Contact
a medical control physician for patients with continued moderate-to-severe
respiratory distress after two nebs.
Standing Orders
1. Begin oxygen therapy and quickly complete patient assessment.
2. Place patient in pneumatic compression trousers(PCT):
a. For suspected ruptured AAA, inflate irrespective of blood pressure;
b. For suspected ruptured ectopic pregnancy, inflate if systolic BP <90;
c. For all other hemorrhagic and non-hemorrhagic conditions, do not inflate without verbal orders.
3. Begin transport immediately
4. Start Normal Saline IV en route.
5. Contact a medical control physician for further orders.
After Obtaining Verbal Orders
6. Consider volume loading for hypotension.
1. Anaphylaxis
Standing Orders
a. For signs and symptoms of anaphylaxis, begin oxygen therapy; assist respirations with PPV as needed; ET intubate, if authorized, for severe respiratory distress and/or ineffective ventilation.
b. Consider placing venous tourniquet proximal to sting or injection site, and/or ice pack at sting or injection site.
c. May administer Epinephrine0.3 mg 1:1000 or one adult EpiPen SC if patient was exposed to commonly recognized allergen and has respiratory distress OR systolic BP <90.
d. Start Normal Saline IV.
e. If patient meets criteria in (c.) above, may also administer diphenhydramineHCL (Benadryl)50 mg IV or, if unable to start IV, 50 mg IM while contacting a medical control physician.
After Obtaining Verbal Orders
f. Consider 0.3 mg 1:1000 Epinephrine(0.3 ml) or one adult EpiPen may be given subcutaneously.
g. Consider pneumatic compression trousers(PCT) and/or volume loading for hypotension.
2. Allergic Reaction
Standing Orders
a. For sign and symptoms consistent with an allergic reactionwhere:
- SBP > 90 and
- patient shows no evidence of respiratory distress
b. Consider diphenhydramine (Benadryl) 50 mg IV/IM.
1. If patient is breathing:
Standing Orders
a. Begin oxygen therapy.
b. For patients in moderate-to-severe respiratory distress, may administer on-site Terbutaline0.25 mg SC if patient <60 years AND no history of cardiac disease.
c. Consider ECG monitoring in older asthmatics receiving parental medications.
d. Move patient to ambulance and begin transport. Asthma patients should always be transported to a hospital for monitoring and further treatment.
e. Give nebulized albuterol,2.5 mg with Atrovent,0.5 mg added. May repeat albuterol neb, 2.5 mg with Atrovent 0.5 mg x1. Additional treatment of nebulized albuterol, 2.5 mg may be given every 15 minutes thereafter as needed.
f. Consider ET intubation.
g. During transport, if patient does not improve, contact medical control physician.
After Obtaining Verbal Orders
h. If not already given, consider Terbutaline0.25 mg SC.
i. Consider 0.3 mg Epinephrine1:1000 (0.3 ml) or one adult EpiPen SC.
j. If unresponsive to other treatments and in impending respiratory failure, may consider magnesium sulfate 1 Gm diluted to 10 ml with Normal Saline or sterile H2O and given IV push over 1 min.
2. If patient in respiratory arrest:
Standing Orders
a.
Insert oral airway and begin positive pressure ventilation. Ventilate
with short insp:long exp ratio at rate of
8-10/min.
b. Insert Combitubeor, if authorized ET tube as soon as possible.
c. May administer Terbutaline0.25 mg SC while awaiting medical control contact.
d. If ET intubated give in-line nebulized albuterol2.5 mg with Atrovent0.5 mg added. May repeat neb of albuterol 2.5 mg with Atrovent 0.5 mg x 1.
e. If lung deflation poor, perform manual exhalation.
f. Start IV Normal Saline and attach ECG leads while contacting a medical control physician.
After Obtaining Verbal Orders
g.
Epinephrine0.05-0.1 mg 1:10,000
(0.5-1 ml) IV if certain problem is asthma. Avoid ET route unless IV cannot
be established.
h. Expedite transport
i. Consider atropine0.5-1.0 mg IV. Avoid ET route unless IV cannot be established.
j. Consider sodium bicarbonate50 mEq IV
3. If patient in full cardiopulmonary arrest:
Standing Orders
a. Treat according to cardiac arrest protocols for rhythm. Contact a medical control physician after first dose of epinephrine
b. Ventilate with short insp:long exp ratio at rate of 8-10/min.
c. If lung deflation poor, perform manual exhalation.
After Obtaining Verbal Orders
d. If patient shows signs and symptoms of tension pneumothorax, may consider needle chest decompression.
e. Treat according to cardiac arrest protocols but:
- consider earlier transport;
- consider early administration of sodium bicarbonatet higher dose.
Standing Orders
1. If history of COPD and symptomatic (presence of wheezing alone does not indicate COPD), en route to hospital, may give nebulized albuterol 2.5 mg with Atrovent 0.5 mg added. May repeat neb of albuterol 2.5 mg with Atrovent 0.5 mg x1.
2.
Contact
a medical control physician for patients with continued moderate-to-severe
respiratory distress after two nebs.
Standing Orders
1. Begin appropriate oxygen therapy and maintain airway.
2. Consult with a medical control physician immediately if tension pneumothorax suspected.
After Obtaining Verbal Orders
3. Consider needle thoracostomyif strong evidence of tension pneumothorax (i.e. increased respiratory distress; weak, rapid pulse; cyanosis; hypotension; uneven chest wall movement; decreased lung sounds on affected side). Perform needle thoracostomy at 2nd intercostal space, midclavicular line of affected side.
4. Treatment based on patient history and physical exam findings.
Standing Orders
1. Position patient to maintain airway. Begin oxygen therapy.
2. Attempt IV access x 1.
a. If seizure ongoing >5 minutes and IV successful after one attempt, administer Ativan (lorazepam) 4 mg slow IV push (2 mg/min)
b. If seizure ongoing >5 minutes and unable to start IV after 1 attempt immediately give Ativan (lorazepam) 2 mg IM prior to further attempts to establish IV. Determine blood glucoseand treat hypoglycemiaper protocol.
3. Contact medical control physician for further orders if necessary.
Standing Orders
1. Begin oxygen therapy.
2. Obtain IV access.
3. Attempt to obtain blood sample for reading by blood glucosedetermination device.
4. If blood glucoseis less than 60, may give 50 ml D50W IV. If IV access difficult or impossible, may give glucagon1 mg IM.
5. Use spinal immobilization unless trauma can definitely be ruled out.
6. Contact a medical control physician for orders.
After Obtaining Verbal Orders
7. If suspected narcotics overdose, consider up to 2 mg NarcanIV.
8. Give or repeat 50 ml D50W IV as appropriate.
9. Consider additional Narcanup to 10 mg IV.
Standing Orders
1. Determine blood glucose
2. If conscious, give sugar, 50 ml of D50W or 80 Gm of oral glucose
3. If patient unable to take oral fluids due to altered level of consciousness:
a. Obtain IV access.
b. Give 50 ml D50W IV.
c. May give glucagon1 mg IM if IV access difficult or impossible.
4. A medical control physician must be contacted in any case where the patient experienced a hypoglycemic event and refuses medical transportation.
After Obtaining Verbal Orders
5. Consider transport of all patients on oral hypoglycemic agents.
Standing Orders
1. Begin oxygen therapy.
2. Tricyclic overdoses requiring ventilatory support should be hyperventilated.
3. For any patient with respiratory rate <8, or history, or physical findings consistent with narcotics overdose assist ventilation and may give up to 2 mg NarcanIV/IM.
4. For all suspected tricyclic overdoses, also monitor ECG.
After Obtaining Verbal Orders
5. Consider additional Narcanup to 10 mg.
6. Consider Sodium Bicarbonate50 mEq IV in tricyclic ingestion.
7. Consider glucagon1 mg IV for known beta blocker overdose.
8. Consider calcium chloride1 Gm for known calcium channel blocker overdose with hypotension or bradycardia.
Standing Orders
1. Assess ABCs and vital signs
2. Provide oxygen per nasal cannula and obtain IV access
3. Check blood sugar and treat if indicated
4. Perform neurological tests (Cincinnati Prehospital Stroke Scale, includes difficulty speaking, arm weakness, facial droop)
5. Establish time of onset of symptoms and notify receiving hospital of suspected stroke patient. Expedite transport.
6. If patient is a potential candidate for reperfusion therapy, consider requesting diversionif difference in transport times to requested hospital vs. closest hospital is >30 minutes
7. Obtain ECG (12-lead ECGif practical) check for arrhythmias
After Obtaining Verbal Orders
8. If patient is a potential candidate for reperfusion therapy, consider diversion if difference in transport times to requested hospital vs. closest hospital is > 30 minutes.
Standing Orders
1. Begin oxygen therapy. If patient unconscious use partial rebreathing mask or assist respirations with positive pressure oxygen.
2. Monitor ECG.
3. Contact a medical control physician.
Standing Orders
1. Recognize toxidrome:
a. Miosis (small pupils) – present in ALL significant exposures, in association with at least two of the following:
- Fasciculations
- Respiratory distress
- Increased secretions
- Vomiting/Diarrhea/Incontinence
- Seizure
- Cardiovascular collapse
2. Wear appropriate personal protective equipment; do NOT enter hot zone.
3. Assure appropriate patient decontamination if liquid or vapor exposures (in concert with fire department/HazMat).
4. Assess ABCs and begin oxygen therapy if possible, intubate if needed (may have high airway resistance).
5. Treat seizures per protocol with ativan.
6. In cases of known organophosphate overdose/exposure or in setting of multiple casualty incident with patients exhibiting this toxidrome. Consider atropine2 mg IV, repeat as necessary to control bronchial secretions.
7. Mark 1 kit, if available (600 mg pralidoxime, 2 mg atropine) auto-injectors 1M x 2 for patients with seizures, severe shortness of breath, cardiovascular collapse.
8. Consider aggressive management of cardiac arrest if resources allow, as good outcomes documented after prolonged resuscitation.
(SPB <90) With Known or Suspected Hyperkalemia
Standing Orders
1. Begin oxygen therapy.
2. Monitor ECG.
3. Obtain IV access. If fluids hung, keep flow rate minimal.
4. Contact a medical control physician.
After Obtaining Verbal Orders
5. Consider calcium chloride10 ml (1 Gm) IV or more if indicated.
6. Consider sodium bicarbonate50 mEq IV.
7. Other treatments based on patient history and physical exam findings.