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2017 RI Statewide EMS Protocols Education Modules - Section 4
- 2. Rhode Island Emergency Medical Services Statewide EMS Protocols October 2016 Rhode Island Department of Health
- 3. Trauma - Environmental - Toxicological Protocols Section 4
- 5. Trauma – Environmental – Toxicological Protocols General Changes and Additions • This is a new section in the EMS protocols • This section has 24 protocols
- 6. Trauma – Environmental – Toxicological Protocols New Protocol Previous Protocol Previous Protocol Section 04.01A Multiple Trauma - Adult 5.1 Trauma Traumatic Emergencies 04.01P Multiple Trauma - Pediatric 5.1 Trauma Traumatic Emergencies 4.02 Head Trauma - Traumatic Brain Injury 5.1 Trauma Traumatic Emergencies 4.03 Spinal Motion Restriction Precautions New – not in previous versions 4.04 External Hemorrhage Control New – not in previous versions 4.05 Extremity and Musculoskeletal Injuries New – not in previous versions 4.06 Traumatic Cardiac Arrest New – not in previous versions 04.07A Thermal - Burn Injury - Adult 5.2 Burns Traumatic Emergencies 04.07P Thermal - Burn Injury - Pediatric 5.2 Burns Traumatic Emergencies 4.08 Chemical and Electrical - Burn Injury 5.2 Burns Traumatic Emergencies 4.09 Crush Injury New – not in previous versions 4.1 Dental Trauma and Emergencies New – not in previous versions 4.11 Ocular Trauma and Emergencies New – not in previous versions
- 7. Trauma – Environmental – Toxicological Protocols New Protocol Previous Protocol Previous Protocol Section 4.12 Heat Related Illness 3.5 Heat Stroke 3.4 Heat Cramps and Heat Exhaustion Environmental Emergencies 04.13A Hypothermia and Localized Cold Injury - Adult 3.1 Cold Exposure - Frostbite 3.2 Cold Exposure - Hypothermia Environmental Emergencies 04.13P Hypothermia and Localized Cold Injury - Pediatric 3.1 Cold Exposure - Frostbite 3.2 Cold Exposure - Hypothermia Environmental Emergencies 4.14 Submersion - Near Drowning 3.3 Drowning Environmental Emergencies 4.15 Diving Emergencies New – not in previous versions 4.16 Marine Envenomation New – not in previous versions 4.17 Bites - Stings - Envenomation New – not in previous versions 04.18A Toxicological Emergencies - General - Adult 3.6 Poisoning and Overdose Environmental Emergencies 04.18P Toxicological Emergencies - General - Pediatric 3.6 Poisoning and Overdose Environmental Emergencies 4.19 Toxicological Emergencies – Nerve Agent or Organophosphate Toxicity New – not in previous versions 4.20 Carbon Monoxide Exposure New – not in previous versions 4.21 Blast Injury - Incident New – not in previous versions 4.22 Radiation Incident New – not in previous versions
- 8. 4.01 Adult Multiple Trauma Protocol Summary • Previously protocol 5.1 Trauma. • This protocol recognizes and provides standing orders for adult patient with blunt or penetrating trauma. • This protocol is divided into different levels of care. ALL Providers Levels • Routine Patient Care • Manage life threatening injuries • Treat as per appropriate protocols • Vented chest seal device • Stabilize impaled Objects • Stabilize pelvis as indicated • Normothermia • Limit on scene time to ≤ 10 min • If indicated (≥45 mins to Trauma Center) follow HEMS Protocol • Transport to Level 1 Trauma Center Paramedic • Perform needle thoracostomy for suspected tension pneumothorax
- 9. 4.01 Pediatric Multiple Trauma Protocol Summary • Previously protocol 5.1 Trauma. • This protocol recognizes and provides standing orders for pediatric patient with blunt or penetrating trauma. • This protocol is divided into different levels of care. ALL Provider Levels • Routine Patient Care • Manage life threatening injuries • Treat as per appropriate protocols • Vented chest seal device over open penetrating torso injury • Stabilize impaled objects • Stabilize pelvis as indicated • Maintain normothermia • Limit in scene time to ≤ 10 min • If indicated (≥45 mins to Trauma Center) follow HEMS Protocol • Transport to Level 1 Trauma Center Paramedic • Perform needle thoracostomy for suspected tension pneumothorax
- 10. 4.02 Head Trauma - Traumatic Brain Injury (TBI) Protocol Summary • Previously protocol 5.1 Trauma. • This protocol recognizes and provides standing orders for adult patient with a history or clinical evidence of blunt or penetrating head trauma. In addition, patients who fell and take anticoagulant/antiplatelet medications. • This protocol is divided into different levels of care. ALL Providers Levels • Routine patient care • Baseline neurologic examination • Evaluate for increased intracranial pressure, manage as indicated per 2.01 Acute Neurologic Event with Evidence of Increased ICP • Provide airway management • Ventilate • Perform blood glucose analysis if AMS • Transport Advanced EMT Cardiac and Paramedic • Manage hypotension as per the age appropriate General Shock and Hypotension Protocol.
- 11. 4.03 Spinal Motion Restriction Precautions Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients experiencing a mechanism of injury with risk for spinal injury. • This protocol is for all levels of care. ALL Providers Levels • If criteria met, apply spinal motion restriction precautions • If criteria is not met, use the algorithm • Apply cervical collar, supine on cot, secure with belts • Self-extrication allowed • Ambulatory patients may sit, then lie on cot • Scoop and flexible devices to move patients • Long spine boards for extrication and movement • Position patient supine on cot, secure with belts • Manage as per Patient Comfort protocol • Immobilize patients with penetrating trauma only if deficit Pediatric Patients • TRANSPORT IN PEDIATRIC RESTRAINT SYSTEM • Apply padding to cervical collar • Avoid movement • Move from car seat to stretcher ONLY if criteria are met
- 12. 4.04 External Hemorrhage Control ALL Providers Levels • Routine Patient Care • Apply direct pressure • Liberal use of a tourniquet to achieve hemostasis • Hemostatic agent dressings and devices as needed • Use of a junctional tourniquet • If involving a dialysis fistula/shunt, use digital pressure, if tourniquet application is necessary, apply PROXIMALY as far from the fistula as possible • Manage as per the age appropriate Hemorrhagic Shock Protocol Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with external hemorrhage. • This protocol is for all levels of care.
- 13. 4.05 Extremity Trauma and Musculoskeletal Trauma ALL Provider Levels • Routine Patient Care • Manage as per appropriate protocol • Remove rings, bracelets, other constricting items • Care for amputated parts • Splint joint above and below possible fracture • Traction for isolated midshaft femoral fractures • Splint dislocations and angulated fractures in place unless distal circulation is compromised • Binder for pelvic fractures Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with musculoskeletal injury/complaint. • This protocol is divided into different levels of care. Paramedics • CEFAZOLIN 2 mg IV/IO for open fractures/ amputations/grossly contaminated wounds • CEFAZOLIN is contraindicated if history of PCN or cephalosporin allergy
- 14. 4.06 Traumatic Cardiac Arrest ALL Providers Levels • Routine Patient Care • IMMEDIATELY INITIATE CPR • Consider medical etiology • Control external hemorrhage • Binder for suspected pelvic fracture • Transport to Level 1 Trauma Center if <15 minutes Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients in cardiopulmonary arrest with presumed traumatic etiology. • This protocol is divided into different levels of care. Advanced EMT Cardiac • LACTATED RINGER’s 1L IV/IO Adult • LACTATED RINGER’s 20 ml/kg Pediatric Paramedic • LACTATED RINGER’s 1L IV/IO Adult • LACTATED RINGER’s 20 ml/kg Pediatric • Perform needle thoracostomy if suspected tension pneumothorax
- 15. 4.07 Adult Thermal Burn Injury ALL Provider Levels • Routine Patient Care • Assess burn/concomitant injury severity using Rule of Nines. • Minor burn management • Serious or critical burns management and transport to Burn Center Protocol Summary • Previously protocol 5.2 Burn. • This protocol recognizes and provides standing orders for patients with minor burn, serious burn and critical burn. • This protocol is divided into different levels of care. Advanced EMT Cardiac • Analgesia, IV for minor burns • IVFs for serious or critical burns and transport to Burn Center Paramedic • Analgesia, IV for minor burns • IVFs, airway management for serious or critical burns and transport to Burn Center
- 16. ALL Providers Levels • Routine Patient Care • Assess burn/concomitant injury severity using Rule of Nines. • Minor burn management • Serious or critical burns transport to Burn Center Protocol Summary • Previously protocol 5.2 Burn. • This protocol recognizes and provides standing orders for pediatric patients with minor burn, serious burn and critical burn injuries. • This protocol is divided into different levels of care. Advanced EMT Cardiac • Analgesia for minor burns • Consider IV • IVFs for serious or critical burns Paramedic • Analgesia for minor burns • Consider IV • IVFs for serious or critical burns • Airway management 4.07 Pediatric Thermal Burn Injury
- 17. 4.08 Chemical and Electrical Burn Injury ALL Providers Levels • Routine Patient Care • Assess chemical source, utilize HAZMAT resources as needed • Assess electrical source • Assess burn/concomitant injury severity • Decontaminate most chemical burns with liquid • Brush off powdered chemicals • Treat Hydrofluoric Acid burns with calcium gel • Remove non-adherent clothing/rings/constricting items • Manage per the age the appropriate Thermal Burn Protocol and Trauma related protocols. • Transport to Adult Burn Center Protocol Summary • Previously protocol 5.2 Burn. • This protocol recognizes and provides standing orders for patients with partial or full thickness burn injury resulting from contact with a chemical agent or energized electrical source. • This protocol is divided into different levels of care. Advanced EMT Cardiac • Initiate cardiac monitoring Paramedic • Consider IV CALCIUM if hydrofluoric acid and hypocalcemia. • Consider nebulized CALCIUM if HF inhalation
- 18. 4.09 Crush Injury ALL Providers Levels • Routine Patient Care • Manage as per Trauma Protocols/Shock Protocols/Hypothermia or Localized Cold Injury Protocols • Remove constricting items • REQUEST ALS response • Analgesia as needed per Patient Comfort Protocol • Transport Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with extremity/body crush, entrapped and crushed under heavy load for > 30 min. • This protocol is divided into different levels of care. Advanced EMT Cardiac • IV NS with SODIUM BICARBONATE during extrication • Manage Cardiac Arrest per appropriate protocol (s) • If ECG suggests hyperkalemia or cardiac arrest occurs, contact MEDICAL CONTROL for administration of CALCIUM CHLORIDE 1 gm IV/IO or CALCIUM GLUCONATE 3 gm IV/IO and SODIUM BICARBONATE 50mEq IV/IO • Albuterol for suspected hyperkalemia Paramedic • Consider IV NS with SODIUM BICARBONATE during extrication • Manage Cardiac Arrest per appropriate protocol(s) • ECG suggestive of hyperkalemia or if cardiac arrest occurs, CALCIUM CHLORIDE 1 gm IV/IO or CALCIUM GLUCONATE 3 gm IV/IO and SODIUM BICARBONATE 50mEq IV/IO • Albuterol for suspected hyperkalemia
- 19. 4.10 Dental Trauma and Emergencies ALL Provider Levels • Routine Patient Care • Consider possible cardiac etiology • Manage bleeding with direct pressure during multisystem trauma treatment • Control dental related bleeding with rolled gauze direct pressure • Put avulsed teeth in saline, milk, or commercial solution. Do NOT scrub or cleanse. • Provide analgesia as indicated per the Patient Comfort Protocol • Transport Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with tooth pain or dental injury. • This protocol is for all levels of care.
- 20. 4.11 Ocular Trauma and Emergencies ALL Providers Levels • Routine Patient Care • Assess visual acuity • Obtain history • Rigid shield over penetrating ocular injuries • Immobilize impaled objects and patch BOTH eyes • Assess EOM for blunt traumatic injuries, elevate HOB, patch • Moist saline over traumatic enucleation • Irrigate chemical eye injuries with water or LACTATED RINGER’S Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with ocular complaint or injury. • This protocol is divided into different levels of care. Advanced EMT Cardiac • ONDANSETRON for penetrating ocular injuries Paramedic • ONDANSETRON for penetrating ocular injuries • TETRACAINE or PROPARACAINE for ocular flash burns or chemical eye injuries • Irrigate with LACTATED RINGER’S utilizing a Morgan lens • Use pH to guide irrigation
- 21. 4.12 Heat Related Illness ALL Provider Levels • Routine Patient Care • Measure body temperature • Begin passive cooling • Oral rehydration for heat cramps • Active cooling for heat exhaustion and heat stroke • Transport Protocol Summary • Previously protocols 3.4 Heat Cramps and Heat Exhaustion and 3.5 Heat Stroke. • This protocol recognizes and provides standing orders for patients with heat cramps, heat exhaustion and heat stroke. • This protocol is divided into different levels of care. Advanced EMT Cardiac and Paramedic • IV NS for heat exhaustion and heat stroke
- 22. 4.13 Adult Hypothermia and Localized Cold Injury ALL Providers Levels • Routine Patient Care • Provide airway management • Check pulse 60 seconds if unresponsive • Assess mental status and treat as indicated • Determine body temperature • ≥ 34 – 35°C external rewarming • < 34 – 35°C warmed humidified air or oxygen if available • Avoid refreezing if localized cold thermal injury Protocol Summary • Previously protocols 3.1 Cold Exposure Frost Bite and 3.2 Cold Exposure Hypothermia in Environmental Emergencies. • This protocol recognizes and provides standing orders for adult patients with core temperature < 35°C (95°F) and patients with cold thermal injury (frostbite). • This protocol is divided into different levels of care. Advanced EMT Cardiac and Paramedic • For patients with a core temperature < 34°C (93.2°F), administer warm (40-42°C/104-107°F) NORMAL SALINE 500 ml IV/IO boluses.
- 23. 4.13 Pediatric Hypothermia and Localized Cold Injury ALL Providers Levels • Routine Patient Care • Provide airway management • Check pulse for 60 seconds if unresponsive • Assess mental status and treat as indicated • Determine body temperature • ≥ 34 – 35°C external rewarming • < 34 – 35°C warmed humidified air or oxygen if available • Avoid refreezing localized cold thermal injury Protocol Summary • Previously protocol 3.1 Cold Exposure Frost Bite 3.2 Cold Exposure Hypothermia in Environmental Emergencies. • This protocol recognizes and provides standing orders for pediatric with core temperature < 35°C (95°F) and patients with cold thermal injury (frostbite). • This protocol is divided into different levels of care. Advanced EMT Cardiac and Paramedic • For patients with a core temperature < 34°C (93.2°F), administer warm (40-42°C/104-107°F) NORMAL SALINE 20 ml/kg IV/IO boluses
- 24. 4.14 Submersion – Near Drowning ALL Providers Levels • Routine Patient Care • Apply Spinal Motion Restriction Precautions • Manage Cardiac Arrest even after prolonged immersion in cold water • Manage Hypothermia and Local Cold Injury as indicated. • Remove wet clothing, dry and warm the patient. • Provide Airway Management and Altered Mental Status as indicated. • Manage per the age appropriate Respiratory Distress Protocol if indicated • Monitor and reassess the patient. • Transport Protocol Summary • Previously protocol 3.3 Drowning. • This protocol recognizes and provides standing orders for patients submersed in water regardless of depth. • This protocol is for all levels of care.
- 25. 4.15 Diving Emergencies ALL Provider Levels • Routine Patient Care • Consult Diver’s Alert Network (DAN) • Analgesia for ear or sinus squeeze • Oxygen and recompression Treatment at HBO Facility for • Pulmonary Overpressure syndrome • Arterial gas embolism • Decompression sickness type I and II • Nitrogen narcosis Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with ear squeeze/sinus squeeze, pulmonary overpressure syndrome, arterial gas embolism, decompression sickness type I and II, Nitrogen Narcosis. • This protocol is divided into different levels of care. Advanced EMT Cardiac and Paramedics • OXYMETAXOLINE or PSEUDOEPHEDRINE for ear or sinus squeeze – Patient Comfort Protocol • IV NS for decompression sickness type II
- 26. 4.16 Marine Envenomation ALL Providers Levels • Routine Patient Care • Manage allergic or anaphylactic reactions • Regional Center for Poison Control and Prevention 800-222-1222 • Sting Ray, Lionfish or Urchin/Starfish related injuries • Immobilize injury and object, or remove barb if small • Jellyfish or Man o’ War related injuries • Lift away tentacles • Irrigate with vinegar or sea water NOT fresh water or ice • Treat pain as per the age appropriate Patient Comfort Protocol Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients exposed to marine organisms with intense localized pain, nausea/vomiting, allergic reaction or anaphylactic reaction. • This protocol is divided into different levels of care. Paramedic • Manage severe muscle spasm with CALCIUM IV
- 27. 4.17 Bite - Stings - Envenomation Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with bee or wasp sting, spider, snake, feline, canine, or human bite. • This protocol is divided into different levels of care. Paramedic • Manage severe muscle spasm with MIDAZOLAM ALL Providers Levels • Routine Patient Care • Manage allergic or anaphylactic reactions • Consider Regional Center for Poison Control and Prevention 800-222-1222 • Spider bites and bee or wasp stings • Elevate, ice, remove constricting jewelry • Snake bites • Immobilize, elevate, remove constricting jewelry • NO ICE • Feline, Canine or Human bites • Wound care • Immobilize • Contact animal control
- 28. 4.18 Adult Toxicological Emergencies ALL Provider Levels • Routine Patient Care • Recognition symptoms (toxidromes) • OPIOID OVERDOSE • NALOXONE UNTIL ADEQUATE VENTILATION • FOLLOW THE RECOVERY COACH ALGORITHM • CONSIDER CONTACTING THE REGIONAL CENTER FOR POISON CONTROL • ORGANOPHOSPHATE NERVE AGENT or INSECTISIDE manage per appropriate protocol Protocol Summary • Previous protocol 3.6 Poisoning and Overdose. • This protocol recognizes and provides standing orders for patients intoxicated with Beta Blockers/Calcium Channel Blockers, Tricyclic Antidepressants/Sodium Channel blocking agents, Opioids, Organophosphates/nerve agents, and anticholinergics. • This protocol is divided into different levels of care. Advanced EMT Cardiac • NALOXONE for Opioid Overdose until adequate ventilation • SODIUM BICARBONATE for suspected antidepressant or other sodium channel blocking agent toxicity • GLUCAGON or CALCIUM for suspected beta blocker or calcium channel blocker toxicity • HYDROXYCOBALAMIN for suspected Cyanide toxicity • MIDAZOLAM or LORAZEPAM for suspected sympathomimetic/stimulant toxicity • Treat seizures Paramedic • INTRALIPID or NOREPINEPHRINE for antidepressant or other sodium channel blocking agent toxicity • GLUCAGON, CALCIUM or INTRALIPID for beta blocker or calcium channel blocker toxicity • SODIUM THIOSULFATE for Cyanide toxicity • ATROPINE / PRALIDOXIME for organophosphate nerve agent or insecticide exposure • MIDAZOLAM or LORAZEPEM for sympathomimetic/stimulant toxicity • DIPHENHYDRAMINE for dystonic reactions • INTRALIPID for lipid-soluble toxicity cardiac arrest / hemodynamic compromise
- 29. 2.17 Obstetrical Delivery4.18 Pediatric Toxicological Emergencies ALL Provider Levels • Routine Patient Care • Recognition symptoms (toxidromes) • OPIOID OVERDOSE • NALOXONE UNTIL ADEQUATE VENTILATION • FOLLOW THE RECOVERY COACH ALGORITHM • CONSIDER CONTACTING THE REGIONAL CENTER FOR POISON CONTROL • ORGANOPHOSPHATE NERVE AGENT or INSECTISIDE • DuoDote Protocol Summary • Previous protocol 3.6 Poisoning and Overdose. • This protocol recognizes and provides standing orders for pediatric patients intoxicated with Beta Blockers/Calcium Channel Blockers, Tricyclic Antidepressants/Sodium Channel blocking agents, Opioids, Organophosphates/nerve agents, and anticholinergics. • This protocol is divided into different levels of care. Advanced EMT Cardiac • NALOXONE for Opioid Overdose until adequate ventilation • SODIUM BICARBONATE for suspected antidepressant or other sodium channel blocking agent toxicity • GLUCAGON or CALCIUM for suspected beta blocker or calcium channel blocker toxicity • HYDROXYCOBALAMIN for suspected Cyanide toxicity • MIDAZOLAM or LORAZEPAM for suspected sympathomimetic/stimulant toxicity • Treat seizures Paramedic • INTRALIPID or NOREPINEPHRINE for antidepressant or other sodium channel blocking agent toxicity • GLUCAGON, CALCIUM or INTRALIPID for beta blocker or calcium channel blocker toxicity • SODIUM THIOSULFATE for Cyanide toxicity • ATROPINE / PRALIDOXIME for organophosphate nerve agent or insecticide exposure • MIDAZOLAM or LORAZEPEM for sympathomimetic/stimulant toxicity unless < 5kg • DIPHENHYDRAMINE for dystonic reactions unless < 5 kg • INTRALIPID for lipid-soluble toxicity cardiac arrest / hemodynamic compromise
- 30. 2.17 Obstetrical Delivery4.19 Nerve Agent or Organophosphate Toxicity ALL Provider Levels • Routine Patient Care • PPE • DuoDote • Adult • Pediatric Protocol Summary • New Protocol • This protocol recognizes and provides standing orders for patient with suspected or know exposure to a nerve or organophosphate agent with salivation, lacrimation, urination, defecation, GI distress, emesis [SLUDGE], muscle twitching, seizures, respiratory arrest), bradycardia, bronchorrhea, and/or bronchospasm. • This protocol is divided into different levels of care. Advanced EMT Cardiac • Manage Seizures as per the age appropriate Seizure Protocol Paramedic • Manage Seizure as per the age appropriate Seizure Protocol • ATROPINE / PRALIDOXIME for organophosphate nerve agent or insecticide exposure
- 31. 4.20 Carbon Monoxide ALL Providers Levels • Routine Patient Care • OXYGEN • Treat as outlined in table Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients involved in fire or in a confined space/poorly ventilated area with potential for the presence of carbon monoxide (combustion of carbon containing fuels or inadequate ventilation of natural gas). • This protocol is divided into different levels of care. Advanced EMT Cardiac and Paramedic • Cardiac monitoring and multi-lead ECG
- 32. 4.21 Blast Injury - Incident ALL Providers Levels • Routine Patient Care • Ensure scene safety. • Determine nature of incident, nature of device, nature of environment, potential for threat of particalization of hazardous materials and distance from blast. • Quantify and triage patients per the Multiple Patient Incident Protocol(s) as indicated. • Manage patient as indicated per age appropriate Trauma and Burn Protocols, Crush Injury Protocol, Radiation Incident Protocol. • Transport Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for Blast explosion occurring in an open space (conventional blast) or enclosed/confined space (vehicle, building, bus, train). • This protocol is divided into different levels of care.
- 33. 4.22 Radiation Incident ALL Providers Levels • Routine Patient Care • Ensure scene safety. • If the incident involves a blast, also manage per Blast Incident and Injury Protocol. • Determine need for additional resources, exposure type, quantification of exposure, quantify and triage patients as per the Multiple Patient Incident Protocol as indicated. • Flush contact areas with NORMAL SALINE for 15 minutes. • If present, manage burn injuries as per age appropriate Burn Protocol(s). • Identify and manage any secondary injuries as per appropriate Trauma Protocols. • Transport Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders for patients with radiation burn or exposure to radiation. • This protocol is for all levels of care.
- 34. Continue on to RI EMS Protocol Education Modules Section 5