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ContentsAUTHORIZATIONFORPROTOCOLS...............................................................................................................................................................White4DEFINITIONS...........................................................................................................................................................................................................Purple1FOREWORD..............................................................................................................................................................................................................Brown1TASERPROBES.......................................................................................................................................................................................................Brown5MAINEEMSSTATEMENTON“RESCUE”OR“ALTERNATE”AIRWAYDEVICES.............................................................................Blue1CONFIRMATIONANDMONITORINGOFENDOTRACHEALINTUBATIONPATIENTS..................................................................Blue2ADULTAIRWAYALGORITHM..............................................................................................................................................................................Blue3MAINEEMSFAILEDINTUBATIONALGORITHM.........................................................................................................................................Blue4PEDIATRICAIRWAYALGORITHM.....................................................................................................................................................................Blue5RESPIRATORYDISTRESSWITHBRONCHOSPASM.....................................................................................................................................Blue7PULMONARYEDEMA...............................................................................................................................................................................................Blue9CHESTPAIN‐GENERAL..........................................................................................................................................................................................Red1CHESTPAIN‐SUSPECTEDCARDIACORIGIN.................................................................................................................................................Red2STELEVATIONMYOCARDIALINFARCTION(STEMI).................................................................................................................................Red4CHESTPAINCHECKLIST.........................................................................................................................................................................................Red5CHESTPAIN‐UNCERTAINETIOLOGY..............................................................................................................................................................Red6GUIDELINESTOTHEPREHOSPITALUSEOF12LEADEKGBYTHEALSPROVIDER....................................................................Red7CARDIACARRESTORDYSRHYTHMIAS............................................................................................................................................................Red8TERMINATIONOFRESUSCITATION................................................................................................................................................................Red10VENTRICULARFIBRILLATION/PULSELESSVENTRICULARTACHYCARDIA...............................................................................Red12WIDECOMPLEXTACHYCARDIA(PROBABLEV‐Tach).............................................................................................................................Red14ASYSTOLE....................................................................................................................................................................................................................Red16PULSELESSELECTRICALACTIVITY.................................................................................................................................................................Red17BRADYCARDIA...........................................................................................................................................................................................................Red18NARROWCOMPLEXTACHYCARDIA................................................................................................................................................................Red20CARDIOGENICSHOCK............................................................................................................................................................................................Red21SYNCOPE......................................................................................................................................................................................................................Red22ALLERGY/ANAPHYLAXIS.....................................................................................................................................................................................Gold1ADULTCOMA..............................................................................................................................................................................................................Gold3ADULTDIABETIC/HYPOGLYCEMICEMERGENCIES..................................................................................................................................Gold5ADULTSEIZURES.......................................................................................................................................................................................................Gold7ACUTESTROKE..........................................................................................................................................................................................................Gold9STROKECHECKLIST..............................................................................................................................................................................................Gold11MEDICALSHOCK.....................................................................................................................................................................................................Gold13ABDOMINALPAIN..................................................................................................................................................................................................Gold15

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NAUSEA/VOMITING..............................................................................................................................................................................................Gold16MINIMUMLANDINGZONE(LZ)AREA..........................................................................................................................................................Green1TRAUMATRIAGEPROTOCOL...........................................................................................................................................................................Green3SPINEASSESSMENTPROTOCOL......................................................................................................................................................................Green6GLASGOWCOMASCALE(GCS).........................................................................................................................................................................Green7REVISEDTRAUMASCALE...................................................................................................................................................................................Green8PEDIATRICTRAUMASCORE..............................................................................................................................................................................Green9CHESTTRAUMAPROTOCOL............................................................................................................................................................................Green10HEMORRHAGE.......................................................................................................................................................................................................Green11HEADTRAUMA......................................................................................................................................................................................................Green12HYPOVOLEMICSHOCK.......................................................................................................................................................................................Green13BURNS.......................................................................................................................................................................................................................Green15RULEOFNINES.....................................................................................................................................................................................................Green16PAINMANAGEMENT...........................................................................................................................................................................................Green17TOXINS......................................................................................................................................................................................................................Yellow1HYPOTHERMIA......................................................................................................................................................................................................Yellow7HYPERTHERMIA...................................................................................................................................................................................................Yellow9OPTHALMOLOGY................................................................................................................................................................................................Yellow11COMBATIVEPATIENTPROTOCOL..............................................................................................................................................................Yellow12KNOWNORSUSPECTEDCYANIDEEXPOSURE.....................................................................................................................................Yellow13PEDIATRICCOMA......................................................................................................................................................................................................Pink1PEDIATRICSEIZURES..............................................................................................................................................................................................Pink3PEDIATRICRESPIRATORYDISTRESS...............................................................................................................................................................Pink5PEDIATRICRESPIRATORYDISTRESSWITHWHEEZING.........................................................................................................................Pink7PEDIATRICRESPIRATORYDISTRESSWITHINSPIRATORYSTRIDOR...............................................................................................Pink9PEDIATRICRESPIRATORYFAILURE...............................................................................................................................................................Pink10PEDIATRICDIABETICEMERGENCIES............................................................................................................................................................Pink11PEDIATRICMEDICALSHOCK.............................................................................................................................................................................Pink13PEDIATRICCARDIACARREST...........................................................................................................................................................................Pink15PEDIATRICCARDIACARRESTDOSAGES......................................................................................................................................................Pink16CHILDBIRTH..............................................................................................................................................................................................................Pink17APGARSCORE...........................................................................................................................................................................................................Pink18NEONATALRESUSCITATION.............................................................................................................................................................................Pink19NORMALPEDIATRICVITALSIGNS..................................................................................................................................................................Pink20ENDOTRACHEALTUBESIZESANDLMASIZES..........................................................................................................................................Pink21

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DONOTRESUSCITATE(DNR)GUIDELINES..................................................................................................................................................Gray1DEATHSITUATIONGUIDELINESFOREMERGENCYMEDICALRESPONDERS...............................................................................Gray4MASSCASUALTY/DISASTERS/HAZMAT.....................................................................................................................................................Gray6SEXUALASSAULTVICTIM..................................................................................................................................................................................Gray10CHILDABUSE...........................................................................................................................................................................................................Gray11ADULTABUSE..........................................................................................................................................................................................................Gray13INTOXICATEDDRIVERS......................................................................................................................................................................................Gray13TRANSPORTPROTOCOL.....................................................................................................................................................................................Gray14TRANSPORTOFMENTALLYILLPATIENTS................................................................................................................................................Gray16PROTECTIVEHEADGEARREMOVAL.............................................................................................................................................................Gray17DEFIBRILLATION/CARDIOVERSIONSETTING.......................................................................................................................................Gray18DRUGDOSAGETABLE..........................................................................................................................................................................................Gray19RATECONVERSIONCHART...............................................................................................................................................................................Gray20INTRAVENOUSADMIXTURES...........................................................................................................................................................................Gray21MAINEEMSDRUG/MEDICATIONLIST.......................................................................................................................................................Gray22TELEPHONE/RADIOREFERENCES/CONTACTNUMBERS...............................................................................................................Gray24NON‐EMSSYSTEMMEDICALINTERVENERS..............................................................................................................................................Black1

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AUTHORIZATIONFORPROTOCOLS

TheseprotocolsareissuedbytheMedicalDirectionsandPracticeBoardandgovernthepracticeofEMSlicenseesbytheauthorityof32MRSA§86.2‐A.AllMaineemergencyphysiciansandtheregionalEMSprogramswereinvitedtoparticipateinthereviewandadoptionoftheseprotocolsthroughtheirMEMSRegionalCouncils.TheRegionalMedicalDirectorsagreethatwhentreatmentsareadoptedintheirregions,theywillbeconsistentwiththeseprotocols.Theseprotocolswillbecontinuallyreviewed.Neworrevisedprotocolswillbeissuedinadhesive‐backedpagesthatcanbeeasilyplacedovertheprotocolbeingreplacedorononeoftheblankpagesprovidedattheendoftheprotocolbook.AllchangeswillalsobelistedontheProtocolErrataformlocatedontheMaineEMSwebsite.MarleneCormier,M.D.,RegionalMedicalDirector Region1 RebeccaChagrasulis,M.D.,RegionalMedicalDirector Region2 TimothyPieh,M.D.,RegionalMedicalDirector Region3 JonnathanBusko,M.D.,RegionalMedicalDirector Region4 PeterGoth,M.D.,RegionalMedicalDirector Region5 WhitneyRandolph,D.O.,RegionalMedicalDirector Region6 MatthewSholl,M.D.,MaineEMSMedicalDirector JayBradshaw,MaineEMSDirector

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DEFINITIONS

“ACLS”meansadvancedcardiaclifesupport.“AdvancedAirway”meanstheskillsofendotrachealintubationanduseofotherairwaymodalitiessuchasBlindInsertionAirwayDevicesperformedonlybythosewhohavecompletedpracticaltrainingineachoftheseskills.“AHA”meanstheAmericanHeartAssociation“ALS”(AdvancedLifeSupport)meanstheabilitytoprovideadvancedlevelofmedicalcare,whichintheprehospitalrealmmeansEMT‐CriticalCareorEMT‐Paramedic.TheALSskillsmayincludethefollowing:IVaccess,advancedairway,cardiacmonitoring,and/ororalorparenteralmedications.“ALS(AdvancedLifeSupport)IfAvailable”meansthatthepatientshallreceivethehighestappropriateALSinterventionassoonaspossible.Thedecisioninthisrealmastowhichinterventionsmaybeappropriaterestswiththecriticalcaretechnicianorparamedic,ifavailable.Ifanyskillsotherthanbasiclifesupportaredeemednecessaryorinitiallyimplemented,anALSresponseshouldbesought,withsimultaneousdispatchifpossible.Theuseofamedicalprioritydispatchingprogram,approvedbythestatemedicaldirector,isencouraged.Whenthiscannothappen,thecrewinattendanceshouldbringALScareandthepatienttogetherinthefastestofthreeways:(1)ALSback‐upatthescene;(2)ALSback‐upmetenroute;or(3)ALSbyhospitalstaffintheemergencydepartmentifprehospitalrendezvousisnotpossible.TheBLSprovidersonthescenemaymodifytheALSresponseasappropriate.“ARC”meanstheAmericanRedCross.“AutomaticVentilation”Automaticventilators(time‐cycled,pressurecontrolled),approvedbyMaineEMS,maybeusedtoassistventilationswhenaBIADorETTisinplacebytheintermediate,criticalcare,orparamedicproviderduringtransportfromasceneresponsetothehospital.Thesedevicesmayalsobeusedtodeliverfacemaskventilations.Duringinter‐facilitytransport,useofthesedevicesislimitedtocriticalcarecapabletransportsystems.“AVPU”meansAlert,responsivetoVerbalstimuli,responsivetoPainfulstimuli,orUnresponsive.“BP”intheseprotocolsreferstothesystolicbloodpressure.

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“CentralLines”meansanyIVcatheterdevice,whichgainsaccesstoapatient’scentralcirculation.EMSproviders,withintheirscopeofpractice,maymonitoranindwellingcentralline(suchasaPort‐a‐cath)whichhasbeenaccessedorestablishedpriortoEMStransportandmaymonitorthemedicationsbeingadministeredthroughtheselines.“CriticalCareTechnician/ParamedicBack‐up”meansusinganadvancedlifesupportresourcewhenapresentingpatientneedsmorethanbasiclifesupport.Asnotedabove,intheprehospitalsettingthisusuallyindicatesacriticalcaretechnicianorparamedicresponse.AnALSback‐upagreementshouldbewrittenbetweenEMSproviderservicesroutinelyofferingandacceptingALSback‐upsupport.Thiswouldestablishmedical/operational/liabilityexpectationsofbothservices.Theseprotocolscannotmandateanyservicetoroutinelyofferorreceiveback‐up.However,anydecisioninthisregard,particularlytorefusetoofferoracceptALSback‐up,shouldbegroundedinreasonablemedical,operational,orfinancialconsiderationsandshouldbereviewedbytheindividualservice’slegalcounsel.“EmergencyDepartment”meansahospitalthatprovidesanorganizedEmergencyServiceorDepartmentthatisavailabletwenty‐four(24)hoursaday,seven(7)daysaweekandhasthecapabilitytoprovideOn‐LineMedicalControl,toevaluate,treat,stabilize,andtorefertoanappropriateoutsideresourceallpersonswhopresentthemselvesfortreatment.“EMSProvider”meansanypersonorservicelicensedbyMaineEMStoprovideemergencymedicalservices.“FluidChallenge”indicatesmaximumfluidadministrationachievablewithoutpumpsorotherspecialequipmentinthefieldsetting.Specifically,runningalargeboreIVwide‐openuntil300‐500mloffluidhasbeenadministered,andrepeatingthisprocessuntiladesirablebloodpressure,basedonthepatient’sunderlyingcondition,isachieved.AtrueIObolus,attheappropriatedosewithasyringe/3‐waystop‐cockassembly,isacceptable.Pediatricbolusesare20ml/kg,andmayberepeatedonetimeifpatientremainshypotensive.“Greater/Lessthan”Intheseprotocols“>”means“greaterthan,”and“

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c) Profoundhypovolemiaorhemodynamicinstabilitywithalterationofmentalstatusorotherevidenceofshock

d) Cardiacarrest(medicalortraumatic)

WithdiscussionwithOLMC,mayconsiderIOplacementforthefollowingconditions:a) Profoundhypovolemia(SystolicBPlessthan90mmHg)withoutalterationsinmental

statusorotherevidenceofshockb) Burnpatientswithbilateralupperextremityburns

*IOiscontraindicatedinthefollowingconditions:

a) Fractureofthetibiaorfemurinlowerextremityplacementorfractureofthehumerusinupperextremityplacement

b) Infectionatinsertionsitec) IOwithintheprior24hoursd) Kneereplacement(identifiedbymidlineverticalscaroverthepatella)e) Tumornearsitef) Inabilitytolocatelandmarksg) Excessivetissueatinsertionsiteh) IOaccessisnotintendedforprophylacticuse.

ApprovedSites(oneperbone):

a) Anterior/medialtibiab) Lateralhumerusc) Medialmalleolus/distaltibia

CriticalCare/Paramedic:Ifinfusionofmedicationsorfluidscausessignificantpain,considerthefollowing:

1) Adult:Considerlidocaine2%(preservationfree)40mgbolusfollowedby10mlNormalSalineflush.Ifpaincontinues,contactOLMCforOPTIONofadditional20mgbolus.

2) Pediatric:Considerlidocaine2%(preservationfree)0.5mg/kg(MAX40mg)slowpushfollowedby10mlNormalSalineflush.Ifpaincontinues,contactOLMCforOPTIONofadditional0.25mg/kg(MAX20mg)slowpush.

“IV”meansanybalancedelectrolytesolutionsmaybeused,suchasLactatedRingersandNormalSaline.NormalSalineisthefluidofchoiceforpatientswithhistoryofrenalfailure,notLactatedRingers.Recommendedcathetersizeforrapidfluidresuscitationinadultsis14‐18gauge.Ifrapidfluidresuscitationisnotrequired,smallercathetersizesandheparin/salinelocksmaybeused.Heparinusedforthisprocedureisnotconsideredamedication.

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“MDPB”meansMaineEMSMedicalDirectionsandPracticeBoard,whichconsistsofthesixRegionalMedicalDirectors,aPhysicianrepresentingtheMaineChapteroftheAmericanCollegeofEmergencyPhysicians,andtheStateEMSMedicalDirector.“NR”meansanon‐rebreatheroxygenmask.“O2”meansoxygentherapyasappropriateforpatient.“OnLineMedicalControl”(“OLMC”)referstotheon‐linephysician/physicianassistant/nursepractitionerwhoislicensedbytheStateofMaineandauthorizedbyahospitaltodirectemergencymedicalservicespersonsconsistentwiththeprotocolsdevelopedbytheMDPB.“OtherAppropriateDestination”meansafacilitythathasbeenapprovedbytheBoardofEMStoreceiveviaambulancepatientswhoareinneedofemergencycare.“PediatricPatient”intheseprotocols,meansprepubertal(withoutpubic,axillary,orfacialhair).“PPV”meanspositivepressureventilationdevicesuchas(inorderofpreference):two‐personbag‐valve‐masktechniquewithoxygen,one‐personbag‐valve‐masktechniquewithoxygen,mouth‐to‐maskventilationwithoxygen,andmouth‐to‐maskventilationwithoutoxygen.

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FOREWORD

Theseprotocolsweredevelopedforthefollowingreasons:1. ToprovidetheEMSproviderwithaquickfieldreference,and2. TodevelopwrittenstandardsofcarewhichareconsistentthroughoutthestateofMaine.UsersoftheseprotocolsareassumedtohaveknowledgeofmoredetailedandbasicpatientmanagementprinciplesfoundinEMStextbooksandliteratureappropriatetotheEMSprovider’sleveloftrainingandlicensure.EMSprovidersareencouragedtocontactOLMCinanysituationinwhichadviceisneeded,notonlyinsituationsasdirectedbytheseswrittenprotocols.Tousetheseprotocolsastheywereintended,itisnecessarytoknowthephilosophy,treatmentprinciples,anddefinitions,whichguidedthephysiciansandotherEMSproviderswhodraftedtheseprotocols:1. DelaysintreatmentshouldveryRARELYdelaytransport!Thisisespeciallytruefor

traumapatients,patientswithchestpainandpatientswithsuspectedstroke.IV’sshouldbestartedenrouteexceptinthosesituationswheretreatmentatthesceneisinthepatient’sbestinterest,suchasshock,withprolongedextrication,oracardiacpatientwhenfullACLScareisavailable.DelaysintransportshouldbediscussedwithOLMC.

2. InabilitytoestablishvoicecontactwithOLMC.Thereareraresituationswherethepatientisunstableanddelayintreatmentthreatensthepatient’slifeorlimb.If,aftergood‐faithattempts,theadvancedEMTcannotcontactOLMC,thentheadvancedEMTisauthorizedtouseanyappropriatetreatmentprotocolsasiftheywerestandingorders.InsuchcasestreatmentsmuststillbeconsistentwiththeadvancedEMT’strainingandlicensure.ContinueattemptstocontactOLMCanddocumenttheseattemptsonthepatientrunrecord.

3. Transportsandtransfers.Duringtransportsandtransfers,ambulancecrewswillfollowtheseMEMSprotocols,includinguseofonlythosemedicationsandproceduresforwhichtheyaretrainedandauthorizedbyprotocol.

4. Hospitaldestinationchoice.Ifapatientneedscarewhichtheambulancecrew,inconsultationwithOLMC,believescannotbeprovidedatthemostaccessiblehospital,thepatientwillbetransportedtothenearestfacilitycapableofprovidingthatcareuponthepatient’sarrival.If,withOLMCconsultation,apatientisbelievedtobetoounstabletosurvivesuchadiversion,thenthepatientwillbetransportedtothemostaccessiblehospitalwithanemergencydepartment.Diversionisalsonon‐binding,andifapatientinsistsorifthecrewdeemsthatbypassisnotinthepatient’sbestinterest,thengoingtoa

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hospital“ondiversion”isappropriate.IfOLMCcontactisnotpossible,theambulancecrewisauthorizedtomakethisdetermination.OLMCcannotlegallyrefusethesepatients.

5. Regionaldestination.Eachregionhastheauthoritytodevelopprotocols,whichdesignatetheappropriatedestinationforpatientstransportedfromthescene.Anysuchprotocolshouldbepatient‐centricandcreatedexclusivelytoofferpatientsemergentcareonlyavailableatselectedregionalsites.ExamplesofsuchprotocolsincludetheMaineEMSTraumaSystem.

6. Treatments/drugsshouldbegivenintheorderspecified:However,theMDPBrecognizesthatoftentreatmentsaredeliveredsimultaneouslyandmorethanoneprotocolmaybeused.OLMCmayrequesttreatments/drugsoutofsequenceformedicalreasons.

7. MEMSpatient/runrecordwillbelegibleandthoroughlycompletedforeachcallorforeachpatientwhenmorethanonepatientisinvolvedinacall.Thisdocumentisourlegacyofpatientcareandholdsinformationvaluabletohospitalproviders.Servicesareencouragedtoleaveacompletedcopyofthepatient/runreportatthehospitalbeforetheyleave.Inrarecircumstances,whenitisnotpossibletocompletethisrecordbeforeleavingthehospital,theservicesmayprovidethehospitalwithaMaineEMSapproved,onepage,patientcaresummary.THISDOCUMENTDOESNOTREPLACETHECOMPLETEDRUNREPORT.Servicesmustcompletethisreportandmakethereportavailabletothehospitalassoonaspossible.

8. QualityAssurance.AllEMSprovidersandservicesmustbeincompliancewiththeRegionalandStateQualityImprovementProgramtothesatisfactionoftheRegionalMedicalDirector.

9. AssumingandReassessingcarealreadyprovided:EMSproviderswhowillbeassumingtheresponsibilityforpatientcarewillalsoberesponsibleforassessingthecareprovidedbeforetheirarrival,andforallsubsequentcareaftertheyarriveuptoandincludingtheirleveloftrainingandlicensure.IfanEMSproviderhasnotbeentrainedinaparticulartreatmentlistedathislevel,orifthattreatmentisnotwithintheEMSprovider’sscopeofpractice,theprovidermaynotperformthetreatment.

10. Ifthereisaparamediconscenethatiswillingto:a. AccompanytheEMT‐Ionthecall,andb. AcceptresponsibilityfortheEMT‐I’sactions,

ThentheparamedicmaydirecttheEMT‐ItoadministermedicationsthatarewithintheEMT‐I’sscopeofpractice.ThismaybeaccomplishedwithoutcontactingOLMCaslongasthemedicationadministrationwouldnotrequireOLMCfortheparamedic.Iftheparamedicisunwillingtoaccepttheaboveresponsibilities,thentheEMT‐I’smustcontactOLMCbeforeadministeringanymedications.

11. Defibrillations:IntermediateEMTsareexpectedtofollowtheseprotocolswithinthelimitationsofthemonitor/defibrillatoravailabletothem.

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12. Carbonmonoxidemonitors:CarbonMonoxidemonitorsmaybeusedforinformationalpurposesonly.AnyalterationsoftreatmentbasedonpulsecarboximetryreadingsmustbeapprovedbyOLMC.

13. MedicalControlpermission:IfatreatmentislistedasrequiringMedicalControlpermissionatonelevelandislistedagainwithoutrequiringOLMCpermissionatahigherlevel,thehigher‐levelEMTneednotseekOLMCpermission.

14. Deviationfromprotocols:TheseprotocolsrepresentaconsensusoftheMDPB.Inunusualsituations,OLMCmaydeviatefromtheseprotocolsifdoneinthepatient’sbestinterest.Thedeviationincareorderedmustbewithinthescopeofpractice,trainingandskilloftheEMSprovider.Thereasonsfordeviatingfromtheseprotocolsmustbedocumentedinthepatient’schart.Undersuchcircumstances,iftheALSprovideragrees,theALSproviderwillverifyandwillcomplywithOLMCorders,willfullydocumentthedeviationonthepatientrunrecord,andwillnotconsiderthecarerenderedtobeanemergencymedicaltreatmenttoberoutinelyrepeated.

15. ArrivalofofficiallydispatchedEMSpersonnel:OnceEMSpersonnelhavearrivedonthescene,theymayinteractwithothermedicalpersonnelonthescenewhoarenotapartoftheorganizedEMSsystemresponsesinthefollowingmanner:a. MaineEMSlicenseesnotaffiliatedwithoneoftherespondingservicemayonlyprovidecarewithintheirscopeofpracticewiththeapprovaloftheambulancecrewmemberinchargeofthecall.

b. Thepatient’sownphysician,physicianassistant,ornursepractitionermaydirectcareaslongastheyremainwiththepatient(intheirabsence,directionofcareissubjectonlytotheseprotocolsandOLMC).Youmayassistthispersonwithinthescopeofyourpracticeandtheseprotocols.OnlyaphysicianorindependentnursepractitionermaygiveordersoutsideoftheMEMSprotocols(referto#14above).QuestionsinthisregardshouldberesolvedbyOLMC.YoumayshowthispersonProtocolpage“Black1”(“Non‐EMSSystemMedicalInterveners”)toassistwithyourexplanation.

c. OtherunsolicitedmedicalintervenersmustbeMainelicensedphysicians,nurses,nursepractitionersorphysicianassistantswhoseassistanceyourequest.Protocolpage“Black1”describesthis,andshouldbeshowntosuchinterveners.

d. Otherhealthcareprovidersinthehome:Otherhealthcareprovidersinthehomeattendingthepatient(e.g.R.N.,L.P.N.,C.N.A.,NurseMidwife,etc.)arebystanderswhomaybeavaluablesourceofinformation.AnyaidortreatmenttheywishtogivemustbeauthorizedbyOLMC.Anydisputeovertreatment/transportshouldbesettledbyOLMC.

16. Homehealthcaredevicesandappliance:Manypatientswillhavedevicesandappliances(drains,ports,LVAD,etc.)withwhichtheyareroutinelydischargedhome.Patients(ortheirlicensedcareprovidersorpreviouslyinstructedfamilymembers),areexpectedtomaintainthemontheirown.Thesedeviceshavesomerisksassociatedwith

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them,butaregenerallyconsideredsafeinthehomeenvironment.Assuch,EMSprovidersarenotrestrictedinthecareortransferofthesepatientsbasedsolelyonthepresenceofthesedevicesorappliances.Ifanissuearisesandunfamiliaritywith,oranyquestionsconcerningthesedevicesthatcannotbeimmediatelyresolvedbythepatientorcaregivers,itshouldbereferredtoOLMC.

17. LeftVentricularAssistDevice(LVAD):Asurgicallyimplantedpumptoassistleftventricularfunction.AnLVADcanbeabridgetoahearttransplant(althoughusedforchroniccareaswell).InformOLMCassoonaspossiblewheninteractingwithapatientwithaLVAD,asdiversiontoahospitalwithahigherlevelofcaremaybesuggested.Directcontactwiththecardiacserviceresponsibleforthispatientisalsosuggestedattheearliestpossiblemoment.NocardiacarrhythmiashouldbetreatediftheLVADisfunctioning,asjudgedbyanaudiblesoundorpulse,withoutmedicalcontrolapprovalforanytreatment.Besuretobringthepatient’sbatteries(includingthe24hourbattery),thelargebatterychargerandallotheraccessories.LocalEMSservicesmayreceivespecializedtrainingandprotocolexemptionstoextendhelptothesepatientsbyworkingwithregionalEMSmedicaldirectorsandMEMS.

18. GraduateswithacurrentcertificationfromaMaineEMSapprovedwildernessEMTcoursemayapplytheprinciplesofcaretaughtinthatcoursewiththeapprovaloftheservicemedicaldirectorandwhenpatientarrivalatadefinitivecaresettingwillbemorethan2hours.

19. RepeatedTreatment:Unlessotherwiseindicated,anytreatmentincludedintheseprotocolsmayberepeatedafterreassessmentandwithOLMCpermission.

20. ExternalPacing(whereindicatedintheseprotocols)shouldbeperformedifapacerisavailable.Pacersarenotrequiredequipment.

21. Oxygensupplementationwillbebynasalcannulaornon‐rebreathermaskasappropriate.

22. PatientSign‐Offs–Thereexistthreeoriginsforpatientsignoffs:1)apatientrefusestransportandtheprovideragreestransportisnotwarranted,2)thepatientrefusestransportbuttheproviderdoesnotfeelthisissafe,and3)thepatientrequeststransportbuttheproviderrefuses(thisfinalexampleiscalledanEMSSysteminitiatedsignoff).Patientinitiatedsignoffsshouldonlybeconsideredinpatientswithdecisionmakingcapacityandresourcesavailabletocareforthemselvesandwhennon‐transportisconsideredsafe.ThesesignoffsdonotrequirediscussionwithOnLineMedicalControl.InsituationswhichthepatientrequestssignoffbuttheEMSproviderdeemsinappropriate,pleaserefertoOLMC.EMSSysteminitiatedpatientsignoffs(i.e.:whenthepatientrequeststransferbuttheEMSproviderrefuses)aretremendouslyriskyinteractionsandarenotpermissible.ThesesignoffsmustbeapprovedbyOLMCandtheserviceisexpectedtoreviewalloftheseeventsthroughthe

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service’squalityassurancemechanism.Patientmedicalrecordsmustbecompletedforalloftheseinteractions.

23. MaineEMSSpecialCircumstanceProtocols:MaineEMSprotocolsareintendedtoaddressthevastmajorityofmedicalemergenciesencounteredbyanEMSprovider.Whileintendedtobecomprehensive,certainpatientsexistwithraremedicalconditionsthatrequirehighlyspecializedemergentcare.Insuchsituations,MaineEMShascreatedthe“SpecialCircumstanceProtocols”.Theseareprearrangedmedicalprotocolsspecializedtoindividualpatients,suggestedbythepatient’smedicalproviderandratifiedbytheEMSservicemedicaldirector.Patientswillpresentwitha“MaineEMSSpecialCircumstanceProtocolForm”thatoutlinesthepatient’sindividualprotocolandissignedbyboththepatient’sphysicianandtheEMSservicemedicaldirector.ThesespecialcircumstanceprotocolsshouldbemadeknowntolocalEMSservicesandproviders.Incasesofquestionoruncertaintyregardingthenatureoftheprotocol,pleaserefertoOLMC.

24. Duringtransport,patientsshouldbesecuredtothestretcherutilizingbothlateralandshoulderstraps.

TASERPROBESTheuseofaTASERdoesnotautomaticallynecessitateanEMSresponseorinvolvement.Inassessingsuchpatients,becognizantofthepotentialforunderlyingmetabolicdysfunction.TASERprobesmayberemovedfromthesubjectbythedeployingofficer.Probesthatareimbeddedinasensitivearea(e.g.face,neck,breast,andgenitalarea)mayneedtoberemovedbymedicalpersonnel.Inthesecases,thesubjectshouldbetransportedtothehospitalforexaminationandremovaloftheprobesbymedicalpersonnelatthehospital.Otheradverseaffects,ifany,(e.g.respiratorydifficulty,seizures,etc.)shouldbetreatedasappropriatebytheapplicableprotocol(s).

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MAINEEMSSTATEMENTON“RESCUE”OR“ALTERNATE”AIRWAYDEVICES

MaineEMSrecognizes2majorclassesofBlindInsertionAirwayDevices(BIAD’s).Thefirstclass,periglotticdevices,includestheLMA®andCobraPLA®.Thesecondclass,transglotticorpotentiallytransglotticdevices,includestheCombitube®andKingLT®.

AnyFDAapproveddevicesfromtheseclassesareapprovedforuse.Itisrecommendedthatagenciesselectonlyonedevicetominimizepurchasecostsandinitialandongoingeducation.

Ifanagencyselectsatransglottic/potentiallytransglotticdevice,continuouscapnography,mustbeusedtoconfirmandmonitorplacement.AC‐spinecollarshouldbeconsideredtohelpprotectplacementofallendotrachealintubations,periglottic,andtransglotticairwaydevices.

Thereareperiglotticdevicesonthemarketthatcanbeusedtofacilitateendotrachealintubation(e.g.ILMA®,IMA®).Ifthesedevicesareplacedwithoutanattemptatendotrachealintubation,theymaybetreatedasanyotherperiglotticdevice.Iftheyareusedtoassistinplacinganendotrachealtube,thattubemustbetreatedandconfirmedasanyotherendotrachealintubation.

ItisrecommendedtohaveNOMORETHANonedeviceperclass(periglotticandtransglottic),andifaserviceelectstohavemultipleoptionsperclass,thentrainingandmaintenanceinproficiencyforalldevicesavailableisrequired.

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CONFIRMATIONANDMONITORINGOFENDOTRACHEALINTUBATIONPATIENTS

ETplacementcorrect

ETplacementuncertainorequivocalfindingsforconfirmation

ETplacementincorrect

Securetubeinplace

YESNO

ImmediatedirectvisualizationofETthroughvocalcords***

RemoveETtubeandventilateviaBVM

ContinueETCO2monitoringenroutetohospitalandrepeatedevaluationofETplacementviabreathsoundsassessment

AttemptcorrectETplacementorcontinueBVMventilation

*Forcardiacarrestpatients,considerplacementoftheETtubeaswellaslackofpulmonarycirculationintheinterpretationofETCO2findings.**Dependingonthedeviceused,ETCO2devicesmaynotbeapplicabletothepediatricpatient.***Nasotracheally‐intubatedpatientsshouldbeassumedtohaveanincorrectplacementiffindingsofbreathsoundsorETCO2resultsareuncertainorequivocal

Intubatepatient

ConfirmETTorBlindinsertionAirwaydeviceplacementwithcontinuouswaveformcapnography.*,**,***

ANDConfirmETandBIADplacementwithphysicalexam,includingabsenceofsoundsoverthe

epigastrium,presenceofbilateralsymmetricbreathsound,etc.

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Blue 3

ADULTAIRWAYMANAGEMENTALGORITHM

Assess ABC’s, including Respiratory Rate, Effort, Adequacy

Pulse Oximetry/Capnography

All Providers Supplemental O2 and Monitoring

Adequate

Inadequate

Basics ‐ Contact ALS

Basic Measures First

‐ Open Airway ‐ Nasal or Oral Airway ‐ Bag‐Valve‐Mask (BVM)

If CHF or COPD consider trial of CPAP

All Providers

Unsuccessful

Blind Insertion Airway Device, OR

EMT‐I/CC/P

SuccessfulBecomes Inadequate

Continue BVM

All Providers

Obstruction

Airway Obstruction Procedures

All Providers

Direct Laryngoscopy

Paramedics: Consider Surgical Airway

(Cricothyrotomy)

Critical Care/ParamedicUnsuccessful

Failed Airway Protocol

Successful

1) Continuous Monitoring 2) Capnography 3) Consider C‐Collar 4) Consider Gastric Tube(Paramedic only) 5) Contact Receiving Hospital

‐ This protocol is for use in patients whose age is > 12 or patients longer than the Broslow Tape (or equivalent)

‐ Continuous Capnography is mandatory with all patients with BIAD or Endotracheal Tube

‐ The goal of Airway Management is adequate Oxygenation, Ventilation, and Airway Protection. If an effective airway is being maintained by BVM with OPA or NPA, it is acceptable to continue with basic airway measures rather than BIAD or Intubation.

‐ An Intubation attempt is defined as passing a Bougie or the endotracheal tube past the teeth or inserted into the nasal passage

Critical Care/Paramedic

Intubation

PEARLS for Endotracheal Intubation * Position the airway for best view of the cords – raise head to the sniffing position (i.e.: earlobe in line with sternal notch) * Preparation: (four cornerstones) 1) ET tube with loaded stylette, 2) laryngoscope with back up blade, 3) suction, 4) Bougie * Always have a back‐up plan should the primary strategy fail

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Blue 4

MaineEMSFailedIntubationAlgorithm

A “Failed” Intubation (the “can’t intubate patient”) is defined as two (2) unsuccessful intubation attempts by most proficient technician on scene OR anatomy inconsistent with intubation

attempts

NO MORE THAN THREE (3) TOTAL ATTEMPTS PER PATIENT WITHOUT OLMC CONSULTATION

Adequate oxygenation and ventilation with BVM?

Continue BVM

Facial trauma, swelling or unrelieved obstruction?

Yes

No

If SPO2 drops

Blue 5

PEDIATRICAIRWAYALGORITHMSurgicalairwaysforparamediconly!

Patient Assessment

‐ Oxygenation ‐ Ventilation ‐ Opening and protecting the

airway

Supplemental O2

Adequate

Inadequate

Basic Measures First ‐ OPA/NPA and ‐ BVM

1) Continuous monitoring 2) Continuous capnography 3) Consider c‐collar 4) (Paramedics only)Consider gastric tube 5) Contact receiving hospital

Successful Becomes inadequate

Unsuccessful

Airway Obstruction Procedures

Obstruction

Continue with ongoing monitoring

3 Unsuccessful attempts

Failed Airway Protocol and notify receiving hospital

Successful

Critical Care/Paramedic

Intubation

Or

EMT‐I/CC/P

Blind Insertion Airway Device

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Blue 6


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Blue 7

RESPIRATORYDISTRESSWITHBRONCHOSPASM(COPD,emphysema,chronicbronchitis,asthma)

CAUTION:RESPIRATORYDISTRESSMAYBEDUETOMULTIPLEOTHERCAUSESFORWHICHOTHERTREATMENTSMAYBEINDICATED,INCLUDINGTHEFOLLOWING:PulmonaryEdemaseepage“Blue9”Anaphylaxisseepage“Gold1”ChestTraumaseepage“Green10”BASIC

1. O2asappropriate2. Ifneeded,assistventilationswithPPVusing100%O23. RequestALSifavailable

4. ForEMT‐Basiclevelproviders–assistwithself‐administeredbronchodilatorinhaler.TellOLMCthenameoftheinhaler.OLMCwillprescribenumberofpuffs

INTERMEDIATE

5. Cardiacmonitor6. ManageairwayasneededSee“Blue3&5”

7. ContactOLMCtoadministeralbuterol,2.5mgbynebulization(use3mlpremixor

0.5mlof0.5%solutionmixedin2.5mlofnormalsaline)

8. ConsiderCPAPinpatients>18y/owithoutasthma–RecallthatCPAPshouldnevertake

theplaceofbronchodilatorsandshouldbeusedonlyafterorinconcertwithinhaledbronchodilatorsinpatientswithacutebronchospasm.

TheEMT‐I,inconsultationwithOLMC,maymodifytheParamedicresponseasappropriate.CRITICALCARE/PARAMEDIC

9. Adult/Pediatric–a. Albuterol2.5mgbynebulization.Mayrepeat1time;orb. Ipratropiumbromide0.5mg/albuterolsulfate3mgnebulizerifgreaterthan1

yearofageandmoresignificantrespiratorydistress,andmayrepeatonetime;

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Blue 8

10. ConsiderCPAP‐inpatients>18y/owithoutasthma–RecallthatCPAPshouldnevertaketheplaceofbronchodilatorsandshouldbeusedonlyafterorinconcertwithinhaledbronchodilatorsinpatientswithacutebronchospasm.

11. ContactOLMCforthefollowingOPTIONS:

a. Repeatedorcontinuousalbuterolbynebulizationorinhaler.b. Methylprednisolone125mgIVx1dosec. Forasthmaonly–pediatric–epinephrine:<30kg,0.15mgIM(0.15mlof

1:1,000),>30kg,0.30mgIM(0.3mlof1:1,000)inanterolateralthighd. Forasthmaonly‐adult–epinephrine0.3mgIMof1:1,000solutionevery20

minutes

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Blue 9

PULMONARYEDEMA(Withoutshock)

Donotgivenitroglycerinifpatienthastakenerectiledysfunctionmedication(suchassildenafil[Viagra],tadalafil[Cialis],orvardenafil[Levitra])withinthepast72hours.

ContactOLMCforoptionsinpatientswhohavetakensuchmedicines.IfinitialsystolicBPislessthan100mmHg,,CardiogenicShockSee“Red21”.BASIC

1. O2asappropriate.Assistventilations(PPV)ifneeded.2. Assessforshock.IfBPgreaterthan100mmHg,placeinsittingposition.3. RequestALSifavailable

INTERMEDIATE

4. Cardiacmonitor5. IVenroute6. ManageairwayasneededSee“Blue3&5”

7. ContactOLMCforadministrationofnitroglycerin0.4mgor1spraySL.Repeat

nitroglycerinat2minuteintervalsifsystolicBPgreaterthan100mmHg.AfterinitiationofSLnitroglycerin,mayplace1inchofnitroglycerineointment2%tothechestwallifBPgreaterthan100mmHgandremovenitroglycerineointment2%ifBPlessthan100mmHg.IfthepatienthashadnitroglycerinbeforeandnoIVisestablished,andsystolicBPisgreaterthan100mmHg,thenitisOKtogivenitroglycerin.Donotadministernitroglycerinifpatienthastakenerectiledysfunctionmedicationwithinthepast72hours.

8. ConsideruseofCPAP

CRITICALCARE/PARAMEDIC

9. Nitroglycerin0.4mgor1spraySL.Repeatnitroglycerinat2minuteintervalsifsystolicBPgreaterthan100mmHg.AfterinitiationofSLnitroglycerin,mayplace1inchofnitroglycerineointment2%tothechestwallifBPgreaterthan110mmHgandremovenitroglycerineointment2%ifBPlessthan95mmHg.IfthepatienthashadnitroglycerinbeforeandnoIVisestablished,andsystolicBPisgreaterthan100mmHg,thenitisOKtogivenitroglycerin.Donotadministernitroglycerinifpatienthastakenerectiledysfunctionmedicationwithinthepast72hours.

10. ConsideruseofCPAP

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Red 1

CHESTPAIN–GENERAL

Forallpatientswithchestpain,evaluationforacutecoronarysyndromesshouldoccur.Commonly,itisdifficultwiththetoolsavailabletoEMSproviderstocompletelyruleoutacardiaccauseofchestpain.AllpatientsthereforeshouldbetransportedforEmergencyMedicalevaluation.CardiacdiseaseisbutoneofthemanycausesofchestpainandtheEMSprovidershouldconsidervariouscausestoinclude,butnotlimitedtothefollowing(pulmonaryembolism,esophageal,chestwall,spontaneouspneumothorax,etc).Patientscommonlyfallintooneoffourcategories;STEMI,suspectedcardiac,suspectedtrauma,oruncertaincauseofchestpain.

Chest Pain

Chest Pain – STEMI

Follow STEMI Protocol Red 4

Chest Pain –Suspect Cardiac

Follow Chest Pain, Suspect

Cardiac Protocol Red 2

Chest Pain –Suspect Trauma

Chest Trauma Protocol Green 10

Chest Pain –Uncertain Cause

Follow Chest Pain, Uncertain Cause Protocol

Red 6

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Red 2

CHESTPAIN(Suspectedcardiacorigin)

Donotgivenitroifpatienthastakenerectiledysfunctionmedications(suchassildenafil[Viagra],tadalafil[Cialis],orvardenafil[Levitra])withinthepast72hours.Contact

OLMCforoptionsinpatientswhohavetakensuchmedicines.BASIC

1. O2–asappropriate2. Treatforshockifindicated3. RequestALS4. Ifpatienthasnottakenanaspirin:administerchewableaspirin324mgPO,ifnot

contraindicatedbyallergy.ALSback‐upstillmandatorydespiteuseofaspirin.

5. ForEMT‐Basiclevelproviders–ContactOLMCfortheOPTIONofassistingwiththeadministrationofpatient’sownnitroglycerin

INTERMEDIATE

6. IVenroute7. Cardiacmonitorand12leadEKGifsotrainedsee“Red7”8. Chewableaspirin,324mgPO,ifnotcontraindicatedbyaspirinallergy

9. ContactOLMCforadministrationof:

a. Nitroglycerin0.4mgSLor1spray,SL.Mayrepeattwotimesat5minuteintervalsifBPgreaterthan100mmHg.IfthepatienthashadnitroglycerinbeforeandnoIVisestablished,andsystolicBPisgreaterthan100mmHg,thenitisOKtogivenitroglycerin.

TheEMT‐I,inconsultationwithOLMC,maymodifytheParamedicresponseasappropriate.


10. Obtain12leadEKG(withinfirst10minutesofpatientcontact)11. Nitroglycerin0.4mgSLor1spray,SL.Mayrepeattwotimesat5minuteintervalsif

BPgreaterthan100mmHg.IfthepatienthashadnitroglycerinbeforeandnoIVisestablished,andsystolicBPisgreaterthan100mmHg,thenitisOKtogivenitroglycerin.

12. Chewableaspirin,324mgPO,ifnotcontraindicatedbyaspirinallergy

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Red 3

13. ContactOLMCforOPTIONS:

b. Additionalnitroglycerinc. Fentanyl1microgram/kgIVorIMtoamaximumdoseof100micrograms

14. Ifpatientdevelopsadysrhythmia,refertoappropriateprotocol.Recall,inferiorMI’s

andrightsidedMI’sinparticulararecommonlyassociatedwithbradycardiaandblocks.Bewaryofthesedysrhythmiasandrefertoappropriateprotocol.

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Red 4

STElevationMyocardialInfarction(STEMI)InclusionCriteria:PatientwithsymptomsofsuspectedcardiacetiologyandhasoneofthefollowinginadiagnosticqualityEKG:1.Anterior,Inferior,orLateralMI:STelevationgreaterthan1mmintwoormorecontiguousleadsANDQRScomplexisnarrowerthan0.12(3smallboxes)seconds(ifLeftBundleBranchBlock,youareunabletodiagnoseasSTEMI)2.PosteriorMI:STdepressiongreaterthan1mminV1andV2withanR/Sratioofgreaterthanorequalto1ANDQRScomplexisnarrowerthan0.12(3smallboxes)secondsORSTsegmentelevationinleadsV8/V93.NEWLeftBundleBranchBlock:Ifpatienthasinhis/herpossessionapreviousEKGwithnarrowQRStodemonstratethatthewidecomplexisanewchange.

TREATMENT:1.Basic/Intermediate:FollowChestPainProtocol“Red2”2.CriticalCare/Paramediconly:Followchestpainprotocolfornitrates,aspirinandpainmanagement.ObtainEKGwithin10minutesoffirstcontact.3.IfpatientmeetsaboveSTEMIcriteria,contactOLMCatreceivinghospital(localhospitalnotification)andalertthereceivingfacilityofimpendingarrival.4.IFthepatientmeetsoneoftheaboveconditionsetsforSTEMIinclusioncriteriarefertolocalorregionalcardiacsystemsofcarefordestinationdecisionsupport5.PatientswhopresentwithinferiorMI,clearlungsounds,andBP<90,giveafluidbolusof250‐500mlofNS.Foradditionalbolus,contactOLMC

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Red 5

CHESTPAINCHECKLISTForchestpainofsuspectedcardiacorigin,initiatetherapyperprotocol“Red2and4”,includingtheearlyuseofaspirinandnitroglycerinifnotcontraindicated.UsetheChestPainChecklistorlocalequivalentifavailable.ReporttheinformationassoonaspracticaltothereceivingED.

1. IssystolicBPlessthan180mmHg? YES NO

2. IsdiastolicBPlessthan100mmHg YES NO

3. Haspainpersistedforgreaterthan15minutes? YES NO

4. CVAorotherseriouscentralnervoussystemproblemsinpreceding6months?

YES NO5. Surgeryormajortraumainpreceding2weeks?

YES NO6. Anybleedingproblems?(e.g.ulcers,hemophilia) YES NO7. Pregnant? YES NO

Youmaycopyandusethispageasyourchecklist,oryoumayuseacheck‐listrecommendedbyyourusualreceivinghospitalwhichcontainsatleastthesequestions.

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Red 6

CHESTPAIN–UNCERTAINETIOLOGY

ForALLpatientswithchestpain,considerthepossibilityofcardiacdiseasenomatterwhatthehistoryandphysicalsuggest,howeverthereareothersourcesofnoncardiacchestpaintoconsider(pulmonaryembolism,esophageal,chestwall,spontaneouspneumothorax,etc)Iftraumasuspected,refertoChestTrauma“Green10”BASIC:

1. AdministerO2asappropriate2. Transportinpositionofcomfort3. REQUESTALS

INTERMEDIATE:

4. EstablishIVatTKOANDREQUESTCRITICALCARE/PARAMEDIC5. Perform12LeadEKG(Ifsotrained)

TheEMT‐I,inconsultationwithOLMC,maymodifytheparamedicresponseasappropriate.CRITICALCARE/PARAMEDIC:

6. Perform12leadEKG7. IF12leadindicatesSTEMI,refertoSTEMIprotocol8. Fornontraumaticchestpaininastablepatientwithanormallevelofconsciousness

andnoevidenceofSTEMIorAcuteCoronarySyndrome,CONTACTOLMCTOCONSIDERDEVIATIONFROM“CHESTPAIN‐SUSPECTEDCARDIACPROTOCOL”ANDFORTHEFOLLOWINGOPTIONS:A. Ifappropriate:administrationoffentanyl1mcg/kgIV

B. Fornauseaorvomiting,administerondansetron(Zofran)4mgIVandmayrepeatonceafter15minutesifneeded.

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Red 7

GUIDELINESTOTHEPREHOPITALUSEOF12LEADEKGBYTHEALSPROVIDER

1.Prehospital12‐leadEKGisnowastandardofcareforincreasingdiagnosticinformationregardingthechestpain/cardiacpatient.2.Acquisitionofa12‐leadEKGshouldbedoneinallpatientswithchestpainorapotentialcardiaccomplaint/diagnosissuchassyncopeorshortnessofbreath.Giventhefrequencyofatypicalpresentationintheelderly,respondersmusthaveahighindexofsuspicioninelderlypatients.3.Transmissionof12‐leadEKGorpresentationofpre‐hospital12‐leadEKGtotreatingpersonnelatthereceivingEDisintendedtoaugmentpatienttriageandfacilitaterapididentificationofapotentialthrombolyticorPTCAcandidate.4.InthecaseofSTEMI,notifyreceivingEDimmediately.

IntermediateandUseof12Leads:ThepurposeofthisistogetbaselinedataASAPandacquire12leadEKGifavailable1. Iftrained,place12leadstickersandacquire12leadEKG2. ThisisintendedtohaveIntermediatepresentthistotheParamedicsorreceiving

facilities3. ThismustnotmodifytheALSresponse

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Red 8

CARDIACARRESTORDYSRHYTHMIAS

BASIC1. O2asappropriate.Ventilateifpatientisinrespiratoryarrest.2. InitiateCPRimmediatelyincardiacarrestuntilAEDavailable3. AttachAEDifcardiacarrest.DonotwithholdCPRwhilewaitingfordefibrillation

equipment.4. RequestALS.

INTERMEDIATE/CRITICALCARE/PARAMEDIC

5. Cardiacmonitorandtreatarrhythmiasfollowingtheappropriatealgorithmandyourtrainingandleveloflicensure.

a. VentricularFibrillation/PulselessVentriculaTachycardia“Red12”b. WideComplexTachycardia“Red14”c. Asystole“Red16”d. PulselessElectricalActivity“Red17”e. Bradycardia“Red18”f. NarrowComplexTachycardia“Red20”

6. Manageairwayasneeded,See“Blue3&5,”andestablishIV(Intermediatesenroute),

perspecificarrhythmiaprotocol.REMEMBER:Effectivechestcompressionsareoneofthemostimportanttherapiesforthepulselesspatient–Effectiveisdefinedas:arateofatleast100compressions/minute,depthofatleast2.0inches,allowforcompletechestrecoil,nointerruptions,andavoidexcessiveventilations.Also,considerresuscitatingthepatientonsceneratherthanmovingtotheambulance,whenappropriate,astheeffectivenessofchestcompressionsisdecreasedduringpatientmovement.Consideruseofcapnographyduringresuscitationforbothconfirmationandmonitoringofadvancedairwaysaswellasmonitoringeffectivenessofchestcompressionsandreturnorlossofspontaneouscirculation.Note:ThealgorithmsforcardiacarrestorarrhythmiasinthefollowingpagesreflecttheMEMSMedicalDirectionandPracticeBoard’sinterpretationofACLSguidelines,astheyshouldbeusedintheprehospitalsetting.

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Red 9


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Red 10

TERMINATIONOFRESUSCITATION

Resuscitationshouldbeterminatedunderthefollowingcircumstances:UnwitnessedArrest:1. Whenthepatientregainspulse/respiration2. Whenthepatientisinasystoleforgreaterthan20minutesORunresponsiveto

advancedcardiaclifesupportwithanon‐shockablerhythmafter20minutesofresuscitation.

3. IntheabsenceofALS,whenthesameMaineEMSlicensedcrewmemberhasdocumentedtheabsenceofallvitalsignsfor20minutes,inspiteofBLS,exceptinthecaseofhypothermia.

4. Whenirreversiblesignsofdeath,suchasdependentlividity,pupilsfixedanddilated,palpablehypothermia(notfromexposure)andnoaudibleheartsoundsarenotedinpatientwithunknowndowntimeordowntime>20minutes.

5. Whentherescuersarephysicallyexhaustedorwhenequallyormorehighlytrainedhealthcarepersonaltakeover

6. WhenitisfoundthatthepatienthasaDNRorderorotheractionablemedicalorder(e.g.POLST/MOLST,etc)form.

7. ContinueresuscitationifconditionsonsceneareNOTamenabletocessationofresuscitation

8. ContinuationofresuscitationbeyondtheseprotocolsmustbeinconsultationwithOLMC*

WitnessedArrest:1. Whenthepatientregainspulse/respiration2. Whenthepatientisinasystoleforgreaterthan20minutesORunresponsiveto

advancedcardiaclifesupportwithanon‐shockablerhythmafter20minutesofresuscitation.

3. IntheabsenceofALS,whenthesameMaineEMSlicensedcrewmemberhasdocumentedtheabsenceofallvitalsignsfor20minutes,inspiteofBLS,exceptinthecaseofhypothermia.

4. Whentherescuersarephysicallyexhaustedorwhenequallyormorehighlytrainedhealthcarepersonaltakeover.

5. WhenitisfoundthatthepatienthasaDNRorotheractionablemedicalorder(e.g.POLST/MOLST,etc)form.

6. ContinueresuscitationifconditionsonsceneareNOTamenabletocessationofresuscitation

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7. ContinuationofresuscitationbeyondtheseprotocolsmustbeinconsultationwithOLMC*

IfResuscitativeEffortsareTerminated:1. Focusattentiononthefamilyorbystanders.Explaintherationalefortermination.2. Consideraccessingsupportforfamilymemberstopotentiallyincludeotherfamily,

friends,orsocialsupportsuchasclergy.3. Ifterminationofresuscitationoccurs,onemustconsidermanagementofpatient

remains.Nooneoptioniscorrectforallcircumstancesandfactorsonscenewilllikelydictatethebestoption.Referto“Grey4”.Ifquestionsremainregardingdispositionofthepatient’sremains,refertoOLMC.

*Patientswhodonotrespondto20minutesofEMScaredonotsurviveneurologicallyintacttohospitaldischarge.Itisdangeroustocrew,pedestriansandothermotoriststoattempttoresuscitateapatientduringambulancetransport.Ifcircumstancesdonotallowterminationofresuscitationforsafetyorotherreasons,notifyOLMC.

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Red 12

VENTRICULARFIBRILLATION/PULSELESSVENTRICULARTACHYCARDIABASIC

1) CheckPulse,ifnopulsethen:a. CPRuntilAEDisavailableb. AnalyzewithAED,followAEDinstructions*c. Ifseverehypothermia,goto“Yellow7”d. Manageairway**

2) REMEMBER:Effectivechestcompressionsareoneofthemostimportanttherapiesforthepulselesspatient–Effectiveisdefinedas:arateofatleast100compressions/minute,depthofatleast2.0inches,allowforcompletechestrecoil,nointerruptions,andavoidexcessiveventilations.Considerresuscitatingthepatientonsceneratherthanmovingtotheambulancewhenappropriateastheeffectivenessofchestcompressionsisdecreasedduringpatientmovement.

3) Afterdefibrillation,immediatelyresumechestcompressions,analyzewithAEDafter2minutesofCPR

4) RequestALS5) RefertoTerminationofResuscitation“Red10”asnecessary

INTERMEDIATE

6) ContinueCPRfor2minutesifnopulseispresent.After2minutes,performpulseandAED/manualdefibrillatorcheck—defibrillateasindicatedX1at360J(monophasic)orequivalentbiphasic

7) Manageairway**8) EstablishIV/IOenroute

9) CallforCriticalCare/ParamedicBack‐upandcontactOLMC10) RefertoTerminationofResuscitationprotocolasnecessarySee“Red10”


11) ContinueCPRifnopulse—after2minutesofCPR,dorhythmandpulsechecksandconsidernextinterventionlistedinorder—doonemedicationinterventionateach2minutere‐assessment

12) RhythmChecka. IfVForpulselessVT,thendefibrillateX1at360J(monophasic)orequivalent

biphasicorAED13) Manageairway**14) EstablishIV/IO15) Epinephrine1:10,0001mgIV/IOpush—repeatevery3‐5minutes

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Red 13

16) Give2minutesofCPR,thendorhythmandpulsechecks–defibrillateX1at360J(monophasic)orequivalentbiphasicifVForVT

17) Amiodarone300mgIV/IOpush,mayconsideradditional150mgIV/IOonetime18) Give2minutesofCPR,thendorhythmandpulsechecks–defibrillateX1at360J

(monophasic)orequivalentbiphasicifVForVT19) Give2minutesofCPR,thendorhythmandpulsechecks–defibrillateX1at360J

(monophasic)orequivalentbiphasicifVForVT

20) ContactOLMCforOPTIONofalternatetherapiessuchassodiumbicarbonate21) UponsuccessfulconversionfromVTorVF:

a. Perform12LeadECG.IfSTEMIpresent,refertoSTEMIProtocol“Red4”andlocalsystemofcare.

b. Optimize,oxygenationandventilationc. Treathypotensiond. FollowlocalPost‐ArrestSystemsofCareincludingconsiderationoftherapeutic

hypothermiainappropriatepatients.e. ContactOLMCforoptionsof:

i. Postresuscitationamiodaronebolusii. Postresuscitationamiodaronedrip

1. RECALL,amiodaroneiscontraindicatedinpatientswith2nddegreeTypeIIAVblock,3rddegreeAVblock,orprolongedQTInterval(greaterthan0.5s)

22) RefertoTerminationofResuscitationprotocolasindicatedSee“Red10”

*Ifreturnofspontaneouscirculation(ROSC)isestablished,contactOLMCandfollowappropriateprotocolforpatientrhythm**SeeAirwayAlgorithmProtocol:“Blue3and5”

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Red 14

WIDECOMPLEXTACHYCARDIA(PROBABLEVT)Ifnopulse,treatasVF/PulselessVT—SeeRed12

PulseisPresent

HeartRateisgreaterthan150andpatientisalert,comfortableandnothypotensive

Basic1. AirwayManagementasindicated2. RequestALSIntermediate

3. EstablishIV/IO4. CardiacMonitor/Perform12LeadEKGifavailable5. RequestCriticalCare/Paramedic6. ContactOLMCCriticalCare/Paramedic

7. InUNDIFFERENTIATEDwidecomplextachycardia:consideradenosineONLYIFREGULARANDMONOMORPHICa. Adenosine6mgIVrapidbolusatcentrally

locatedperipheralIVwithrapidsalineflush

b. Mayrepeatadenosinex1at12mgIVrapidbolusatcentrallylocatedperipheralIVwithrapidsalineflush

8. Consideramiodarone150mgIV/IOover10minutes

9. DCcardioversionifunstableatanytimea. ContactOLMCforoptionforsedationwith

eithermidazolam3mgIV/IOorfentanyl1mcg/kgtoamaxinitialdoseof100mcg

___________________________________________

10. ContactOLMCforfurtheroptions

Heartrateisgreaterthan150andpatienthashypotension,alteredlevelofconsciousness,signsofshock,ischemicchestpain,oracuteheartfailure

Basic

1. Airwaymanagementasindicated2. RequestALS

Intermediate

3. EstablishIV/IO4. Cardiacmonitor/Perform12leadEKGif

available5. RequestCriticalCare/Paramedic6. AEDormanuallydefibrillatex1at360Jor

biphasicequivalent7. ContactOLMC

CriticalCare/Paramedic

8. Considersynchronizedcardioversion:a. Ifnecessary,contactOLMCforoptionof

sedationwithmidazolam3mgIV/IOorfentanyl1mcg/kgIV/IOtomaxof100mcgininitialdose

b. IfunabletosyncorinthecaseofpatientinstabilityorpolymorphicVT,defibrillatex1at360Jorequivalentbiphasic

___________________________________________

9. ContactOLMCforfurtheroptionsincludingamiodaronedrip

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Red 15

ForPolymorphicVentricularTachycardiaorTorsades:ContactOLMCandconsidermagnesiumsulfate1‐2gramsIVover5minutes.DoNOTgiveadenosinetoapatientwithPolymorphicVentricularTachycardiaorTorsades.DoNOTgiveamiodaronetoapatientconvertedfromPolymorphicVentricularTachycardiaUNLESSQTintervalislessthan0.500s.IfQTintervalisgreaterthan0.500s,contactOLMCforoptions.

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Red 16

ASYSTOLEShouldbeconfirmedintwoleads.Ifrhythmisunclearandpossibleventricularfibrillation(VF),thentreatasVF.BASIC

1) CheckPulse,ifnopulsethen:a.CPRuntilAEDisavailableb.AnalyzewithAED,followAEDinstructionsc.Ifseverehypothermia,goto“Yellow7”d.ManageAirway*

2) 2minutesofCPRandthenreassesswithpulsecheckandAEDcheck3) RequestALS4) RefertoTerminationofResuscitationprotocol“Red10”asindicated

INTERMEDIATE

5) ContinueCPRfor2minutes,ifnopulseispresentperformpulseandAED/manualdefibrillatorcheck—defibrillateasindicated

6) Manageairway*7) EstablishIV/IOenroute

8) CallforCriticalCare/ParamedicBack‐up/InterceptandcontactOLMC9) RefertoTerminationofResuscitationprotocolasnecessarySee“Red10”


10) ContinueCPRifnopulse—after2minutesofCPR,dorhythmandpulsechecksandconsidernextinterventionlistedinorder

11) EstablishIV/IOandconsidertreatablecauses,includingtheAHA’s“H’s+T’s”andtreatperappropriateprotocol.

12) Epinephrine1:10,0001mgIV/IOPush—repeatevery3‐5minutes13) Give2minutesofCPR,thendorhythmandpulsechecks14) Manageairway*15) Give2minutesofCPR,thendorhythmandpulsechecks

16) RefertoTerminationofResuscitationProtocol“Red10”asindicated

*SeeAirwayAlgorithmProtocol:Blue3and5

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Red 17

PULSELESSELECTRICALACTIVITY

BASIC

1) Checkpulse,ifnopulsethen:a.CPRuntilAEDisavailableb.AnalyzewithAED,followAEDinstructionsc.Ifseverehypothermia,goto“Yellow7”d.Manageairway*

2) 2minutesofCPRandthenreassesswithpulsecheckandAEDcheck3) RequestALS

INTERMEDIATE

4) ContinueCPRfor2minutes,ifnopulseispresent,After2minutes,performpulseandAED/manualdefibrillatorcheck—defibrillateasindicated

5) Manageairway*6) EstablishIV/IOenroute,andgiveIVnormalsalinewideopen

7) CallforCriticalCare/ParamedicBack‐up/InterceptandcontactOLMC


8) ContinueCPRifnopulse,after2minutesofCPR,dorhythmandpulsechecksandconsidernextinterventionlistedinorder

9) ManageAirway*10) EstablishIV/IOandconsidertreatablecauses,includingtheAHA’s“H’s+T’s”

andtreatperappropriateprotocol.11) Epinephrine1:10,0001mgIV/IOpushrepeatevery3‐5minutes12) Give2minutesofCPR,thendorhythmandpulsechecks13) ManageAirway*14) Give2minutesofCPR,thendorhythmandpulsechecks

15) RefertoTerminationofResuscitationProtocol“Red10”asindicated

*SeeAirwayAlgorithmProtocol:Blue3and5

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Red 18

BRADYCARDIA

(Heartratelessthan50beatsperminute)ConcerningSignsorSymptoms:Bloodpressurelessthan100mmHg,alteredmentalstatus,syncope/pre‐syncope,chestpain,dyspnea,orcyanosis/pallor.A)IfNOconcerningsignsorsymptoms,thenalllevels(Basic/Intermediate/CriticalCare/Paramedic)maydothefollowing:

1) O2asappropriate

B)IfANYconcerningsignsorsymptoms,then:BASIC

1) O2asappropriate2) RequestALS

INTERMEDIATE

3) IVenroute4) Cardiacmonitor5) CallforCriticalCare/ParamedicBack‐up/Intercept


6) Atropine0.5mgIV/IO*,**;giveinrepeatdosesevery3‐5minutesuptoamaximumdoseof0.04mg/kg**(oruptoatotalof3mgintheadultpatient)

7) Applyexternalpacer—Initiatetranscutaneouspacing(TCP)forpatientswhodonotrespondtoatropine;ifserioussignsorsymptoms,donotdelayTCPwhileawaitingIV/IOaccessorforatropinetotakeeffect.Considerpremedicatingwithmidazolam(Versed)3mgIV/IOORfentanyl1mcg/kgIV/IOtoamaximumfirstdoseof100mcg.NotifyOLMCassoonaspossible.

8) IfcontinuedSignsorsymptoms,thencontactOLMCforoptionsofthefollowing:

a. Repeatatropineb. Dopamine(800mgin500ml,orpremix).TitratetomaintainBPgreaterthan100

mmHg(5to20mcg/kg/min).DopamineinfusionsinpediatricsmustbeadministeredviaaMaineEMSapprovedmedicationpump.Considerusingapumpinadultinfusions.

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Red 19

NOTE:ApplicationofTCPshouldbeconsideredifdeteriorationisanticipatedbecauseofthefollowing:

a. Observedsinuspausesb. Episodesof2nddegreeTypeII,or3rddegreeAVBlock.

*Transplanteddenervatedheartswillnotrespondtoatropine.Proceedtopacing,catecholamineinfusion,orboth**Atropineshouldbeusedwithcautionin2nddegreeTypeIIAVblockandnew3rddegreeAVblockwithwideQRScomplexes.

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Red 20

NARROWCOMPLEXTACHYCARDIA

NOTE: For all cases, attempt to identify and treat the underlying cause of the patient’s tachycardia which may include, maximizing oxygenation or (for Intermediates/Critical Care/Paramedics) maximizing hemodynamics. If uncertainty exists between sinus tachycardia and SVT, please contact OLMC.

Heartrateisgreaterthan150andpatientisalertandcomfortable,nothypotensive

Basic1. Manageairwayasindicated2. RequestALS

Intermediate3. EstablishIV/IO4. CardiacMonitor/Perform12leadEKGif

available5. RequestCriticalCare/Paramedic6. ContactOLMC

CriticalCare/Paramedic7. ValsalvaManeuver8. Adenosine6mgIVrapidbolusatcentrally

locatedperipheralIVwithrapidsalineflush

a. Mayrepeatadenosinex1at12mgIVrapidbolusatcentrallylocatedperipheralIVwithrapidsalineflush

9. Ifrhythmpersists,contactOLMCforfurtheroptions

Heartrateisgreaterthan150andpatientishypotensive,hasalteredstateofconsciousness,

evidenceofshock,ischemicchestpain,orevidenceofheartfailure

Basic1. Manageairwayasindicated2. RequestALS

Intermediate/CriticalCare3. EstablishIV/IOandperformfluidchallenge4. CardiacMonitor/Perform12leadEKGif

available5. RequestParamedic

Paramedic6. RatecontrolforAFib/AFlutter

ONLY,contactOLMCforoptionofmetoprolol5mgIVover5minutes.REMEMBER,metoprololmustnotbeusedinhypotension.

a. Repeatwithmetoprolol5mgIVover5minutesafterconsultwithOLMC

7. Ifunstablenarrowcomplextachycardia,considersynchronizedcardioversion.Firstattemptat50‐100Jorbiphasicequivalent.Subsequentattemptsifneededprogressto100J,then200J,then300J,360J(orbiphasicequivalents)

a. ContactOLMCtoconsiderpremedicationwithfentanyl1microgram/kgIVpushtoamaximuminitialdoseof100microgramsORmidazolam(Versed)3mgIVbolus.HavearunningIVinplaceofNSorLR.

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Red 21

CARDIOGENICSHOCK

BASIC

1. O2asappropriate2. RequestALS

INTERMEDIATE

3. Cardiacmonitor4. IVenroute5. CallforCriticalCare/ParamedicBack‐up/Intercept

6. ContactOLMCwithfollowinginformation:

Vitalsigns,lungsounds,cardiacrhythm,pedaledemaassessmentforOPTIONOF:a. Fluidchallenge


7. FluidChallenge

8. ContactOLMCforthefollowingOPTION:a. Dopamine(800mgin500mlorpremix).TitratetomaintainsystolicBP

greaterthan100mmHg.DopamineinfusionsinpediatricsmustbeadministeredviaaMaineEMSapprovedmedicationpump.Considerusingapumpinadultinfusions.

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SYNCOPE

Basic:

1. Obtainhistory(seizure,stroke,fluidloss,palpitations,chestpain,dizzy,trauma)Considerspinalimmobilizationifappropriate

2. O2asappropriate3. Obtainbloodglucoseiftrained4. Treatforshockifappropriate5. RequestALS

Intermediate:

6. EstablishIV/IO7. Cardiacmonitorand12leadEKG(ifsotrained)8. Fluidchallengeifappropriate,250mlover10minutes9. ObtainBloodGlucose10. CallforCriticalCare/ParamedicBack‐Up/Intercept

CriticalCare/Paramedic:

11.Cardiacmonitor12.ObtainBloodGlucose13.12‐leadEKG

NOTE:Atanytime,ifrelevantsigns/symptomsfound,gotoappropriateprotocolAllofthesepatientsshouldbetransportedforemergencyevaluation.Morethan25%ofgeriatricsyncopeiscardiacdysrhythmiabased.Considerothercauses:GIbleed,ectopicpregnancy,seizure,stroke,hypoglycemia,shock,toxicologic(alcohol),andmedications.

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Gold 1

ALLERGY/ANAPHYLAXIS

BASIC1. Manageairwayasappropriate2. Ifshockpresent,treat3. RequestALSifavailable4. Considerlocalmeasurestopreventabsorption

5. ContactOLMC

a. Assistadministrationofpatient’sownanaphylaxiskitb. Administeranadultorpediatric(asapplicable)epinephrineautoinjectorifthe

serviceisauthorizedandthepersonnelsotrained

INTERMEDIATE6. IVenroute7. Cardiacmonitor8. Ifshockpresent,performfluidchallenge

9. ContactOLMCforOPTIONofadministrationofEpinephrine0.3mg,1:1,000IMinanterolateralthigh

10. ContactOLMCforoptionofpediatricdoseofepinephrinewhichisasfollows:<30

kg,0.15mgIM(0.15mlof1:1,000),>30kg,0.3mgIM(0.3mlof1:1,000)IMinanterolateralthigh

EMT‐I,inconsultationwithOLMC,maymodifytheParamedicresponseasappropriate.


11. ManageairwayasneededSee“Blue3&5”12. Epinephrine:

a. Adult:0.3mg(0.3mlof1:1,000)IMinanterolatralthighb. Pediatric:<30kg,0.15mgIM(0.15mlof1:1,000),>30kg,0.3mgIM(0.3

mlof1:1,000)inanterolateralthigh13. Diphenhydramine(Benadryl)

a. Adult:25‐50mgIV/IO/IMb. Pediatric:1‐2mg/kgIV/IO/IM

14. Albuterol2.5mgbynebulization;Considerrepeattimes1asneededornebulizerof5mlof1:1,000Epinephrine

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Gold 2

15. Methylprednisolone(Solu‐Medrol):a. Adult:125mgIVb. Pediatric:2mg/kgIVc. Considerglucagon1mgIVq5minutesforpatientstakingbeta‐blockers

ContactOLMCforrepeatoptionsand/orIVdosingofepinephrineforshockorcardiovascularcollapsewhichmaytypicallybedosedthefollowingway:0.5to1mlofepinephrine1:10,000(0.1mg)IV,pushedoveroneminute,repeated,asneeded,in10to20minutes.

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Gold 3

ADULTCOMA(Decreasedlevelofconsciousness)

Assessfortrauma,drugs,diabetes,breathodor,needletracks,medicalalerttagssuspectedseizure.Refertoappropriateprotocolforspecificsuspectedconditions.

BASIC

1. Immobilizespineifindicated2. Manageairwayasappropriate3. RequestALSifavailable4. Ifshockpresent,refertomedicalshockprotocol“Gold13”5. OptiontoperformfingersticktomeasurebloodglucoseusingMEMSapproved

technique/devicelimitedtoproviderswhohavecompletedtheMEMSBGmonitoringtrainingprogram

INTERMEDIATE

6. ManageairwayasappropriateSee“Blue3&5”7. IVenroute8. DrawbloodasIVestablishedordofingerstick,tomeasurebloodglucoseusingMEMS

approvedtechnique/device9. Cardiacmonitor10. Ifshockpresent,refertomedicalshockprotocol“Gold13”


a. Ifbloodglucoselessthan80mg/dL,refertoDiabetic/HypoglycemicProtocol“Gold5”

b. Ifrespirationslessthan12perminuteANDnarcoticoverdosesuspectedi. Naloxone(Narcan)0.1–2mgIV/IO/IMorintranasal(mayopttogive2mgasstartingdoseifusingintranasalroute)titratetoimproverespiratorydrive

ii. NOTE:patientsabruptlyfullyawakenedmaybecomecombative,orsufferacutenarcoticwithdrawalsymptoms.Somedrugssuchaspropoxyphene,Talwin,ormethadonemayrequirehighdoses.

iii. OnceairwaymanagedbyBIAD,donotgivenaloxone

CRITICALCARE/PARAMEDIC12. Administerthefollowing:

a. Ifbloodglucoselessthan80mg/dL,refertoDiabetic/HypoglycemicProtocol“Gold5”

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Gold 4

13. Ifrespirationslessthan12perminuteANDnarcoticoverdosesuspecteda. Naloxone(Narcan)0.1–2mgIV/IO/IMorintranasal(mayopttogive2mgas

startingdoseifusingintranasalroute)titratetoimproverespiratorydriveb. NOTE:patientsabruptlyfullyawakenedmaybecomecombative,orsufferacute

narcoticwithdrawalsymptoms.Somedrugssuchaspropoxyphene,Talwin,ormethadonemayrequirehighdoses.

c. OnceairwaymanagedbyETTorBIAD,donotgivenaloxone14. Ifshockpresent,refertomedicalshockprotocol“Gold13”


a. Repeatdextroseb. Repeatbolusofnaloxone(Narcan)0.1–2mgIV/IO/IM

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Gold 5

ADULTDIABETIC/HYPOGLYCEMICEMERGENCIESPediatricDiabeticEmergenciesSee“Pink11”

BASIC

1. Manageairwayasappropriate2. RequestALSifavailable3. Ifpatientisaknowndiabetic,hasaknownlowbloodsugar,orhasanalteredmental

status,andifthepatientisconsciousandabletoswallow,giveglucoseorally4. OptiontoperformfingersticktomeasurebloodglucoseusingMEMSapproved


Glucosepasteistobeadministeredassoonaspossibleinpatientspresentingwiththesigns/symptomsofdiabeticemergency.INTERMEDIATE

5. IVenroute6. DrawbloodasIVestablishedordofingerstick,tomeasurebloodglucoseusingMEMS

approvedtechnique/device7. Cardiacmonitor8. Ifbloodglucoseislessthan80mg/dL,

a. Ifpatientisconsciousandabletoswallow,giveglucoseorally

b. ContactOLMCforOPTIONofadministeringdextrose25gm(50mlof50%solutionIVor250mlof10%solutionIV).Recheckbloodglucosein5minutes.

c. IfIVunavailable,DONOTPLACEIO.i. ContactOLMCforOPTIONofglucagon1mgIM.

9. Ifbloodglucosegreaterthan300mg/dL,give500mlNSfluidchallenge


10. Dextrosea. Ifbloodglucoselessthan80mg/dLadministerdextroseforadultcomaand

diabeticemergenciesi. Ifpatientisconsciousandabletoswallow,giveglucoseorally.ii. Ifpatientunabletotolerateoralglucose,administerdextrose25gm(50

mlof50%solutionor250mlof10%solution)IV.iii. IfIVunavailable,DONOTPLACEIO.

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Gold 6

1. Administerglucagon1mgIM11. Ifbloodglucosegreaterthan300mg/dL,give500mlNSfluidchallenge12. Repeatglucosemeasurementin5minutes.

ContactOLMCforOPTIONofrepeatingdextrose,repeatingglucagon,orplacinganIO a.IfIOplaced,administer250mlofD10WviaIO.

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Gold 7

ADULTSEIZURES

PediatricSeizuresSee“Pink3”

Note:Mostseizuresareself‐limited.Unlessaspecificunderlyingconditionexists(i.e.diabeteswithhypoglycemia),treatmentofaseizureormultipleseizureswithatotaldurationofless

than5minutesshouldfocusonpatientprotectionandoxygenation.BASIC

1. Manageairwayasappropriate2. Leftlateralrecumbentpositionandprotectpatientfrominjury3. SpinalimmobilizationifindicatedSee“Green6”4. RequestALSifavailable5. OptiontoperformfingersticktomeasurebloodglucoseusingMEMSapproved


INTERMEDIATE

6. ManageairwayasneededSee“Blue3&5”7. Cardiacmonitor8. IVenroute9. DrawbloodasIVestablishedordofingerstick,tomeasurebloodglucoseusingMEMS

approvedtechnique/device

10. ContactOLMCforthefollowingOPTIONS:a. Ifbloodglucoselessthan80mg/dL,refertoDiabetic/Hypoglycemic

Protocol“Gold5”

11. Ifshockpresent,refertomedicalshockprotocol“Gold13”CRITICALCARE/PARAMEDIC

12. Ifbloodglucoselessthan80mg/dL,refertoDiabetic/HypoglycemicProtocol“Gold5”

13. Ifthepatientishasasingleseizurelastinggreaterthan5minutesORstatusepilepticus,

a. Midazolam(Versed)1mgIV/IO,every1minuteforatotalof3mgi. IfIVorIOcannotbeestablished,midazolam(Versed)5mgIM.

14. Forpatientsvisiblypregnantorlessthan2weekspostpartuma. Magnesiumsulfate4gmIV/IOover10minutes

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Gold 8

i. IfIV/IOnotavailable,magnesiumsulfate8gmIM(4gmineachbuttock)

15. ContactOLMCforthefollowingOPTIONS:a. Ifrepeatofanyoftheseoptionsisnecessary

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Gold 9

ACUTESTROKEStrokeshouldbesuspectedifanyofthefollowinghaveappearedinthelastfewhoursordays:weaknessononesideofface,weaknessinonearmorleg,abnormalspeech(slurred,incoherent,absent).Refertothenextpageforearlyhospitalnotificationprocessforpatientswhoarepotentialstrokepatients.See“Gold3”AdultComaifwarrantedSee“Gold5”DiabeticEmergenciesifwarrantedBASIC1.Manageairwayasappropriate2.RequestALSifavailable3.OptiontoperformfingersticktomeasurebloodglucoseusingMEMSapprovedtechnique/devicelimitedtoproviderswhohavecompletedtheMEMSBGmonitoringtrainingprogram.INTERMEDIATE4.ManageairwayasneededSee“Blue3&5”5.Cardiacmonitor6.IVenroute7.DrawbloodasIVestablishedordoafingerstick,tomeasurebloodglucoseusingMEMSapprovedtechnique/device. 8.Ifbloodglucoseislessthan80mg/dL,

a.ContactOLMCforOPTIONofadministeringdextrose25gm(50mlof50%solutionor250mlof10%solution)IV.

i.IfIVunavailableDONOTPLACEIO.ContactOLMCforoptionofIO. A.IfIOplaced,administer250mlofD10WviaIO

CRITICALCARE/PARAMEDIC9.Ifbloodglucoselessthan80mg/dL

a.Ifpatientisconsciousandabletoswallow,giveglucoseorallyb.Ifpatientunabletotolerateoralglucose,administerdextrose25gm(50mlof50%solutionor250mlof10%solution)IVc.IfIVunavailable,DONOTPLACEIO.Administerglucagon1mgIM

i.ContactOLMCforOPTIONofrepeatingdextrose,repeatingglucagon,orplacinganIO

A.IfIOplaced,administer250mlofD10WviaIO.

d.Recheckbloodglucosein5minutes.

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Gold 10

AcuteStroke

1. PerformtheCincinnatiPrehospitalStrokeScaleandassessmentalstatus.Ifanyelementisabnormal,proceedtoStep2

a. CincinnatiPrehospitalStrokeScale: i. Speech:Havept.state“Youcan’tteachanolddognewtricks”

1. Abnormal=wrongword,slurred,orabsentspeechii. Facialdroopwhenaskedtoshowteethorsmile

1. Abnormal=onesidedoesnotmoveaswellasotheriii. Motor:Havepatientcloseeyesandholdoutbotharms

1. Abnormal=armcannotmoveordriftsdownwhenheldoutb. AlsoassessLevelofconsciousness

i. Abnormal=lethargic,stuporous,comatose2. Determinebloodglucoselevel.Ifitisgreaterthan80mg/dL,proceedtoStep3.

a. BasicEMT’smayonlycheckbloodglucoseiftheyhavecompletedtheMEMSBGMonitoringTrainingprogram

b. Ifbloodglucoseislessthan80mg/dLtreatperMEMSprotocols.Recheckthebloodglucosein5minutesand,ifitisgreaterthan80mg/dL,repeattheCincinnatiPrehospitalStrokeScale,ifitispositive(1ormorepositives)proceedtoStep3.

3. Determinetimeof“LastSeenNormal.”a. Gethistoryfromthepatientandallavailablebystandersb. “TimeLastSeenNormal”startswiththeonsetoffirstsymptomsor,ifthe

symptomsimprovedorwentaway,thetimethesymptomsreturnedorgotworseagain.

c. Makesuretorecordcontactinformation(cellphone,numberetc.)fortheindividualabletoidentifytheexacttimewhenthepatientwaslastasymptomatic

4. Asearlyaspossible,alertthereceivinghospitalofa“CodeStroke”a. Relaythefollowinginformation:

i. Patientageandgenderii. Identifythepatientasapotentialstrokepatientiii. Thepatient’sneurologicdeficitsandthefindingsoftheCincinnatiPre‐

hospitalStrokeScaleiv. The“TimeLastSeenNormal”v. Thepatient’smentalstatusvi. Thepatient’svitalsignsandfingerstickbloodglucoseresultsvii. ETA

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Only

Gold 11

StrokeChecklistTimeofsymptomonset/TimeLastSeenNormal:_________________YesNo Historyofintracranialhemorrhage? Knownarteriovenousmalformation,neoplasm,oraneurysm? Witnessedseizureatstrokeonset? Activeinternalbleedingoracutetrauma(fracture)? Intracranialorintraspinalsurgery,seriousheadtrauma,orpreviousstrokewithin

thepast3months? CurrentuseofCoumadinorreceivedheparinwithinthelast48hours? Arterialpunctureatanoncompressiblesitewithinpast7days?Adaptedfrom‐Anonymous.“Table3:FibrinolyticChecklist”fromPart9:AdultStroke.Circulation2005;IV:116.

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Gold 12


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Gold 13

MEDICALSHOCKSee“Red21”CardiogenicShockifappropriateSee“Green13”HypovolemicShockifappropriateSee“Gold1”AllergyandAnaphylaxisifappropriateSee“Blue3”AdultAirwayAlgorithmifappropriateDefinitionofSevereInflammatoryResponseSyndrome(SIRS),Sepsis,SevereSepsisandSeptic

ShockVariable DefinitionSIRS Greaterthanorequalto2of

thefollowingTemp>38.3°Cor<36°CHR>90bpmRespiratoryrate>20bpmHyperglycemia>120mg/dl1AlteredLevelofConsciousnessDecreasedcapillaryrefillLactate>2mmol/L

Sepsis SIRS+apresumedoridentifiedsourceofinfectionSevereSepsis Sepsis+oneormoreorgandysfunction2,hypotensionbefore

fluidchallenge,orLactate>4mmol/LSepticShock Severesepsis+hypotension3despitefluidchallenge

Tableadoptedfrom2001SCCM/ESICM/ACCP/ATS/SISInternationalSepsisDefinitionsConference. 1Hyperglycemiawithouthistoryofdiabetes,Hypoglycemia,withoutdiabetes,inanimmunocompromisedpatient

increasessuspicionofinfection.2Organdysfunctioncanbedefinedas:respiratoryfailure,acuterenalfailure,acuteliverfailure,coagulopathy,or

thrombocytopenia.Laboratoriesthatwillsuggestorgandysfunctioninclude:PaO2(mmHg)/FiO22.0mg/dlORCreatinineIncrease>0.5mg/dL,INR>1.5,PTT>60sec,Platelets<100,000/uL.Total

bilirubin>4mg/dL�3SystolicBloodPressure<90mmHgorMeanArterialPressure<65mmHgBASIC1.Attempttoidentifycause(i.e.allergicreaction)2.Manageairwayasappropriate3.RequestALSintercept4.TransportINTERMEDIATE/CRITICALCARE/PARAMEDIC5.Considercauses

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Gold 14

a.MassiveGIbleed,vaginalbleeding,vomiting,diarrhea,rupturedaneurysm‐Treatper“Green13”HypovolemicShock

b.Cardiogenicshock‐Treatper“Red21” c.Anaphylaxis‐Treatper“Gold1” d.SevereSepsis

i.Assessforacutepulmonaryedema.Ifpresent,refertocardiogenicshock“Red21”

ii.Ifavailableandtrainedperformpointofcarelactate:A. IfPOClactate>4andnoevidenceofpulmonaryedema,administer1000

mlNSbolusiii.IfPOClactatenotavailableandnoevidenceofpulmonaryedema

A. ContactOLMCforOPTIONof500mlNSbolus

iv.Notifyreceivinghospitalthatthepatientisa“CodeSepsis”CRITICALCARE/PARAMEDIC

6.Foranaphylacticorpresumedsepticshock a.Ifnoresponsetoinitialtreatment

i.Contactmedicalcontroltodiscussadditionalfluidbolusversusinitiatingdopamineinfusion.DopamineinfusionsinpediatricsmustbeadministeredviaaMaineEMSapprovedmedicationpump.Considerusingapumpinadultinfusions.

A.Dose5‐20mcg/kg/min(2‐9mcg/pound/min) B.Ti

prehospital treatment protocols › ems › sites › maine.gov.ems › ...“automatic...

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