San Diego County Paramedic Protocols 2011/2012

Front 1

When is synchronized cardioversion a standing order?

Back 1

- Unconscious SVT
- Unstable/Unconscious VT
- Unconscious A-Fib/A-Flutter with HR > or equal to 180

Front 2

When is CPAP a standing order?

Back 2

- Age > or equal to 15 years
- Respiratory distress; CHF, COPD, asthma, pneumonia or drowning
- Moderate to severe respiratory distress, retractions or accessory muscle use AND
- RR > or equal to 25/min OR SpO2 <94%

Front 3

When is defibrillation a standing order?

Back 3

- Pulseless VF/VT
- Repeat PRN

Front 4

When is external cardiac pacing a standing order?

Back 4

- Narrow complex bradycardia with a pulse, refractory to 1mg of Atropine
- Wide complex bradycardia

Front 5

When is IO Infusion standing order?

Back 5

For fluid/medication administration in an acute status patient when needed for definitive therapy and unable to establish venous access

Front 6

When is intubation standing order?

Back 6

Apnea or ineffective respirations for unconscious patient or decreasing LOC

Front 7

List the (14) ALS Standing Order skills.

Back 7

- Cardioversion (Synchronized)
- CPAP
- External Cardiac Pacing
- Defibrillation
- Glucose Monitoring
- Indwelling Devices Access
- Intubation
- Intraosseous Infusion
- Magil Forceps
- Naso/Orogastric Tube Insertion
- Needle Thoracostomy
- Realignment of Fracture
- Tourniquet
- Valsalva Maneuver

Front 8

When is needle thoracostomy standing order?

Back 8

Severe respiratory distress with unilateral breath sounds and systolic BP <90 in intubated or postive pressure patients

Front 9

Abdominal Discomfort S-120

Back 9

- Monitor EKG
- IV/IO SO adjust prn
- Treat pain per protocol
- 500 ml fluid bolus IV/IO for suspected volume depletion SO to sytolic BP of 80

For nausea and/or vomiting
- Zofran 4mg IV/IM/ODT SO, MR x 1 q10" SO

Front 10

Abdominal Discomfort S-120
For suspected intra-abdominal catastrophe or AAA transport to facility with surgical resources immediately available and titrate fluid to systolic BP of _____.

Back 10

80

Front 11

Allergic Reaction/Anaphylaxis S-122

Define a mild allergic reaction

Back 11

Rash and uticaria

Front 12

Allergic Reaction/Anaphylaxis S-122

Mild allergic reaction Rx

Back 12

- Benadryl 50mg SIVP/IM SO

Front 13

Allergic Reaction/Anaphylaxis S-122

Define an acute allergic reaction

Back 13

Facial/cervical angioedema, bronchospasm or wheezing

Front 14

Allergic Reaction/Anaphylaxis S-122

Acute allergic reaction Rx

Back 14

* Epi first *
- Epinephrine 1:1000 0.3mg IM SO. MR x2 q10" SO
- Benadryl 50mg IM/SIVP SO
- Albuterol 6ml 0.083% via neb SO. MR SO
- Atrovent 2.5ml 0.02% via neb added to the first dose of Alubterol SO

Front 15

Allergic Reaction/Anaphylaxis S-122

Define anaphylaxis

Back 15

shock or cyanosis

Front 16

Allergic Reaction/Anaphylaxis S-122

Anaphylaxis Rx

Back 16

- Epinephrine 1:1000 0.3mg IM SO. MR q10" x2 SO.
- 500 ml fluid bolus IV/IO for systolic BP < 90 SO. MR to maintain systolic BP of > or equal to 90 systolic SO
- Benadryl 50mg IM/SIVP SO
- Albuterol 6ml 0.083% via neb SO. MR SO
- Atrovent 2.5ml 0.02% via neb added to the first dose of Alubterol SO
- Epinephrine 1:10000 0.1mg IV/IO BHO. MR x2 q3-5" BHO
- Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip; titrate systolic BP > or equal to 90 BHO

Front 17

Altered Neurologic Function S-123

For suspected stroke with major deficit with onset of symptoms known to be _____ in duration, expedite transport.

Back 17

< 4 hours

Front 18

Altered Neurologic Function S-123

Only use supplemental O2 for O2 saturation _____.

Back 18

94%

Front 19

Altered Neurologic Function S-123

True or False. In symptomatic ?opioids OD (excluding opioid dependent pain management patients) administer Narcan IV prior to IN/IM dose.

Back 19

False. Administer Narcan IN/IM prior to IV dose.

Front 20

Altered Neurologic Function S-123

Symptomatic ?opioids OD with respiratory rate <12 rx

Back 20

* Narcan IN/IM prior to IV *
- Narcan 2mg IN/IM/IV SO titrate IV dose to effect MR SO
- If patient refuses transport give additional Narcan 2mg IM SO

Front 21

Altered Neurologic Function S-123

Describe the dilution and dose of IV Narcan

Back 21

Dilute 2mg/2cc dose of Narcan with an additional 8cc of NS. New dilution is 2mg/10cc. Administer .5cc and titrate to effect.

Front 22

Altered Neurologic Function S-123

Hypoglycemia Rx

Back 22

- D50 25Gm IV/IO SO if BS <60
- If patient remains symptomatic and BS remains <60 MR SO

If no IV:
- Glucagon 1ml IM SO if BS <60

Front 23

Altered Neurologic Function S-123

Types of seizures treated SO

Back 23

A. Ongoing generalized seizure lasting > or equal to 5" (includes seizure time prior to arrival of prehospital provider
B. Focal seizure with respiratory compromise
C. Recurrent seizure without lucid interval
D. Eclamptic seizure of any duration

Front 24

Altered Neurologic Function S-123

Seizure rx

Back 24

- Versed 0.1mg/kg SIVP (1mg/min)/IO to max dose 5mg SO (d/c if seizure stops). MR x1 SO

If no IV/IO:
- Versed 0.2mg/kg IM to max dose of 10mg SO MR x1 SO
or
- Versed 0.2mg/kg IN to max dose of 5mg SO MR x1 SO

Front 25

Burns S-124

For patients with > or equal to _____ 2nd degree burns or > or equal to _____ 3rd degree burns Rx with the following:

Back 25

For patients > or equal to 15yo
- 20%, 5%
- 500ml fluid bolus IV/IO, then TKO SO

Front 26

Burns S-124

In the presence of respiratory with bronchospasm rx

Back 26

Albuterol 6ml 0.083% via nebulizer SO MR SO

Front 27

Burns S-124

Thermal burns of <10% BSA rx

Back 27

Stop burning with non-chilled water or saline

Front 28

Burns S-124

Thermal burns of > or equal to 10% BSA Rx

Back 28

- Cover with dry dressings and keep warm
- Do not allow patient to become hypothermic

Front 29

Burns S-124

BSA Percentages - Adult

Back 29

- Head 9%
- Arms 9% each
- Chest and Back 18% each
- Legs 18% each
- Groin 1%

Front 30

Burns S-124

BSA Percentages - Peds

Back 30

- Head 18%
- Chest / Back 18% each
- Arms 9% each
- Legs 14% each
- Groin 1%

Front 31

Burns S-124

Burn Center Criteria

Back 31

- > or equal to 20% 2nd or > or equal to 5% 3rd degree of BSA
- suspected respiratory involvement or significant smoke inhalation in a confined space
- significant injury of the face, hands, feet or perineum or circumferential
- significant electrical injury due to high voltage (> 110v)

Front 32

Discomfort/Pain of Suspected Cardiac Origin S-126

If systolic BP > or equal to 100 rx

Back 32

- NTG 0.4mg SL SO. MR q3-5" SO
- NTG ointment 1" SO
- MS 2-4mg IV SO. MR to max of 10mg SO. MR to max of 20mg BHO.

Front 33

Discomfort/Pain of Suspected Cardiac Origin S-126

If systolic BP <100 Rx

Back 33

- NTG 0.4mg SL BHO. MR BHPO.
- MS 2-4mg IV BHO. MR to max of 20mg BHO.

Front 34

Discomfort/Pain of Suspected Cardiac Origin S-126

With associated shock Rx

Back 34

- 250cc fluid bolus with clear lungs SO. MR to maintain systolic BP > or equal to 90 SO

If BP refractory to fluid boluses:
- Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip titrated to systolic BP > or equal to 90 BHO

Front 35

Discomfort/Pain of Suspected Cardiac Origin S-126

True or False. Give patient additional ASA regardless of prior doses.

Back 35

True

Front 36

Discomfort/Pain of Suspected Cardiac Origin S-126

If any patient has taken an erectile dysfunction medication such as Viagra, Cialis or Levitra within _____ hours, NTG is contraindicated.

Back 36

48

Front 37

Discomfort/Pain of Suspected Cardiac Origin S-126

List additional HTN medications that NTG is also contraindicated for

Back 37

- Revatio
- Flolan
- Veletri

Front 38

Define the "Unstable" criteria:

Back 38

Chest pain, dyspnea or altered LOC
AND BP <90

Front 39

Dysrhythmias S-127
Unstable Bradycardia with a Pulse
Narrow Complex Bradycardia initial Rx

Back 39

- Monitor EKG
- 250 cc fluid bolus IV/IO with clear lungs SO. MR to maintain BP > or equal to 90 SO
- Atropine 0.5mg IV/IO for pulse <60 SO. MR q3-5" to max 3mg SO

Front 40

Dysrhythmias S-127
Unstable Bradycardia with a Pulse
Narrow Complex Bradycardia Rx if rhythm is refractory to a minimum of Atropine 1mg

Back 40

External cardiac pacing SO

Front 41

Dysrhythmias S-127
Unstable Bradycardia with a Pulse
Narrow Complex Bradycardia Rx after capture occurs and BP is > or equal to 100

Back 41

Consider Morphine 2-10mg IV/IO prn SO

Front 42

Dysrhythmias S-127
Unstable Bradycardia with a Pulse
Narrow Complex Bradycardia Rx for discomfort related to pacing not relieved with Morphine and BP > or equal to 100

Back 42

Consider Versed 1-5mg SIVP/IO SO

Front 43

Dysrhythmias S-127
Unstable Bradycardia with a Pulse
External pacing on standing orders should begin with rate set at _____ although some machines are set for other acceptable rates.

Back 43

60/min

Front 44

Dysrhythmias S-127
Unstable Bradycardia with a Pulse
Energy output for pacing should be dialed up until capture occurs, usually between _____ and _____ mA. The mA should then be increased a small amount, usually about _____.

Back 44

- 50
- 100
- 20%

Front 45

Dysrhythmias S-127
Unstable Bradycardia with Pulse
After max Atropine or initiation pacing consider the following to maintain BP of >90

Back 45

Dopamine 400mg/250ml at 10-40mcg/kg/min IV/IO drip BHO

Front 46

Dysrhythmias S-127
Unstable Bradycardia with a Pulse
Wide Complex Bradycardia initial Rx

Back 46

- Monitor EKG
- 250ml fluid bolus IV/IO with clear lungs SO. MR to maintain BP > or equal to 90 SO
- External cardiac pacemaker SO

Front 47

Dysrhythmias S-127
SVT
Initial Rx

Back 47

- Monitor EKG
- 250ml fluid bolus IV/IO with clear lungs SO. MR to maintain BP > or equal to 90 SO
- VSM SO. MR SO
- Adenosine 6mg IV/IO, followed with 20ml NS IV/IO SO (patients with history of bronchospasm or COPD BHO)
- Adenosine 12mg IV/IO followed with 20ml NS IV/IO SO. If no sustained rhythm change, MR x1 in 1-2" SO

Front 48

Dysrhythmias S-127
SVT
If a CONSCIOUS patient is unstable with severe symptoms or rhythm is refractory to treatment:

Back 48

- Versed 1-5mg SIVP/IO prn pre-cardioversion BHO (if age > or equal to 60 consider lower dose with attention to age and hydration status
- Synchronized cardioversion at manufacturer's recommended energy dose BHO. MR BHO (50, 75, 100 and 200)

Front 49

Dysrhythmias S-127
SVT
Unconscious Rx

Back 49

Synchronized cardioversion at manufacturer's recommended energy dose SO. MR x 3 SO. MR BHO.

Front 50

Dysrhythmias S-127
Unstable A-Fib / A-Flutter
Initial Rx

Back 50

- Monitor EKG
- 250ml fluid bolus IV/IO with clear lungs SO. MR to maintain BP > or equal to 90 SO

Front 51

Dysrhythmias S-127
Unstable A-Fib / A-Flutter
The Rx in the presence of a ventricular response with heart rate > or equal to 180 in a CONSCIOUS patient

Back 51

- Versed 1-5mg IV/IO prn pre-cardioversion BHPO
- Synchronized cardioversion at manufacturer's recommended energy dose BHPO

Front 52

Dysrhythmias S-127
Unstable A-Fib / A-Flutter
The Rx in the presence of a ventricular response with heart rate > or equal to 180 in an UNCONSCIOUS patient

Back 52

- Synchronized cardioversion at manufacturer's recommended energy dose SO. MR x3 SO. MR BHO.