Marin County EMS Protocols (ALS Treatment Guidelines)

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nickgp
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208855
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Marin County EMS Protocols (ALS Treatment Guidelines)
Updated:
2013-03-22 01:30:24
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Marin county ems protocols paramedic
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A set of flash cards for studying Marin County ALS protocols.
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  1. ROUTINE MEDICAL CARE (RMC) ALS
    • INDICATION ƒ
    • To define procedures indicated by ALS RMC per treatment guidelines or ƒ
    • Patient condition warrants ALS care/assessment, but does not meet the indication of any other treatment policy
    • TREATMENT ƒ
    • As indicated:ƒ
    • -Vascular access ƒ
    • -Blood glucose monitoring as indicated by ALOC or patient historyƒ
    • -Cardiac monitor ƒ
    • -Advanced airway management ƒ
    • -Pulse oximetry ƒ
    • -Temperatureƒ ETCO2ƒ
    • -12 lead ECG ƒ
    • -For pediatric patients, use length based color-coded resuscitation tape and apply corresponding wrist band
  2. ADULT INTRAOSSEOUS INFUSION
    • INDICATION ƒ
    • Patient in extremis, cardiac arrest, profound hypovolemia, or septic and in need of immediate delivery of medications / fluids and immediate IV access is not possible
    • CRITICAL INFORMATION ƒ
    • All approved ALS IV medications may be administered IO ƒ
    • No more than 2 attempts for IO access at sceneƒ
    • Absolute contraindications: ƒ
    • -Recent fracture of involved bone (less than 6 weeks) ƒ
    • -Vascular disruption proximal to insertion site ƒ
    • -Inability to locate landmarks ƒ
    • Relative contraindications: ƒ
    • -Infection or burn overlying the site ƒ
    • -Congenital deformities of the bone ƒ
    • -Metabolic bone diseaseSPECIAL
    • CONSIDERATION ƒ
    • Pressure bags for optimal flow of IO infusionsƒ
    • Administer Lidocaine 2% prior to saline bolus if patient responsive to painful stimuli
    • DOCUMENTATION- ESSENTIAL ELEMENTS ƒ
    • Insertion site
  3. DETERMINATION OF DEATH
    • INDICATION Patient in cardiac arrest where resuscitation may be limited or not indicated and who does not meet criteria for BLS Determination of Death
    • PROCEDURE ƒ
    • Confirm pulseless and apneic. Apply leads and document rhythm in two monitoring leads for one minute or in one lead if an AED is the only available monitor. ƒ
    • Determination of death can be made prior to initiating resuscitation when:ƒ
    •  Medical (ALL must be present)ƒ
    •    The presenting rhythm is asystole or a non-perfusing wide ventricular complex ƒ
    •    Event was unwitnessedƒ
    •    Effective bystander CPR, based on CPR guidelines and paramedic judgment, was not initiatedƒ
    • No AED or manual shock delivered ƒ
    • Trauma (Either may be present)ƒ
    • MCI incident where triage principles preclude initiation of CPRƒ
    • Blunt, penetrating or profound multi-system trauma with asystole or a non-perfusing wide ventricular complex ƒ
    • If determination of death cannot be made, perform ALS resuscitation for 20 minutes or until three rounds of medication appropriate for presenting rhythm have been administered.ƒ
    • If the above procedures have been completed without ROSC, resuscitation may be discontinued and determination of death made when any of the following are present:ƒ
    • Information becomes available precluding initiation of resuscitation efforts ƒ
    • ETCO2 is less than or equal to 10mm/Hg ƒ The rhythm is asystole or a non-perfusing wide ventricular complex ƒ
    • When applicable, notify the appropriate law enforcement agency and remain on the scene until law enforcement or coroner arrives ƒ
    • Complete the Determination of Death form and leave a copy at the scene if the patient will be transferred to the coroner.
  4. ADULT SEDATION
    • INDICATION ƒ
    • Agitation / combativeness interfering with critical ALS interventions and airway control or that endangers patient or caregiver ƒ
    • Cardioversion / Cardiac Pacing
    • CRITICAL INFORMATION ƒ
    • Relative contraindications:ƒ
    • -Nausea / vomiting ƒ
    • -ALOC ƒ
    • -Hypotension (SBP < 100) ƒ Suspected drug / alcohol intoxication ƒ
    • -Concomitant narcotic administration in the agitated/ combative patient
    • TREATMENT ƒ
    • ALS RMCƒ
    • Cardioversion / cardiac pacing- Midazolam 1 mg slow IV/IO push loading dose; may repeat 1-2 mg in 3 minutes to achieve desired degree of sedation up to a maximum dose of 0.1mg/kg ƒ
    • Agitation / combativeness- Midazolam ƒ
    • -IV/IO: 2 mg slowly; MR in 3 minutes to maximum dose 0.1mg/kg. ƒ
    • -IN: 5 mg (2.5 mg in each nostril)ƒ
    • -IM: 0.1 mg/kg ƒ
    • Patients receiving sedation for airway management who have long transport times may receive sedation maintenance doses of Midazolam 1 mg IV/IO every 15 minutes
    • Weight based calculation: (weight in kg)(.1)=(dose in mg) 
    • * <40kg=4mg, >100kg=10mg
    • SPECIAL CONSIDERATIONƒ
    • Sedation for airway management does not mandate intubation, but may require airway/ventilation support ƒ
    • Patients receiving Midazolam may experience hypotension
  5. ADULT PAIN MANAGEMENT
    • INDICATION ƒ
    • Patient exhibits or is determined to have measurable or anticipated pain or discomfort
    • CRITICAL INFORMATION ƒ
    • Origin of pain (examples: isolated extremity trauma, chronic medical condition, burns, abdominal pain, multi-system trauma) ƒ
    • Mechanism of injury ƒ
    • Approximate time of onset ƒ
    • Complaints or obvious signs of discomfort ƒ
    • Use Visual Analog Scale (0-10) or Wong/Baker Faces Pain Rating Scale if non-English speaking adult. Express results as a fraction (i.e. 2/10 or 7/10) ƒ
    • Vital signs ƒ
    • Presence of special infusion apparatus for narcotic or oncology agents may help to determine dosing
    • TREATMENT ƒ
    • Morphine Sulfate IV/IO: 5 mg slowly; MR q 5 minutes, max. dose 20 mg. ƒ
    • -If unable to establish IV/IO, administer Morphine Sulfate IM 5-10 mg; MR in 20 minutes, max. dose 20 mg ƒ
    • If significant pain persists after Morphine Sulfate 10 mg IV/IO, consider Midazolam 2 mg IV/IO; MR in 3 minutes to a max of 0.05 mg/kg. Monitor patient’s ETCO2. ƒ
    • If patient unable to take Morphine Sulfate, consider Midazolam ƒ
    • -IV/IO: 2 mg slowly; MR in 3 minutes to maximum dose 0.1mg/kg. ƒ
    • -IN: 5 mg (2.5 mg in each nostril)ƒ
    • -IM: 0.1 mg/kg ƒ
    • Patients with SBP<100, head trauma, multi-system trauma with abdominal/thoracic trauma, decreased respirations, ALOC (GCS < 15), or women in labor
    • DOCUMENTATION- ESSENTIAL ELEMENTS ƒ
    • Initial and post treatment pain score, expressed in a measurable form (i.e. 7/10) ƒ
    • Interventions used for pain management (i.e. ice pack, splint, Morphine Sulfate, Midazolam) ƒ
    • Reassessment after interventions ƒ
    • Initial and post treatment vital signs (including GCS in patients with ALOC) ƒ
    • Physician consult if requiredƒ
    • ETCO2

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