Contact Medical Control to request orders for additional doses of nitroglycerine in excess of three. Note: the maximum dosage of Nitroglycerine is three. The total dosage includes the patient has taken on their own combined with your subsequent dosages. AEMT STOP Perform serial EKGs in to document progression of EKG changes. Treat arrhythmia appropriately. Patients with probable AMI should be transported to an appropriate cardiac facility as soon as possible. Treat arrhythmia appropriately. Obtain and transmit EKG to PCI capable hospital within the first 10 minutes of patient contact. If systolic BP < 100 mmHg, give 250 ml NS bolus (assess for signs of pulmonary congestion) If PVCs > 15/min – Lidocaine 1 – 1.5 mg/kg over 2 min, repeat to a of 3 mg/kg If chest pain/discomfort continues: Continue Nitrate therapy Complete thrombolytic screening If chest pain greater than 7 on a scale of 1 – 10, treat per chart below until pain is tolerated by patient Contact Medical Control Transport
CARDIAC EMERGENCY SOP # 111 Persistent Ventricular Fibrillation / Pulseless Ventricular Tachycardia Assessment Unresponsive, pulseless Persistent ventricular fibrillation/tachycardia or return to this rhythm post ROSC/ other rhythm changes For use after SOP # 110 Ventricular Fibrillation / Pulseless Ventricular Tachycardia Protocol has been ineffective. If there is no change in V-Fib Complete 5 cycles of CPR, check rhythm and pulse Repeat defibrillation. Resume CPR without further pulse checks If there IS a change in V-Fib Apply new defibrillation pads at new sites Complete 5 cycles of CPR, check rhythm and pulse Repeat defibrillation, pause 5 seconds maximum to check rhythm and pulse Resume CPR Notes: Recurrent ventricular fibrillation/tachycardia is successfully broken by standard defibrillation techniques, but subsequently returns. It is managed by ongoing treatment of correctible causes and use of anti-arrhythmic medication therapies. Refractory ventricular fibrillation/tachycardia is an arrhythmia not responsive to standard external defibrillation techniques. It is initially managed by treating correctible causes and medications. Prolonged cardiac arrests may lead to tired providers and decreased quality. Ensure compressor rotation, summon additional resources as needed, use mechanical CPR device if available and ensure provider rest and rehab during and post event.
MISCELLANEOUS SOP # 603 Mandatory EKG EKGs will be mandatory under the following conditions: Patients complaining of or presenting with: pain regardless of source (trauma or illness) Abdominal pain All males > 40 years old All females > 50 years old Nausea and vomiting All males > 40 years old All females > 50 old Shortness of breath – all new onset All diabetics and smokers Known heart disease (including CHF, post-surgery, previous MI) Weakness – new onset Syncope Unresponsive Patients with sympathomimetically active drug use (cocaine, crack, methamphetamine, etc.) Cardiac arrest with or without CPR in progress That are non-viable (other than those exhibiting body decomposition, dependent lividity, or rigor mortis, decapitation) EKGs will have the following information printed on the recording: Name or report number Age (if possible) Unit number and date EKGs will be appended to the patient care report 12 Lead EKGs may be applied and transmitted by any provider EMT or higher on scene, however treatment decisions may only be made by a Paramedic.
REFERENCE Quality Improvement Document Criteria Documentation on all patients must include the following and any other information pertinent to patient care: OPQRST and SAMPLE are the acronyms for the United States DOT EMS and Paramedic patient assessment curriculum O – Circumstance surroundings on the onset of complaint P – What provoked (or provokes) the complaint? Environment Q – Describe the quality (sharp, burning, stabbing counter etc.) of the complaint? R – Where does the pain radiate? S – Describe the severity of the pain on a 1-10 scale 1 (minimal) – 10 (maximum) T – Time of onset? S – Signs, symptoms, physical exam findings A – Allergies to medications or the environment M – Medications, prescription or over the counter P – Past medical history L – Last oral intake E – Event, what happened to the patient All patients transported by EMS should have at least two sets of vital signs assessed and documented. Initial set of vitals will include blood pressure (systolic/diastolic), pulse rate, respiratory rate, pulse oximetry and blood glucose if indicated, and the time they were assessed must be recorded. All medications taken by the patient should be listed on the report. If medications are taken to ER document in narrative who the medications were left with. When documenting the presumed presence of alcohol that is based solely upon breath odor, do so in the following manner: “Patient’s breath has the odor that is commonly associated with the consumption of alcohol.” ABDOMINAL PAIN/PROBLEMS Location of pain Distension Tenderness/radiation Nausea/Vomiting/Diarrhea Urinary complaints LMP if applicable Vaginal bleeding/discharge if applicable Treatment/reassessments Report given and signature of RN ALCOHOL INTOXICATION Patient’s breath has odor of ETOH Patient admits to drinking (type, amount, time frame) Speech (normal, slurred) Gait (normal, unsteady) Any obvious injuries noted Blood glucose level of consciousness Treatment/reassessments Report and signature of RN ALTERED MENTAL STATUS OPQRST, SAMPLE as appropriate ETOH/Substance use Any obvious injuries noted Blood glucose level Normal mental status EKG and strip attached Treatment/reassessments Report given and signature of RN ASSAULT/FIGHT OPQRST, SAMPLE as appropriate Method of assault Any obvious injuries or pain Loss of consciousness, how long Treatment/reassessments Report given and signature of RN
Chest pain/dyspnea Nausea/vomiting Headache/mental status Neuro Assessment Treatments/Reassessments Report given and signature of RN Approximate ambient air temperature Estimate exposure time Type of environment (inside, outside, wet) Loss of consciousness Fluid intake Skin turgor/condition ETOH/Substance abuse Treatments/reassessments Report and signature of RN INHALATION INJURY GAS/SMOKE) Type of gas Duration of exposure Area of exposure (enclosed room) Heated environment Burns/singing (oral, nasal, facial area) Treatments/reassessments Report given and signature of RN POISONING/DRUG INGESTION Name of substance Amount Route of intake How long ago Vomiting since ingestion as appropriate Intentional vs. Unintentional ETOH/substance use Oral mucosa burns if appropriate Treatments/reassessments Report given and signature of RN PREGNANCY/OB DELIVERY Separate report required for mother and each delivery Non-Delivery Abdominal Pain Gravida/Para/Abortion Length of gestation/estimated due date Edema (pedal)/BP/Headache/Visual Disturbance Vaginal bleeding/discharge – if yes, describe Treatments/reassessments Report given and signature of RN Last time movement REFUSALS Documentation of: Competency MMSE Lack of Trauma Situation Ability to make good decisions Safety of patient is assured by caretakers, family, etc. Delivery Multiple fetuses Mucous plug resented Membranes ruptured – if yes, is amniotic clear? Crowning as appropriate SEIZURES OPQRST and SAMPLE as appropriate Obvious injures (mouth, head, tongue) Duration and number of events Incontinence Level of consciousness (postictal) Treatments/reassessments Report given and signature of RN NEONATE Time of Thoroughly dried and warmed Oral and nasal suctioning STROKE/CVA/TIA OPQRST and SAMPLE as appropriate Onset and duration of symptoms Headache/Vision disturbances
REFERENCE Trauma Score Revised Trauma Score Respiratory Rate 10 – 24/min 4 24 – 35/min 3 > 36/min 2 1 – 9/min 1 None 0 Respiratory Expansion Normal 1 Retractive 0 Systolic Blood Pressure > 90 mmHg 4 70 – 89 mmHg 3 50 – 69 mmHg 2 0 – 49 mmHg 1 No Pulse 0 Capillary Refill Normal 2 Delayed 1 Points to add to the RTS based on the GCS 14 – 15 5 11 – 13 4 8 – 12 3 5 – 7 2 3 – 4 1 REFERENCE Glasgow Coma Scale Eye Opening Spontaneous 4 Opening to voice 3 Response to pain 2 None 1 Verbal Oriented 5 Verbal confused 4 Inappropriate 3 Incomprehensible sounds 2 None 1 Motor Obeys commands 6 Localizes pain 5 Withdraws (pain) 4 Flexion 3 Extension 2 None 1