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2008 SOGs Update Page 1 If the SOGs are utilized, you must document on your Medical Records as to what procedures/treatments were carried out utilizing SOGs. Note: A prolonged extrication alone is not reason to call specialty transport. Serious injury must accompany prolonged extrication.
2008 SOGs Update Page 3 Instructions for Use of Standard Operating Guidelines Special Considerations: Consider causes: A Alcohol, abuse E Epilepsy, electrolytes, I Insulin O Opiates, overdose U Uremia T Trauma, temperature I Infection, intussusception, encephalopathy inborn errors P Psychogenic P Poison S Shock, seizures, stroke, occupying lesion, subarachnoid hemorrhage, shunt
2008 SOGs Update Page 5 Patient Assessment Pediatric Initial Assessment 3. A. Airway Maintenance/Spinal Motion Restriction 1. Maintain patent airway head tilt-chin lift / or modified jaw thrust oral or nasal airway / or intubation suction / minimize risk of aspiration 2. Spinal Motion Restriction manual stabilization and full spinal motion restriction on backboard or in car seat (if significant injury suspected, package and immobilize on board).
2008 SOGs Update Page 8 INITIAL MEDICAL CARE Adult / Pediatric BLS 1. Maintain patent airway via a head tilt/chin lift or modified jaw thrust. 2. Utilize oral or nasal airway as necessary. 3. Place on side (vomiting precautions) unless contraindicated. 4. Suction to minimize risk of aspiration. 9. Pain management should be considered in the care of all patients. ask patient to rate their pain on a scale of 1 -10 or use Wong Bakers Scale (See pg. 6).
2008 SOGs Update Page 8 continued Initial Medical Care BLS 11. If altered mental status: Place patient on side (vomiting precautions), unless contraindicated. Check glucose level. If glucose < 80 adult, < 60 children and infants treat per Diabetic/Glucose Emergencies SOG (See pg. 69) or Cold Emergencies Frostbite and Hypothermia Guidelines (See pg. 88 -89). Contact Medical Control as soon as possible.
2008 SOGs Update Page 9 Initial Medical Care ILS 15. Establish TKO (30 ml/hr) IV of Isotonic Solution for adults. Keep open pediatric IV’s will be infused at 20 ml/hr. For pediatric patients, use a dial-aflow or infuse at 20 ml/hr when utilizing IV tubing without dial-a-flow. Establish vascular access IV/IO. NORMAL SALINE/LACTATED RINGERS. Fluid bolus with 20 ml/kg. Repeat if no improvement to maximum of 60 ml/kg. (Pediatric patient < 16 years of age. )
2008 SOGs Update Page 10 GENERAL ILLNESS Sick / Unknown / Nausea / Vomiting Adult / Pediatric BLS 1. Provide Initial Medical Care NOTE: Pre-hospital personnel must be acutely aware of patients who present with no specific complaints or minor complaints. These patients’ history and assessment is to be closely evaluated to determine the most appropriate care required. Female patients do not necessarily have classic symptoms of MI; their symptoms may be diaphoresis and “not feeling right. ” 2. Obtain blood glucose check
2008 SOGs Update Page 10 Continued General Illness ILS – In addition to BLS care 3. Initiate an IV of Isotonic Solution at TKO for adults unless hypotensive, then titrate to maintain the SBP >100. Pediatric IV of LACTATED RINGERS with infusion rate of 20 ml/hr.
2008 SOGs Update Page 15 Withholding or Withdrawing or Resuscitative Efforts Living Will/Surrogates 11. A Living Will by itself may not be honored by field personnel. Begin or continue treatment. Contact Medical Control, explain the situation, and follow any orders received.
2008 SOGs Update Page 18 Emergency Cardiac Care CONSIDER CONTRIBUTING CAUSES OR FACTORS FOR UNRESPONSIVENESS AND/OR RHYTHM DISTRUBANCES ● Hypovolemia ● Hypoxia ● Hydrogen ion (acidosis) ● Hypo-/hyperkalemia ● Hypothermia ● Toxins ● Tamponade, cardiac ● Tension pneumothorax ● Thrombosis (coronary or pulmonary) ● Trauma
2008 SOGs Update Page 19 SUSPECTED CARDIAC PATIENT WITH CHEST PAIN STABLE: Alert, Blood pressure within normal limits (SBP>100 mm. Hg) BLS – Provide Initial Medical Care 1. Special considerations: Carefully inquire of patient’s use of Viagra (sildenafil citrate), Cialis, Levitra, within 4 hours or the use of Cocaine within the past 24 hours. May potentiate the effects of nitrates. NOTE: Viagra (Sildenafil citrate) Revatio, Cialis, Levitra. . . is indicate for the treatment of pulmonary hypertension to improve exercise ability.
2008 SOGs Update Page 19 Continued Suspected Cardiac Patient with Chest Pain 2. Baby ASPIRIN 4 -81 mg tablets (324 mg’s) chewed and swallowed unless contraindicated. May assist the patient with their own NITROGLYCERINE tablets if patient has not taken the maximum dose of NITROGLYCERINE, assist the patient to administer one tablet of NITROGLYCERINE 0. 4 mg SL if the BP > 100 mm Hg systolic. The NITROGLYCERINE may be repeated with the guidance of medical control. Maintain the patient in a reclining position.
2008 SOGs Update Page 22 Sinus Bradycardia 4. Treatment necessary if pulse less than 60 BPM per minute and: a. Deviation from patient’s normal level of consciousness b. Diaphoretic c. Blood pressure < 90 mm. Hg systolic d. Frequent PVCs e. Symptoms of angina or dyspnea f. Or other signs of shock
2008 SOGs Update Page 36 Ventricular Tachycardia (Ventricular Rate > 150) BLS 1. Provide Initial Medical Care 2. Consider shock position.
2008 SOGs Update Page 39 Ventricular Fibrillation / Pulseless V-Tach BLS 1. Initiate CPR and resume after interventions as appropriate.
2008 SOGs Update Page 41 PEDIATRIC VENTRICULAR FIBRILLATION OR PULSELESS VENTRICULAR TACHYCARDIA BLS 1. Begin CPR and continue until AED available. 2. Refer to AED guidelines for 1 -8 year olds. Transport as soon as possible.
2008 SOGs Update Page 47 AUTOMATIC EXTERNAL DEFIBRILLATION (A. E. D. ) BLS 1. Provide Initial Medical Care NOTE: If a patient has an automated internal defibrillator (AICD) or pacemaker, do not place the electrode over the implanted device. 2. Initiate CPR and continue until Automatic External Defibrillator (AED) has been made ready 3. Turn on the AED power (some devices will “power on” automatically when lid is opened) and stop CPR. 4. Choose the correct pads (adult vs. child) for size/age of victim. Use child pads or child system for children less than 8 years of age if available. Do not use child pads or child system for victims 8 years and older. Attach AED electrodes to the pulseless, non-breathing patient
2008 SOGs Update Page 47 Continued Automatic External Defibrillation (AED) 5. Assure that all rescuers have cleared the patient and allow the AED to analyze the patients rhythm 6. If the AED advises “shock”, have all rescuers clear the patient and deliver 1 shock 7. Immediately resume CPR beginning with chest compressions. Do not delay CPR to recheck the rhythm or pulse. NOTE: Call for Advanced Life Support assistance
2008 SOGs Update Page 47 Continued Automatic External Defibrillation (AED) 8. Transport should be initiated at this time 9. After 2 minutes (5 cycles) of CPR repeat steps 5 and 6 until the advanced care providers take over or the victim starts to move
2008 SOGs Update Page 48 HYPERTENSIVE EMERGENICES BLS 2. Special Considerations: Carefully inquire of patient’s use of Viagra (sildenafil citrate, Cialis, Levitra) within 4 hours or the use of Cocaine within the past 24 hours. May potentiate the effects of nitrates. ILS – in addition to BLS care 4. Obtain IV with saline lock
2008 SOGs Update Page 52 Airway Obstruction UNCONSCIOUS 8. Attempt to ventilate. If obstructed: Look into mouth when opening the airway during CPR, use finger sweep only to remove visible foreign body if unresponsive. 9. Continue CPR until ALS arrives.
2008 SOGs Update Page 54 Pediatric Respiratory Arrest 5. If not breathing; administer 100% O 2 with BVM. Observe for increase in heart rate and improved color. If pulse <60 initiate CPR refer to Bradycardia SOG (See pg. 22 -23)
2008 SOGs Update Page 56 GUIDELINES FOR OROTRACHEAL INTUBATION Policy: Tracheal intubation is the preferred technique for controlling the airway in patients who are unable to maintain an open airway. Indications: 1. Unable to ventilate an unconscious patient with conventional methods. 2. The patient cannot protect his or her airway. 3. Prolonged artificial ventilation is needed.
2008 SOGs Update Page 56 Continued Guidelines for Orotracheal Intubation Prior to Insertion: 1. Preoxygenate the patient for several minutes with 100% oxygen prior to insertion attempt. 2. Ventilations should never be interrupted for more than 30 seconds for any reason. 3. Trauma patient orotracheal intubation is done with the patient’s head and neck stabilized in a neutral position. 4. Don protective equipment. 5. Prepare equipment.
2008 SOGs Update Page 56 Continued Guidelines for Orotracheal Intubation Insertion Procedure: 1. Insert the laryngoscope blade into the right side of the patient’s airway to the correct depth, sweeping toward the center of the airway while observing the desired landmarks. 2. After identifying the desired landmarks, insert the endotracheal (ET) tube between the patient’s vocal cords to the desired depth. 3. The laryngoscope is then removed while holding the ET tube in place; the depth marking on the side of the ET tube is noted. 4. If a stylet has been used, it should be removed at this time.
2008 SOGs Update Page 56 Continued Guidelines for Orotracheal Intubation 5. Inflate the pilot valve with enough air to complete the seal between the patient’s trachea and the cuff of the ET tube (usually 8 -10 m. L). 6. Attach a BVM and ventilate while observing for chest rise and each delivered breath. 7. To ensure proper ET tube placement bilateral breath sounds and absence of air sounds over the epigastrium are indications that the ET tube is properly placed. 8. Continue to manually stabilize or secure the ET tube in the determined proper position and monitor for good oxygenation and ventilation.
2008 SOGs Update Page 63 Reactive (Lower) Airway Disease Pediatric Wheezing (<8 yrs of age) ILS – in addition to BLS care 2. Pediatric IV of LACTATED RINGERS with infusion rate of 20 ml/hr.
2008 SOGs Update Page 66 Pediatric Near Drowning BLS Beware of personal safety if victim is still in water. 1. Initiate ventilations while patient is still in the water if possible. 2. Remove the patient from the water as soon as possible. Note: Patient is at high risk for vomiting. 3. Provide Initial Trauma Care. 4. Handle patient gently. 5. Remove wet clothing. 6. Dry off and wrap in blanket when possible.
2008 SOGs Update Page 66 Continued Pediatric Near Drowning 7. Assess patient’s temperature. ● If normothermic, treat dysrhythmias per appropriate SOG ● If hypothermic, treat per Cold Emergencies Frostbite and Hypothermia SOG (See pg. 88 -89) 8. Treat other signs and symptoms per appropriate Regional SOG. 9. Transport as soon as possible. NOTE: All patients with low core body temperatures should be resuscitated.
2008 SOGs Update Page 66 Continued Pediatric Near Drowning ILS in addition to BLS care 10. Intubate if GCS < 8. 11. Obtain IV of LACTATED RINGERS with infusion rate of 20 m. L/hr. 12. Obtain red or yellow top blood tube for hospital. Label with patient name, date of birth (if available), time drawn and initial.
2008 SOGs Update Page 67 Allergic Reaction / Anaphylaxis BLS Adult: Peds: *EPINEPHRINE 1: 1000 0. 5 mg SQ *EPINEPHRINE 1: 1000 May repeat x 1 after 15 min. if minimal response. SQ 0. 01 mg/kg to maximum of 0. 3 mg’s. To be considered for children weighing 30 kgs or less. Not for neonates. OR *EPINEPHRINE PEN PEDIATRIC 0. 15 mg into thigh muscle. To be used for children < 30 kgs. OR *EPINEPRHINE PEN ADULT 0. 3 mg into thigh muscle.
2008 SOGs Update Page 69 Diabetic / Glucose Emergencies BLS 4. NOTE: If blood sugar <80 adult, <60 children and < 60 infants, and patient is alert with an intact gag reflex, consider the administration of ORAL GLUCOSE. Refer to Oral Glucose Guideline (See pg. 70 -71).
2008 SOGs Update Page 76 Coma of Unknown Origin / Drug Overdose Intoxication BLS 1. Ensure scene and personal safety. 2. Secure and maintain airway. Support ventilations with 100% Oxygen. 3. Pulse oximetry. 4. Obtain a thorough history from patient, family or friends. 5. Consider hypoglycemia in an unconscious or convulsing patient. 6. Safely obtain any substance or substance container of a suspected poison and transport with the patient.
2008 SOGs Update Page 76 Continued Coma of Unknown Origin / Drug Overdose Intoxication ILS– in addition to BLS care 7. Obtain blood glucose level and draw a red or yellow top blood tube for hospital testing. Label all blood tubes drawn with patient’s name, the date of birth (if available), time of draw and your initials. 8. Intubate if necessary. 9. Obtain IV of Isotonic Solution at TKO for adults. Pediatrics IV of LACTATED RINGERS with infusion rate of 20 ml/hr.
2008 SOGs Update Page 80 Toxicologic / Poisoning Emergencies BLS 2. Consult Medical Control or Poison Control 1 -800 -222 -1222 for specific treatment to prevent further absorption.
2008 SOGs Update Page 81 Continued Toxicologic / Poisoning Emergencies POTENTIAL EXPOSURES ● Burning overstuffed furniture = Cyanide ● Old burning buildings = Lead fumes and Carbon monoxide ● Pepto-Bismol like products = Aspirin ● Pesticides = Organophosphates & Carbamates ● Common Plants = Treat symptoms and bring plant/flower to ED
2008 SOGs Update Page 82 Toxicologic / Poisoning Emergencies SMELLS ● Almond ● Fruit ● Garlic ● Mothballs ● Natural gas ● Rotten eggs ● Silver polish ● Stove gas ● Wintergreen = Cyanide = Alcohol = Arsenic, parathion, DMSO = Camphor = Carbon monoxide = Hydrogen sulfide = Cyanide = Think CO (CO and methane are odorless) = Methyl salicylate
2008 SOGs Update Page 83 State of Illinois Nerve Gas Auto-Injector Guidelines Purpose To provide Illinois EMS agencies with guidelines on the appropriate use of Mark 1 kits. The Mark 1 kit contains antidotes to be used in instances of exposure to nerve agents (Sarin, Soman, Tabun, VX) or to organophosphate agents (lorsban, Cygon, Delnav, malathion, Supracide parathion, Carbopenthion). Equipment Each Mark 1 kit consists of two auto-injectors containing Atropine Sulfate 2 mg in 0. 7 ML Pralidoxime Chloride (2 PAM) 600 mg in 2 ML
2008 SOGs Update Page 83 Continued State of Illinois Nerve Gas Auto-Injector Guidelines Key Provisions Only those licensed EMS providers that are governed by the State of Illinois EMS Act (210 ICLS 50 are authorized by any EMS Medical Director to utilize the special equipment and medications needed in WMD incidents, including Mark 1 auto-injectors. When appropriate conditions warrant, contact Medical Control. Other organized response teams not governed by the EMS Act may use the Mark 1 auto-injectors on themselves or other team members when acting under the Illinois Emergency Management Agency Act (20 ILCS 3305).
2008 SOGs Update Page 83 Continued State of Illinois Nerve Gas Auto-Injector Guidelines The guidelines for the use of the Mark 1 kits were developed by the EMS Cap Committee of the Illinois College of Emergency Physicians (ICEP). They were then adopted by the Illinois Medical Directors, Illinois Department of Public Health and the Mutual Aid Box Alarm System (MABAS) in the Illinois Terrorism Task Force to provide guidance to EMS agencies and providers who are part of an EMS system.
2008 SOGs Update Page 83 Continued State of Illinois Nerve Gas Auto-Injector Guidelines There are 10 provisions in the guidelines: 1. To utilize these kits you must be an EMS agency or provider within an Illinois EMS system and participate within an EMS disaster preparedness plan. 2. The decision to utilize the Mark 1 antidote is authorized by this State protocol. 3. At a minimum and EMS provider must be an Illinois EMT at any level including First Responder with additional training in the use of the auto-injector.
2008 SOGs Update Page 84 State of Illinois Nerve Gas Auto-Injector Guidelines 4. The Mark 1 kit is not to be used for prophylaxis. The injectors are antidotes, not a preventative device. The Mark 1 kit may be self-administered if you become exposed and are symptomatic. Exit immediately to the Safe Zone for further medical attention. 5. Use of the Mark 1 kit is to be based on signs and symptoms of the patient. The suspicion or identified presence of a nerve agent is not sufficient reason to administer these medications. 6. Atropine may be administered IV or IM in situations where Mark 1 kits are not available. 7. Auto-injectors are not to be used on children under 88 pounds (40 kg). Pediatric Mark 1 injectors are currently being reviewed by the FDA.
2008 SOGs Update Page 84 Continued State of Illinois Nerve Gas Auto-Injector Guidelines 8. If available, diazepam (Valium) or midazolam (Versed) may be cautiously given under Medical Control direction or by Standard Operating Procedures (ALS see pg. 73 Seizure/Status Epilepticus), if convulsions are not controlled. 9. When the nerve agents have been ingested exposure may continue for some time due to slow absorption from the lower bowel. Fatal relapses have been reported after initial improvement. Continual medical monitoring is mandatory. 10. If dermal exposure has occurred decontamination is critical and should be done with standard decontamination procedures. Patient monitoring should be directed to the signs and symptoms as with all nerve organophosphate exposures. Continual medical monitoring and transport is mandatory.
2008 SOGs Update Page 88 - 89 Cold Emergencies BLS 2. Avoid unnecessary manipulation and rough handling. 3. Check pulse for 30 -60 seconds. Anticipate bradycardia. If no pulse, begin CPR and implement AED if available. Give one shock if advised. 4. Resume CPR.
2008 SOGs Update Page 94 Initial Trauma Care BLS INITIAL ASSESSMENT: 1. AIRWAY/C-SPINE: Spinal motion restriction in age appropriate device as indicated. Chin lift or modified jaw thrust. Oral airway as necessary and suction as needed. Vomiting and seizure precautions.
2008 SOGs Update Page 94 Continued Initial Trauma Care BLS (Continued) 2. BREATHING/VENTILATION: expose chest. Observe for adequate breathing After airway is established. Auscultate breath sounds Note respiratory rate, rhythm & efforts of respiration Chest expansion Oxygen 4 -6 L/NC. If acute, altered mental status, hemodynamically Unstable (low B/P, Tachycardia and delayed capillary refill) or signs of Hypoxemia. Criteria: 100% oxygen/NRM or assist with BVM.
2008 SOGs Update Page 94 Continued Initial Trauma Care BLS (Continued) 3. CIRCULATION: assess cardiovascular status. Assess heart rate, peripheral and central pulses Apparent hydration Skin color and temperature Obtain BP with appropriate size cuff If no carotid pulse – Traumatic Arrest SOP Control all external hemorrhage Determine if load and go situation NOTE: Evaluate using Glasgow Coma Scale, AVPU and pupil assessment. Obtain and record Blood Glucose level.
2008 SOGs Update Page 94 -95 Continued Initial Trauma Care BLS (Continued) 4. EXPOSURE: Expose patient as appropriate as assessment Prevent heat loss 5. Pain assessment (0 -10 scale or Wong Baker Face Scale pg. 6)
2008 SOGs Update Page 95 Initial Trauma Care ILS– in addition to BLS care 7. If circulatory support required, NORMAL SALINE IV/IO fluid bolus of 20 ml/kg.
2008 SOGs Update Page 96 Initial Trauma Care LOAD & GO SITUATIONS There are circumstances that demand hospital care to allow stabilization of a patient. It may be necessary for the prehospital provider to abridge certain procedures described in Region 4 Standard Operating Guidelines. When critical circumstances require urgent transport, it is necessary to document thoroughly the rationale for leaving the scene and deviating from Region 4 Standard Operating Guidelines. The emphasis is on rapid patient packaging and limited on-scene times as is possible. Prolonged extrication times greater than 10 minutes should be accounted for in the patient documentation.
2008 SOGs Update Page 97 Pediatric Trauma < 16 Years of Age ILS – in addition to BLS care If signs of shock, refer to Hypovolemic and Distributive Shock SOG (See pg. 98 -99) or Asystole or Pulseless Electrical Activity SOG (See pg. 44) (e. g. hypotension, tachycardia, poor capillary refill), initiate:
2008 SOGs Update Page 103 Head and Spine Injuries BLS 3. Special Consideration: Mild hyperventilation is 4 ventilations above the normal rate. Consider performing mild hyperventilation ONLY IF suspected impending herniation (non-reactive/unequal pupils or posturing).
2008 SOGs Update Page 108 Ophthalmic Emergencies BLS/ILS/ALS 1. Provide Initial Trauma Care Assess pain on a scale of 0 -10 or Wong Baker’s Face Scale (See pg. 6) CHEMICAL SPLASH/BURN 3. Do not contaminate the uninjured eye during eye irrigation.
2008 SOGs Update Page 111 Musculoskeletal Injuries AMPUTATIONS/DEGLOVING INJURIES 4. Care of amputated parts: Clean wound surface. DO NOT pick out embedded particles. Remove large particles from the surface with sterile dressing when possible. Wrap in saline-moistened gauze or towel. Place in plastic bag and seal. DO NOT submerge tissue in water or saline without plastic covering. Place plastic bag in second container filled with ice water or cold water. OR, place on cold packs and bring with patient to the hospital, if unable to place in plastic and immerse. Label bag with name, date and time.
2008 SOGs Update Page 112 Musculoskeletal Injuries CRUSH SYNDROME BLS 3. Monitor for tachycardia, restlessness, and increased respiratory rate.
2008 SOGs Update Page 113 Sudden Infant Death Syndrome (SIDS) Sudden Infant Death Syndrome is the sudden, unexpected death of an apparently healthy infant under one year of age, which remains unexplained after a thorough postmortem evaluation. Including performance of a complete autopsy, examination of the death scene, and review of the clinical history. A. What SIDS is not: 1. Not caused by external suffocation 2. Not caused by vomiting or choking 3. Not contagious 4. Does Not cause pain or suffering to the infant 5. Can Not be predicted 6. Can Not be prevented B. How to distinguish between SIDS and Child Abuse or Neglect
2008 SOGs Update Page 113 Sudden Infant Death Syndrome (SIDS) SIDS Incidence: Deaths: 3, 000/year in the US When: More frequent in winter months Physical Appearance: No external signs of injury “Natural” appearance of death - Lividity-settling of blood: Frothy drainage from nose/mouth - Small marks (e. g. diaper rash) look more severe - Cooling/rigor mortis-takes place quickly in infants (approx. 3 hours) Purple mottled markings on the head and facial area Appears to be well-developed baby, though may be small for age Other siblings appear to be normal and healthy Normal hydration and nutrition
2008 SOGs Update Page 113 Continued Sudden Infant Death Syndrome (SIDS) CHILD ABUSE/NEGLECT Incidence: Deaths: 2000 to 5000 die annually in the US When: No Seasonal Difference Physical Appearance: Visible signs of injury (Fx. , bruises, burns, cuts, head trauma, scars, welts, wounds) May be obviously malnourished Other siblings may show patterns of injuries
2008 SOGs Update Page 113 Continued Sudden Infant Death Syndrome (SIDS) NOTE: As a Healthcare Provider you are considered a mandated provider. What this means is that you are required by law to report suspected child abuse and maltreatment immediately when you have reasonable cause to believe that a child known to you in your professional or official capacity may be abused or neglected child. You may do this by calling the DCFS hotline at: 1 -800 -2522873 or 1 -800 -25 ABUSE.
2008 SOGs Update Page 114 Sudden Infant Death Syndrome (SIDS) May Initially Suspect SIDS When: All the above characteristics appear be accurate May Initially Suspect Abuse: All of the above characteristics to appear to be accurate PLUS Parents say that the infant as well And healthy when put to sleep (last time seen alive) Parents’ story does not “sound right” or cannot account for all injuries on infant
2008 SOGs Update Page 114 Continued Sudden Infant Death Syndrome (SIDS) NOTE: THE DETERMINATION OF WHETHER THE CHILD IS OR IS NOT A SIDS VICTIM IS THE RESPONSIBILITY OF THE MEDICAL EXAMINER OR MEDICAL CORONER. IT IS NOT THE RESPONSIBILITY OF THE FIRST RESPONDER. ONLY AN AUTOPSY CAN CONCLUSIVELY DETERMINE SIDS. C. When a child is apneic and pulseless: 1. All resuscitation measures should be carried out immediately. 2. Obtain accurate information in a non-threatening manner. 3. Note how the child was found and the surroundings. D. Keep in mind the parent’s reactions may range from a numb silence to a violent hysteria.
2008 SOGs Update Page 115 Suspected Abuse or Neglect Child, Domestic, Sexual, Elder BLS/ILS/ALS 3. Perform history, physical exam, scene survey as usual. 4. Document findings on run sheet: Child interactions with parents and/or caregivers Note: Discrepancies in parents history of injuries and child(s). SUSPECTED SEXUAL ASSAULT: A. Assess and prioritize and treat the patients medical needs. B. When the sexual assault has occurred at the location of the call treat the site as a crime scene and preserve any evidence. C. Notify law enforcement. D. Encourage the victim to allow transport to a hospital and provide the emergency department a medical treatment history. E. Document the patients history, physical exam and scene survey on the run sheet. Do not document suppositions.
2008 SOGs Update Page 116 Rape / Sexual Assault Sexual assault is an attack against a person that is sexual in nature, the most common of which is rape. EMS personnel may be called on to treat a victim of sexual assault, molestation, or actual or alleged rape cases. Such cases mandate professionalism, tact, kindness and sensitivity. Patient Care 1. Whenever possible a female rape victim should be given the option of being treated by a female paramedic to abate the hindrance of an assessment and for the patient’s psychological well-being. 2. Determine if the victim is physically injured and treat accordingly (limit physical exam to a brief survey for life threatening injuries.
2008 SOGs Update Page 116 Continued Rape / Sexual Assault 3. 4. 5. 6. 7. 8. Do not attempt to elicit information regarding the assault. Do not present as judgmental. Protect the victim from the judgment of others on scene. Remember the location is considered a crime scene. Preserve evidence. Do not cut through any clothing or throw away anything from the scene. Place bloodstained articles in separate paper-not plastic bags (if possible obtain an evidence bag from police). 9. Gently persuade the patient to not clean themselves up. 10. Should the victim decline transport offer to call a friend or relative who can stay with them. 11. Keep documentation concise and record only what the patient stated in their own words. Use quotation marks to indicate that the report is the patient’s version of events.
2008 SOGs Update Page 116 Continued Rape / Sexual Assault 12. Do not insert your own opinion or offer any conclusions regarding the event. 13. Record all observations that the physical exam elicits and the condition of clothing. ILS/ALS Follow appropriate Regional SOG as physical exam dictates.
2008 SOGs Update Page 118 Hemorrhage in Pregnancy / Obstetrical Complications A pregnant woman does not have to be in labor to have excessive bleeding. Bleeding in early pregnancy may be due to miscarriage. If the bleeding occurs in late pregnancy it may be due to problems involving the placenta. BLS 1. Provide Initial Medical Care: Oxygen at 100% by NRB mask or assist with BVM 2. Treat for shock as indicated by signs and symptoms. Keep patient warm Massage the fundus (uterus) Allow infant to nurse Monitor vital signs at least every 5 minutes
2008 SOGs Update Page 118 Continued Hemorrhage in Pregnancy / Obstetrical Complications 3. 4. 5. Note type, color and amount of any vaginal discharge or bleeding. Retain expelled tissue or large blood clots and give to the emergency department personnel. Provide emotional support to parents. Third Trimester Bleeding: should be attributed to either placenta previa or abruptio placenta until proven otherwise. Consider patient to be at high risk for hemorrhage and treat as indicated for hemorrhagic shock. Including positioning her on the left side.
2008 SOGs Update Page 124 Neonatal Resuscitation BLS 1. Leave at least 6 inches of umbilical cord when cutting the cord on an infant in obvious distress. One team member should note the 1 minute and 5 minutes APGAR scores. Do not interrupt resuscitation efforts to obtain APGAR. 11. Establish vascular access IV/IO NS/LR at TKO.
2008 SOGs Update Page 130 Medications Aspirin (ASA) Dose/Route: Action: 324 mg PO (four 81 mg tablets) chewed and swallowed Blood-thinning, anti-clotting, inhibits platelet aggregation (clumping) Indications: Suspected myocardial ischemia Contraindications: Vomiting, allergy, gag reflex, clotting/bleeding, disorders, ulcers, rx heparin or Coumadin, third trimester pregnancy Side Effects: Minimal unless allergic to ASA
2008 SOGs Update Page 151 Guidelines for Defibrillation is the process by which a surge of electric energy is delivered to the heart that is contracting erratically. The purpose of defibrillation is to depolarize the muscle cells with the intent of producing organized depolarization, leading to functional cardiac contraction. Indications 1. Ventricular Fibrillation, 2. Pulseless Ventricular Tachycardia
2008 SOGs Update Page 151 Continued Guidelines for Defibrillation Procedure 1. Place the patient in a safe environment if initially in contact with electrical conductive material such as water or metal. 2. Initiate or continue CPR. 3. Perform CPR for 2 minutes before delivering the first shock. 4. Attach the adhesive defibrillation pads or apply gel to the paddles. 5. Turn on and charge the defibrillator to 360 joules (monophasic) or 200 joules (biphasic) for the first shock. Turn “lead select” switch on. 6. Ensure that the electrodes are appropriately placed on the patient’s thorax (sternum-apex) with proper pressure. 7. Visually check the monitor display and assure the rhythm.
2008 SOGs Update Page 151 Continued Guidelines for Defibrillation 8. 9. 10. 11. 12. 13. 14. Turn oxygen off or direct the flow away from the patient’s chest. Ensure that no one else is in contact with the patient. Verbally and visually clear everybody, including yourself before any defibrillation attempts. Press the “shock” button on the defibrillator or press the two paddle “discharge” buttons simultaneously after confirming that all personnel are clear of the patient. Resume CPR immediately after the shock. Administer appropriate medications. After five cycles of CPR, check the rhythm again. If a shockable rhythm, continue CPR (if defibrillator takes longer than 10 seconds to charge) while defibrillator is charging and administer second and consecutive shocks as necessary.
2008 SOGs Update Page 159 Guidelines for BLS Pediatric Tracheostomy Tube GUIDELINES FOR BLS PEDIATRIC TRACHEOSTOMY TUBE 1. Initial Medical Care. 2. Administer 100% O 2 per tracheostomy collar 3. Suction 4. Reassess airway patency* OBSTRUCTED 5. Repeat suction, after removing inner cannula if present 6. Have caregiver change trach tube 7. Reassess patency 8. Ventilate with 100% O 2 bag bask to trach tube 9. If trach tube not patent even after changing, ventilate with bag mask to mouth (cover stoma). If no chest rise, ventilate with infant maks to stoma.
2008 SOGs Update Page 159 Continued Guidelines for BLS Pediatric Tracheostomy Tube OBSTRUCTED 10. Must have rise and fall of chest with each ventilation. 11. Refer to Respiratory Distress SOG (See pg. 53) or Pulseless Arrest SOG (See pg. 54) PATENT 5. Do not change trach tube 6. Complete initial assessment 7. Perform frequent reassessments 8. Call for ALS 9. Contact Medical Control 10. Support ABC’s
2008 SOGs Update Page 159 Continued Guidelines for BLS Pediatric Tracheostomy Tube PATENT 11. Observe 12. Keep warm 13. Transport in position of comfort Special Considerations * If chest rise inadequate: ● Reposition the airway ● If using mask to stoma, consider inadequate volume delivery. Compress bag further and/or depress pop-off valve.
2008 SOGs Update ALS UPDATE
2008 SOGs Update Page 9 Initial Medical Care ALS – In addition to BLS/ILS care. 18. Consider 12 -Lead EKG in suspected cardiac patients with chest pain. Utilize Risk Stratification for Chest Pain criteria sheet, when system applicable.
2008 SOGs Update Page 10 General Illness ALS – In addition to BLS care. 4. If signs of hypoperfusion, e. g. low B/P, tachycardia, delayed capillary refill etc. infuse IV fluids for adult at 20 ml/kg provided lungs are clear. In pediatric patients 1 -8 years old infuse the LACTATED RINGERS at 20 ml/kg. Neonates 0 -1 month, obtain IV of LACTATED RINGERS, infuse at 10 ml/kg. If unable to obtain IV after one attempt seek direction from Medical Control. 5. Nausea and Vomiting Assure that the patient receive nothing by mouth. Obtain orthostatic vital signs if time allows
2008 SOGs Update Page 10 Continued General Illness Adult & Children > 12 yrs of age ZOFRAN 4 mg IV/IM. IVP ZOFRAN is given over 2 minutes. ZOFRAN 8 mg disintegrating tab place on top of tongue. When dissolved (in seconds) ask patient to swallow saliva. Children 4 -11 yrs of age ZOFRAN 4 mg disintegratingplace on top of tongue. When dissolved (in tab seconds) ask patient to swallow saliva.
2008 SOGs Update Page 11 Pain Protocol ALS – in addition to BLS/ILS care 6. Adult: TORADOL 30 mg IV or IM (IM dosage should be reserved for longer transport times). Peds: TORADOL (Peds 2 -16 yrs. ) 0. 5 mg/kg IV - Max of 15 mg’s OR 1 mg/kg IM - Max of 30 mg’s Special Note: Do not mix TORADOL in syringe with any other medications. Do not give TORADOL to patients with aspirin or ibuprofen allergies or elderly patients with a cardiac history. Do not give to patients with: Renal problems, GI Bleeding, ulcers, or bleeding disorders.
2008 SOGs Update Page 12 Pain Protocol 10. Patients received analgesics should remain on oxygen.
2008 SOGs Update Page 13 Initiation of ALS Care ALS should be initiated according to the following guidelines: n. o. p. q. Burns Cyanosis Failure of child to recognize parents Petichiae (small purplish hemorrhagic spots on skin – seen in many febrile illnesses)
2008 SOGs Update Page 14 Withholding or Withdrawing of Resuscitative Efforts ALS – in addition to BLS/ILS care 6. Attach a copy of the EKG rhythm strip to the provider copy of the run sheet.
2008 SOGs Update Page 16 Cardiac Protocols 9. Obtain a 12 -Lead EKG in suspected cardiac patients with chest pain. Utilize Risk Stratification for Chest Pain criteria sheet, when system applicable.
2008 SOGs Update Page 19 Suspected Cardiac Patient with Chest Pain 8. If NTG SL effective and SBP >100 mm Hg apply NTG paste 1 inch.
2008 SOGs Update Page 22 Sinus Bradycardia ALS - in addition to BLS care 5. Medication options: Pacing should be considered immediately for severely symptomatic patients. Refer to Non-Invasive External Cardiac Pacing Guidelines SOG (pg. 29 -30) Use without delay for high degree blocks (Type II, Second-Degree Block, or Third-Degree AV Block). a. ATROPINE: 0. 5 mg IVP while awaiting pacer. May repeat to a total dose of 3 mg. If ineffective, begin pacing upon arrival. May be given per ETT at twice the IV dose.
2008 SOGs Update Page 23 Sinus Bradycardia 5. b. DOPAMINE: 400 mg in 250 ml D 5 W (1600 mcg/ml). Titrate to maintain systolic BP of 90 -100 mm. Hg by slowly increasing drip rate. Dosing range 10 -20 mcg/kg/min.
2008 SOGs Update Page 24 Second Degree Heart Block Mobitz Type II ALS – in addition to BLS/ILS care 3. Consider sedation prepare for transcutaneous pacing. (Refer to Non-Invasive External Cardiac Guidelines SOG pg. 29 -30). Consider ATROPINE 0. 5 mg IVP, may repeat to a total of 3 mg’s. Consider DOPAMINE 10 -20 mcg/kg/min.
2008 SOGs Update Page 25 Third Degree Heart Block (Complete Heart Block) ALS – in addition to BLS/ILS care 3. Consider sedation prepare for transcutaneous pacing. (Refer to Non. Invasive External Cardiac Guidelines pg. 29 -30). Consider ATROPINE 0. 5 mg IVP, may repeat to a total of 3 mg’s. Consider DOPAMINE 10 -20 mcg/kg/min. a. Never treat third degree heart block with ventricular escape beats with AMIODARONE.
2008 SOGs Update Page 26 Pediatric Bradyarrhythmias ALS – in addition to BLS/ILS care 6. EPINEPHRINE (1: 1, 000) 0. 1 mg/kg (0. 1 ml/kg) ET or EPINEPHRINE (1: 10, 000) 0. 01 mg/kg (0. 1 ml/kg) IVP/IO. Repeat q 3 -5 minutes as long as dysrhythmia with hypoperfusion persists. NOTE: If increase vagal tone or primary AV block, consider ATROPINE as first line medication.
2008 SOGs Update Page 27 12 Lead Electrocardiogram Guideline (EKG) 1. Utilize in the event of a suspected Acute Coronary Syndrome or anginal equivalents (dyspnea, syncope, weakness, diaphoresis and palpitations, DKA) ● pre and post cardioversion of patients ● patients experiencing dysrhythmias ● patients experiencing heart failure 6. 7. 8. Do not remove EKG electrodes once they have been placed. Upon completion of the 12 -Lead EKG transmit to the receiving facility if possible. Attach a copy of the 12 -Lead EKG to EMS run sheets.
2008 SOGs Update Page 29 Non-Invasive External Cardiac Pacing Guidelines Start at 80 MA (milli-amps) if patient is asystolic
2008 SOGs Update Page 35 Ventricular Ectopy 5. Never treat third degree heart block with ventricular escape beats with AMIODARONE. 6. If bradycardia present with PVCs treat per ACLS Bradycardic algorithm 7. Medication Options: a. After obtaining verbal order for AMIODARONE 150 mg IVP over 20 -60 minutes IV. b. Call Medical Control for repeat dose of AMIODARONE.
2008 SOGs Update Page 36 Ventricular Tachycardia (Ventricular Rate >150) 6. Stable patient: Adult: a. AMIODARONE 150 mg IV over 10 minutes. b. If Ventricular Tachycardiac persists after AMIODARONE 150 mg’s consider cardioversion. c. If AMIODARONE ineffective or as signs and symptoms dictate it may be necessary to proceed to unstable algorithm. Peds: a. AMIODARONE 5 mg/kg IV/IO over 20 minutes. 7. Contact Medical Control as soon as possible.
2008 SOGs Update Page 37 Ventricular Tachycardia 3. 4. 5. Consider sedation with Adult: DIAZEPAM 5 mg IV or VERSED 2 -4 mg IVP Peds: DIAZEPAM 0. 1 mg/kg IV/IO for children <5 years max 5 mg. >5 years max 10 mg. VERSED 0. 1 -0. 2 mg/kg IV/IO. Max 0. 15 mg/kg Peds: for synchronized cardioversion, use an initial dose of 0. 5 to 1 joule/kg for unstable VT with a pulse and cardiovascular instability. Increase the dose to 2 joule/kg if the initial dose is ineffective. Adult: SYNCHRONIZED CARDIOVERSION at 100 Joules (or equivalent biphasic or manufacturer’s recommendation) and Adult: AMIODARONE 150 mg IV over 10 minutes. Peds: AMIODARONE 5 mg/kg IV/IO over 20 -60 minutes IV/IO bolus.
2008 SOGs Update Page 37 -38 Ventricular Tachycardia 6. Adult: SYNCHRONIZED CARDIOVERSION at 200 Joules (or equivalent biphasic or manufacturer’s recommendation) if ventricular tachycardia persists. 7. Adult: SYNCHRONIZED CARDIOVERSION at 300 Joules (or equivalent biphasic or manufacturer’s recommendation) if ventricular tachycardia persists. 8. Adult: May repeat AMIODARONE 150 mg IVP bolus over 10 minutes if V-tach persists. Peds: If V-tach persists contact Medical Control. 9. Adult: SYNCHRONIZED CARDIOVERSION at 360 Joules (or equivalent biphasic or manufacturer’s recommendation) after each AMIODARONE bolus, if V-tach persists. 10. Call Medical Control for additional anti-arrhythemic orders.
2008 SOGs Update Page 39 Ventricular Fibrillation / Pulseless V-tach 5. Unwitnessed arrest: a. Maintain CPR until defibrillator available c. Immediately defibrillate with monophasic at 360 joules or equivalent biphasic or manufacturer’s recommendation. d. Resume CPR. e. EPINEPHRINE 1. 0 mg IV/IO (repeat after 3 -5 min. ). VASOPRESSIN one dose/40 units IV/IO may replace either the first or second dose of EPINEPHRINE. If IV/IO access cannot be established or is delayed, give EPINEPHRINE 1: 10, 000, 2 -2. 5 mg diluted in 5 -10 ml of water or NORMAL SALINE and injected directly into the ET tube.
2008 SOGs Update Page 40 Ventricular Fibrillation / Pulseless V-tach g. h. i. j. k. l. Defibrillate monophasic maximum joules or biphasic per manufacturer guidelines. Resume CPR immediately after each intervention. AMIODARONE 300 mg IVP. Note: Consider MAGNESIUM SULFATE 1 -2 gm if rhythm Torsades De Pointes. Consider additional dose of AMIODARONE 150 mg IVP. Defibrillate monophasic maximum joules or biphasic per manufacturer guidelines. Call Medical Control for additional anti-arrhythmic orders.
2008 SOGs Update Page 41 Pediatric Ventricular Fibrillation or Pulseless Ventricular Tachycardia 6. 7. DEFIBRILLATE at 2 joules/kg monphasic or biphasic. Resume CPR for 2 minutes. 9. Resume CPR for 2 minutes after each defibrillation if indicated. 11. If no change, resume CPR and INTUBATE. Establish vascular access IV/IO 15. 16. AMIODARONE 5 mg/kg IV/IO. Consider MAGNESIUM SULFATE 25 to 50 mg/kg IV/IO (maximum dose; 2 g) for torsades de pointes. Call Medical Control for additional anti-arrhythmic orders. 17.
2008 SOGs Update Page 43 Asystole / Ventricular Standstill 7. EPINEPHRINE 1. 0 mg IV/IO (repeat after 3 -5 min. ). VASOPRESSIN one dose/40 units IV/IO may replace either the first or second dose of EPINEPHRINE. If IV/IO access cannot be established or is delayed, give EPINEPHRINE 1: 10, 000, 2 -2. 5 mg diluted in 5 -10 ml of water or NORMAL SALINE and injected directly into the ET tube. 8. ATROPINE 1. 0 mg IVP. May repeat every 3 -5 minutes (if asystole persists) to a maximum of 3 doses (3 mg). May be given by ETT at twice the IV dose or 2 mg’s diluted in a minimum of 10 ml of NORMAL SALINE.
2008 SOGs Update Page 44 Asystole or Pulseless Electrical Activity 8. Consider causes and treat them accordingly: a. Hypoxia Tension Pneumothorax Hypovolemia Tamponade, cardiac Hyper/Hypokalemia Toxins Hydrogen Ion Acidosis Thrombosis, coronary or pulmonary Hypothermia Trauma Hypoglycemia
2008 SOGs Update Page 45 Pulseless Electrical Activity (PEA) 5. EPINEPHRINE 1. 0 mg IV/IO (repeat after 3 -5 min. ). VASOPRESSIN one dose/40 units IV/IO may replace either the first or second dose of EPINEPHRINE. If IV/IO access cannot be established or is delayed, give EPINEPHRINE 1: 10, 000, 2 -2. 5 mg diluted in 5 -10 ml of water or NORMAL SALINE and injected directly into the ET tube. 6. Consider ATROPINE 1. 0 mg IV or IO for PEA with rate less than 60. May repeat every 3 -5 minutes to a maximum of 3 doses (3 mg). May be given by ETT at twice the IV dose or 2 mg’s diluted in a minimum of 10 ml of NORMAL SALINE. 7. Consider the possible underlying causes: Hypoxia Tension Pneumothorax Hypovolemia Tamponade, cardiac Hyper/Hypokalemia Toxins Hydrogen Ion Acidosis Thrombosis, coronary or pulmonary Hypothermia Trauma Hypoglycemia
2008 SOGs Update Page 48 Hypertensive Emergencies 7. Apply NTG topically 1 inch unless allergic or SBP < 100 mm. Hg
2008 SOGs Update Page 51 Cardiogenic Shock 4. DOPAMINE DRIP starting at 10 mcg/kg/min. with 60 drop tubing or Dial-a-Flow as available. Titrate to SBP > 90 mm. Hg
2008 SOGs Update Page 58 Intubation Using Versed 4. Administer VERSED 5 mg’s IVP followed by VERSED 5 mg’s IVP at two minute intervals until sedation is achieved or to a maximum of 10 mg’s total. If additional sedation is necessary to reduce or eliminate a recurrent state of agitation following intubation, administer VERSED 4 mg’s (if BP >100/70). Immediately contact Medical Control.
2008 SOGs Update Page 59 Intubation Using Etomidate ALS Considerations: Consider potential for hypoglycemia prior to implementing sedation and intubation. Adult 1. Initial Medical Care 2. Continue to assist ventilations with 100% Oxygen via BVM during preparation for intubation. 3. Do not allow the patient to become hypoxic, proceed immediately with intubation. 4. Administer ETOMIDATE 0. 3 mg/kg rapid IVP. 5. Depress and hold cricoid pressure until tube passed.
2008 SOGs Update Page 60 Intubation Using Etomidate 6. 7. 8. 9. 10. 11. 12. Attempt oral or in-line intubation as is case appropriate. If proper muscle tone relaxation has not been achieved to allow for intubation after 60 seconds, may repeat ETOMIDATE 0. 3 mg/kg rapid IV. Intubation must be confirmed using cord visualization and auscultation (refer to instructions on SOG pg. 1 for suggested confirmation techniques). Utilize CO 2 detectors or system specific tube placement devices as a method of confirmation of appropriate endotracheal tube placement. Secure ETT and reassess breath sounds. When available place the patient on an approved transport ventilator. Call Medical Control for post intubation sedation. If unable to assist ventilate be prepared for Translaryngeal Jet Ventilation SOG procedure. (See pg. 162 -163).
2008 SOGs Update Page 61 Pediatric Drug Doses Albuterol 1. 25 mg (1. 5 ml) via nebulizer Amiodarone 5 mg/kg IV/IO; can repeat the 5 mg/kg IV/IO bolus. Maximum single dose of 300 mg’s. Atropine 0. 02 mg/kg IV/IO or 0. 03 mg/kg ETT minimum single dose 0. 1 mg maximum doses: <8 years single dose 0. 5 mg <8 years total dose 1 mg 8 -16 years single dose 1 mg 8 -16 years total dose 2 mg
2008 SOGs Update Page 62 Continued Pediatric Drug Doses *Glucagon (0. 5 mg IM) is recommended for peds patients weighing < 25 kg or **younger than 6 -8 yrs**. *As per system protocol.
2008 SOGs Update Page 66 Pediatric Near Drowning ALS in addition to BLS/ILS care 12. Capnography may be utilized. 13. Apply cardiac monitor. 14. Contact Medical Control as soon as possible .
2008 SOGs Update Page 67 Allergic Reaction / Anaphylaxis 6. Peds: EPINEPHRINE 1: 1, 000 SQ 0. 01 ml/kg to maximum of 0. 3 mg’s. To be considered for children weighing 30 kgs or less. Not for neonates.
2008 SOGs Update Page 69 Diabetic / Glucose Emergencies 8. Blood sugar <80 adult, <60 children and < 60 infants or signs and symptoms of Insulin Shock/Hypoglycemia Adults and children > 8 years DEXTROSE 50% 25 Gm (50 ml) IVP *GLUCAGON 1 mg IM If after 15 min. the patient remains unconscious, may give an additional 1 mg of GLUCAGON IM Peds: 1 -8 years: DEXTROSE 25% 2 -4 ml/kg IVP < 1 year: DEXTROSE 12. 5% 2 -4 ml/kg IVP *GLUCAGON half adult dose (0. 5 mg IM) is recommended for peds patients weighing < 25 kg or **younger than 6 -8 yrs**.
2008 SOGs Update Page 76 Coma of Unknown Origin / Drug Overdose Intoxication ALS – in addition to BLS/ILS care 11. 12. 13. Adults: If intubation attempt is unsuccessful refer to the Intubation Using Versed SOG (See pg. 57 -58). If intubation continues to be unsuccessful, BVM to ventilate and refer to the Translaryngeal Jet Ventilation SOG (See pg. 162 -163). Capnography may be utilized. Apply cardiac monitor.
2008 SOGs Update Page 77 Coma of Unknown Origin / Drug Overdose Intoxication 14. Medications: If patient is conscious and can maintain gag reflex, administer ORAL GLUCOSE. a. Infants < 1 year old: hypoglycemia; DEXTROSE 12. 5% 2 -4 ml/kg IVP Note: Refer to pediatric drug dosing for DEXTROSE 25% and 12. 5% direction. Pediatrics (1 -8 years): DEXTROSE 25% 2 -4 ml/kg IVP or *GLUCAGON half adult dose (0. 5 mg IM) is recommended for peds patients weighing < 25 kg or **younger than 6 -8 yrs**.
2008 SOGs Update Page 77 Coma of Unknown Origin / Drug Overdose Intoxication NARCAN < 20 kg 0. 1 mg/kg IV/IO > 20 kg 2 mg dose IV/IO Consider Sodium Bicarbonate for tricyclic ingestions. SODIUM BICARBONATE 1 m. Eq/kg c. Adults: THIAMINE 100 mg IV or IM DEXTROSE 50% 50 ml SLOW IVP NARCAN 2 mg IVP SODIUM BICARBONATE 1 m. Eq/kg IVP for tricyclic ingestion. *As per system protocol.
2008 SOGs Update Page 80 Toxicologic / Poisoning Emergencies 4. Respiratory compromise or altered LOC: Adult: Peds: NARCAN 2 mg IVP, May < 20 kg NARCAN 0. 1 mg/kg repeat after 5 min. IV/IO or 0. 2 mg/kg ET > 20 kg NARCAN 2. 0 mg IV/IO maximum dose of 2 mg’s SODIUM BICARBONATE 1 m. Eq/kg for tricyclic 1 m. Eq/kg IVP for tricyclic ingestions ingestion.
2008 SOGs Update Page 81 Toxicologic / Poisoning Emergencies 8. DO NOT INDUCE VOMITING, ESPSCIALLY IN CASES WHERE CAUSTIC SUBSTANCE INGESTION IS SUSPECTED. 9. Contact medical control for specific information about individual toxic exposures and treatments. 10. Treatment for toxic exposure may be instituted as permitted by medical control, including the following: ● High-dose atropine for organophosphates ● Sodium bicarbonate for tricyclic antidepressants ● Glucagon for calcium channel blockers or beta-blockers ● Diphenhydramine for dystonic reactions ● Dextrose for insulin overdose
2008 SOGs Update Page 81 Continued Toxicologic / Poisoning Emergencies POTENTIAL EXPOSURES ● Burning overstuffed furniture ● Old burning buildings ● Pepto-Bismol like products ● Pesticides ● Common Plants = Cyanide = Lead fumes and Carbon monoxide = Aspirin = Organophosphates & Carbamates = Treat symptoms and bring plant/flower to ED
2008 SOGs Update Page 82 Toxicologic / Poisoning Emergencies SMELLS ● Almond ● Fruit ● Garlic ● Mothballs ● Natural gas ● Rotten eggs ● Silver polish ● Stove gas ● Wintergreen = Cyanide = Alcohol = Arsenic, parathion, DMSO = Camphor = Carbon monoxide = Hydrogen sulfide = Cyanide = Think CO (CO and methane are odorless) = Methyl salicylate
2008 SOGs Update Page 89 Cold Emergencies 9. If rhythm V-fib defibrillate once at 360 Joules (or equivalent biphasic manufacturer recommendation)
2008 SOGs Update Page 112 Musculoskeletal Injuries 6. For relief of pain: Refer to Pain Management SOG (pg. 11 -12)
2008 SOGs Update Page 124 Neonatal Resuscitation 12. ALS: Apply cardiac monitor Special Considerations per medical control: ● D 12. 5% 1 -2 ml/kg IV/IO (Dilute D 50 into ½ then ½ again to make D 12. 5%) ● Fluid Bolus 10 ml/kg NS/LR ● NARCAN 0. 1 mg/kg IV/IO/ET
2008 SOGs Update Page 130 Medications AMIODARONE 150 mg (Cordarone) Dose/ Route: Pulseless arrest: 300 mg rapid IVPWide-complex tachycardia: 150 mg’s IV over 10 minutes Peds: Pulseless arrest: 5 mg/kg rapid IV bolus Action: Antiarrhythmic Indications: Recurrent ventricular fibrillation or hemodynamically unstable ventricular tachycardia Contraindications: Hypersensitivity to Amiodarone, cardiogenic shock, sinus bradycardia, second or third degree AV blocks. Side Effects: Hypotension, bradycardia, AV block
2008 SOGs Update Page 130 Medications Benadryl (Diphenhydramine) Peds: 1 mg/kg IM or slow IVP not to exceed 50 mg’s
2008 SOGs Update Page 131 Medications Dextrose 50% Peds: 1 -8 yrs Dextrose 25% 2 -4 ml/kg IVP <1 yr Dextrose 12. 5% 2 -4 ml/kg IVP
2008 SOGs Update Page 132 Medications Etomidate 20 mg vial 2 mg/ml Amidate (Generic) Dose/ Route: 0. 3 mg/kg rapid IVP May repeat x’s 1 Action: Nonbarbituate hypnotic & general anesthetic minimal effects on myocardial activity, BP and Respirations. Onset 30 -60 seconds; duration 3 -5 minutes Indications: Prolonged ventilation needed. Pt. unable to protect airway. GCS <8. Severe chest injury. Imminent tracheal/laryngeal closure. Altered LOC with aspiration risk. Contraindications: Le. Forte fractures. Midface swelling. Nose bleeding. Nasal flattening. Spinal fluid leak. Side Effects: Low BP. Jerking of skeletal muscle. N/V. Transient pain at IV site. Hiccoughs.
2008 SOGs Update Page 132 Medications Glucagon (Gluca. Gen) Dose/ Route: Adult: 1 mg IM may repeat 1 mg IM in 15 min. if pt. remains unconscious Peds: 0. 5 mg (<25 kg) or younger than 6 -8 yrs. IM for a total dose of 1 mg if unable to start IV Action: blood glucose by stimulating the breakdown of glycogen in the liver; stimulating glucose metabolism in the liver Indications: It provides an alternative to D 50 W when IV access is not possible, overdose of beta blockers Contraindications: Allergy to proteins Side Effects: Generally well tolerated. Nausea and vomiting most common reaction
2008 SOGs Update Page 133 Medications Magnesium Sulfate Peds: 25 -50 mg/kg IV/IO over 10 -20 minutes max 2 gm for Torsades de Pointe Morphine Sulfate Peds: 0. 05 -0. 10 mg/kg IV. Max 2 mg use 0. 05 mg/kg dose on infant <6 mos. Max dose of 0. 5 mg’s
2008 SOGs Update Page 135 Medications Toradol (Ketorolac) Dose/Route: Adult: 30 mg’s IV or IM Peds: 1 mg/kg IM max of 30 mg’s 0. 5 mg/kg IV max of 15 mg’s Action: Anti-inflammatory analgesic. Indications: Mild to moderate pain. Contraindications: Hypersensitivity to drugs. Aspirin or ibuprofen allergy. Pregnant of nursing mother. Cerebrovascular bleed. Side Effects: GI bleeding, edema, rash or heart burn
2008 SOGs Update Page 135 Medications Versed (Midazolam) Dose/Route: Adult: Peds: 5 mg increments slow IVP up to 20 mg’s 0. 1 -0. 2 mg/kg IV/IO max of 0. 15 mg/kg
2008 SOGs Update Page 135 Medications Zofran (Ondansetron) Dose/Route: Adult: 4 mg’s IV/IM 12 yr & older: 8 mg disintegrating tab on tongue then swallow saliva Peds: Age 4 to 11 yrs 4 mg disintegrating tab on tongue then swallow saliva Action: Antiemetic Indications: Nausea and vomiting Contraindications: Known hypersensitivity to the drug. Children less than 12 years Side Effects: Diarrhea, constipation, abd pain, headache, dizziness, sedation, anxiety, tachycardia, chest pain
2008 SOGs Update Page 143 Region IV Additional Transfer Drugs Dobutamine Hydrochloride (Dobutrex) Description: Stimulates heart’s beta 1 receptors to increase myocardial contractility and stroke volume. At therapeutic doses, increases cardiac output by decreasing peripheral vascular resistance, reducing ventricular filling pressure, and facilitating AV node conduction. Indications: Increased cardiac output in short-term treatment of cardiac decompensation caused by depressed contractility, such as during refractory heart failure; adjunctive therapy in cardiac surgery. Contraindications: Patients hypersensitive to the drug or it’s components and in those with idiopathic hypertrophic subaortic stenosis. Dosage/Route: IVPB. 0. 5 to 1 mcg/kg/minute titrating to optimal dosage of 2 to 20 mcg/kg/minute. Side Effects: Headache; tachycardia; hypertension; PVC’s; chest pain; nausea/vomiting; SOB; asthma attacks.
2008 SOGs Update Page 152 Guidelines for Electrical Cardioversion Algorithm Cardioversion is the use of the defibrillator to terminate arrhythmias other than pulseless rhythms. Indications Rapid Ventricular and Supraventricular rhythms associated with severely compromised cardiac output. 1. Ventricular Tachycardia (VT) with a pulse 2. Supraventricular Tachycardia (SVT) Note: Emergency Cardioversion should not be used outside the hospital to convert rapid rhythms that result from digitalis toxicity (for this purpose the reference is to any tachyarrhythmia in any patient taking digitalis).
2008 SOGs Update Page 152 Continued Guidelines for Electrical Cardioversion Algorithm Procedure 1. Consider sedation. 2. Turn on defibrillator (monophasic or biphasic). 3. Attach monitor leads to the patient and ensure proper display of the patient’s rhythm. 4. Engage the synchronization mode by pressing the “sync” control button. 5. Look for markers on R waves indicating sync mode (if necessary adjust monitor gain until sync markers occur with each R wave). 6. Select appropriate energy level. ● Ventricular Tachycardia 100 J, 200 J ● Paroxysmal SVT 300 J, 360 J Monophasic energy dose (or clinically equivalent biphasic dose)
2008 SOGs Update Page 152 Continued Guidelines for Electrical Cardioversion Algorithm 7. Position conductor pads on patient (or apply gel to paddles). 8. Position paddle on patient (sternum-apex). 9. Announce to team members “stand clear – charging for Cardioversion”. 10. Announce to team members “I’m going to shock”, visually check to ensure that no one is touching the patient. 11. Turn oxygen off or direct the flow away from the patient’s chest. 12. Adhesive electrodes are preferred; if paddles used, apply 25 lb pressure on both paddles. 13. Press the “discharge” buttons simultaneously on paddles or shock button on the unit. 14. Check the monitor. If tachycardia persists, increase the joules according to the energy levels listed in item 6. (algorithm follows ACLS guidelines). Note: Reset the sync mode after each synchronized cardioversion. Most defibrillators default back to unsynchronized mode.
2008 SOGs Update Page 153 Guidelines for Orotracheal Intubation Policy Tracheal intubation is the preferred technique for controlling the airway in patients who are unable to maintain an open airway. Indications Adult & Pediatric 1. Unable to ventilate an unconscious patient with conventional methods. 2. The patient cannot protect his or her airway 3. Prolonged artificial ventilation is needed Note: Bag-mask ventilations may be considered in the pediatric patient when transport times are short. However, if bag-mask ventilations are not producing adequate ventilations and oxygenation, the infant or child should be intubated.
2008 SOGs Update Page 153 Continued Guidelines for Orotracheal Intubation Prior to Insertion 1. Preoxygenate the patient for several minutes with 100% oxygen prior to insertion attempt. 2. Ventilations should not be interrupted for more than 30 seconds for any reason. 3. Trauma patient orotracheal intubation is done with the patient’s head and neck stabilized in a neutral position. 4. Don protective equipment. 5. Have suction available. 6. Prepare intubation equipment.
2008 SOGs Update Page 153 Continued Guidelines for Orotracheal Intubation Insertion Procedure Note: When intubating a child the head is placed in a neutral position for patients with suspected trauma or sniffing position otherwise. 1. Insert the laryngoscope blade into the right side of the patient’s airway to the correct depth, sweeping the tongue toward the center of the airway while observing the desired landmarks. 2. Apply cricoid pressure as necessary. 3. After identifying the desired landmarks and lubricating the endotracheal (ET) tube, insert the ET tube between the patient’s vocal cords to the desired depth. 4. The laryngoscope is then removed while holding the ET tube in place; the depth marking on the side of the ET tube is noted. 5. If a stylet has been used, it should be removed at this time.
2008 SOGs Update Page 153 -154 Continued Guidelines for Orotracheal Intubation 6. 7. 8. 9. Inflate the pilot valve with enough air to complete the seal between the patient’s trachea and the cuff of the ET tube (usually 8 -10 m. L). Attach a BVM and ventilate while observing for chest rise with each delivered breath. To ensure proper ET tube placement bilateral breath sounds and absence of air sounds over the epigastrium are indications that the ET tube is properly placed. Visualization of the endotracheal tube passing thru the cords is essential.
2008 SOGs Update Page 154 Continued Guidelines for Orotracheal Intubation Note: Breath sounds travel easily in a child due to the small chest size. Carefully auscultate over the epigastrium to ensure that no bubbling or gurgling sounds are present. These sounds indicate esophageal intubation, mandating immediate removal of the tube and reverting to bag-mask ventilation. 10. 11. Confirm proper placement with the commercial tube check device, or end tidal CO 2 detector. Continue to manually stabilize or secure the ET tube in the determined proper position and monitor for continued proper placement while ventilating.
2008 SOGs Update Page 165 Guidelines for Initiation of Intraosseous Infusion (IO) I. Drugs authorized by this route: 2. AMIODARONE