2000 Adult ALS Medical Protocols

TABLE OF CONTENTS

ADULT PROTOCOLS

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Part I: GENERAL GUIDELINES

Medical Control...................................................................... 1

Communications Failure.......................................................... 1

Physician Presence at the Emergency Scene............................ 2

Patient Consent and Refusal.................................................... 2

Equipment.............................................................................. 3

Airway Management.............................................................. 3

IV Therapy............................................................................ 4

Limiting Resuscitation............................................................. 5

Patient Disposition.................................................................. 5

Infectious Disease Precautions................................................ 6

Hazardous Materials Response................................................ 7

Response to Multiple Casualty Incidents................................... 7

Peer Counseling and CISD...................................................... 7

Part II: CARDIAC EMERGENCIES

Standing Orders for All Cardiac Problems................................ 8

Specific Conditions:

· · Suspected MI.......................................................... 8

· · Suspected Pulmonary Edema.................................. 10

· · Cardiogenic Shock/Pump Failure............................. 11

Arrhythmias Associated with Myocardial Ischemia:

PVC’s.............................................................................. 12

Bradyarrhythmias.............................................................. 12

Narrow-Complex Tachycardia............................................ 14

Ventricular Tachycardia Perfusing................................... 15

Cardiac Arrest States:

Ventricular Fibrillation and Tachycardia............................... 16

Asystole............................................................................ 18

All Other Pulseless Electrical Activity (PEA)...................... 19

Special Situations/Considerations......................................... 20

Part III: MEDICAL EMERGENCIES

Non-Traumatic Shock........................................................... 21

Anaphylaxis.......................................................................... 21

Asthma Attack..................................................................... 22

COPD Acute Exacerbation................................................ 24

All Other Respiratory Distress............................................... 24

Status Seizures..................................................................... 24

Unconsciousness Unknown Etiology................................... 25

Symptomatic Known Diabetic................................................ 25

Drug Overdose..................................................................... 26

Suspected CVA.................................................................... 26

Suspected Carbon Monoxide Poisoning.................................. 27

Symptomatic Renal Patient.................................................... 27

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TABLE OF CONTENTS (Continued)

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Part IV: TRAUMATIC EMERGENCIES

Standing Orders for All Trauma Patients................................ 28

General Trauma/Traumatic Shock.......................................... 29

Head and Spine Injuries......................................................... 30

Amputations......................................................................... 30

Part V: OTHER EMERGENCIES

Hypothermia......................................................................... 31

Hyperthermia....................................................................... 31

Burns................................................................................... 32

Chemical Eye Injuries........................................................... 33

Behavioral Emergencies........................................................ 33

Severe Nausea or Vomiting................................................... 33

Part VI: OBSTETRICS

Normal Labor and Delivery................................................... 33

Obstetric Complications......................................................... 34

PEDIATRIC PROTOCOLS (see separate table of contents)

APPENDICES: Appendix A: ALS Procedures, Equipment and Drug Lists

Appendix B: Endotracheal Intubation

Appendix C: Rapid Sequence Intubation

Appendix D: Surgical Airways

Appendix E: Nitronox Administration

Appendix F: DNR Guidelines Document and Standard Form

Appendix G: ICD Emergency Management

Appendix H: Transcutaneous/External Cardiac Pacing

Appendix I: Intraosseous Infusion

Appendix J: System Plan for Multiple Casualty Incident

PART I. GENERAL GUIDELINES

1. 1. These Medical Protocols apply to adult patients age 18 and over.

2. 2. Remember: Courtesy to the patient, the patient's family and other emergency care personnel is of utmost importance.

3. 3. A Hennepin County EMS System ambulance report form must be completed on all patients and a copy left with the patient at the hospital. Specific prehospital care information must also be recorded on all patient contacts as part of the System data collection program.

4. 4. The specific conditions listed for treatment in this document, although frequently stated as medical diagnoses, are merely operational diagnoses to guide the paramedic in initiating appropriate treatment. The medical control physician, when consulted, will either concur or further evaluate the paramedic's clinical findings and suggest an alternate diagnosis and treatment.

5. 5. In all circumstances, physicians have latitude in the care they give and may deviate from these Medical Protocols if it is felt such deviation is in the best interest of the patient. Nothing in these protocols shall be interpreted as to limit the range of treatment modalities available to medical control physicians to utilize, other than the modalities and the medications used must be consistent with the paramedic's training.

6. 6. MEDICAL CONTROL: A medical control physician should be contacted as specified in these protocols. Whenever possible, medical control should be obtained from the hospital of destination requested by the patient. Medical control as required by protocol for cardiac and other non-trauma patients should be established without delay upon completion of necessary ALS procedures. If no request for medical control has been made before three minutes from hospital arrival, patient information only should be communicated (for hospital notification) in lieu of medical control. Except for load-and-go situations with short transport times, any such delay in establishing medical control will be explained in a System Incident Report submitted by paramedics to their medical director and to the ~~System Quality Improvement Officer~~ Community Health Department. This policy in no way precludes establishment of medical control at any time during the run to obtain physician advice or assistance.

7. 7. MEDICAL CONTROL COMMUNICATIONS FAILURE: In the occurrence of communication failure, paramedics may perform those orders outlined in the ALS Medical Protocols under "After Obtaining Verbal Orders" for patients with life-threatening or potentially life-threatening conditions. Initiation and performance of these orders must be in accordance with the paramedic's training and must be carried out as written in these Medical Protocols. Any instance of communications failure where procedures are carried out without a physician's verbal order must be reported in a System Incident Report within 48 hours to the paramedic's medical director and to ~~the System Quality Improvement Officer~~ Community Health Department.

8. PHYSICIAN PRESENCE AT THE EMERGENCY SCENE:

A. A. If the patient's personal physician is present and wishes to assume responsibility for the patient's care:

1) 1) The paramedic should defer to the orders of the personal physician as long as those orders are appropriate and not in conflict with ALS Medical Protocols. (Paramedics should establish radio medical control any time they are uncomfortable with carrying out orders from a patient's physician.)

2) 2) Orders given by the personal physician should be written on the EMS report form and signed by the physician.

3) 3) The paramedic should contact the medical control physician during transport to report treatment given and to obtain further orders if the personal physician does not accompany the patient.

B. B. If a System ALS Medical Director or medical control physician is present and wishes to assume responsibility for the patient's care, the same guidelines apply as in (A) above.

C. C. If any other intervening physician wishes to assume responsibility for the patient when no radio medical control exists, the paramedics should relinquish responsibility for patient management if the physician:

1) 1) can show appropriate identification (or is known to the paramedics); and

2) 2) agrees in advance to accompany the patient to the hospital (exception: major multiple casualty incident); and

3) 3) signs the EMS report form assuming responsibility and verifying orders.

· · If radio medical control exists, the intervening physician should be allowed to communicate with the medical control physician prior to the paramedics accepting orders. If there is any disagreement between the two physicians, the paramedics will follow the orders of the medical control physician and allow the physicians to continue their communication.

· · In the case of multiple intervening physicians at the scene, the paramedics should request the physicians designate one physician to direct patient care.

D. D. An intervening physician not wishing to assume responsibility for care and accompanying the patient to the hospital may be asked to assist the paramedics and/or act as a medical consultant to them and to the medical control physician.

9. 9. PATIENT CONSENT AND REFUSAL: Whenever an ambulance is requested for a patient, it is the responsibility of the EMS system to treat and transport that patient with his/her consent. Transport by ambulance should always be offered to a patient. If a competent patient or parents of a minor refuse treatment or transportation, they should sign the refusal statement on the ambulance report form. If they refuse to sign, this should be documented, including witnesses' names if possible. In general, a person is mentally competent if he/she:

1) 1) is capable of understanding the nature and consequences of the proposed treatment; and,

2) 2) has sufficient emotional control, judgment, and discretion to manage their own affairs.

Emergency care for life-threatening conditions should never be delayed or withheld to carry out legal consent procedures. Any time contact with the patient occurs and the patient is not transported, the run is a "left," not a "cancel," and requires full documentation of all sections of the ambulance report form including what the patient (or parent) was told at the scene regarding non-transport and any other follow-up advice or information given at the scene.

Adults: A mentally competent adult has the right to refuse treatment and/or transport; however, the paramedic and/or medical control physician (by phone or radio) should explain thoroughly the alternatives and potential consequences of this action. A medical control physician should always be consulted if in doubt as to the mental competency of a patient, or if the paramedic feels it is detrimental to leave the patient.

Minors: Consent or refusal of treatment/transport of minors (less than 18 years) must be given by the child's parent or legal guardian. Although less desirable, consent or refusal may be given by a responsible adult (over 18) caretaker if the parent has deliberately left the minor in the care of this adult, and the adult is competent and capable. If unsure whether it is appropriate to allow someone to give consent or refuse treatment of a minor, a medical control physician should be consulted.

10. 10. EQUIPMENT: All equipment appropriate to the nature of the call for assessment, treatment and transport should be taken to the site of the patient at the time of initial patient contact. A list of required and optional permitted equipment for the Hennepin County EMS System is found in Appendix A.

11. AIRWAY MANAGEMENT:

A. A. Airway Devices:

Oropharyngeal or nasopharyngeal airway insertion should be attempted on all unconscious patients for airway maintenance.

Esophageal obturator airways and Combitubes are to be inserted only in apneic patients unless ordered verbally by the medical control physician or, if authorized by the ALS medical director, in patients with Glasgow Coma Score <8 who cannot be endotracheally intubated. The EOA should be used with caution in trauma patients (see Traumatic Emergencies section).

Endotracheal intubation is not a required procedure but is sanctioned in the Hennepin County EMS System for various categories of patients. Endotracheal intubation is to be performed only by paramedics trained and authorized to intubate and only for those types of patients specified by the ALS Medical Director. Endotracheal intubation shall be performed in accordance with the information and protocol contained in Appendix B and consistent with other protocols in this document.

Other airway interventions not required but sanctioned by the System are rapid sequence endotracheal intubation and the establishment of surgical airways (i.e., transtracheal needle ventilation and cricothyrotomy) for patients that cannot be ventilated by any other means. These interventions must be authorized by a service's ALS Medical Director and shall be performed in accordance with the information and protocols contained in Appendices C and D.

B. B. Adjunctive Airway Equipment:

· · End-tidal CO₂ monitoring: An end-tidal carbon dioxide (CO₂) detector may be used (but is not required) to accomplish confirmation of endotracheal tube placement and is most reliable in patients with spontaneous circulation. This device often is not able to detect CO₂ in cardiac arrest patients due to extremely low blood flow to the lungs.

· · Pulse oximetry: A pulse oximeter may be used (but is not required) for any patient with suspected hypoxemia, in respiratory distress, or whenever sedating medications are administered. Obtaining a normal pulse oximetry reading does not negate the need for oxygen therapy as specified in these protocols.

C. C. Drug Administration By Inhalation or Via the Airway:

Nitronox, oxygen and albuterol sulfate are the prehospital drugs administered by inhalation. Of the three, Nitronox is not a required drug, but is sanctioned for use in the Hennepin County EMS System. It may be used to treat pain of many varieties including non-traumatic headache, back pain, isolated musculoskeletal trauma, burns not involving the face or respiratory tract and other medical conditions such as kidney stones and third trimester labor. Paramedics trained and authorized by their ALS Medical Director to administer Nitronox shall do so in accordance with the information and protocol contained in Appendix E of this document.

Oxygen therapy should be administered in accordance with the following guidelines:

· · If patient has no history of COPD, oxygen should be administered by mask at a minimum of
10 liters per minute or, if intolerant of mask, by nasal cannula at 4-6 liters per minute.

· · If patient has a history of COPD, use a nasal cannula at 2-3 liters per minute initially. Oxygen may need to be increased if the patient’s respiratory status worsens.

· · Patients with suspected pulmonary burns or CO toxicity should receive oxygen by partial rebreather mask for the highest possible oxygen delivery.

Drugs that may be administered via the tracheobronchial tree by injection into an endotracheal tube are narcan, atropine, epinephrine and lidocaine. This drug administration route may be used in cardiac arrest whenever an endotracheal tube has been placed and venous access is delayed or impossible. Medications via the ET route should be administered at twice the IV dose and should be diluted with sterile normal saline or water to a volume of at least 10 ml. A suction catheter should be passed beyond the tip of the endotracheal tube, chest compressions stopped and the drug solution quickly injected into the catheter. This should be followed by several quick ventilations to aerosolize the medication before resuming chest compressions.

12. IV THERAPY: If IV access cannot be established rapidly at the scene (in two attempts) in patients with non-traumatic problems, begin transport to the hospital. Further IV attempts can be made during transport, provided all other necessary treatment is being done. There should be no delay at the scene for IV attempts on trauma patients or patients in shock--these IV's should be started during transport.

For most patients, the paramedic has the option of either running fluids through the IV or capping the catheter with a saline lock. However, as specified in these protocols, IV fluids must always be hung in situations:

1) 1) when the administration of multiple IV medications is anticipated; and

2) 2) whenever it is likely the patient will require fluid volume replacement.

At the paramedic’s discretion, a saline lock may be established any time it is felt IV access will be needed.