A. Airway Devices:
1. Oropharyngeal or nasopharyngeal airway insertion should be attempted on all unconscious patients for airway maintenance.
2. Combitubes are to be inserted only in apneic patients unless ordered verbally by the medical control physician or if authorized by the service medical director. The combitube should be used with caution in patients with trauma causing bleeding into the pharynx.
3.
Endotracheal intubation is not a required procedure but is sanctioned by
the Willmar Ambulance Service for various categories of patients. Endotracheal
intubation is to be performed only by paramedics trained and authorized to
intubate and only for those types of patients specified by the ALS Medical
Director. Endotracheal intubation shall be performed so as to be consistent
with other protocols in this document. After endotracheal intubation, tube
position must be confirmed using end tidal carbon dioxide detection and/or the
endotracheal tube locator device.
a.
An end-tidal carbon dioxide (CO2) detector should be used to
accomplish confirmation of endotracheal tube placement and is most reliable in
patients with spontaneous circulation. This device may not be able to detect CO2
in cardiac arrest patients due to extremely low blood flow to the lungs.
b. The endotracheal tube locator device utilizes anatomical differences between the trachea and the esophagus to verify proper endotracheal tube placement and is to be used in conjunction with an end-tidal CO2 detector device to confirm tube placement.
B. Pulse oximetry: A pulse oximetermay be used (but is not required) for any patient with suspected hypoxemia, in respiratory distress, or whenever sedating medications are administered. Obtaining a normal pulse oximetry reading does not negate the need for oxygen therapy as specified in these protocols.
Oxygen therapy should be administered in accordance with the following guidelines:
Standing Orders
A. If patient has no history of COPD, oxygen should be administered by mask at a minimum of 10 liters per minute or by nasal cannula at 4-6 liters per minute. Oxygen flow should be adjusted per SaO2 if available to achieve 97% or greater oxygen saturation (unless the patient has a history of COPD and normally lower oxygen saturation).
B. If patient has a history of COPD, use a nasal cannula at 2-3 liters per minute initially. Oxygen may need to be increased if the patient's oxygenation status worsens.
C.
Patients with suspected pulmonary burns or CO toxicity should receive
oxygen by mask for the highest possible oxygen delivery.
Intravenous fluid therapy should be administered in accordance with the
following guidelines:
Standing Orders
A. For most patients, the paramedic has the option of either running fluids through the IV or capping the catheter with a saline lock. However, as specified in these protocols, IV fluids must always be hung in situations:
1. when the administration of multiple IV medications is anticipated; and
2.
whenever it is likely the patient will require fluid volume replacement.
B. If IV access cannot be established rapidly at the scene (in two attempts) in patients with non-traumatic problems, begin transport to the hospital. Further IV attempts can be made during transport provided all other necessary treatment is being done. There should be no delay at the scene for IV attempts on trauma patients or patients in shock, these IV's should be started during transport.
C. Consider IO access for major trauma or cardiac arrest patients. IO May also be used for other patients that need IV access after peripheral attempts have been made. (See Appendix G – IO Procedure)
Standing Orders
1. Medications that may be administered via the tracheobronchial tree by injection into an endotracheal tube:
a. Narcan
b. Atropine
c. Epinephrine
d.
Lidocaine
2. This drug administration route should only be used in cardiac arrest whenever:
· an endotracheal tube has been placed,
· venous access is significantly delayed, or
·
three attempts at venous access have failed.
3.
Medications via the ET route should be administered at twice the IV dose
and should be diluted with sterile normal saline or water to a volume of at
least 10 ml.
4. A suction catheter should be passed beyond the tip of the endotracheal tube, chest compressions stopped and the drug solution quickly injected into the catheter. This should be followed by several quick ventilations to aerosolize the medication before resuming chest compressions.
Standing Orders
1. If patient is ET intubated and becomes agitated from increased consciousness, consider: Verseditrated 2-5 mg IV/IM or Ativan 2 mg IV/IM while maintaining a BP of 100 or greater.
2. If BP less than 100 or if additional sedation is necessary, contact a medical control physician.
After Obtaining Verbal Orders
3. Consider initial or additional Ativan1-2 mg IV/IM or Versedtitrated 2-5 mg IV/IM.
To provide relief of pain when indicated. This protocol
is NOT to be used in cases where the patient:
· has systolic blood pressure less than or equal to 90,
· has pain determined to be cardiac in origin (see chest pain protocol page 1-13),
·
is in active labor.
Standing Orders
1. Assess pain on 0-5 scale.
2. Inform patient that pain is an important diagnostic parameter and the goal of this protocol is to relieve suffering not totally eliminate pain.
3. Administer Morphine Sulfate 2-10 mg IV/IM/SQ.
a. If patient is allergic to Morphine Sulfate may use Dilaudid1-2 mg IV/IM. (Maximum total dose 2 mg)
4. Reassess pain scale and titrate additional doses of Morphine Sulfatein, up to 5 mg increments every 5-10 minutes as needed.
5. Monitor vital signs (including O2 saturation). If respiratory depression or hypotension occurs after administration of Morphine Sulfateor Dilaudidventilate patient as necessary and administer Narcan0.4 - 2 mg IV. Notify a medical control physician.
6. Contact medical control physician for orders if:
a. patient has SBP £ 90,
b. if further Dilaudid is required.
After Obtaining Verbal Orders
7. Consider initial or additional pain medication as appropriate.