Transcript 2008 SOGs Update - Sugar Creek Ambulance Service

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 20ml/hr. For pediatric patients, use a dial-aflow or infuse at 20ml/hr when utilizing IV tubing without dial-a-flow.
Establish vascular access IV/IO. NORMAL SALINE/LACTATED
RINGERS. Fluid bolus with 20ml/kg. Repeat if no improvement to
maximum of 60ml/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 20ml/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 mmHg)
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 4-81mg 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 0.4mg 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 mmHg 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% O2 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 8-10mL).
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 20ml/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 mL/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 0.5mg SQ
*EPINEPHRINE 1:1000
May repeat x 1 after 15 min.
if minimal response.
SQ 0.01mg/kg to maximum
of 0.3mg’s . To be considered for
children weighing 30 kgs or less.
Not for neonates.
OR *EPINEPHRINE PEN
PEDIATRIC 0.15mg into thigh
muscle. To be used for children <
30 kgs.
OR *EPINEPRHINE PEN
ADULT 0.3mg 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 20ml/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
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 1-800-25ABUSE.
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
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:
324mg PO (four 81mg 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
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. Turn oxygen off or direct the flow away from the patient’s chest.
9. Ensure that no one else is in contact with the patient.
10. Verbally and visually clear everybody, including yourself before any
defibrillation attempts.
11. 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.
12. Resume CPR immediately after the shock.
13. Administer appropriate medications.
14. 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% O2 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% O2 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 20ml/kg provided
lungs are clear. In pediatric patients 1-8 years old infuse the
LACTATED RINGERS at 20ml/kg. Neonates 0-1 month, obtain
IV of LACTATED RINGERS, infuse at 10ml/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 4mg IV/IM. IVP ZOFRAN is given over 2 minutes.
ZOFRAN 8mg disintegrating tab place on top of tongue. When dissolved (in
seconds) ask patient to swallow saliva.
Children 4-11 yrs of age
ZOFRAN 4mg disintegrating tab place on top of tongue. When dissolved (in
seconds) ask patient to swallow saliva.
2008 SOGs Update
Page 11
Pain Protocol
ALS – in addition to BLS/ILS care
6. Adult:
TORADOL 30mg IV or IM (IM dosage should be reserved for longer transport
times).
Peds:
TORADOL (Peds 2-16 yrs.) 0.5mg/kg IV - Max of 15mg’s OR
1mg/kg IM - Max of 30mg’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: 0.5mg IVP while awaiting pacer. May
repeat to a total dose of 3mg. 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: 400mg in 250ml D5W (1600mcg/ml). Titrate to
maintain systolic BP of 90-100 mmHg by slowly increasing drip
rate. Dosing range 10-20mcg/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 0.5mg IVP,
may repeat to a total of 3mg’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 NonInvasive External Cardiac Guidelines pg. 29-30). Consider ATROPINE
0.5mg IVP, may repeat to a total of 3mg’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 150mg 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 150mg IV over 10 minutes.
b. If Ventricular Tachycardiac persists after AMIODARONE 150mg’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 5mg/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 5mg IV or VERSED 2-4mg IVP
Peds:
DIAZEPAM 0.1mg/kg IV/IO for children <5 years max 5mg. >5 years max 10mg.
VERSED 0.1-0.2mg/kg IV/IO. Max 0.15mg/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 150mg IV over 10 minutes.
Peds:
AMIODARONE 5mg/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 150mg 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 300mg IVP.
Note: Consider MAGNESIUM SULFATE 1-2gm if rhythm
Torsades De Pointes.
Consider additional dose of AMIODARONE 150mg 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 5mg/kg IV/IO.
Consider MAGNESIUM SULFATE 25 to 50 mg/kg IV/IO (maximum dose; 2g)
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 1.0mg IVP. May repeat every 3-5 minutes (if asystole
persists) to a maximum of 3 doses (3mg). May be given by ETT at twice
the IV dose or 2mg’s diluted in a minimum of 10ml 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 1.0mg IV or IO for PEA with rate less than 60. May repeat
every 3-5 minutes to a maximum of 3 doses (3mg). May be given by ETT at twice the
IV dose or 2mg’s diluted in a minimum of 10ml 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 mmHg
2008 SOGs Update
Page 51
Cardiogenic Shock
4. DOPAMINE DRIP starting at 10mcg/kg/min. with 60 drop tubing or
Dial-a-Flow as available. Titrate to SBP > 90mmHg
2008 SOGs Update
Page 58
Intubation Using Versed
4.
Administer VERSED 5mg’s IVP followed by VERSED 5mg’s IVP at two
minute intervals until sedation is achieved or to a maximum of 10mg’s total.
If additional sedation is necessary to reduce or eliminate a recurrent state of
agitation following intubation, administer VERSED 4mg’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 0.3mg/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 0.3mg/kg rapid IV.
Intubation must be confirmed using cord visualization and auscultation (refer to
instructions on SOG pg. 1 for suggested confirmation techniques).
Utilize CO2 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
1.25mg (1.5ml) via nebulizer
Amiodarone
5mg/kg IV/IO; can repeat the 5mg/kg IV/IO bolus. Maximum single
dose of 300mg’s.
Atropine
0.02 mg/kg IV/IO or 0.03mg/kg ETT
minimum single dose 0.1mg
maximum doses:
<8 years single dose 0.5mg
<8 years total dose 1mg
8-16 years single dose 1mg
8-16 years total dose 2mg
2008 SOGs Update
Page 62 Continued
Pediatric Drug Doses
*Glucagon
(0.5mg IM) is recommended for peds patients weighing < 25kg 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 0.01ml/kg to maximum of 0.3mg’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% 25Gm (50ml)
IVP
*GLUCAGON 1mg IM
If after 15 min. the patient
remains unconscious, may give an
additional 1mg of GLUCAGON
IM
Peds:
1-8 years: DEXTROSE 25% 2-4ml/kg
IVP
< 1 year: DEXTROSE 12.5%
2-4ml/kg IVP
*GLUCAGON half adult dose
(0.5mg IM) is recommended for peds
patients weighing < 25kg 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% 2-4ml/kg IVP
Note: Refer to pediatric drug dosing for DEXTROSE 25% and 12.5% direction.
Pediatrics (1-8 years): DEXTROSE 25% 2-4ml/kg IVP or *GLUCAGON
half adult dose (0.5mg IM) is recommended for peds patients weighing
< 25kg or **younger than 6-8 yrs**.
2008 SOGs Update
Page 77
Coma of Unknown Origin / Drug Overdose
Intoxication
NARCAN < 20kg 0.1mg/kg IV/IO
> 20kg 2mg dose IV/IO
Consider Sodium Bicarbonate for tricyclic ingestions.
SODIUM BICARBONATE 1 mEq/kg
c. Adults:
THIAMINE 100mg IV or IM
DEXTROSE 50% 50ml SLOW IVP
NARCAN 2mg IVP
SODIUM BICARBONATE 1mEq/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 2mg IVP, May
< 20kg NARCAN 0.1mg/kg
repeat after 5 min.
IV/IOor 0.2mg/kg ET
> 20kg NARCAN 2.0mg
IV/IO maximum dose of 2mg’s
SODIUM BICARBONATE
SODIUM BICARBONATE
1 mEq/kg for tricyclic
1 mEq/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:
● D12.5% 1-2 ml/kg IV/IO (Dilute D50 into ½ then ½ again to make
D12.5%)
● Fluid Bolus 10 ml/kg NS/LR
● NARCAN 0.1 mg/kg IV/IO/ET
2008 SOGs Update
Page 130
Medications
AMIODARONE 150mg (Cordarone)
Dose/ Route:
Pulseless arrest: 300mg rapid IVPWide-complex
tachycardia:150mg’s IV over 10 minutes
Peds: Pulseless arrest: 5mg/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: 1mg/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% 2-4ml/kg IVP
<1 yr Dextrose 12.5% 2-4ml/kg IVP
2008 SOGs Update
Page 132
Medications
Etomidate 20mg vial 2mg/ml
Amidate (Generic)
Dose/ Route:
0.3mg/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:LeForte 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 (GlucaGen)
Dose/ Route:
Adult: 1mg IM may repeat 1mg IM in 15 min. if pt. remains
unconscious
Peds: 0.5mg (<25kg) or younger than 6-8yrs. IM for a total
dose of 1mg 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 D50W 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:
25-50mg/kg IV/IO over 10-20 minutes max 2gm for Torsades de
Pointe
Morphine Sulfate
Peds:
0.05-0.10mg/kg IV. Max 2mg use
0.05mg/kg dose on infant <6 mos. Max dose of 0.5mg’s
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Medications
Toradol (Ketorolac)
Dose/Route:
Adult: 30mg’s IV or IM
Peds: 1mg/kg IM max of 30mg’s
0.5mg/kg IV max of 15mg’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
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Medications
Versed (Midazolam)
Dose/Route:
Adult:
Peds:
5mg increments slow IVP up to 20mg’s
0.1-0.2mg/kg IV/IO max of 0.15mg/kg
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Medications
Zofran (Ondansetron)
Dose/Route:
Adult: 4mg’s IV/IM
12yr & older: 8mg disintegrating tab on tongue then swallow
saliva
Peds: Age 4 to 11 yrs 4mg 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
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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.
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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).
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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)
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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.
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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.
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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.
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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.
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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 8-10mL).
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.
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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 CO2 detector.
Continue to manually stabilize or secure the ET tube in the determined proper
position and monitor for continued proper placement while ventilating.
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Guidelines for Initiation of Intraosseous
Infusion (IO)
I.
Drugs authorized by this route:
2.
AMIODARONE