Midstate Protocals

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Midstate Protocals
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  1. STROKE GUIDELINE
    • 1.¬†UNIVERSAL PATIENT CARE GUIDLELINE
    • 2. IV Access >= 18g
    • 3. Check Blood Glucose Level
    • 3b. If Blood Glucose < 70 mg/dcl then Admin 25G of D50
    • 4. Cincinnati Prehospital Stroke Scale
    • 4a. Assess for new unilateral arm or leg weakness
    • 4b. Assess speech - slurred or inappropriate words?
    • 4c. Assess for new facial droop?
    • 5. Transport Patient to appropriate receiving facility
    • 6. Contact Medical Control
    • 6a. Contact receiving hospital for "Acute Stroke Alert"
    • 1) Time of sympton onset
    • 2) Description of neurologic deficits (Cincinnati stroke scale)
    • 3) Blood glucose level
  2. UNIVERSAL PATIENT CARE GUIDLELINE
    • 1) Scene Safety/BSI
    • 2a) Initial Assessment
    • 2b) Adult or Pediatric
    • 2c) C-Spine stabilization if indicated
    • 2A) Cardiac Arrest -> Cardiac Arrest Guideline (Adult of Pediatric)
    • 3a) Vital Signs (including temp & pain severity)
    • 4) Airway Guideline (Adult or Pediatric)
    • 5) Consider Pulse Oximetry
    • 6) Consider Cardiac Monitor & 12 Lead EKG
    • 7) Appropriate Guideline -> If patient doesn't fit a guideline Contact Medical Control
  3. ANAPHYLAXIS
    • 1. Unstable Hemodynamics w/ hypotoensive pt or impending upper airway obstruction; stridor; severe wheezing &/or respitory distress.
    • 2. UNIVERSAL PATIENT CARE GUIDLELINE
    • 3. AIRWAY MANAGEMENT GUIDELINE
    • 4. Oxygen
    • 5. Epinephrine 1:1000 0.3mg SQ *
    • 6. IV Ringers Lactate or Normal Saline titrated to a BP > 100 systolic
    • 7. Cardiac monitoring
    • 8. If patient remains unstable hemodynamically, adminitster Epinephrine 1:10,000 0.1mg Slow (over 3 minutes) IV or IO (ET if no vascular access), to a maximum of 0.3mg, titrated to effect. Repeat in 2 min prn.
    • 9. Benadryl 1mg/kg Slow IVP (max. 50mg)
    • 10. Albuterol 2.5mg via nebulizer for respiratory distress
    • 11. Establish Medical Control -> possible physician orders: Dopamine Drip, Repeat doses of Epinehphrine (or Epi-Pen for EMTs)
    • * (EMT protocal: Epinephrine 1:1000 0.3mg SQ [Epi-Pen autoinjector] Unstable anaphylaxis patients must meet all the following criteria for EMTs: 1)Unstable Hemodynamics w/ hypotension (SBP < 90mmHg) 2)Difficulty in breathing and severe wheezing 3)Hives & Itching 4)Patient has been exposed to known allergen 5)Difficulty in swallowing)
  4. High-Risk Conditions That Merit Paramedic Care (mostly)
    • 1. primary complaint of chest pain, chest discomfort, palpitations, or syncope in pt's of any age
    • 2. complaint of shortness of breath or difficulty breathing
    • 3. pt's w/ a new neurological deficit or presentation of stroke
    • 4. pt's w/ an initial diagnostic finding of blood glucose <60 ro >400
    • 5. pt's who meet the physiologic or anatomic triage criteria for transport to a level 1 or 2 trauma center
    • 6. pt's for whom the transporting service reqeuests the presence of the Paramedic
    • 7. pt's for whom Paramedic treatment (not assessment only) has been initiated
  5. 12-Lead ECG Indications
    • (after initial set of vitals)
    • 1. chest pain, presure or discomfort
    • 2. radiating pain to neck or left arm. also right arm, shoulder or back
    • 3. dyspnea
    • 4. CHF
    • 5. cardiac arrhythmias
    • 6. syncope/near syncope
    • 7. profound weakness
    • 8. epigastric discomfort
    • 9. hyperglycemia in diabetic pt's
    • 10. sweating incongruent w/ enviroment
    • 11. nausea, vomiting
    • 12. previous cardiac history or other cardiac factors
    • 13. presence of anginal equivalents
    • 14. overdoses
    • 15. altered mental status
    • DO NOT DELAY SCENE TIME > 4 MIN TO PERORM 12-LEAD ECG
  6. PEDIATRIC BURN PT (<13y/o)
    • 1. PEDIATRIC PT ASSESSMENT GUIDELINE
    • 2. OXYGEN
    • 3. IV LACTATED RINGERS (in non affected area of burn if possible) [IO ACCESS IF INDICATED]
    • 4. TYPE OF BURN
    • a) THERMAL
    • b) CHEMICAL
    • c) OPTHALMIC
    • d) ELECTRICAL
  7. PEDIATRIC BURN PT (<13y/o)
    THERMAL BURNS
    • 1. COVER BURNS w/ CLEAN, DRY DRESSING (< 10% & superficial or partial thickness you may moisten towels/sheets w/ sterile NS for comfort.)
    • 2. IF > 20% BSA, BEGIN FLUID RESUSCITATION @ 250-500 ML FLUID BOLUS & TITRATE BP > 100 SBP
    • 3. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
    • 4. ESTABLISH MEDICAL CONTROL (possible orders: additional MS, Intubation.
  8. PEDIATRIC BURN PT (<13y/o)
    CHEMICAL BURNS
    • 1. CONSIDER ANY CHEMICAL BURN SITUATION AS A HAZMAT SITUATION
    • a) if potential hazmat situation exists, notify receiving hospital ASAP
    • b) identify chemical if possible
    • 2. REMOVE AFFECTED CLOTHING & JEWELRY
    • 3. FLUSH w/ COPIOUS AMOUNTS OF WATER OR SALINE (unless contraindicated). IRRIGATE BURNS TO EYES w/ MIN OF 1L LACTATED RINGERS. ALKALINE BURNS SHOULD RECEIVE CONTINUOUS IRRIGATION THROUGHOUT TRANSPORT. CONSIDER MORGAN LENS FOR EYE IRRIGATION IF > 6 y/o. BRUSH OFF DRY POWDER
    • 4. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
    • 5. ESTABLISH MEDICAL CONTROL (possible orders: additional MS)
  9. PEDIATRIC BURN PT (<13y/o)
    OPTHALMIC BURNS
    • 1. IMMEDIATE/CONTINUOUS FLUSHING OF THE AFFECTED EYE w/ LACTATED RINGERS. IF CONTACT LENSES ARE KNOWN TO BE IN THE PT'S EYES, AN ATTEMPT SHD/ BE MADE TO REMOVE THEM & CONTINUE FLU. SHING.
    • 2. INSTILL 1/2 DROPS OF OPHTHALMIC ANESTEHESIA (unless contraindicated). PLACE MEDICATION ONTO THE LOWER LID.
    • 3. PLACE MORGAN LENS (if pt > 6 y/o) IN THE AFFECTED EYE(S) CONTINUOUSLY FLUSH w/ LACTATED RINGERS WHILE ENROUTE TO THE HOSPITAL. RUN 2L OF FLUID WIDE PER EYE, THEN ADMINISTER KVO RATE.
    • 4. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
  10. PEDIATRIC BURN PT (<13y/o)
    ELECTRICAL BURNS
    • 1. SUSPECT SPINAL INJURY 2NDARY TO TETANIC MUSCLE CONTRACTION. IMMOBILIZE PT. ASSESS FOR ENTRANCE & EXIT WOUNDS.
    • 2. IV NS
    • 3. CARDIAC MONITOR. TREAT ANY CARDIAC RHYTHM DISTURBANCES PER QUIDELINE.
    • 4. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
    • 5. ESTABLISH MEDICAL CONTROL
  11. CINCINNATI PREHOSPITAL STROKE SCALE
    • 1. FACIAL DROOP: Have pt show teeth or smile
    • 2. PRONATOR DRIFT: Have pt close eyesy & extends both arms straight out, palms up, for 10 seconds. Normal: Both arms move the same, or both do not move at all. Abnormal: 1 arm either does not move, or 1 arm drifts downward (pronator drift) compared to the other.
    • 3. SPEECH: Have pt repeat "The sky is blue in Cincinnati". Abnormal: slurs, says wrong words or is unable to speak.
  12. PEDIATRIC GCS "CHILD"
    • EYE OPENING
    • 4 opens spontaneously
    • 3 opens to speech
    • 2 opens to pain
    • 1 none
    • VERBAL RESPONSE
    • 5 oriented
    • 4 confused
    • 3 inappropriate words
    • 2 incomprehensible words
    • 1 none
    • MOTOR RESPONSE
    • 6 obeys commands
    • 5 localizes pain
    • 4 withdrawl to pain
    • 3 flexion (pain)
    • 2 extention (pain)
    • 1 none
  13. PEDIATRIC GCS "INFANT"
    • EYE OPENING
    • 4 opens spontaneously
    • 3 opens to speech
    • 2 opens to pain
    • 1 none
    • VERBAL RESPONSE
    • 5 coos & babbles
    • 4 irritable cry
    • 3 cries in pain
    • 2 moans in pain
    • 1 none
    • MOTOR RESPONSE
    • 6 spontaneous movement
    • 5 withdrawls to touch
    • 4 withdrawls to pain
    • 3 flexion (pain)
    • 2 extention (pain)
    • 1 none
  14. RULE OF NINES ADULT
  15. RULE OF NINES PEDI
  16. EMERGENCY CHILDBIRTH
    • 1. UNIVERSAL PT CARE GUIDELINE
    • 2. O2
    • 3. ESTABLISH IV NS KVO
    • 4. CROWNING OR URGE TO PUSH - VISUAL INSPECTION (if no crowning or urge to push Transport to OB facility)
    • 5. PREPARE FOR CHILD BIRTH
    • 6. CONTROL DELIVERY w/ PALM OF HAND SO INFANT DOES NOT "EXPLODE" OUT OF VAGINA. SUPPORT INFANTS HEAD AS IT EMERGES & SUPPORT THE PERINEUM w/ GENTLE HAND PRESSURE.
    • 7. SUPPORT & ENCOURAGE MOTHER TO CONTROL THE URGE TO PUSH.
    • 8. TEAR THE AMNIOTIC MEMBRANE, IF STILL INTACT & VISIBLE OUTSIDE THE VAGINA. CHECK FOR CORD AROUND THE NECK.
    • 9. GENTLY SUCTION MOUTH & NOSE (w/ BULB SYRINGE) OF INFANT AS SOON AS HEAD DELIVERED
    • 10. NOTE PRESENCE OF ABSENCE OF MECONIUM STAINING. (if meconium is present & infant has a HR<100, poor respiratory effort or poor muscle tone intubate & suction prior to stimulating breathing. ventilate w/ BVM after suctioning.)
    • 11. AS SHOULDERS EMERGE, QUIDE HEAD & NECK SLIGHTLY DOWNWARD TO DELIVER ANTERIOR SHOULDER, THEN THE POSTERIOR SHOULDER.
    • 12. REST OF INFANT SHOULD DELIVER w/ PASSIVE PARTICIPATION. GET FIRM HOLD ON THE BABY.
    • 13. REPEAT GENTLE SUCTIONING THEN PROCEED TO POSTPARTUM CARE OF INFANT & MOTHER.
    • 14. DRY & KEEP INFANT WARM. IF POSSIBLE SKIN SKIN TO SKIN CONTACT w/ THE MOTHER WHILE COVERING THE INFANT w/ A BLANKET.
    • 15. ESTABLISH DATE & TIME OF BIRTH & RECORD, DO APGAR @ 1 & 5 MIN.
  17. AEIOU-TIPS
    • General Causes of Reduced LOC
    • 1. Alcohol
    • 2. Epilepsy
    • 3. Insulin (Hypo/Hyperglycemia)
    • 4. Over Dose
    • 5. Uremia
    • 6. Trauma
    • 7. Infarctions (Cardiac or Cerebral)
    • 8. Poisoning, Phychological
    • 9. Sepsis
  18. PEDIATRICS ANAPHYLAXIS
    • 1. Pediatric Assessment Guide
    • 2. Oxygen & Pediatric Airway Guide
    • 3. Epi (1:1000) 0.01 mg/kg IM
    • 4. IV/IO access Fluid Bolus 20 ml/kg of NS or LR
    • 5. If bronchospasm admin 2.5mg Albuterol via Neb, Benedryl 1mg/kg (50mg max) IV/IO over 1 min (IM if no IV/IO). If no improvement Epi 1:10,000 .0.01 mg/kg (max 0.3mg) slow IV/IO push.
    • 6. Establish Medical Control
    • Possible Physician Orders1. Repeat Epi IM or IV doses q 52. Epi infusion 0.1 - 0.3 mcg/kg/min increasing to 1.0 mcg/kg/min as necessary3. Fluid Bolus 20 ml/kg of NS or LR
  19. NEONATAL RESUSCITATION
    • 1. UNIVERSAL PATIENT GUIDELINE
    • 2. POST PARTUM CARE FOR INFANTS GUIDELINE
    • 3. Position infant on his/her back w/ head down. Check for Meconium
    • 4. If thick Meconium, w/ HR < 100, weak respiratory effort, or poor muscle tone, aggressively suction until clear using ET Tube immediately following birth. Ventilate w/ BVM after suctioning.
    • 5. Suction mouth & nose w/ bulb syringe. Dry infant & keep warm.
    • 6. Stimulate infant by rubbing his/her back or flicking the soles of the feet. If the infant show decreased LOC, mottling or cyanosis, &/or presents w/ a HR < 100 BPM.
    • a. Breathing, HR > 100
    • b. Breathing, HR > 100 but cyanotic
    • c. Apneic or HR < 100
  20. NEONATAL RESUSCITATION
    Breathing, HR > 100
    1. observe
  21. NEONATAL RESUSCITATION
    Breathing, HR > 100 but cyanotic
    • 1. admin supplemental O2
    • 2. if after 30 sec, persistent cyanosis admin positive pressure ventilation
  22. NEONATAL RESUSCITATION
    Apneic or HR < 100
    • 1. positive presure ventilation
    • 2. if after 30 sec, HR < 60, admin positive presure ventilat ion & chest compressions
    • 3. if after 30 sec, HR < 60, admin EPINEPHRINE 0.01 mg/kg (1:10,000) IV/IO; 0.1 mg/kg (1:1,000) ET. consider maternal condition including medications. NARCAN 0.1 mg/kg
    • 4. IM/IV/IO/ET IV/IO access, 10-20 mg/kg NORMAL SALINE bolus
    • 5. obtain BGL
    • 6. ESTABLISH MEDICAL CONTROL Possible Physician Orders: repeat EPINEPHRINE, NARCAN. DEXTROSE 5% 5-10 ml/kg over 20 min other treatment options per consultation

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