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SNHD Protocols
SNHD Manual - The goal of the manual is to standardize prehospital care in Clark County If a physician giving on-line medical consultation directs you to provide care not explicitly stated in the protocol manual you must...? - You and the telemetry physician must immediately notify OEMSTS. In addition, after finishing the call, you as the provider must make all prehospital care documentation/records of your deviation and telemetry physician's name available to OEMSTS. This will then be used for Quality Improvement Review. If a physicians orders are against protocol, could possibly endanger patient, or there is a lack of resources. What must you do...? - You must notify telemetry physician why you are not able to carry out the order. Then, indicate the following on prehospital records: the order given, time it was given, and reason the order could not be carried out. Then all documentation/records must be available immediately after the call to OEMSTS and then will be used for Quality Improvement Review. What is a PATIENT -
- A person who has a complaint or mechanism suggestive of potential illness or injury;
- A person who has obvious evidence of illness or injury; or
- A person identified by an informed 2nd or 3rd party caller as requiring evaluation for potential illness or injury. Pediatric Patient Destination Age - < ASA - Acetylsalicylic Acid CCC CPR - Continuous Chest Compression CPR: Compressions - Push hard (≥2 Inches) Push fast (≥100/min) BVM - at 8 BPM DCAP-BTLS - Deformities; Contusions; Abrasions; Punctures/Penetrations; Burns; Tenderness; Lacerations; Swelling M.A.D. - Mucosal Atomizer Device Drugs that can be administered through a M.A.D. - Nalaxone
START triage - RED (Immediate/Life Threatening): Dyspnea, severe bleeding, severe medical problem, signs of shock, severe burns, open chest or abdominal injuries Yellow (Delayed/Seriously injured but no life threats): Burns (with no airway obstruction), multiple bone/joint injuries, back injuries with/without spinal cord injuries. Green (Walking Wounded): Minor fractures/soft tissue injuries Black (Dead/Fatally injured): Obviously dead, Fatally injures such as open brain trauma, respiratory arrest (if resources limited), cardiac arrest. Trauma Patients shall be transported... - According to Trauma Field Triage Protocol Burn patients shall be transported.... - According to Burn Protocol Pediatric patients shall be transported... - (<18 y/o) According to the Pediatric Destination Protocol Patients with evidence of a stroke shall be transported... - According to Stroke (CVA) protocol Sexual assault victims <13 y/o shall be transported to - Sunrise Hospital Sexual assault victims ≥18 y/o shall be transported to - UMC Sexual assault victims between ages 13 and 18 y/o shall be transported to - Either UMC or Sunrise Hospital Sexual assault victims outside the 50 mile radius of appropriate facility shall be transported to - Nearest appropriate facility Where should stable patients be transported to - Their hospital of choice or nearest facility For patients outside of the 50 mile radius of protocol designated transport destination shall be transported to - Nearest appropriate facility Waiting Room Placement requisites - Patient cannot be on a legal psychiatric hold and must meet the following requirements:
- Telemetry is required for STEMI's Nitroglycerine Contraindications -
- BP < 100 systolic
- HR < 60-100 > HR
- RHF
- Inferior Wall STEMI
- Any ED medications have been taken (Viagra/Levitra within the last 24 hours and Tadalifil/Cialis within the last 48 hours) ADULT Allergic Reaction: What is the treatment if no airway obstruction or breathing difficulties are present -
- Obtain vascular access
- Administer 50 mg IM/IV of Diphenhydramine
- Reassess in 5 min. ADULT Allergic Reaction: What is the treatment if airway obstruction or breathing difficulties are present -
- Administer 0.5 mg of 1:1000 IM Epinephrine (may repeat up to 1.5 mg with 15 min in between)
- 2.5 mg in 3 cc SVN Albuterol (repeat as necessary)
- IV access
- 500 cc NS bolus (may repeat until 2L)
- Administer 50 mg IM/IV Diphenhydramine
- Notify Receiving Hospital Epinephrine is a first-line drug that should be used... - Specifically for ACUTE allergic reactions (signs of airway involvement) Allergic Reaction Severity levels: -
- MILD: involves skin rashes, itchy sensations, or hives w/o respiratory involvement
- MODERATE: involve skin disorders and may include respiratory involvement such as wheezing, however patient is still able to maintain adequate tidal volume
- SEVERE: involve skin disorders, respiratory difficulty, and may include hypotension AMS - Altered Mental Status What should be checked on all AMS patients - Blood Glucose testing If AMS patient has a BG reading of < 60, you should -
- Administer Oral Glucose if patient is protecting airway (EMT-B) (or)
- Administer 25 g of D10 IV, may repeat after x1 after 5 min (or)
- Administer 1.0 mg of Glucagon IM if IV access is not available
If AMS patient has a BG reading of > 60, you should - Consider a 500 cc bolus of NS (repeatable to 2L) If AMS patient is unresponsive, with respiratory depression, and suspected narcotic overdose, you should - Administer NALOXONE 0.4 - 2.0 mg IN/IM/IV; may repeat 2.0 mg IN/IM/IV if patient slow to respond; titrate to effect; max dose 10 mg With an AMS patient consider the following differentials: -
- Head trauma
- CNS (stroke, tumor, seizure, infection)
- Cardiac (MI, CHF)
- Hypothermia
- Infection
- Thyroid
- Shock (septic, metabolic, traumatic)
- Diabetes
- Toxicological or ingestion
- Acidosis/Alkalosis
- Environmental exposure
- Hypoxia
- Electrolyte abnormality
- Psychiatric disorder Behavior Emergencies: Consider the following medical causes -
- Hypoxia
- Intoxication / Overdose
- Hypoglycemia / Electrolytes
- Head Injury
- Post-ictal State
- Excited Delirium What does the pneumonic S.A.F.E.R. stand for in S.A.F.E.R. Model -
- S-STABILIZE the situation by containing and lowering the stimuli.
- A-ASSESS and acknowledge the crisis.
- F-FACILITATE the identification and activation of resources (chaplain, family, friends or police).
- E-ENCOURAGE patient to use resources and take actions in his/her best interest.
- R-RECOVERY or referral - leave patient in care of responsible person or professional, or transport to appropriate facility. In a behavior emergency if patient is a harm to self you should - Apply 2 point restraints; consider law enforcement; use a 4 point restraint if needed In a behavior emergency if a patient is a harm to others - 4-point restraints; hood
If CO inhalation has occurred SPO2 will read high (even 100%) not because of oxygen but because of the CO. These patients are to be given 100% oxygen Which patients shall be transported to the UMC Burn Center via the Adult or Pediatric Trauma Center: -
- Second and/or third degree burns >20% body surface area (BSA).
- Second and/or third degree burns >10% body surface area (BSA) in patients under 10 years old or over 50 years old.
- Burns that involve the face, hands, feet, genitalia, perineum or major joints.
- Electrical burns, including lightning injury.
- Chemical burns.
- Circumferential burns.
- Inhalational injury. In case of a chemical burn and no NS or sterile water is present what should be used. - Use to cleanest and immediate water source (tap) Non-Traumatic Cardiac Arrest - If unwitnessed by EMS start 2 min of CCC, then proceed to following If witnessed, initiate CCC at ≥2 Inches/>100 BPM Apply AED and defibrillate if prompted Insert OPA/NPA and BVM at 8 BPM Shock if advised Continue CPR for 2 min Obtain vascular access Consider an extraglottic device Continue CPR/Defibrillation cycle H's & T's - Reversible Causes of Cardiac Arrest: · Hypovolemia - Volume infusion · Hypoxia - Oxygenation & ventilation, CPR · Hydrogen ion (acidosis) - Ventilation, CPR · Hypo/Hyperkalemia - Calcium Chloride, Glucose, Sodium Bicarbonate, Albuterol · Hypothermia - Warming · Tension pneumothorax - Needle decompression · Tamponade, cardiac - Volume infusion · Toxins - Agent specific antidote · Thrombosis, pulmonary - Volume infusion · Thrombosis, coronary - Emergent PCI Non-Specific Chest Pain treatment -
- Access IV
- Consider administering 2.5 mg of SVN Albuterol for constricted airways Suspected Aortic Dissection treatment -
- Ensure SPO2 is >94%
- Access IV
- Administer a 500 cc bolus of NS and repeat until 2L in order to treat hypoperfusion Normal Presentation Birth/Labor -
- Puncture amniotic sac if not already bursted
- Facilitate delivery of the head
- Suction the MOUTH 1st THEN THE NOSE
- Deliver upper shoulder then lower shoulder
- Deliver remainder of the baby
- Clamp and cut
- Repeat if multiple births
- Deliver placenta
- Obtain Vascular Access Limb Presentation Birth/Labor -
- Place patient in left lateral recumbent position
- Obtain IV
- Transport Breech Presentation Birth/Labor -
- Support body of the baby during delivery of the head
- IV access Cord Presentation Birth/Labor -
- Position patient on elbows and knees with hips elevated
- Wrap cord and keep it moist
- Insert gloved hand to lift baby off the cord and document cord pulse
- IV access If patient (mother) shows signs of hypoperfusion after delivery, what is the recommended NS bolus - 500 cc repeatable to 2L APGAR should be scored - 1 min and 5 min after birth APGAR - ACTIVITY - limp (0) / extremities flexed (1) / actively moving (2)
Remove from ambient heat, remove tight clothing, and use passive cooling measures HEAT CRAMPS: PO fluids if tolerated HEAT EXHAUSTION: Active cooling measures, 500 cc bolus IV/IO ; repeat until >90 BP or 2L HEAT STROKE: Assess airway as indicated, assess AMS as indicated, active cooling measures, fluid resuscitation Hypothermia Categories - MILD: 90°- 95° F (33°- 35° C) MODERATE: 82°- 90° F (28°- 32° C) SEVERE: <82 degrees F (<28° C) HYPOTHERMIA: Localized Cold Injury - Remove from ambient temperature Remove wet clothing Dry/warm patient Passive warming measures Do not allow the injury to refreeze and do not rub the injury warm Systemic Hypothermia - Remove from ambient temperature Remove wet clothing Dry/warm patient Passive warming measures Active warming (hot packs) IV access 500 cc bolus IV/IO ; repeat until >90 BP or 2L Preeclampsia indications - Severe headache, vision changes or RUQ pain may indicate pre-eclampsia. Overdose/Poisonings - If not contraindicated administer 50 g of Activated Charcoal PO Extraglottic Device if indicated IV access OPIATES: 0.4-2 mg IM,IN,IV repeatable until 10 mg Dystonic Reaction: 50 mg of Dyphenhydramine IM/IV
Pulmonary Edema/CHF - Ventilate patient if necessary and maintain SPO2 >94% IV access Reassess BP:
- Hypotensive: SBP < 100
- Normaltensive: SBP > 100
- Hypertensive: DBP > 100 Respiratory Distress: Wheezing or Bronchospasms - Administer 2.5 mg/3 cc SVN Albuterol Respiratory Distress: Stridor - Nebulize normal saline SVN AEMT Seizure Treatment - Ventilation Management Asses, reassess, and monitor VS (BG) Obtain IV access If indicated administer D10 (Glucagon if no IV is available) Retest Glucose and maintain ventilation Trauma Related Shock Treatment - Ventilate if necessary, maintain SPO2 > 94% Obtain IV Administer 1L NS bolus if no palpable pulse *** Follow General Trauma Protocol Non Trauma / Non Cardiogenic Shock Treament - Ventilate if necessary, maintain SPO2 > 94% Obtain IV Administer 1L NS bolus may repeat x1 if no rales present Cardiogenic Shock - Ventilate if necessary, maintain SPO2 > 94% Obtain IV Administer 500 cc NS bolus, may repeat x1 if no rales are present Distributive Shock - Sepsis, anaphylaxis, neurogenic, toxins
How long should scene time be with a suspected CVA patient - <10min Cincinnati Stroke Scale contains what three components - Facial Droop: (abnormal) one side of the face does not move at all Arm Drift: (abnormal) one arm drifts compared to the other Speech: (abnormal) none/slurred/inappropriate words Target Temperature Management & Post-Resuscitation - AFTER ROSC Obtain x2 IVs Perform Neuro Exam Expose patient and apply ice packs Administer cold NS 250cc/hr up to 1L Transport to approved Hypothermia Center Approved Hypothermia Centers - Centennial Hills Desert Springs MountainView Hospital St. Rose De Lima St. Rose Siena Southern Hills Spring Valley Summerlin Sunrise UMC Valley Hyperventilation is recommended for cardiac arrest or ROSC patients T/F - F When ventilating/oxygenating a patient what are your targeted SPO2 values -
94% with most patients 90% for patients on home oxygen for chronic conditions Difficult BVM Ventilation-MOANS: - M-Mask seal is difficult due to facial hair, anatomy, blood or secretions/trauma O-Obese or late pregnancy A-Age >
N-No teeth (roll gauze and place between gums and cheeks to improve seal) S-Stiff or increased airway pressures (asthma, COPD, obese, pregnant). Difficult Laryngoscopy-LEMON: - L-Look externally for anatomical distortions (small mandible, short neck, large tongue) E-Evaluate 3-3-2 Rule (Mouth open should accommodate 3 patient fingers, mandible to neck junction should accommodate 3 patient fingers, chin-neck junction to thyroid prominence should accommodate 2 patient fingers) M-Mallampati (difficult to assess in the field) O-Obstruction / Obese or late pregnancy N-Neck mobility. Difficult Extraglottic Device Placement-RODS: - R-Restricted mouth opening O-Obstruction / Obese or late pregnancy D-Distorted or disrupted airway S-Stiff or increased airway pressures (asthma, COPD, obese, pregnant). Pediatric Protocol (not destination) considers a patient a pediatric at what age - 12 and younger When is a pediatric patient under cardiac arrest - HR < 60 BPM In a general trauma assessment for a pediatric patient, what is the fluid bolus - 20cc/kg fluid bolus With a pediatric patient complaining of abdominal/flank pain, nausea and vomiting, what is the proper treatment if signs of hypovolemia are present - a 20cc/kg NS fluid bolus repeatable up to 60cc/kg Pediatric Allergic Reaction Treatment - No Signs of Airway/Breathing Compromise: +Obtain IV access
- Administer 1.0mg/kg IM/IV Diphenhydramine with
Also remember pediatrics can struggle to maintain body temperature so protect from hypothermia Transport to UMC Parkland Formula for Fluid Replacement: - 4 ml x (body wt in kg) x (% BSA burned) = total fluids for 24 hrs Give 1⁄2 in the first 8 hrs; give remainder over next 16 hrs. RULE of 9s for Pediatrics (child) - 18% for head 9% for arms 18% for anterior torso 18% for posterior torso 14% for a leg What is the difference in Pediatric and Adult Cardiac Arrest Management - Pediatric CPR is not CCC and if two person it is 15: neonates 3: Pediatric Drowning Protocol Is Similar to of an Adult, Except - If CPR is needed perform 15:2 CPR In case of Pediatric Hyperthermia/Hypothermia what is the fluid bolus - NS bolus 20 ml/kg IV/IO; repeat to effect age appropriate SBP ≥70 + 2 x Age max 60 mL/kg What can occur as patient is cooled - Intense Shivering What are forms of active cooling - Ice packs, fanning (either manually or a/c) Neonatal Resuscitation - If baby is not crying and/or doesnt have good tone you:
- Dry and warm the baby
- Open Airway
- Stimulate it Then if HR <100 or baby is apneic or gasping:
- Ventilate with BVM and Monitor SPO
- Keep SPO2>94%
- Maintain warm
- If HR<60 begin 3:1 CPR
Finally transport to appropriate facility and notify them If overdose/poisoning was ingested within 1 hour of EMS arrival you should - Administer Activated Charcoal as long as it is not contraindicated and administer it at 1.0g/kg PO with a minimum dose of 10 g and max dose of 50 g In Pediatric Opiate Overdose - Administer nalaxone at 0.1 mg/kg IM/IN/IV w/ max single dose of 2.0 mg and max dosage of 10 mg In Pediatric Dystonic Reaction - Administer 1mg/kg Diphenhydramine Im/IV with a max dose of 50 mg If Pediatric patient is seizing you must check if patient is ________________ and if so _______________ - febrile; cool the patient Pediatric dose of D10 for a seizure event - 5ml/kg w/ max of 250 ml Pediatric dose of Glucagon for seizure - 0.5 mg if no IV is available Estimated minimum SBP calculation - (Age in years x 2) + 70 Only works till age 10 For a non-trauma pediatric shock patient you should... - Check BG: If Hypoglycemic (<60 or <40 for newborn): Administer oral glucose (or) 1ml/kg IV D10 w/ max of 250 ml (or) 0.5 mg if <20kg or 1.0 mg if >20kg Glucagon IM Administer 20cc/kg NS bolus repeat x2 if no rales If Hyperglycemic (>250): NS bolus of 10cc/kg for hypotension; may be repeated x2 if no signs of rales Normal BG: Administer NS bolus of 20cc/kg for hypotension; may be repeated x2 if no signs of rales What is the fluid bolus in a pediatric with inhalation injuries - 20cc/kg fluid bolus; repeatable to 60cc/kg to treat hypoperfusion
transport. I. For patients meeting "Code White" or "Code STEMI" criteria, a preliminary telemetry report should be made to notify the receiving facility of the type of activation, and an estimated arrival time. An "Information Only" telemetry should follow once transport has been initiated. Notification reports should include the following: -
- Patient age
- Chief complaint
- Type of bed required (monitored/unmonitored)
- Unit number
- ETA What is a DNR - A valid DNR Identification is a form, wallet card, or medallion issued by the Southern Nevada Health District, Nevada Division of Public and Behavioral Health, or an identification issued by another state indicating a person's desire and qualification to have life-resuscitating treatment withheld. Who writes a DNR - A physician licensed in this state T/F? A verbal instruction from a friend/family constitutes as a valid DNR/POLST - F Who can revoke a DNR/POLST - Only the patient If the patient revokes their DNR/Polst what should the ems provider do? - The EMS provider shall document the presence of the DNR/POLST Order or Identification, and how the patient indicated that he/she wanted the Order or Identification to be revoked. Faxed, copied or electronic versions of the DNR Identification/POLST are legal and valid. T/F? - T What can an EMS provider do if a DNR/POLST is NOT revoked. - ONLY supportive care and withhold life-resuscitating treatment. What are forms of supportive care? -
- Suction the airway
- Administer oxygen
- Position for comfort
- Splint
- Control bleeding
- Provide pain medication (ALS only)
- Provide emotional support
- Contact hospice, home health agency, attending physician or hospital as appropriate
- Be attentive of any actions the patient may take to revoke his authorization to withhold life- resuscitating treatment If an EMS provider is unable to agree with/follow a DNR/POLST he can - transfer the patient with the DNR/POLST to another provider/facility that can follow the orders What are limitations on who an EMS provider can provide inter-facility transport to - Their capabilities (scope of practice). They are only allowed to transport a patient who's therapies are in-line with the ambulance attendant's capabilities Arterial lines should be discontinued unless appropriate personnel from the initiating facility accompany the patient. T/F? - T INTERFACILITY: what should be done with IV pumps - Discontinued unless there is a capable personnel able to accompany the patient INTERFACILITY: what should be done with oro/nasalgastric tubes - may be left in place and should either be closed off or left to suction per order of the transferring physician. INTERFACILITY: At whose discretion may orthopedic devices be left? - ambulance attendant's discretion as to ability to properly transport the patient with existing device(s) in place. INTERFACILITY: a patient in need of ventilatory assistance should have ... - If on a mechanical device, someone capable of operating the apparatus If manual ventilation is needed, at least two personnel INTERFACILITY: prior to transport what must be relayed between the two physicians -
- Reason for transfer
- Patient condition
- Estimated time of arrival INTERFACILITY: what must the physician provide you with -
- name of the receiving facility and receiving physician
- copies of any available diagnostic tests, X-rays,
