capnography2 (if EGD or ETT) for evaluation of CPR quality and detection

of ROSC

GENERAL GUIDELINES • Initiate compressions immediately: C-A-B Sequence • If arrest secondary to hypoxia suspected, proceed with A-B-C Sequence • Begin CPR (5 cycles of 30 compressions : 2 ventilations) and immediately attach defibrillator –

defibrillate without delay if indicated

Compressions : Ventilation Ratio Depth Rate

One Rescuer 30:2 1/3 chest depth • Infants: 1.5 inches • Child: 2 inches

At least 100 per minute Two Rescuers 15:2

• If no advanced airway, interrupt compressions for ventilations • If advanced airway, give 8-10 ventilations per minute with continuous compressions (avoid

excessive ventilations)

• Ensure high quality CPR o Minimize interruptions in CPR o Allow full recoil of the chest between compressions o Rotate rescuers every 2 minutes (if resources allow) concurrent with pulse checks

• Proceed to appropriate algorithm • If return of spontaneous circulation (ROSC) proceed immediately with Pediatric Post Cardiac

Arrest Care Protocol (Pg 96) • If re-arrest occurs during transport, resume Cardiac Arrest Protocol

HYPOTHERMIC CARDIAC ARREST (CORE TEMPERATURE LESS THAN 32ºC) • Hypothermic patients are to be resuscitated as per normal with defibrillation and up to three

doses of epinephrine. Do not administer any other medications. • Resuscitation will be continued until active re-warming has returned core temperature to

normal or there has been ROSC.

93

PEDIATRIC CARDIAC ARREST Cont’d



2 ROLE OF ETCO2 MONITORING IN CARDIAC ARREST

1) Detection of ROSC – abrupt and sustained rise in ETCO2 (greater than 35 mmHg) 2) Monitoring of CPR quality – if ETCO2 is less than 10 mmHg during CPR try to improve CPR

quality by optimizing chest compressions

94

PEDIATRIC VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA


1) Sodium bicarbonate 1 mEq/kg IVP/IO if suspected metabolic acidosis or hyperkalemia (Dialysis patient, ECG findings of hyperkalemia), or TCA overdose • Age less than 2 years: Use 4.2%

solution (2 mL/kg) • Age greater than 2 years: Use 8.4%

solution (1 mL/kg) 2) Calcium chloride 10% 20 mg/kg SIVP/IO

(Over 2 to 5 minutes) if suspected hyperkalemia (Dialysis patient, ECG findings of hyperkalemia) • Repeat once in 10 minutes if indicated

Initiate CPR immediately • Attach defibrillator • O2 via BVM

Shockable rhythm?

Continue CPR while defibrillator charging • Defibrillate once at 2 J/kg • Resume CPR immediately for 2 minutes • IV/IO access • Epinephrine every 3 to 5 minutes:

o IV/IO: 0.01 mg/kg 1:10 000 (0.1 mL/kg) [Not to exceed a maximum single dose 1 mg (10 mL)]

o ETT: 0.1 mg/kg 1:1000 (0.1 mL/kg) [Not to exceed a maximum single dose of 2.5 mg (2.5 mL)]

Check pulse • If pulse present, proceed with Pediatric

Post Cardiac Arrest Care Protocol (Pg 96)

• If Asystole or PEA proceed with Pediatric Asystole / PEA Protocol (Pg 95)

Shockable rhythm?

Continue CPR while defibrillator charging • Defibrillate once at 4 J/kg Resume CPR immediately for 2 minutes • Amiodarone 5 mg/kg IVP/IO (Not to

exceed a maximum single dose of 300 mg) o Repeat amiodarone 5 mg/kg IVP/IO

(Not to exceed a maximum single dose of 300 mg) twice if indicated (Not to exceed a maximum total of 15 mg/kg)

• Consider advanced airway placement if BVM ineffective

Perform rhythm check every 2 minutes


OR • Arrival to hospital

YES NO

YES

NO

Pulseless Torsades De Pointes • Defibrillate as per VF/VT Protocol • Administer magnesium sulfate 25-50

mg/kg [Not to exceed a maximum single dose of 2 g (2000 mg)] diluted in 10 mL 0.9% NaCl IVP/IO

95

PEDIATRIC PULSELESS ELECTRICAL ACTIVITY (PEA) / ASYSTOLE


1) Sodium bicarbonate 1 mEq/kg IVP/IO if suspected metabolic acidosis or hyperkalemia (Dialysis patient, ECG findings of hyperkalemia), or TCA overdose • Age less than 2 years: Use 4.2%

solution (2 mL/kg) • Age greater than 2 years: Use 8.4%

solution (1 mL/kg) Calcium chloride 10% 20 mg/kg SIVP/IO (Over 2 to 5 minutes) if suspected hyperkalemia (Dialysis patient, ECG findings of hyperkalemia)

• Repeat once in 10 minutes if indicated

Shockable rhythm?

NO

Continue CPR and proceed with Pediatric VF / Pulseless VT Protocol (Pg 94)

Resume CPR immediately for 2 minutes • IV/IO access • Epinephrine every 3 to 5 minutes:

o IV/IO: 0.01 mg/kg 1:10 000 (0.1 mL/kg) [Not to exceed a maximum single dose 1 mg (10 mL)]

o ETT: 0.1 mg/kg 1:1000 (0.1 mL/kg) [Not to exceed a maximum single dose of 2.5 mg (2.5 mL)]

Shockable rhythm?


OR • Arrival to hospital

Resume CPR immediately for 2 minutes • Consider advanced airway placement if

BVM ineffective • Treat Reversible Causes1 • Perform rhythm check every 2 minutes

YES

YES

Initiate CPR immediately • Attach defibrillator • O2 via BVM • Confirm asystole in two leads

NO

1Reversible Causes: Hypovolemia Tension Pneumothorax Hypoxia Tamponade Hypothermia Toxins Hypo/Hyperkalemia Thrombosis Hypoglycemia Trauma Hydrogen Ion (acidosis)

96

PEDIATRIC POST CARDIAC ARREST CARE (RETURN OF SPONTANEOUS CIRCULATION) 1. Manage airway 2. O2 100% and assist ventilations as necessary

• Ventilatory rate: o Infants: 20-30 breaths per minute o Children: 16-20 breaths per minute o Adolescents: 8-12 breaths per minute

• Inspiratory time should not exceed 1 second • Deliver only enough tidal volume to make the chest rise • Avoid excessive ventilation

3. If defibrillator was used, leave pads in place 4. Continuous cardiac, SpO2, ETCO2 (waveform capnography) and BP monitoring 5. Perform 12 Lead ECG 6. Two peripheral IVs or single IO (initiate second IV during transport) 7. Treat Reversible Causes1 8. Adjust ventilation, oxygenation, and fluid resuscitation to target values of:

• SBP – greater than age-specific hypotension (Pg 163)2 • ETCO2 – 35 to 45 mmHg • SpO2 – greater than or equal to 95%

o Utilize PEEP to optimize oxygenation if needed 9. If re-arrest occurs, resume Pediatric Cardiac Arrest Protocol (Pg 92) and appropriate algorithm 10. If persistent hypotension, proceed with Pediatric Shock Protocol (Pg 97)



NOTES 2 Hemodynamic instability and ectopy are common immediately post-ROSC. Monitor patient

carefully and prepare for IV fluid administration and/or dopamine administration if hypotension persists, as per Pediatric Shock Protocol (Pg 97).

A copy of the code summary and PCR must be left with the receiving facility

97

PEDIATRIC SHOCK (Symptomatic Age-Specific Hypotension1) 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Control bleeding (if applicable) 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure temperature AND blood glucose 6. Two IVs or single IO (Initiate second IV during transport) 7. Perform 12 lead ECG 8. Consider causes of shock and treat accordingly:

• If shock due to anaphylaxis, proceed with Pediatric Allergy and Anaphylaxis Protocol (Pg 90)

• If shock due to sepsis, proceed with Pediatric Septic Shock Protocol (Pg 99) • If cardiac dysrhythmia identified, proceed with appropriate dysrhythmia protocol (Pg 100-105) • If shock due to toxic ingestion, proceed with appropriate Pediatric Specific Toxin

Management Protocol (Pg 117) 9. For all other causes of shock, or when the cause of shock is unknown, administer a fluid bolus as

per Pediatric Fluid Therapy Protocol (Pg 125)

Contact OLMC if age-specific hypotension persists after initial fluid bolus for consideration of:


10 minutes, up to a maximum of 20 mcg/kg/min until age-specific hypotension resolved (See Pg 192 for dopamine infusion instructions)

1 AGE-SPECIFIC HYPOTENTION (5th PERCENTILE FOR SBP) GUIDELINES

Age Hypotension SBP

0 to 28 days Less than 60 mmHg

1 month to 12 months Less than 70 mmHg

1 year to 10 years Less than [70 + (2 x age in years)] mmHg

Greater than 10 years Less than 90 mmHg

NOTE • Trendelenberg positioning is not indicated in the treatment of shock, and is not to be utilized as

a treatment option.

98

PEDIATRIC SHOCK Cont’d

CAUTION: • Neonates and pediatric patients with hyperglycemia (greater than 15 mmol/L) must be

restricted to 10 mL/kg bolus to maintain SBP greater than age-specific hypotension to avoid induction of cerebral edema.

• Contact OLMC to administer additional IV fluid if age-specific hypotension persists after initial IV bolus of 10 mL/kg of 0.9% NaCl in the hyperglycemic patient.

99

PEDIATRIC SEPTIC SHOCK 1. Manage airway and assist ventilations as necessary 2. O2 as Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose:

• Treat hypoglycemia in accordance with Pediatric Symptomatic Hypoglycemia Protocol (Pg 106)

• Treat hyperglycemia in accordance with Pediatric Symptomatic Hyperglycemia Protocol (Pg 108)

5. Two IVs or single IO (Initiate second IV during transport) 6. If patient meets Pediatric Septic Shock Inclusion Criteria1 administer fluid bolus in accordance

with Pediatric Fluid Therapy Protocol (Pg 125)

1 PEDIATRIC SEPTIC SHOCK INCLUSION CRITERIA 1) History suspicious for infection OR confirmed infection

AND

2) Age-specific hypotension (Pg 163)

AND

3) Any ONE OR MORE of the following clinical findings:

• Temperature less than 36ºC or greater than 38.5ºC • Altered mental status • Abnormal heart rate

o Infants – less than 90 or greater than 160 per minute o Children – less than 70 or greater than 150 per minute

7. If fever (temperature greater than 38.5ºC) present, administer acetaminophen 15 mg/kg PO/PR.

If acetaminophen already administered within the last 4 hours, administer a “top-up” dose so total dose administered within the last 4 hours is equal to 15 mg/kg

8. If hypotension persists after initial fluid bolus repeat IV fluid bolus to resolve age-specific hypotension

Contact OLMC if age-specific hypotension persists after second fluid bolus for consideration of:


10 minutes, up to a maximum of 20 mcg/kg/min until age-specific hypotension resolved (Pg 163) (See Pg 192 for dopamine infusion instructions)

100

PEDIATRIC SYMPTOMATIC BRADYCARDIA (HR less than 60) 1. Manage airway and assist ventilations as necessary 2. O2 as Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV/IO access 6. Perform 12 Lead ECG 7. Consider and treat underlying cause 8. If Signs of Cardiopulmonary Compromise1 proceed with Pediatric Bradycardia Algorithm (Pg

101)

1 SIGNS OF CARDIOPULMONARY COMPROMISE 1) Age-specific hypotension (Pg 163) 2) Acutely altered mental status 3) Signs of shock (hypotonia, mottled skin, cap refill greater than 2 seconds, absent peripheral

pulses)

CAUTION • Bradydysrhythmias are the most common pre-arrest rhythms in children and are most likely

secondary to hypoxia. • Ensure adequate oxygenation and ventilation prior to further intervention.

101

PEDIATRIC BRADYCARDIA

NOTES • Consider and treat underlying cause throughout management algorithm

Consider and treat underlying cause – Rule out hypoxia • Manage airway, assist ventilations as necessary• Administer 100% O2

• Continuous cardiac, SpO2, and BP monitoring• IV access• 12 lead ECG

Are Signs of Cardiopulmonary Compromise present? 1) Age-specific hypotension (Pg 163)2) Acutely altered mental status3) Signs of shock (hypotonia, mottled skin, cap refill greater than 2

seconds, absent peripheral pulses)

Is heart rate less than 60 per minute despite adequate oxygenation and ventilation?

YES

Begin CPR

YES

Is heart rate less than 60 per minute despite adequate oxygenation, ventilation, and CPR?

YES Resume CPR immediately and administer • Epinephrine every 3 to 5 minutes if indicated:

o IV/IO: 0.01 mg/kg 1:10 000 (0.1 mL/kg) [Not to exceed amaximum single dose 1 mg (10 mL)]

o ETT: 0.1 mg/kg 1:1000 (0.1 mL/kg) [Not to exceed amaximum single dose of 2.5 mg (2.5 mL)]

OR • Atropine 0.02 mg/kg IV/IO (Minimum single dose 0.1 mg and

not to exceed a maximum single dose of 0.5 mg) if increasedvagal tone or primary AV block.o Repeat once in 5 minutes if indicated

Consider transcutaneous pacing if bradycardia refractory to epinephrine or atropine and Signs of Cardiopulmonary Compromise persist

• Support ABC• Supplemental O2

• Supportive care• Transport

NO

NO

NO

102

PEDIATRIC NARROW COMPLEX TACHYCARDIA (QRS duration less than 120 ms)

1. Manage airway and assist ventilations as necessary 2. O2 as Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. Perform 12 Lead ECG to evaluate QRS duration

• Distinguish between Supraventricular Tachycardia (SVT) and Sinus Tachycardia (ST) as outlined in table below1, and proceed with Pediatric Narrow Complex Tachycardia Algorithm (Pg 103)

6. IV/IO access

Contact OLMC if unable to identify rhythm OR uncertainty over most appropriate clinical pathway

1 DISTINGUISHING FEATURES OF SINUS TACHYCARDIA AND SVT Feature Sinus Tachycardia SVT

History History compatible with a cause for sinus tachycardia Causes of sinus tachycardia • Dehydration2 • Nausea and vomiting • Decreased intake • Diarrhea • Sepsis • Hypoglycemia

• Vague history • Non-specific • Abrupt change

Heart Rate Infants: Less than 220 per minute Child: Less than 180 per minute

Infants: Greater than 220 per minute Child: Greater than 180 per minute

ECG • P waves present and normal • Constant PR interval • Variable R-to-R interval (variable heart

rate)

• Absent or abnormal P waves • Heart rate NOT variable (fixed)

2 DEHYDRATION

Children can demonstrate a profound tachycardia response to dehydration. In this setting the most appropriate intervention is IV fluid administration rather than medication administration.

History • Vomiting • Diarrhea • Decreased PO intake • Fever

Physical Exam • Dry lips and mouth • Absent tears • Sunken eyes • Decreased capillary refill

103

PEDIATRIC NARROW COMPLEX TACHYCARDIA ALGORITHM (QRS duration less than 120 ms)

Contact OLMC if unable to identify rhythm OR uncertainty over most appropriate clinical pathway

Contact OLMC if IV/IO access is not attainable or adenosine ineffective for consideration of

• Synchronized cardioversion (Pg 147) • Amiodarone 5 mg/kg IV/IO (Not to

exceed a maximum single dose of 150 mg) by infusion over 60 minutes (See Pg 183 for amiodarone infusion instructions)

Distinguish between ST and SVT • Evaluate rhythm with 12 lead ECG • Consider history, physical exam, and

clinical context

Probably Sinus Tachycardia Probable SVT

Consider and treat underlying cause and proceed with appropriate protocol Consider: • Dehydration • Sepsis • Hypoglycemia • Hyperglycemia If present, treat shock according to Pediatric Shock Protocol (Pg 97)

Attempt Pediatric Vagal Maneuvers1 unless Signs of Cardiopulmonary Compromise2 or maneuvers would unduly delay chemical or electrical cardioversion

If IV/IO established administer adenosine: • 1st dose: 0.1 mg/kg (Not to exceed a

maximum single dose of 6 mg) • 2nd dose: 0.2 mg/kg (Not to exceed a

maximum single dose of 12 mg) Each dose must be administered by rapid IVP and be followed immediately by a 10 mL bolus of 0.9% NaCl

104

PEDIATRIC NARROW COMPLEX TACHYCARDIA Cont’d

1 PEDIATRIC VAGAL MANEUVERS • Infants and young children – Apply an ice bag to the face without occluding the airway. Do

not apply pressure to the eyes • Older children – Modified Valsalva maneuver

o Place patient upright on stretcher and instruct them to blow on the end of a 10 mL syringe

(without needle) with maximum force for 15 seconds. Immediately follow this by simultaneously placing their head flat and elevating legs to 45 degrees for 15 seconds. Allow up to one minute for cardioversion.

o Modified Valsalva maneuver is 43% effective at cardioversion of SVT compared to 17% for standard Valsalva maneuver.

o Do not attempt carotid sinus massage.

2 SIGNS OF CARDIOPULMONARY COMPROMISE 1) Age-specific hypotension (Pg 163) 2) Acutely altered mental status 3) Signs of shock (hypotonia, mottled skin, cap refill greater than 2 seconds, absent peripheral

pulses)

105

PEDIATRIC WIDE COMPLEX TACHYCARDIA (QRS greater than 120 ms) 1. Manage airway and assist ventilations as necessary 2. O2 as Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. Perform 12 Lead ECG to evaluate QRS duration

• If wide complex tachycardia identified (QRS greater than 120 ms) proceed with algorithm

below

6. IV/IO access

Contact OLMC if failure to convert despite appropriate intervention

Contact OLMC for consideration of::

• Amiodarone 5 mg/kg IV/IO (Not to exceed a maximum single dose of 150 mg) by infusion over 60 minutes (See Pg 183 for amiodarone infusion instructions)

• Synchronized cardioversion (Pg 147)

Possible Ventricular Tachycardia

Synchronized cardioversion (Pg 147)

YES

Are Signs of Cardiopulmonary Compromise present? 1) Age-specific hypotension (Pg 163) 2) Acutely altered mental status 3) Signs of shock (hypotonia, mottled skin, cap refill greater than 2

seconds, absent peripheral pulses) NO

106

PEDIATRIC SYMPTOMATIC HYPOGLYCEMIA

CAUTION • The protocol contained herein is NOT intended for routine management of hypoglycemia in

patients that have just been born. • For patients that have just been born refer to Neonatal Assessment and Resuscitation

Protocol (Pg 136). • In neonatal patients (other than those who have just been born), if BGL is less than 2.6 mmol/L

proceed with IV dextrose or glucagon administration as outlined in this protocol.

For neonatal patients (other than those who have just been born) with BGL between 2.6 and 4 mmol/L, contact OLMC for direction.

1. Manage airway and assist ventilations as necessary 2. O2 as Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access 6. If BGL is less than 4 mmol/L in the non-neonate, administer ONE of the following medications and

recheck BGL in accordance with tables below: Patient able to maintain own airway (Awake and able to cough and swallow)

IV established Unable to establish IV

Oral glucose options: 1) Dex 4® tablets 20 g (5 tablets) 2) Insta-glucose® 1 tube (30 g) 3) 1 cup of juice or pop (Non-diet) 4) 4 teaspoons (20 mL) or 4 packets

of table sugar dissolved in water

IV dextrose as per dosing guidelines below

Glucagon1 as per dosing guidelines on following page

Recheck BGL in 15 minutes Recheck BGL in 10 minutes Recheck BGL in 20 minutes DEXTROSE DOSING GUIDELINES (See Pg 188 for instructions on preparing Dextrose 10% and 25%) Weight Volume-based Dosing mL/kg (0.5 g/kg SIVP)

Less than 10 kg Dextrose 10% - 5 mL/kg SIVP

10 – 20 kg Dextrose 25% - 2 mL/kg SIVP

20 – 40 kg Dextrose 50% - 1 mL/kg SIVP [to a maximum of 50 mL (25 g)]

Greater than 40 kg Dextrose 50% - 50 mL (25 g) SIVP

107

PEDIATRIC SYMPTOMATIC HYPOGLYCEMIA Cont’d GLUCAGON DOSING GUIDELINES

Weight Dose

Less than 20 kg 0.5 mg IM

Greater than or equal to 20 kg 1 mg IM 7. Repeat Step 6 ONCE if necessary

All pediatric hypoglycemic patients must be transported for assessment. If a parent, guardian, or mature minor is refusing transport, contact OLMC for direction.

1 NOTES • Anticipate that it could take up to 20 minutes to observe an effect from glucagon. • While waiting for glucagon to take effect, manage patient’s airway as indicated and initiate

transport.

CAUTION

• If head injury or stroke suspected administer half of the usual dose of dextrose, recheck BGL, and then administer the second half dose if necessary.

• The goal is to correct hypoglycemia while avoiding transient hyperglycemia that may lead to cerebral edema.

108

PEDIATRIC SYMPTOMATIC HYPERGLYCEMIA This protocol is intended for patients who demonstrate findings of significant dehydration and presentations suggestive of diabetic ketoacidosis (DKA). Many diabetic patients may have blood glucose levels greater than 15 mmol/L during times of physiologic stress in the absence of dehydration and age-specific hypotension will NOT require fluid administration. 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access 6. If Indications for IV Fluid Administration in Pediatric Hyperglycemia1 present administer

10 mL/kg 0.9% NaCl IV over 1 hour4

Contact OLMC if you are uncertain as to whether the patient meets criteria for fluid administration OR if age-specific hypotension persists despite administration of 10 mL/kg 0.9% NaCl IV for consideration of administration of additional IV fluids.

1 INDICATIONS FOR IV FLUID ADMINISTRATION IN PEDIATRIC HYPERGLYCEMIA 1) BGL greater than 15 mmol/L

AND 2) Signs and Symptoms of DKA2 OR Signs of Dehydration3

AND

3) Age-Specific Hypotension (Pg 163)

2 SIGNS AND SYMPTOMS OF DKA 3 SIGNS OF DEHYDRATION • Polyuria • Polydipsia • Polyphagia • Tachypnea • Tachycardia • Nausea and vomiting • Abdominal pain • Signs of dehydration

• Dry mucous membranes • Absence of tears • Sunken fontanelle • Delayed capillary refill • Mottled skin • Decreased urine output (oliguria) • Tachycardia • Age-specific or postural hypotension • Weakness or lethargy

109

PEDIATRIC SYMPTOMATIC HYPERGLYCEMIA Cont’d

4 CAUTION • Rapid bolus administration of 20 mL/kg IV fluid bolus is contraindicated in pediatric patients

with DKA due to the risk of cerebral edema. SIGNS AND SYMPTOMS OF CEREBRAL EDEMA Early Warning Sign • Headache Additional Warning Signs • Drowsiness • Altered behavior • Decreasing level of consciousness MANAGEMENT OF CEREBRAL EDEMA 1) Manage airway, assist ventilations as necessary 2) O2 as per Oxygen Therapy Protocol (Pg 79) 3) Stop IV fluids 4) Measure BGL and treat hypoglycemia as per Pediatric Symptomatic Hypoglycemia

Protocol (Pg 106) 5) Provide early notification to receiving facility of change in mental status

110

PEDIATRIC CONVULSIVE SEIZURES 1. Manage airway and assist ventilations as necessary 2. Spinal immobilization as indicated by mechanism of injury or evidence of injury above the clavicles 3. Position patient

• Actively seizing – place supine and protect from injury • Postictal – place left lateral recumbent and maintain airway

4. O2 as per Oxygen Therapy Protocol (Pg 79) 5. Continuous cardiac, SpO2, and BP monitoring 6. Measure temperature AND blood glucose

• Treat hypoglycemia as per Pediatric Symptomatic Hypoglycemia Protocol (Pg 106) 7. IV access 8. If the patient is actively seizing administer:

• Midazolam 0.1 mg/kg IV (Not to exceed a maximum single dose of 5 mg) OR

• Midazolam 0.2 mg/kg IN (Not to exceed a maximum single dose of 5 mg) if unable to establish

IV access Repeat in 5 minutes if seizure continues or recurs (Not to exceed a maximum total dose of 10 mg by any route)

9. If fever present (greater than 38.5˚C), administer acetaminophen 15 mg/kg PO/PR. If

acetaminophen already administered within 4 hours – administer a “top up” dose so total dose administered within 4 hours is equal to 15 mg/kg

Contact OLMC if status epilepticus for consideration of additional midazolam

NOTES • In the event you are unable to establish IV access and contraindications to intranasal

administration of midazolam are present, administer midazolam 0.2 mg/kg PR (Not to exceed a maximum single dose of 5 mg). Repeat once in 15 minutes if seizure continues or recurs.

111

PEDIATRIC NAUSEA AND VOMITING 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access 6. Position the patient in a position of comfort 7. If severe nausea and vomiting1 administer:

• DimenhyDRINATE 1 mg/kg IV (Not to exceed a maximum single dose of 25 mg)

o Contraindicated in the setting of heat exhaustion or heat stroke

OR

• Metoclopramide 0.1 mg/kg SIVP (Over 2 to 5 minutes) (Not to exceed a maximum single dose of 10 mg) if any of the following criteria apply: o Severe nausea and vomiting refractory to dimenhydrinate after 15 minutes since last dose o Allergy or contraindication to dimenhydrinate o Altered LOC or head injury

8. If metoclopramide has been administered and extrapyramidal2 signs or symptoms acutely

develop, reassure patient and administer diphenhydrAMINE 1 mg/kg IV (Not to exceed a maximum single dose of 50 mg)

NOTES 1 Treatment of nausea and vomiting with parenteral anti-emetics should be reserved for cases of

severe nausea and vomiting only. Current in-hospital treatment guidelines of pediatric nausea and vomiting secondary to gastroenteritis favor oral medication and rehydration without the need for IV access, except in severe cases.




Administration of diphenhydramine is not indicated for treatment of chronic extrapyramidal signs and symptoms

112

PEDIATRIC PAIN MANAGEMENT 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access as needed depending on pain severity1 5. If severe pain2 administer:

• Fentanyl 1 mcg/kg IV (Not to exceed a maximum single dose of 25 mcg)

o Repeat every 15 minutes if indicated until reasonable control of pain (Not to exceed a maximum total dose of 50 mcg)

6. If ocular pain due to ocular foreign body, chemical exposure, or minor trauma administer:

• Tetracaine 0.5% 1-2 drops to affected eye(s) o Repeat every 5 to 10 minutes if indicated until reasonable control of pain o DO NOT administer tetracaine if suspected globe rupture3, instead administer fentanyl and

metoclopramide as per Pediatric Nausea and Vomiting Protocol (Pg 111)

7. If patient develops nausea or vomiting proceed with Pediatric Nausea and Vomiting Protocol (Pg 111)

Contact OLMC if severe pain and unable to establish IV for consideration of:

• Fentanyl 1.5 mcg/kg IN • Administration of fentanyl by alternate routes

NOTES 1 Document pain severity pre and post intervention using age and language appropriate pain

scale (Pg 165) 2 Treatment of pain with parenteral opioids should be reserved for cases of severe pain only.

Current in-hospital treatment guidelines of analgesia favor oral medication without the need for IV access, except in severe cases

3 If globe rupture suspected DO NOT administer tetracaine and do not touch the eye. Administer systemic analgesia and anti-emetic(s) to avoid vomiting and increased intra-ocular pressure

Signs of Globe Rupture 1) Irregular pupil 2) Large subconjunctival hematoma (blood collection on surface of globe) 3) Eye swollen closed 4) Hyphema - blood pooling in front of the iris (colored portion of eye) 5) Loss of globe integrity or shape

113

PEDIATRIC PROCEDURAL SEDATION (For pacing or cardioversion) 1. Manage airway, assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access 5. Administer:

• Fentanyl 1 mcg/kg IV (Not to exceed a maximum single dose of 25 mcg)

o Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum total dose of 50 mcg) AND

• Midazolam 0.05 -0.1 mg/kg SIVP/IO (Not to exceed a maximum single dose of 2 mg) o Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum total dose of 5 mg)

Contact OLMC IV for consideration of:

• Repeat fentanyl administration • Repeat midazolam administration • Administration of lower dose fentanyl and/or midazolam in the hypotensive patient (SBP

less than age-specific hypotension – Pg 163)

CAUTION

• Be sure to actively monitor and manage the airway and breathing of a sedated patient at all times.

• Administer smaller doses of fentanyl and midazolam if the SBP is near, but above age-specific hypotension (Pg 163) prior to intervention.

114

PEDIATRIC AGITATED / COMBATIVE 1. Contact police and request that they attend the scene immediately 2. Manage airway and assist ventilations as necessary 3. O2 as per Oxygen Therapy Protocol (Pg 79) 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure temperature AND blood glucose

• Treat hypoglycemia as per Pediatric Symptomatic Hypoglycemia Protocol (Pg 106)

6. Consider and treat Reversible or Treatable Causes of Altered Mental Status1 7. IV access 8. Attempt verbal management techniques for crisis intervention to de-escalate the situation and

calm the patient 9. If severe agitation or imminent risk of harm3 to self and/or bystanders administer one of the

following depending on degree of risk to provider:

• Midazolam 0.1 mg/kg SIVP (Not to exceed a maximum single dose of 2 mg) o Repeat every 5 minutes if indicated until reasonable cooperativeness is achieved

OR

• Midazolam 0.2 mg/kg IM (Not to exceed a maximum single dose of 5 mg) if unable to establish IV access o Repeat every 15 minutes if indicated until reasonable cooperativeness is achieved

Not to exceed a total dose of 5 mg by any route

10. If Indications for Physical Restraint2 present, apply the least amount of physical restraint necessary to protect the patient from harming themselves or bystanders until police arrive as per Agitated Combative / Physical Restraint Reference (Pg 158)

11. If cocaine or other sympathomimetics are suspected as the cause of agitation or combativeness, proceed with Specific Toxin Management Protocol (Pg 117)


• Repeat midazolam administration • Administration of midazolam by alternate route(s)

1 REVERSIBLE OR TREATABLE CAUSES OF ALTERED MENTAL STATUS • Hypoxia • Hypotension • Hypoglycemia • Medications or Toxins • Sepsis

115

PEDIATRIC AGITATED / COMBATIVE Cont’d

2 INDICATIONS FOR PHYSICAL RESTRAINT 1) Imminent danger3 to life OR threat of physical harm to patient and/or bystanders

AND

2) Attempts at verbal de-escalation have failed AND


NOTES 3 Imminent Danger – an immediate threat of significant harm to one’s self or others, up to and

including death Examples of Imminent Danger: • Actively attempting suicide • Actively attempting to cause serious bodily injury to others • Attempting to jump from a building or moving vehicle

CAUTION

• There is a high risk of positional asphyxia and/or aspiration in patients undergoing chemical or physical restraint. Close and continuous monitoring of these patients, including airway patency and adequacy of respirations is mandatory.

• At NO TIME should the patient be restrained in the prone (face or chest-down) position. • Always maintain an ability to escape the scene. Position yourself between the patient and the

exit at all times to maintain a safe exit should the situation escalate. • Be alert for potential weapons and hazards. If the patient has a weapon, do not attempt to

disarm them. Instead, leave the scene and stage until the police declare the scene safe to re-enter.

• Be aware of signs of increased agitation or aggression including, but not limited to: o Tense posture o Loud speech o Pacing o Threatening statements o Clenched hands o Hostile or aggressive body language

116

PEDIATRIC GENERAL APPROACH TO TOXINS MANAGEMENT 1. Scene safety: protect rescuers and patients from immediate danger and contamination

• Toxic exposures might require special precautions, including CBRNE precautions or

decontamination, before patient treatment begins 2. Manage airway and assist ventilations as necessary 3. O2 as per Oxygen Therapy Protocol (Pg 79) 4. Continuous cardiac, SpO2, and BP monitoring 5. Measure temperature AND blood glucose 6. IV access 7. Perform 12 Lead ECG 8. If seizure occurs administer midazolam as per Pediatric Convulsive Seizure Protocol (Pg 110) 9. Consider administration of charcoal as outlined below:

Contact OLMC for consideration of charcoal 1 g/kg PO if oral ingestion of an agent likely to produce significant toxicity AND ALL of the following criteria are met:

1) Alert 2) Able to cough and swallow 3) Ingested substance known to adsorb charcoal1 4) Less than 60 minutes elapsed since time of ingestion 5) Hemodynamically stable

1 SUBSTANCES THAT DO NOT ADSORB CHARCOAL

1) Lithium 2) Metals (Iron) 3) Alcohols (ethanol, methanol, ethylene glycol, and isopropyl alcohol) 4) Organophosphates and carbamates 5) Hydrocarbons 6) Borate 7) Bromide 8) Acids and alkalis

117

PEDIATRIC SPECIFIC TOXIN MANAGEMENT

CAUTION The following protocols are intended to be used as guides in the management of severely symptomatic patients with suspected ingestion of the specific toxin indicated. Contact with OLMC is mandatory for initiation of the management options indicated. • Do not delay transport in cases of severely symptomatic patients • Contact with OLMC should be made while preparing for or initiating transport • The goal of prehospital management is to initiate life-saving therapies and to sustain life until

arrival to hospital • Toxicity is unlikely to resolve completely with isolated prehospital management • Do not delay transport in favor of completion of all management options presented in the

prehospital setting

PEDIATRIC ANTIPSYCHOTIC-INDUCED DYSTONIC REACTION

This protocol is intended for management of acute dystonic reactions in patients confirmed to be taking antipsychotic medication. 1. Administer diphenhydrAMINE 1 mg/kg IV/IM (Not to exceed a maximum single dose of 50

mg)

NOTES • Dystonia – state of increased muscle rigidity or muscle contraction that may result in twisting

or abnormal postures. • Acute dystonic reactions usually develop within the first several doses or after a large increase

in dose of antipsychotic medications. • It is possible to have an acute dystonic reaction in the absence of overdose.

118

PEDIATRIC SPECIFIC TOXIN MANAGEMENT Cont’d

PEDIATRIC OPIOIDS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion or use of an opioid agent. If ALL of the following criteria are met proceed with naloxone administration as outlined :

1) Impaired consciousness 2) Respiratory rate less than 10 per minute 3) Pupil constriction (except in suspected meperidine (Demerol) or tramadol ingestion) 4) Requiring assisted ventilation

1. Administer naloxone1 as outlined below:

• 0.2-0.5 mg IV/IM

o Repeat every 2-3 minutes if indicated, titrated to improved respiratory drive (Not to exceed a maximum total dose of 5 mg)

o In opioid dependent patients start with a lower dose of naloxone (0.05 mg to 0.1 mg IV/IM) to avoid precipitating acute withdrawal and titrate to sufficient respiratory drive

OR

• 2mg IN in each nare of a 2mg/mL solution o Repeat every 2-3 minutes if indicated, titrated to improved respiratory drive (Not to

exceed a maximum total dose of 10 mg)

In the event of a cardiac arrest in the setting of suspected or confirmed opioid ingestion, administer:

• Naloxone 6 mg IV/IO 1 NOTES • Meperidine (Demerol) or tramadol are opioids that do not cause pupil constriction. • IV route is preferred for pre-hospital naloxone administration. IN route is not considered first

line therapy and should only be considered if unable to establish IV access. IN route is unlikely to be effective without spontaneous respirations.

• Return to normal alertness is not a required outcome following naloxone administration. • If no response after 2 doses, initiate transport and continue treatment en route to hospital. • Examples of shorter acting opioids include, but are not limited to: fentanyl, hydromorphone

(Dilaudid), morphine (Morphine-IR), meperidine (Demerol), codeine, heroin, sufentanyl, Darvon, oxycodone.

• Examples of longer acting opioids include, but are not limited to: methadone, MS-Contin, OxyNEO, OxyContin, Hydromorph-Contin, morphine-SR.

119


Contact with OLMC is mandatory for initiation of the Pediatric Specific Toxin Management guidelines presented in Pages 119 to 122.

PEDIATRIC COCAINE OR OTHER SYMPATHOMIMETICS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of a sympathomimetic agent. Findings suggestive of severe toxicity include:

1) Severe agitation or combativeness 2) Tachydysrhythmias 3) Severe hypertension 4) Hyperthermia 5) Ischemic chest pain

1. Administer midazolam 0.1 mg/kg SIVP (Not to exceed a maximum single dose of 2.5 mg)

• Repeat every 5 minutes if indicated (Not to exceed a maximum total dose of 5 mg unless otherwise directed by OLMC)

2. Administer 20 mL/kg 0.9% NaCl IV bolus

3. If wide complex dysrhythmia (QRS greater than 120 ms) administer sodium bicarbonate

1 mEq/kg IV/IO (Over 1 to 2 minutes) (Not to exceed a maximum of 50 mEq) as outlined below:

• Age less than 2 years – use 4.2% solution (2 mL/kg) • Age greater than 2 years – use 8.4% solution (1 ml/kg) Repeat once in 5 to 10 minutes if indicated

4. If unable to establish an IV and severe agitation or combativeness is present proceed with the

Agitated / Combative Protocol (Pg 114)

120


PEDIATRIC TRICYCLIC ANTIDEPRESSANTS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of a tricyclic antidepressant. 1. Perform 12 Lead ECG

• Determine rhythm and assess for findings suggestive of TCA toxicity (QTc prolongation and

wide QRS)

2. If age-specific hypotension (Pg 163) administer 20 mL/kg 0.9% NaCl IV bolus

3. Treat seizures with midazolam as per Pediatric Convulsive Seizure Protocol (Pg 110)

4. Assess for Indications for Sodium Bicarbonate administration:

1) QRS duration greater than 120 ms (as indicated on 12 lead ECG printout) AND

2) Age-specific hypotension OR Life-threatening dysrhythmia OR Seizure has occurred 5. If Indications for Sodium Bicarbonate present administer sodium bicarbonate 1 mEq/kg IV/IO

(Over 1 to 2 minutes) (Not to exceed a maximum of 50 mEq) as outlined below:

• Age less than 2 years – use 4.2% solution (2 mL/kg) • Age greater than 2 years – use 8.4% solution (1 ml/kg) Repeat once in 5 to 10 minutes if indicated

6. If corrected QT interval (QTc) is greater than 500 ms (as indicated on 12 Lead ECG printout) administer magnesium sulfate 25 mg/kg IV [Not to exceed a maximum single dose of 1 g (1000 mg)] by infusion over 20 minutes (See Pg 206 for magnesium infusion instructions)

7. If age-specific hypotension persists despite 0.9% IV fluid boluses and administration of sodium bicarbonate consider dopamine 5 mcg/kg/min for refractory hypotension. Titrate by 5 mcg/kg/min, every 5 to 10 minutes, up to a maximum of 20 mcg/kg/min until age-specific hypotension resolved (See Pg 192 for dopamine infusion instructions)

NOTES • Examples of TCAs include, but are not limited to: amitriptyline (Elavil), amoxapine (Asendin),

clomipramine (Anafranil), doxepin (Adapin / Sinequan), and imitramine (Tofranil)

121


PEDIATRIC ORGANOPHOSPHATES, CARBAMATES AND OTHER ANTICHOLINESTERASES

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of an organophosphate, carbamate, or anticholinesterase agent resulting in cholinergic toxicity. Signs of Cholinergic Toxicity

Muscarinic Cholinergic Toxicity Nicotinic Cholinergic Toxicity S L U D G E B

Salivation Lacrimation Urination Defecation Gastrointestinal cramps Emesis Bronchorrhea

Seizures Coma Fasciculations Muscle weakness Paralysis Mydriasis (dilated pupils)

If ANY of the following criteria are met proceed as outlined :

1) Severe respiratory distress 2) Paralysis

OR 3) Impaired consciousness

1. Manage airway and provide positive pressure ventilation as needed

2. Administer atropine as outlined below:

• Age less than 12 years – 0.05 mg/kg IV/IO o Maximum single dose for children – 0.5 mg o Repeat every 10 minutes until decreased bronchial secretions and improved ability to

ventilate and oxygenate

• Age greater than 12 years – 1-2 mg IV/IO o If no response, double the previous dose every 5 to 10 minutes until decreased

bronchial secretions and improved ability to ventilate and oxygenate

122


PEDIATRIC BETA BLOCKERS AND CALCIUM CHANNEL BLOCKERS

This protocol is intended for management of the severely symptomatic patient with suspected or confirmed ingestion of a beta blocker or calcium channel blocker. In the presence of life threatening signs and symptoms, including profound bradycardia AND age-specific hypotension (Pg 163) proceed as outlined.

1. Administer 10 mL/kg 0.9% NaCl (Not to exceed 500 mL) IV bolus. Repeat once if age-specific

hypotension persists. 2. Administer atropine as outlined below:

• Age less than 12 years – 0.02 mg/kg IV/IO (Not to exceed a maximum single dose of 0.5 mg) o Repeat once in 3 to 5 minutes if indicated (Not to exceed a maximum total dose of 1 mg)

• Age greater than 12 years – 0.5-1 mg IV/IO

o Repeat every 3 to 5 minutes if indicated (Not to exceed a maximum total dose of 3 mg) 3. If no improvement after two doses of atropine, consider further intervention(s) as outlined

below:

• Calcium chloride 10% solution 10-20 mg/kg SIVP/IO (0.1-0.2 mL/kg) (Over 10 minutes) o Repeat once in 10 minutes if indicated (Not to exceed a maximum total dose of 1000

mg) • Glucagon 0.1 mg/kg mg SIVP/IO (Over 1 to 2 minutes) (Not to exceed a maximum total

dose of 5 mg) (Administer at maximum rate of 1 mg per minute) • Dopamine 5 mcg/kg/min for refractory age-specific hypotension. Titrate by 5 mcg/kg/min,

every 5 to 10 minutes, up to a maximum of 20 mcg/kg/min until age-specific hypotension resolved (See Pg 192 for dopamine infusion instructions)

• External pacing if bradycardia refractory to all other interventions

The sequence of management in cases of beta blocker or calcium channel blockers may be modified based on advice received from OLMC

123

PEDIATRIC HEAT RELATED ILLNESS This protocol is intended for the management of patients with exposure to high temperatures or high levels of exertion and without history of recent infection 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose

• Treat hypoglycemia as per Pediatric Symptomatic Hypoglycemia Protocol (Pg 106) 5. IV access

• If signs of dehydration present, administer fluid bolus as per Pediatric Fluid Therapy Protocol (Pg 125)

6. Begin cooling measures1 if signs of heat exhaustion or heat stroke present2. Continue until temperature is less than 39°C or patient starts shivering.

7. If severe agitation or combativeness is present, concurrently manage as per Pediatric Agitated / Combative Protocol (Pg 114)

8. If seizure occurs, proceed with Pediatric Convulsive Seizure Protocol (Pg 110). Continue cooling.

9. If severe nausea and vomiting, administer: • Metoclopramide 0.1mg/kg SIVP over 2-5 mins. Not to exceed 10 mg

1COOLING MEASURES (STOP if patient starts shivering) 1) Remove the patient from hot environment and cool ambient temperature in the ambulance. 2) Remove patient’s clothing and apply cool water to patient’s skin. 3) Promote evaporation by using a fan or open window. 4) Apply ice packs to the groin, neck and axilla. DO NOT APPLY DIRECTLY TO SKIN

NOTES: • Patients may have normal to slightly elevated temperature with heat exhaustion. • Lack of perspiration is a late sign of heat stroke. • Patients with exertional heat illness may have profound sinus tachycardia as a normal physiological

response. • Dehydration may induce a profound tachycardic response in the pediatric patient.

2SIGNS OF HEAT EXHAUSTION and HEAT STROKE Patients with heat related illness may exhibit one or more of the following:

Heat Exhaustion

• Decreased coordination • Sweating • Tachycardia and hypotension

• Hyperventilation • Headache • Abdominal pain and/or nausea and vomiting

Heat Stroke

1) Temperature greater than 40°C AND 2) Altered mental status or CNS dysfunction

124

PEDIATRIC HYPOTHERMIA This protocol is intended for the management of patients with exposure to environmental conditions consistent with hypothermia. 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose

• Treat hypoglycemia as per Pediatric Symptomatic Hypoglycemia Protocol (Pg 106) 5. IV access

• Treat hypotension as per Pediatric Fluid Therapy Protocol (Pg 125) 6. If signs of frostbite present:

• Splint or pad effected area to minimize injury • Remove jewelry if required • Pad between effected digits and bandage effected tissue loosely with a soft, sterile dressing. Do

not put pressure on the effected parts. 7. If signs of hypothermia proceed with steps for rewarming1 8. If Cardiac Arrest occurs proceed to Pediatric Cardiac Arrest Protocol (Pg 92)

1STEPS FOR REWARMING • Remove patient from cold environment • Remove wet clothing (cutting preferred) • Cover with blankets • Increase ambient temperature in ambulance • Apply radiant heat and/or warm blankets to core • Use warmed IV fluids for resuscitation

Mild Hypothermia Severe Hypothermia 1) 32°C-35°C 2) Normal mental status 3) Shivering 4) Normal to slightly elevated vital signs

1) Temperature less than 32°C 2) Decreased LOC, slurred speech and ataxia 3) Decreased heart rate and respiratory rate 4) Shivering absent below 30°C

CAUTION

• Patients in severe hypothermia often become extremely bradycardic. Transcutaneous pacing is not indicated unless patient is warmed to greater than 32°C.

• Hypothermic patients are at a high risk for VF if handled roughly. Patient movement should be limited and a horizontal position maintained whenever possible.

• Severely hypothermic patients should have their core areas warmed first. Warming extremities before core can precipitate a secondary drop in temperature.

• DO NOT attempt to thaw frostbitten areas. • DO NOT ambulate patients with hypothermia.

125

PEDIATRIC FLUID THERAPY When IV medication or fluid therapy may be required, start a peripheral IV line or lock using 0.9% NaCl solution. Unless otherwise directed by protocol or OLMC the drip rate will be set at TKVO rate as outlined below: • If age less than 8 years: 15 mL/hour • If age greater than or equal to 8 years: 30-60 mL/hour Fluid bolus should be initiated as follows unless otherwise specified by a specific treatment protocol.

FLUID ADMINISTRATION IN TRAUMA CASES Bolus administration of IV fluid is to be reserved for cases of hypotension with evidence of poor perfusion. When indicated, administer IV 0.9% NaCl as outlined below: • 20 mL/kg bolus until SBP greater than or equal to age-specific hypotension guidelines

(Pg 163) • There is no limit to the amount of fluid that may administered to achieve the desired target

SBP Routine administration of bolus IV fluids in the absence of age-specific hypotension is CONTRAINDICATED in the trauma patient. IV fluid boluses are only to be administered when above criteria is met to avoid inducing coagulopathy.

FLUID ADMINISTRATION IN MEDICAL CASES (NON-TRAUMA) When indicated as per protocol administer IV 0.9% NaCl as outlined below: • 20 mL/kg bolus until SBP greater than or equal to age-specific hypotension guidelines

(Pg 163) • May repeat bolus administration once while indications persist • If indications for additional IV fluid persist despite administration of two IV fluid boluses,

contact OLMC

126

PEDIATRIC FLUID THERAPY Cont’d

NOTES

• Carefully observe for signs of pulmonary edema. Auscultate chest for crackles after every 10 mL/kg. If crackles are detected stop IV fluid bolus.

• A buretrol or syringe should be used when delivering IV fluid boluses to pediatric patients when possible (mandatory in children less than 8 years of age).

• Intraosseous access should only be initiated after attempts at intravenous access fails after 3rd attempt OR 90 seconds OR is otherwise unattainable in critically ill patients with life-threatening conditions.

CAUTION

• Neonates and pediatric patients with hyperglycemia (Greater than 15 mmol/L) must be restricted to 10 mL/kg bolus to maintain SBP greater than age-specific hypotension to avoid induction of cerebral edema.

• Contact OLMC to administer additional IV fluid if age-specific hypotension persists after initial IV bolus of 10 mL/kg of 0.9% NaCl in the hyperglycemic patient.

127

PEDIATRIC ADRENAL INSUFFICIENCY

1. Manage airway and assist ventilations as necessary2. O2 as per Oxygen Therapy Protocol (Pg 79)3. Continuous cardiac, SpO2, and BP monitoring4. Measure temperature AND closely monitor blood glucose


5. IV access• Administer 20 mL/kg bolus NaCl 0.9% if signs or symptoms of adrenal crisis1 present

6. If patient meets Criteria for Hydrocortisone Administration2, administer hydrocortisone, asoutlined below:Age Dose3

Less than 3 years 25 mg IV 3 to 10 years 50 mg IV Greater than 10 years 100 mg IV

3IM route permitted if IV is delayed or otherwise unattainable

2CRITERIA FOR HYDROCORTISONE ADMINISTRATION

1) Patient has any one of the following:• Trauma or significant physical stressor• Significant emotional crisis• Vomiting or diarrhea• Signs/symptoms of acute adrenal crisis1

• Fever of greater than or equal to 38ºC or signs of infection

AND

2) Medical history of any one of the following:• 3 weeks or more of chronic glucocorticoid use• Malcompliance or cessation of glucocorticoid medication within 3 months• Addison’s Disease• Congenital Adrenal Hyperplasia• Pituitary insufficiency/hypopituitarism (i.e.: tumors, previous radiation, hypopituitary

disorders)• Bilateral adrenalectomy (removal of adrenal glands)• Patient presents a home adrenal insufficiency kit containing a glucocorticoid medication• Patient is wearing a Medic-Alert stating the patient has adrenal insufficiency

1SIGNS AND SYMPTOMS OF ADRENAL CRISIS • Nausea/Vomiting• Hypoglycemia• Abdominal pain• Arrhythmia• Age specific hypotension (Pg 163)• Altered LOC

• Weakness• Dizziness• Pallor• Confusion• Lethargy

128

ADRENAL INSUFFICIENCY Cont’d

NOTES • PMO maintains a low therapeutic threshold to administer hydrocortisone in the acutely ill or

injured patient suspected to have adrenal insufficiency. There is little to no risk from a single stat dose of hydrocortisone. The risk of a low glucocorticoid level during crisis far outweighs the risk of unnecessary hydrocortisone administration.

• IV route is preferred for the administration of hydrocortisone. IM route via lateral thigh may be used if an IV is unsuccessful or otherwise delayed.

• Stress is defined as a circumstance that changes the physiological norm for the patient, and includes illness, trauma, and mental health crisis.

• Administer hydrocortisone regardless of any recent self-administration prior to EMS arrival • Glucocorticoids are used to support treatment of a multitude of medical conditions, including

but not limited to: autoimmune disorders, inflammatory bowel disease, asthma, cancer, autism, chronic allergies, and genetic enzyme deficiencies.

• Commonly prescribed glucocorticoids include, but are not limited to: prednisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, triamclinolone, cortisone acetate, hydrocortisone (cortisol).

• Past history of adrenal crisis presents increased risk for repeat adrenal crisis.

CAUTION

• It is preferable to administer hydrocortisone prior to transport, as some patients in adrenal crisis may not have sufficient adrenal reserves to manage movement, even to the ambulance. These patients may deteriorate rapidly.

• Do not ambulate these patients to the ambulance • In the rare event that a patient with adrenal insufficiency presents with anaphylaxis,

administer epinephrine first, followed immediately by hydrocortisone.

129


130

PART III: OBSTETRICAL EMERGENCY PROTOCOLS

131

ECLAMPSIA (PREECLAMPSIA WITH SEIZURE)

1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. Measure temperature AND blood glucose 5. IV access – establish two IVs 6. Asses for Indications for Eclampsia Treatment1 7. If Indications for Eclampsia Treatment present AND the patient is actively seizing administer:

• Magnesium sulfate 4 g in 100 mL 0.9% NaCl by rapid IV infusion over 5 minutes (See Pg 206 for magnesium infusion instructions) o Stop infusion immediately if patient develops Signs of Magnesium Toxicity2

AND

• Midazolam as per Convulsive Seizure Protocol (Pg 52) while preparing magnesium sulfate infusion or if seizure refractory to magnesium sulfate

Contact OLMC as outlined below:

• If persistent seizure despite magnesium sulfate administration for consideration of repeat magnesium sulfate AND/OR additional midazolam

• If patient postictal on arrival for consideration of administration of magnesium sulfate 4 g IV in 100 mL 0.9% NaCl by infusion over 20 minutes (See Pg 206 for magnesium infusion instructions)

• If Signs of Magnesium Toxicity2 develop for consideration of administration of calcium chloride 10% 1 g SIVP (Over 5 to 10 minutes)

1 INDICATIONS FOR ECLAMPSIA TREATMENT 1) Third trimester pregnancy (Greater than 28 weeks)

AND

2) Hypertension (SBP greater than 160 mmHg OR DBP greater than 100 mmHg)

AND

3) Seizure

2 SIGNS OF MAGNESIUM TOXICITY • Rapid administration of large doses of parenteral magnesium may lead to magnesium toxicity

including loss of muscle tone, respiratory depression and even respiratory arrest. Magnesium administration must be accompanied by continuous clinical observation for Signs of Magnesium Toxicity.

If respiratory depression develops: 1) Manage airway as needed 2) O2 as per Oxygen Therapy Protocol (Pg 79) 3) Contact OLMC for consideration of administration of calcium chloride 10% 1g SIVP

(Over 5 to 10 minutes)

132

CHILDBIRTH 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access 5. Visually examine the patient and determine if crowning2 present (see following page):

• No crowning – place in left lateral recumbent position, discourage patient from bearing down,

and initiate transport • Crowning present – place supine and prepare for imminent delivery

IMMINENT DELIVERY AND POST-PARTUM CARE

1) Call for second crew or additional resources, if available 2) Warm ambient temperature and prepare equipment

• Neonatal resuscitation equipment • Warm blankets • Clamps and scissors to cut umbilical cord • Bag for placenta

3) Apply gentle pressure to the perineum (skin stretched between the vagina and rectum) using a cupped hand and encourage a controlled (non-explosive) delivery

4) Upon delivery of the head sweep your finger around the newborn’s neck to determine if a nuchal cord is present. If nuchal cord present: • Discourage pushing and attempt to guide the loop of cord over the newborn’s head prior to

delivery of the shoulders • If the cord is tight and you are unable to guide over the head, double clamp the cord

approximately 2.5 cm apart and cut the cord1 5) Gently guide the delivery of the anterior shoulder followed by the posterior shoulder 6) As the delivery proceeds keep the newborn below the level of the cord 7) Upon delivery of the newborn clamp the umbilical cord approximately 8 cm from the newborn

and cut between the clamps 8) Proceed immediately with the Neonatal Assessment and Resuscitation Protocol (Pg 136)

• If full-term, breathing or crying spontaneously, and with good tone, wrap the newborn and place on the mothers chest to encourage skin to skin contact and reduce risk of hypothermia

9) Calculate APGAR Score at 1 and 5 minutes (Pg 162) 10) Prepare for delivery of placenta

• Do not pull on umbilical cord. Allow placenta to deliver without being forced. • Administer oxytocin 10 units IM • Upon delivery of the placenta, place in a plastic bag along with the umbilical cord

11) Perform uterine fundal massage (Pg 133)

133

CHILDBIRTH Cont’d

1 NOTES • When the cord is cut be aware that supply of oxygenated blood to the baby has been

terminated • Do not delay delivery after the nuchal cord has been cut • Encourage active delivery once the nuchal cord has been cut

2 CROWNING • The phase at the end of labor in which the fetal head is

seen at the opening of the vagina

3 UTERINE FUNDAL MASSAGE • Place one hand horizontally across the abdomen,

just above the Symphysis Pubis (Pubic bone) • Cup the other hand across the top of the uterus

(Fundus) • Using a kneading or circular motion, massage the

uterus between your two hands

134

POST-PARTUM HEMORRHAGE This protocol is intended for persistent and heavy vaginal bleeding post-vaginal delivery that is estimated to be greater than 500 mL and is refractory to conservative measures including firm uterine fundal massage. 1. Manage airway and assist ventilations as necessary 2. O2 as per Oxygen Therapy Protocol (Pg 79) 3. Continuous cardiac, SpO2, and BP monitoring 4. IV access 5. Apply pressure to any bleeding perineal tears or lacerations of the perineum 6. Perform immediate uterine fundal massage1 7. Initiate fluid bolus as per Adult Fluid Therapy Protocol (Pg 78)

Contact OLMC if persistent and voluminous vaginal bleeding (estimated to be greater than 500 mL) and refractory to firm uterine fundal massage for consideration of:

• Oxytocin infusion o Add oxytocin 20 units to a 1000 mL of 0.9 % NaCl Infuse 500 mL of oxytocin admixture as a bolus Administer remaining 500 mL of oxytocin admixture (500 mL) over 2 hours

• See Pg 216 for oxytocin infusion instructions

1 UTERINE FUNDAL MASSAGE • Place one hand horizontally across the abdomen,

just above the Symphysis Pubis (Pubic bone) • Cup the other hand across the top of the uterus

(Fundus) • Using a kneading or circular motion, massage the

uterus between your two hands

135

COMPLICATIONS OF DELIVERY SHOULDER DYSTOCIA

• Place patient in semi-fowler’s position and perform McRoberts Maneuver1 • Insert Foley catheter and empty the bladder • Have assistant stand beside the patient and facing the feet, use the heel of their hand to apply

downward suprapubic pressure (just above pubic bone) to encourage the anterior shoulder to slip beneath pubic bone

• During contraction, encourage mom to push while assistant continues application of suprapubic pressure – attempt to deliver the anterior shoulder from under the pubic bone

• If all methods fail to deliver the newborn then initiate rapid transport and notify receiving hospital immediately

BREECH PRESENTATION (BUTTOCKS FIRST) If delivery not imminent: • Discourage pushing and initiate rapid transport and notify receiving hospital immediately

If delivery imminent: • Place patient in semi-fowler’s position and perform McRoberts Maneuver1 • Insert Foley catheter and empty the bladder • Sweep out legs and allow the buttocks and trunk to deliver spontaneously • Support the body with your dominant forearm positioned under the newborn’s torso and attempt to

guide head from beneath pubic bone

LIMB PRESENTATAION • Place patient in semi-fowler’s position and perform McRoberts Maneuver1 • Keep prolapsing limb warm and moist • Discourage mother from pushing with contractions

PROLAPSED CORD • Place patient in supine position and perform McRoberts Maneuver1 with the hips elevated • Avoid unnecessary manipulation of the cord • Digitally elevate presenting part off the umbilical cord in order to maintain pulsation • Cover exposed cord with moist, sterile dressing • Initiate rapid transport and notify receiving hospital immediately

1 MCROBERTS MANEUVER

• Place mother positioned supine or semi-sitting • With knees bent and out to the side, have patient pull knees

towards her shoulders • Have assistant push on the bottom of the feet to bring knees

as high as possible to increase the anterior-posterior diameter of the pelvis

136

NEONATAL ASSESSMENT AND RESUSCITATION 1. Determine gestational age and proceed with Neonatal Resuscitation Algorithm (Pg Error!

Bookmark not defined.) and in accordance with General Guidelines outlined below 2. Employ strategies to prevent hypothermia in term or pre-term newborns1

GENERAL GUIDELINES

NEONATAL CPR • Use a two-thumb, encircling the chest, technique • Ensure high quality CPR

o Minimize interruptions in CPR o Allow full recoil of the chest between compressions

Compressions : Ventilation Ratio Depth Rate

3:1 1/3 chest depth 90 compressions / minute 30 compressions / minute

ASSISTED VENTILATION • To be provided if ineffective or absent spontaneous respirations without need for chest

compressions • Acceptable methods include BVM or PPV via advanced airway • Rate: 40-60 breaths / minute

1 TEMPERATURE CONTROL IN THE JUST-BORN PRETERM PATIENT (LESS THAN 37

WEEKS) • Hypothermia will have significant deleterious effects on the preterm patient • Warm ambient temperature in anticipation of delivery (above 26ºC where possible) • Dry the newborn • Cover newborn, from the neck down with plastic “wrap” (non-circumferential) • Wrap newborn a warm blanket or place skin-to-skin with mother and cover both mother and

newborn with a warm blanket

BLOOD GLUCOSE MEASUREMENT AND HYPOGLYCEMIA IN THE JUST BORN PATIENT • Patients that have just been born will typically have blood sugars below normal adult values • Routine measurement of BGL in the just born patient is not recommended

INDICATIONS FOR BGL MEASUREMENT IN THE JUST-BORN PATIENT • BGL measurement is required ONLY if the patient is:

1) Pre-term OR

2) Full-term AND requiring intervention or resuscitation beyond routine post-natal supportive care

• If BGL is less than 2.6 mmol/L – administer dextrose 10% 5 mL/kg SIVP

Contact OLMC if BGL between 2.6 and 4 mmol/L in the populations indicated above to discuss need for intervention and management options

137

NEONATAL RESUSCITATION \ Assess patient: • Term gestation? • Breathing or crying spontaneously? • Good tone?

Routine Post-Natal Care • Clear airway if necessary • Warm and dry • Provide ongoing evaluation

Initiate resuscitation • Provide warmth • Clear airway if necessary1 • Dry and stimulate

Evaluate heart rate and breathing • Heart rate less than 100?

OR • Gasping or apnea?

Initiate BMV, SpO2 / Cardiac monitoring

Heart rate less than 100?

Evaluate for Chest Movement, Take Ventilation Corrective Steps2 if needed, Continue BVM

Initiate CPR • Coordinate chest compressions with BMV, 100% O2 • Consider advanced airway placement if poor chest rise


Continue CPR • Continue chest compressions coordinated with BMV • Establish IV/IO and administer epinephrine 1:10000

0.01mg/kg (0.1 ml/kg) o Repeat every 3-5 mins if indicated

• Consider and treat Reversible Causes3

Post-Resuscitation Care • Keep warm • Continuous cardiac and SpO2 monitoring • Measure BGL and treat hypoglycemia (Pg Error!

B k k t d fi d )

2 VENTILATION CORRECTIVE STEPS

M: Mask readjustment R: Reposition airway

S: Suction mouth and nose O: Open mouth P: Pressure increase A: Airway alternative

3 REVERSIBLE CAUSES 1) Hypovolemia 2) Hypoglycemia (Pg Error!

Bookmark not defined.) 3) Hypothermia

1 IF MECONIUM PRESENT AND NON-VIGOROUS (Poor respiratory effort, poor tone OR heart rate less than 100):

• Suction mouth, oropharynx and then nose

YES

YES

Proceed with Routine Post-Natal Care (Above) NO

NO

15 sec

30 sec

YES

NO

NO

YES

60 sec

YES


138

NEONATAL RESUSCITATION Cont’d

4 NOTES • Newborns requiring prolonged ventilation via BVM may develop gastric insufflation that leads

to impaired ability to ventilate. • Consider orogastric tube insertion if difficulty with ventilation is encountered and is unresolved

by Ventilation Corrective Steps (see previous page) and there is a history of prolonged BVM use with suspected gastric insufflation.

139


140


141


142

PART IV: REFERENCES

143

12 LEAD ECG GUIDELINES

INDICATIONS FOR 12 LEAD ECG 12 lead acquisition is required in any patient presenting with: • Chest pain • Jaw pain • Left arm pain • Epigastric pain • Non-traumatic back pain

• Shortness of breath • Syncope • Palpitation • Weakness • Nausea or vomiting • Altered LOC

• Toxic ingestion or overdose • Suspected electrolyte disturbance • Dysrhythmia on 3 lead ECG • Irregular pulse • Diaphoresis disproportionate to

environment In addition to the indications listed above a 12 lead ECG should be performed any time the paramedic feels it is indicated

SERIAL 12 LEAD ECGs If the initial 12 lead does not show evidence of ST elevation in a patient experiencing chest pain serial 12 lead ECGs must be performed as outlined below: 1) In ambulance just prior to transport 2) Every 15 minutes during transport (if transport time > 30 minutes) 3) Just prior to arrival to receiving health care facility 4) Any time patient condition or ECG rhythm changes If the initial 12 lead demonstrates evidence of ST elevation MI serial 12 leads are not required unless there is a change in patient condition or ECG rhythm changes

NOTES • Acquiring a 12 lead ECG should not prolong scene time or transport more than 2 minutes. • 12 lead acquisition should be performed concurrent with other assessment and care and

should not interfere with treatment protocols. • Any time a 12 lead has been acquired a copy of the 12 lead must be attached (stapled) to the

PCR to be left at the receiving facility and labeled with the patient’s surname and MCP number. A second copy of the 12 lead ECG must be attached (stapled) in an identical manner to the copy of the PCR to be kept by the ambulance service provider.

• You must document your interpretation of the 12 lead ECG in the narrative portion of the PCR.

144

12 LEAD ECG ACQUISITION TECHNIQUE

Procedure

1. Place the patient in a supine or semi-sitting position2. Expose chest enough to acquire a 12 lead ECG. Take all steps necessary and possible to protect

the patient’s dignity and privacy3. Prep the skin with alcohol or other wipe. Remove excess chest hair where needed for good

contact. If patient is large breasted or obese, be sure to place leads correctly.4. Attach the four limb and chest leads to the patient5. Reduce causes of artifact. Stop patient movement. If en route to hospital, stop ambulance to

acquire ECG.

145

15 LEAD ECG GUIDELINES

INDICATIONS FOR 15 LEAD ECG 15 lead ECG is indicated in any patient where a 12 lead ECG has been performed demonstrating evidence of inferior AND/OR posterior cardiac ischemia or infarction.

Findings Suggestive of LV inferior Ischemia • ST elevation, ST depression, or T wave inversion in leads II, III, aVF • Cardiac monitor interpretation suggestive of acute ischemia or infarction in the inferior leads

Findings Suggestive of LV Posterior Ischemia • ST depression in leads V1 and or V2 • Cardiac monitor interpretation suggestive of posterior ischemia or infarction in the posterior leads

15 LEAD ECG ACQUISITION TECHNIQUE

ANTERIOR POSTERIOR

Added Leads Location

V4R Right mid-clavicular line - 5th intercostal space

V8 Left posterior mid-scapular line – level with V6

V9 Left posterior paravertebral line (between spine and scapula) – level with V6

Procedure

1. Modify the placement of the 12 lead ECG electrodes as indicated below and repeat “12 lead” acquisition

• Move V4 lead to V4R position • Move V5 lead to V8 position • Move V6 lead to V9 position

2. Overwrite the newly printed “12 lead ECG” indicating the change in V4, V5, and V6 as outlined below: • Cross out “V4” and write “V4R” in its place • Cross out “V5” and write “V8” in its place • Cross out “V6” and write “V9” in its place

146

15 LEAD ECG GUIDELINES Cont’d

NOTES • Any time a 15 lead has been acquired a copy of both the 12 lead and 15 lead ECG must be

attached (stapled) to the PCR to be left at the receiving facility and labeled with the patient’s surname and MCP number. A second copy of the 12 lead and 15 lead ECG must be attached (stapled) in an identical manner to the copy of the PCR to be kept by the ambulance service provider.

• You must document your interpretation of the 15 lead ECG in the narrative portion of the PCR.

147

SYNCHRONIZED CARDIOVERSION GUIDELINES 1. Apply appropriately sized defibrillation pads AND electrodes 2. Set lead select to “pads” 3. Pre-medicate whenever possible as per Procedural Sedation Protocol (Pg 56 and 113) 4. Engage the synchronization mode by pressing the “sync” button before each attempt 5. Look for sync markers on the R waves indicating the sync mode is operative. If necessary, adjust

monitor gain until sync markers occur with each R wave 6. Select appropriate energy level as outlined below 7. Announce that you are charging the defibrillator and press “charge” button 8. When defibrillator is fully charged clear the patient and announce impending discharge 9. Press and hold the “shock” button until the shock is delivered 10. Return to step 4 if tachycardia and indications for synchronized cardioversion persist

ADULT

RHYTHM ENERGY LEVEL SEQUENCE Narrow / Regular • SVT • Atrial flutter

1st Dose 2nd Dose Subsequent Dose(s)

50 J 100 J 200 J

Narrow / Irregular • Atrial fibrillation (A Fib) • Atrial flutter (A Flutter) with variable

response • Multifocal Atrial Tachycardia

1st Dose Subsequent Dose(s)

100 J 200 J

Wide / Regular • Ventricular tachycardia • SVT with aberrancy Wide / Irregular • A Fib with bundle branch block (BBB) • A Flutter with variable block and BBB • A Fib with Wolff Parkinson White (WPW)

PEDIATRIC ENERGY LEVELS 1st Dose Subsequent Dose(s)

0.5 – 1 J /kg 2 J/kg

CAUTION

• If unable to synchronize despite adjustment of the gain, proceed with unsynchronized cardioversion in the critically ill and unstable patient.

• If synchronized cardioversion triggers VF perform immediate unsynchronized cardioversion (defibrillation).

148

NON-EMS MEDICAL PERSONNEL ON SCENE The medical care provided at the scene is the responsibility of the highest level of pre-hospital care provider who has responded by usual dispatch systems to that scene. Bystanders, who stop to help, even if more highly trained than the system providers, may not assume responsibility (except as outlined below). Any healthcare provider (MD, RN, off duty EMR/Paramedic, etc.) who is not an active member of the responding unit, and who is either at the scene at the time of the ambulance arrival or arrives after an EMR/Paramedic has initiated care, and who desires to continue to participate may be allowed to help in care at the discretion of the lead provider.

AUTHORIZATION FOR PATIENT CARE Only those individuals meeting the criteria outlined below are authorized to assume, direct, or assist in the provision of patient care: 1) Assistant or bystander has a scope of practice that exceeds that of the responding ambulance

AND 2) Permission to assist or intervene has been granted by the attending EMR or Paramedic

AND 3) Assistant or bystander can provide proof of licensure to practice in Newfoundland and

Labrador1 1 Off-duty pre-hospital practitioners must obtain errors and omissions insurance coverage through

one of the following means: • A pre-existing written Memorandum of Understanding (MOU) specifically granting errors and

omission coverage during off-duty hours and for when a practitioner is placed in a humanitarian situation in the Province when you skill set is likely to improve patient care

• Contact your supervisor or employer for an extension of errors and omission coverage prior to the provision of patient care

Off-duty practitioners without coverage for errors and omissions or who have not adhered to the above instructions may be held personally responsible in the event of legal action resulting from the patient encounter

149

NON-EMS MEDICAL PERSONNEL ON SCENE Cont’d

PHYSICIAN ON-SCENE Any physician on-scene who has initiated medical care or is requesting interventions that exceeds the scope of practice of the responding crew must be advised that the care that has been initiated exceeds the scope of practice of the attending crew and be requested to accompany the crew to the destination facility so that the care provided by that physician is not interrupted and so that any adverse events that result from interventions unfamiliar to the attending crew can be anticipated and managed by that physician. The attending physician must be requested to document patient care on the Patient Care Report (PCR) and accompany the patient to the destination hospital. If after requesting that the physician continue his or her care of the patient en-route to hospital the attending physician indicates intent to terminate the patient-provider relationship, notify the physician that you are required to discuss the case with the OLMC physician and that the OLMC physician may wish to discuss the patient care provided. An on-scene physician, who is providing medical care outside the scope of practice of the attending practitioner must agree to take responsibility for patient care, be willing to document their involvement on the Patient Care Report (PCR), and accompany the patient to the hospital. Any disagreements between the attending crew and the on-scene physician must be discussed with OLMC.

CAUTION

• At no time are practitioners permitted to deviate from the patient care protocols except when advised to do so by OLMC.

150

REFUSAL OF CARE Adult patients (or a mature minor1) with medical decision-making capacity have the right to refuse pre-hospital assessment, management, or transport. These patients must sign a Refusal of Care Form provided they meet the criteria outlined below. Persons that meet the criteria below can refuse treatment: 1) An adult over the age of 18 2) A mature minor1 3) A parent or legal representative2 of a minor 4) Legal representative of dependent adults3 Procedure 1. Determine the patient’s capacity4 for decision making and document on PCR. The patient has

the capacity for medical decision-making if they meet ALL of the following criteria:

• GCS of 15 • Converse spontaneously • FULLY oriented and follow commands • DO NOT have impairment due to drugs or alcohol • Not in a postictal state • Have a reasonable understanding of :

o the nature of the illness/injury o the recommendations made o the benefits that could result from treatment or transport o the risks involved in not seeking treatment or transport (as outlined and documented by the

practitioner)

• The decision of non-transport is consistent with the patient’s normal set of values and beliefs (e.g. Is this a decision that the patient would normally make under similar circumstances?)

2. Ensure absence of medical conditions that may affect patients capacity for medical decision-making including but not limited to:

• Hypoglycemia • Hypotension • Hypoxia • Delirium • Dementia • Developmental disability • Intoxication

151

REFUSAL OF CARE cont'd 3. If it is determined that the patient has capacity for medical decision-making, contact with OLMC is

NOT required. Practitioners must ensure to:

• Explain and document on the PCR the possible risks and consequences of refusal of treatment or transport

• Educate patient and bystanders to call back if patient worsens or if they change their mind regarding treatment and transport

• Recommend that contact be made with the patient’s family physician • Offer assistance in arranging alternative transportation • Have patient and witness sign the Refusal of Care Form

4. If it is determined that the patient does NOT have capacity for medical decision-making and is suicidal, poses a risk of bodily injury to themselves or others as a result of mental illness, or is intoxicated and in need of medical treatment, contact Police and/or OLMC for assistance

NOTES • A refusal of care or transport must be a patient-initiated request or inquiry. Practitioners must

never suggest or encourage patients to refuse care and/or transport. Patients have a right to access the care provided in the Emergency Department via medical transport

• Medical decision-making and refusal of care or transport must be a decision made by the patient free of fear, constraint, compulsion, coercion or duress

• Patients who are minors (under age 19 and not considered to be a mature minor1) cannot refuse care. However, if the minor’s parent or legal guardian demonstrates capacity for medical decision-making and agrees to assume responsibility for the minor, they must sign the Refusal of Care Form on behalf of the minor

DEFINITIONS 1 Mature minor: A teenager who is assessed by a health care provider to have capacity to make

a specific treatment decision based on a demonstrated ability to understand information surrounding his or her presentation including: • Nature of his or her medical condition • Proposed treatment and/or alternatives • Risk and benefits of the proposed treatment and/or alternatives • Risks or foreseeable consequences of consent to treatment or refusal of care

2 Legal representative: Court appointed individual(s) responsible for making health care related decisions for dependent adult or minors

3 Dependent adult: Any adult who is greater than or equal to 18 years of age, completely or partially dependent upon one or more other person(s) for care or support, has not established financial independence and would likely be in danger if care or support was withdrawn

4 Capacity: The patient understands the nature of his or her medical condition, risks and benefits of care and/or transport, risks or foreseeable consequences or refusal of care or transport, and the patient demonstrates this understanding of the explanation(s) of these elements by the attending practitioners

152

POTENTIAL COMMUNICABLE/QUARANTINABLE DISEASE

INDICATORS OF POTENTIAL COMMUNICABLE OR QUARANTINABLE DISEASE

1) Fever (Temperature greater than or equal to 38ºC) AND

2) Any ONE OR MORE of the following: • Appearing obviously unwell • Shortness of breath (recent onset) • Multiple ill travelers aboard conveyance • Persistent cough or coughing blood • Persistent vomiting or diarrhea • Bruising or bleeding (without previous injury)

• Headache • Confusion (recent onset) • Sore throat • Muscle pains • Intense weakness • Skin rash

QUARANTINE OFFICER (ATLANTIC REGION) – 902-873-7659 1. If the patient meets the above indicators of a potential communicable disease, alert all emergency

responding agencies of appropriate personal protective equipment (PPE) requirements (to include, but not limited to: gloves, gown, goggles and N95 mask for the emergency responder; mask and appropriate draping for the patient)

2. If the patient meets the potential communicable/quarantinable indicators OR case involves a Known Quarantinable Disease1 AND is an international traveler being picked up at a port of entry (air or sea) notify the Quarantine Officer (QO) before leaving the vessel or aircraft and passing through customs (902-873-7659) for further direction

3. Notify the receiving facility of a Potential Communicable/Quarantinable Disease 4. Notify dispatch that the transport vehicle will be unavailable after transport until decontamination

has occurred (confer with local hospital Infection Control)

1 KNOWN QUARANTINABLE DISEASES Active pulmonary tuberculosis Anthrax Botulism Cholera Diphtheria Measles Pandemic Influenza Type A Plague Poliomyelitis Smallpox Severe Acute Respiratory Syndrome (SARS)

Argentine hemorrhagic fever Bolivian hemorrhagic fever Brazilian hemorrhagic fever Crimean-Congo hemorrhagic fever Ebola hemorrhagic fever Marburg hemorrhagic fever Venezuelan hemorrhagic fever Rift Valley Fever Tularemia Typhoid Fever Yellow Fever Lassa fever

QUARANTINE OFFICER (ATLANTIC REGION) – 902-873-7659

153

MASS CASUALTY INCIDENT MANAGEMENT ORGANIZATION

1. Incident Command and Triage Coordinator are established by the first arriving unit • Roles may change as additional personnel arrive

2. Scene size up

INCIDENT COMMAND 1. Estimate number of victims, and notify dispatch 2. Request appropriate number of responding units, special equipment, mutual aid units, and

additional resources as needed 3. Identify staging area, access and egress routes 4. Identify treatment area 5. Assign other positions as additional crews and help arrive:

• Treatment Coordinator • Transport Coordinator • Litter bearers / extrication teams • Other duties as required

TRIAGE COORDINATOR (Lowest trained personnel) 1. Direct all walking wounded to a designated area

• If possible, direct a few people to remain in the triage area and assist victims as required 2. Triage of victims should be initiated immediately using the START (Pg 154) or JumpSTART

system (Pg 155) 3. Perform only the most life saving measures (open airway, stop bleeding) 4. Oversee and direct litter bearers to transport patients from the triage area to the treatment area

according to triaged priority

TREATMENT COORDINATOR (Highest trained personnel) 1. Establish treatment areas

• If incident is large, designate separate treatment areas for each triage level, including a morgue separate from other victims

2. Ensure aggressive treatment and rapid packaging of patients 3. Assign and supervise treatment teams 4. Assign transport priorities (transport highest priority first) and communicate this to transport

coordinator

TRANSPORT COORDINATOR 1. Establish and supervise the Staging Area as well as access and egress routes 2. Establish and supervise the patient loading zone 3. Assign and supervise rapid and efficient loading of patients 4. Ensure smooth flow of ambulance traffic and avoid congestion of vehicles 5. Maintain a log containing the victim names, nature of injuries, time of transport, destination, and

triage tag number 6. Notify the receiving facility of patient transports, including a brief description of injuries

NOTES • There must be adequate medical personnel working in the treatment area prior to initiating

transportation of the patients to receiving facilities • All personnel are to restrict radio communications to a minimum

154

SIMPLE TRIAGE AND RAPID TREATMENT (START) TRIAGE SYSTEM The purpose of the Simple Triage And Rapid Treatment (START) system is to efficiently triage and transport adult victims of a multiple or mass casualty incident. This is used when the number of injured exceed the capabilities of the first arriving units or for large scale incidents.

GENERAL GUIDELINES • Triage of victims should take no longer than 60 seconds per patient • Assess “R-P-M” (Respirations, Perfusion, and Mental Status) for each patient • Tags of appropriate color should be placed on the upper extremity or in a visible location • Reassessments may be conducted and priority may be changed once all patients have been

triaged PROCEDURE 1. Identify “Walking Wounded”

• Voice triage should be used to direct the walking wounded to a designated area • If patient (s) able to walk to the designated area Tag GREEN – Minor • Proceed with evaluation of remaining patients as outlined in Steps 2 – 5

2. Assess R – Respirations

• If respiratory rate is greater than 30 Tag Red – Immediate • If patient is not breathing Open airway and reassess

o If patient remains apneic despite airway opening Tag Black – Deceased 3. Assess P – Perfusion (Radial pulse and capillary refill)

• If absent radial pulse OR capillary refill greater than 2 seconds Tag Red – Immediate 4. Assess M – Mental Status

• If patient is unconscious, disoriented, OR unable to follow simple commands Tag Red – Immediate

5. For all remaining patients Tag Yellow – Delayed

155

JUMP SIMPLE TRIAGE AND RAPID TREATMENT (JumpSTART) TRIAGE SYSTEM The purpose of the Jump Simple Triage And Rapid Treatment (JumpSTART) system is to efficiently triage and transport pediatric (Age 1-8 years) victims of a multiple or mass casualty incident. This is used when the number of injured exceed the capabilities of the first arriving units or for large scale incidents.

GENERAL GUIDELINES • The JumpSTART system is to be utilized in pediatric patients (Age 1-8 years) only • Triage of victims should take no longer than 60 seconds per patient • Assess “R-P-M” (Respirations, Perfusion, and Mental Status) for each patient • Tags of appropriate color should be placed on the upper extremity or in a visible location • Reassessments may be conducted and priority may be changed once all patients have been

triaged PROCEDURE 1. Identify “Walking Wounded”

• Voice triage should be used to direct the walking wounded to a designated area • If patient(s) able to walk to the designated area Tag GREEN – Minor • The “walking wounded” categorization does not apply to pediatric patients being carried by

an adult to the designated area • Proceed with evaluation of remaining patients, and those being carried, as outlined below

2. Assess R – Respirations

• If respiratory rate is less than 15 or greater than 40 Tag Red – Immediate • If patient is not breathing Open airway and reassess

o If breathing resumes Tag Red – Immediate o If patient remains apneic Check pulse If no pulse Tag Black – Deceased If pulse present Perform BVM for 15 seconds (5 ventilations)

- If respirations resume Tag Red – Immediate - If no respirations Tag Black – Deceased

3. Assess P – Perfusion (Radial and brachial pulse)

• If absent radial AND brachial pulse Tag Red – Immediate 4. Assess M – Mental Status (AVPU)

• Assess using the AVPU scale and proceed as outlined below: o If Alert, responsive to Verbal stimulus, or appropriately responsive to Pain Tag

Yellow – Delayed o If Unresponsive, or demonstrates an inappropriate response to Pain Tag Red –

Immediate

156

COMMUNICATIONS REFERENCE

RADIO REPORT TO RECEIVING FACILITY Radio reports should be kept as concise as possible and contain essential information to ensure Emergency Department preparedness to receive the patient and provide necessary care without delay. A concise radio report should be followed by a more detailed verbal report upon arrival to the receiving facility. The purpose of the radio report is to provide an opportunity for the receiving facility to activate the appropriate resources and services to address the immediate needs of the patient.

RADIO REPORT COMPONENTS 1) Unit identification 2) Age and gender of patient 3) Level of consciousness 4) Chief complaint or primary reason for transport 5) History of present illness or injury 6) Relevant Past Medical History 7) Relevant Medications (Contributing to presentation or taken by patient) 8) Relevant physical exam findings 9) Treatment rendered and response 10) Estimated time of arrival (ETA)

CONSULTATION WITH OLMC (1-877-709-3535) Consultation with OLMC should take place when directed to do so by a protocol OR any time the practitioner requires the advice of a physician to care for his or her patient. Be prepared to provide a comprehensive verbal report to the OLMC physician that includes all the necessary information in order for the physician to properly advise you with respect to patient care. Upon being connected with the physician you must provide the physician with the following identifying information at the start of the conversation:

1) Your name 2) Level of training 3) Registration number

This identifying information must be repeated to the physician even if you have already provided this information to the dispatcher.

157

COMMUNICATIONS REFERENCE Cont’d

OLMC PATIENT REPORT COMPONENTS When discussing the patient with the OLMC physician it is important that all necessary pieces of information are presented. This is important to ensure the physician has all the details necessary to provide you with the safest and most appropriate advice for each individual patient. Please be sure to include all of the following OLMC Report components in your case presentation:

1) Age and gender of patient 2) Chief complaint or primary reason for transport 3) History of present illness or injury 4) Past Medical History 5) Medications 6) Allergies 7) Physical exam findings 8) Complete set of vital signs 9) Treatment rendered 10) Specific questions practitioner has for the physician or request for order(s) When orders are received from the physician the practitioner must repeat the order(s) including drug name, route of administration, dose and repeats to the physician for clarification. It is essential that you state the numerical value of each vital sign rather than making a general statement such as “vital signs are normal”. What is “normal” will vary depending on the case and the physician requires the actual vital sign result to make a medical recommendation.

COMMUNICATIONS FAILURE In case of a communications failure with OLMC due to equipment (radio, cell phone, and/or landline) malfunction or due to incident location, the following will apply: • Practitioner(s), may within the limits of their Certification(s), perform necessary procedures,

that are contained within the protocols that would require a direct physician order under normal circumstances

• Procedures performed must be limited to the minimum amount necessary to prevent the loss of life or the critical deterioration of a patient’s condition

• All the procedures performed under this order and the conditions that contributed to the communications failure must be documented in detail on the patient care record

• Practitioner must continue to make efforts to contact OLMC during transport Practitioners are required to contact PMO the following business day to report the details of the communications failure

158

AGITATED COMBATIVE / PHYSICAL RESTRAINT Physical restraint is an intervention of last resort that should only be utilized when there is an imminent danger to life or threat of physical harm to the patient and/or bystanders and reasonable attempts to defuse the situation with verbal de-escalation strategies have failed. Practitioners should utilize the least amount of restraint necessary to protect the patient and/or bystanders from harm until police arrive. Practitioners may apply physical restraint up to the point where such force would reasonably be considered to be excessive or where practitioners are no longer able to safety apply restraint as a result of imminent danger of harm to them. Provided that indications for physical restraint are present, such restraint may be applied regardless of whether or not the patient has been formally evaluated under the Mental Health Care and Treatment Act, or if the patient is categorized as “voluntary” or “involuntary” under the Act.

INDICATIONS FOR PHYSICAL RESTRAINT 1) Imminent danger to life OR threat of physical harm to patient and/or bystanders

AND 2) Attempts at verbal de-escalation have failed

AND


Police attendance must be requested immediately if there is a need to physically restrain a patient or if a patient has been physically restrained based on the presence of the criteria listed above. If the estimated time of arrival for the police is anticipated to be prolonged, contact OLMC regarding the transport decision. IMMINENT DANGER Imminent danger refers to an immediate threat of significant harm to one’s self or others, up to and including death. Examples of imminent danger include, but are not limited to the following: • Actively attempting suicide • Actively attempting to cause serious bodily injury to others • Attempting to jump from a building or moving vehicle

159

SITUATIONAL CONSIDERATIONS Scene Calls

• If previous dispatch information alerts practitioners to a potentially dangerous situation and police are not on scene prior to crew arrival, crews should stage at a safe distance away from the scene and wait for police arrival prior to initiating patient contact.

• If the patient becomes hostile while crew is on scene, exit the scene and remain in the ambulance a safe distance away until police arrive.

• Request that police accompany the patient in the ambulance enroute to hospital • If hard restraints (i.e. hand cuffs) are placed by police, police must accompany the patient in the

ambulance. Inter-facility Transfers (Prior to departure)

• Type of restraint should be ordered by the attending physician and applied before departure from the facility.

• Patients requiring physical restraints must be accompanied by facility escort trained in the use of the applied physical restraints. If hard restraints (i.e. hand cuffs) are in place, police must accompany the patient in the ambulance.

• If chemical restraint is used, a facility escort or ACP must accompany the patient. • If practitioners feel that some sort of restraint is required and is not ordered, they should discuss

their concerns with staff at the sending facility. If the matter cannot be satisfactorily resolved practitioners are required to contact OLMC to discuss need for chemical or physical restraint for safe transport. If deemed necessary, the OLMC physician will discuss patient care needs for safe transport with the attending physician at the sending facility.

If at any time during transport the patient’s behavior escalates beyond the crew’s ability to safely manage the situation (Scene calls or Interfacility transfers):

• Immediately call for the police assistance and ask the driver to pull the ambulance over to the side of the road

• Attempt verbal management techniques to de-escalate the situation and calm the patient. • If verbal management techniques are unsuccessful, and indications for physical restraint are

present, both crew members should attempt to physically restrain the patient as per Agitated / Combative Protocol.

• If practitioners are unable to safely apply restraint as a result of imminent danger of harm to themselves, practitioners should exit the vehicle, remove the keys from the vehicle, and move to a safe location, away from the road, while waiting for police to arrive.

160

AIRWAY REFERENCE PREDICTORS OF DIFFICULT LARYNGOSCOPY “MMAP”

M – Measure “3-3-1” 3: Thyromental Distance – The distance between the thyroid cartilage (Adam’s Apple) and the tip

of the chin (mentum) with the head/neck extended. Distance is reassuring if greater than or equal to 3 fingerbreadths.

3: Mouth Opening – The distance between the upper and lower front teeth when the mouth is

open. Distance is reassuring if greater than or equal to 3 fingerbreadths. 1: Jaw Protrusion – Ability to protrude the lower front teeth anterior to the upper front teeth by 1

cm. Any one or more distance that is less than those indicated above is predictive of difficult laryngoscopy M – Mallampati Classification scheme based on extent of visualization of the posterior pharynx when the mouth is open without phonation. DO NOT have patient say “ahhhh”. Class III and IV are predictive of difficult laryngoscopy

Class I II III IV

A – Atlanto-Occipital Extension In the absence of C-spine precautions, formally assess the patient’s ability to flex and extend the neck. Extension of less than 90º is predictive of difficult laryngoscopy P – Pathology Assess for anatomical airway obstruction including medical (e.g. angioedema, airway infections, tumors) or traumatic (e.g. burns, penetrating or blunt neck trauma) conditions. Any obstructive airway pathology is predictive of difficult laryngoscopy.

161

AIRWAY REFERENCE Cont’d LARYNGOSCOPIC VISUALIZATION – CORMACK LEHANE VIEWS

Cormack Lehane Views

Grade I Grade II Grade III Grade IV Classification scheme based on extent of visualization of the laryngeal structures. Grades II and III laryngoscopic views are predictive of difficult laryngoscopy and Bougie should be utilized. Grade IV laryngoscopy indicates an extremely difficult or impossible intubation for which Bougie is unlikely to be useful. Consider EGD or BVM for ventilation. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia1984 ; 39 : 1105-11

RAMPING FOR PATIENTS WITH OBESITY

Figure A: Patient positioned without ramping

Figure B Patient ramped so that the sternum and ear line up. This position should improve laryngoscopic view and BVM use.

ETCO2 REFERENCE RANGE • Attempt to maintain ETCO2 in normal physiologic range, between 35-45 mmHg, in order to avoid

hyperventilation (ETCO2 less than 35 mmHg). • In rare cases patients may require mild hyperventilation to maintain SpO2 greater than 90%. In

these cases PEEP and FIO2 must be optimized. If SpO2 remains less than 90% a slightly lower ETCO2 is acceptable to maintain SpO2 greater than 90%.

http://www.ncbi.nlm.nih.gov/pubmed/6507827

162

PEDIATRIC REFERENCE

CLASSIFICATION OF PEDIATRIC PATIENTS Pediatric patient: Pre-pubescent. Signs of puberty include breast development on the female and underarm or chest hair on the male. • Neonate 0 to 28 days • Infant 29 days to 12 months • Child 1 year to puberty • Adolescent pre-puberty to adult MATURE MINOR A teenager who is assessed by a health care provider to have capacity to make a specific treatment decision based on a demonstrated ability to understand information surrounding his or her presentation including, but not limited to: • Nature of his or her medical condition • Proposed treatment and/or alternatives • Risks and benefits of the proposed treatment and/or alternatives • Risks and foreseeable consequences of consent to treatment and/or alternatives • Risks and foreseeable consequences of refusal of care APGAR SCORE

Parameter 0 1 2

Appearance, color Blue, pale Centrally pink Completely pink

Pulse, heart rate None Less than 100 Greater than 100

Grimace, reflex No response Grimace Cough, gag, cry

Activity, attitude Flaccid or limp muscle tone Some flexion Well-flexed or active

motion Respiratory effort None Weak, irregular irritable Good, crying

163

PEDIATRIC REFERENCE Cont’d PEDIATRIC VITAL SIGNS HEART RATE AND RESPIRATIONS

Age Heart Rate Respirations

Less than 1 year 100 – 160 30 – 60

1 – 2 years 90 – 150 24 – 40

2 – 5 years 80 – 140 22 – 34

6 – 12 years 70 – 120 18 – 30

Greater than 12 years 60 – 100 12 – 16 AGE-SPECIFIC HYPOTENSION (5th PERCENTILE FOR SBP) GUIDELINES

Age Hypotension SBP (Less than 5th Percentile for SBP)

0 – 28 days Less than 60 mmHg

1 month – 12 months Less than 70 mmHg

1 year – 10 years [70 + (2 x age in years)] mmHg

Greater than 10 years Less than 90 mmHg PEDIATRIC WEIGHT ESTIMATION • Weight (Kg) = 3 x (Age in years) + 7

NOTES • Broselow tape is one of the most accurate ways to estimate pediatric parameters including but

not limited to vital signs and weight, and should be used if available.

164

PEDIATRIC DEVICE REFERENCE

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17-1

8

10

2.5

15

Chi

ld

19-2

3 kg

Chi

ld

Pedi

atric

70

2 St

raig

ht

or C

urve

d

5.5

Unc

uffe

d 5.

0 C

uffe

d

16.5

10

2-2.

5

15

Chi

ld

15-1

8 kg

Chi

ld

Pedi

atric

60

2 St

raig

ht

5.0

Unc

uffe

d 4.

5 C

uffe

d

14-1

5

10

2 15

Chi

ld

12-1

4 kg

Chi

ld

Pedi

atric

60

2 St

raig

ht

4.5

Unc

uffe

d 4.

0 C

uffe

d

13.5

10

2 15

Chi

ld

10-1

1 kg

Chi

ld

Pedi

atric

60

1 St

raig

ht

4.0

Unc

uffe

d 3.

5 C

uffe

d

11-1

2

10

2 15

Chi

ld

8-9

kg

Chi

ld

Pedi

atric

50

1 St

raig

ht

3.5

Unc

uffe

d 3.

0 C

uffe

d

10.5

-11

8 1.5

18 /

15

Chi

ld

6-7

kg

Infa

nt /

Chi

ld

Pedi

atric

50

1 St

raig

ht

3.5

Unc

uffe

d 3.

0 C

uffe

d

10.5

-11

8 1.5

18 /

15

Infa

nt /

Chi

ld

3-5

kg

Infa

nt

Infa

nt

40-5

0

0-1

Stra

ight

3.0-

3.5

Unc

uffe

d

8-10

5-8

1 18

Infa

nt /

Chi

ld

Und

er 3

kg

Infa

nt

Infa

nt

30-4

0

00-0

St

raig

ht

2.5-

3.5

Unc

uffe

d

6-9

5-6

1 18

Neo

nata

l #5

/ In

fant

Equi

pmen

t

Res

usci

tatio

n B

ag

Oxy

gen

Mas

k (N

RB

)

OPA

(mm

)

Lary

ngos

cope

B

lade

ET tu

be (m

m)

ETT

Dep

th

(cm

)

Suct

ion

Cat

hete

r (F)

LMA

Siz

e

IO (g

a)

BP

Cuf

f

Information contained in this chart is to be used as a guide and is not a substitute for clinical judgment

165

PAIN SCALES

166

DEFINITIONS SURROUNDING DNR, TOR, AND DETERMINATION OF DEATH SUBSTITUTE HEALTH CARE DECISION MAKER The person appointed by the Maker of an advance health care directive to make health care decisions on his or her behalf. The first named person or a member of the category of persons on the following list may, if he or she is at least 19 years of age, act as a SHCDM; the patient's:

1) Appointed substitute decision maker, or a guardian that has been appointed for the purpose by a court and named on the advance health care directive

2) Spouse 3) Children 4) Parents 5) Siblings 6) Grandchildren 7) Grandparents 8) Uncles and aunts 9) Nephews or nieces 10) Another relative 11) Health care professional who is responsible for the proposed health care VALID ADVANCE HEALTH CARE DIRECTIVE (AHCD)

A document which sets out the Maker's instructions or the Maker's general principles regarding his or her health care treatment or in which a Maker appoints a substitute decision maker or both (Maker means a person who makes an advance health care directive). An Advance Health Care Directive shall be: 1) In writing 2) Witnessed by at least 2 independent persons 3) Signed by the Maker VALID DO NOT RESUSCITATE (DNR)

Is a written order issued and signed by a physician that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest. Such an order may be instituted on the basis of an AHCD from a person, or from a substitute health care decision maker, or by a physician, and it is designed to prevent unnecessary suffering.

167

BURN REFERENCES

RULE OF NINES

• A method of estimating burn injury that divides the total body surface area (BSA) into sections that are multiples of 9%

• This method provides a rough estimate of burn injury size and is most accurate for adults and children greater than 10 years of age

• If burns are irregularly shaped or have a

scattered distribution, the Rule of Palms may provide a better estimate of burn surface area. The surface of the patient’s hand (palm and fingers) equals approximately 1% of the total BSA.

PARKLAND FORMULA

Formula used to estimate the total volume of fluid replacement required by the burn patient in the first 24 hours post-injury

• Total fluid required in first 24 hours (mL) = [4 x (Weight in Kg) x (TBSA1) o Administer ½ of the total volume over 8 hours o Administer the second ½ of the total volume over the subsequent 16 hours

NOTES 1 TBSA should be the whole number percent estimate of the TBSA rather than the percentage

expressed as a decimal. For example – for a 40 Kg patient suffering 27% burns: • Total fluid required in first 24 hours = [4 x 40 x 27] = 4320 mL

168

GLASGOW COMA SCALE The Glasgow Coma Scale is a clinical tool used to assess the degree of consciousness and neurological functioning - and therefore severity of brain injury - by testing eye opening, verbal response, and motor activity.

ADULT CHILDREN INFANT

EYE OPENING

4 Spontaneously Spontaneously Spontaneously

3 To verbal stimulus To verbal stimulus To verbal stimulus

2 To painful stimulus To painful stimulus To painful stimulus

1 No opening No opening No opening VERBAL RESPONSE

5 Completely alert, oriented and appropriate

Completely alert, oriented, and appropriate

Coos, babbles, and smiles as normal

4 Confused Confused Irritable cries

3 Inappropriate words Inappropriate words Inappropriate cries, screams

2 Incomprehensible Incomprehensible words or non-specific sounds

Moans in response to pain

1 No verbal response No verbal response No verbal response

MOTOR ACTIVITY

6 Obeys commands Spontaneous and appropriate

Spontaneous and appropriate

5 Localizes pain Localizes pain Localizes pain

4 Withdraws to pain Flexion withdrawal Flexion withdrawal

3 Abnormal flexion Abnormal flexion Abnormal flexion

2 Extension Extension Extension

1 No motor activity No motor activity No motor activity

169

OXYGEN TANK DURATION CHARTS Table entries represent duration of tank use in minutes

D Cylinder (Minus safe residual of 200 PSI)

PSI

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

2000

288

144

96

72

58

48

41

36

32

29

26

24

22

21

19

1900

272

136

91

68

54

45

39

34

30

27

25

23

21

19

18

1800

256

128

85

64

51

43

37

32

28

26

23

21

20

18

17

1700

240

120

80

60

48

40

34

30

27

24

22

20

18

17

16

1600

224

112

75

56

45

37

32

28

25

22

20

19

17

16

15

1500

208

104

69

52

42

35

30

26

23

21

19

17

16

15

14

1400

192

96

64

48

38

32

27

24

21

19

17

16

15

14

13

1300

176

88

59

44

35

29

25

22

20

18

16

15

14

13

12

1200

160

80

53

40

32

27

23

20

18

16

15

13

12

11

11

1100

144

72

48

36

29

24

21

18

16

14

13

12

11

10

10

1000

128

64

43

32

26

21

18

16

14

13

12

11

10

9 9

900

112

56

37

28

22

19

16

14

12

11

10

9 9 8 7

800

96

48

32

24

19

16

14

12

11

10

9 8 7 7 6

700

80

40

27

20

16

13

11

10

9 8 7 7 6 6 5

600

64

32

21

16

13

11

9 8 7 6 6 5 5 5 4

500

48

24

16

12

10

8 7 6 5 5 4 4 4 3 3

400

32

16

11

8 6 5 5 4 4 3 3 3 2 2 2

300

16

8 5 4 3 3 2 2 2 2 1 1 1 1 1

200 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PSI

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

← Liters per minute →

170

OXYGEN TANK DURATION CHARTS Cont’d Table entries represent duration of tank use in minutes

E Cylinder - Minus safe residual of 200 PSI

PSI

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

2000

504

252

168

126

101

84

72

63

56

50

46

42

39

36

34

1900

476

238

159

119

95

79

68

60

53

48

43

40

37

34

32

1800

448

224

149

112

90

75

64

56

50

45

41

37

34

32

30

1700

420

210

140

105

84

70

60

53

47

42

38

35

32

30

28

1600

392

196

131

98

78

65

56

49

44

39

36

33

30

28

26

1500

364

182

121

91

73

61

52

46

40

36

33

30

28

26

24

1400

336

168

112

84

67

56

48

42

37

34

31

28

26

24

22

1300

308

154

103

77

62

51

44

39

34

31

28

26

24

22

21

1200

280

140

93

70

56

47

40

35

31

28

25

23

22

20

19

1100

252

126

84

63

50

42

36

32

28

25

23

21

19

18

17

1000

224

112

75

56

45

37

32

28

25

22

20

19

17

16

15

900

196

98

65

49

39

33

28

25

22

20

18

16

15

14

13

800

168

84

56

42

34

28

24

21

19

17

15

14

13

12

11

700

140

70

47

35

28

23

20

18

16

14

13

12

11

10

9

600

112

56

37

28

22

19

16

14

12

11

10

9 9 8 7

500

84

42

28

21

17

14

12

11

9 8 8 7 6 6 6

400

56

28

19

14

11

9 8 7 6 6 5 5 4 4 4

300

28

14

9 7 6 5 4 4 3 3 3 2 2 2 2

200 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PSI

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15


171

OXYGEN TANK DURATION CHARTS Cont’d Table entries represent duration of tank use in minutes

M Cylinder - Minus safe residual of 200 PSI

PSI

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

2000

2808

1404

936

702

562

468

401

351

312

281

255

234

216

201

187

1900

2652

1326

884

663

530

442

379

332

295

265

241

221

204

189

177

1800

2496

1248

832

624

499

416

357

312

277

250

227

208

192

178

166

1700

2340

1170

780

585

468

390

334

293

260

234

213

195

180

167

156

1600

2184

1092

728

546

437

364

312

273

243

218

199

182

168

156

146

1500

2028

1014

676

507

406

338

290

254

225

203

184

169

156

145

135

1400

1872

936

624

468

374

312

267

234

208

187

170

156

144

134

125

1300

1716

858

572

429

343

286

245

215

191

172

156

143

132

123

114

1200

1560

780

520

390

312

260

223

195

173

156

142

130

120

111

104

1100

1404

702

468

351

281

234

201

176

156

140

128

117

108

100

94

1000

1248

624

416

312

250

208

178

156

139

125

113

104

96

89

83

900

1092

546

364

273

218

182

156

137

121

109

99

91

84

78

73

800

936

468

312

234

187

156

134

117

104

94

85

78

72

67

62

700

780

390

260

195

156

130

111

98

87

78

71

65

60

56

52

600

624

312

208

156

125

104

89

78

69

62

57

52

48

45

42

500

468

234

156

117

94

78

67

59

52

47

43

39

36

33

31

400

312

156

104

78

62

52

45

39

35

31

28

26

24

22

21

300

156

78

52

39

31

26

22

20

17

16

14

13

12

11

10

200 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PSI

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15


172

IV RATE CONVERSION CHART

Drip rate (gtts / minute) according to drop set utilized Target administration rate (mL/hour) 10 drop set 15 drop set 20 drop set 60 drop set

30 5 8 10 30

40 7 10 13 40

60 10 15 20 60

100 17 25 33 100

125 21 31 42 125

150 25 38 50 150

175 29 44 58 175

200 33 50 67 200

250 42 63 83 250

300 50 75 100 300

350 58 88 117 350

400 67 100 133 400

450 75 113 150 450

500 83 125 167 500

550 92 138 183 550

600 100 150 200 600

650 108 163 217 650

700 117 175 233 700

750 125 188 250 750

800 133 200 267 800

850 142 213 283 850

900 150 225 300 900

950 158 238 317 950

1000 167 250 333 1000 CALCULATING DRIP RATE FOR CRYSTALLOID FLUID ADMINISTRATION • Drip rate (gtts / minute) = Total amount to be administered (mL) x Drip Factor

Desired time frame (minutes)

173

METRIC CONVERSION CHARTS

TEMPERATURE WEIGHT WEIGHT °F °C lbs kg lbs kg 106 41.1 396 180 66 30 105 40.6 385 175 64 29 104 40 374 170 62 28 103 39.4 363 165 59 27 102 38.9 352 160 57 26 101 38.3 341 155 55 25 100 37.8 330 150 53 24 99 37.2 319 145 51 23 98.6 37 308 140 48 22 97 36.1 297 135 46 21 96 35.6 286 130 44 20 95 35 275 125 42 19 94 34.4 264 120 40 18 93 33.9 253 115 37 17 92 33.3 242 110 35 16 91 32.8 231 105 33 15 90 32.2 220 100 31 14 89 31.7 209 95 29 13 88 31.1 198 90 26 12 87 30.6 187 85 24 11 86 30 176 80 22 10 85 29.4 165 75 20 9 84 28.9 154 70 18 8 83 28.3 143 65 15 7 82 27.8 132 60 13 6 81 27.2 121 55 11 5 80 26.7 110 50 9 4 79 26.1 99 45 7 3 78 25.5 88 40 4 2 77 25 77 35 2 1

174

ACRONYMS / ABBREVIATIONS

ACLS Advanced Cardiac Life Support LL Left Leg AC Antecubital LOC Level Of Consciousness ACP Advanced Care Paramedic LPM Liters Per Minute AED Automated External Defibrillator LSN Last Seen Normal AF Atrial Fibrillation Lt Left ALS Advanced Life Support MAO Monoamine oxidase AMI Acute Myocardial Infarction MCC Motorcycle Crash AP Anterior Posterior mcg Micrograms ASA Acetylsalicylic Acid MDI Metered Dose Inhaler BG Blood Glucose mEq Milliequivalent BLS Basic Life Support mL Milliliter BMV Bag Mask Ventilation mmHg Millimeters of Mercury BP Blood Pressure mmol/L Millimoles Per Liter BSA Body Surface Area MOI Mechanism of Injury BVM Bag Valve Mask MVC Motor Vehicle Crash C Celsius/Centigrade NIPPV Non-Invasive Positive Pressure Ventilation CCP Critical Care Paramedic NRP Neonatal Resuscitation Program CHF Congestive Heart Failure NS Normal Saline COPD Chronic Obstructive Pulmonary Disease NYD Not Yet Diagnosed CPAP Continuous Positive Airway Pressure OLMC Online Medical Control CPR Cardiopulmonary Resuscitation PALS Pediatric Advanced Life Support CVA Cerebral Vascular Accident PCI Percutaneous Coronary Intervention D10/25/50 Dextrose 10,25 & 50% PCP Primary Care Paramedic DBP Diastolic Blood Pressure PCR Patient Care Report

DHCS Department of Health and Community Services PEA Pulseless Electrical Activity

DKA Diabetic Ketoacidosis PMO Provincial Medical Oversight Program DNR Do Not Resuscitate PO Per Os (by mouth, orally) ECG Electrocardiogram PPE Personal Protective Equipment EDD Esophageal Detector Device PPV Positive Pressure Ventilation EGD Extraglottic Device PR Per Rectum EMR Emergency Medical Responder PSI Pounds per Square Inch ETCO2 End Tidal Carbon Dioxide q Every g Gram QO Quarantine Officer GCS Glasgow Coma Scale RA Right Arm GI Gastrointestinal RL Right Leg gtt(s) Drop(s) ROM Range of Motion HAZMAT Hazardous Materials ROSC Return of Spontaneous Circulation

HHNC Hyperosmolar Hyperglycemia Non-Ketotic Coma RR Respiratory Rate

HR Heart Rate Rt Right HTN Hypertension SBP Systolic Blood Pressure Hx History SC Subcutaneous IDDM Insulin-Dependent Diabetes Mellitus SHCDM Substitute Health Care Decision Maker IM Intramuscular SIVP Slow Intravenous Push IN Intra Nasal SL Sublingual IO Intraosseous SpO2 Saturation of Peripheral Oxygen ITLS International Trauma Life Support STEMI ST Elevated Myocardial Infarction IV Intravenous SVT Supraventricular Tachycardia IVP Intravenous Push TIA Transient Ischemic Attack J Joules TKVO To Keep Vein Open JVD Jugular Vein Distention TOR Termination of Resuscitation kg Kilogram VF Ventricular Fibrillation LA Left Arm VT Ventricular Tachycardia lbs Pounds WPW Wolff-Parkinson-White

175


176


177


178

PART V: MEDICATION FORMULARY

179

FORMULARY

CAUTION

• All calculations contained within this formulary are to be used as a guide and must be verifiedby the individual practitioner

• The information contained herein is not a substitute for clinical judgment

ACETAMINOPHEN

CLASS Antipyeretic, analgesic

INDICATIONS Pediatric Fever (temperature greater than 38.5ºC)

CONTRAINDICATIONS 1) Hypersensitivity2) Nausea and vomiting (PO)

PEDIATRIC DOSE 15 mg/kg PO/PR

NOTES • If acetaminophen already administered within the last 4 hours,

administer a “top-up” dose to so total dose administered within the last4 hours is equal to 15 mg/kg

ACETYLSALACYLIC ACID (ASA)

CLASS Platelet aggregation inhibitor

INDICATIONS Ischemic Chest Pain

CONTRAINDICATIONS

1) Hypersensitivity to ASA or NSAIDS2) History of active bleeding3) Active bronchospasm or history of severe asthma with bronchospasm

related to ASA or NSAIDS4) Age less than 16 years

PRECAUTIONS • Pregnancy• Bleeding disorders

ADULT DOSE 160-162 mg PO chewed

NOTES

• ASA should still be administered if patient has already taken their usualprescribed daily dose of ASA

• If the patient has taken ASA on the advice of the emergency medicaldispatcher, confirm correct identity of medication, dose, and expirationdate. If able to confirm appropriate self-administration do notadminister additional ASA. If ASA taken is enteric coated, administerASA as per protocol.

• Regular use of anticoagulants, such as warfarin, is not acontraindication to ASA administration.

180

ADENOSINE

CLASS Antiarrhythmic

INDICATIONS Adult Stable Narrow Complex Tachycardia (SVT) Pediatric Narrow Complex Tachycardia (SVT)

CONTRAINDICATIONS

1) Hypersensitivity2) Wide complex tachycardia3) Second or third degree AV block4) Wolff-Parkinson White Syndrome (WPW)5) Sinus node disease (Sick Sinus Syndrome)6) Active bronchospasm or history of severe asthma7) Concurrent use of carbamazepine (Tegretol) or dipyridamole

(Persantine)

SIDE EFFECTS • Hypotension• Bradydysrhythmias

ADULT DOSE 1st Dose 2nd Dose

6 mg rapid IVP 12 mg rapid IVP

Each dose must be followed immediately by a 20 mL bolus of 0.9% NaCl

PEDIATRIC DOSE

1st Dose

2nd Dose

0.1 mg/kg rapid IVP (Not to exceed maximum single dose of 6 mg) 0.2 mg/kg rapid IVP (Not to exceed maximum single dose of 12 mg)

Each dose must be followed immediately by a 10 mL bolus of 0.9% NaCl

NOTES

• This medication has a very short half-life. Insert a large bore IV into alarge but proximal peripheral vein if possible. Use the closestmedication port or a 3-way stop cock to administer the rapid IVP andfollow with a rapid flush of 0.9% NaCl.

• It is inadequate to subjectively evaluate rhythm regularity. The ECGmust be printed off and the R-R wave regularity measured prior toadministration.

• May induce a brief period of asystole that may be very uncomfortablefor the patient. Inform the patient of this possibility prior toadministration.

181

AMIODARONE

CLASS Antiarrhythmic

INDICATIONS

Adult Ventricular Fibrillation / Pulseless Ventricular Tachycardia Adult Stable, Regular, Wide Complex Tachycardia (VT) with a pulse Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia Pediatric Narrow Complex Tachycardia (SVT) (OLMC) Pediatric Wide Complex Tachycardia (VT) with a pulse (OLMC)

CONTRAINDICATIONS 1) Hypersensitivity to amiodarone or iodine2) Sinus node disease (Sick Sinus Syndrome)3) Second or third degree AV block

PRECAUTIONS • Pulmonary disease

SIDE EFFECTS • Hypotension• Bradydysrhythmias

ADULT DOSE

Adult Ventricular Fibrillation / Pulseless Ventricular Tachycardia • 300 mg IVP/IO• Administer 150 mg IVP/IO in 3 to 5 minutes if indicated

Adult Stable, Regular, Wide Complex Tachycardia (VT) with a pulse • 150 mg IV loading dose by infusion over 10 minutes• Follow with maintenance infusion of 1 mg/min (if successful conversion

AND transport time greater than 30 minutes)• See Pg 183 for amiodarone infusion instructions

PEDIATRIC DOSE

Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia • 5 mg/kg IV/IO (Not to exceed maximum single dose of 300 mg)• Repeat 5 mg/kg IV/IO (Not to exceed maximum single dose of 300 mg)

twice, up to a total of 15 mg/kg for refractory VF / Pulseless VTPediatric Narrow Complex Tachycardia (SVT) refractory to adenosine (OLMC) • 5 mg/kg IV/IO (Not to exceed maximum single dose of 150 mg) by

infusion over 60 minutes• See Pg 183 for amiodarone infusion instructionsPediatric Wide Complex Tachycardia (VT) with a pulse (OLMC) • 5 mg/kg IV/IO (Not to exceed maximum single dose of 150 mg) by

infusion over 60 minutes• See Pg 183 for amiodarone infusion instructions

182

AMIODARONE Cont’d

NOTES

• Use in-line 0.22 micron filter for all amiodarone infusions.• Dilute only with D5W. Do not dilute with 0.9% NaCl as compatibility

data is conflicting.• Do not administer concurrently with sodium bicarbonate due to

incompatibility. Either initiate a second IV line or ensure existing IV lineis flushed completely and is free of amiodarone.

• Foaming may occur when drawing up or diluting amiodarone. Do notshake vial.

183

AMIODARONE INFUSIONS

ADULT INFUSIONS

Adult Stable, Regular, Wide Complex Tachycardia (VT) with a pulse

LOADING DOSE INFUSION Admixture Instructions: • Add amiodarone 150 mg to 100 mL bag of D5W (concentration 1.5

mg/mL)Infusion Instructions • Infuse total volume of amiodarone admixture (100 mL) over 10 minutes• Using 10 drop set (10 gtts/mL) deliver the total volume of the admixture

(100 mL) at a drip rate of 100 gtts/minute (25 gtts over 15 seconds) MAINTENANCE INFUSION Admixture Instructions: • Add amiodarone 150 mg to 100 mL D5W in a buretrol (concentration

1.5 mg/mL)Infusion Instructions • Administer 1 mg/min for first 6 hours post-conversion• Using 60 drop set (60 gtts/mL) deliver admixture at a drip rate of 40

gtts/minute (10 gtts over 15 seconds)

PEDIATRIC DOSE

Pediatric Narrow Complex Tachycardia (SVT) refractory to adenosine (OLMC) AND Pediatric Wide Complex Tachycardia (VT) with a pulse (OLMC) LESS THAN 10 KG Admixture Instructions: • Add amiodarone 5 mg/kg to 50 mL of D5W in a buretrolInfusion Instructions • Infuse total volume of amiodarone admixture (50 mL) over 60 minutes• Using 60 drop set (60 gtts/mL) deliver the total volume of the admixture

(50 mL) at a drip rate of 50 gtts/minute (25 gtts over 30 seconds)GREATER THAN 10 KG Admixture Instructions: • Add amiodarone 5 mg/kg to 100 mL of D5W in a buretrolInfusion Instructions • Infuse total volume of amiodarone admixture (100 mL) over 60 minutes• Using 60 drop set (60 gtts/mL) deliver the total volume of the admixture

(100 mL) at a drip rate of 100 gtts/minute (25 gtts over 15 seconds)

184

AMIODARONE INFUSIONS Cont’d

NOTES

• Use in-line 0.22 micron filter for all amiodarone infusions.• Dilute only with D5W. Do not dilute with 0.9% NaCl as compatibility

data is conflicting.• Do not administer concurrently with sodium bicarbonate due to

incompatibility. Either initiate a second IV line or ensure existing IV lineis flushed completely and is free of amiodarone.

• Foaming may occur when drawing up or diluting amiodarone. Do notshake vial.

• Non-PVC bag is required for all infusions lasting greater than 2hours.• Rapid infusion is more likely to induce hypotension.

ATROPINE

CLASS Anticholinergic

INDICATIONS

Adult Symptomatic Bradycardia (With Pulse) Adult Organophosphates, Carbamates, & Anticholinesterases (OLMC) Adult Beta Blockers and Calcium Channel Blockers (OLMC) Pediatric Symptomatic Bradycardia Pediatric Organophosphates, Carbamates, & Anticholinesterases (OLMC) Pediatric Beta Blockers and Calcium Channel Blockers (OLMC)

CONTRAINDICATIONS

1) Hypersensitivity2) Bradycardia secondary to hypothermia3) Narrow angle glaucoma4) Heart Transplant

PRECAUTIONS • Myocardial ischemia or infarction

ADULT DOSE

Adult Symptomatic Bradycardia (With Pulse) • 0.5 mg IVP• Repeat every 3 to 5 minutes if indicated (Not to exceed a maximum

total dose of 3 mg)Adult Organophosphates, Carbamates, & Anticholinesterases (OLMC) • 1-2 mg IVP• If no response, double the previous dose every 5 to 10 minutes until

decreased bronchial secretions and improved ability to ventilate andoxygenate

Adult Beta Blockers and Calcium Channel Blockers (OLMC) • 0.5 mg IVP• Repeat every 5 minutes if indicated (Not to exceed a maximum total

dose of 3 mg)

185

ATROPINE Cont’d

PEDIATRIC DOSE

Pediatric Symptomatic Bradycardia • 0.02 mg/kg IV/IO (Minimum single dose 0.1 mg and not to exceed a

maximum single dose of 0.5 mg) if increased vagal tone or primary AVblock

• Repeat once in 5 minutes if indicatedPediatric Organophosphates, Carbamates, & Anticholinesterases (OLMC) AGE LESS THAN 12 YEARS

• 0.05 mg/kg IV/IOo Maximum single dose for children: 0.5 mg

• Repeat every 10 minutes until decreased bronchial secretions andimproved ability to ventilate and oxygenate

AGE GREATER THAN OR EQUAL TO 12 YEARS • 1-2 mg IV/IO• If no response, double the previous dose every 5 to 10 minutes until

decreased bronchial secretions and improved ability to ventilate andoxygenate

Pediatric Beta Blockers and Calcium Channel Blockers (OLMC)

AGE LESS THAN 12 YEARS • 0.02 mg/kg IV/IO (Not to exceed a maximum single dose of 0.5 mg)• Repeat once in 3 to 5 minutes if indicated (Not to exceed a maximum

total dose of 1 mg)AGE GREATER THAN OR EQUAL TO 12 YEARS • 0.5-1mg IV/IO• Repeat every 3 to 5 minutes if indicated (Not to exceed a maximum

total dose of 3 mg)

NOTES

• Atropine is unlikely to be effective in wide complex bradycardia or 3rd

degree AV block.• Atropine is contraindicated for patients with a history of heart transplant

as it is unlikely to be effective as a result of denervation of the heart.

186

CALCIUM CHLORIDE 10%

CLASS Electrolyte

INDICATIONS

Cardiac Arrest with Suspected Hyperkalemia (OLMC) Adult Beta Blockers and Calcium Channel Blockers (OLMC) Eclampsia with Suspected Magnesium Toxicity (OLMC) Pediatric Cardiac Arrest with Suspected Hyperkalemia (OLMC) Pediatric Beta Blockers and Calcium Channel Blockers (OLMC)

CONTRAINDICATIONS 1) Hypersensitivity2) Digoxin toxicity

ADULT DOSE

Adult Cardiac Arrest with Suspected Hyperkalemia (OLMC) • 1 g SIVP (Over 2 to 5 minutes)• Repeat once in 10 minutes if indicated

Adult Beta Blockers and Calcium Channel Blockers (OLMC) • 1 g SIVP (Over 10 minutes)• Repeat once in 10 minutes if indicated

Eclampsia with Suspected Magnesium Toxicity (OLMC)

• 1 g SIVP (Over 5 to 10 minutes)

PEDIATRIC DOSE

Pediatric Cardiac Arrest with Suspected Hyperkalemia (OLMC) • 20 mg/kg (0.2 mL/kg) SIVP/IO (Over 2 to 5 minutes)• Repeat once in 10 minutes if indicatedPediatric Beta Blockers and Calcium Channel Blockers (OLMC) • 10-20 mg/kg SIVP/IO (0.1-0.2 mL/kg) (Over 10 minutes)• Repeat once in 10 minutes if indicated (Not to exceed a maximum total

dose of 1000 mg)

NOTES • Extravasation may cause tissue necrosis.• Do not mix with sodium bicarbonate.

187

CHARCOAL

CLASS Antidote, Adsorbent

INDICATIONS Adult Specific Toxin Management (OLMC) Pediatric Specific Toxin Management (OLMC)

CONTRAINDICATIONS

1) Sedation or potential for sedation2) Altered LOC or uncooperative patient3) Inability to cough or swallow4) Greater than 60 minutes since ingestion5) Ingestion of petroleum or caustic based products6) Suspected intestinal obstruction7) Vomiting8) Risk of GI perforation or hemorrhage9) Ingestion of a substance that DOES NOT adsorb charcoal

SIDE EFFECTS • Vomiting

ADULT DOSE 1 g/kg PO

PEDIATRIC DOSE 1 g/kg PO

NOTES

• The patient must be cooperative and able to drink the charcoal.• Shake well before administration.• Advise patient to drink slowly to decrease the risk of vomiting.• Charcoal with cathartic agent (e.g.: sorbitol) included is not permitted

under protocol.

188

DEXTROSE

CLASS Caloric Agent

INDICATIONS Adult Symptomatic Hypoglycemia Pediatric Symptomatic Hypoglycemia

CONTRAINDICATIONS 1) Hypersensitivity to corn or corn products

PRECAUTIONS • Head injury or suspected stroke (Protocol modification)

o Administer half of the usual dose, recheck BGL within recommendedtime parameters, and then administer the second half dose ifindicated

ADULT DOSE • Dextrose 50% (D50%) 25 g (50 mL) IVP• Repeat once in 10 minutes if indicated

PEDIATRIC DOSE

WEIGHT LESS THAN 10 KG • Dextrose 10% (D10%) 5 mL/kg SIVP• Repeat once in 10 minutes if indicatedWEIGHT 10-20 KG

• Dextrose 25% (D25%) 2 mL/kg SIVP• Repeat once in 10 minutes if indicatedWEIGHT 20-40 KG • Dextrose 50% (D50%) 1 mL/kg SIVP [Not to exceed a maximum single

dose of 50 mL (25g)]• Repeat once in 10 minutes if indicatedWEIGHT GREATER THAN 40 KG • Dextrose 50% (D50%) 25 g (50 mL) IVP• Repeat once in 10 minutes if indicated

NOTES

• To create dextrose 10% (D10%):o Remove 40 mL from D50% preload syringe and replace with 40 mL

0.9% NaCl to yield a final concentration of 5 g of dextrose in 50 mL(D10%).

• To create dextrose 25% (D25%):o Remove 25 mL from D50% preload syringe and replace with 25 mL

0.9% NaCl to yield a final concentration of 12.5 g of dextrose in 50mL (D25%).

• Extravasation may cause tissue necrosis.• If you are unable to establish an IV, dextrose may be administered via

IO if an IO is being established for concurrent treatment of shock orother critical illness. An IO may be considered for primary managementof hypoglycemia if glucagon is ineffective, as a last resort, if prolongedtransport time.

189

DIMENHYDRINATE (GRAVOL) CLASS Antiemetic

INDICATIONS Adult Nausea and Vomiting Pediatric Nausea and Vomiting

CONTRAINDICATIONS

1) Hypersensitivity to dimenhyDRINATE, diphenhydrAMINE, or propyleneglycol

2) Narrow angle glaucoma3) Hypotension (SBP less than 100 mmHg in adults and less than age-

specific BP criteria in pediatrics)4) Altered LOC (Including alcohol or drug intoxication)

PRECAUTIONS

• Simultaneous administration with ipratropium bromide may causeenhanced anticholinergic effects

• Elderly patients may be more sensitive to adverse effects. Consideradministration of a lower dose in patients greater than 65 years of age

SIDE EFFECTS • Sedation• Hypotension• Paradoxical excitation in children

ADULT DOSE

• 25 – 50 mg IV• Repeat once in 15 minutes if indicated (Not to exceed a maximum total

dose of 50 mg)

May administer by IM route if indications are present AND you are unable to establish an IV

PEDIATRIC DOSE • 1 mg/kg IV (Not to exceed a maximum single dose of 25 mg)

NOTES • May cause stinging at the injection site.

190

DIPHENHYDRAMINE (BENADRYL) CLASS Antihistamine

INDICATIONS

Adult Allergy and Anaphylaxis Adult Extrapyramidal Signs and Symptoms (Post metoclopramide or olanzapine administration) Adult Antipsychotic-Induced Dystonic Reaction Pediatric Allergy and Anaphylaxis Pediatric Extrapyramidal Signs and Symptoms (Post metoclopramide administration) Pediatric Antipsychotic-Induced Dystonic Reaction

CONTRAINDICATIONS 1) Hypersensitivity to dimenhyDRINATE or diphenhydrAMINE2) Narrow angle glaucoma

SIDE EFFECTS • Sedation• Hypotension• Paradoxical excitation in children

ADULT DOSE

Adult Anaphylaxis • 50 mg IVP

May administer 50 mg IM if indications are present AND you are unable to establish an IV Adult Isolated Hives

• 25-50 mg IV/IMAdult Extrapyramidal Signs and Symptoms (Post metoclopramide or olanzapine administration) • 50 mg IVP

Adult Antipsychotic-Induced Dystonic Reaction

• 50 mg IV/IM

PEDIATRIC DOSE

Pediatric Anaphylaxis • 1 mg/kg IV (Not to exceed a maximum single dose of 50 mg)

May administer 1 mg/kg IM (Not to exceed a maximum single dose of 50 mg) if indications are present AND you are unable to establish an IV Pediatric Isolated Hives

• 1 mg/kg PO (Not to exceed a maximum single dose of 50 mg)Pediatric Extrapyramidal Signs and Symptoms (Post metoclopramide or olanzapine administration) • 1 mg/kg IV (Not to exceed a maximum single dose of 50 mg)

Pediatric Antipsychotic-Induced Dystonic Reaction

• 1 mg/kg IV/IM (Not to exceed a maximum single dose of 50 mg)

191

DOPAMINE

CLASS Sympathomimetic

INDICATIONS

Adult Allergy and Anaphylaxis (OLMC) Adult Shock (OLMC) Adult Sepsis (OLMC) Adult Cardiogenic Shock (OLMC) Adult Symptomatic Bradycardia (With Pulse) Adult Tricyclic Antidepressants (OLMC) Pediatric Allergy and Anaphylaxis (OLMC) Pediatric Shock (OLMC) Pediatric Septic Shock (OLMC) Pediatric Tricyclic Antidepressants (OLMC)

CONTRAINDICATIONS

1) Hypersensitivity to bisulfites2) Tachydysrhythmias3) Pheochromocytoma4) Pregnancy

PRECAUTIONS • Tachycardia• Hypovolemia• Myocardial ischemia or infarction

SIDE EFFECTS

• Tachycardia• Cardiac ectopy• Hypotension• Headache• Nausea and/or vomiting

ADULT DOSE

ALL INDICATIONS • 5 mcg/kg/min• Titrate by 5 mcg/kg/min, every 5 to 10 minutes, up to a maximum of 20

mcg/kg/min until MAP greater than 65 mmHg

PEDIATRIC DOSE

ALL INDICATIONS

• 5 mcg/kg/minTitrate by 5 mcg/kg/min, every 5 to 10 minutes, up to a maximum of 20mcg/kg/min until age-specific hypotension resolved (Pg168)

NOTES • Extravasation may cause tissue necrosis.• See Pg 192 for dopamine infusion instructions

192

DOPAMINE INFUSION TABLE

Pre-Mixed Dopamine (400 mg/250 mL=1600 mcg/mL) Drip Rates Using Micro-Drip (60 gtts/mL)

Target Infusion Rate 5 mcg/kg/min 10 mcg/kg/min 15 mcg/kg/min 20 mcg/kg/min

Weight (Kg) DRIP RATE TO BE ADMINISTERED (GTTS/MIN)

40 8 16 22 30

50 10 18 28 38

60 12 22 34 46

70 14 26 40 52

80 16 30 46 60

90 16 34 50 68

100 18 38 56 76

110 20 42 62 82

120 22 46 68 90

130 24 48 74 98

140 26 52 78 106

150 28 56 84 112

160 30 60 90 120

170 32 64 96 128

180 34 68 102 136

NOTES

• Drip rates have been rounded to the nearest even number for ease ofadministration.

• Drip rates contained in this table are ONLY correct when using pre-mixed dopamine (400 mg/250 mL) administered using a 60 drop set(60 gtts/mL).

193

EPINEPHRINE 1:1000


INDICATIONS

Adult Respiratory Distress With Bronchospasm Adult Allergy and Anaphylaxis Pediatric Respiratory Distress with Bronchospasm Pediatric Respiratory Distress with Inspiratory Stridor Pediatric Allergy and Anaphylaxis Pediatric Cardiac Arrest Pediatric Bradycardia (With Pulse)

RELATIVE CONTRAINDICATIONS

1) Cardiac ischemia or infarction2) Tachydysrhythmias (Greater than 150 beats per minute in adults and

180 beats per minute in pediatrics)

PRECAUTIONS • Cardiac dysrhythmias• Cardiac valvular abnormalities

ADULT DOSE

Adult Respiratory Distress With Bronchospasm

• 0.3 mg IM

Adult Anaphylaxis

• 0.3 mg IM• Repeat once in 5 minutes if no improvement

194

EPINEPHRINE 1:1000 Cont’d

PEDIATRIC DOSE

Pediatric Respiratory Distress with Bronchospasm • 0.01 mg/kg (0.01 mL/kg) IM [Not to exceed a maximum single dose of

0.3 mg (0.3 mL)]Pediatric Respiratory Distress with Inspiratory Stridor

AGE LESS THAN 1 YEAR AND LESS THAN 5 KG

• 0.5 mg (0.5 mL) in 2 mL 0.9% NaCl nebulized

AGE LESS THAN 1 YEAR AND GREATER THAN OR EQUAL TO 5 KG

• 2.5 mg (2.5 mL) nebulized

AGE GREATER THAN OR EQUAL TO 1 YEAR

• 5 mg (5 mL) nebulized

Pediatric Anaphylaxis • 0.01 mg/kg (0.01 mL/kg) IM [Not to exceed a maximum single dose of

0.3 mg (0.3 mL)]• Repeat once in 5 minutes if no improvementPediatric Cardiac Arrest • 0.1 mg/kg (0.1 mL/kg) ETT [Not to exceed a maximum single dose of

2.5 mg (2.5 mL)]• Repeat every 3 to 5 minutes if indicatedPediatric Bradycardia (With Pulse) • 0.1 mg/kg (0.1 mL/kg) ETT [Not to exceed a maximum single dose of

2.5 mg (2.5 mL)]

NOTES

• Epinephrine 1:1000 is never to be given as a bolus via IV/IO route.• When administered via ETT, epinephrine 1:1000 must be followed by

5 mL flush of 0.9% NaCl and 5 consecutive positive pressureventilations.

195

EPINEPHRINE 1:10 000


INDICATIONS

Adult Allergy and Anaphylaxis (OLMC) Adult Cardiac Arrest Pediatric Allergy and Anaphylaxis (OLMC) Pediatric Cardiac Arrest Pediatric Bradycardia (With Pulse) Neonatal Resuscitation

RELATIVE CONTRAINDICATIONS

1) Cardiac ischemia or infarction2) Tachydysrhythmias (Greater than 150 beats per minute in adults and

180 beats per minute in pediatrics)

PRECAUTIONS • Cardiac dysrhythmias• Cardiac valvular abnormalities

ADULT DOSE

Adult Anaphylaxis (OLMC) • 0.1 mg (1 mL) in 100 mL NaCl 0.9% over 5 minutes

o Add 0.1 mg (1 mL) epinephrine 1:10 000 to 100 mL NaCl 0.9% andinfuse total volume of epinephrine admixture rapidly over 5 minutes.

o Using 10 drop set (10 gtts/mL) deliver the total volume of theadmixture (100 mL) at a drip rate of 3 gtts/second

• Repeat every 5 to 15 minutes if indicated [Not to exceed a maximumtotal dose of 1 mg (10 mL)]

Adult Cardiac Arrest • 1 mg IVP/IO• Repeat every 3 to 5 minutes if indicated

PEDIATRIC DOSE

Pediatric Anaphylaxis (OLMC) • 0.01 mg/kg (0.1 mL/kg) SIVP/IO (Over 5 minutes) [Not to exceed a

maximum single dose of 0.1 mg (1 mL)]• Repeat every 5 to 15 minutes if indicated [Not to exceed a maximum

total dose of 1 mg (10 mL)]Pediatric Cardiac Arrest • 0.01 mg/kg IV/IO (0.1 mL/kg) [Not to exceed a maximum single dose of

1 mg (10 mL)]• Repeat every 3 to 5 minutes if indicatedPediatric Bradycardia (With Pulse) • 0.01 mg/kg IV/IO (0.1 mL/kg) [Not to exceed a maximum single dose of

1 mg (10 mL)]Neonatal Resuscitation

• 0.01 mg/kg IV/IO (0.1 mL/kg)• Repeat every 3 to 5 minutes if indicated

196

FENTANYL

CLASS Opioid Analgesic

INDICATIONS

Adult Ischemic Chest Pain Adult Pain Management Adult Procedural Sedation Post Intubation Management Pediatric Pain Management Pediatric Procedural Sedation

CONTRAINDICATIONS

1) Hypersensitivity2) Monoamine oxidase inhibitor (MAO) therapy within the last 14 days3) Altered LOC if no advanced airway in place4) Hypotension (SBP less than 100 mmHg in adults and less than age-specific

BP criteria in pediatrics)

PRECAUTIONS

• Active pulmonary disease (e.g.: COPD, asthma, etc.)• Head trauma• Suspected right ventricular myocardial infarction or ischemia (OLMC)• Myasthenia gravis• Elderly patients may be more sensitive to adverse effects. Consider

administration of a lower dose in patients over the age of 65

SIDE EFFECTS

• Sedation• Hypotension• Bradycardia• Nausea and vomiting• Respiratory depression• Chest wall rigidity (Rare)

ADULT DOSE

Adult Ischemic Chest Pain

• 25-50 mcg IV• Repeat every 5 minutes if indicated until reasonable control of pain (Not to

exceed a maximum total dose of 300 mcg)Adult Post Intubation Management

• 1 mcg/kg SIVP/IO

• Repeat every 5 to 10 minutes if indicatedAdult Pain Management

• 25-50 mcg IV• Repeat every 5 minutes if indicated until reasonable control of pain (Not to

exceed a maximum total dose of 300 mcg)

• May administer 50-100 mcg IN if severe pain AND you are unable to establishan IV (OLMC)

Adult Procedural Sedation

• 25-50 mcg IV• Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum total

dose of 300 mcg)

197

FENTANYL Cont’d

PEDIATRIC DOSE

Pediatric Post Intubation Management

• 1 mcg/kg SIVP/IO (not to exceed a single maximum dose of 200 mcg)• Repeat every 5 to 10 minutes if indicatedPediatric Pain Management • 1 mcg/kg IV (Not to exceed a maximum single dose of 25 mcg)• Repeat every 15 minutes if indicated until reasonable control of pain

(Not to exceed a maximum total dose of 50 mcg)

May administer 1.5 mcg/kg IN or by alternate route of administration if severe pain AND you are unable to establish an IV (OLMC) Pediatric Procedural Sedation • 1 mcg/kg IV (Not to exceed a maximum single dose of 25 mcg)• Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum

total dose of 50 mcg)

FUROSEMIDE

CLASS Diuretic

INDICATIONS Adult Pulmonary Edema

CONTRAINDICATIONS

1) Hypersensitivity or sulfonamide allergy2) Hypotension (SBP less than 100 mmHg in adults)3) Suspected right ventricular myocardial infarction or ischemia4) Anuria5) Suspected sepsis6) Fever7) Pregnancy

SIDE EFFECTS • Hypotension

ADULT DOSE • 40 mg SIVP

198

GLUCAGON

CLASS Hyperglycemic Agent

INDICATIONS

Adult Symptomatic Hypoglycemia Adult Beta Blockers and Calcium Channel Blockers (OLMC) Pediatric Symptomatic Hypoglycemia Pediatric Beta Blockers and Calcium Channel Blockers (OLMC)

CONTRAINDICATIONS 1) Hypersensitivity to glucagon, glycerin, or phenol2) Anaphylaxis to lactose3) Pheochromocytoma

PRECAUTIONS • Glycogen depleted state (Starvation, chronic hypoglycemia, alcoholism)• Adrenal insufficiency• Insulinoma

SIDE EFFECTS • Nausea and vomiting• Hypertension and hypotension• Tachycardia

ADULT DOSE

Adult Symptomatic Hypoglycemia • 1 mg IM• Repeat once in 20 minutes if indicated

Adult Beta Blockers and Calcium Channel Blockers (OLMC)

• 5 mg SIVP (Over 1 to 2 minutes)

PEDIATRIC DOSE

Pediatric Symptomatic Hypoglycemia

LESS THAN 20 KG • 0.5 mg IM• Repeat once in 20 minutes if indicatedGREATER THAN 20 KG • 1 mg IM• Repeat once in 20 minutes if indicatedPediatric Beta Blockers and Calcium Channel Blockers (OLMC) • 0.1 mg/kg SIVP/IO (Over 1 to 2 minutes) (Not to exceed a maximum

total dose of 5 mg) (Administer at a maximum rate of 1 mg/minute)

NOTES

• Glucagon is unlikely to be effective in glycogen depleted states asglucagon requires sufficient storage of glycogen in the liver to beeffective.

• Inject the content of the pre-loaded syringe into the bottle of powderedglucagon and swirl to mix contents until all of the glucagon is dissolved.The resultant solution should be clear.

• Response to glucagon is not immediate; anticipate that it may take upto 20 minutes to see an effect.

199

GLUCOSE (ORAL) CLASS Caloric Agent

INDICATIONS Adult Symptomatic Hypoglycemia Pediatric Symptomatic Hypoglycemia

CONTRAINDICATIONS 1) Depressed mental status2) Unable to cough or swallow

ADULT DOSE

ONE of the following options: 1) Dex 4® tablets 20 g (5 tablets)2) Insta-glucose® 1 tube (30 g)3) 1 cup of juice or pop (Non-diet)4) 4 teaspoons (20 mL) or 4 packets of table sugar dissolved in water

PEDIATRIC DOSE

ONE of the following options: 1) Dex 4® tablets 20 g (5 tablets)2) Insta-glucose® 1 tube (30 g)3) 1 cup of juice or pop (Non-diet)4) 4 teaspoons (20 mL) or 4 packets of table sugar dissolved in water

200

HYDROCORTISONE

CLASS Corticosteroid

INDICATIONS

Adult Respiratory Distress with Bronchospasm (OLMC) Adult Adrenal Insufficiency Pediatric Respiratory Distress with Bronchospasm (OLMC) Pediatric Adrenal Insufficiency

CONTRAINDICATIONS 1) Hypersensitivity to hydrocortisone or other corticosteroids2) Systemic fungal infections (precaution during adrenal crisis)

PRECAUTIONS

• History of seizure• Peptic ulceration or inflammatory bowel disease• Diabetes (monitor blood glucose levels)• Hypertension• Renal insufficiency• Tuberculosis• Chronic psychosis• Ocular herpes simplex

SIDE EFFECTS • Hypertension• Agitation• Headache and/or vertigo

ADULT DOSE

Adult Respiratory Distress With Bronchospasm (OLMC)

• 100 mg SIVP (OLMC)

Adult Adrenal Insufficiency

• 100 mg IV/IM

PEDIATRIC DOSE

Pediatric Respiratory Distress With Bronchospasm (OLMC)

• 1 mg/kg SIVP (OLMC)

Pediatric Adrenal Insufficiency

AGE LESS THAN 3 YEARS

• 25 mg IV/IM

AGE 3 TO 10 YEARS

• 50 mg IV/IM

GREATER THAN 10 YEARS

• 100 mg IV/IM

201

IPRATROPIUM BROMIDE

CLASS Anticholinergic

INDICATIONS Adult Respiratory Distress With Bronchospasm Pediatric Respiratory Distress With Bronchospasm

CONTRAINDICATIONS 1) Hypersensitivity to ipratropium bromide, atropinics, or aerosol

components2) Cardiac ischemia or infarction

PRECAUTIONS • Narrow angle glaucoma• Myasthenia Gravis

ADULT DOSE

• 4-8 puffs (20 mcg/puff) via MDI with aerochamberOR

• 500 mcg nebulized

• Repeat every 5 minutes if indicated (Not to exceed a maximum total of3 administrations)

PEDIATRIC DOSE

• 3 puffs (20 mcg/puff) via MDI with aerochamberOR

• 500 mcg nebulized

• To be administered with 2nd and 3rd dose of salbutamol if indicated• Repeat every 5 minutes if indicated (Not to exceed a maximum total of

2 administrations)

NOTES

• Patients should be treated with MDI and aerochamber unless it isdeemed inappropriate, ineffective, or patient cannot tolerate.

• Each puff administered via MDI with aerochamber must be followed byat least 4 breaths.

• May be administered through an MDI adapter attached to a BVM.• Avoid contact with eyes. Ensure nebulizer mask is fitted well to the

patient’s face to minimize risk of mist getting into the eyes.• MDI must be primed by pressing downwards on the actuator a

minimum of four times. Prime MDI outside of aerochamber.• Hold pump in an upright position to ensure proper function.• This is a single patient use medication only.

202

KETOROLAC CLASS NSAID

INDICATIONS Adult Pain Management

CONTRAINDICATIONS

1) Hypersensitivity to ASA or NSAIDS2) Active bronchospasm or history of severe asthma with bronchospasm

related to ASA or NSAIDS3) History of active bleeding or bleeding disorder4) History of CVA or cardiovascular disease5) Renal or hepatic insufficiency6) Peptic ulcer or inflammatory bowel disease7) NSAID use, including aspirin, in previous 6 hours8) Age less than 16 years or greater than 65 years9) Known or suspected hyperkalemia10) Pregnancy

PRECAUTIONS • Hypertension

SIDE EFFECTS

• Headache• Edema• GI bleeding• Hypertension

• Nausea, abdominal pain and/or dyspepsia• Drowsiness• Dizziness• Rash

ADULT DOSE • 15 mg SIVP/IM

203

LIDOCAINE SPRAY 10% (10 MG/SPRAY) CLASS Topical Anesthetic

INDICATIONS Topical Airway Anesthesia

CONTRAINDICATIONS 1) Hypersensitivity to local anesthetics2) Age less than 2 years

PRECAUTIONS • Bradycardia• Impaired cardiovascular function or shock

ADULT DOSE • Up to 20 sprays (Not to exceed a maximum total dose of 5 mg/kg)• Reduce dose by half if age greater than 65 years

PEDIATRIC DOSE • Up to 10 sprays (Not to exceed a maximum total dose of 5 mg/kg)

NOTES

• When using the spray for the first time, attach the nozzle and prime thepump by pressing down on the actuator 5 to 10 times. Hold the pumpin an upright position to ensure proper function.

• Nozzle must not be reused and should be discarded immediately afteruse.

• Excessive administration may result in systemic absorption and toxicity.The lowest dose that results in effective anesthesia should be used toavoid high plasma levels and serious adverse effects.

• Avoid contact with the eyes.

204

MAGNESIUM SULFATE

CLASS Electrolyte Replacement, Antidysrhythmic

INDICATIONS

Adult Respiratory Distress With Bronchospasm Adult Cardiac Arrest and Pulseless Torsades De Pointes Adult Tricyclic Antidepressants (OLMC) Adult Eclampsia Pediatric Respiratory Distress With Bronchospasm Pediatric Cardiac Arrest and Pulseless Torsades De Pointes Pediatric Tricyclic Antidepressants (OLMC)

CONTRAINDICATIONS 1) Hypersensitivity2) Any degree of heart block

PRECAUTIONS

• Myasthenia Gravis• Impaired renal function (except in patient without pulse)• Concurrent use of digoxin• Hypotension (SBP less than 100 mmHg in adults and less than age-

specific BP criteria in pediatrics)

SIDE EFFECTS • Respiratory depression• Heart block• Hypotension

ADULT DOSE

Adult Respiratory Distress with Bronchospasm (severe or refractory asthma or COPD only) • 2 g IV in 100 mL 0.9% NaCl by infusion over 20 minutes• See Pg 206 for magnesium infusion instructionsAdult Cardiac Arrest and Pulseless Torsades De Pointes

• 2 g diluted in 10 mL 0.9% NaCl IVP/IO

Adult Tricyclic Antidepressants With Prolonged QTc (OLMC) • 1 g IV in 100 mL 0.9% NaCl by infusion over 20 minutes• See Pg 206 for magnesium infusion instructionsAdult Eclampsia With Active Seizure

• 4 g IV in 100 mL 0.9% NaCl by infusion over 5 minutes• OLMC contact required for repeat administration• See Pg 206 for magnesium infusion instructionsAdult Eclampsia – Postictal (OLMC) • 4 g IV in 100 mL 0.9% NaCl by infusion over 20 minutes• See Pg 206 for magnesium infusion instructions

205

MAGNESIUM SULFATE Cont’d

PEDIATRIC DOSE

Pediatric Respiratory Distress with Bronchospasm (severe or refractory asthma only) • 25 mg/kg IV [(Not to exceed a maximum single dose of 2 g (2000 mg)]

by infusion over 20 minutes• See Pg 206 for magnesium infusion instructionsPediatric Cardiac Arrest With Torsades De Pointes

• 25-50 mg/kg [(Not to exceed a maximum single dose of 2 g (2000 mg)]diluted in 10 mL 0.9% NaCl IVP/IO

Pediatric Tricyclic Antidepressants With Prolonged QTc (OLMC) • 25 mg/kg IV [(Not to exceed a maximum single dose of 1 g (1000 mg)]

by infusion over 20 minutes• See Pg 206 for magnesium infusion instructions

206

MAGNESIUM INFUSIONS

ADULT INFUSIONS

Adult Respiratory Distress with Bronchospasm (severe or refractory asthma or COPD only) Admixture Instructions: • Add magnesium sulfate 2 g to 100 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (100 mL) over 20

minutes• Using 10 drop set (10 gtts/mL) deliver the total volume of the admixture

(100 mL) at a drip rate of 50 gtts/minuteAdult Tricyclic Antidepressants With Prolonged QTc (OLMC) Admixture Instructions: • Add magnesium sulfate 1 g to 100 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (100 mL) over 20


(100 mL) at a drip rate of 50 gtts/minute Adult Eclampsia With Active Seizure Admixture Instructions: • Add magnesium sulfate 4 g to 100 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (100 mL) rapidly

over 5 minutes• Using 10 drop set (10 gtts/mL) deliver the total volume of the admixture

(100 mL) at a drip rate of 3 gtts/secondAdult Eclampsia – Postictal (OLMC) Admixture Instructions: • Add magnesium sulfate 4 g to 100 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (100 mL) over 20


(100 mL) at a drip rate of 50 gtts/minute

207

MAGNESIUM INFUSIONS Cont’d

PEDIATRIC INFUSIONS

Pediatric Respiratory Distress with Bronchospasm (severe or refractory asthma only) LESS THAN 10 KG Admixture Instructions: • Add magnesium sulfate 25 mg/kg to a 50 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (50 mL) over 20


(50 mL) at a drip rate of 25 gtts/minuteGREATER THAN 10 KG Admixture Instructions: • Add magnesium sulfate 25 mg/kg [(Not to exceed a maximum single

dose of 2 g (2000 mg)] to a 100 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (100 mL) over 20


(50 mL) at a drip rate of 50 gtts/minute Pediatric Tricyclic Antidepressants With Prolonged QTc (OLMC)

LESS THAN 10 KG Admixture Instructions: • Add magnesium sulfate 25 mg/kg to a 50 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (50 mL) over 20


(50 mL) at a drip rate of 25 gtts/minuteGREATER THAN 10 KG Admixture Instructions: • Add magnesium sulfate 25 mg/kg [(Not to exceed a maximum single

dose of 1 g (1000 mg)] to a 100 mL bag of 0.9% NaClInfusion Instructions • Infuse total volume of magnesium sulfate admixture (100 mL) over 20


(50 mL) at a drip rate of 50 gtts/minute

208

METOCLOPRAMIDE

CLASS Antiemetic

INDICATIONS Adult Nausea and Vomiting Adult Nausea and Vomiting (Migraine) Pediatric Nausea and Vomiting

CONTRAINDICATIONS

1) Hypersensitivity to metoclopramide or procainamide2) Hypotension (SBP less than 100 mmHg in adults and less than age-

specific BP criteria in pediatrics)3) Pheochromocytoma4) Suspected GI hemorrhage, bowel obstruction or perforation5) Seizure disorders6) Monoamine oxidase inhibitor (MAO) therapy within the last 14 days7) Concurrent use of antipsychotic medications

PRECAUTIONS

• Parkinson’s Disease• Altered LOC (Including alcohol or drug intoxication)• Elderly patients may be more sensitive to adverse effects. Consider

administration of a lower dose in patients greater than 65 years of age

SIDE EFFECTS

• Sedation• Hypotension or hypertension• Bronchospasm• Bradycardia• Tachycardia• Extrapyramidal signs and symptoms

ADULT DOSE

Adult Nausea and Vomiting

• 10 mg SIVP (Over 2 to 5 minutes)o May administer 10 mg IM if indications are present AND you are

unable to establish an IV

Adult Pain Management (Migraine)

• 10 mg SIVP (Over 2 to 5 minutes)o May administer 10 mg IM if indications are present AND you are

unable to establish an IV

PEDIATRIC DOSE • 0.1 mg/kg SIVP (Over 2 to 5 minutes) (Not to exceed a maximum singledose of 10 mg)

NOTES

• Risk of development of extrapyramidal symptoms is reduced ifmetoclopramide is administered slowly when using an IV route.

• If extrapyramidal signs and symptoms develop, reassure the patientand administer diphenhydrAMINE as per protocol.

209

MIDAZOLAM CLASS Benzodiazepine

INDICATIONS

Endotracheal Intubation, Airway Pharmacology Adult Post Intubation Management Adult Convulsive Seizure Adult Procedural Sedation Adult Agitated / Combative Adult Alcohol Withdrawal Adult Cocaine or Sympathomimetics (OLMC) Pediatric Post Intubation Management Pediatric Convulsive Seizure Pediatric Procedural Sedation Pediatric Agitated / Combative Pediatric Cocaine or Sympathomimetics (OLMC)

CONTRAINDICATIONS

1) Hypersensitivity to benzodiazepines2) Hypotension (SBP less than 100 mmHg in adults and less than age-

specific BP criteria in pediatrics) 3) Acute narrow angle glaucoma4) Myasthenia Gravis

PRECAUTIONS • Elderly patients may be more sensitive to adverse effects. Consideradministration of a lower dose in patients over the age of 65

SIDE EFFECTS

• Sedation• Hypotension• Respiratory depression• Nausea and vomiting• Amnesia• May cause paradoxical excitation in pediatric, psychiatric, or elderly

patients

210

MIDAZOLAM Cont’d

ADULT DOSE

Adult Endotracheal Intubation, Airway Pharmacology

• 2.5 mg SIVP/IO• Consider reduced dose in patients over age 65Adult Post Intubation Management • 1-2 mg SIVP/IO• Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum

total dose of 10 mg without OLMC direction)Adult Convulsive Seizure • 5 mg IV• Repeat once in 5 minutes if seizure continues or recurs

OR• 5 mg IN if unable to establish IV access• Repeat once in 5 minutes if seizure continues or recurs

OR• 10 mg IM if unable to establish IV access AND contraindications to

intranasal administration are present• Repeat once in 15 minutes if seizure continues or recursAdult Procedural Sedation

• 1-2 mg SIVP/IO• Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum

total dose of 10 mg)Adult Agitated / Combative

• 2.5-5 mg SIVP• Repeat every 5 minutes if indicated until reasonable cooperativeness is

achieved (Not to exceed a maximum total dose of 10 mg)OR

• 5-10 mg IM/IN if unable to establish an IV• Repeat every 15 minutes if indicated until reasonable cooperativeness

is achieved (Not to exceed a maximum total dose of 10 mg)Adult Alcohol Withdrawal AND Adult Cocaine or Sympathomimetics (OLMC) • 2.5-5 mg SIVP• Repeat every 5 minutes if indicated (Not to exceed a maximum total

dose of 10 mg unless otherwise directed by OLMC)

211

MIDAZOLAM Cont’d

PEDIATRIC DOSE

Pediatric Endotracheal Intubation, Airway Pharmacology

• 0.05 mg/kg SIVP/IO to a maximum of 2.5 mg

Pediatric Post Intubation Management

• 0.05-0.1 mg/kg SIVP/IO (Not to exceed a maximum single dose of 2 mg)• Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum total dose

of 5 mg without OLMC direction)

Pediatric Convulsive Seizure

• 0.1 mg/kg IV (Not to exceed a maximum single dose of 5 mg)• Repeat once in 5 minutes if seizure continues or recurs

OR• 0.2 mg/kg IN (Not to exceed a maximum single dose of 5 mg) if unable to

establish IV access• Repeat once in 5 minutes if seizure continues or recurs

OR• 0.2 mg/kg PR (Not to exceed a maximum single dose of 5 mg) if unable to

establish IV access AND contraindications to IN administration present• Repeat once in 15 minutes if seizure continues or recurs

Pediatric Procedural Sedation

• 0.05-0.1 mg/kg SIVP/IO (Not to exceed a maximum single dose of 2 mg)• Repeat every 5 to 10 minutes if indicated (Not to exceed a maximum total dose

of 5 mg)

Pediatric Agitated / Combative

• 0.1 mg/kg SIVP (Not to exceed a maximum single dose of 2 mg)Repeat every 5 minutes if indicated until reasonable cooperativeness isachieved (Not to exceed a maximum total dose of 5mg)OR

• 0.2 mg/kg IM (Not to exceed a maximum single dose of 5 mg) if unable toestablish IV access

• Repeat every 15 minutes if indicated until reasonable cooperativeness isachieved (Not to exceed a maximum total dose of 5mg)

Pediatric Cocaine or Sympathomimetics (OLMC)

• 0.1 mg/kg SIVP (Not to exceed a maximum single dose of 2.5 mg)• Repeat every 5 minutes if indicated (Not to exceed a maximum total dose of 5

mg without OLMC direction)

NOTES

• Midazolam should only be administered while the patient is actively seizing.Never administer midazolam in anticipation of seizure or if the seizure hassubsided.

• Midazolam may be administered using the IV dose via IO if an IO is establishedfor concurrent treatment of shock.

• Severe alcohol withdrawal may require large doses of midazolam. ContactOLMC if additional midazolam is required.

• Avoid rapid IV administration in neonates.

212

NALOXONE HYDROCHLORIDE CLASS Opioid antagonist

INDICATIONS

Adult Cardiac Arrest Adult Opioids Pediatric Cardiac Arrest Pediatric Opioids

CONTRAINDICATIONS 1) Hypersensitivity

SIDE EFFECTS • Acute opioid withdrawal

ADULT DOSE

Adult Cardiac Arrest (suspected or confirmed opioid ingestion)

• 6 mg IV/IOAdult Opioids • 0.2-0.5 mg IV/IM• Repeat every 2-3 minutes if indicated, titrated to improved respiratory

drive• In opioid dependent patients start with a lower dose of naloxone

(0.05 – 0.1 mg IV/IM) to avoid precipitating acute withdrawal andtitrate to sufficient respiratory driveo Draw up 1mg (1mL) of a 1mg/mL solution into a 10 mL syringe. Add

9mL of 0.9% NaCl to create a 0.1 mg/mL solution.OR • 2mg IN in each nare of a 2mg/mL solution• Repeat every 2-3 minutes if indicated, titrated to improved respiratory

drive

PEDIATRIC DOSE

Pediatric Cardiac Arrest (suspected or confirmed opioid ingestion)

• 6 mg IV/IOPediatric Opioids

• 0.2-0.5 mg IV/IM• Repeat every 2-3 minutes if indicated, titrated to improved respiratory

drive (Not to exceed a maximum total dose of 5 mg)• In opioid dependent patients start with a lower dose of naloxone

(0.05 – 0.1 mg IV/IM) to avoid precipitating acute withdrawal andtitrate to sufficient respiratory driveo Draw up 1mg (1mL) of a 1mg/mL solution into a 10 mL syringe. Add

9mL of 0.9% NaCl to create a 0.1 mg/mL solution.OR • 2mg IN in each nare of a 2mg/mL solution• Repeat every 2-3 minutes if indicated, titrated to improved respiratory

drive (Not to exceed a maximum total dose of 10 mg)

213

NALOXONE HYDROCHLORIDE Cont’d

NOTES

• IV route is preferred for pre-hospital naloxone administration. IN routeis not considered first line therapy and should only be considered ifunable to establish IV access. IN route is unlikely to be effectivewithout spontaneous respirations.

• Naloxone hydrochloride is light sensitive. If naloxone hydrochloride iscontained in a glass ampoule it must be protected from light duringstorage.

• The duration of action of the opioid may be longer than the duration ofaction of naloxone and repeat administration of naloxone may berequired if respiratory depression recurs.

• Be alert for potential acute agitation or combativeness followingadministration of naloxone to patients with opioid dependency. Titratedose only to improve respiratory drive.

• Examples of shorter acting opioids include, but are not limited to:fentanyl, hydromorphone (Dilaudid), morphine (Morphine-IR),meperidine (Demerol), codeine, heroin, sufentanyl, Darvon, oxycodone.

• Examples of longer acting opioids include, but are not limited to:methadone, MS-Contin, OxyNEO, OxyContin, Hydromorph-Contin,morphine-SR.

214

NITROGLYCERIN CLASS Antianginal Agent, Vasodilator

INDICATIONS Adult Ischemic Chest Pain Adult Pulmonary Edema

CONTRAINDICATIONS

1) Hypersensitivity to nitrates2) Hypotension (SBP less than 100 mmHg in adults)3) Heart rate less than 50 or greater than 150 beats per minute4) Suspected right ventricular myocardial infarction or ischemia5) Concurrent use of phosphodiesterase inhibitor(s) (Erectile dysfunction

medication) within preceding 48 hours6) Altered LOC

PRECAUTIONS • Hypertrophic cardiomyopathy

SIDE EFFECTS • Hypotension• Headache• Dizziness

ADULT DOSE

Adult Pulmonary Edema

SBP GREATER THAN 140 MMHG • 0.8 mg SL• Repeat every 5 minutes if indicatedSBP GREATER THAN 100 MMHG AND LESS THAN 140 MMHG

• 0.4 mg SL• Repeat every 5 minutes if indicatedAdult Ischemic Chest Pain

• 0.4 mg SL• Repeat every 5 minutes if indicated until chest pain resolved or SBP

less than 100 mmHg

NOTES

• Blood pressure must be monitored and recorded before and after eachadministration

• The patient should be sitting or lying prior to administration• Prime the pump by depressing down on the actuator, discarding the

first spray away from the patient • Hold the pump in an upright position to ensure proper function• This is a single use medication only• Phosphodiesterase inhibitors include, but are not limited to: sildenafil

(Viagra), tadalafil (Cialis), vardenafil (Levitra)

215

OLANZAPINE CLASS Antipsychotic

INDICATIONS Adult Agitated / Combative

CONTRAINDICATIONS

1) Hypersensitivity2) Hypotension (SBP less than 100 mmHg in adults)3) Sedation4) Age greater than 65 years AND history of dementia

PRECAUTIONS • Seizure history

SIDE EFFECTS

• Somnolence• Headache• Dizziness• Extra-pyramidal signs and symptoms

ADULT DOSE • 10 mg PO (wafer)

NOTES • If extrapyramidal signs and symptoms develop, reassure the patientand administer diphenhydrAMINE as per protocol

216

OXYTOCIN CLASS Oxytocic Agent

INDICATIONS Childbirth Post-Partum Hemorrhage (OLMC)

CONTRAINDICATIONS 1) Hypersensitivity2) Uterine inversion3) Fetus not yet delivered

SIDE EFFECTS

• Hypertension or hypotension• Nausea and vomiting• Dysrhythmias• Anxiety• Tetanic contraction of the uterus• Uterine rupture

ADULT DOSE

Childbirth

• 10 units IM upon delivery of the fetus

Post-Partum Hemorrhage (OLMC) Admixture Instructions: • Add oxytocin 20 units to a 1000 mL bag of 0.9% NaClInfusion Instructions • Infuse 500 ml of oxytocin admixture as a bolus• Infuse remaining 500 mL of oxytocin admixture (500 mL) over 2 hours• Using 10 drop set (10 gtts/mL) deliver the remaining volume of the

admixture (500 mL) at a drip rate of 42 gtts/minute (10 gtts/15 seconds)

NOTES

• Ensure complete delivery of the fetus prior to administration.• Be aware of the potential for unpredicted multiple gestation. Do not

administer until delivery of the fetuses is complete. • Oxytocin is considered a hazardous material. Use appropriate

guidelines for handling and disposal.

217

SALBUTAMOL

CLASS Beta2 Agonist

INDICATIONS

Adult Respiratory Distress With Bronchospasm Adult Allergy and Anaphylaxis Pediatric Respiratory Distress With Bronchospasm Pediatric Allergy and Anaphylaxis

CONTRAINDICATIONS

1) Hypersensitivity2) Cardiac ischemia or infarction3) Tachydysrhythmias (Heart rate greater than 150 in adults, and greater

than 180 in pediatrics)

PRECAUTIONS • Cardiovascular disorders (Cardiac dysrhythmias, valvular heartdisease)

SIDE EFFECTS

• Tachydysrhythmias• Hypertension and hypotension• Restlessness• Dizziness• Drowsiness• Headache• Nausea and vomiting• Dry mouth

ADULT DOSE

• 4-8 puffs (100 mcg/puff) via MDI with aerochamberOR

• 5 mg nebulized• Repeat every 5 minutes if indicated (Not to exceed a total of 3

administrations)• If severe respiratory distress, there is no maximum number of

salbutamol administrations

PEDIATRIC DOSE

AGE LESS THAN 5 YEARS • 5 puffs (100 mcg/puff) via MDI with aerochamber

OR• 2.5 mg nebulized

• Repeat every 5 minutes if indicated (Not to exceed a total of 3administrations)

AGE GREATER THAN OR EQUAL TO 5 YEARS • 10 puffs (100 mcg/puff) via MDI with aerochamber

OR• 5 mg nebulized

• Repeat every 5 minutes if indicated (Not to exceed a total of 3administrations)

218

SALBUTAMOL Cont’d

NOTES

• Patients should be treated with MDI and aerochamber unless it isdeemed inappropriate, ineffective, or patient cannot tolerate.

• Each puff administered via MDI with aerochamber must be followed byat least 4 breaths.

• May be administered through an MDI adapter attached to a BVM.• Avoid contact with eyes. Ensure nebulizer mask is fitted well to the

patient’s face to minimize risk of mist getting into the eyes.• MDI must be primed by pressing downwards on the actuator a

minimum of four times. Prime MDI outside of aerochamber.• Hold pump in an upright position to ensure proper function.• This is a single patient use medication only.

219

SODIUM BICARBONATE (4.2% AND 8.4%) CLASS Alkalinizing agent, electrolyte

INDICATIONS

Adult Cardiac Arrest (Metabolic acidosis, hyperkalemia, TCA overdose) (OLMC) Adult Cocaine or Other Sympathomimetics (OLMC) Adult Tricyclic Antidepressants (OLMC) Pediatric Cardiac Arrest (Metabolic acidosis, hyperkalemia, TCA overdose) (OLMC) Pediatric Cocaine or Other Sympathomimetics (OLMC) Pediatric Tricyclic Antidepressants (OLMC)

CONTRAINDICATIONS None in the emergency setting

ADULT DOSE

Adult Cardiac Arrest with Suspected Metabolic Acidosis, Hyperkalemia, or TCA Overdose (OLMC) • Sodium bicarbonate 8.4% 1 mEq/kg (1 mL/kg) IVP/IO

Adult Cocaine or Other Sympathomimetics (OLMC) • Sodium bicarbonate 8.4% 1 mEq/kg (1 mL/kg) IV (Over 1 to 2 minutes)• Repeat once in 5 to 10 minutes if indicatedAdult Tricyclic Antidepressants With Prolonged QTc (OLMC) • Sodium bicarbonate 8.4% 1 mEq/kg IV (1 mL/kg) (Over 1 to 2 minutes)• Repeat once in 5 to 10 minutes if indicated

220

SODIUM BICARBONATE (4.2% AND 8.4%) Cont’d

PEDIATRIC DOSE

Pediatric Cardiac Arrest with Suspected Metabolic Acidosis, Hyperkalemia, or TCA Overdose (OLMC) (OLMC) AGE LESS THAN 2 YEARS

• Sodium bicarbonate 4.2% 1 mEq/kg (2 mL/kg) IVP/IO

AGE GREATER THAN 2 YEARS

• Sodium bicarbonate 8.4% 1 mEq/kg(1 mL/kg) IVP/IO

Pediatric Cocaine or Other Sympathomimetics (OLMC)


• Sodium bicarbonate 4.2% 1 mEq/kg (2 mL/kg) IV/IO (Over 1 to 2minutes)

• Repeat once in 5 to 10 minutes if indicatedAGE GREATER THAN 2 YEARS


• Repeat once in 5 to 10 minutes if indicatedPediatric Tricyclic Antidepressants With Prolonged QTc (OLMC)



• Repeat once in 5 to 10 minutes if indicatedAGE GREATER THAN 2 YEARS


• Repeat once in 5 to 10 minutes if indicated

NOTES

• Use of sodium bicarbonate 8.4% in patients less than 2 years of age iscontraindicated.

• If age less than 2 years, use sodium bicarbonate 4.2% to decreaseosmotic load.

• Be suspicious of hyperkalemia in the dialysis patient OR if ECG findingsof hyperkalemia are present.

• Simultaneous administration of sodium bicarbonate with calciumchloride or epinephrine should be avoided. Ensure IV line is adequatelyflushed between administrations of medication if an alternate IV is notavailable.

• Extravasation may cause tissue necrosis.• Examples of TCAs include, but are not limited to: amitriptyline (Elavil),

amoxapine (Asendin), clomipramine (Anafranil), doxepin (Adapin /Sinequan), and imitramine (Tofranil).

221

TETRACAINE 0.5% CLASS Topical anesthetic

INDICATIONS Adult Pain Management Pediatric Pain Management

CONTRAINDICATIONS 1) Hypersensitivity2) Suspected globe rupture

SIDE EFFECTS

• Blurred vision• Burning sensation• Lacrimation• Photophobia• Conjunctival redness

ADULT DOSE • 1-2 gtts per affected eye• Repeat in 5 to 10 minutes if indicated until reasonable control of pain

PEDIATRIC DOSE • 1-2 gtts per affected eye• Repeat in 5 to 10 minutes if indicated until reasonable control of pain

NOTES

• The anesthetized eye should be protected from contact to preventinadvertent damage. Do not touch or rub the eye and instruct patient toavoid rubbing or touching the eye.

• Instruct patient to remove contact lenses prior to administration (unlesssuspected globe rupture).

• To administer, tilt the patient’s head back, pull down on the lower eyelidto form a pocket. Hold the dropper tip down and in close proximity tothe lower lid without making contact with the eye. Gently squeeze thedropper and allow drop(s) to fall into the pocket made by the lower lid.

• Burning sensation may last up to 1 minute after instillation.• Solution must be clear. Discard any cloudy, discolored, or crystallized

solution.

222

THIAMINE

CLASS Vitamin

INDICATIONS Adult Symptomatic Hypoglycemia Adult Alcohol Withdrawal Emergencies

CONTRAINDICATIONS 1) Hypersensitivity

SIDE EFFECTS

• Hypotension• Pulmonary Edema• Restlessness• Anxiety• Weakness• Tenderness at injection site• Feeling of warmth

ADULT DOSE • 100 mg SIVP/IM

NOTES

• Thiamine should be co-administered with glucose in patients with a history ofalcoholism, malnourishment or starvation to avoid a precipitation ofWernicke’s encephalopathy.

• Administer immediately following the administration of glucose in thehypoglycemic patient, where indicated.

TRANEXAMIC ACID (TXA) CLASS Antifibrinolytic, Hemostatic Agent

INDICATIONS Uncontrolled, life-threatening hemorrhage

CONTRAINDICATIONS

1) Hypersensitivity to Tranexamic acid2) Isolated or obvious significant head injury3) Active intravascular clotting disorder (DVT, PE)4) Less than 16 years of age5) Greater than 3 hours since injury

PRECAUTIONS • Renal Impairment, Chronic anticoagulant use

SIDE EFFECTS

• Hypotension (with rapid injection)• Blurred vision• Dizziness• Diarrhea, Nausea, Vomiting• CNS depression

ADULT DOSE

Uncontrolled Life-threatening hemorrhage

• 1g in 100ml 0.9% NaCl by IV infusion over 10 mins.o Using 10 drop set (10 gtts/mL) deliver the total volume of the admixture

(100 mL) at a drip rate of 100 gtts/minute (25 gtts over 15 seconds)

NOTES • TXA must be administered through IV dedicated for TXA• Seizures have been reported with use. If seizure occurs treat as per

convulsive seizure protocol

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MEDFLIGHT NL – AUTO LAUNCH CRITERIA

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Documents

Patient Care Protocols - Government of Newfoundland and