Berrien County
Protocols
Adult and Pediatric Protocols
Revised July 2007
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT TREATMENT PROTOCOLS INDEX
REVISED JULY 2007
CARDIAC
Table of Contents
General Pre-Hospital Care
Adult
Cardiac Arrest – General Protocol
Automated External Defibrillator (AED)
VF / Pulseless VT
Asystole / PEA Protocol
Chest Pain / Acute Coronary Syndrome
Acute Pulmonary Edema / CHF
Cardiogenic Shock
Wide Complex Tachycardia
Narrow Complex Tachycardia
Bradycardia Protocol
Pediatric
Cardiac Protocols – General Protocol
Pediatric - VF / Pulseless VT
Pediatric - Asystole / PEA
Pediatric - Wide Complex Tachycardia
Pediatric - Narrow Complex Tachycardia
Pediatric - Bradycardia
CBRNE
General CBRNE Identification of Agents
Chemical Exposure
CHEMPACK
Communicable Disease
Cyanide Exposure
Mass Causality Incident
MEDRUN
ENVIRONMENTAL
Drowning/ Near Drowning
Hyperthermia
Hypothermia/Frostbite
MEDICAL
Abdominal Problems
Allergic Reaction/ Anaphylaxis
General Weakness/ Illness
Hemorrhage (Non-Traumatic)
Hypertensive Emergency
Poisoning/ Overdose
Respiratory Distress
Sexual Assault
Shock
NEUROLOGICAL
Acute Altered Mental Status
Cerebrovascular Accident (CVA)
Seizures
Syncope
OB/GYN
Obstetrical Emergencies
PSYCH
Psychiatric Emergencies
TRAUMA
Assessment/ Stabilization
Burns
Chest Injury
Head Trauma
Soft Tissue Injuries
Spinal Injury
PEDIATRICS
General Pediatric Assessment & Treatment
Altered Mental Status
Anaphylaxis/Allergic Reaction
Bronchospasm
Burns
Death of a Child
Foreign Body Airway Obstruction
Near - Drowning
Newborn Resuscitation
Non-Traumatic Shock
Pain Management
Respiratory Distress, Failure, or Arrest
Seizures
Toxic Exposure
Trauma
GENERAL PROCEDURES
Table of Contents
APPENDIX
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT TREATMENT PROTOCOLS
REVISED JULY 2007
Cardiac
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 1
Table of Contents
Table of Contents 1
General Pre-Hospital Care 2
Adult Cardiac Arrest – General Protocol 3
Automated External Defibrillator (AED) Procedure 4
Ventricular Fibfillation / Pulseless Ventricular Tachycardia 5
Asystole / PEA Protocol 6
Chest Pain / Acute Coronary Syndrome Protocol 7
Acute Pulmonary Edema / CHF Protocol 8
Cardiogenic Shock 9
Wide Complex Tachycardia 10
Narrow Complex Tachycardia 11
Bradycardia Protocol 12
Pediatric Cardiac Protocols – General Protocol 13
Pediatric Ventricular Fibfillation / Pulseless Ventricular Tachycardia 14
Pediatric Asystole / PEA Protocol 15
Pediatric Wide Complex Tachycardia 16
Pediatric Narrow Complex Tachycardia 17
Pediatric Bradycardia 18
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 2
General Pre-Hospital Care
In most cases, the stabilization of patients presenting with medical conditions should be carried out at the patient’s side prior to patient movement or transport. Before attempting the following procedures, implement appropriate blood borne and/or airborne pathogen protective procedures. Contact medical control according to local protocol.
I. Pre-Medical Control
M B S P A. Assure ABCs while maintaining c-spine precautions where indicated.
A. Do airway intervention using appropriate airway adjuncts when necessary:
MFR / EMT / EMT-S / EMT-POropharyngeal Airway / X / X / X / X
Nasopharyngeal Airway / X / X / X / X
Bag-Valve-Mask Ventilation / X / X / X / X
Supraglottic Airway (per MCA approval) / X / X / X
Oral / Nasal Endotracheal Intubation / X / X
Needle / Surgical Cricothyroidotomy / X
X: Approved Intervention
B. Administer oxygen and assist ventilations, as indicated in accordance with Airway / Oxygenation Procedure. Use 2-person BVM technique whenever possible.
C. Obtain a history and physical exam using the following as a guideline:
1. Age and sex
2. Present complaint
3. Pertinent medical history
4. Pertinent medications patient is taking
5. Medication allergies
D. Obtain vital signs approximately every 15 minutes, or as frequently as necessary to monitor the patient’s condition:
1. Blood pressure
2. Pulse rate
3. Respiratory rate
4. Lung sounds
5. Pupil reactions (as appropriate)
6. Skin condition and color
7. Level of consciousness
E. Follow specific protocol for patient condition.
S P G. Establish vascular access per Vascular Access Procedure in accordance with a specific protocol.
P H. Apply cardiac monitor and treat rhythm according to appropriate protocol. If available and applicable, obtain 12-lead EKG. A copy of the rhythm strip or 12-lead EKG should be attached to the patient care record and should be left at the receiving facility.
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 3
Adult Cardiac Arrest - General Protocol
This protocol should be followed for all adult cardiac arrests. Once arrest is confirmed emphasis should be on avoiding interruptions in CPR. When an ALS unit is present, follow this general cardiac arrest protocol until a rhythm is determined. Once this is done, see the appropriate rhythm specific protocol. CPR should be done in accordance with current guidelines established by the American Heart Association.
I. Pre-Medical Control
M B S A. If unwitnessed arrest perform 2 minutes of CPR or,
B. If witnessed or unwitnessed and bystander CPR in progress, apply AED if available and follow AED protocol.
P C. If unwitnessed arrest perform 2 minutes of CPR.
D. Apply cardiac monitor and treat rhythm according to appropriate protocol.
M B S P E. Confirm Arrest: If pulseless, continue CPR.
F. Establish a patent airway, maintaining C-Spine precaution if indicated, using appropriate airway adjuncts and high flow oxygen.
G. Reassess ABC’s as indicated by rhythm or patient condition change. Pulse checks should take no more than 10 seconds.
B S P H. Insert advanced airway as authorized by local MCA. Avoid significant interruptions in CPR.
S P I. Start an IV NS KVO at the most proximal location, with the largest appropriate size IV catheter. If IV is unsuccessful may start an IO line. Endotracheal administration of medication should be avoided unless other options do not exist.
II. Post-Medical Control
P J. Consider termination of resuscitation per local MCA protocol.
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 4
Automated External Defibrillator (AED) Procedure
The Automated External Defibrillator (AED) shall be applied only to patients found in cardiopulmonary arrest. Interruptions to CPR should be kept to a minimum. The AED should not be used on patients found lying on conductive surfaces or patients in moving vehicles. There are no age or weight limits for AED use. In pediatric patients, attenuated pads should be used, if available. If adult pads are used in pediatric patients, place in an anterior/posterior configuration.
I. Pre-Medical Control
M B S P A. Follow the General Cardiac Arrest protocol.
B. Stop CPR to analyze patient and shock once, if needed.
C. Continue CPR immediately after the shock, or immediately if no shock is indicated and continue for 2 minutes (5 cycles) or when AED initiates analysis.
D. If no pulse, analyze the patient and repeat one shock, if needed.
E. If patient converts to a non-shockable rhythm at any time, continue CPR until AED prompts to check the patient.
F. Should a patient who is successfully defibrillated arrest again, analyze the patient. If the AED indicates shockable rhythm then deliver shock as directed.
G. If ALS is not available and the patient is either in a non-shockable rhythm or the patient has received two cycles of CPR and shocks, the patient should be transported to the nearest appropriate facility with continued CPR and advanced airway (EMT/SPECIALIST).
P H. If ALS arrives and the AED allows for manual shocks, it may remain in place. If not, complete any shock you are administering, and then disconnect the AED. ALS should attach their ECG monitor and continue treating the patient per protocol. ALS does not need to repeat any of the AED shocks.
Note: Follow manufacturer’s instructions except age limits.
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 5
Ventricular Fibrillation / Pulseless Ventricular Tachycardia
If AED is applied prior to ALS arrival, perform CPR and reassess the rhythm as indicated. After each intervention resume CPR immediately and reassess the rhythm after each 2 minute interval.
All defibrillations will be at the device’s maximum recommended energy.
I. Pre-Medical Control
P A. Follow the Cardiac Arrest – General Protocol.
B. Defibrillate x1 and immediately resume compressions
C. Continue CPR for 2 minutes and reassess rhythm.
D. Establish an advanced airway. Avoid significant interruptions in CPR.
E. Defibrillate x1 and immediately resume compressions
1. Continue CPR for 2 minutes and reassess rhythm.
F. Start an IV NS KVO at the most proximal location.
G. If IV is unsuccessful, start an IO line. Endotracheal administration of medication should be avoided unless other options do not exist.
H. Administer Epinephrine 1 mg 1:10,000 IV/IO, (10 ml). Repeat every 3-5 minutes. May be administered before or after defibrillations.
I. Administer Vasopressin 40 units IV/IO in place of second dose of Epinephrine as approved by local medical control.
J. Defibrillate x1 and immediately resume compressions
1. Continue CPR for 2 minutes and reassess rhythm.
K. For persistent or recurrent VF/Pulseless VT, administer Amiodarone 300 mg IV/IO. May be administered before or after defibrillations.
L. Administer Magnesium Sulfate 2 gm IV/IO for suspected torsades de pointes.
M. Defibrillate x1 and immediately resume compressions
1. Continue CPR for 2 minutes and reassess rhythm.
N. For persistent or recurrent VF/Pulseless VT, administer Amiodarone 150 mg IV/IO. May be administered before or after defibrillations.
O. Defibrillate x1 and immediately resume compressions
1. Continue CPR for 2 minutes and reassess rhythm.
P. Repeat defibrillation x1 every 2 minutes with CPR, as indicated.
II. Post-Medical Control
P Q. Initiate transport.
R. Consider termination of arrest (if persistent fine VF)
* Need to choose between Vasopressin or epinephrine
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 6
Asystole / Pulseless Electrical Activity Protocol
During CPR, consider reversible causes of Asystole/PEA and treat as indicated. Causes and efforts to correct them include:
Hypovolemia – fluid bolus
Hypoxia – reassess airway and ventilate with high flow oxygen
Tension pneumothorax – pleural decompression
Hypothermia – follow Hypothermia Protocol rapid transport
Hyperkalemia (history of renal failure) – Calcium Chloride per protocol
a. Hypoxia – reassess airway and ventilate with high flow oxygen
b. Tension pneumothorax – pleural decompression
c. Hypothermia – warming
d. Hyperkalemia (history of renal failure) – Calcium chloride per Medical Control
I. Pre-Medical Control
P A. Follow the Cardiac Arrest - General Protocol.
B. Administer Epinephrine 1 mg 1:10,000 IV/IO (10 ml), repeat every 3-5 minutes.
C. Administer Vasopressin 40 units IV/IO in place of second dose of Epinephrine as approved by local medical control.
D. Administer Atropine Sulfate 1 mg IV/IO for asystole and PEA with a HR less than 60/minute, repeat every 3-5 minutes to a total dose of 3 mg.
E. If renal failure is suspected, administer Calcium Chloride 1gm IV/IO and Sodium Bicarbonate 1 mEq/kg IV/IO with flush in between medications.
F. Continue CPR and reassess rhythm every 2 minutes.
II. Post-Medical Control
P G. Initiate transport
H. Consider termination of resuscitation
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 7
Chest Pain / Acute Coronary Syndrome Protocol
The goal is to reduce cardiac workload and to maximize myocardial oxygen delivery by reducing anxiety, appropriately oxygenating and relieving pain.
I. Pre-Medical Control
M B S P A. Follow General Pre-Hospital Care Protocol.
B. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or similar medications in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN.
C. Assist patient in the use of their own Nitroglycerin sublingual tabs or spray, (check expiration date) if available and if the patient’s systolic BP is above 120 mmHg, for a maximum of 3 doses.
D. Administer aspirin 324 mg (chew and swallow if no aspirin within 24 hours).
B S P E. Do not delay transport.
S P F. Start an IV NS KVO. If the patient has a systolic BP of less than 100 mmHg, administer a NS fluid bolus in 250 ml increments and reassess.
P G. Obtain 12-lead ECG if available. Follow local MCA transport protocol if ECG is positive for acute ST Segment Elevation Myocardial Infarction (STEMI) and alert hospital as soon as possible.
H. Administer nitroglycerin 0.4 mg sublingual if systolic BP is above 100 mmHg. Dose may be repeated at 3 to 5 minute intervals if chest pain persists and systolic BP remains above 100 mmHg or to a maximum of 3 doses. This may be done prior to IV placement if systolic BP is 120 mm Hg or above.
I. Administer aspirin 324 mg (chew and swallow if no aspirin within 24 hours).
J. If pain persists, administer pain medication per Pain Management Protocol if local MCA authorizes this Pre-Medical Control Contact.
II. Post-Medical Control
P K. If pain persists, administer pain medication per Pain Management Protocol if local MCA authorizes this Pre-Medical Control Contact.
L. Continue nitroglycerin 0.4 mg sublingual every 3 to 5 minutes
BERRIEN COUNTY MEDICAL CONTROL AUTHORITY
ADULT CARDIAC TREATMENT PROTOCOLS
REVISED JULY 2007 Page: 8
Acute Pulmonary Edema / CHF Protocol
This protocol is to be followed for patients in acute respiratory distress situations, not chronic.
I. Pre-Medical Control
M B S P A. Follow General Pre-Hospital Care Protocol.
B. Initiate supplemental oxygen by non-rebreather mask.
C. Position patient upright with legs dependent, if possible.
B S P D. If indicated, establish an advanced airway in the patient to maintain an adequate airway.
S P E. Start an IV NS KVO.
P F. Apply cardiac monitor and treat rhythm according to appropriate protocol.
G. Obtain 12-lead ECG if available. Follow local MCA transport protocol if ECG is positive.
H. Inquire of all patients (male and female) if they have taken Viagra (sildenafil citrate) or a similar medication in the last 48 hours. If yes, DO NOT ADMINISTER NITROGLYCERIN.
I. If BP above 100 mm Hg, administer Nitroglycerin 0.4 mg SL. Repeat every 5 minutes if BP above 100 mm Hg. Nitroglycerin may be administered prior to IV placement if the BP is above 120 mm Hg.
J. Consider CPAP / Bi-PAP, if available.
II. Post-Medical Control
P K. Administer Furosemide (Lasix) 40 mg IV.
L. If systolic BP remains above 100 mm Hg, administer Morphine Sulfate 2 mg IV.