PREHOSPITAL PROVIDER SCOPE OF PRACTICE Level of Certification Medical control & Skills Capabilities Medication Administration Responder MPD protocols, patient assessment, CPR, AED, BVM, Bandaging, splinting, trauma, triage, medical, and pediatrics. 02 Emergency Medical Technician MPD protocols, patient assessment, CPR AED, BVM, Bandaging, splinting, trauma, triage, medical, pediatrics, OB/GYN 02, Aspirin, Epinephrine auto-injector, Charcoal, Glucose, assist with patient’s own metered dose inhaler as well as prescribed medication Emergency Medical MPD protocols, EMT skills and knowledge, IV Therapy skills, ET, airway. 02, IV Fluid Therapy, Nalonxone, Glucose, Aspirin, Dextrose 50/25, Albuterol Nebulizer, Nitroglycerin, Charcoal, Epinephrine for anaphylaxis by commercially preloaded measured-dose device. Emergency Medical Technician- Paramedic MPD protocols, EMT skills and knowledge, IV Therapy skills, ET, Multi-lumen airway, advanced airway control, ACLS w/manual defibrillation, and advanced patient assessment, trauma and medical skills. 02, IV Fluid Therapy, Medications per MPD protocol.
Cardiogenic History: Cardiac ischemia (MI, CHF) Medications Allergic reaction Signs/Symptoms: Restlessness, confusion Weakness, dizziness Weak, pulse Pale, cook, clammy skin Delayed capillary refill Hypotension Rates & pulmonary edema on exam Differential: Dysrhythmias Vasovagal Pearls: Be cautious of impending pulmonary Hypotension can be defined as systolic blood pressure of less than 100 Consider performing orthostatic vital signs on patients in nontrauma situations if suspected blood or fluid loss fluid bolus and reevaluate lung sounds Meds: Dopamine 5 – 20 mcg/kg/prn titrate SBP>100 Epinephrine mix 1mg 1:1000 in 250 NS titrate to SBP>100 drip 2-10 mcg/min Legend EMT A EMT-A A P EMT-P P M MC M A Obtain IV Access A A Fluid Bolus NS A P 12 lead ECG P P Dopamine Or Epinephrine P M Contact Medical Control M Adult Bradycardia Legend EMT A EMT-A A P EMT-P P M MC Order M (With Pulse)
Notes: ● For this protocol, adult is defined any person who does not fit the Broselow-Luten tape ● EMT’s must have multi-lumen airway training to use Combitubes or King-LTD ● Capnometry or Capnography is mandatory with all methods of intubation. Document result. ● Maintain immobilization for patients with suspected spinal injury ● Paramedics should consider combitube or King-LTD when unable to intubate ● Reconfirm ETT placement each time patient is ● Continuous oximetry should be utilized in all patients with compromised respiratory function Pulse Oximetry Pulse Oximetry M Contact Medical ontrol M Combitube/ King-LTD P Oral-tracheal Intubation P Airway, Adult Failed Continue BVM Legend EMT A EMT-A A P EMT-P P M MC Order M P Surgical Airway P Combitube/ King-LTD Reactive Airway Disease History: Asthma COPD – Emphysema, chronic Bronchitis Congestive Heart Failure Home treatment (0₂, nebulizer) Medications, (Theophylline, Steroids, Inhalers) Toxic exposure Smoking and Symptoms: Shortness of breath Pursed-lip breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi Use of accessory muscles Fever, cough Tachycardia Differential: Asthma Anaphylaxis Aspiration COPD (Emphysema, Bronchitis) Pleural effusion Pneumonia Pulmonary Embolus Pneumothorax Cardiac (MI or CHF) Pericardial Tamponade Hyperventilation Inhaled Toxin (Carbon monoxide, etc.) Universal Patient Care Protocol Legend EMT A EMT-A A P EMT-P P M MC Order M Pt’s MDI per prescription A Obtain IV access A Febrile or Hypotensive? ― Yes A Obtain IV access A P ECG P A Albuterol prn A p And prn Atrovent p p Methylprednisolone prn p p Epinephrine p
Pearls: Barotrauma is often caused by the over-ventilation of Reactive Airway Patients Consider NIPPV if available Meds: Albuterol- 2.5 mg SVN Atrovent- 0.5 mg SVN Epinephrine- 1:1,000 0.1-03ml IM Magnesium- 2 g/100mg IV over 10-15 min Methylprednisolone- 125 mg IV p Magnesium p M Contact Medical Control M Pulmonary Edema History: • Congestive Heart Failure • Past Medical history • Medications (Digoxin, Lasix) • Viagra, Levitra, Cialis • Cardiac history – past Myocardial Infarction Signs/Symptoms: • Respiratory distress, rales • Apprehension, Orthopnea • Jugular vein distention • Pink, frothy sputum • Peripheral edema, Diaphoresis • Hypotension, shock • Chest pain Differential: • Myocardial Infarction • Congestive Heart Failure • Asthma • Anaphylaxis • Aspiration • COPD • Pleural effusion • Pneumonia • Pulmonary Embolus • Pericardial Tamponade Mild Moderate- able to speak sentences, crackles base only, 0₂ sat ≥ 92% Severe- respiratory distress, crackles throughout, 0₂ sat <92% Near Death- Decreased LOC, cyanosis, dropping sats, ineffective respiratory drive Legend EMT A EMT-A A P EMT-P P M MC Order M Universal Patient Care Protocol A Obtain IV Access A P ECG / 12 Lead P P Consider Capnography P A Nitroglycerin if SBP> 100 A P And / or Furosemide P
Pearls: · of shock include SBP <90 · The shorter the onset from contact to symptoms, the more severe the reaction. · A single dose of Epinephrine may not reverse the effects of Anaphylaxis. Administer additional doses as needed. · Obtain ECG tracing during pharmacological administrations. · EMT may assist with patients own MDI Meds: Epinephrine 0.1=0.3 cc IM; 0.1-0.3mg SQ, SL Repeat Epinephrine PRN Diphenhydramine 25-50 mg PO/IM/IV Albuterol 2.5.mg Pt.’s MDI per prescription SVN Albuterol 2.5 mg & Atrovent 0.5 mg SVN Methylprednisolone 125 mg IV History: Known diabetic, medic alert tag Drugs, drug paraphernalia Report of illicit drug use or toxic ingestion Past Medical history Medications History of Trauma GI History Syncope Signs/Symptoms: Decreased mental status Change in baseline mental status Bizarre behavior Hypoglycemia (cool, diaphoretic skin) Hyperglycemia (warm dry skin; fruity breath, Kussmal resps: signs of dehydration) Diabetic Syncope Differential: Head Trauma CNS (stroke, tumor, seizure, infection Cardiac (MI, CHF) Thyroid (hyper/hypo) Shock Diabetes (Hyper/hypoglycemia) Toxicologic Acidosis / Alkalosis Environmental exposure Pulmonary (Hypoxia) Electrolyte abnormality Psychiatric disorder Syncope Altered Mental Status/Diabetic Emergency Legend EMT A EMT-A A P EMT-P P M MC Order M A Obtain IV access A Blood Glucose check A Normal Saline A Administer Oral Glucose A Normal Saline A Yes No P Thiamine P A Dextrose A A Naloxone prn A P Glucagon prn P
Legend EMT A EMT-A A P EMT-P P M MC M Consider other appropriate protocol as needed Notes: • Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke symptoms would be defined as an onset time of the previous night when patient was symptom free) • The differential listed on the Altered Mental Status Protocol should also be considered. • Be alert for airway problems (swallowing difficulty, vomiting) • Hypoglycemia can present as a localized neurologic deficit, especially in the elderly. Meds: Dextrose 12.5-25 g IV PRN Glucagon 1 mg IV/IM Hyperglycemia can be very dangerous in ischemia P Prehospital Thrombolytic Screening P M Contact Medical Control “Code Stroke” M Eclampsia History: · Past Medical history · Prenatal care · Medications/drugs · Familial incidence · Primigravida ∙ Renal Disease Signs / Symptoms: ·Seizure · Hypertension · Tachycardia ∙ Edema ∙ Headache · Visual disturbance · Abdominal pain · Amnesia and/or change in mental status Differential: · Hypertension · Multiple fetuses ∙ Gestational diabetes · Micro thrombi · Embolic stroke · Improper placental implantation Universal Patient Care Protocol Place in left lateral recumbent position A Obtain IV A
A Obtain Iv access (maintain SBP≥90 mm Hg A Remove wet clothing Cover with dry (warm) blankets Warming Measures Monitor and reassess M Contact Medical Control M Pearls: Exam: Check Head, neck, Chest, Abdomen, Pelvis, Back, Extremities, Skin, Neuro for Trauma With cold there is no time limit – resuscitate all. All near drowning victims should be transported – conditions may deteriorate during the next several Scene safety! Drowning is a leading cause of death in would-be rescuers. Consider transport to facility with hyperbaric chamber if any chance of decompression sickness. Head Injury History: · Onset · Mechanism (blunt / penetrating) · Loss of consciousness · Bleeding · Medical history (ETOH…) · Medications (Coumadin…) · Geriatric Signs / Symptoms: ·Pain, swelling, bleeding, oto/rhinorrhea · Altered Level of Consciousness · Respiratory distress/failure ∙ Vomiting ∙ Significant mechanish of injury Signs of Herniation: ∙ GCS <8 ∙ Fixed or asymmetric pupils ∙ Neurologic Posturing ∙ Cushings Triad ∙ Intermittent ∙Neurologic deterioration (decrease in GCS≥2) Differential: · Cerebral Concussion · Cerebral Contusion · Non-Traumatic causes of ALOC · Epidural hematoma · Scalp hematoma · Seizure · fracture · Stroke · Subdural hematoma · Syncope · Subarachnoid hemorrhage Universal Patient Care Protocol Legend EMT A EMT-A A P EMT-P P M MC Order M Isolated Head Trauma? Multi-system Trauma Protocol pg No Yes Spinal Immobilization with head of board elevated approx..
Maintain Spo₂≥90% GCS GCS ≥14 GCS 3-8 GCS 0-13 A Obtain Iv access (maintain SBP≥90 mm Hg A Treat S/S Per Appropriate Protocol A Obtain Iv access (maintain SBP≥90 mm Hg A P Intubate (RSI) prn P P Capnography P P Zofran Lorazepam Versed P No Yes P Capnography where available (maintain EtCO₂ 32-37 mmHg) P M Contact Medical Control M Multi-System Trauma History: · Time and Mechanism of injury · Damage to structure or vehicle · Location in structure or vehicle · Others injured or dead · Speed and details of MVA · Restraints / protective equipment · Past medical history · Medications Signs / Symptoms: ·Altered mental status or unconscious ·Hypotension or · Arrest Deformity Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling Differential: · Chest Tension pneumothorax Flail Chest Pericardial Tamponade Open Chest wound Hemothorax · Intra-abdominal bleeding · Pelvis/femur fracture · Spine fracture / Cord injury · Extremity fracture / Dislocation · HEENT (Airway Obstruction) · Hypothermia Universal Patient Care Protocol Legend EMT A EMT-A A P EMT-P P M MC Order M Expose injuries Arrange transport according to the Washington State Trauma Triage Tool Spinal Immobilization Procedure
Legend EMT A EMT-A A P EMT-P P M MC M Bradycardia Algorithm Pediatric Bradycardia With a and Poor Perfusion A Identify and treat underlying cause ●Maintain patient airway; assist breathing as necessary ●Oxygen ●Cardiac monitor to identify rhythm; monitor blood pressure and oximetry ●IO/IV access ●12-Lead ECG if available; don’t delay therapy A Cardiopulmonary Compromise ●Hypotension ●Acutely altered mental status ●Signs of shock Doses/Details Epinephrine IO/IV Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration). Repeat every 3-5 minutes. If IO/IV access not available but endotracheal (ET) tube in place, may give ET dose: 0.1 mg/kg (0.1 mL/kg of 1:1000). Atropine IO/IV Dose: 0.02 mg/kg. May repeat once. Minimum dose 0.1 mg and maximum single dose 0.5 mg. No ●Support ABC’s ●Give oxygen ●Observe ●Consider expert consultation Yes No ●Epinephrine ●Atropine for increased vagal tone or primary AV block ●Consider transthoracic pacing/transvenous pacing ●Treat underlying causes If pulseless arrest develops, go to Cardiac Arrest Algorithm Yes Legend EMT A EMT-A A P EMT-P P M MC M Tachycardia Algorithm Pediatric Tachycardia With a Pulse and Poor Perfusion
Check blood glucose <60 Pt able to swallow? Yes Administer oral glucose No Condition improves? A Obtain IV access A A Dextrose A Unable to gain IV access No P Glucagon P Yes M Contact Medical Control M Notes: Keep patient warm. An inadequate amount of glucose for heat production, combined with profound diaphoresis, many hypoglycemic patients are at risk for hypothermia Use D10 for Neonates (birth – 30 days) Meds: Oral Glucose PRN Dextrose D25 2cc/kg IV/IO repeat once PRN D10 Glucagon SQ 1 mg or 0.5mg<20kg Pediatric Seizure History: Fever Prior history of seizures Seizure Medications Reported seizure activity History of recent head trauma Congenital abnormality Signs/Symptoms: Observed seizure activity Altered mental status Hot, dry skin or elevated body Temperature Differential: Fever Infection Head Trauma Medication or Toxin Hypoxia or Respiratory failure Hypoglycemia Metabolic abnormality / acidosis
CPR CPR Adult and Older Child (Puberty and (I year old to puberty) Infant (Less than one year old) Establish Unresponsiveness Consider/call for additional resources Open the Airway Head tilt – chin lift (suspected spinal trauma: Jaw thrust) Check Breathing Open the airway- look, listen and feel. Take at least 5 seconds and no more than 10 seconds 2 breaths Give 2 breaths (1 second each) Check Pulse At 5 seconds and no more than 10 seconds Carotid Pulse (if no pulse, start chest compressions) Carotid Pulse (if no pulse or pulse < 60 bpm with signs of poor perfusion, start chest compressions) Brachial Pulse (if no pulse or pulse < 60 bpm with of poor perfusion, start chest compressions Start CPR • Compression location Center of breastbone between nipples Just below nipple line on breastbone • Compression depth Heel of 1 hand, other on top (or 1 hand for small patients) 2 fingers (thumb-encircling for 2- person) • Compression depth 1 ½ to 2 inches 1/3 to ½ depth of chest ● Compression rate 100 per minute • Compression- ventilation ratio 30:2 15:2 Discontinuation of CPR Do not attempt Resuscitation Determination of Field Death Procedure: ALS/BLS Treatment: CPR may be discontinued without Base Station contact and the patient determined to be dead for the following reasons ONLY IF: 1. Upon further examination it is determined that the patient meets the “Determination of Death Criteria” and CPR was initiated prior to this discovery. a. Field EMS providers may declare apparent death but may not pronounce death. Once CPR has been initiated and there is no favorable response,
Drug Reference Equivalents: 1kg – 2.2 lb 1 gm = 1000 mg 1kg – 1000 gm 1 L = 1000 ml 1ml = 60 mcgtts tubing) 1 ml = 10, 15, 20 gtts (macro tubing) 1 ml and 1 cc are interchangeable Conversions: MULTIPLY to convert a larger unit into a smaller unit the above table. DIVIDE to convert a smaller unit into a larger unit using the above table. Dosage Calculations: To calculate the amount of drug to be drawn up or administered, use the following formula: WHAT (type and amount of drug ordered) Multiplied by the QUANTITY (volume of fluid in the container) Divided by MINUTES (time of the infusion) = Number of drops/minute to the solution. . WHAT x QUANITY = Amount to be HAVE administered IV Rate: To calculate the flow rate of an IV in gtts per minute use the following formula: VOLUME (the amount of to be infused) Multiplied by the DRIP FACTOR (Number of drops per milliliter) Divided by MINUTES (time of the infusion) = Number of drops/minute to the solution. VOLUME x DRIP FACTOR = Number of drops/minute MINTUES to the solution
5 – Establish a diagnosis. clinically and epidemiologically; always send specimens for culture. Symptom (individuals) Possible Diagnosis Pulmonary Tularemia, plague, staph enterotoxin B (SEB) Neuromuscular Botulism, Venezuelan equine encephalitis (VEE) Bleeding/purpura VHF, ricin, plague (late) Flu-like symptoms Varies Immediate Symptoms (large numbers) Possible Diagnosis Pulmonary SEB, mustard, Lewisite, phosgene, cyanide Neurologic Nerve gases, cyanide Delayed Symptoms (large numbers) Possible Diagnosis Pulmonary Biologic agents, mustard, phosgene Neurologic Botulism, VEE, other encephalitis 6 – Render prompt treatment A irway, B reathing, C irculation. 7 – Provide good infection control. • Gown, gloves, mask and hand washing, and eyewear if necessary, are sufficient. • Recommended isolation precautions for biologic agents include: Standard Precautions – for all individuals/patients Contact Precautions – Viral Hemorrhagic Fevers Droplet Precautions – Pheumonic Plague and Tularemia Airborne Precautions - Smallpox 8 – Alert the proper authorities. CALL Your local law enforcement agency; call either 911 or your local phone number for law enforcement. CALL SECOND: Your area FBI office Western WA: 206-622-0460 Eastern WA: 509-747-5196 After hours statewide in WA: 206-622-0460 CALL THIRD: Your local emergency management agency, or if unavailable, the WA state EM Duty Officer at: 1-800-258-5990 9 – Assist in the epidemiologic investigations. Steps in an epidemiologic investigation so as to determine who may be at risk • cases; • Relate to the at-risk population; • Make comparisons; • Develop hypotheses; • Test hypotheses; • Make inferences; • Conduct studies; • Interpret and evaluate.