UEMR Medical Protocols

What is part of the primary survey?

1. ABCs

2. Airway patency, suction, NPA/OPA/BVM

3. Shock

4. Hemorrhage

What is the secondary survey?

focused assessment based on chief complaint

Universal guidelines for any patient

1. Safe? PPE? Extra resources?

2. SMR?

3. Primary

4. Secondary?

5. Vitals?

6. SAMPLE

7. OPQRST

8. Designate appropriate patient disposition

AMS-> Unknown cause

1. AEIOUTIPS

2. SpO2 of atleast 94%

AEIOU TIPS

Alcohol/Acidosis

Endocrine/pilepsy/Electrolytes/Encephalopathy

Infection

Overdose

Uremia/Underdose

Trauma

Insulin

Poisoning/Psychosis/Pharma

Stroke/Seizure/Syncope

Sudden giving up in a violent/aggressive patient is a sign of

imminent cardiac arrest

Hyperventilation could be a sign of

a serious condition, like pulmonary embolism

mild and local allergic reaction

Diphenhydramine 25 mg PO

Anaphylaxis

0.5 mg epi

supp O2 to maintain 94%

albuterol if wheezing

Signs of mild/local allergic reaction

hives, itching, angioedema

vomit, cramp, ab pain, incontinence

signs of anaphylaxis

known exposure with respiratory (dyspnea, wheezing, stridor, hypoxemia) or cardiac (collapse, hypotension, syncope)

possible exposure with hypotension

Bradycardia Defined as:

symptomatic HR under 50

Bradycardia

symptomatic HR under 50

check airway/res drive

Patient assessment (look for hypotension, AMS, weakness, syncope)

Request RFD

Symptomatic bradycardia often presents with

lightheadedness, SOB, sudden weakness

A common cause of bradycardia is...

Some others are...

hypoxia

beta blocker overdose, opioid abuse, pacemaker malfunction

assess and rule out from differential diagnosis

Pulse check every

two minutes

CPR quality

2 inch depth, 100 to 120 bpm

Chest pain

1. RFD

2. 324 Asprin (CHEW), even if self administered before arrival

3. History (OPQRST, Cardiac, blood thinner, ED)

Ischemic chest pain may have the following atypical presentations

epigastric pain

shoulder, neck, back pain

indigestion

SOB

sweating/pallor

AMS

Define the stages of hypothermia

1. conscious, shivering (95 to 90 core)

2. impaired, not shivering (90 to 82)

3. neither, but with vitals (82 to 75)

Stage 1 hypothermia

1. warm and dry environment

remove wet clothes and wrap in dry blanket

Stage 2/3 hypothermia

1. RFD

2. minimize movement (prepare for cardiac arrest)

3. Prevent further heat loss (remove wet clothes and dry environment)

Hypoglycemia definition

less then 70

Hypoglycemia

1. 15 g oral glucose if symptomatic if fully responsive and can protect airway

2. repeat BGL -> RFD if no improvement

hyperglycemia

1. repeat BGL

2. Sepsis/shock assessment

3. AMS assessment

4. supplemental o2 to maintain 94%

What to do for patients with hypoglycemia and insulin pumps

turn off or remove

Glucose should be administered with caution in patients with S/S of

stroke

DKA presentation

ab pain

high BGL

vomit

rapid breathing

Fever

ABOVE 100.4

- Up to 1 g acetominophen OR up to 600 g Ibuprofen

- consider sepsis

ABOVE 103

1. RFD

2. Sepsis?

3. Active Cooling (ice packs, cool environment

underlying causes of fever other then viral/infection

1. med/drug reaction

2. heat stroke

Heat related emergencies

1. reposition (cool/shady and remove clothing as needed)

2. active cooling if AMS or over 104

- mist exposed skin with water, fan skin

- icepacks to groin, armpits, neck

Non life threatening heat emergency

heat cramps: legs and ab wall

heat syncope: b/c of blood pooling in extremeties

Life threatening heat emergencies

heat exhaustion: water and salt depeletion

stroke: life threat-> exertional or classic

classic heat stroke

external heat source, no exertion, elderly, slow onset, no sweat

exertional heat stroke

previously healthy, exercise/work induces, fast onset

General Airway assesment

1. assessment

- History (onset, S/S, res disease, FBAO)

- physical exam (SOB, skin, rate/rhythm, position, AMS, lung sounds, cough, spo2)

2. Patent?

3. Supplemental O2

4. BVM

4. RFD if more then supp O2 is needed

Nausea/Vomiting

1. position of comfort and ensure patent airway

- LLR if can't protect airway

2. Emesis bag

Obstructed Airway

1. manually open airway and HTCL

2. try to visualize obstruction

- if visible-> finger sweep

- if not-> maneuvers

3. ventilate if no spontaneous (NPA or OPA)

4. suction as needed

5. cardiac arrest guidelines if pulse lost

Psych/behavioral

- use AMS and psych disposition procedures too

1. scene safety

2. assess for life threats with AMS guidelines

3. remove from enviornemt/reduce stimuli if safe

4. verbal de-escalation

5. suicidal/homicidal intention?

6. blood glucose

Res Distress

1. if wheezing-> 2.5 mg/3ml albuterol (repeat up to three times five minutes apart)

- if contra indications present (CHF, volume overload, tachy) only one dose

2. supp O2

3. Check for anaphylaxis

4. causes (res disease, cardiac disease, overdose, sepsis, chem exposure, chest trauma, airway burn)

5. smoke/co inhalation

- high flow NRB

Actively seizing

1. Oxygenation and ventilation

2. Airway Patency

- suction, LLR if no trauma

Postictal

1. supp O2

2. assessment: pay attention to BGL, Overdose, sepsis, heat, hypoxia, trauma

What mnemonic is used for possible underlying causes of seizure?

AEIOUTIPS

Statis epilepticus definition

seizures lasting more then five minutes or seizures lasting 2 minutes without lucid interval

Sepsis criteria

1. infection

2. 2 of (temperature over 100.2 or under 96, respiratory rate over 20, heart rate over 90)

3. EtCO2 over 30

Sepsis

1. alert dispatch and request RFD

2. cause (temp and AMS guidelines)

3. spO2 over 94

Septic shock sign

hypotension with sepsis

Syncope or near syncope

1. SMR?

2. Asses: BGL, stroke, trauma

3. Causes (GI bleed? ectopic? seizure? heat? cardiac? fluid loss?)

syncope in elderly is quite commonly a

cardiac issue

Stroke

1. CPSS screen

2. RFD

3. LA Motor Scale if CPSS is positive and LKN was less then a day

Shock

1. RFD

2. ABCs

3. Position

- elevate legs if trauma isn't expected

- cover if hypothermic

Cardiogenic shock S/S

respiratory crackles

Hypovolemic shock S/S

hypoperfusion

Distributive (ana, sepsis) shock S/S

skin, external signs (hives/flushed skin)

Neurogenic shock S/S

spinal cord injury

bradycardia

Obstructive shock S/S

tamponade, PE, tension Pneumo

sudden onset chest pain and difficulty breathing-> PE

Compensated vs Decompensated shock S/S

High vs Low BP

tachycardia for both

tachypnea for compensated

Tachycardia definition

symptomatic HR above 125 bpm

Tachycardia

1. RFD

2. underlying causes

3. focused history (cardiac, drugs)

4. prepare for arrest

Toxic Exposure/Overdose

If opiod and Res Dis

1. Naloxone 1 mg (repeat twice, every 5 min)

CO

1. NRB high flow

For trauma involving massive hemorrhage, follow

M: assive hemorrhaging

A: irway

R: espirations

C: irculation (blood thinners?)

H: ead injury (GCS/AMS)

Abdominal injury

if Open-> moist gauze

pelvic fracture-> pelvic binder

suspect internal bleed

Chest injury

open/sucking-> chest seal

Extremity injury

1. splint/pad for comfort if RFD isn't en route

2. don't attempt reduction

3. monitor distal pulses/PMS on all injuries

Burns

1. severity? (degree and % if 2nd or 3rd)

2. if airway (stridor, sooty sputum, face burns)-> aggressive airway

3. remove burned clothes

4. cover and prevent heat loss

Degrees of burns?

1st: superficial, red

2nd: blistering

3rd: charring, sensation?

Envenomenation/Bites

1. Manage airway (prepare ana)

2. immobilize and splint (can slightly elevated)

- no constricted circulation, incise wound, apply ice/heat

3. Focused assessment (animal? PMS? time?)

Signs of envenomation from snakes

sudden onset of pain

swelling

bruising

Globe avulsion/open injury

1. protect globe with an onbjecy

2. RFD

Riot control agent

1. res dis

2. irrigate

3. transport 30 min after exposure if no change

Head Injury

1. ABCs

2. AMS

3. SMR

4. oxygenation

5. BGL

Cushings triad

increasing BP gap, irregular breathing, bradycardia

Extremity hemmorhage

1. direct pressure

2. approved tourniquet (document time , replace bystander)

Junctional hemorrhage

1. pack wound and apply direct pressure

Abdominal/head hemorrhage

direct pressure and trauma center

Extremity amputations

1. tourniquet

2. moist (not bulky dressings)

3. Find body part (rinse with saline, wrap with moist dressing, place in plastic bag)

Orthopedic injury

1. control bleeding

2. SMR?

3. PMS

4. Splint if deformity, moderate to sever pain, and RFD isn't coming

Ancle sprain

1. PMS

2. physical assessment and palpate areas

3. deformity-> splint

4. no deformity-> ice pack

PAT

Appearance, work of breathing, circulation/skin

Ped ana

1. epi (0.01 mg/kg) every 10 minutes as needed

2. O2

3. albuterol if needed

4. position

ALTE Criteria

younger then one year and having a brief and resolved episode of

1. cyanosis or pallor

2. altered breathing

3. change in tone

4. change in consciousness

ALTE

1. recognize

2. ABCs

3. transport

Oral Glucose ped

over 7: full dose

Ped fever

1. temperature 100.4 to 102 not from heat or toxin

- acetaminophen (15 mg/kg) or ibuprofen (10 mg/kg)

2. Temperature above 102

- administer both

Ped albuterol

2.5 mg, revaluate after each treatment, max of three doses

febrile seizure information

not in children under 6 months or above 6

ped sepsis criteria

1. infection

2. two or more of the following

- temperature over 101.3 or less then 96.8

- abnormal cap refill (flash or >3 seconds)

- history of being sick for 5 days or longer

ped naloxone

0.1 mg/kg

a patient is anyone who meets any of the following criteria

1. person who contacted UTD PD or 911 requesting EMS or someone else (legally responsible for them/law enforcement) contacted them on their behalf

2. potential for self harm expressed or third party concerned

3. any physical assessment beyond visual trauma

4. significant trauma

Eligibility for refusal

1. at least 18 or under the age of 18 with consent of parent

2. AOx4

3. doesn't meet RFD Dispatch Critera

High risk refusal

abnormal vitals

given oxygen or glucose

Pregnant

above 75

postictal

ab pain

SMR and not consenting

pertinent substantial medical history

not completely AO 4

Evidence of drug or alcohol

CAPTIAN MUST APPROVE WITH WITNESS

High risk refusal vitals

two full sets including

consciousness, BP, HR, RR, O2

one set atleast of

BGL and Temp

Release to law enforcement criterea

complete full assessment as in high risk

if

1. police department wishes to transport

2. only related to one of the following: alcohol intox, psychiatric, minor injury

3. psych assessment done

3. no life threat

Refusal on psych patient

1. consider high risk refusal

if

1. full capacity

2. not suicidal/homicidal

3. no evidence/intention of self harm

4. no RFD dispatch criterial

5. police officer approves

6. psych assessment done and no life threat

Refusal on minors

1. high risk

2. contact guardian by phone or in person

3. otherwise, dispatch RFD

4. UTD PD will sign if parent consents over phone

5. Captain will report with heavy documentation

If RFD is not called, you must either complete a

patient refusal or no-patient documentation

Criteria to determine death in the field

pulseless, apneic AND

decapitation, incineration, decomposition, rigor mortis, dependent lividity, mortal wounds, DNR braclet

Once death has been determined

immediatly notify law enforcement if not already there

providers are required to report

child, elderly, and disabled abuse/neglect

request RFD for transport to hospital and tell them about concerns for abuse

make UTD PD officer on scene aware of your concerns

include pt name, address and same plus phone number for person responsible for patient's care

info about abuse

BVM might be the best option for patients with

O2 less then 90%

poor tidal volume

signs of hypoxia