DO NOT PRINT – 384 PAGES 2026.10 ERAFD_EMR_Renewal_Packet_Printable

EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R JOINT MUNICIPAL FIRE COMMISSION City of Eagle River · Town of Cloverland · Town of Lincoln · Town of Washington EAGLE RIVER AREA FIRE DEPARTMENT EMERGENCY MEDICAL RESPONDER SERVICE OPERATIONAL PLAN Renewal / Replacement Filing Wisconsin EMR Service Provider · Non-Transporting First Response Document status WORKING DRAFT — not yet approved by Wisconsin DHS EMS Action type Renewal and replacement of the existing EMR / first-responder operational plan. Not a new-service application. No feasibility study required (DHS 110.35(1)). Plan being replaced Existing DHS-approved ERAFD EMR operational plan. There is no separate plan ID. The State approval date of the plan being replaced is October 31, 2008. Proposed effective date Upon written DHS approval of this replacement. The current approved plan remains in force until then. Revision 1.0-R · 24 September 2026 Service address 820 E. Pine Street, Eagle River, WI 54521 Station phone / fax (715) 479-8835 / (715) 477-8835 FDID 63030 License level Emergency Medical Responder (EMR) — non-transporting. No service-level upgrade is requested in this filing. Service Director Spencer Daniel Holms, EMT · WI 70110317 Service Medical Director Choon Heong P'ng, M.D. · WI 47602-20 Online medical control Aspirus Eagle River Hospital Emergency Department Transport partner Aspirus MedEvac — Aspirus Eagle River Hospital Note. Placeholders in gold-shaded boxes and blank signature lines must be completed before e-Licensing submission. Newly listed optional skills shall not be placed in service until DHS accepts this plan (Wis. Admin. Code § DHS 110.33(3) — submit changes at least 60 days before intended implementation). This document is not itself a DHS license. Controlled document. Official copy maintained at 820 E. Pine Street and in Wisconsin EMS e-Licensing. ERAFD · Working draft · Not a DHS license Page 1 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R Contents 1. Purpose and authority 2. Service identification 3. Primary service area 4. Organization and required personnel 5. Medical direction 6. Communications and dispatch 7. Required operational policies (DHS 110.35(2)(e)) 8. Scope of practice, skills, and formulary 9. Equipment 10. Infection control 11. Documentation and data 12. Training, competency, and training-center affiliation 13. Mutual aid, coverage, and partners 14. Mass casualty, special operations, and special events 16. Records retention and plan maintenance 17. Certification and signatures Appendix A — Primary service area map (attached) Appendix B — Signed EMR protocols (P-02875 + cover) (attached) Appendix C — Aspirus coordination letter (attached) Appendix D — Insurance certificates (attached when received) Appendix E — Municipal endorsement letters (attached) Appendix F — e-Licensing roster (25 September 2026) (attached) Appendix G — Exposure-control forms G-1 to G-4 (attached; program is § 10.3) Appendix H — EMS emergency-mode driver roster (attached typed Form H-1) ERAFD · Working draft · Not a DHS license Page 2 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 1. Purpose and authority This Operational Plan is the renewal and replacement of the Eagle River Area Fire Department (ERAFD) Wisconsin Department of Health Services (DHS) approved Emergency Medical Responder operational plan. The prior approved plan cannot be located in department paper files. This document reconstructs current practice, required policies, and supporting attachments so the file in EMS e- Licensing matches operations. ERAFD operates under the Joint Municipal Fire Commission of the City of Eagle River and the Towns of Cloverland, Lincoln, and Washington. ERAFD does not operate a licensed ambulance and does not transport patients. Licensed 9-1-1 ambulance and paramedic transport in the primary service area is provided by Aspirus MedEvac based at Aspirus Eagle River Hospital. ERAFD’s EMS role is first response, scene support, lift assist, landing-zone operations, and care within the Wisconsin EMR Scope of Practice until Aspirus or mutual-aid EMS assumes patient care. 1.1 Binding legal basis • Municipal organization: towns provide fire protection under Wis. Stat. § 60.55(1), including a joint fire department under § 60.55(1)(a)2.; a city may create a joint fire department with a town under Wis. Stat. § 62.13(1m); the four municipalities may contract for the joint exercise of that power under Wis. Stat. § 66.0301(2). Commission adoption of this Plan is subject to the Open Meetings Law, Wis. Stat. §§ 19.81 to 19.98. • EMS program and EMR practice: Wis. Stat. § 256.12(2) (municipal EMS program after a department- approved plan); § 256.15(2) (may not act or advertise as an emergency medical responder without a certificate); § 256.15(8) (EMR certification and authorized acts set by department rule); § 256.15(8m) (medical-director qualifications, implemented for this service by Wis. Admin. Code § DHS 110.49). • Wis. Admin. Code ch. DHS 110, promulgated under Wis. Stat. §§ 256.08(4) and 256.15(13). Controlling sections for this EMR service: § DHS 110.32(2) (EMR service; no transport); § DHS 110.33 (only licensed services in the approved plan; submit changes at least 60 days before implementation); § DHS 110.34 (responsibilities; EMR services are exempt from 24/7 response under § DHS 110.34(5) but shall make every effort); § DHS 110.35 (plan contents; first-responder / EMR services are not required to file a feasibility study); § DHS 110.46 (renewal); §§ DHS 110.47–110.50 (personnel and staffing — when the EMR service responds, at least one certified EMR shall respond, § DHS 110.50(1)(g)); §§ DHS 110.52–110.53 (local credentialing). • Wisconsin EMS Scope of Practice, EMR column (DHS P-00451, current revision). An EMR may perform only the skills, equipment, and medications specified for that level. Wis. Admin. Code § DHS 110.12. • Wisconsin EMS Protocols, DHS P-02875, limited to EMR scope, with only those optional (O) skills and medications the Service Medical Director initials in § 8.2. Signed set is Appendix B. Wis. Admin. Code § DHS 110.35(2)(a). • Wisconsin EMS Communications Plan (§ DHS 110.34(12)) and the EMS Standards and Procedures of Practical Skills manual (DHS P-00908), used only to the extent they apply to EMR practice. • Confidentiality and workplace safety: Wis. Stat. § 146.82 is the primary patient-record statute. HIPAA (45 CFR Parts 160 and 164) applies only if ERAFD is a covered entity or business associate, which is not assumed for a non-billing fire EMR service. Bloodborne-pathogen duties follow 29 CFR 1910.1030 as applied to public-sector fire employees through Wis. Admin. Code ch. SPS 332. Fire-department occupational safety is Wis. Admin. Code ch. SPS 330. SPS 330 does not adopt NFPA emergency- medical-service requirements as DSPS rules (SPS 330.002(4)(b); note to SPS 330.23 — EMS practice is administered by DHS under ch. DHS 110 and Wis. Stat. ch. 256). Emergency-vehicle privileges are ERAFD · Working draft · Not a DHS license Page 3 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R Wis. Stat. §§ 340.01(3) and 346.03; a privately owned response vehicle is not an authorized emergency vehicle unless it independently meets § 340.01(3). 1.2 Reference standards — not Wisconsin law unless separately adopted The following are consensus or federal guidance documents. They are used as benchmarks in the same way the DSPS Fire Service Guidebook treats NFPA. They are not self-executing Wisconsin statutes, and SPS 330 expressly does not adopt NFPA emergency-medical-service requirements as DSPS rules: • NFPA 1720 — Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations by Volunteer Fire Departments (deployment and EMS first-response objectives). • NFPA 1550 — Emergency Responder Health and Safety (occupational safety, incident management, command safety; consolidates former 1500 / 1521 / 1561). • NFPA 1580 — Emergency Responder Occupational Health and Wellness (infection control, occupational medical program, fitness, rehabilitation; consolidates former 1581–1584). • NFPA 1225 — Emergency Services Communications. • NFPA 1950 — Protective Ensembles for Technical Rescue, EMS, and Wildland (EMS protective clothing elements formerly in NFPA 1999). • NFPA 1020 / 1021 — professional qualifications for fire and EMS officers, used as a training reference, not as a staffing mandate. • NIMS / ICS (FEMA) for incident organization, including multi-patient and landing-zone operations. • DHS P-01098 — Wisconsin EMS Mass Casualty Incident Response Planning Guide (guidance, not a standalone license condition). • This Plan does not treat Wis. Stat. § 256.15(4) as the EMR staffing rule. That subsection governs licensed ambulance service providers. EMR staffing is Wis. Admin. Code § DHS 110.50(1)(g). • Official DHS operational-plan checklist item (copied from § DHS 110.35(2)(d)): “Proof of professional liability or medical malpractice insurance, and, if the emergency medical service provider is an ambulance service provider, proof of vehicle insurance.” Malpractice / professional-liability proof is required of this EMR service. Vehicle-insurance proof is required only of an ambulance service provider. ERAFD is a non-transporting EMR service and does not attach automobile certificates to this operational plan. Fire-apparatus insurance remains a municipal / fire-department matter and does not convert ERAFD into an ambulance service or create a Trans 309 duty. • Wis. Admin. Code § DHS 110.35(2)(f) endorsement letters are required for a 9-1-1 ambulance service or a non-transporting EMS provider (EMT or higher) on initial licensure or a level upgrade. An EMR-service renewal is a different license type. Hospital and municipal letters are included as recommended support, not as a statutory EMR-renewal element. • Cross-references printed inside § DHS 110.47 that point to §§ 110.49 / 110.50 / 110.51 for the director titles are internally inconsistent with the section titles. This Plan cites each requirement by the section that actually contains it: service director § DHS 110.48; service medical director § DHS 110.49; staffing § DHS 110.50. 1.3 Mission Minimize loss of life and suffering by placing trained Emergency Medical Responders on scene as quickly as volunteer and paid-on-call resources allow, supporting Aspirus MedEvac, and delivering only those skills, medications, and equipment authorized at the EMR level. ERAFD · Working draft · Not a DHS license Page 4 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 1.4 What this filing is not • Not an application to start a new EMS service. • Not a request to upgrade to EMT, AEMT, or paramedic service, and not a non-transporting EMS provider license at EMT-or-higher. • Not authorization to transport patients. • Not authorization for individually licensed EMTs or paramedics to practice above EMR while operating under this service license. ERAFD · Working draft · Not a DHS license Page 5 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 2. Service identification 2.1 Provider Eagle River Area Fire Department, a joint municipal fire department governed by the Joint Municipal Fire Commission. Member municipalities: City of Eagle River and the Towns of Cloverland, Lincoln, and Washington, Vilas County, Wisconsin. 2.2 Service type and level • Type: Emergency Medical Responder service provider (non-transporting). Wis. Admin. Code § DHS 110.32(2). • Level: EMR only. Members who hold EMT or higher Wisconsin licenses practice only to the EMR skills, medications, and equipment listed in this Plan unless and until the Commission submits and DHS approves a service-level upgrade. • Staffing rule: When the EMR service responds, at least one certified Emergency Medical Responder (or higher licensee credentialed to this service and practicing at EMR) shall respond. Wis. Admin. Code § DHS 110.50(1)(g). • 24/7 response: EMR services are exempt from the 24-hour, 7-day guarantee that applies to ambulance and non-transporting EMT-or-higher providers, but shall make every reasonable effort to respond to 9-1- 1 first-responder requests in the primary service area. Wis. Admin. Code § DHS 110.34(5). 2.3 Authorized services ERAFD is authorized to provide emergency medical care at the EMR level before hospitalization and before arrival of an ambulance. ERAFD shall not advertise or provide ambulance transport, interfacility transfer, intercept as an ambulance, tactical EMS, community EMS, or any skill above EMR. Wis. Admin. Code §§ DHS 110.33 and 110.34(2). 2.4 How first responders are used Vilas County Communications Center dispatches Aspirus MedEvac as the primary ambulance for medical emergencies in the primary service area. ERAFD is dispatched as follows: 1. Automatically for fire, rescue, extrication, motor-vehicle collision, ice/water, and landing-zone requests. 2. On request of Aspirus, dispatch, or law enforcement for lift assist, manpower, CPR, hemorrhage control, AED, or other first-responder need. 3. If the Commission later places a paid duty crew in quarters, that crew may be dispatched concurrently with Aspirus on medical calls in the primary service area. That change shall be submitted as a Plan addendum before it is treated as the standing dispatch model. ERAFD personnel do not cancel or replace the ambulance. They stabilize, assist movement, document, and transfer care. ERAFD · Working draft · Not a DHS license Page 6 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 3. Primary service area The primary service area is the corporate limits of the City of Eagle River and the Towns of Cloverland, Lincoln, and Washington, Vilas County — approximately 105 to 109.5 square miles. Mutual aid and MABAS responses outside this area are not part of the licensed primary service area. 3.1 Community characteristics • Year-round residents plus large seasonal and tourism influx (lakes, snowmobile trails, events). • Rural / small-city mix; long driveways, private roads, trail access, and water/ice exposure. • Nearest hospital: Aspirus Eagle River Hospital, 201 E. Hospital Road, Eagle River. • Higher-level trauma / specialty destinations used by the transporting service: Howard Young Medical Center (Woodruff), Marshfield Medical Center (Minocqua), Aspirus Rhinelander, Aspirus Wausau (air). ERAFD does not choose destination. 3.2 Map Appendix A is the labeled primary-service-area map: City of Eagle River and Towns of Cloverland, Lincoln, and Washington; Station 1 at 820 E. Pine Street; Station 2 at 1844 Rangeline Road; Aspirus Eagle River Hospital at 201 E. Hospital Road; US-45, STH-70, and STH-17. FDID 63030. Non-transporting EMR primary service area. ERAFD · Working draft · Not a DHS license Page 7 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 4. Organization and required personnel 4.1 Governance The Joint Municipal Fire Commission oversees budget, policy, and appointment of the Fire Chief. The Fire Chief appoints the Service Director required by Wis. Admin. Code § DHS 110.48 unless the Commission names another person in writing. Day-to-day EMS operations are supervised by the Service Director. 4.2 Required positions (DHS 110.47 and 110.48–110.49) An EMS provider shall designate a Service Director, Service Medical Director, infection-control designee, quality-assurance designee, training designee, and data-contact designee. One person may hold more than one designee role if qualified. Role Name / credential Contact Fire Chief James Alan Randall, EMT 70124709 Station (715) 479-8835 Service Director (DHS 110.48) Spencer Daniel Holms, EMT 70110317 715-891-1927 · Station (715) 479-8835 Service Medical Director (DHS 110.49) Choon Heong P'ng, M.D., WI 47602-20 715-393-2508 · heong.png@aspirus.org Online medical control Aspirus Eagle River Hospital ED physician on duty Hospital / HEAR / cellular as assigned Infection Control Officer Spencer Daniel Holms, EMT 70110317 715-891-1927 Quality Assurance designee Spencer Daniel Holms, EMT 70110317 715-891-1927 Training designee Spencer Daniel Holms, EMT 70110317 715-891-1927 Data / WARDS contact Spencer Daniel Holms, EMT 70110317 715-891-1927 4.3 Service Director duties (DHS 110.48) • Serve as primary contact with Wisconsin DHS EMS. • Keep this Operational Plan current and submit required updates at least 60 days before implementation. • Assure EMS professionals are properly licensed or certified and locally credentialed. • Provide day-to-day supervision of EMR operations. 4.4 Roster and credentials • Only members with a current Wisconsin EMR certification (or higher license practiced down to EMR) who are credentialed to this service by the Service Medical Director may provide patient care. Wis. Admin. Code §§ DHS 110.11, 110.52. The Local Credential Agreement is submitted by the individual in e-Licensing in the manner specified by the department. Keep the service copy in the personnel file at the station. Do not attach LCAs to this operational-plan packet. • Each credentialed member shall maintain current professional CPR/AED (AHA BLS for Healthcare Providers or another organization listed in DHS 110.17). • The Service Director shall keep a current roster in Wisconsin EMS e-Licensing and at the station (Appendix F). • Target: expand EMR/EMT certification across the membership so every responding apparatus has at least one credentialed EMR. ERAFD · Working draft · Not a DHS license Page 8 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 4.5 Current e-Licensing extract The following names appear on the Wisconsin EMS e-Licensing public-portal printout dated 25 September 2026 (Joint Municipal Fire Commission – Eagle River, service 6604861; EMR service license issued 04/07/2026, expires 06/30/2029). That printout is Appendix F. No additional members are expected before filing. If a name is added or dropped after this date, reprint and replace Appendix F. Name Level Number Role (as listed) Holms, Spencer Daniel EMT 70110317 Service Director P'ng, Choon Heong Physician 47602-20 Service Medical Director Heritage, Kaemyn David EMT 70125909 Credentialed member Randall, James Alan EMT 70124709 Fire Chief Croker, Logan Robert EMT 70111370 Credentialed member Pikka, Kristian EMR 70128030 Credentialed member Perry, Tanner Hansen Paramedic 70115527 Credentialed member — practices to EMR only under this license McDonald, Michael EMT 70111364 Credentialed member KOGA, JAMES B EMR 70127270 Credentialed member Note. A Wisconsin-licensed EMT or paramedic operating under an EMR service license may perform only EMR- scope skills for this service. Individual higher licensure does not raise the service level. 4.6 Current operating model Volunteer and paid-on-call members respond from home or work via IamResponding (or successor) after Vilas County pages the department. Daytime paid station staff respond when on duty. Minimum EMR response: one certified EMR. Additional firefighters may assist with lifting, scene safety, and equipment under EMR direction and may not independently perform EMR skills unless they are themselves credentialed. ERAFD · Working draft · Not a DHS license Page 9 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 5. Medical direction 5.1 Service Medical Director qualifications and duties (DHS 110.49) The Service Medical Director is Choon Heong P'ng, M.D., Wisconsin physician license 47602-20. The Medical Director shall meet the qualifications in DHS 110.49 within 180 days of appointment, including current healthcare-provider CPR, education and experience in emergency medicine, familiarity with prehospital EMS systems, quality-improvement training or experience, and the DHS service medical director course or an equivalent unless board-certified in emergency medicine. The Medical Director shall: • Prescribe and sign the patient-care protocols used under this Plan. • Approve the EMR formulary and optional skills in writing. • Ensure online medical-control physicians follow the approved protocols. • Ensure all aspects of the service remain under medical supervision. • Establish and participate in the quality-assurance program. • Approve, limit, suspend, or revoke local credentials under DHS 110.53. • Maintain liaison with Aspirus Eagle River Hospital and the regional medical community. • Approve and assist with training that keeps EMRs competent on the approved protocols. 5.2 Online medical control (DHS 110.34(3)) Day-to-day online medical consultation is the Emergency Department physician at Aspirus Eagle River Hospital. EMRs contact medical control when a protocol requires it, when a patient refuses recommended care, when care would fall outside standing orders, or when the EMR is uncertain. If radio or phone contact cannot be made, the EMR follows standing orders within EMR scope and documents the communication failure. 5.3 Regional trauma affiliation (DHS 110.34(11)) Vilas County is in Wisconsin Trauma / HERC Region 2. ERAFD shall maintain affiliation with the North Central Regional Trauma Advisory Council (NCRTAC), ncrtac-wi.org. Coordinator contact published by DHS: Adam Meshak, Adam.Meshak@ncrtac-wi.org. ERAFD · Working draft · Not a DHS license Page 10 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 6. Communications and dispatch 6.1 Dispatch Vilas County Communications Center (PSAP), 330 Court Street, Eagle River, is the 9-1-1 center. Fire/EMS dispatch and department operations are on county fire/EMS channels, not HEAR. The 2008 first-responder plan listed ERAFD on 155.64 MHz. Vilas County licenses also include 155.550 MHz and 155.640 MHz. Members acknowledge response through IamResponding and/or radio. The first credentialed EMR or officer on the air advises dispatch of response and of any inability to staff. Patient reports and hospital patches to Aspirus Eagle River Hospital are on 155.340 MHz PL 118.8 (KVD512), not on the fire channel. 6.2 On-scene and hospital communications (DHS 110.34(12)) • Tactical: Vilas fire/EMS talk groups and fireground as assigned. • Hospital (patient report / medical control): Aspirus Eagle River Hospital (formerly Eagle River Memorial Hospital), 201 Hospital Road, on the statewide hospital HEAR channel 155.340 MHz, PL 118.8, FCC call sign KVD512 (license listed to the Hospital Road site; active through March 11, 2033). Cellular may be used if the radio path fails. This is the ambulance-to-hospital frequency. It is not the fire department operations channel. • Air medical: landing-zone coordination on the channel designated by the flight service and Vilas County. 6.3 Acknowledgement standard Goal: first radio or app acknowledgement within 90 seconds of page when members are available. EMR services cannot guarantee a unit on every call. Inability to staff shall be reported immediately to dispatch so Aspirus and mutual aid are not delayed. NFPA 1720 deployment objectives for volunteer EMS first response are used as internal benchmarks, not as a statutory staffing floor. ERAFD · Working draft · Not a DHS license Page 11 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 7. Required operational policies (DHS 110.35(2)(e)) The following nine policies are required contents of an operational plan. Detailed member-level procedures live in the companion EMR SOP Book (EMR-001 through EMR-028 series) and may later be adopted into the department fire SOP manual without changing this Plan, provided the policy substance below is not altered. 7.1 Response cancellation (item 1) If dispatch, Aspirus, or the officer in charge cancels ERAFD while members are en route, all units shall acknowledge, stop emergency operation, and return to service. Members already on scene shall make contact with the cancelling unit, confirm no patient remains in ERAFD care, and clear. Cancellation shall be logged. 7.2 Use of lights and sirens (item 2) Emergency lights and siren may be used only when responding to a true emergency as classified by dispatch or the officer in charge (life-threatening medical, fire, rescue, or equivalent). Downgrade to non-emergency response when dispatch advises the incident is non-emergent (example: delayed lift assist with a stable patient). Lights and siren do not relieve the driver of due regard under Wisconsin traffic law. No lights-and-siren driving of personal vehicles. 7.3 Dispatch and response (item 3) Members respond directly to the fire station unless the Incident Commander directs otherwise (Fire SOP Policy No. 109). Privately owned vehicles shall obey traffic law. Going direct to a scene in a personal vehicle is allowed only under Fire SOP Policy No. 126 (vehicle accident on the way to the station if aid is required and the ambulance is not already there; or an EMS assist with CPR in progress when the scene is closer than the station). No member may put lights or siren on a personal vehicle except by written Chief authorization (Policy No. 126). Only department apparatus, and members who meet Fire SOP driver qualifications and Appendix H, may operate department vehicles with emergency lights and siren. The first-arriving credentialed EMR assumes medical lead until a higher-level EMS practitioner from the transporting ambulance or mutual aid takes report. 7.4 Refusal of care (item 4) An EMR may accept refusal only from a patient who has decision-making capacity (adult or legally authorized decision-maker), has been advised of the nature of the complaint and the risks of refusal, and signs a refusal form (or a witness documents a verbal refusal if the patient will not sign). Minors cannot refuse except as allowed by Wisconsin law. When in doubt, contact medical control and keep Aspirus en route. EMRs shall not coerce or abandon a patient. 7.5 Destination determination (item 5) ERAFD does not transport. Destination is determined by Aspirus MedEvac or another transporting agency under that agency’s operational plan and medical direction. ERAFD may request air medical through dispatch when mechanism or patient condition meets trauma or time-critical criteria and ground transport would be delayed. ERAFD establishes and secures the landing zone; the flight crew assumes clinical care at handoff. ERAFD · Working draft · Not a DHS license Page 12 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 7.6 Emergency vehicle operation and driver safety training (item 6) No member shall drive department apparatus in emergency mode until the Service Director documents completion of department emergency-vehicle operator training and a valid Wisconsin driver license. Drivers shall complete an annual refresher. Seat belts are required. Backing requires a spotter when a spotter is available. Driver policy is SOP EMR-019. Appendix H is the roster (Forms H-1 and H-2). 7.7 Controlled substances (item 7) ERAFD does not obtain, store, carry, or administer controlled substances at the EMR level. No DEA registrant activity is conducted under this Plan. If a future upgrade would add controlled substances, this section shall be rewritten and submitted to DHS with storage, security, accounting, and exchange procedures before any such medication is placed in service. 7.8 Continuous quality assurance and improvement (item 8) The Medical Director and Service Director (or QA designee) shall review selected patient-care reports at least quarterly, and shall review all cardiac arrests, all refusals, all exposures, all medication administrations, and any complaint. Findings are used for individual feedback and for continuing- education topics. Results are shared with credentialed members at skills nights and documented. Members do not independently change protocol based on QI findings; protocol changes require Medical Director signature and, if they alter skills or formulary, a Plan update to DHS. 7.9 Multiple-patient incidents (item 9) On an MCI, the first-arriving officer implements ICS, begins START / JumpSTART triage, requests additional ambulances through Vilas County, and uses Wisconsin EMS MCI guidance (DHS P-01098). ERAFD’s role remains non-transport first response, triage, treatment-area support, and landing-zone operations. Patient tracking uses triage tags and a written or electronic tally turned over to the transporting agency and the incident commander. Special events that exceed day-to-day resources require a written addendum under DHS 110.44. ERAFD · Working draft · Not a DHS license Page 13 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 8. Scope of practice, skills, and formulary Practice is limited to the current Wisconsin EMR Scope of Practice published by DHS (P-00451) and the skills and medications approved in writing by the Service Medical Director. Members shall not perform EMT or higher skills even if individually licensed at a higher level, except under a future approved upgrade. Wis. Admin. Code § DHS 110.12. 8.1 Required (R) EMR skills Required EMR skills in the current Wisconsin Scope of Practice shall be available when the service responds. These include, at minimum and as designated “R” for EMR in P-00451: • Scene size-up, standard precautions, and request for additional resources. • Primary assessment; manual airway maneuvers; suction of the upper airway; oropharyngeal and nasopharyngeal airways. • Bag-valve-mask ventilation; cardiopulmonary resuscitation per current AHA guidelines; automated / semi-automated defibrillation (AED). • Hemorrhage control by direct pressure; tourniquet; wound packing as authorized. • Emergency childbirth support at EMR level; newborn warming and stimulation. • Stabilization of injuries; basic splinting; burn care at EMR level; shock positioning. • Spinal motion restriction when indicated by protocol (not routine for penetrating trauma without neurologic deficit). • Intramuscular auto-injector and intranasal auto-injector routes as designated required at EMR. • Structured handoff to the transporting ambulance: age/sex, chief complaint, history, vitals if obtained, interventions, response, allergies. 8.2 Optional EMR skills — Medical Director authorization Optional (O) EMR items are not in service unless marked Yes below, initialed by the Medical Director, and accepted by DHS. The service requests YES for: oxygen by nasal cannula and non-rebreather; pulse oximetry; blood glucose monitoring; oral glucose; aspirin; naloxone (intranasal or auto-injector); non-visualized (extraglottic) airway; hemostatic gauze / wound packing; and assist with the patient’s own prescribed medication when the route is in EMR scope. The service does not request epinephrine (auto-injector or manual IM) or albuterol. Items marked No shall not be used. Skill / item (EMR optional unless noted) Authorized? MD initials Oxygen by nasal cannula and non-rebreather Yes ________ Pulse oximetry Yes ________ Blood glucose monitoring (with required training) Yes ________ Oral glucose / glucose gel Yes ________ Aspirin (service-supplied or patient-assist if allowed at EMR) Yes ________ Naloxone — intranasal or auto-injector Yes ________ Non-visualized (extraglottic) airway Yes ________ Hemostatic gauze / wound packing products Yes ________ ERAFD · Working draft · Not a DHS license Page 14 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R Skill / item (EMR optional unless noted) Authorized? MD initials Patient’s own prescribed medication assist, if route is in EMR scope Yes ________ 8.3 Formulary Only medications listed here and marked ON SERVICE by the Medical Director may be carried on ERAFD apparatus for EMR use. Medication Route / notes On service? MD initials Oxygen Inhalation Yes — on service ________ Oral glucose Oral Yes — on service ________ Aspirin Oral Yes — on service ________ Naloxone Intranasal / auto-injector Yes — on service ________ No controlled substances are stocked. Expired medications shall be removed from service and replaced. Storage shall protect from extreme cold and heat on Northwoods apparatus. 8.4 Protocols (DHS 110.35(2)(a)) Patient care follows DHS P-02875 (Wisconsin EMS Protocols) as signed by the Service Medical Director, limited to EMR scope, plus only the optional skills initialed in § 8.2. The signed set is Appendix B. Until Appendix B is signed, members provide only core EMR care that does not depend on optional skills: scene safety, airway/breathing/circulation, CPR/AED, bleeding control, comfort, and transfer to Aspirus. ERAFD · Working draft · Not a DHS license Page 15 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 9. Equipment 9.1 Minimum kit on medical apparatus Each primary response apparatus used for medical first response shall carry, at minimum: • PPE: gloves, eye protection, N95 or equivalent, gown as needed, hand sanitizer (OSHA / SPS 332 bloodborne-pathogen program; NFPA 1580 used as a purchasing and practice reference only). • AED with spare pads; BVM adult/child/infant; OPA/NPA set; portable oxygen with regulator and spare cylinder; suction. • Trauma kit: tourniquets, hemostatic packing gauze (authorized), pressure dressings, triangular bandages, occlusive dressing. • Splints / SAM or equivalent; emergency blanket; shears; flashlight. • PCR forms or electronic reporting device; refusal forms; triage tags. • Approved formulary medications in labeled, temperature-appropriate storage. 9.2 Inventory The EMRs shall inventory medical kits monthly during maintenance and after each use. Failed or expired items are removed the same day. ERAFD · Working draft · Not a DHS license Page 16 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 10. Infection control 10.1 Authority ERAFD follows 29 CFR 1910.1030 as applied to public-sector fire employees through Wis. Admin. Code ch. SPS 332, and the infection-control program required of an EMS provider under Wis. Admin. Code § DHS 110.47(3). NFPA 1580 is a reference structure only; SPS 330 does not adopt NFPA EMS infection-control chapters as DSPS rules. 10.2 Practice and exposure • Standard precautions on every patient contact. • Sharps in approved containers; no recapping. • Contaminated PPE and linens bagged; apparatus and equipment cleaned with EPA-registered disinfectant after each patient. • Exposure: immediate first aid, notify the officer and Infection Control Officer, complete an exposure report, and follow the Aspirus / occupational-health source-patient and baseline-testing pathway. • Annual bloodborne-pathogen training; hepatitis B vaccination offered. • Members with known communicable illness shall not provide patient care until cleared. 10.3 Written program This subsection is the written exposure-control program required of an EMS provider under Wis. Admin. Code § DHS 110.47(3) and of a public-sector fire employer under 29 CFR 1910.1030 as applied by Wis. Admin. Code ch. SPS 332. It does not convert ERAFD into an Aspirus employee-health program. Members are employees of the Joint Municipal Fire Commission. Immediate evaluation is at Aspirus Eagle River Hospital. Follow-up and workers’ compensation run through Society Insurance, policy WP10087465, expiration 06/04/2027. Forms G-1 through G-4 are in Appendix G. 10.3.1 Purpose and scope Protect credentialed EMR members and assisting firefighters from occupational exposure to blood and other potentially infectious materials (OPIM) during first response, and set the steps after an exposure incident. Applies to every member who may have patient contact under this Plan, including lift-assist, landing- zone, extrication, and MCI support. Does not authorize skills outside the Wisconsin EMR Scope of Practice. Does not replace the municipal workers’ compensation policy or the fire-department SPS 330 occupational-safety program. 10.3.2 Responsible persons Infection Control Officer — Spencer Daniel Holms, EMT 70110317, 715-891-1927. Receives every exposure report, opens the post-exposure pathway, keeps HBV and training records, and reviews this program annually. Service Director — Spencer Daniel Holms, EMT 70110317. Keeps this program current with the Operational Plan and sees that PPE and sharps containers are on apparatus. Service Medical Director — Choon Heong P’ng, M.D. Advises on source-patient testing requests and return-to-duty after an exposure when medical judgment is required. ERAFD · Working draft · Not a DHS license Page 17 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R Officer in Charge on scene — Starts first aid, relieves the exposed member from patient care if needed, and notifies the Infection Control Officer before the shift ends. 10.3.3 Exposure determination Job classifications in which all members have occupational exposure: credentialed Emergency Medical Responders and higher-licensed members practicing at EMR; firefighters who assist with lifting, extrication, hemorrhage control under EMR direction, or decontamination of apparatus. Tasks with reasonably anticipated exposure: patient assessment and movement; airway and ventilation; hemorrhage control; childbirth support; CPR/AED; cleaning of kits and cabs; handling of contaminated PPE and linens; landing-zone and MCI treatment-area support. Authorized EMR skills that create sharps or splash exposure on this service: blood glucose monitoring (lancet); non-visualized airway placement; hemostatic wound packing; naloxone auto-injector. Epinephrine auto-injectors and nebulizer treatments are not authorized and shall not be stocked for EMR use. Use a safety lancet when one is supplied. Place used lancets immediately in the sharps container on the apparatus. OPIM includes blood, visibly bloody fluids, and any body fluid when it is difficult to differentiate. Sweat is not OPIM. 10.3.4 Methods of compliance Standard precautions. Treat all blood and OPIM as infectious. Gloves for every patient contact. Add eye protection when splash is reasonably anticipated (airway, hemorrhage, childbirth, vomiting). Add gown and N95 or equivalent when splash or airborne droplets are likely. Hand hygiene with soap and water or alcohol sanitizer immediately after glove removal. Approved sharps containers on each primary medical apparatus. Do not recap, bend, or break contaminated sharps. If a kit item has a safety feature (retractable lancet, shielded needle, needleless adapter), use that feature. Do not bypass it. When a sharps container reaches the fill line, close it and replace it. Do not force another sharp into a full container. Eat, drink, apply cosmetics, or handle contact lenses only in clean areas — never in the cab after a patient or in the decon bay during cleaning. Contaminated PPE and linens go in a labeled biohazard bag. Do not take contaminated gear home. Clean patient-contact surfaces and kits with an EPA-registered hospital disinfectant after each patient. Allow the labeled contact time. Grossly soiled turnout gear is isolated and cleaned under the department gear policy, not in a home washing machine. Personal protective equipment. The department furnishes gloves, eye protection, N95 or equivalent, gowns, hand sanitizer, and biohazard bags on first-response apparatus (§ 9). PPE is worn whenever exposure is reasonably anticipated. Damaged or saturated PPE is replaced at the scene if a spare is on the rig; otherwise the member is rotated out of patient care. 10.3.5 Hepatitis B vaccination The hepatitis B vaccine series is offered at no charge to every member with occupational exposure, after required BBP training and within 10 working days of initial assignment to patient-care duties, unless the member has already completed the series, antibody testing shows immunity, or the vaccine is contraindicated. ERAFD · Working draft · Not a DHS license Page 18 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R A member may decline. Declination must use the exact OSHA mandatory statement in Form G-3. A member who declines may request the series later, still at no charge, while assigned to exposure-prone duties. Vaccination and titer arrangements are made through the municipal occupational-health / workers’ compensation pathway. Aspirus Eagle River Hospital Lab (201 E. Hospital Road, 715-479-0268 option 2) may be used for blood draw when the Commission’s provider so directs. 10.3.6 Post-exposure evaluation and follow-up An exposure incident is a specific eye, mouth, other mucous-membrane, non-intact skin, or parenteral contact with blood or OPIM that results from a member’s duties. Exposed member — immediate actions: (1) Stop the task if it is safe to do so. Do not delay first aid. (2) Needle stick or cut: wash with soap and water. Do not squeeze, bleach, or inject antiseptic into the wound. (3) Splash to eyes, nose, or mouth: flush with clean water or saline for at least 15 minutes. (4) Notify the Officer in Charge on scene before leaving if possible. Notify the Infection Control Officer as soon as appropriate. (5) Report to Aspirus Eagle River Hospital Emergency Department the same shift for evaluation. Do not wait until the next business day. Officer and Infection Control Officer: relieve the member from further patient care if the wound or splash cannot be controlled; preserve the source patient’s identity for the receiving clinician only and do not chart HIV/HBV/HCV status on the fire incident report; ask Aspirus / the transporting service to request source-patient testing under hospital policy and Wisconsin law (the source may refuse — document the request); complete Form G-2 before the end of the shift and deliver it to the Infection Control Officer; the Infection Control Officer notifies the Service Director and opens the municipal workers’ compensation / occupational-health file the same day or next business morning. Where to go. Any hour — Aspirus Eagle River Hospital Emergency Department, 201 E. Hospital Road, (715) 479-0279; main (715) 479-7411. Lab / blood draw — Aspirus Eagle River Hospital Lab, (715) 479-0268 option 2. Aspirus Business Health scheduling (715) 847-2812 option 1 only if the Commission’s occupational-health provider routes follow-up there. Aspirus operator (800) 283-2881. Municipal WC — Society Insurance, Fond du Lac, policy WP10087465, expiration 06/04/2027; nurse triage 877-501-3050; claims 888-576-2738 ext. 5519; claims@societyinsurance.com. Baseline testing of the exposed member (HIV, HBV, HCV as ordered) should be drawn as soon as possible after the incident, preferably the same day. Repeat testing and any post-exposure prophylaxis follow the evaluating clinician’s order and current CDC guidance. The member may decline testing; document the decline. ERAFD does not receive or store the member’s or source patient’s lab results at the station except the fact that evaluation occurred and duty status. Medical records of the exposure stay with the evaluating provider and the municipal occupational-health file. They are confidential under Wis. Stat. § 146.82. 10.3.7 Communication of hazards and training Biohazard labeling on sharps containers and bags used for contaminated material. Initial bloodborne-pathogen training before independent patient care, and at least annually thereafter. Training covers 1910.1030(g)(2) elements: epidemiology and symptoms, modes of transmission, this program, PPE, HBV vaccine, emergency response, exposure reporting, and post-exposure evaluation. Attendance is recorded on Form G-4. The Training designee and Infection Control Officer keep the roster. This program is available at 820 E. Pine Street and is reviewed with new members during EMR orientation. ERAFD · Working draft · Not a DHS license Page 19 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 10.3.8 Recordkeeping Exposure incident report (Form G-2): duration of employment plus 30 years (1910.1030(h)); confidential occupational-health file — not the station daybook. HBV acceptance / declination (Form G-3): duration of employment plus 30 years; Infection Control Officer file. Annual BBP training roster (Form G-4): three years from the training date; Training designee / station training book. Sharps injury log (if a contaminated sharp is involved): five years; Infection Control Officer; type and location of device only — no member name on the log copy kept for review. 10.3.9 Program review The Infection Control Officer and Service Director review this program at least annually and after every exposure incident. A change that alters § 10 policy language is submitted to DHS as an operational- plan update under § DHS 110.33(3). Member-level SOP detail may change without a DHS filing if § 10 is not altered. ERAFD · Working draft · Not a DHS license Page 20 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 11. Documentation and data (DHS 110.34(7)–(9)) 11.1 Patient-care reports A written or electronic report shall be provided to the ambulance service provider at the time of patient- care transfer. A department patient-care report shall be completed for every patient contact, refusal, and cancelled-on-scene medical call in which ERAFD made patient contact. 11.2 WARDS WARDS reporting rule for an EMR service: submit a patient-care report to WARDS when an advanced / optional EMR skill is used. For this service that includes blood glucose monitoring, oral glucose, aspirin, naloxone, non-visualized airway, hemostatic wound packing, and assist with the patient’s prescribed medication. Oxygen and pulse oximetry follow the current P-00451 / WARDS instruction in effect on the date of the call. Use the abbreviated EMR report when that is the DHS path. Wis. Admin. Code § DHS 110.34(8). Records are confidential under Wis. Stat. § 146.82 and applicable provisions of Wis. Stat. ch. 256, and are released only as authorized. HIPAA applies only if ERAFD is a covered entity or business associate. Retention follows municipal records schedules and DHS guidance. ERAFD · Working draft · Not a DHS license Page 21 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 12. Training, competency, and training-center affiliation (DHS 110.34(13)–(14)) 12.1 Competency and skills • New members complete department orientation and Medical Director credentialing before independent patient care. • Quarterly EMR skills covering airway, AED, tourniquet, BVM, and handoff. • CPR/AED renewal before expiration. • Annual protocol and Plan review with documented attendance. • Refresher training sufficient for Wisconsin EMR certificate renewal (DHS 110.07). 12.2 Affiliated training center Affiliated Wisconsin-certified EMS training center for initial and refresher EMR training: Nicolet Area Technical College (NATC), Rhinelander. NATC is a DHS-listed EMS training center approved for Emergency Medical Responder, EMT, AEMT, and paramedic refresher. ERAFD · Working draft · Not a DHS license Page 22 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 13. Mutual aid, coverage, and partners (DHS 110.34(10)) 13.1 Partners • Ambulance and paramedic transport: Aspirus MedEvac, Aspirus Eagle River Hospital. • County mutual aid: Conover, Three Lakes, and other Vilas County departments through MABAS box cards. • Law enforcement: Vilas County Sheriff and Eagle River Police Department. • Air medical: Aspirus MedEvac air and other regional services as requested through dispatch. 13.2 Written coordination Appendix C is the Aspirus Eagle River Hospital / Aspirus MedEvac coordination letter (ERAFD_Appendix_C_Aspirus_Coordination_Letter.docx). Obtain a signature before filing. Attach any separate written MABAS or ambulance coverage agreement the department already holds. ERAFD · Working draft · Not a DHS license Page 23 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 14. Mass casualty, special operations, and special events 14.1 Multiple-patient and special operations MCI operations follow Section 7.9 and SOP EMR-017. Ice, water, and technical rescue remain fire/rescue functions. Patient care during those operations still follows EMR scope. 14.2 Special events Special events (DHS 110.44): if ERAFD provides on-site medical coverage that exceeds day-to-day personnel or equipment, a special-event addendum shall be submitted to DHS as required (department guidance is not less than 10 business days for the event application packet). Standing festival coverage that uses only normal first-response resources does not, by itself, create a separate license. ERAFD · Working draft · Not a DHS license Page 24 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 16. Records retention and plan maintenance 16.1 Annual review This Plan shall be reviewed annually by the Service Director and Medical Director, and whenever DHS publishes a new Scope of Practice or protocol set. Future changes that affect service level, skills, formulary, primary service area, or medical director shall be submitted to DHS not less than 60 days before implementation and shall not be used until approved. Wis. Admin. Code §§ DHS 110.33(3) and 110.35(2)(g). 16.2 Plan updates An update filing shall state the section revised, the intended impact, Service Director approval, and Medical Director approval when the change involves patient care or patient-care equipment. ERAFD · Working draft · Not a DHS license Page 25 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R 17. Certification and signatures 17.1 Certification By signing, the parties certify that this Operational Plan accurately describes current and intended EMR operations and that it is submitted as a renewal/replacement of the plan approved by the State on October 31, 2008. The existing approved plan stays in effect until DHS issues written approval of this replacement. New or changed optional skills listed herein shall not be placed in service until that approval. Service Director Signature: ________________________________ Date: ______________ Printed name: Spencer Daniel Holms Service Medical Director, M.D. / D.O. Signature: ________________________________ Date: ______________ Printed name: Choon Heong P'ng, M.D. WI 47602-20 Fire Chief Signature: ________________________________ Date: ______________ Printed name: James Alan Randall Joint Municipal Fire Commission Chair Signature: ________________________________ Date: ______________ Printed name: Mark J. Vanden Boom ERAFD · Working draft · Not a DHS license Page 26 of 27 EAGLE RIVER AREA FIRE DEPARTMENT FDID 63030 EMR Operational Plan — Renewal / Replacement Rev. 1.0-R Appendices A through H are attached as separate files, in that order. They are not reprinted in this narrative. Appendix A — Primary service area map. Appendix B — Signed EMR protocol cover and DHS P-02875 (EMR scope). Appendix C — Aspirus coordination letter. Appendix D — Professional liability / medical malpractice certificate when received. Automobile insurance is not attached. Appendix E — Municipal endorsement letters (Eagle River, Cloverland, Lincoln, Washington). Appendix F — e-Licensing roster dated 25 September 2026. Appendix G — Forms G-1 through G-4. Written program is § 10.3. Appendix H — EMS emergency-mode driver roster (Form H-1 / H-2). Contacts • Station / Service Director: 820 E. Pine Street, Eagle River, WI 54521 · (715) 479-8835. • City Clerk (Commission packets and open records): Becky Bolte, bbolte@eagleriverwi.gov. • Wisconsin DHS EMS operational plans: dhs.wisconsin.gov/ems/licensing/operational.htm. • WARDS: www.emswards.org (organization path as published by DHS). Note. End of Operational Plan. Companion document: ERAFD EMR Standard Operating Procedures, EMR- 001 through EMR-028 series. That SOP book may be adopted later as a chapter of the fire SOP manual without a new DHS filing unless a procedure changes a policy already stated in this Plan. ERAFD · Working draft · Not a DHS license Page 27 of 27 APPENDIX A — PRIMARY SERVICE AREA MAP FDID 63030 · service 6604861 · plan approved 31 October 2008 EAGLE RIVER AREA FIRE DEPARTMENT · EMR Service · Appendix B APPENDIX B SIGNED EMR PROTOCOLS Wisconsin Statewide EMS Protocols adopted and limited to EMR scope Document Status Protocol book Scope table Appendix B MD signed 29 September 2026 — statewide book attached DHS P-02875 current posted revision DHS P-00451 (03/2026) This cover and skill list are Appendix B of the ERAFD EMR Operational Plan. They satisfy Wis. Admin. Code § DHS 110.35(2)(a) (signed patient-care protocols) and § DHS 110.49(2)(a)–(b) (Medical Director prescribes and approves protocols in writing). The protocol pages themselves are the official Wisconsin DHS Statewide EMS Protocols. Do not type those pages into this Word file. Print the current DHS PDF and place it behind this cover. B-1. Adoption Eagle River Area Fire Department adopts the current Wisconsin Statewide EMS Protocols published by the Department of Health Services (publication P-02875, or the successor document posted at dhs.wisconsin.gov/ems) as the patient-care protocols for this EMR service. Adoption is limited as follows: • Members practicing under this service license may use only the assessment steps, skills, equipment, and medications that are “R” or authorized “O” for EMR in the current Wisconsin EMS Scope of Practice (P- 00451) and that are marked authorized in B-3 below. • Any EMT, AEMT, Intermediate, or paramedic step printed in the statewide book is not authorized for ERAFD. Individual members who hold a higher Wisconsin license still practice only to EMR while operating under this service license. • ERAFD does not transport. Destination, intercept, and air-medical decisions belong to Aspirus MedEvac or another transporting agency. ERAFD may request air medical through Vilas County dispatch and secure a landing zone. • If a statewide protocol and P-00451 ever conflict, P-00451 controls. If this cover and the DHS book ever conflict on service level, this cover controls. • When a protocol requires medical control, EMRs contact the Aspirus Eagle River Hospital Emergency Department physician on duty (Plan §5.2). B-3. EMR skills and formulary authorized for this service R = required EMR skill under P-00451 (03/2026) and must be available when the service responds. O = optional. Every optional skill listed in Operational Plan §8.2 is authorized: pulse oximetry, blood glucose monitoring, oral glucose, aspirin, naloxone, non-visualized airway, hemostatic packing, and patient’s own prescribed medication assist. The Medical Director initials each row. Blank or NO would mean the skill shall not be used. Skill / medication (EMR column of P-00451) R / O Authorized? MD initials Scene size-up, standard precautions, request additional resources R Yes ________ Primary assessment; manual airway; suction; OPA / NPA R Yes ________ Bag-valve-mask R Yes ________ Oxygen by nasal cannula and non-rebreather R Yes ________ CPR per current AHA guidelines R Yes ________ ERAFD EMR Operational Plan — Appendix B · Protocol adoption · Draft 24 Sep 2026 · Page 1 EAGLE RIVER AREA FIRE DEPARTMENT · EMR Service · Appendix B AED / semi-automated defibrillation R Yes ________ Hemorrhage control — direct pressure and tourniquet R Yes ________ Emergency childbirth support; newborn warming / stimulation R Yes ________ Basic splinting; burn care at EMR level; shock positioning R Yes ________ Spinal motion restriction when protocol indicates R Yes ________ IM auto-injector route and IN auto-injector route R Yes ________ Structured handoff to the transporting ambulance R Yes ________ Pulse oximetry O Yes ________ Blood glucose monitoring O Yes ________ Oral glucose / glucose gel O Yes ________ Aspirin (service-supplied or patient-assist) O Yes ________ Naloxone — intranasal or auto-injector O Yes ________ Non-visualized airway O Yes ________ Hemostatic gauze / wound packing products O Yes ________ Patient’s own prescribed medication assist (route in EMR scope) O Yes ________ Controlled substances are not stocked and are not authorized. Expired medications are removed the same day. Live P-00451 on dhs.wisconsin.gov/ems controls if DHS revises the table after this signature. B-4. Statewide protocol topics EMRs may use — EMR-scope steps only When the attached DHS book contains these topics, ERAFD members follow the EMR-level assessment and treatment steps only. They stop when the printed step requires EMT or higher skill, equipment, or medication that is not authorized in B-3. Universal / routine medical care Airway obstruction and BVM ventilation Cardiac arrest — CPR and AED Chest pain / suspected ACS (ASA if authorized) Altered mental status Seizure — protect airway, recovery position Stroke recognition and rapid handoff Allergic reaction — EMR steps only Respiratory distress — O2 / NC / NRB Diabetic emergency — oral glucose if authorized Opioid overdose — naloxone if authorized Shock / hypovolemia — positioning, keep warm Hemorrhage / tourniquet / packing if authorized Burns — EMR burn care Spinal motion restriction when indicated Emergency childbirth and newborn care Hypothermia / frostbite — EMR steps Submersion — EMR steps Refusal of care (Plan §7.4) Multiple-patient / START support (Plan §7.9) Topics in the DHS book that exist only at EMT or higher (examples: 12-lead, CPAP, nebulized bronchodilator, IV/IO, advanced airway beyond an authorized non-visualized device, nitroglycerin, epinephrine 1:1,000 drawn, any controlled substance) are not ERAFD protocols. ERAFD EMR Operational Plan — Appendix B · Protocol adoption · Draft 24 Sep 2026 · Page 2 EAGLE RIVER AREA FIRE DEPARTMENT · EMR Service · Appendix B B-5. Signatures By signing, the Service Medical Director approves the statewide protocol book named above, limited to EMR scope, and initials the B-3 authorizations. Optional skills marked Yes shall not be placed in service until DHS accepts the Operational Plan (Wis. Admin. Code § DHS 110.33(3)). Service Medical Director Signature: ________________________________ Date: ______________ Printed name: Choon Heong P'ng, M.D. Wisconsin 47602-20 Service Director Signature: ________________________________ Date: ______________ Printed name: Spencer Daniel Holms, EMT 70110317 Online medical control: Aspirus Eagle River Hospital ED · (715) 479-0279 ERAFD EMR Operational Plan — Appendix B · Protocol adoption · Draft 24 Sep 2026 · Page 3 P-02875 (08/2023) Wisconsin EMS Protocols JUNE 2023 2021 The “Wisconsin Protocols for Emergency Medical Services” is also available on the DHS website. Protocols are occasionally amended during the year; notice and publication will be communicated through DHS. Please check the DHS website t o be sure you have the most up-to-date version. The edition date appears on this cover page. Table of Contents Introduction ......................................................................................................................... 5 Purpose and Notes ............................................................................................................. 5 Acknowledgements ........................................................................................................ 6 Universal Care ..................................................................................................................... 7 Universal care guideline ................................................................................................ 7 Functional needs ........................................................................................................... 16 Patient refusals .............................................................................................................. 19 Cardiovascular ................................................................................................................... 21 Adult and pediatric syncope and near syncope ..................................................... 21 Chest Pain/Acute Coronary Syndrome (ACS)/ST-segment Elevation Myocardial Infarction (STEMI) .................................................................................. 25 Bradycardia ..................................................................................................................... 28 Implantable ventricular assist devices .................................................................... 31 Tachycardia with a pulse ............................................................................................. 34 Suspected stroke/Transient Ischemic Attack ........................................................ 39 General Medical ................................................................................................................ 42 Abdominal pain .............................................................................................................. 42 Abuse and maltreatment ............................................................................................. 45 Agitated or violent patient/behavioral emergency .............................................. 48 Anaphylaxis and allergic reaction ............................................................................. 53 Altered mental status ................................................................................................... 57 Back pain ......................................................................................................................... 60 End-of-life care/hospice care ..................................................................................... 62 Hyperglycemia ............................................................................................................... 64 Hypoglycemia ................................................................................................................. 66 Nausea-vomiting ........................................................................................................... 70 Pain management ......................................................................................................... 73 Seizures ........................................................................................................................... 79 Shock ................................................................................................................................ 82 Sickle cell pain crisis ..................................................................................................... 86 Resuscitation ..................................................................................................................... 89 Cardiac arrest (VF/VT/Asystole/PEA) ...................................................................... 89 Adult Post-ROSC (Return Of Spontaneous Circulation) Care ............................. 96 Determination of death/withholding resuscitative efforts ................................. 98 Do Not Resuscitate Status/Advance Directives/Health Care Power Of Attorney (POA) Status ................................................................................................ 100 Termination of resuscitative efforts ........................................................................ 101 Resuscitation in traumatic cardiac arrest .............................................................. 104 Pediatric-Specific Guidelines ........................................................................................ 107 Brief Resolved Unexplained Event (BRUE) & acute events in infants ............. 107 Pediatric respiratory distress (Bronchiolitis) ........................................................ 111 Pediatric respiratory distress (Croup) ..................................................................... 114 Neonatal resuscitation ................................................................................................ 117 OB/GYN .............................................................................................................................. 122 Childbirth ....................................................................................................................... 122 Eclampsia/pre-eclampsia ........................................................................................... 127 Obstetrical and gynecological conditions ............................................................... 130 Respiratory ........................................................................................................................ 132 Airway management ................................................................................................... 132 Respiratory distress (includes bronchospasm, pulmonary edema) ................. 141 Mechanical ventilation (invasive) ............................................................................ 147 Tracheostomy management ...................................................................................... 152 Trauma ............................................................................................................................... 156 General trauma management ................................................................................... 156 Blast injuries ................................................................................................................. 161 Burns ............................................................................................................................... 164 Crush injury/crush syndrome ................................................................................... 167 Extremity trauma/external hemorrhage management ...................................... 170 Facial/dental trauma ................................................................................................... 174 Head injury .................................................................................................................... 176 High threat considerations/active shooter scenario ........................................... 179 Spinal care ..................................................................................................................... 181 Trauma mass casualty incident ................................................................................ 185 Toxins and environmental ............................................................................................. 187 Poisoning/overdose universal care ......................................................................... 187 Acetylcholinesterase inhibitors (carbamates, nerve agents, organophosphates) exposure ................................................................................... 195 Radiation exposure ...................................................................................................... 205 Topical chemical burn ................................................................................................. 208 Stimulant poisoning/overdose ................................................................................. 212 Cyanide exposure ......................................................................................................... 215 Beta blocker poisoning/overdose ............................................................................ 218 Bites and envenomation ............................................................................................. 221 Calcium channel blocker poisoning/overdose ...................................................... 224 Carbon monoxide/smoke inhalation ....................................................................... 227 Opioid poisoning/overdose ....................................................................................... 230 Airway respiratory irritants ....................................................................................... 234 Riot control agents ...................................................................................................... 242 Hyperthermia/heat exposure ................................................................................... 244 Hypothermia/cold exposure ...................................................................................... 248 Drowning ........................................................................................................................ 254 Dive (SCUBA) injury/accidents ................................................................................. 257 Conducted electrical weapon injury (i.e., TASER®) ............................................ 260 Electrical injuries .......................................................................................................... 262 Lightning/lightning strike injury .............................................................................. 265 Appendices ........................................................................................................................ 268 I. Medications ........................................................................................................... 268 II. Approved abbreviations ...................................................................................... 285 III. Burn and Burn Fluid Charts ................................................................................ 289 IV. Neurologic status assessment .......................................................................... 295 V. Abnormal vital signs ............................................................................................ 296 VI. 2022 National Guideline for the Field Triage of Injured Patients ............ 297 Introduction The Wisconsin Model EMS Clinical Guidelines are not mandatory. The focus of these guidelines is primarily clinical; operational decisions must be determined at the agency level as community resources vary considerably throughout the state. These guidelines were adapted from the National Association of State EMS Officials’ National Model EMS Clinical Guidelines and are aligned with the metrics developed through the EMS Compass Project and the National EMS Quality Alliance. Purpose and Notes The Wisconsin Model EMS Clinical Guidelines are intended to help Emergency Medical Services (EMS) systems ensure a more standardized approach to the practice of patient care and are to be used in conjunction with the DHS-approved Wisconsin EMS Scope of Practice. In the event of error in this clinical guideline document, the Wisconsin EMS Scope of Practice is the arbiter and defines scope of care at the EMS Provider (Agency) and Professional (Individual) levels. These clinical guidelines will be maintained by the Wisconsin Department of Health Services, Division of Public Health, Office of Preparedness and Emergency Health, EMS Section and will be reviewed and updated annually with input from the Physician Advisory Committee and the Wisconsin EMS Board among other partners and stakeholders. Key: EMS provider skills, equipment, or medications, based on the DHS-approved Wisconsin EMS Scope of Practice and authorized for use by the service EMS medical director, are located in the Patient Management and Notes and Education Pearls sections and highlighted in an [italicized bracket] followed by an “R” or and “O” to designate when the intervention is a required or optional skill for the EMS provider practice level. For example, if the clinical guideline directs oxygen delivery for shortness of breath, it will be followed by [EMR -O; EMT -R] which directs that oxygen is an optional skill for the EMR practice level but a required skill for EMT and higher. If the clinical guideline directs splinting with a pelvic compression device for suspected pelvic fracture, it will be followed by [EMR -O; PARA -R] which directs that a pelvic compression device is an optional skill for EMR through INT practice levels but required at the paramedic level. Finally, if the clinical guideline directs isopropyl alcohol for nausea, it will be followed by [ALL EMS SERVICE PROVI DERS -O] since isopropyl alcohol is an optional intervention for all service levels. Universal Care and Poisoning/Overdose Universal Care guidelines are included to reduce the need for extensive reiteration of basic assessment and other considerations in every guideline. The appendices contain material such as neurologic status assessment and burn assessment tools, to which many guidelines refer, to increase consistency in internal standardization and to reduce duplication. While some specific guidelines have been included for pediatric patients, considerations of patient age and size (pediatric, geriatric, and bariatric) have been interwoven in the guidelines throughout the document. Generic medication names are utilized throughout the guidelines. A complete list of these, along with respective brand names, may be found in Appendix I—Medications. Medications and appropriate dosages that align with the 2021 Scope of Practice can be found in Appendix II. Acknowledgements The EMS Section recognizes the valuable input and support from the EMS Physician Advisory Committee, the Wisconsin EMS Board, EMS Service and Medical Directors, and EMS Professionals. Universal Care Universal care guideline Aliases Patient assessment Patient history Physical assessment Primary survey Secondary survey Patient care goals Facilitate appropriate initial assessment and management of any EMS patient and link to appropriate specific guidelines as dictated by the findings within the Universal Care guideline Patient presentation Inclusion criteria All patient encounters with and care delivery by EMS personnel Exclusion criteria None Patient management Assessment 1. Assess scene safety a. Evaluate for hazards to EMS personnel, patient, bystanders b. Safely remove patient from hazards prior to beginning medical care c. Determine number of patients d. Determine mechanism of injury or potential source of illness e. Request additional resources if needed and weigh the benefits of waiting for additional resources against rapid transport to definitive care f. Consider declaration of mass casualty incident if needed 2. Use appropriate personal protective equipment (PPE) a. Consider suspected or confirmed hazards on scene b. Consider suspected or confirmed highly contagious infectious disease (e.g., contact [bodily fluids], droplet, airborne) 3. Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g., operations at night or in darkness, on or near roadways) 4. Consider cervical spine stabilization and/or spinal care if traumatic injury suspected. [See Spinal Care Guideline ] 5. Primary survey (Airway, Breathing, Circulation (ABC) is cited below; although there are specific circumstances where Circulation, Airway, Breathing (CAB) may be indicated, such as for cardiac arrest, or Massive hemorrhage, Airway, Respirations, Circulation, Hypothermia and head injury (MARCH) may be indicated for trauma or major arterial bleeding) a. Airway (assess for patency and open the airway as indicated) – go to Airway Management Guideline i. Patient is unable to maintain airway patency—open airway 1. Head tilt/chin lift 2. Jaw thrust 3. Suction 4. Consider use of the appropriate airway management adjuncts and devices: oral airway, nasal airway, supraglottic airway device or endotracheal tube 5. For patients with laryngectomies or tracheostomies, remove all objects or clothing that may obstruct the opening of these devices, maintain the flow of prescribed oxygen, and reposition the head and/or neck b. Breathing i. Evaluate rate, breath sounds, accessory muscle use, retractions, patient positioning, and oxygen saturation. ii. Provide supplemental oxygen as appropriate to achieve the target of 94–98% oxygen saturation (SPO 2) based upon clinical presentation and assessment of ventilation (e.g., EtCO2). iii. Apnea (not breathing) – go to Airway Management Guideline. c. Circulation i. Control any major external bleeding [See General Trauma Management Guideline and/or Extremity Trauma/External Hemorrhage Management Guideline] ii. Assess pulse 1. If none – go to Resuscitation Section 2. Assess rate and quality of carotid and radial pulses iii. Evaluate perfusion by assessing skin color and temperature 1. Evaluate capillary refill d. Disability i. Evaluate patient responsiveness: AVPU (Alert, Verbal, Painful, Unresponsive) ii. Evaluate gross motor and sensory function in all extremities iii. Check blood glucose in patients with altered mental status (AMS) or suspected stroke. If blood glucose is less than 60 mg/dL – go to Hypoglycemia Guideline iv. If acute stroke suspected – go to Suspected Stroke/Transient Ischemic Attack Guideline e. Expose patient for exam as appropriate to complaint i. Be considerate of patient modesty ii. Keep patient warm 6. Assess for urgency of transport 7. Secondary survey The performance of the secondary survey should not delay transport in critical patients. See also secondary survey specific to individual complaints in other protocols. Secondary surveys should be tailored to patient presentation and chief complaint. The following are suggested considerations for secondary survey assessment: a. Head i. Pupils ii. Ears iii. Naos-oropharynx iv. Skull and scalp b. Neck i. Jugular venous distension ii. Tracheal position iii. Spinal tenderness c. Chest i. Retractions ii. Breath sounds iii. Chest wall tenderness, deformity, crepitus, and excursion iv. Respiratory pattern, symmetry of chest movement with respiration d. Abdomen and back i. Tenderness or bruising ii. Abdominal distension, rebound, or guarding iii. Spinal tenderness, crepitus, or step-offs iv. Pelvic stability or tenderness e. Extremities i. Pulses ii. Edema iii. Deformity and crepitus f. Neurologic i. Mental status and orientation ii. Motor and sensory g. Evaluate for medical equipment (e.g., pacemaker/defibrillator, left ventricular assist device (LVAD), insulin pump, dialysis fistula) 8. Obtain baseline vital signs (an initial full set of vital signs is required: pulse, blood pressure, respiratory rate, neurologic status assessment, and obtain pulse oximetry if indicated) a. Neurologic status assessment [See Appendix VII. Neurologic Status Assessment] involves establishing a baseline and then trending any change in patient neurologic status i. Glasgow Coma Score (GCS) is frequently used, but there are often errors in applying and calculating this score. With this in consideration, a simpler field approach may be as valid as GCS. Either AVPU or only the motor component of the GCS may more effectively serve in this capacity ii. Sternal rub as a stimulus is discouraged b. Patients with cardiac or respiratory complaints i. Pulse oximetry ii. 12-lead electrocardiogram (EKG) should be obtained promptly in patients with cardiac or suspected cardiac complaints iii. Continuous cardiac monitoring, if available iv. Consider waveform capnography for patients with respiratory complaints (essential for critical patients and those patients who require invasive airway management) c. Patient with altered mental status i. Check blood glucose. If low, go to Hypoglycemia Guideline. ii. Consider waveform capnography (essential for critical patients and those patients who require invasive airway management) or digital capnometry. d. Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should be taken shortly before arrival at receiving facility. e. Critical patients should have pertinent vital signs frequently monitored. 9. Obtain OPQRST history: a. Onset of symptoms b. Provocation: location; any exacerbating or alleviating factors c. Quality of pain d. Radiation of pain e. Severity of symptoms: pain scale f. Time of onset and circumstances around onset 10. Obtain SAMPLE history: a. Symptoms b. Allergies: medication, environmental, and foods c. Medications: prescription and over the counter; bring containers to ED if possible d. Past medical history i. Look for medical alert tags, portable medical records, advance directives ii. Look for medical devices/implants (some common ones may be dialysis shunt, insulin pump, pacemaker, central venous access port, gastric tubes, urinary catheter) iii. For females of childbearing age, inquire of potential or recent pregnancy. e. Last oral intake f. Events leading up to the 911 call In patients with syncope, seizure, altered mental status, or acute stroke, consider bringing the witness to the hospital or obtain their contact phone number to provide to ED care team Treatment and interventions 1. Administer oxygen as appropriate with a target of achieving 94–98% saturation and select the appropriate method of oxygen delivery to mitigate or treat hypercarbia associated with hypoventilation. 2. Place appropriate monitoring equipment as dictated by assessment; these may include: a. Continuous pulse oximetry. b. Cardiac rhythm monitoring. c. Waveform capnography or digital capnometry. d. Carbon monoxide assessment. 3. Establish vascular access if indicated or in patients who are at risk for clinical deterioration. a. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of lidocaine 0.1 mg/mL with slow push through IO needle to a maximum of 40 mg to mitigate pain from IO medication administration. 4. Monitor pain scale if appropriate. 5. Monitor agitation-sedation scale if appropriate. 6. Reassess patient. Transfer of care 1. The content and quality of information provided during the transfer of patient care to another party is critical for seamless patient care and maintenance of patient safety. 2. Ideally, a completed electronic or written medical record should be provided to the next caregiver at the time of transfer of care. 3. If provision of the completed medical record is not possible at the time of transfer of care, a verbal report and an abbreviated written run report should be provided to the next caregiver. If the emergency medical services provider is an ambulance service provider, submit a written report to the receiving health care facility upon delivering a patient and a complete patient care report within 24 hours of patient delivery. 4. The information provided during the transfer of care should include, but is not limited to, a. Patient’s full name. b. Age. c. Chief complaint. d. History of present illness/Mechanism of injury. e. Past medical history. f. Medications. g. Allergies. h. Vital signs with documented times. i. Patient assessment and interventions along with the timing of any medication or intervention and the patient’s response to such interventions. 5. The verbal or abbreviated written run report provided at the time of transfer of care does not take the place of or negate the requirement for the provision of a complete electronic or written medical record of the care provided by EMS personnel. Patient safety considerations 1. Routine use of lights and sirens is not warranted. 2. Even when lights and sirens are in use, always limit speeds to level that is safe for the emergency vehicle being driven and road conditions on which it is being operated. 3. Be aware of legal issues and patient rights as they pertain to and impact patient care (e.g., patients with functional needs or children with special health care needs). 4. Be aware of potential need to adjust management based on patient age and comorbidities, including medication dosages. 5. The maximum weight-based dose of medication administered to a pediatric patient should not exceed the maximum adult dose except where specifically stated in a patient care guideline. 6. Medical direction should be contacted when mandated or as needed. 7. Consider air medical transport, if available, for patients with time-critical conditions where ground transport time exceeds 30 minutes. Notes and educational pearls Key considerations 1. Pediatrics: Documentation of patient weight and method obtained. Acceptable methods are direct from patient/parent or length-based tape to estimate patient weight and guide medication therapy and adjunct choice. a. Although the defined age varies by state, the pediatric population is generally defined by those patients who weigh up to 40 kg or up to 14 years of age, whichever comes first. b. Consider using the pediatric assessment triangle (appearance, work of breathing, circulation) when first approaching a child to help with assessment. 2. Geriatrics: Although the defined age varies by state, the geriatric population is generally defined as those patients who are 65 years old or more. a. In these patients, as well as all adult patients, reduced medication dosages may apply to patients with renal disease (i.e., on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e., severe cirrhosis or end-stage liver disease). 3. Co-morbidities: Reduced medication dosages may apply to patients with renal disease (i.e., on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e., severe cirrhosis or end-stage liver disease). 4. Vital signs: a. Oxygen i. Administer oxygen as appropriate with a target of achieving 94–98% saturation. ii. Supplemental oxygen administration is warranted to patients with oxygen saturations below this level and titrated based upon clinical condition, clinical response, and geographic location and altitude. iii. The method of oxygen delivery should minimize or treat hypercarbia associated with hypoventilation (e.g., non-invasive positive airway pressure devices). b. Normal vital signs (See Table 1. Normal Vital Signs) i. Hypotension is considered a systolic blood pressure less than the lower limit on the chart. ii. Tachycardia is considered a pulse above the upper limit on the chart. iii. Bradycardia is considered a pulse below the lower limit on the chart. iv. Tachypnea is considered a respiratory rate above the upper limit on the chart. v. Bradypnea is considered a respiratory rate below the lower limit on the chart. c. Hypertension. Although abnormal, may be an expected finding in many patients i. Unless an intervention is specifically suggested based on the patient’s complaint or presentation, the hypertension should be documented, but otherwise, no intervention should be taken acutely to normalize the blood pressure. ii. The occurrence of symptoms (e.g., chest pain, dyspnea, vision change, headache, focal weakness or change in sensation, altered mental status) in patients with hypertension should be considered concerning, and care should be provided appropriate with the patient’s complaint or presentation. 5. Secondary survey: If patient has critical primary survey problems, it may not be possible to complete. 6. Critical patients: Proactive patient management should occur simultaneously with assessment. a. Ideally, one clinician should be assigned to exclusively monitor and facilitate patient- focused care. b. Other than lifesaving interventions that prevent deterioration en route, treatment and Interventions should be initiated as soon as practical, but should not impede extrication or delay transport to definitive care. 7. Air medical transport: Air transport of trauma patients should generally be reserved for higher acuity trauma patients where there is a significant time saved over ground transport, where the appropriate destination is not accessible by ground due to systemic or logistical issues, and for patients who meet the American College of Surgeons Committee on Trauma (ACS-COT) 2022 National Guideline for the Field Triage of Injured Patients anatomic, physiologic, and situational high-acuity triage criteria. In selected circumstances, air medical resources may be helpful for non-trauma care (e.g., stroke, STEMI when geographically constrained). 8. Additional protective measures for the EMS clinician: Due to suspected or confirmed hazards and/or highly infectious contagious diseases, traditional patient treatment and care delivery may be altered due to recommendations by federal, state, local or jurisdictional officials. Pertinent assessment findings Refer to individual guidelines Table 1. Normal Vital Signs Age Pulse- Awake (beats/ minute) Pulse- Sleeping (beats/ minute) Respirato ry Rate (breaths / minute) Systoli c BP (mmH g) Preterm less than 1 kg 120–160 30–60 39–59 Preterm 1–3 kg 120–160 30–60 60–76 Newborn 100–205 85–160 30–60 67–84 Up to 1 year 100–190 90–160 30–60 72–104 1–2 years 100–190 90–160 24–40 86–106 2–3 years 98–140 60–120 24–40 86–106 3–4 years 80–140 60–100 24–40 89–112 4–5 years 80–140 60–100 22–34 89–112 5–6 years 75–140 58–90 22–34 89–112 6–10 years 75–140 58–90 18–30 97–115 10–12 years 75–118 58–90 18–30 102– 120 12–13 years 60–100 58–90 15–20 110– 131 13–15 years 60–100 50–90 15–20 110– 131 15 years or older 60–100 50–90 15–20 110– 131 Source: Extrapolated from the 2020 American Heart Association Pediatric Advanced Life Support’s tables from the Nursing Care of the Critically Ill Child, and from Web Box 1: Existing reference ranges for respiratory rate and heart rate in the appendix of the article by Fleming, et al, published in Lancet Note: While many factors affect blood pressure (e.g., pain, activity, hydration), it is imperative to rapidly recognize hypotension, especially in children. For children of the ages 1–10, hypotension is present if the systolic blood pressure is less than 70 mmHg + (child’s age in years x 2) mmHg. Table 2. Glasgow Coma Scale ADULT GLASGOW COMA SCALE PEDIATRIC GLASGOW COMA SCALE Eye Opening (4) Eye Opening (4) Spontaneous 4 Spontaneous 4 To Speech 3 To Speech 3 To Pain 2 To Pain 2 None 1 None 1 Best Motor Response (6) Best Motor Response (6) Obeys Commands 6 Spontaneous Movement 6 Localizes Pain 5 Withdraws to Touch 5 Withdraws from Pain 4 Withdraws from Pain 4 Abnormal Flexion 3 Abnormal Flexion 3 Abnormal Extension 2 Abnormal Extension 2 None 1 None 1 Verbal Response (5) Verbal Response (5) Oriented 5 Coos, Babbles 5 Confused 4 Irritable Cry 4 Inappropriate 3 Cries to Pain 3 Incomprehensible 2 Moans to Pain 2 None 1 None 1 Total Total Source : https://www.cdc.gov/masstrauma/resources/gcs.pdf Functional needs Aliases Developmental delay Disabled Handicapped Impaired Special needs Mental Illness Intellectual disability Patient care goals To meet and maintain the additional support required for patients with functional needs during the delivery of prehospital care Patient presentation Inclusion criteria Patients who are identified by the World Health Organization’s International Classification of Functioning, Disability, and Health that have experienced a decrement in health resulting in some degree of disability. According to the U.S. Department of Health and Human Services, this includes, but is not limited to, individuals with physical, sensory, mental health, and cognitive and/or intellectual disabilities affecting their ability to function independently without assistance. Exclusion criteria None noted Patient management Assessment 1. Identify the functional need by means of information from the patient, the patient’s family, bystanders, medic alert bracelets or documents, or the patient’s adjunct assistance devices. 2. The physical examination should not be intentionally abbreviated, although the way the exam is performed may need to be modified to accommodate the specific needs of the patient. Treatment and interventions Medical care should not intentionally be reduced or abbreviated during the triage, treatment, and transport of patients with functional needs, although the way the care is provided may need to be modified to accommodate the specific needs of the patient. Patient safety considerations For patients with communication barriers (language or sensory), it may be desirable to obtain secondary confirmation of pertinent data (e.g., allergies) from the patient’s family, interpreters, or written or electronic medical records. The family members can be an excellent source of information and the presence of a family member can have a calming influence on some of these patients. Notes and educational pearls Key considerations 1. Communication barriers a. Language barriers: i. Expressive and/or receptive aphasia ii. Nonverbal iii. Fluency in a different language than that of the EMS professional iv. Examples of tools to overcome language barriers include: 1. Transport of an individual who is fluent in the patient’s language along with the patient to the hospital. 2. Medical translation cards. 3. Telephone-accessible services with live language interpreters. 4. Methods through which the patient augments his/her communication skills (e.g., eye blinking, nodding) should be noted, utilized as able, and communicated to the receiving facility. 5. Electronic applications for translation. b. Sensory barriers: i. Visual impairment ii. Auditory impairment iii. Examples of tools to overcome sensory barriers include: 1. Braille communication card. 2. Sign language. 3. Lip reading. 4. Hearing aids. 5. Written communication. 2. Physical barriers: a. Ambulatory impairment (e.g., limb amputation, bariatric) b. Neuromuscular impairment 3. Cognitive barriers: a. Mental illness b. Developmental challenge or delay Pertinent assessment findings 1. Assistance adjuncts Examples of devices that facilitate the activities of daily living for the patient with functional needs include, but are not limited to: a. Extremity prostheses b. Hearing aids c. Magnifiers d. Tracheostomy speaking valves e. White or sensory canes f. Wheelchairs or motorized scooters 2. Service animals a. As defined by the American Disabilities Act, “any guide dog, signal dog, or other animal individually trained to do work or perform tasks for the benefit of an individual with a disability, including, but not limited to guiding individuals with impaired vision, alerting individuals with impaired hearing to intruders or sounds, providing minimal protection or rescue work, pulling a wheelchair, or fetching dropped items”. Service animals are not classified as a pet and should, by law, always be permitted to accompany the patient with the following exceptions: i. A public entity may ask an individual with a disability to remove a service animal from the premises if: 1. The animal is out of control and the animal's handler does not take effective action to control it; or 2. The animal is not housebroken b. Service animals are not required to wear a vest or a leash. It is illegal to make a request for special identification or documentation from the service animal’s partner. EMS clinicians may only ask the patient if the service animal is required because of a disability and the form of assistance the animal has been trained to perform. c. EMS clinicians are not responsible for the care of the service animal. If the patient is incapacitated and cannot personally care for the service animal, a decision can be made whether to transport the animal in this situation. d. Animals that solely provide emotional support, comfort, or companionship do not qualify as service animals. Patient refusals Aliases Against medical advice Refusal of treatment Refusal of transport Patient care goals/Patient presentation (Overview) If an individual (or the parent or legal guardian of the individual) refuses secondary care and/or ambulance transport to a hospital after prehospital clinicians have been called to the scene, clinicians should determine the patient’s capacity to make decisions. Patient management Assessment 1. Decision-making capacity a. An individual who is alert, oriented, and can understand the circumstances surrounding his/her illness or impairment, as well as the possible risks associated with refusing treatment and/or transport, typically is considered to have decision-making capacity. b. The individual’s judgment must also not be significantly impaired by illness, injury, or drugs/alcohol intoxication. Treatment and interventions 1. Obtain a complete set of vital signs and complete an initial assessment, paying particular attention to the individual’s neurologic and mental status. 2. Determine the individual’s capacity to make a valid judgment concerning the extent of his/her illness or injury; if the EMS clinician has doubts about whether the individual has the mental capacity to refuse or if the patient lacks capacity, the EMS clinician should contact medical direction. 3. If patient has capacity, clearly explain to the individual and all responsible parties the possible risks and overall concerns with regards to refusing care and that they may reengage the EMS system if needed. 4. Perform appropriate medical care with the consent of the individual. 5. Complete the patient care report clearly documenting the initial assessment findings and the discussions with all involved individuals regarding the possible consequences of refusing additional prehospital care and/or transportation. Notes and educational pearls Key considerations 1. An adult or emancipated minor who has demonstrated possessing sufficient mental capacity for making decisions has the right to determine the course of his/her medical care, including the refusal of care. 2. Individuals must be advised of the risks and consequences resulting from refusal of medical care to enable an informed decision regarding consent or refusal of treatment. 3. An individual determined to lack decision-making capacity by EMS clinicians should not be allowed to refuse care against medical advice or to be released at the scene. Mental illness, drugs, alcohol intoxication, or physical/mental impairment may significantly impair an individual’s decision-making capacity. Individuals who have attempted suicide, verbalized suicidal intent, or had other factors that lead EMS clinicians to suspect suicidal intent, should not be regarded as having demonstrated sufficient decision-making capacity; contact medical control or law enforcement for assistance. 4. The determination of decision-making capacity may be challenged by communication barriers or cultural differences. 5. EMS clinicians should not put themselves in danger by attempting to treat and/or transport an individual who refuses care. Law enforcement personnel should be requested if needed. 6. Always act in the best interest of the patient. EMS clinicians, with the support of direct medical oversight, must strike a balance between abandoning the patient and forcing care. 7. Special considerations – Minors It is preferable for minors to have a parent or legal guardian who can provide consent for treatment on behalf of the child. a. Wisconsin allows health care clinicians to provide emergency treatment of life- threatening conditions when a parent is not available to provide consent. This is known as the emergency exception rule or the doctrine of implied consent. For minors, this doctrine means that the EMS clinician can presume consent and proceed with appropriate treatment and transport if the following six conditions are met: i. The child is suffering from an emergent condition that places their life or health in danger. ii. The child’s legal guardian is unavailable or unable to provide consent for treatment or transport. iii. Treatment or transport cannot be safely delayed until consent can be obtained. iv. The EMS clinician administers only treatment for emergency conditions that pose an immediate threat to the child. v. As a rule, when the EMS clinician’s authority to act is in doubt, EMS clinicians should always do what they believe to be in the best interest of the minor. vi. If a minor is injured or ill and no parent contact is possible, the EMS clinician may contact medical direction for additional instructions. Cardiovascular Adult and pediatric syncope and near syncope Aliases Loss of consciousness Patient care goals 1. Stabilize and resuscitate when necessary 2. Initiate monitoring and diagnostic procedures 3. Transfer for further evaluation Patient presentation 1. Syncope is heralded by both the loss of consciousness and the loss of postural tone and resolves spontaneously without medical interventions. Syncope typically is abrupt in onset and resolves equally quickly. EMS clinicians may find the patient awake and alert on initial evaluation. 2. Near syncope is defined as the prodromal symptoms of syncope. The symptoms that can precede syncope last for seconds to minutes with signs and symptoms that may include pallor, sweating, lightheadedness, visual changes, or weakness. It may be described by the patient as “nearly blacking out” or “nearly fainting.” 3. Rapid first aid during the onset may improve symptoms and prevent syncope. Inclusion criteria 1. Abrupt loss of consciousness with loss of postural tone 2. Prodromal symptoms of syncope Exclusion criteria Conditions other than the above, including: 1. Patients with alternate and obvious cause of loss of consciousness (e.g., trauma – See Head Injury Guideline). 2. Patients with ongoing mental status changes or coma should be treated per the Altered Mental Status Guideline. 3. Patients with persistent new neurologic deficit [See Suspected Stroke/Transient Ischemic Attack Guideline]. Patient management Assessment 1. Pertinent History a. Review the patient’s past medical history including a history of: i. Cardiovascular disease (e.g., cardiac disease/stroke, valvular disease, hypertrophic cardiomyopathy, mitral valve prolapse). ii. Seizure. iii. Recent trauma. iv. Active cancer diagnosis. v. Dysrhythmias including prior electrophysiology studies/pacemaker and/or implantable cardioverter defibrillator (ICD). vi. History of syncope. vii. History of thrombosis or emboli. b. History of present illness, including: i. Conditions leading to the event: after transition from recumbent/sitting to standing; occurring with strenuous exercise (notably in the young and seemingly healthy). 1. Syncope that occurs during exercise often indicates an ominous cardiac cause. Patients should be evaluated in the emergency department. ii. Patient complaints before or after the event including prodromal symptoms. iii. History of symptoms described by others on scene, including seizures or shaking, presence of pulse/breathing (if noted), duration of the event, events that lead to the resolution of the event. c. Review of systems: i. Current medications (new medications, changes in doses) ii. Fluid losses (nausea/vomiting/diarrhea) and fluid intake iii. Last menstrual period/pregnant iv. Occult blood loss (gastrointestinal (GI)/genitourinary (GU)) v. Palpitations vi. Unilateral Leg swelling, history of recent travel, prolonged immobilization, malignancy d. Pertinent physical exam including: i. Attention to vital signs and evaluation for trauma. ii. Note overall patient appearance, diaphoresis, pallor. iii. Detailed neurologic exam (including stroke screening and mental status). iv. Heart, lung, abdominal, and extremity exam. v. Additional evaluation: 1. Cardiac monitoring 2. Oxygen saturation (SPO2) 3. Ongoing vital signs 4. 12-lead EKG 5. Blood glucose level (BGL) Treatment and interventions: 1. Should be directed at abnormalities discovered in the physical exam or on additional examination and may include management of cardiac dysrhythmias, cardiac ischemia/infarct, hemorrhage, shock, etc. a. Manage airway as indicated [naso/oropharyngeal EMR-R; non-visualized EMR-O, EMT-R; intubation INT-O, PARA-R]. b. Oxygen as appropriate [EMR-O, EMT-R; HFNC PARA-O]. c. Evaluate for hemorrhage and treat for shock if indicated [direct pressure, pressure points, tourniquet EMR-R; hemostatic agents, skin clamps All EMS Service Providers -O; wound packing EMR-O, EMT-R]. d. Establish IV access [AEMT-R]. e. Fluid bolus if appropriate[0.9%NS AEMT-R; LR AEMT-O]. f. Cardiac monitor [acquire/transmit EMR-O, INT-R; interpret INT-R]. g. 12-lead EKG [acquire/transmit EMR-O, INT-R; interpret INT-R]. h. Monitor for and treat arrhythmias (if present, refer to appropriate guideline) [AED defib EMR-R, manual defib EMT-O, INT-R, see specific arrhythmia guideline for medications]. Patient safety considerations: 1. Patients suffering from syncope due to arrhythmia may experience recurrent arrhythmias and should therefore be placed on a cardiac monitor. 2. Geriatric patients suffering falls from standing may sustain significant injury and should be diligently screened for trauma [General Trauma Management Guideline]. Notes and educational pearls Key considerations 1. By being most proximate to the scene and to the patient’s presentation, EMS clinicians are commonly in a unique position to identify the cause of syncope. Consideration of potential causes, ongoing monitoring of vitals and cardiac rhythm and detailed exam and history are essential pieces of information to pass on to hospital clinicians. 2. For patients where a lower risk etiology is suspected, e.g., vasovagal syncope, decisions regarding delayed or non -transport should be made in consu ltation with medical direction. 3. High-risk causes of syncope include, but are not limited to, the following: a. Cardiovascular i. Myocardial infarction ii. Aortic stenosis iii. Hypertrophic cardiomyopathy (consider in young patient with unexplained syncope during exertion) iv. Pulmonary embolus v. Aortic dissection vi. Dysrhythmia vii. Mitral valve prolapse is associated with higher risk for sudden death b. Neurovascular i. Intracranial hemorrhage ii. Transient ischemic attack or stroke iii. Vertebral basilar insufficiency c. Hemorrhagic i. Ruptured ectopic pregnancy ii. GI bleed iii. Aortic rupture 4. Consider high-risk 12-lead EKG features including, but not limited to: a. Evidence of QT prolongation (generally over 500 msec). b. Delta waves. c. Brugada syndrome (incomplete right bundle branch block (RBBB) pattern in V1/V2 with ST segment elevation). d. Hypertrophic obstructive cardiomyopathy. Pertinent assessment findings 1. 12-lead EKG findings 2. Evidence of alternate etiology, including seizure 3. Evidence of cardiac dysfunction (e.g., evidence of congestive heart failure (CHF), arrhythmia) 4. Evidence of hemorrhage 5. Evidence of neurologic compromise 6. Evidence of trauma 7. Initial and ongoing cardiac rhythm Chest Pain/Acute Coronary Syndrome (ACS)/ST-segment Elevation Myocardial Infarction (STEMI) Aliases Heart attack Myocardial infarction (MI) Patient care goals 1. Identify ST-elevation myocardial infarction (STEMI) by 12-lead ECG within 10 minutes for patients with chest pain or a suspected myocardial infarction. 2. Determine the time of symptom onset. 3. Activate hospital-based STEMI system of care within 10 minutes of ECG recognition. 4. Monitor vital signs and cardiac rhythm and be prepared to provide CPR and defibrillation if needed. 5. Administer appropriate medications. 6. Transport to appropriate facility. Patient presentation Inclusion criteria 1. Chest pain or discomfort in other areas of the body (e.g., arm, jaw, epigastrium) of suspected cardiac origin, shortness of breath, associated or unexplained sweating, nausea, vomiting, or dizziness. Atypical or unusual symptoms are more common in women, the elderly, and diabetic patients. May also present with CHF, syncope, and/or shock. 2. Chest pain associated sympathomimetic use (e.g., cocaine, methamphetamine). 3. Some patients will present with likely non-cardiac chest pain and otherwise have a low likelihood of ACS (e.g., blunt trauma to the chest of a child). For these patients, defer the administration of aspirin (ASA) and nitrates per the Pain Management Guideline. Exclusion criteria None noted Patient management Assessment, treatment, and interventions 1. Signs and symptoms include chest pain, congestive heart failure (CHF), syncope, shock, symptoms similar to a patient’s previous MI. 2. Assess the patient’s cardiac rhythm and immediately address pulseless rhythms, symptomatic tachycardia, or symptomatic bradycardia [See Cardiovascular Section and Resuscitation Section ]. 3. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, EMS clinicians should administer oxygen as appropriate with a target of achieving 94– 98% saturation [Refer to Universal Care Guideline ] [EMR-O, EMT-R; HFNC PARA- O]. 4. The 12 -lead EKG is the primary diagnostic tool that identifies a STEMI; it is imperative that EMS clinicians routinely acquire a 12- lead EKG within 10 minutes for all patients exhibiting s igns and symptoms of ACS [acquire/transmit EMR -O, INT-R; interpret INT-R]. a. The EKG may be transmitted for remote interpretation by a physician or screened for STEMI by properly trained EMS clinicians or other health care providers with or without the assistance of computer-interpretation. b. Advance notification should be provided to the receiving hospital for patients identified as having a STEMI. c. Performance of serial EKGs is encouraged for symptomatic patients with EKGs initially non-diagnostic for STEMI. d. All EKGs should be made available to treating personnel at the receiving hospital, whether hand delivered as hard copy or transmitted from the field. 5. Administer aspirin; chewable, non-enteric-coated aspirin preferred (162–325 mg) [EMR-O, EMT-R]. 6. Establish IV access [AEMT-R]. 7. Nitroglycerin 0.4 mg sublingual (SL), can repeat q (quaque, every) 3–5 minutes if SBP greater than 100 mmHg [AEMT-R]. a. The use of nitrates should be avoided in any patient who has used a phosphodiesterase inhibitor within the past 48 hours. b. Examples include sildenafil (Viagra®, Revatio®), vardenafil (Levitra®, Staxyn®), tadalafil (Cialis®, Adcirca®) which are used for erectile dysfunction and pulmonary hypertension. Also avoid use in patients receiving intravenous epoprostenol (Flolan®). or treporstenil (Remodulin®) which is used for pulmonary hypertension c. Care should always be taken when giving nitroglycerin when the patient’s blood pressure is marginal. If used in this setting, the clinician should weigh the risk and benefit of nitrate administration over the administration of an opiate analgesic and be ready to respond to hypotension with fluid bolus or pressor. 8. The location of the infarct does not preclude the use of nitrates. Right-sided leads are of no additional value if an inferior STEMI has been diagnosed and such findings (presumed RV infarct) do not preclude the use of nitroglycerin: however, continually monitor the patient’s hemodynamic status and be prepared to resuscitate if hypotension occurs. 9. If the pain is unresponsive to nitrates, opiates are an acceptable alternative. Morphine should be used with caution in unstable angina (UA)/non -STEMI due to an association with increased mortality. 10. Transport and destination decisions should be based on local resources and system of care. 11. Early notification to receiving facility of any changes in patient condition or serial EKGs. Patient safety considerations 1. Observe for signs of clinical deterioration: dysrhythmias, chest pain, shortness of breath, decreased level of consciousness/syncope, or other signs of shock/hypotension. 2. Perform serial 12-lead EKGs (especially if clinical changes are noted). 3. Consider placing defibrillator pads on high-risk patients. 4. Consider configuring monitor/defibrillator to allow automatic VT/VF alert. 5. Consider configuring monitor/defibrillator to allow ST-segment trending if available. Notes and educational pearls Key considerations Acute coronary syndrome may present with atypical pain, vague or only generalized complaints. Ischemic burden time is a risk for morbidity and mortality, EMS can help decrease first medical contact to intervention time/reflow by efficient scripting/training of safely minimizing scene time. Pertinent assessment findings A complete medication list should be obtained from each patient. It is especially important for the treating physician and health care providers to be informed if the patient is taking beta-blockers, calcium channel blockers, clonidine, digoxin, blood thinners (anticoagulants), and medications for the treatment of erectile dysfunction or pulmonary hypertension. Bradycardia Aliases Heart block Junctional rhythm Patient care goals 1. Maintain adequate perfusion. 2. Treat underlying cause: a. Hypoxia b. Shock c. Second- or third-degree atrioventricular (AV) block d. Toxin exposure (beta-blocker, calcium channel blocker, organophosphates, digoxin) e. Electrolyte disorder f. Hypoglycemia g. Increased intracranial pressure (ICP) h. Other Patient presentation Inclusion criteria 1. Heart rate less than 60 beats per minute (BPM) with either symptoms (altered mental status (AMS), chest pain (CP), congestive heart failure (CHF), seizure, syncope, shock, pallor, diaphoresis) or evidence of hemodynamic instability. 2. The major EKG rhythms classified as bradycardia include: a. Sinus bradycardia b. Second-degree AV block i. Type I-Wenckebach/Mobitz I ii. Type II-Mobitz II c. Third-degree AV block, complete heart block d. Ventricular escape rhythms 3. See additional inclusion criteria for pediatric patients. Exclusion criteria None noted Patient management Assessment, treatment, and interventions 1. Adult management a. Manage airway as necessary [naso/oropharyngeal EMR-R; non-visualized EMR-O, EMT- R; intubation INT-O, PARA-R]. b. Administer oxygen as appropriate with a target of achieving 94–98% saturation [EMR- O, EMT-R; HFNC PARA-O]. c. Initiate monitoring and perform 12-lead EKG [acquire/transmit EMR-O, INT-R; interpret INT-R]. d. Establish IV access [AEMT-R]. e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Guideline and Hyperglycemia Guideline [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R] . f. Consider the following additional therapies if bradycardia and symptoms or hemodynamic instability continue: i. Atropine 1 mg IV q 3–5 minutes (maximum total dose of 3 mg) [INT-R]. ii. Vasopressor medications (in order of preference) [PARA-O]. 1. Epinephrine IV drip 0.02–0.2 mcg/kg/min titrated to a MAP greater than 65 mmHg. OR 2. Epinephrine by push dose (dilute boluses): for example, prepare 10 mcg/mL by adding 1 mL of “cardiac epinephrine” (which is 100 mcg/ml) to 9 mL of normal saline yielding 10 mcg/ml, then administer 10–20 mcg boluses (1–2 mL) q 2 minutes titrated MAP greater than 65 mmHg. OR 3. Norepinephrine 0.02–0.4 mcg/kg/minute IV titrated to a MAP greater than 65 mmHg. iii. Transcutaneous Pacing – If pacing is performed, consider sedation or pain control [INT-R]. 2. Pediatric management Treatment is only indicated for patients who are symptomatic (pale/cyanotic, diaphoretic, altered mental status, hypoxic). a. For infants and newborns, initiate chest compressions for heart rate less than 60 BPM and signs of poor perfusion despite effective ventilation with oxygen (altered mental status, hypoxia, hypotension, weak pulse, delayed capillary refill, cyanosis) [EMR-R]. b. Manage airway and assist ventilations as necessary with minimally interrupted chest compressions using a comp ression-to-ventilation ratio 15:2 (30:2 if single clinician is present) [naso/oropharyngeal EMR -R; non - visualized EMR-O, EMT-R; intubation INT-O, PARA-R]. c. Administer oxygen as appropriate with a target of achieving 94– 98% saturation [EMR- O, EMT-R; HFNC PARA-O]. d. Initiate monitoring and perform 12- lead EKG [acquire/transmit EMR-O, INT-R; interpret INT-R]. e. Establish IV access [AEMT-R]. f. Check blood glucose and treat hypoglycemia per the Hypoglycemia Guideline [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R]. g. Consider the following additional therapies if bradycardia and symptoms or hemodynamic instability continue: i. Epinephrine by push dose (dilute boluses). For example, prepare 10 mcg/mL by adding 1 mL of “cardiac epinephrine” (which is 100 mcg/ml) to 9 mL of normal saline yielding 10 mcg/ml, then administer 0.01 mg/kg (0.1 mL/kg) maximum single dose 10 mcg (1 mL) q 3–5 minutes titrated to MAP greater than 65 mmHg [PARA-O]. ii. Also consider atropine 0.01–0.02 mg/kg IV with minimum dose of 0.1 mg if increased vagal tone or cholinergic drug toxicity to maximum initial dose of 0.5 mg (maximum total dose of 3 mg) [INT-R]. iii. Transcutaneous pacing: If pacing is performed, consider sedation or pain control [INT-R]. iv. Epinephrine may be used for bradycardia and poor perfusion unresponsive to ventilation and oxygenation [INT-R]. 1. It is reasonable to administer atropine for bradycardia caused by increased vagal tone or cholinergic drug toxicity. Patient safety considerations If pacing is performed, consider sedation or pain control. Notes and educational pearls Key considerations 1. Observe for signs of decreased end-organ perfusion: chest pain (CP), shortness of breath (SOB), decreased level of consciousness, syncope, or other signs of shock/hypotension. 2. Patients who have undergone cardiac transplant will not respond to atropine. 3. Consider potential culprit medications including beta-blockers, calcium channel blockers, sodium channel blockers/anti-depressants, digoxin, and clonidine. a. If medication overdose is considered, refer to appropriate guideline in the Toxins and Environmental Section . 4. The differential diagnosis includes the following: myocardial infarction (MI), hypoxia, pacemaker failure, hypothermia, sinus bradycardia, athletes, head injury with increased intracranial pressure (ICP), stroke, spinal cord lesion, sick sinus syndrome, AV blocks, overdose, and cholinergic nerve agents. 5. Consider hyperkalemia in the patient with wide complex bradycardia. 6. Bradycardia should be managed via the least invasive manner possible, escalating care as needed. a. Third-degree heart block or the denervated heart (as in cardiac transplant) may not respond to atropine and in these cases, proceed quickly to chronotropic agents (such as epinephrine or dopamine) or transcutaneous pacing. b. Dopamine is not indicated for pediatric patients. c. In cases of impending hemodynamic collapse, proceed directly to transcutaneous pacing. d. For shock that is suspected to be from sepsis, norepinephrine is preferred over dopamine due to its reduced risk of arrhythmias and its lower mortality rate. 7. Be aware of acute coronary syndrome as a cause of bradycardia in adult patients. 8. When dosing medications for pediatric patients, dose should be weight-based for non-obese patients and based on ideal body weight for obese patients. 9. Although dopamine is often recommended for the treatment of symptomatic bradycardia, recent research suggests that patients in cardiogenic or septic shock treated with norepinephrine have a lower mortality rate compared to those treated with dopamine. 10. Caution: norepinephrine can theoretically cause reflex bradycardia. Pertinent assessment findings None noted Implantable ventricular assist devices Aliases Biventricular assist device (BiVAD) Left ventricular assist device (LVAD) Right ventricular assist device (RVAD) Ventricular assist device (VAD) Patient care goals 1. Rapid identification of, and interventions for, cardiovascular compromise in patients with VADs. 2. Rapid identification of, and interventions for, VAD-related malfunctions or complications. Patient presentation Inclusion criteria 1. Adult patients that have had an implantable ventricular assist device (VAD), including a left ventricular assist device (LVAD), right ventricular assist device (RVAD), or biventricular-assist device (BiVAD) and have symptoms of cardiovascular compromise. 2. Patients with VADs that are in cardiac arrest. 3. Patients with VADs that are experiencing a medical or injury-related event not involving the cardiovascular system or VAD malfunction. Exclusion criteria Adult patients who do not have a VAD in place. Patient management Assessment 1. Assess for possible pump malfunction a. Assess for alarms b. Auscultate for pump sound “hum” c. Signs of hypoperfusion including pallor, diaphoresis, altered mental status 2. If the VAD pump has malfunctioned: a. Utilize available resources to troubleshoot potential VAD malfunctions and to determine appropriate corrective actions to restore normal VAD function: i. Contact the patient’s VAD-trained companion, if available. ii. Contact the patient’s VAD coordinator, using the phone number on the device. iii. Check all the connections to system controller. iv. Change VAD batteries, and/or change system controller if indicated/advised by coordinator. v. Have patient stop all activity and assess for patient tolerance. vi. Follow appropriate cardiovascular condition-specific protocol(s) as indicated. Treatment and interventions 1. Manage airway as indicated [naso/oropharyngeal EMR-R; non-visualized EMR-O, EMT-R; intubation INT-O, PARA-R]. 2. Cardiac monitoring [acquire/transmit EMR-O, INT-R; interpret INT-R]. 3. IV access [AEMT-R]. 4. Acquire 12-lead EKG [acquire/transmit EMR-O, INT-R; interpret INT-R]If patient is experiencing VAD-related complications or cardiovascular problems, expedite transport to the medical facility where VAD was placed if patient’s clinical condition and time allows. 5. If patient has a functioning VAD and is experiencing a non -cardiovascular-related problem, transport to a facility that is appropriate for the patient’s main presenting problem without manipulating the device. 6. If patient has a functioning VAD and is hypoperfused [AEMT-R]: a. Administer IV fluids (30 mL/kg isotonic fluid; maximum of 1 liter) over less than 15 minutes, using a push-pull method of drawing up the fluid in a syringe and pushing it through the IV. b. May repeat up to 3 times based on patient’s condition and clinical impression for a total cumulative dose not to exceed 3 L. 7. If patient is in full cardiac arrest: a. CPR should not be performed if there is any evidence the pump is still functioning. The decision whether to perform CPR should be made based upon best clinical judgment in consultation with the patient’s VAD-trained companion and the VAD coordinator (or direct medical oversight if VAD coordinator unavailable). b. CPR may be initiated only where [EMR-R]: i. You have confirmed the pump has stopped and troubleshooting efforts to restart it have failed, and ii. The patient is unresponsive and has no detectable signs of life. Notes and educational pearls 1. You do not need to disconnect the controller or batteries to: a. Defibrillate or cardiovert. b. Acquire a 12-lead EKG. 2. Automatic non-invasive cuff blood pressures may be difficult to obtain due to the narrow pulse pressure created by the continuous flow pump. 3. Flow though many VAD devices is not pulsatile, and patients may not have a palpable pulse or accurate pulse oximetry. 4. The blood pressure, if measurable, may not be an accurate measure of perfusion. 5. Ventricular fibrillation, ventricular tachycardia, or asystole/PEA may be the patient’s “normal” underlying rhythm. Evaluate clinical condition and provide care in consultation with VAD coordinator. 6. The patient’s travel bag should always accompany them with back-up controller and spare batteries. 7. If feasible, bring the patient’s power module, cable, and display module to the hospital. 8. All patients should carry a spare pump controller with them. 9. The most common cause for VAD alarms is low batteries or battery failures. 10. Although automatic non-invasive blood pressure cuffs are often ineffective in measuring systolic and diastolic pressure, if they do obtain a measurement, the MAP is usually accurate. 11. Other VAD complications: a. Infection b. Stroke/Transient ischemic attack (TIA) c. Bleeding d. Arrhythmias e. Cardiac tamponade f. Congestive heart failure (CHF) g. Aortic insufficiency Tachycardia with a pulse Aliases Atrial fibrillation (A-FIB) Atrial flutter Supraventricular tachycardia (SVT) Multifocal atrial tachycardia (MAT) Torsades de Pointes Ventricular tachycardia (VT) Patient care goals 1. Maintain adequate oxygenation, ventilation, and perfusion. 2. Control ventricular rate. 3. Restore regular sinus rhythm in unstable patient. 4. Search for underlying cause: a. Medications (caffeine, diet pills, thyroid, decongestants) b. Drugs (cocaine, amphetamines) c. History of dysrhythmia d. Congestive heart failure (CHF) Patient presentation Patients will manifest elevated heart rate for age and may or may not also present with associated signs or symptoms such as palpitations, dyspnea, chest pain, syncope/near-syncope, hemodynamic compromise, altered mental status, or other signs of end organ malperfusion. Inclusion criteria Heart rate greater than 100 BPM in adults or relative tachycardia in pediatric patients. Exclusion criteria Sinus tachycardia Patient management Assessment, treatments, and interventions 1. Adult management a. Manage airway as necessary [naso/oropharyngeal EMR-R; non-visualized EMR-O, EMT- R; intubation INT-O, PARA-R]. b. Administer oxygen as appropriate with a target of achieving 94–98% saturation [EMR- O, EMT-R; HFNC PARA-O]. c. Initiate monitoring and perform 12-lead EKG [acquire/transmit EMR-O, INT-R; interpret INT-R]. d. Establish IV access [AEMT-R]. e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Guideline [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R]. f. Consider the following additional therapies if tachycardia with signs and symptoms or hemodynamic instability continues: i. Regular narrow complex tachycardia – stable (SVT) 1. Perform vagal maneuvers [EMT-O, AEMT-R]. 2. Adenosine 6 mg IV (proximal site) followed by 10 mL fluid bolus [INT-R]. a. If tachycardia continues, give adenosine 12 mg IV. b. A third dose of adenosine, 12 mg IV, can be given. c. Diltiazem 0.25 mg/kg slowly IV over 2 minutes [PARA-O]. After 15 minutes, a second dose of diltiazem 0.35 mg/kg IV may be given if needed. d. For patients older than 65 years old, recommend maximum initial dose of diltiazem 10 mg IV and a maximum second dose of 20 mg. 3. Metoprolol 5 mg IV given over 1–2 minutes. May repeat as needed q 5 minutes for a total of 3 doses [PARA-O]. 4. Verapamil 2.5–5 mg IV given over 2 minutes. May repeat with verapamil 5–10 mg after 15–30 minutes. [PARA-O]. ii. Regular narrow complex tachycardia – unstable 1. Deliver a synchronized shock based on manufacturer’s recommendations [INT- R]. 2. For responsive patients, consider sedation and analgesia. iii. Irregular narrow complex tachycardia – stable (atrial fibrillation (A-FIB), atrial flutter, multifocal atrial tachycardia). 1. Diltiazem 0.25 mg/kg slowly IV over 2 minutes [PARA-O]. a. After 15 minutes, a second dose of diltiazem 0.35 mg/kg IV may be given if needed. b. For patients older than 65 years old, recommend maximum initial dose of diltiazem 10 mg IV and a maximum second dose of 20 mg. 2. Metoprolol 5 mg IV given over 1–2 minutes. May repeat as needed q 5 minutes for a total of 3 doses [PARA-O]. iv. Irregular narrow complex tachycardia – unstable 1. Deliver a synchronized shock based on manufacturer’s recommendation [INT-R]. 2. For responsive patients, consider sedation. v. Regular wide complex tachycardia – stable (ventricular tachycardia, supraventricular tachycardia, atrial fibrillation/flutter with aberrancy, accelerated idioventricular rhythms, pre-excited tachycardias with accessory pathways). 1. Amiodarone 150 mg IV over 10 minutes [INT-O, PARA-R]. a. May repeat once as needed. 2. Procainamide 20–50 mg/min] until arrhythmia suppressed, hypotension ensues, QRS duration increases greater than 50%, or maximum dose 17 mg/kg given [PARA-O]. a. Maintenance infusion: 1–4 mg/min. b. Avoid if prolonged QT or CHF. 3. Lidocaine 1–1.5 mg/kg IV [INT-O, PARA-R]. a. May be repeated at 5-minute intervals for a maximum dose of 3 mg/kg IV. 4. Adenosine 6 mg IV (proximal site) followed by 10 mL fluid bolus [INT-R]. a. If monomorphic tachycardia continues, give adenosine 12 mg IV. vi. Regular wide complex tachycardia – unstable 1. Deliver a synchronized shock based on manufacturer’s recommendation [INT-R]. 2. For responsive patients, consider sedation. vii. Irregular wide complex tachycardia – stable (A-FIB with aberrancy, pre- excited A-FIB (i.e., A-FIB using an accessory pathway), multifocal atrial tachycardia (MAT) or polymorphic VT/Torsades de Pointes. 1. Procainamide 20–50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases greater than 50%, or maximum dose 17 mg/kg given [PARA-O]. a. Maintenance infusion: 1–4 mg/min. b. Avoid if prolonged QT or CHF. 2. If Torsades de Pointes, give magnesium 1–2 g IV over 10 minutes [PARA-R]. 3. Amiodarone 150 mg IV over 10 minutes [INT-O, PARA-R]. a. May repeat once as needed. b. Administration of amiodarone, if needed, should follow procainamide in patients with Wolff–Parkinson–White syndrome. viii. Irregular wide complex tachycardia – unstable 1. Deliver a synchronized shock based on manufacturer’s recommendation [INT-R]. 2. For responsive patients, consider sedation. 2. Pediatric management a. Manage airway as necessary [naso/oropharyngeal EMR-R; non-visualized EMR-O, EMT- R; intubation INT-O, PARA-R]. b. Administer oxygen as appropriate with a target of achieving 94–98% saturation [EMR- O, EMT-R; HFNC PARA-O]. c. Initiate monitoring and perform 12-lead EKG [acquire/transmit EMR-O, INT-R; interpret INT-R]. d. Establish IV access [AEMT-R]. e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Guideline [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R]. f. Consider the following additional therapies if tachycardia and symptoms or hemodynamic instability continue: i. Regular narrow complex tachycardia – stable (SVT) 1. Perform vagal maneuvers [EMT-O, AEMT-R] 2. Adenosine 0.1 mg/kg (maximum of 6 mg) [INT-R] a. If unsuccessful, may repeat with 0.2 mg/kg (maximum of 12 mg) ii. Regular narrow complex tachycardia – unstable 1. Deliver a synchronized shock: 0.5–1 J/kg for the first dose [INT-R] 2. Repeat doses should be 2 J/kg iii. Regular, wide complex tachycardia — stable 1. Consider adenosine 0.1 mg/kg (maximum of 6 mg) for SVT with aberrancy [INT- R] 2. Otherwise give amiodarone 5 mg/kg IV (maximum of 150 mg) over 10 minutes [INT-O, PARA-R] iv. Regular, wide complex tachycardia – unstable 1. Synchronized cardioversion 0.5–1.0 J/kg [INT-R] Notes and educational pearls Key considerations 1. Causes: a. Hypovolemia b. Hypoxia c. Hydrogen (acidosis) d. Myocardial infarction e. Hypokalemia/Hyperkalemia f. Hypoglycemia g. Hypothermia h. Toxins/Overdose i. Tamponade j. Tension pneumothorax k. Thrombus – central or peripheral l. Trauma m. Hyperthyroidism 2. A-FIB rarely requires cardioversion in the field. As it is difficult to ascertain the onset of this rhythm, the risk of stroke needs to be considered prior to cardioversion. 3. A wide-complex irregular rhythm should be considered pre-excited A-FIB; extreme care must be taken in these patients. a. Characteristic EKG findings include a short PR interval and, in some cases, a delta wave. b. Avoid AV nodal blocking agents such as adenosine, calcium channel blockers, digoxin, and possibly beta-blockers in patients with pre-excitation A-FIB (e.g., Wolff-Parkinson-White Syndrome, Lown-Ganong-Levine Syndrome) because these drugs may cause a paradoxical increase in the ventricular response. c. Blocking the AV node in some of these patients may lead to impulses that are transmitted exclusively down the accessory pathway, which can result in ventricular fibrillation. d. Amiodarone or procainamide may be used as an alternative. 4. Amiodarone or procainamide can be used as a rate-controlling agent for patients who are intolerant of or unresponsive to other agents, such as patients with CHF who may not otherwise tolerate diltiazem or metoprolol. a. Caution should be exercised in those who are not receiving anticoagulation, as amiodarone can promote cardioversion. 5. Administer metoprolol to patients with SBP greater than 120 mmHg. a. Worsening CHF, chronic obstructive pulmonary disease (COPD), asthma, as well as hypotension and bradycardia can occur with use of metoprolol. 6. Biphasic waveforms have been proven to convert A-FIB at lower energies and higher rates of success than monophasic waveforms. a. Strategies include dose escalation (70, 120, 150, 170 joules (J) for biphasic or 100, 200, 300, 360 J for monophasic) versus beginning with single high energy/highest success rate for single shock delivered. 7. Studies in infants and children have demonstrated the effectiveness of adenosine for the treatment of hemodynamically stable or unstable SVT. 8. Adenosine should be considered the preferred medication for stable SVT. a. Verapamil may be considered as alternative therapy in older children but should not be routinely used in infants. b. Procainamide or amiodarone given by a slow IV infusion with careful hemodynamic monitoring may be considered for refractory SVT. Pertinent assessment findings None noted Patient safety considerations 1. Only use one antidysrhythmic at a time. 2. Patients who receive beta-blockers (e.g., metoprolol) with calcium channel blockers (e.g., diltiazem) are at increased risk for hypotension and bradycardia. 3. If using cardioversion, consider sedation and pain control. 4. With irregular wide complex tachycardia (A-FIB with aberrancy such as Wolff- Parkinson-White and Lown-Ganong Levine), avoid use of AV nodal blocking agents (e.g., adenosine, calcium channel blockers, beta-blockers). 5. Patients with Wolff–Parkinson–White should be given procainamide prior to amiodarone. Suspected stroke/Transient Ischemic Attack Aliases Cerebrovascular Accident (CVA) Transient Ischemic Attack (TIA) Patient care goals 1. Detect neurological deficits using a validated stroke scale. 2. Determine eligibility for transport to a stroke center. 3. Identify patients who have potentially sustained a stroke involving a large vessel occlusion (LVO). 4. Limit scene time and transfer to most appropriate hospital as determined by local stroke plan; acute stroke is a time-sensitive emergency. 5. Activate hospital-based stroke system of care within 10 minutes of stroke recognition. Patient presentation 1. Neurologic deficit such as facial droop, localized weakness, gait disturbance, slurred speech, altered mentation, sudden onset of dizziness/vertigo. 2. Hemiparesis or hemiplegia. 3. Dysconjugate gaze, forced or crossed gaze (if patient is unable to voluntarily respond to exam, makes no discernible effort to respond, or is unresponsive). 4. Severe headache, neck pain/stiffness, difficulty seeing. Inclusion criteria Patient has signs and symptoms consistent with stroke or Transient Ischemic Attack (TIA). Exclusion criteria 1. If glucose less than 60 mg/dL (deciliter), treat per the Hypoglycemia Guideline. 2. If trauma and Glasgow Coma Score (GCS) less than or equal to 13, treat per the Head Injury Guideline and General Trauma Management Guideline. Patient management Assessment 1. Use a validated prehospital stroke scale that may include, but is not limited to: a. Facial smile/grimace – ask patient to smile. b. Arm drift – close eyes and hold out arms for count of 10 seconds. c. Speech – ask patient to say, “You can’t teach an old dog new tricks.” 2. Use a validated prehospital stroke severity scale that may include, but is not limited to: a. Vision changes b. Sensory neglect c. Aphasia 3. Pertinent historical data includes: a. History – “last known well” and source of that information. b. Neurologic status assessment [See Appendix VII. Neurologic Status Assessment]. c. Patient is taking warfarin or any anticoagulant medication. d. History of recent trauma. e. History of recent seizure. f. History of recent surgery. g. History of recent hemorrhage (e.g., GI bleed). 4. Evaluate for the presence of stroke mimics including: a. Hypoglycemia b. Seizure c. Sepsis d. Migraine e. Intoxication Treatment and interventions 1. Determine “last known well” time. 2. Administer oxygen as appropriate with a target of achieving 94–98% saturation [EMR-O, EMT-R; HFNC PARA-O]. 3. If seizure activity present, treat per Seizures Guideline. 4. Check blood glucose level (BGL) [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT- R; IV dextrose AEMT-R]. a. Treat only if glucose less than 60 mg/dL. 5. Acquire 12-lead EKG, if possible and does not delay transport decision; it can also be done enroute [acquire/transmit EMR-O, INT-R; interpret INT-R]. 6. Early hospital notification per local stroke plan that should include any suspected large vessel occlusion (LVO) stroke. Patient safety considerations 1. Prevent aspiration – elevate head of stretcher 15–30 degrees if systolic BP greater than 100 mmHg. a. Maintain head and neck in neutral alignment, without flexing the neck. 2. Protect paralyzed limbs from injury. Notes and educational pearls Key considerations 1. Transport and destination decisions should be based on local resources and stroke system of care. a. Destination hospitals may include: i. Stroke ready ii. Primary stroke center iii. Thrombectomy-capable stroke center iv. Comprehensive stroke center 2. Time of onset of stroke or last known well is critical data for patient treatment. a. Positive stroke scale with time of onset or last known well less than 4½ hours may be eligible for thrombolytic agents. b. Positive stroke severity scale with time of onset or last known well less than 24 hours may be eligible for mechanical thrombectomy. i. Consider transport to hospital capable of mechanical thrombectomy per local stroke plan. 3. Do not treat hypertension. 4. Place on cardiac monitor. 5. Pediatrics: a. Treatment principles remain the same. b. Although rare, pediatric patients can have strokes. c. Stroke scales are not validated for pediatric patients. d. The EMS crew should call ahead to make sure that the hospital can manage the patient. General Medical Abdominal pain Aliases None noted Patient care goals 1. Improve patient comfort. 2. Identify life-threatening causes of abdominal pain. Patient presentation Inclusion criteria Abdominal pain or discomfort related to a non-traumatic cause. Exclusion criteria 1. Abdominal pain due to trauma [See General Trauma Management Guideline]. 2. Abdominal pain due to or related to pregnancy [See OB/GYN Section]. Patient management Assessment 1. Perform airway assessment and management per the Airway Management Guideline. 2. Obtain vital signs including pulse, blood pressure, respiratory rate, neurologic status assessment. 3. Obtain blood glucose if hyperglycemia is suspected per Hyperglycemia Guideline. 4. Provide evaluation and management of pain per the Pain Management Guideline. 5. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation. 6. Assess for life-threatening causes of abdominal pain, which may include: a. Signs and symptoms of ischemic, necrotic, or perforated bowel. i. Severe tenderness ii. Abdominal pain with motion or palpation of the abdomen iii. Fever iv. Bloody stool v. Nausea and vomiting vi. Absence of passage of stool or gas vii. Abdominal distention, with tympany to percussion b. Signs and symptoms of dissecting or ruptured abdominal aortic aneurysm (AAA). i. Unequal femoral or distal lower extremity pulses ii. “Pulsatile” abdominal mass iii. Associated back pain and/or chest pain iv. Known history of abdominal aortic aneurysm c. Signs and symptoms of ruptured ectopic pregnancy. i. Vaginal bleeding ii. Recently diagnosed pregnancy iii. Recent missed period/menstrual cycle in women of childbearing age d. Signs and symptoms of appendicitis. i. Focal right lower quadrant tenderness, possibly with rebound and guarding ii. Right lower quadrant tenderness noted during palpation of the left lower quadrant (positive Rovsing’s sign) iii. Peri-umbilical or diffuse abdominal tenderness with palpation of the abdomen/pelvis iv. Fever v. Nausea, vomiting vi. Lack of appetite e. Signs and symptoms of acute cholecystitis. i. Right upper quadrant or epigastric tenderness ii. Fever iii. Nausea and vomiting iv. History of gallstones f. Signs and symptoms of pyelonephritis. i. Fever ii. Nausea, vomiting iii. Urinary frequency/urgency iv. Dysuria v. Hematuria vi. Back/flank pain vii. Costovertebral angle tenderness to percussion 7. Assess for signs of shock. a. If shock is present, provide treatment per appropriate Shock Guideline. 8. Assess for other non-life-threatening causes of abdominal pain. a. Signs and symptoms of kidney stone i. Unilateral flank pain ii. Nausea, vomiting iii. Hematuria Treatment and interventions 1. Medication administration: a. Provide analgesia per the Pain Management Guideline (see guideline). b. Administer antiemetics per the Nausea-Vomiting Guideline (see guideline). c. Provide transport to an appropriate receiving facility. Consider specialty destination centers for conditions such as suspected abdominal aortic aneurysm and aortic dissection. d. Reassess vital signs [EMR-R] and response to therapeutic interventions throughout transport. Patient safety considerations Abdominal pain in older adults, patients with bleeding disorders, patients on anticoagulation medications, children less than 2 years old and patients that are immunocompromised may be a harbinger for severe illness. Notes and educational pearls Key considerations 1. Assess for life-threatening causes of abdominal pain. 2. Provide appropriate treatment for pain, vomiting, and shock. 3. Consider transport to a specialty surgical center if aortic aneurysm or aortic dissection is suspected. Pertinent assessment findings 1. Rebound tenderness 2. Guarding 3. Abdominal distension 4. Abdominal tympany to percussion 5. Tenderness focal to a specific abdominal quadrant 6. Presence of “pulsatile” abdominal mass 7. Absence of or significant inequality of femoral or distal arterial pulses in lower extremities 8. Hyper or hypothermia 9. Rectal bleeding, hematemesis, vaginal bleeding 10. Jaundice Abuse and maltreatment Aliases Maltreatment of vulnerable populations Non-accidental trauma Definitions 1. Abuse/maltreatment: Any act or series of acts of commission or omission by a caregiver or person in a position of power over the patient that results in harm, potential for harm, or threat of harm to a patient of any age group. EMS clinicians should have a heightened awareness for vulnerable populations which include, but is not limited to, children, elderly, and adults with mental or physical disabilities. 2. Child abuse/maltreatment: Child maltreatment includes any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. An act of commission (child abuse) is the physical, sexual, or emotional maltreatment or neglect of a child or children. An act of omission (child neglect) includes, but is not limited to, failure to provide for the child’s needs (e.g., physical, emotional, medical/dental, and educational neglect) and failure to supervise (e.g., inadequate supervision or safety precautions, lack of appropriate car seat use, and exposure to violent or dangerous environments). 3. Human trafficking: When people are abducted or coerced into service (e.g., being forced into servitude without compensation and/or prostitution). Signs may include, but are not limited to, patient with branding/tattoos and environmental clues such as padlocks and/or doorknobs removed on interior doors and intact windows that are boarded up. Patient care goals 1. Recognize any act or series of acts of commission or omission by a caregiver or person in a position of power over the patient that results in harm, potential for harm, or threat of harm to a patient. 2. Take appropriate steps to protect the safety of the responders as well as bystanders. 3. Remove the patient from immediate danger. 4. Assess any patient injuries that may be the result of acute or chronic events. 5. Attempt to preserve evidence whenever possible; however, the overriding concern should be providing appropriate emergency care to the patient. 6. Complete all mandatory reporting requirements per state guidelines. Patient presentation 1. Clues to abuse or maltreatment can vary with age group of the patient and type of abuse. 2. Not all abuse or maltreatment is physical. 3. EMS role is to: a. Document concerns. b. Assess potentially serious injuries. c. Disclose concerns to appropriate authorities. d. Initiate help to get the patient and any other vulnerable individuals at the scene into a safe situation. e. Not to investigate or intervene beyond the steps above. f. Leave further intervention to law enforcement personnel. Inclusion/exclusion criteria Absolute inclusion/exclusion criteria are not possible in this area. Rather, clues consistent with different types of abuse/maltreatment should be sought: 1. Potential clues to abuse/maltreatment from caregivers or general environment: a. Caregiver apathy about patient’s current situation. b. Caregiver overreaction to questions about situation. c. Inconsistent histories from caregivers or bystanders regarding what happened. d. Information provided by caregivers or patient that is not consistent with injury patterns. e. Injuries not appropriate for patient’s age or physical abilities (e.g., infants with injuries usually associated with ambulatory children, elders who have limited mobility with injury mechanisms inconsistent with their capabilities). f. Caregiver not allowing adult patient to speak for themselves, or who appears controlling – pay special attention to patients who cannot communicate due to young age or language and/or cultural barriers. g. Inadequate safety precautions or facilities where the patient lives and/or evidence of security measures that appear to confine the patient inappropriately. 2. Potential clues to abuse or maltreatment that can be obtained from the patient: a. Multiple bruises in various stages of healing. b. Age-inappropriate behavior (e.g., adults who are submissive or fearful, children who act in a sexually inappropriate way). c. Pattern burns, bruises, or scars suggestive of specific weaponry used. d. Evidence of medical neglect for injuries or infections. e. Unexplained trauma to genitourinary systems or frequent infections to this system. f. Evidence of malnourishment and/or serious dental problems. 3. Have a high index of suspicion for abuse in children presenting with a Brief Resolved Unexplained Event (BRUE) [See Brief Resolved Unexplained Event (BRUE) & Acute Events in Infants Guideline]. Patient management Assessment 1. Primary survey and identify any potentially life-threatening issues. 2. Document thorough secondary survey to identify clues of for potential abuse/maltreatment: a. Multiple bruises in various stages of healing. A complete skin exam can help identify suggestive findings that would otherwise be missed. b. Age-inappropriate behavior (e.g., adults who are submissive or fearful, children who act in a sexually inappropriate way). c. Pattern burns, bruises, or scars suggestive of specific weaponry used. d. Evidence of medical neglect for injuries or infections. e. Unexplained trauma to genitourinary systems or frequent infections to this system. f. Evidence of malnourishment and/or serious dental problems. 3. Assess physical issues and avoid extensive investigation of the specifics of abuse or maltreatment, but document any statements made spontaneously by patient. a. Avoid asking directed questions of a child Treatment and interventions 1. Address life-threatening issues. 2. Remove the patient to a safe place even if no medical indication for transport. 3. Report concerns about potential abuse/maltreatment to law enforcement immediately, in accordance with state law, including: a. Caregivers impeding your ability to assess/transport patient. b. Caregivers refusing care for the patient. 4. For patients transported, report concerns to hospital and/or law enforcement personnel (including Child Protective Services agencies where appropriate) per mandatory reporting laws. Patient safety considerations 1. If no medical emergency exists, the next priority is safe patient disposition/removal from the potentially abusive situation. 2. Do not confront suspected perpetrators of abuse/maltreatment. This can create an unsafe situation for EMS and for the patient. 3. In situations of parental or religious objections to life-saving medical care when EMS suspects abuse, law enforcement should be notified for assistance. Notes and educational pearls Key considerations 1. All states have specific mandatory reporting laws that dictate which specific crimes such as suspected abuse or maltreatment must be reported and to whom they must be reported. It is important to be familiar with the specific laws in your state including specifically who must make disclosures, what the thresholds are for disclosures, and to whom the disclosures must be made. 2. Clues to abuse or maltreatment can vary depending on the age group of the patient and on the nature of the abuse. Remember that not all abuse or maltreatment involves physical harm. EMS clinicians are often unique in being the only members of the medical team to observe the home environment or injury scene. It is important to realize that the job of EMS is to document their concerns, assess the patient for potentially serious injuries, make sure that their concerns are disclosed to the appropriate legal authorities, and work towards getting the patient into a safe situation. EMS personnel should not take it upon themselves to investigate, interview, or intervene above and beyond those concepts and should leave further intervention to the appropriate law enforcement personnel. 3. Abuse and maltreatment can happen to patients of all ages. 4. Patients may be unwilling or unable to disclose abuse or maltreatment, so the responsibility falls on EMS personnel to assess the situation, document appropriately, and take appropriate action to secure a safe place for the patient. 5. Document findings by describing what you see and not ascribing possible causes (e.g., “0.5- inch round burn to back” as opposed to “burn consistent with cigarette burn”). Pertinent assessment findings As noted above Agitated or violent patient/behavioral emergency Aliases Acute psychosis Patient restraint Patient care goals 1. Provision of emergency medical care to the agitated, violent, or uncooperative patient. 2. Maximizing and maintaining safety for the patient, EMS personnel, and others. Patient presentation Inclusion criteria Patients of all ages who are exhibiting agitated or violent behavior, are a danger to self or others and in the sole assessment of the EMS clinician require physical and/or pharmacologic restraint to mitigate injury to self or others. Exclusion criteria 1. Patients exhibiting agitated or violent behavior due to medical conditions including, but not limited to: a. Head injury. b. Metabolic disorders (e.g., hypoglycemia, hypoxia). Patient management Assessment 1. Note medications/substances on scene that may contribute to the agitation, or may be relevant to the treatment of a contributing medical condition. 2. Maintain and support airway. 3. Note respiratory rate and effort – If possible, monitor pulse oximetry and/or capnography. 4. Assess circulatory status: a. Blood pressure (if possible) b. Pulse rate c. Capillary refill 5. Assess mental status. a. Check blood glucose (if possible) 6. Obtain temperature (if possible). 7. Assess for evidence of traumatic injuries. 8. Use a validated risk assessment tool such as RASS (Richmond Agitation Sedation Score), AMSS (Altered Mental Status Score), or BARS (Behavioral Activity Rating Scale) to risk stratify violent patients to help guide interventions. Treatment and interventions 1. Establish patient rapport a. Attempt verbal reassurance and calm patient prior to use of pharmacologic and/or physical management devices. b. Engage family members/loved ones to encourage patient cooperation if their presence does not exacerbate the patient’s agitation. c. Continued verbal reassurance and calming of patient following use of chemical/physical management devices. 2. Pharmacologic management a. Notes: i. Selection of medications for pharmacologic management should be based upon the patient’s clinical condition, current medications, and allergies in addition to EMS resources and medical direction. ii. The medications are annotated to indicate when they are preferred for patients that are particularly high-risk for violence as assessed by a validated scale – note that the dosing can be adjusted to achieve different levels of sedation. iii. The numbering of medications below is not intended to indicate a hierarchy/preference of administration. b. Benzodiazepines i. Diazepam [INT-O] 1. Adults: a. 5 mg IV; (2–5 minute onset of action) OR b. 10 mg IM; (15–30 minute onset of action) 2. Pediatrics: a. 0.05–0.1 mg/kg IV (maximum dose is 5 mg) OR b. 0.1–0.2 mg/kg IM (maximum dose is 10 mg) ii. Lorazepam [INT-O] 1. Adults: a. 2 mg IV; (2–5 minute onset of action) OR b. 4 mg IM; (15–30 minute onset of action) 2. Pediatrics: a. 0.05 mg/kg IV (maximum dose is 2 mg) OR b. 0.05 mg/kg IM (maximum dose is 2 mg) iii. Midazolam [INT-O] 1. Adults: a. 5 mg IV; (3–5 minute onset of action) OR b. 5 mg IM; (10–15 minute onset of action) OR c. 5 mg IN; (3–5 minute onset of action) 2. Pediatrics: a. 0.05–0.1 mg/kg IV (maximum dose 5 mg) OR b. 0.1–0.15 mg/kg IM (maximum dose is 5 mg) OR c. 0.3 mg/kg IN (maximum dose is 5 mg) c. Antipsychotics i. Droperidol (option for high violence risk) [PARA-O] 1. Adults: a. 2.5 mg IV; 10-minute onset of action OR b. 5–10 mg IM; 20-minute onset of action 2. Pediatrics: Not routinely recommended ii. Haloperidol (Limited data available, optimal dose not established) [PARA-O] 1. Adults: a. 5 mg IV; (5–10 minute onset of action) OR b. 5–10 mg IM; (10–20 minute onset of action) 2. Pediatrics: Age 6–12 years old: 1–3 mg IM (maximum dose 0.15 mg/kg) iii. Olanzapine [PAPA-O] (Note: Concurrent use of IM/IV benzodiazepines and olanzapine IM is not recommended as fatalities have been reported) 1. Adults: a. 10 mg IM; (15–30 minute onset of action) b. 10 mg ODT PO or SL 2. Pediatrics: a. Age 6–11 years old: 5 mg IM (limited data available for pediatric use) b. Age 12–18 years old: 10 mg IM c. Age 6–18 years old: 5 mg ODT PO or SL iv. Ziprasidone [PARA-O] 1. Adults: 10 mg IM; (10-minute onset of action) 2. Pediatrics: a. Age 6–11 years old: 5 mg IM (limited data available for pediatric use) b. Age 12–18 years old: 10 mg IM d. Dissociative Agents (provide sedation and anesthesia) i. Ketamine (option for high violence risk) [PARA-O] 1. Adults: a. 2 mg/kg IV; (1 minute onset of action) OR b. 4 mg/kg IM; (3–5 minute onset of action) 2. Pediatrics: a. 1 mg/kg IV OR b. 3 mg/kg IM e. Antihistamines i. Diphenhydramine [PARA-O] 1. Adults: 25–50 mg IM/IV/PO 2. Pediatrics: 1 mg/kg IM/IV/PO (maximum dose of 25 mg) 2. Physical Management Devices [EMR-O, EMT-R] a. Body i. Stretcher straps should be applied as the standard procedure for all patients during transport. ii. Physical management devices, including stretcher straps, should never restrict the patient’s chest wall motion. iii. If necessary, sheets may be used as improvised supplemental stretcher straps. Other forms of improvised physical management devices should be discouraged. iv. Supplemental straps or sheets may be necessary to prevent flexion/extension of torso, hips, legs by being placed around the lower lumbar region, below the buttocks, and over the thighs, knees, and legs. b. Extremities i. Soft or leather devices should not require a key to release them. ii. Secure all four extremities to maximize safety for patient, staff, and others. iii. Secure all extremities to the stationary frame of the stretcher. iv. Multiple knots should not be used to secure a device. Patient safety considerations The management of violent patients requires a constant reevaluation of the risk/benefit balance for the patient and bystanders to provide the safest care for all involved. These are complex and high- risk encounters. There is no “one size fits all” solution for addressing these patients. 1. Don PPE. 2. Do not attempt to enter or control a scene where physical violence or weapons are present. 3. Dispatch law enforcement immediately to secure and maintain scene safety. 4. Urgent de-escalation of patient agitation is imperative in the interest of patient safety as well as for EMS personnel and others on scene. 5. Uncontrolled or poorly controlled patient agitation and physical violence can place the patient at risk for sudden cardiopulmonary arrest due to the following etiologies: a. Delirium with agitated behavior: A postmortem diagnosis of exclusion for sudden death thought to result from metabolic acidosis (most likely from lactate) stemming from physical agitation or physical control measures and potentially exacerbated by stimulant drugs (e.g., cocaine) or alcohol withdrawal. b. Positional asphyxia: Sudden death from restriction of chest wall movement and/or obstruction of the airway secondary to restricted head or neck positioning resulting in hypercarbia and/or hypoxia. 6. Apply a cardiac monitor as soon as possible, particularly when pharmacologic management medications have been administered. 7. All patients who have received pharmacologic management medications must be monitored closely for the development of hypoventilation and over sedation. a. Utilize capnography if available 8. Patients who have received antipsychotic medication for pharmacologic management must be monitored closely for the potential development of: a. Dystonic reactions (this can easily be treated with diphenhydramine/benzodiazepines). b. Mydriasis (dilated pupils). c. Ataxia. d. Cessation of perspiration. e. Dry mucous membranes. f. Cardiac arrhythmias (particularly QT prolongation). 9. Patients who require physical management should also receive pharmacological treatment for agitation to prevent consequences of delirium with agitated behavior. 10. Placement of stretcher in sitting position prevents aspiration and reduces the patient’s physical strength by placing the abdominal muscles in the flexed position. 11. Patients who are more physically uncooperative should be physically secured with one arm above the head and the other arm below the waist, and both lower extremities individually secured. 12. The following techniques should be expressly prohibited for use by EMS clinicians: a. Secure or transport in a prone position with or without hands and feet behind the back (hobbling or “hog-tying”). b. "Sandwiching” patients between backboards. c. Techniques that constrict the neck or compromise the airway. Notes and educational pearls Key considerations 1. Direct medical direction should be contacted at any time for advice, especially when patient’s level of agitation is such that transport may place all parties at risk. 2. Transport by air is not advised. 3. Stretchers with adequate foam padding, particularly around the head, facilitates patient’s ability to self-position the head and neck to maintain airway patency. 4. For patients with key-locking devices, applied by another agency, consider the following options: a. Remove device and replace it with a device that does not require a key. b. Administer pharmacologic management medication then remove and replace device with another non-key-locking device after patient has become more cooperative. c. Transport patient accompanied in patient compartment by person who has device key. d. Transport patient in the vehicle of person who has the device key if medical condition of patient is deemed stable, direct medical direction so authorizes, and law allows. Pertinent assessment findings 1. Continuous monitoring of: a. Airway patency. b. Respiratory status with pulse oximetry and/or capnography. c. Circulatory status with frequent blood pressure measurements. d. Mental status and trends in level of patient cooperation. e. Cardiac status, especially if the patient has received pharmacologic management medication. f. Extremity perfusion with capillary refill in patients in physical management device. Anaphylaxis and allergic reaction (Adapted from an evidence-based guideline created using the National Prehospital Evidence- Based Prehospital Guideline Model Process) Aliases Anaphylactic shock Patient care goals 1. Provide timely therapy for potentially life-threatening reactions to known or suspected allergens to prevent cardiorespiratory collapse and shock. 2. Provide symptomatic relief for symptoms due to known or suspected allergens. Patient presentation Inclusion criteria Patients of all ages with suspected allergic reaction and/or anaphylaxis. Exclusion criteria None noted Patient management Assessment 1. Evaluate for patent airway and presence of oropharyngeal edema. 2. Auscultate for wheezing and assess level of respiratory effort. 3. Assess for adequacy of perfusion. 4. Assess for presence of signs and symptoms of anaphylaxis. a. Anaphylaxis – More severe and is characterized by an acute onset involving: i. The skin (urticaria) and/or mucosa with either respiratory compromise or decreased BP or signs of end-organ dysfunction. OR ii. Hypotension for that patient after exposure to a known allergen. 1. Adults: Systolic BP less than 90 2. Pediatrics: See Appendix VIII. Abnormal Vital Signs OR iii. Two or more of the following occurring rapidly after exposure to a likely allergen: 1. Skin and/or mucosal involvement (urticaria, itchy, swollen tongue/lips) a. Skin involvement may be ABSENT in up to 40% of cases of anaphylaxis 2. Respiratory compromise (dyspnea, wheezing, stridor, hypoxemia) 3. Persistent gastrointestinal symptoms (vomiting, abdominal pain, diarrhea) 4. Hypotension or associated symptoms (syncope, hypotonia, chest tightness, incontinence) b. Non-anaphylactic allergic reaction i. Signs involving only one organ system (e.g., localized angioedema that does not compromise the airway, or not associated with vomiting; hives alone) Treatment and interventions 1. If signs of allergic reaction without signs of anaphylaxis, go to Step 8. 2. Epinephrine administration is the primary treatment for anaphylaxis. If signs of anaphylaxis, administer epinephrine 1 mg/mL at the following dose and route [EMR-O, EMT-R]: a. Adult (25 kg or more) 0.3 mg IM in the anterolateral thigh b. Pediatric (less than 25 kg) 0.15 mg in the anterolateral thigh c. Epinephrine 1 mg/mL may be administered from a vial or via auto-injector, if available 3. If respiratory distress with wheezing is present, consider administering: a. Albuterol 2.5–5 mg nebulized [EMR-O, EMT-R]. AND/OR b. Epinephrine 1 mg/mL, 5 mL nebulized [EMT-O]. 4. If stridor is present, consider administering epinephrine 1 mg/mL, 5 mL nebulized [EMT-O]. 5. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine, additional IM epinephrine can be repeated q5–15 minutes at above noted doses. 6. For signs of hypoperfusion, also administer 20 mL/kg isotonic fluid (normal saline or lactated Ringer’s) rapidly (over 15 minutes) via IV or IO, and repeat as needed for ongoing hypoperfusion [AEMT-R]. 7. Consider an epinephrine IV drip (0.5 mcg/kg/minute) when cardiovascular collapse (hypotension with altered mental status, pallor, diaphoresis and/or delayed capillary refill) is present despite repeated IM doses of epinephrine in conjunction with at least 60 mL/kg isotonic fluid boluses [PARA-O]. 8. For urticaria or pruritus, administer a diphenhydramine 1 mg/kg, up to maximum dose of 50 mg IM, IV, or PO) [PARA-O]. a. The IV route is preferred for the patient in severe symptoms. b. As a supplement to diphenhydramine given for urticaria, any H2-blocking antihistamine (e.g., famotidine, cimetidine) can be given IV or PO in conjunction with diphenhydramine [PARA-O]. 9. Transport as soon as possible, and perform ongoing assessment as indicated. Cardiac monitoring is not required, but should be con sidered for those with known heart problems or who received multiple doses of epinephrine. Patient safety considerations 1. Time to epinephrine delivery 2. Concentration of epinephrine in relation to route 3. Weight-based dosing of medications Notes and educational pearls Key considerations 1. When anaphylaxis is suspected, EMS personnel should always consider epinephrine as first- line treatment. 2. Allergic reactions and anaphylaxis are serious and potentially life-threatening medical emergencies. It is the body’s adverse reaction to a foreign protein (e.g., food, medicine, pollen, insect sting or any ingested, inhaled, or injected substance). A localized allergic reaction (e.g., urticaria or angioedema that does not compromise the airway) may be treated with antihistamine therapy. Cardiovascular collapse may occur abruptly, without the prior development of skin or respiratory symptoms. Constant monitoring of the patient’s airway and breathing is essential. 3. Contrary to common belief that all cases of anaphylaxis present with cutaneous manifestations, such as urticaria or mucocutaneous swelling, a significant portion of anaphylactic episodes may not inv olve these signs and symptoms on initial presentation. Moreover, most fatal reactions to food -induced anaphylaxis in children were not associated with cutaneous manifestations. 4. A thorough assessment and a high index of suspicion are required for all potential allergic reaction patients – consider: a. History of present illness. i. Onset and location ii. Insect sting or bite iii. Food allergy/exposure iv. New clothing, soap, detergent v. Past history of reactions vi. Medication history b. Signs and symptoms. i. Itching or urticaria ii. Coughing, wheezing, or respiratory distress iii. Chest tightness or throat constriction iv. Hypotension or shock v. Persistent gastrointestinal symptoms (nausea, vomiting, and diarrhea) vi. Altered mental status (AMS) c. Other considerations. i. Angioedema (drug-induced) ii. Aspiration/airway obstruction iii. Vasovagal event iv. Asthma or chronic obstructive pulmonary disease (COPD) v. Heart failure 5. Gastrointestinal symptoms occur most commonly in food-induced anaphylaxis, but can occur with other causes. a. Oral pruritus is often the first symptom observed in patients experiencing food- induced anaphylaxis. b. Abdominal cramping is also common, but nausea, vomiting, and diarrhea are frequently observed as well. 6. Patients with asthma are at high-risk for a severe allergic reaction. 7. There is no proven benefit to using steroids in the management of allergic reactions and/or anaphylaxis. 8. There is controversy among experts with very low-quality evidence to guide management for the use of empiric IM epinephrine after exposure to a known allergen in asymptomatic patients with a history of prior anaphylaxis. Pertinent assessment findings 1. Presence or absence of angioedema 2. Presence or absence of respiratory compromise 3. Presence or absence of circulatory compromise 4. Localized or generalized urticaria 5. Response to therapy Altered mental status Aliases Altered level of consciousness Confusion Patient care goals 1. Identify treatable causes. 2. Perform appropriate assessment and diagnostics (e.g., oxygen saturation, glucose check, and monitor). 3. Protect patient from complications of altered mental status (e.g., respiratory failure, shock, cardiopulmonary arrest). Patient presentation Inclusion criteria Impaired decision-making capacity Exclusion criteria Traumatic brain injury Patient management Assessment Look for treatable causes of altered mental status (AMS): 1. Airway: Make sure airway remains patent; reposition patient as needed 2. Breathing: Look for respiratory depression; check SPO2, EtCO2, and CO detector readings 3. Circulation: Look for signs of poor perfusion 4. Glasgow Coma Score and/or AVPU 5. Pupils 6. Head and neck: Evaluate for signs of trauma 7. Neck: Rigidity or pain with range of motion 8. Stroke assessment tool including focal neurologic findings 9. Blood glucose level 10. EKG or cardiac monitor: arrhythmia limiting perfusion 11. Breath odor: Possible unusual odors include alcohol, acidosis, ammonia 12. Chest/Abdominal: Intra-thoracic hardware, assist devices, abdominal pain or distention, signs of trauma 13. Extremities/skin: Track marks, hydration, edema, dialysis shunt, temperature to touch (or if able, use a thermometer), signs of trauma 14. Signs of infection: Fever, cough, skin changes, dysuria 15. Environment: Survey for pills, paraphernalia, substance use, medication patches, medical devices, ambient temperature, social indicators of neglect, carbon monoxide exposures, multiple casualties with same complaint Treatment and interventions (include scopes here or in linked guidelines?) 1. Oxygen [Refer to Universal Care Guideline] 2. Glucose [Refer to Hypoglycemia Guideline or Hyperglycemia Guideline] 3. Naloxone [Refer to Opioid Poisoning/Overdose Guideline] 4. Restraint: physical and chemical [See Agitated or Violent Patient/Behavioral Emergency Guideline] 5. Anti-dysrhythmic medication [See Cardiovascular Section for specific dysrhythmia guidelines] 6. Active cooling or warming [See Hypothermia/Cold Exposure Guideline or Hyperthermia/Heat Exposure Guideline] 7. IV fluids [See fluid administration doses in Shock Guideline and Hypoglycemia Guideline or Hyperglycemia Guideline] 8. Vasopressors [See Shock Guideline] Patient safety considerations 1. With depressed mental status, initial focus is on airway protection, oxygenation, ventilation, and perfusion. 2. The violent patient may need pharmacologic and/or physical management to insure proper assessment and treatment. 3. Hypoglycemic and hypoxic patients can be irritable and violent [See Agitated or Violent Patient/Behavioral Emergency Guideline]. Notes and educational pearls Key considerations 1. History from bystanders and caregivers 2. Age of the patient 3. Development age and baseline functional status 4. Consider the following differential using the mnemonic AEIOU-TIPS: A – Alcohol, Abuse, Atypical migraine E – Epilepsy, Electrolytes I – Insulin (hypoglycemia) O – Oxygen, Overdose U – Uremia (kidney failure) T – Trauma, Tumor I – Infection P – Psych, Poisoning S – Seizure, Subarachnoid hemorrhage, Sepsis 5. Environment where patient found 6. Recent complaints (e.g., headache, chest pain, difficulty breathing, vomiting, fever) 7. Medical alert tags and accessory medical devices 8. Evaluate for reduced PO intake and/or vomiting and/or diarrhea or dehydration as a cause of AMS in the pediatric and geriatric populations 9. Evidence of ingestion or topical placement (e.g., pill bottles/medications, patches, detergent pods) 10. Medications a child may have access to including but not limited to (includes patches, drops, pills, injectables): a. Analgesics b. Antidepressants c. Antihypertensives/Cardiac medications d. Oral hypoglycemic e. Opioids f. Benzodiazepines g. Antiepileptics h. Prenatal vitamins 11. Substance use in the home (e.g., tobacco, marijuana, cocaine, amphetamines, PCP, alcohol) 12. Use of herbal or holistic medications Pertinent assessment findings 1. Track marks 2. Breath odor 3. Skin temperature 4. Rash and/or petechiae 5. Evidence of trauma 6. Focal neurologic changes 7. Location Back pain Aliases None noted Patient care goals 1. Improve patient discomfort 2. Identify life-threatening causes of back pain Patient presentation Inclusion criteria Back pain or discomfort related to a non-traumatic cause Exclusion criteria 1. Back pain from spinal trauma [See Trauma Section] 2. Back pain due to sickle cell pain crisis [See Sickle Cell Pain Crisis Guideline] 3. Back pain from suspected labor [See OB/GYN Section] Patient management Assessment 1. Perform airway assessment and management, per the Airway Management Guideline. 2. Obtain vital signs including pulse, blood pressure, respiratory rate, neurologic status assessment, pulse oximetry, temperature. 3. Provide evaluation and management of pain, per the Pain Management Guideline. 4. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation. 5. Assess for life-threatening causes of back pain, which may include: a. Spinal cord compression (e.g., from spinal epidural abscess, malignancy, spinal epidural hematoma for patients on anticoagulants). i. Urinary and/or bowel incontinence ii. Inability to walk due to weakness iii. New neurologic deficits in extremities iv. Loss of sensation in saddle distribution b. Aortic dissection or ruptured abdominal aortic aneurysm. i. Unequal femoral or distal lower extremity pulses ii. “Pulsatile” abdominal mass iii. Associated abdominal pain and/or chest pain iv. Known history of abdominal aortic aneurysm or dissection c. Pyelonephritis. i. Fever ii. Nausea, vomiting iii. Urinary frequency/urgency iv. Dysuria v. Hematuria vi. Abdominal pain vii. Costovertebral angle tenderness to percussion 6. Assess for signs of shock. If shock is present, provide treatment per appropriate Shock Guideline. 7. Assess for other non-life-threatening causes of back pain. a. Kidney stone i. Unilateral flank pain ii. Nausea, vomiting iii. Possible hematuria iv. History of kidney stones Treatment and interventions 1. Medication Administration a. Provide analgesia, per Pain Management Guideline. b. Administer antiemetics, per Nausea-Vomiting Guideline. c. Provide transport to an appropriate receiving facility. Consider specialty destination centers for conditions such as suspected aortic emergency. d. Reassess vital signs and response to therapeutic interventions throughout transport [EMR-R]. Patient safety considerations None noted Notes and educational pearls Key considerations 1. Assess for life-threatening causes of back pain. 2. Provide appropriate treatment for pain, vomiting, and shock. 3. Consider transport to appropriate specialty center if aortic emergency suspected. 4. Back and abdominal pain can often coexist with similar disease processes. 5. Identify patients on anticoagulants since they are higher risk for spinal epidural hematoma or retroperitoneal hemorrhage which can present as back pain. 6. Identify patients with intravenous drug abuse (IVDA) history and/or impaired immune system since they are higher risk for spinal epidural abscess. 7. Identify patients with a history of cancer or with one suspicious for cancer – spinal metastases can cause spinal cord compression. 8. Identify older adults or patients with prolonged use of corticosteroids at risk for vertebral body compression fracture. Pertinent assessment findings 1. Midline back tenderness 2. Back erythema or swelling 3. Motor and/or sensory loss in arms or legs 4. Loss of perianal sensation 5. Absence of or significant inequality of femoral or distal arterial pulses in lower extremities 6. Hyper or hypothermia 7. Rectal bleeding or hematemesis End-of-life care/hospice care Aliases None noted Patient care goals 1. When providing care for a patient near end-of-life: a. Provide relief from pain and other distressing symptoms. b. Affirm dying as a normal process. c. Integrate psychological and spiritual aspects of patient care. d. Offer a support system to help the family cope during the patient’s illness and in their own bereavement. Patient presentation Inclusion criteria Patients enrolled in hospice or end-of-life care, or who have advance care directives, experiencing complaints related to the illness for which the patient is receiving those services. Exclusion criteria Complaints unrelated to the illness for which the patient is receiving those services. Patient management Assessment, treatment, and interventions 1. Perform general patient management. 2. Engage with the patient’s hospice or end-of-life care team or their primary care physician if possible. If not a viable option, contact medical direction. 3. If the patient can communicate and has the capacity to make decisions regarding treatment and transport, consult directly with the patient before treatment and/or transport. If patient is not able to communicate their wishes, may utilize other end of life documents in coordination with medical direction. 4. If the patient requires pain relief [See Pain Management Guideline]. a. Opioid medications are frequently the most appropriate choices for pain management. b. Multimodal analgesia may be required for pain relief. c. Do not withhold opioids for fear of respiratory depression as patient comfort is the primary goal for hospice and end-of-life care. 5. If the patient is experiencing severe respiratory distress, consider: a. Oxygen and bedside/handheld fan [EMR-O, EMT-R; HFNC PARA-O]. b. Noninvasive ventilation (BiPAP/CPAP) if aligned with patient care goals [EMT-O, AEMT- R]. c. Opioids are the drug of choice for dyspnea for hospice and end-of-life care. Morphine 1–5mg IV, IM [INT-O] OR Fentanyl 0.5–1mcg/kg IV/IM/IN (maximum initial dose of 100mcg) [INT-O] OR d. Hydromorphone [PARA-O] 0.015 mg/kg IM, IV or IO (maximum initial dose 2 mg; maximum cumulative dose of 4mg) e. Anxiolytic if needed for anxiety: Benzodiazepines (diazepam, lorazepam, midazolam) [INT-O] 6. If the patient has nausea [See Nausea-Vomiting Guideline]. 7. If the patient has excessive secretions or aspiration, provide suctioning [oral EMR-R; trach EMR-O, EMT-R]. 8. If the patient is anxious or has delirium, in addition to nonpharmacologic interventions such as creating a quiet environment, frequent reassurance, touch and verbal orientation, consider: a. Benzodiazepines (diazepam, lorazepam, midazolam) [INT-O] OR b. Haloperidol 5 mg PO/IM/IV (pediatric: 0.5-1 mg) [PARA-O] OR c. Ziprasidone 20 mg IM (pediatric 5 years old or older 0.2 mg/kg IM [PARA-O] 9. If the patient appears dehydrated a. Encourage PO fluid intake if patient can swallow b. If available, offer ice chips and swabs soaked in ice water c. Consider administration of normal saline at 10–20 mL/kg IV [AEMT-R] 10. In collaboration with hospice or end-of-life care clinician, coordinate with guardian, power of attorney, or other accepted health care proxy if non-transport is considered. Patient safety considerations 1. Careful and thorough assessments should be performed to identify complaints not related to the illness for which the patient is receiving hospice or end-of-life care. 2. Care should be delivered with the utmost patience and compassion. Notes and educational pearls Key considerations 1. Social interactions with family may affect end-of-life care. 2. Scene safety should be considered when deciding on management. Pertinent assessment findings 1. Vital signs 2. Pain score 3. Neurologic exam 4. Lung sounds Hyperglycemia Aliases Diabetes Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic state (HHS) Patient care goals 1. Limit morbidity from hyperglycemia by: a. Appropriate use of glucose monitoring. b. Appropriate hydration for hyperglycemia. Patient presentation Inclusion criteria 1. Adult or pediatric patient with altered level of consciousness [See Altered Mental Status Guideline]. 2. Adult or pediatric patient with stroke symptoms (e.g., hemiparesis, dysarthria) [See Suspected Stroke/Transient Ischemic Attack Guideline]. 3. Adult or pediatric patient with seizure [See Seizures Guideline]. 4. Adult or pediatric patient with symptoms of hyperglycemia (e.g., polyuria, polydipsia, weakness, dizziness, abdominal pain, tachypnea). 5. Adult or pediatric patient with history of diabetes and other medical symptoms,. Exclusion criteria Patient in cardiac arrest Patient management Assessment 1. Monitoring: a. Check blood glucose level [EMR-O, EMT-R] 2. Secondary survey pertinent to altered blood glucose level: a. Constitutional: assess for tachycardia, hypotension, and tachypnea b. Eyes: assess for sunken eyes from dehydration c. Nose/mouth/ears: assess for dry mucous membranes or tongue bite from seizure d. Abdominal pain including nausea and vomiting especially in children e. Neurologic: i. Assess Glasgow Coma Score (GCS) and mental status ii. Assess for focal neurologic deficit: motor and sensory 3. Evaluate for possible concomitant sepsis and septic shock [See Shock Guideline]. 4. Obtain 12-lead EKG to assess for findings consistent with hyperkalemia or acute coronary syndrome [EMR-O, EMTB-O, AEMT-O, Para-R]. Treatment and interventions 1. If altered level of consciousness, stroke, or sepsis/septic shock, treat per Altered Mental Status Guideline, Suspected Stroke/Transient Ischemic Attack Guideline, or Shock Guideline accordingly. 2. If glucose greater than 250 mg/dL with symptoms of dehydration, vomiting, abdominal pain, or altered level of consciousness: a. Provide volume expansion with normal saline bolus [AEMT-R],. i. Adult: Normal saline 20 mL/kg at rate of 1000 mL/hr; if symptoms of hypovolemic shock, follow Shock Guideline. ii. Pediatric: Normal saline 10 mL/kg bolus IV, reassess, and repeat up to 40 mL/kg total; if symptoms of hypovolemic shock, follow Shock Guideline. 3. Reassess patient a. Reassess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) [EMR-R], mental status, and signs of dehydration. b. If mental status changes, reassess blood glucose level and provide appropriate treatment if hypoglycemia has developed [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R]. 4. Disposition a. Transport to closest appropriate receiving facility. Patient safety considerations 1. Overly aggressive administration of fluid in hyperglycemic patients may cause cerebral edema or dangerous hyponatremia. Cerebral edema is a leading cause of death in children with DKA but is very rare in adults. a. Closely monitor for signs of altered mental status, increased intracranial pressure, and immediately discontinue IV fluids and elevate head of bed if signs of increased ICP develop. b. Reassess and manage airway as needed. 2. Asymptomatic hyperglycemia poses no risk to the patient while inappropriately aggressive interventions to manage blood sugar may harm patients. Notes and educational pearls Key considerations 1. New onset DKA in pediatric patients commonly presents with nausea, vomiting, abdominal pain, and/or urinary frequency. 2. Consider causes for hyperglycemia by thinking about the 3I’s: a. Insulin: This refers to any medication changes for insulin or oral medications including poor compliance or malfunctioning insulin pump. b. Ischemia: This refers to hyperglycemia sometimes being an indication of physiologic stress in a patient and can be a clue to myocardial ischemia in particular. c. Infection: Underlying infection can cause derangements in glucose control. Pertinent assessment findings 1. Concomitant trauma 2. Abdominal pain, “fruity breath,” and rapid-deep respirations may be associated with DKA Hypoglycemia Aliases None noted Patient care goals 1. Limit morbidity from hypoglycemia by: a. Describing appropriate use of glucose monitoring. b. Treating symptomatic hypoglycemia. Patient presentation Inclusion criteria 1. Patients with blood glucose less than 60 mg/dL with symptoms of hypoglycemia. 2. Patients with altered level of consciousness [See Altered Mental Status Guideline]. 3. Patients with stroke symptoms (e.g., hemiparesis, dysarthria) [See Suspected Stroke/Transient Ischemic Attack Guideline]. 4. Patients with seizure [See Seizures Guideline]. 5. Patients with history of diabetes and other medical symptoms. 6. Patients with suspected alcohol ingestion. 7. Patients with metabolic disorders (glycogen storage disease, fatty oxidation or organic acid disorders, maple syrup urine disease). 8. Patients who appear to be intoxicated. Exclusion criteria Patient in cardiac arrest. Patient with normal mental status in absence of inclusion criteria listed above. Patient management Assessment 1. Monitoring: a. Check blood glucose level [EMR-O, EMT-R] 2. Secondary survey pertinent to altered blood glucose level: a. Evaluate for presence of an automated external insulin delivery device (insulin pump) b. Constitutional: assess for tachycardia and hypotension c. Eyes: assess for sunken eyes from dehydration d. Nose/mouth/ears: assess for dry mucous membranes or tongue bite from seizure e. Neurologic: i. Assess GCS and mental status ii. Assess for focal neurologic deficit: motor and sensory Treatment and interventions 1. If altered level of consciousness or stroke, treat per Altered Mental Status Guideline or Suspected Stroke/Transient Ischemic Attack Guideline accordingly. 2. If blood glucose is 60 mg/dL or less administer one of the following: a. Conscious patient with a patent airway: i. Glucose, oral (in form of glucose tablets, glucose gel, tube of cake icing, etc.) [EMR- O, EMT-R] 1. Adult Dosing: 25 g 2. Pediatric Dosing: 0.5–1 g/kg b. Unconscious patient, or patients who are unable to protect their own airway: i. Dextrose IV – administer in incremental doses until mental status improves or maximum field dosing is reached (if available, D10% is preferred)[AEMT-R]. 1. Maximum field adult dosing: 25 g of 10–50% dextrose IV a. 50 mL of 50% dextrose b. 100 mL of 25% dextrose c. 250 mL of 10% dextrose 2. Maximum field pediatric dosing: 0.5–1 g/kg of 10–25% dextrose IV a. 2–4 mL/kg of 25% dextrose for those greater than 8 years old b. 5–10 mL/kg of 10% dextrose (newborns 2 mL/kg) ii. Glucagon IM/IN – an option for patients for whom IV access cannot be established [EMT-O]. 1. Adult dosing: 1 mg IM/IN (or prefilled 3 mg dry powder IN or prefilled IM autoinjector) 2. Pediatric dosing: a. 1 mg IM/IN if ≥ 20 kg (or ≥ 5 years old (or prefilled 4 mg dry powder IN for patients greater than 4 years old or prefilled IM autoinjector) b. 0.5 mg IM/IN if less than 20 kg (or less than 5 years old) iii. Turn insulin pump off if above treatments cannot be completed. a. For patients with an insulin pump who are hypoglycemic with associated altered mental status (GCS less than 15): i. Stop the pump, disconnect, or remove at insertion site if patient cannot ingest oral glucose or ALS is not available. ii. Leave the pump connected and running if able to ingest oral glucose or receive ALS interventions. 2. Reassess patient a. Reassess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) and mental status [EMR-O]. b. Repeat check of blood glucose level if previous hypoglycemia and mental status has not returned to normal [EMR-O, EMT-R]. i. It is not necessary to repeat check of blood glucose level blood sugar if mental status has returned to normal. c. If maximal field dosage of dextrose solution does not achieve euglycemia and normalization of mental status: i. Initiate transport to closest appropriate receiving facility for further treatment of refractory hypoglycemia. ii. Evaluate for alternative causes of altered mental status. iii. Continue treatment of hypoglycemia using dextrose solutions as noted above. 3. Disposition a. If hypoglycemia with continued symptoms, transport to closest appropriate receiving facility. b. Hypoglycemic patients who have had a seizure should be transported to the hospital regardless of their mental status and response to therapy. c. If symptoms of hypoglycemia resolve after treatment, release without transport should only be considered if all the following are true: i. Repeat glucose is greater than 80 mg/dL. ii. Patient takes insulin or metformin to control diabetes and does not take long-acting insulin or oral sulphunylurea agents (e.g., glipizide, glyburide, or others). iii. Patient returns to normal mental status, with no focal neurologic signs/symptoms after receiving glucose/dextrose. iv. Patient can promptly obtain and will eat a carbohydrate meal. v. Patient or legal guardian refuses transport and EMS clinicians agree transport not indicated. vi. A reliable adult will be staying with patient. vii. No major co-morbid symptoms exist, like chest pain, shortness of breath, seizures, intoxication. viii. A clear cause of the hypoglycemia is identified (e.g., missed meal). Patient safety considerations 1. Dextrose 10% can be safely used in all ages of patient. Dextrose 10% works as effectively and quickly as other concentrations. 2. Dextrose 50% can cause local tissue damage if it extravasates from vein and may cause hyperglycemia. Dextrose 50% carries risk for little clinical gain. EMS systems may consider carrying no more than 25% concentration of dextrose for treating hypoglycemia in adults. 3. For children less than 8 years old, dextrose concentration of no more than 25% should be used. 4. For neonates and infants less than 1 month of age, dextrose concentration of no more than 10– 12.5% should be used. 5. Sulfonylureas (e.g., glyburide, glipizide) have long half-lives ranging from 12–60 hrs. Patients with corrected hypoglycemia who are taking these agents are at particular risk for recurrent symptoms and frequently require hospital admission. Key considerations 1. Using 10% dextrose is as effective as and safer than other stronger concentrations. 2. Consider contribution of oral diabetic medications to hypoglycemia. 3. If possible, have family/patient turn off insulin pump. 4. Consider potential for intentional overdose of hypoglycemic agents. 5. Avoid overshoot hyperglycemia when correcting hypoglycemia. Administer dextrose- containing IV fluids in small doses until either mental status improves or a maximum field dose is achieved. Pertinent assessment findings 1. Concomitant trauma 2. Diaphoresis or hypothermia may be associated with hypoglycemia Nausea-vomiting Aliases Emesis Gastroenteritis Patient care goals Identify hypoglycemia or hyperglycemia Prevent dehydration Patient presentation Inclusion criteria Currently nauseated and/or vomiting Exclusion criteria None noted Patient management Assessment 1. Routine patient care (e.g., vital signs). 2. History and physical examination focused on potential causes of nausea and vomiting (e.g., gastrointestinal, cardiovascular, obstetric, gynecologic, hypoglycemia, hyperglycemia, neurologic, oncologic, psychogenic, or toxidrome) as well as medications that may prolong the QT interval. 3. Obtain glucose level. Treatment and interventions 1. Antiemetic medication administration a. Isopropyl alcohol: Allow patient to inhale vapor from isopropyl alcohol wipe 3 times q (quaque, every) 15 minutes as tolerated [EMR-O]. b. Ondansetron (contraindicated for suspected or known diagnosis of prolonged QT syndrome) [AEMT-O]. i. Adult: 1. 4 mg IV/PO/SL OR 2. 4 or 8 mg SL of the ODT formulation ii. Pediatric (6 months – 14 years old): 1. 0.15 mg/kg IV/PO (maximum dose of 4 mg) OR 2. 2 mg SL for ages 1–5 years old; age 6 and older use 4 mg of the ODT formulation c. Metoclopramide [PARA-O] i. Adult: 10 mg IV/IM ii. Pediatric (greater than 2 years old only and greater than 12 kg): 1. 0.1 mg/kg IM OR 2. 0.1 mg/kg IV (maximum 10 mg) a. May repeat x 1 in 20–30 minutes if no relief d. Prochlorperazine [PARA-O] i. Adult: 5 mg IV/IM ii. Pediatric (over 2 years old only and greater than 12 kg): 1. 0.1 mg/kg slow IV OR 2. 0.1 mg/kg deep IM (maximum 10 mg) e. Droperidol [PARA-O] i. Adult: 1.25 mg IV/IM (contraindicated for suspected or known diagnosis of prolonged QT syndrome) f. Diphenhydramine [PARA-O] i. Adult: 12.5–25 mg IV/IM/PO ii. Pediatric (over 2 years old only and greater than 12 kg): 0.1 mg/kg IV (maximum 25 mg) Patient safety considerations 1. Ondansetron should not be administered to patients who have a prolonged QT interval as it can cause Torsades de Pointes. 2. For very young pediatric patients, ondansetron can be sedating. 3. Dystonic and extrapyramidal symptoms are possible side effects of antiemetics – If encountered, consider diphenhydramine [PARA-O]: a. Adult: 25–50 mg IV/IM/PO b. Pediatric: 1 mg/kg IV/IM/PO (maximum dose 50 mg) 4. Medications that prolong the QT interval may alter treatment options. Notes and educational pearls Key considerations 1. Ondansetron is preferred in children for the treatment of nausea and vomiting. 2. Metoclopramide has fewer adverse effects than prochlorperazine in children. 3. Prochlorperazine and metoclopramide (phenothiazines) have an increased risk of dystonic reactions. a. Some phenothiazines also have an increased risk of respiratory depression when used with other medications that cause respiratory depression, and some phenothiazines can cause neuroleptic malignant syndrome. b. Prochlorperazine carries a black box warning for use in elderly patients with dementia- related psychosis. 4. IV form of ondansetron may be given PO in same dose. 5. Nausea and vomiting are symptoms of illness – in addition to treating the patient’s nausea and vomiting a thorough history and physical are key to identifying what may be a disease in need of emergent treatment (e.g., bowel obstruction, myocardial infarction, pregnancy). 6. While ondansetron has not been adequately studied in pregnancy to determine safety, women should be counseled regarding the available data. In the first trimester of pregnancy, the administration of metoclopramide 5–10 mg IV with diphenhydramine 25 mg IV is recommended over the administration of ondansetron. Pertinent assessment findings 1. Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) 2. Risk factors for heart disease/EKG if applicable 3. Pregnancy status 4. Abdominal exam 5. Blood glucose levels Pain management Aliases Analgesia Pain control Patient care goals 1. Compassionately manage all patients with pain. 2. Minimize adverse events in the treatment of pain. Patient presentation Inclusion criteria Patients who are experiencing pain regardless of transport interval. Exclusion criteria Pregnancy with active labor Patient management Assessment, treatment, and interventions 11. Choice of medication class, route of administration, dosing and frequency are based on pain severity and the need for escalation from oral to parenteral routes. 12. The dosing guidelines apply to patients of all ages except where noted. 13. Determine patient’s pain score assessment using standard pain scale. a. Less than 4 years old or those with cognitive impairment unable to self-report: • Observational Scales • Faces, Legs, Arms, Cry, Consolability (FLACC) b. 4–12 years old: • Self-report scale • Wong Baker Faces • Faces Pain Scale (FPS) • Faces Pain Scale Revised (FPS-R) c. Greater than 12 years old: • Self-report scale • Numeric Rating Scale (NRS) 14. Non-pharmacologic pain management options include: a. Placement of the patient in a position of comfort. b. Application of ice packs and/or splints for pain secondary to trauma. c. Verbal reassurance to control anxiety. 15. Minor pain or as an adjunct for moderate/severe pain consider the following non-opioid analgesic options: a. Acetaminophen 15 mg/kg PO or IV (maximum dose 1 g) [EMT-O, AEMT-R] b. Nonsteroidal anti-inflammatories • Ibuprofen 10 mg/kg PO for patients greater than 6 months of age (maximum dose 800 mg) OR [EMT-O] • Ketorolac [AEMT-O] • Adult: 30 mg IM or 15 mg IV • Pediatric age 2–16 years old: 0.5 mg/kg (maximum dose of 30 mg IM or 15 mg IV) • Naproxen [AEMT-O] • Adult: 220 mg to 550 mg PO based on formulary available • Pediatric age 12 and older: 220 mg PO c. Nitrous oxide [AEMT-O] 16. For Moderate to Severe pain, analgesics include: a. Fentanyl [INT-O]: • 1 mcg/kg IN, IM, IV or IO (maximum initial dose of 100 mcg); may repeat every 15 mins as needed. b. Morphine sulfate [INT-O]: • 0.1 mg/kg IM, IV or IO (maximum initial dose is 10 mg) c. Hydromorphone [PARA-O]: • 0.015 mg/kg IM, IV, or IO (maximum initial dose 2 mg) d. Ketamine [PARA-O]: • 0.25 mg/kg IM, IV or IO (maximum initial dose 25 mg) 17. Use of non-invasive capnography [EMR-O, INT-R] is an earlier predictor of hypoventilation than pulse oximetry if opioid medications are administered. 18. Consider administration of oral, sublingual, or IV antiemetics to prevent nausea [See Nausea/Vomiting Guideline]. 19. If indicated based on pain assessment, and vital signs allow, repeat pain medication administration (excluding acetaminophen and nonsteroidal anti- inflammatory medicines) as needed and directed. 20. Transport in position of comfort and reassess as indicated. Patient safety considerations 1. All patients should have drug allergies identified prior to administration of pain medication. 2. Administer opioids with caution to patients with Glasgow Coma Score (GCS) less than 15, hypotension, identified medication allergy, hypoxia (SPO 2 less than 90%) after maximal supplemental oxygen therapy, or signs of hypoventilation. 3. Opioids are contraindicated for patients who have taken monoamine oxidase inhibitors (MAOI) during the previous 14 days. 4. Avoid non-steroidal anti-inflammatory medications such as ibuprofen and ketorolac in patients with NSAID allergy, aspirin-sensitive asthma, renal insufficiency, pregnancy, or known peptic ulcer disease. 5. Ketorolac should not be used in patients with hypotension (due to renal toxicity). 6. Use of splinting techniques and application of ice should be done to reduce the total amount of medication used to keep the patient comfortable. Notes and educational pearls Key considerations 1. Intranasal routes of opioid analgesia are preferred as the initial dosing route in pediatrics where IV access may be problematic; consider in other patient populations when an IV in not otherwise indicated. 2. Onset of action is dependent on the pharmacokinetics of the drug class as well as route of administration; oral analgesics are effective for pain control but have a slower onset of action so plan accordingly. 3. Pain severity scores should be recorded before and after analgesic medication administration and upon arrival at destination. 4. Patients with acute abdominal pain should receive analgesic interventions – Use of analgesics for acute abdominal pain does not mask clinical findings or delay diagnosis. 5. Opiates may cause a rise in intracranial pressure. Pertinent assessment findings 1. Mental status (Glasgow Coma Score (GCS) and pain level) 2. Respiratory system (tidal volume, chest rigidity) 3. Gastrointestinal (assess for tenderness, rebound, guarding, and nausea) Table 1. Adult Nonverbal Pain Scale University of Rochester Medical Center Source : Odhner M, Wegman D, Freeland N, Ingersoll G. Evaluation of a newly developed non-verbal pain scale (NVPS) for assessment of pain in sedated critically ill patients. Table 2. Universal Pain Assessment Tool Wong- Baker FACES® Verbal Descript or Scale No Pain Mild Pai n Moderat e Pain Severe Pain Very Severe Pain Excruciating Pain Descriptiv e Scale Alert Smilin g No Humor Serious , Flat Furrowed Brow Pursed Lips Breath Holding Wrinkled Nose Raised Upper Lip Rapid Breathin g Slow Blink Open Mouth Eyes Closed Moaning Crying Activity Toleran ce Scale No Pain Can be Ignore d Interfere s with Tasks Interferes with Concentratio n Interferes with Basic Needs Bed Rest Required Spanish Nada de Dolor Un Poquito de Dolor Un Dolor Leve Dolor Fuerte Dolor Desmasiad o Fuerte Un Dolor Insoportable Source : Hybrid of scales by authors. Wong-Baker FACES® Pain Scale Rating license grants this use. Reproduction of the Wong-Baker FACES® material requires licensing at www.wongbakerfaces.org. Pediatric-appropriate pain assessment tools Table 3. Faces, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale Appropriate age for use (per guideline): less than 4 years Categories Scorin g Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging, or being talked to, distractible Difficult to console or comfort Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0– 2, which results in a total score between zero and ten. Source: © 2002, The Regents of the University of Michigan. All Rights Reserved. Instructions: ● Patients who are awake: Observe for at least 1–2 minutes. Observe legs and body uncovered. Reposition patient or observe activity, assess body for tenseness and tone. Initiate consoling interventions if needed. ● Patients who are asleep: Observe for at least 2 minutes or longer. Observe body and legs uncovered. If possible, reposition the patient. Touch the body and assess for tenseness and tone. Face ● Score 0 point if patient has a relaxed face, eye contact and interest in surroundings. ● Score 1 point if patient has a worried look to face, with eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed. ● Score 2 points if patient has deep furrows in the forehead, with closed eyes, open mouth and deep lines around nose/lips. Legs ● Score 0 points if patient has usual tone and motion to limbs (legs and arms). ● Score 1 point if patient has increase tone, rigidity, tense, intermittent flexion/extension of limbs. ● Score 2 points if patient has hyper tonicity, legs pulled tight, exaggerated flexion/extension of limbs, tremors. Activity ● Score 0 points if patient moves easily and freely, normal activity/restrictions. ● Score 1 point if patient shifts positions, hesitant to move, guarding, tense torso, pressure on body part . ● Score 2 points if patient is in fixed position, rocking, side-to-side head movement, rubbing body part. Cry ● Score 0 points if patient has no cry/moan awake or asleep. ● Score 1 point if patient has occasional moans, cries, whimpers, sighs. ● Score 2 points if patient has frequent/continuous moans, cries, grunts. Consolability ● Score 0 points if patient is calm and does not require consoling. ● Score 1 point if patient responds to comfort by touch or talk in ½ – 1 minute. ● Score 2 points if patient require constant consoling or is unconsoled after an extended time. Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self- report is not possible, interpretation of pain behaviors and decision-making regarding treatment of pain requires careful consideration of the context in which the pain behaviors were observed. Each category is scored on a 0–2 scale, which results in a total score of 0–10 Assessment of behavioral score: 0 = Relaxed and comfortable 1–3 = Mild discomfort 4–6 = Moderate pain 7–10 = Severe discomfort/pain © 2002, The Regents of the University of Michigan. All Rights Reserved. Source : The FLACC: A behavioral scale for scoring postoperative pain in young children, by S Merkel and others, 1997, Pediatr Nurse 23(3), p. 293–297. Graphic 1. Faces Pain Scale – Revised (FPS-R) In the following instructions, say "hurt" or "pain", whichever seems right for a particular child. "These faces show how much something can hurt. This face [point to face on far left] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to face on far right] — it shows very much pain. Point to the face that shows how much you hurt [right now]." Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so “0” = “no pain” and “10” = “very much pain”. Do not use words like “happy” or “sad.” This scale is intended to measure how children feel inside, not how their face looks. Source: Permission for Use. Copyright of the FPS-R is held by the International Association for the Study of Pain (IASP) ©2001. This material may be photocopied for non-commercial clinical, educational and research use. For reproduction of the FPS-R in a journal, book, or web page, or for any commercial use of the scale, request permission from IASP online at https://www.iasp-pain.org/publications/copyright-permissions/. Seizures (Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process) Aliases Convulsions Febrile seizure Status epilepticus Eclampsia Patient care goals 1. Prompt cessation of seizures in the prehospital setting. 2. Minimizing adverse events in the treatment of seizures in the prehospital setting. 3. Minimizing seizure recurrence during transport. Patient presentation Seizures due to trauma, pregnancy, hyperthermia, or toxic exposure should be managed according to those condition-specific guidelines. Inclusion criteria Seizure activity upon arrival of prehospital personnel or new/recurrent seizure activity lasting greater than 5 minutes. Exclusion criteria None noted Patient management Assessment 1. History a. Duration of current seizure b. Prior history of seizures, diabetes, or hypoglycemia c. Typical appearance of seizures d. Baseline seizure frequency and duration e. Focality of onset, direction of eye deviation f. Concurrent symptoms of apnea, cyanosis, vomiting, bowel/bladder incontinence, or fever g. Bystander administration of medications to stop the seizure h. Current medications, including anticonvulsants i. Recent dose changes or non-compliance with anticonvulsants j. History of trauma, pregnancy, heat exposure, or toxin exposure 2. Exam a. Airway patency b. Breath sounds, respiratory rate, and effectiveness of ventilation c. Signs of perfusion (pulses, capillary refill, color) d. Neurologic status (GCS, nystagmus, pupil size, focal neurologic deficit, or signs of stroke) Treatment and interventions 1. If signs of airway obstruction are present and a chin-lift, jaw thrust, positioning, and/or suctioning does not alleviate it, place oropharyngeal airway (if gag reflex is absent) or nasopharyngeal airway [EMR-R]. 2. Place pulse oximeter and/or waveform capnography to monitor oxygenation/ventilation [pulse ox EMR-O, EMT-R; end tidal EMR-O, INT-R]. 3. Administer oxygen as appropriate with a target of achieving 94–98% saturation. Use bag- valve-mask (BVM) ventilation [EMR-R] if oxygenation/ventilation are compromised [EMR-O, EMT-R; HFNC PARA-O]. 4. Assess perfusion. 5. Assess neurologic status. 6. Routes for treatment a. IN/IM routes are preferred over IV or IO routes (if not already established) and rectal (PR) route as an alternative. i. If no other route of delivery (IM/IV/IO/IN), diazepam 0.2 mg/kg PR (maximum dose 20 mg) [INT-O]. b. IV placement is not necessary for treatment of seizures, but could be obtained if needed for other reasons [AEMT-R]. 7. Anticonvulsant Treatment a. If vascular access is absent: i. Midazolam 0.2 mg/kg (maximum dose 10 mg), IM preferred, or IN [INT-O]. b. If vascular access (IV or IO) is present: i. Midazolam 0.1 mg/kg IV or IO, maximum 4 mg [INT-O]. ii. Diazepam 0.2 mg/kg IV or IO, maximum 10 mg [INT-O]. iii. Lorazepam 0.1 mg/kg IV or IO, maximum 4 mg [INT-O]. 8. Glucometry a. If still actively seizing, check blood glucose level [EMR-O, EMT-R]. b. If less than 60 mg/dL, treat per the Hypoglycemia Guideline. 9. Administer magnesium sulfate in the presence of seizure in the third trimester of pregnancy or postpartum [See Eclampsia/Pre-eclampsia Guideline] [PARA-R]. 10. For febrile seizures, consider the following interventions after stopping the seizure. Please note that the administration of nonsteroidal anti-inflammatory medications is contraindicated in infants less than 6 months of age. The following interventions provide symptomatic relief for fevers, but do not stop the seizure: a. Acetaminophen 15 mg/kg, maximum dose 650 mg, PR/IV/IO (if unable to swallow) or PO (if able to swallow) [EMT-O, AEMT-R] AND/OR b. Ketorolac 1 mg/kg, maximum dose 15 mg, IV (if unable to swallow) [AEMT- O] OR Ibuprofen 10 mg/kg, maximum dose 800 mg, PO (if able to swallow) [EMT-O] AND/OR c. Removing excessive layers of clothing AND/OR d. Applying cool compresses to the body 11. Consider acquiring a 12- lead EKG following cessation of seizure in patients without a history of seizure to determine possible cardiac cause [acquire/transmit EMR -O, INT -R; interpret INT-R]. Patient safety considerations 1. Trained personnel should be able to give medication without contacting medical direction, however, more than two doses of benzodiazepines are associated with high-risk of airway compromise. a. Use caution, weigh risks/benefits of deferring treatment until hospital, and/or consider consultation with medical direction if patient has received two doses of benzodiazepines by bystanders and/or prehospital clinicians. 2. Hypoglycemic patients who are treated in the field for seizure should be transported to hospital, regardless of whether they return to baseline mental status after treatment. Notes and educational pearls Key considerations 1. Many airway/breathing issues in seizing patients can be managed without intubation or placement of an advanced airway. Reserve these measures for patients that fail less invasive maneuvers as noted above. 2. For children with convulsive status epilepticus requiring medication management in the prehospital setting, trained EMS personnel should be allowed to administer medication without medical direction. 3. For new onset seizures or seizures that are refractory to treatment, consider other potential causes including, but not limited to, trauma, stroke, electrolyte abnormality, toxic ingestion, pregnancy with eclampsia, hyperthermia. 4. A variety of safe and efficacious doses for benzodiazepines have been noted in the literature for seizures. a. The doses for anticonvulsant treatment noted above are those that are common to the forms and routes of benzodiazepines noted in this guideline. b. One dose, rather than a range, has been suggested to standardize a common dose in situations when an EMS agency may need to switch from one type of benzodiazepine to another due to cost or resource limitations. 5. Recent evidence supports the use of midazolam IM as an intervention that is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation. Pertinent assessment findings The presence of fever with seizure in children less than 6 months old and greater than 6 years old is not consistent with a simple febrile seizure, and should prompt evaluation for meningitis, encephalitis, or other cause. Shock (Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process) Aliases None noted Patient care goals 1. Initiate early fluid resuscitation and vasopressors to maintain/restore adequate perfusion to vital organs. 2. Differentiate between possible underlying causes of shock to promptly initiate additional therapy. Patient presentation Inclusion criteria 1. Signs of poor perfusion (due to a medical cause) such as one or more of the following: a. Altered mental status b. Delayed capillary refill (> 3 seconds) c. Flash capillary refill (> 1 second) seen in early septic shock d. Decreased urine output e. Respiratory rate greater than 20 breaths per minute in adults or elevated in children (See normal vital signs table) f. Hypotension for age (lowest acceptable systolic blood pressure in mmHg): i. Less than 1 years of age: 60 ii. 1–10 years old: (age in years) (2) + 70 iii. Greater than 10 years old: 90 g. Tachycardia or bradycardia for age, out of proportion to temperature [See Appendix VIII. Abnormal Vital Signs] h. Weak, decreased, or bounding pulses i. Cool/mottled or flushed/ruddy skin 2. Potential etiologies of shock: a. Hypovolemic (hemorrhagic or non-hemorrhagic) b. Distributive (sepsis, anaphylaxis, neurogenic, overdose, endocrine) c. Cardiogenic (cardiomyopathy, dysrhythmia, valve disorder) d. Obstructive (pulmonary embolism (PE), tension pneumothorax, cardiac tamponade) e. Combined (one form causing another) Exclusion criteria Shock due to suspected trauma [See Trauma Section] Patient management Assessment 1. History a. History of GI bleeding b. Cardiac problems c. Stroke d. Fever e. Nausea/vomiting, diarrhea f. Frequent or no urination g. Syncopal episode h. Allergic reaction i. Immunocompromise (malignancy, transplant, asplenia) j. Adrenal insufficiency k. Presence of a central line or port l. Other risk of infection (spina bifida or other genitourinary anatomic abnormality) m. Overdose 2. Exam a. Airway/breathing (airway edema, rales, wheezing, pulse oximetry, respiratory rate) b. Circulation (heart rate, blood pressure, capillary refill) c. Abdomen (hepatomegaly) d. Mucous membrane hydration e. Skin (turgor, rash) f. Neurologic (GCS, sensorimotor deficits) 3. Determination of type of shock a. Cardiogenic b. Distributive (neurogenic, septic, anaphylactic) c. Hypovolemic d. Obstructive (e.g., pulmonary embolism, cardiac tamponade, tension pneumothorax) Treatment and interventions 1. Check vital signs [EMR-R]. 2. Administer oxygen as appropriate with a target of achieving 94–98% saturation EMR-O, EMT-R; HFNC PARA-O]. 3. Cardiac monitor [acquire/transmit EMR-O, INT-R; interpret INT-R]. 4. Pulse oximetry and EtCO2 (reading of less than 25 mmHg may be sign of poor perfusion) [pulse ox EMR-O, EMT-R; end tidal EMR-O, INT-R]. 5. Check blood sugar and correct if less than 60 mg/dL [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R]. 6. EKG [acquire/transmit EMR-O, INT-R; interpret INT-R]. 7. Check lactate, if available (greater than 2 mmol/L is abnormal) [obtain venous blood sample AEMT-O, blood chemistry analysis PARA-O]. 8. Establish IV access [AEMT-R]. If unable to obtain within two attempts or less than 90 seconds, place an IO needle [AEMT-R]. 9. IV fluid volume goal attained by giving boluses that are pressure infused over less than 15 minutes each based on patient’s condition and clinical impression. Fluid volume goal to achieve a mean arterial pressure (adults) or other targets (pediatrics). Mean Arterial Pressure is calculated: (MAP = [(2X diastolic) + (systolic]/3). a. Adult i. Physiologic target: MAP goal 65 mmHg ii. Fluid goal of up to 30 mL/kg of isotonic fluid by administering rapid, predetermined boluses (e.g., 500 mL) unless the MAP goal is achieved, or pulmonary edema develops. [AEMT-R] iii. If available, the administration of packed red blood cells or whole blood may be indicated for hemorrhagic shock [PARA-O] b. Pediatric i. Physiologic targets: Systolic blood pressure at least fifth percentile for age, strong distal pulses, warm skin perfusion, capillary refill less than 2 seconds and improving mental status. ii. Fluid goal of up to a total of 60 mL/kg or 1 liter of isotonic fluid by giving 20 mL/kg of isotonic fluid by administering rapid boluses (for cardiogenic shock give 10 mL/kg boluses) [AEMT-R] iii. If available, the administration of packed red blood cells or whole blood may be indicated for hemorrhagic shock [PARA-O] 10. If there is a history of adrenal insufficiency, long-term steroid dependence, or fluid- refractory shock requiring vasopressors give [PARA-O]: a. Hydrocortisone succinate, 2 mg/kg (maximum 100 mg) IV/IM (preferred) OR b. Methylprednisolone 2 mg/kg IV (maximum 125 mg) OR c. Dexamethasone 0.6 mg/kg IV/IM (maximum dose of 16 mg) d. Any patient prescribed steroid medication can be given with online medical control approval [All EMS Service Providers-O]. 11. Vasopressors (shock unresponsive to IV fluids) titrated to physiologic targets [PARA-R] a. Cardiogenic, hypovolemic, obstructive shock and distributive shock: i. Norepinephrine 0.05–0.5 mcg/kg/minute 1. Preference in both neurogenic and infectious (sepsis) causes of distributive shock ii. Epinephrine, 0.05–0.3 mcg/kg/minute 1. Alternative to a drip, push dose epinephrine may be administered: a. Prepare 10 mcg/mL of push-pressor epi by diluting 1 mL of “cardiac epinephrine”(1:10,000) in to 9 mL of normal saline to yield a concentration of 100 mcg/ml. b. Administer 0.01 mg/kg (0.1 mL/kg) up to a maximum single dose of 10 mcg (1 mL) q 3–5 minutes titrated to maintain goal MAP. An example is shown below: ● 10 kg child receives 1 mL of the diluted epinephrine ● 20 kg child receives 2 mL of the diluted epinephrine ● 30 kg child receives 3 mL of the diluted epinephrine 12. For anaphylactic shock, treat per the Anaphylaxis and Allergic Reaction Guideline . 13. Provide advanced notification to the hospital. 14. Antipyretics for fever – nonsteroidal anti -inflammatory agents are contraindicated in infants less than 6 months of age. a. Acetaminophen (15 mg/kg; maximum dose of 1000 mg) [EMT-O, AEMT-R] b. Ibuprofen (10 mg/kg; maximum dose of 800 mg) [EMT-O] Patient safety considerations Recognition of cardiogenic shock - If the patient condition deteriorates after fluid administration, rales or hepatomegaly develop, then consider cardiogenic shock and withholding further fluid administration. Notes and educational pearls Key considerations 1. Early, aggressive IV fluid administration is essential in the treatment of suspected septic shock. 2. Patients predisposed to shock: a. Immunocompromised (patients undergoing chemotherapy or with a primary or acquired immunodeficiency) b. Adrenal insufficiency (Addison's disease, congenital adrenal hyperplasia, chronic or recent steroid use) c. History of a solid organ or bone marrow transplant d. Infants e. Elderly 3. In most adults, tachycardia is the first sign of compensated shock, and may persist for hours. Tachycardia can be a late sign of shock in children and a tachycardic child may be close to cardiovascular collapse. 4. Hypotension indicates uncompensated shock, which may progress to cardiopulmonary failure within minutes. Hypotension is a late and ominous sign in pediatric uncompensated shock. 5. Hydrocortisone succinate, if available, is preferred over methylprednisolone and dexamethasone for the patient with adrenal insufficiency because of its dual glucocorticoid and mineralocorticoid effects. a. Patients with no reported history of adrenal axis dysfunction may have adrenal suppression due to their acute illness, and hydrocortisone should be considered for any patient showing signs of treatment-resistant shock. b. Patients with adrenal insufficiency may have an emergency dose of hydrocortisone available that can be administered IV or IM. Pertinent assessment findings 1. Decreased perfusion manifested by altered mental status, or abnormalities in capillary refill or pulses, decreased urine output (1 mL/kg/hr): a. Cardiogenic, hypovolemic, obstructive shock: capillary refill greater than 2 seconds, diminished peripheral pulses, mottled cool extremities. b. Distributive shock: flash capillary refill, bounding peripheral pulses. Sickle cell pain crisis Aliases None noted Patient care goals 1. Identify potentially life-threatening complications of a sickle cell disease. 2. Improve patient comfort. Patient presentation Inclusion criteria Patient with known sickle cell disease experiencing a pain crisis. Exclusion criteria 1. Pain due to acute traumatic injury [See Trauma Section]. 2. Abdominal pain due to or related to pregnancy [See OB/GYN Section]. 3. Patients with sickle cell trait. Patient management Assessment 1. Perform airway assessment and management per the Airway Management Guideline. 2. Obtain vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) and pulse oximetry. 3. Provide evaluation and management of altered mental status per the Altered Mental Status Guideline. 4. Provide evaluation and management of pain per the Pain Management Guideline. 5. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation. 6. Assess for potentially serious complications other than pain crisis which may include: a. Acute chest syndrome i. Hypoxia ii. Chest pain iii. Fever b. Stroke [See Suspected Stroke/Transient Ischemic Attack Guideline] i. Focal neurologic deficits c. Meningitis i. Headache ii. Altered mental status iii. Fever d. Septic arthritis i. Severe pain in a single joint ii. Fever e. Splenic sequestration crisis (usually young pediatric patients) i. Abdominal pain, LUQ ii. Splenic enlargement (examine with care) iii. Hypotension, tachycardia f. Severe anemia i. Pallor ii. Fatigue iii. Dyspnea or dyspnea on exertion iv. Shock g. Infections i. Pneumonia (cough, fever, sputum shortness of breath) h. Priapism i. Painful, prolonged erection in the absence of sexual activity i. Venous thromboembolism i. Calf pain, tenderness, swelling, chest/back pain especially with inspiration, shortness of breath 7. Assess for signs of shock – If shock is present, treat per Shock Guideline. Treatment and interventions 1. Medication Administration: a. Provide analgesia per the Pain Management Guideline b. Start oxygen by nasal cannula if hypoxic [EMR-O, EMT-R] c. Cardiac monitor [acquire/transmit EMR-O, INT-R; interpret INT-R] d. EKG [acquire/transmit EMR-O, INT-R; interpret INT-R] e. Start an IV [AEMT-R] and provide saline 10 mL/kg normal saline bolus (up to 1 L) [AEMT-R] f. Provide transport to an appropriate receiving facility. g. Reassess vital signs [EMR-R] and response to therapeutic interventions throughout transport 2. Comfort measures: a. Keep patient warm and dry b. Transport in a position of comfort unless clinical condition requires otherwise Patient safety considerations None noted Notes and educational pearls Key considerations 1. Assess for life-threatening complications of sickle cell disease – these patients have significantly higher risk of numerous complications in addition to pain crises. 2. Provide appropriate treatment for pain, respiratory distress, and shock. 3. These patients may have a higher tolerance to narcotic pain medications if they are taking them on a regular basis. 4. These patients will tolerate acute blood loss poorly due to baseline anemia. 5. Patients with sickle cell trait can have acute pain crises in extreme conditions (e.g., heat exhaustion, dehydration) and several college athlete deaths have been linked to sickle cell trait. Pertinent assessment findings 1. Lung exam and assessment of respiratory distress 2. Altered mental status 3. Focal neurologic deficits 4. Inability to move a joint Resuscitation Cardiac arrest (VF/VT/Asystole/PEA) Aliases Arrest Full arrest Heart attack Patient care goals 1. Return of spontaneous circulation (ROSC). 2. Preservation of neurologic function. 3. High-quality chest compressions/CPR with minimal interruption from recognition of cardiac arrest until confirmation of ROSC or field termination of care. Patient presentation Inclusion criteria Patients with cardiac arrest. Exclusion criteria 1. Patients suffering cardiac arrest due to severe hypothermia [See Hypothermia/Cold Exposure Guideline]. 2. Patients with identifiable Do Not Resuscitate (or equivalent such as POLST) order [See Do Not Resuscitate Status/Advance Directive/Healthcare Power of Attorney (POA) Status Guideline]. 3. Patients in arrest due to traumatic etiology [See General Trauma Management Guideline]. Patient management Assessment 1. The patient in cardiac arrest requires a prompt balance of treatment and assessment. 2. In cases of cardiac arrest, assessments should be focused and limited to obtaining enough information to reveal the patient is pulseless. 3. Once pulselessness is discovered, treatment should be initiated immediately, and any further history must be obtained by bystanders while treatment is ongoing. Treatment and interventions The most important therapies for patients suffering from cardiac arrest are prompt cardiac defibrillation for shockable rhythms and minimally interrupted effective chest compressions. 1. Initiate chest compressions in cases with no bystander chest compressions or take over compressions from bystanders while a second rescuer is setting up the AED or defibrillator [EMR-R]. a. If adequate, uninterrupted bystander CPR has been performed or if the patient arrests in front of the EMS clinicians, immediately proceed with rhythm analysis. and defibrillation, if appropriate [with AED, EMR-R; manual defib EMT-O, INT-R] b. It is realistic for EMS clinicians to tailor the sequence of rescue actions to coincide the most likely cause of arrest. c. There is insufficient evidence to recommend for or against delaying defibrillation to provide a period of CPR for patients in VF/pulseless VT out- of-hospital cardiac arrest. d. For adults and children with unwitnessed cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use. 2. The maximum setting on the defibrillator should be used for initial and subsequent defibrillation attempts. Defibrillation dosing should follow manufacturer’s recommendation in the case of biphasic defibrillators. If the manufacturer’s recommendation is unknown, use highest setting possible. In the case of monophasic devices, the setting should be 360J (joule) (or 4 J/kg for children). 3. Chest compressions should resume immediately after defibrillation attempts with no pauses for pulse checks for 2 minutes regardless of the rhythm displayed on the cardiac monitor. 4. All attempts should be made to prevent avoidable interruptions in chest compressions, such as pre-charging the defibrillator and hovering over the chest, rather than stepping away during defibrillations. 5. If feasible, IV or IO access should be obtained [AEMT-R]. Administer epinephrine during the first or second round of compressions. Prioritize early administration of epinephrine for non- shockable rhythms [INT-R]. 6. Continue the cycle of chest compressions for 2 minutes, followed by rhythm analysis and defibrillation of shockable rhythms; during this period, the proper strategy of airway management is currently not defined and many options for airway management exist. Regardless of the airway management and ventilation strategy, consider the following principles: a. The airway management strategy should not interrupt compressions. b. Successful resuscitation from cardiac arrest depends primarily on effective, minimally interrupted chest compressions and prompt defibrillation if the patient is in pulseless VT/VF. As opposed to children, an adult’s airway management is of secondary importance and should not interfere with compressions and defibrillation. Options for airway management include: i. Passive ventilation: 1. High flow oxygen is applied via a non-rebreather mask with an oropharyngeal airway [EMR-O; EMT-R]. 2. Some oxygen will be entrained with each decompression of the chest. 3. This may be applied for the first 3–4 compression cycles (6–8 minutes), after which one may consider BVM ventilation or placement of an advanced airway. ii. BVM ventilation at 10 breaths per minute (1 breath every 10 compressions), applied during the upstroke between compressions, without interrupting the compressions [EMR-R]. iii. BVM ventilation with 30:2 ventilation to compression ratio: Each 30 compressions, the compressions are paused briefly to allow 2 BVM ventilations, then compressions immediately resumed. 1. Pediatric consideration: For multiple rescuer CPR in children, 15:2 is the recommended compression-to-ventilation ratio (30:2 for single rescuer) 2. Pediatric consideration: For neonates, 3:1 is the recommended compression-to- ventilation ratio iv. Advanced airway placement: 1. Either a supraglottic airway or an endotracheal tube may be placed without interruption of compressions [non-visualized EMR-O, EMT-R; intubation INT-O, PARA-R]. 2. Ventilations are provided at 10 breaths/minute for adults. 3. Pediatric consideration: for children, 1 breath every 3–5 seconds is recommended (12–20 breaths/minute). 4. Pediatric consideration: deliver volume needed to achieve chest rise. 7. Consider use of antiarrhythmic for recurrent VF/Pulseless VT. a. The principal objective of antiarrhythmic drug therapy in shock-refractory VF and pulseless VT is to facilitate the restoration and maintenance of a spontaneous perfusing rhythm in concert with the shock termination of VF/VT; some antiarrhythmic drugs have been associated with increased rates of ROSC and hospital admission, but none have yet been proven to increase long-term survival or survival with good neurologic outcome. i. Amiodarone (5 mg/kg IV, max of 300 mg) [INT-O, PARA-R] may be considered for VF/pulseless VT that is unresponsive to CPR, defibrillation, and a vasopressor therapy. ii. Lidocaine (1 mg/kg IV) [INT-O, PARA-R] may be considered as an alternative to amiodarone for VF/pulseless VT that is unresponsive to CPR, defibrillation, and vasopressor therapy. iii. The routine use of magnesium for VF/pulseless VT is not recommended in adult patients unless it is refractory, polymorphic VT, or Torsades de Pointes. b. There is inadequate evidence to support the routine use of lidocaine and beta- blockers after cardiac arrest by EMS. There is insufficient evidence to recommend for or against the routine initiation or continuation of other antiarrhythmic medications after ROSC from cardiac arrest. c. For Torsades de Pointes, give magnesium sulfate 2 g IV administered over 1–2 minutes (or 25–50 mg/kg for pediatrics)[PARA-R]. 8. Consider reversible causes of cardiac arrest which include the following: a. Hypothermia – additions to care include attempts at active rewarming [See Hypothermia/Cold Exposure Guideline]. b. The dialysis patient/known hyperkalemic patient – Additions to care include the following: i. Calcium gluconate 10% 2 to 3 g IV bolus over 2 minutes [PARA-R](for pediatrics, the dose is 100 mg/kg which is 1 mL/kg), can repeat the dose if no response OR ii. Calcium chloride 10% 1 g IV bolus over 2 minutes [PARA-R](for pediatrics, the dose is 20 mg/kg which is 0.2 mL/kg) iii. Sodium bicarbonate 1 mEq/kg IV [PARA-R] c. Tricyclic antidepressant overdose. Additions to care include sodium bicarbonate 1 mEq/kg IV [PARA-R]. d. Hypovolemia. Additions to care include normal saline 2 L IV (or 20 mL/kg, repeated up to 3 times for pediatrics; max of 2L) [AEMT-R]. e. If the patient is intubated at the time of arrest, assess for tension pneumothorax and misplaced ETT. f. If tension pneumothorax suspected, perform needle decompression [INT- R]. Assess ETT, if misplaced, replace ETT. Use end-tidal CO2 detection to confirm device positioning and effective ventilation. 9. If at any time during this period of resuscitation the patient regains return of spontaneous circulation, treat per Adult Post-ROSC (Return of Spontaneous Circulation) Care Guideline. 10. If resuscitation remains ineffective, consider termination of resuscitation [See Termination of Resuscitative Efforts Guideline]. Patient safety considerations 1. Performing manual chest compressions in a moving vehicle may pose a clinician safety concern. 2. In addition, manual chest compressions during patient movement are less effective in regard to hands on time, depth, recoil and rate. 3. Ideally, patients should be resuscitated as close to the scene as operationally possible. 4. Risks and benefits should be considered before patient movement in cardiac arrest situations. Notes and educational pearls Key considerations 1. Effective chest compressions and defibrillation are the most important therapies to the patient in cardiac arrest. Effective chest compressions are defined as: a. A rate of greater than 100 and less than 120 compressions/minute. b. Depth of at least 2 inches (5 cm) and less than 2.4 inches (6 cm) for adults and children OR 1.5 inches (4 cm) for infants; adolescents who have entered puberty should receive the same depth of chest compressions as an adult. c. Allow for complete chest recoil (avoid leaning). d. Minimize interruptions in compressions. e. Avoid rescuer fatigue by rotating rescuers at least every 2 minutes. Some EMS pit crew approaches use a clinician on either side of the chest, alternating compressions every minute or every 100 compressions to avoid fatigue. 2. Avoid excessive ventilation and consider delayed airway management – If no advanced airway, consider: a. Passive ventilation using an NRB with 3– 4 cycles of uninterrupted chest compressions (for arrests of suspected cardiac etiology). Consider BVM ventilation or advanced airway after 3–4 cycles. b. BVM ventilation every 10 –15 compressions with cycles of uninterrupted chest compressions. Upstroke ventilation between compressions.30:2 ventilation to compression ratio for adults, and 15:2 for children when 2 rescuers are present. c. If an advanced airway is placed, ventilations should not exceed 10 breaths/minute (1 breath every 6 seconds or 1 breath every 10 compressions) in adults. Pediatric consideration: For children with an advanced airway, 1 breath every 3–5 seconds is recommended (equivalent to 12–20 breaths/minute). 3. Quantitative end-tidal capnography (EtCO2) should be used to monitor effectiveness of chest compressions. a. If EtCO2 less than 10 mmHg during the initial phases of resuscitation, attempt to improve chest compression quality. b. Consider additional monitoring with biometric feedback which may improve compliance with suggested Resuscitation Section. 4. Chest compressions are usually the most rapidly applied therapy for the patient in cardiac arrest and should be initiated as soon as the patient is noted to be pulseless. If the patient is being monitored with pads in place at the time of arrest, immediate defibrillation should take precedence over all other therapies. However, if there is any delay in defibrillation (e.g., in order to place pads), chest compressions should be initiated while the defibrillator is being applied. There is no guidance on how long these initial compressions should be applied; however, it is reasonable to either complete between 30 seconds and 2 minutes of chest. compressions in cases of no bystander chest compressions or to perform defibrillation as soon as possible after chest compressions initiated in cases of witnessed arrest 5. There is insufficient evidence to recommend the routine use of extracorporeal CPR (ECPR) for patients with cardiac arrest. In settings where it can be rapidly implemented, ECPR may be considered for select cardiac arrest patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support. 6. Chest compressions should be reinitiated immediately after defibrillation as pulses, if present, are often difficult to detect and rhythm and pulse checks interrupt compressions. 7. Continue chest compressions between completion of AED analysis and AED charging. 8. The effectiveness of chest compressions decreases when moving patients. a. Patients should therefore be resuscitated as close to the point at which they are first encountered and should only be moved if the conditions on scene are unsafe or do not operationally allow for resuscitation. b. Chest compressions are also less effective in a moving vehicle. c. It is also dangerous to EMS clinicians, patients, pedestrians, and other motorists to perform chest compressions in a moving ambulance. d. For these reasons and because in most cases the care provided by EMS clinicians is equivalent to that provided in emergency departments, resuscitation should occur on scene. 9. The maximum setting on the defibrillator should be used for initial and subsequent defibrillation attempts. Defibrillation dosing should follow manufacturer’s recommendation in the case of biphasic defibrillators. If the manufacturer’s recommendation is unknown, use highest setting possible. In the case of monophasic devices, the setting should be 360 J (joule) (or 4 J/kg for children). 10. IV or IO access without interrupting chest compressions. 11. Administer epinephrine (0.1 mg/kg, maximum dose 1 mg) IV/IO during the first or second round of compressions. 12. At present, the most effective mechanism of airway management is uncertain due to some systems managing the airway aggressively and others managing the airway with basic measures and both types of systems finding excellent outcomes. Regardless of the airway management style, consider the following principles: a. Airway management should not interrupt chest compressions. b. Carefully follow ventilation rate and prevent hyperventilation. c. Consider limited tidal volumes. d. There is uncertainty regarding the proper goals for oxygenation during resuscitation. i. Current recommendations suggest using the highest flow rate possible through NRB or BVM. ii. This should not be continued into the post-resuscitation phase in which the goal should be an oxygen saturation (SpO2) of 94–98%. e. Pediatric considerations: Special attention should be applied to the pediatric population and airway management/respiratory support. Given that the most likely cause of cardiac arrest is respiratory, airway management may be considered early in the patient’s care. i. However, the order of Circulation-Airway-Breathing is still recommended as the order of priority by the American Heart Association for pediatric resuscitation to ensure timely initiation of chest compressions to maintain perfusion, regardless of the underlying cause of the arrest. ii. In addition, conventional CPR is preferred in children, since it is associated with better outcomes when compared to compression-only CPR. 13. Special circumstances in cardiac arrest a. Trauma, treat per the General Trauma Management Guideline b. Pregnancy i. The best hope for fetal survival is maternal survival ii. Position the patient in the supine position with a second rescuer performing manual uterine displacement to the left to displace the gravid uterus and increase venous return by avoiding aorto-caval compression iii. If manual displacement is unsuccessful, the patient may be placed in the left lateral tilt position at 30°. This position is less desirable than the manual uterine displacement as chest compression s are more difficult to perform in this position iv. Chest compressions should be performed slightly higher on the sternum than in the non-pregnant patient to account for elevation of the diaphragm and abdominal contents in the obviously gravid patient v. Defibrillation should be performed as in non-pregnant patients c. Arrests of respiratory etiology (including drowning). In addition to the above, consider early management of the patient’s airway. Passive ventilation with a NRB is not indicated for these patients 14. Application of the “pit crew” model of resuscitation a. Ideally, clinicians in each EMS agency will use a “pit crew” approach when using this protocol to ensure the most effective and efficient cardiac arrest care. Training should include teamwork simulations integrating first responders, BLS, and ALS crewmembers who regularly work together. High-performance systems should practice teamwork using “pit crew” techniques with predefined roles and crew resource management principles. For example (the Pennsylvania State EMS Model for Pit Crew): i. Rescuer 1 and 2 set up on opposite sides of patient’s chest and perform continuous chest compressions, alternating after every 100 compressions to avoid fatigue. ii. Use a metronome or CPR feedback device to ensure that compression rate is 100– 120/minute. iii. Chest compressions are only interrupted during rhythm check (AED analysis or manual) and defibrillation shocks – Continue compressions when AED/defibrillator is charging. iv. Additional rescuer obtains IO (or IV) access and gives epinephrine. For IO access: 1. The proximal humerus is the preferred site for adults. 2. The tibial site is preferred for infants and children. v. During the first four cycles of compressions/defibrillation (approximately 10 minutes) consider avoiding advanced airway placement. vi. One responding clinician assumes code leader position overseeing the entire response. vii. Use a CPR checklist to ensure that all best practices are followed during CPR. b. For efficient “pit crew” style care, the EMS agency medical director should establish the options that will be used by clinicians functioning within the EMS agency. Options include establishing: i. The airway/ventilation management, if any, that will be used. ii. The initial route of vascular access. 15. The EMS agency must perform a Quality Improvement (QI) review of care and outcome, overseen by the agency medical director, for every patient that receives CPR. a. The QI should be coordinated with local receiving hospitals to include hospital admission, discharge, and condition information. This EMS agency QI can be accomplished by participation an organized cardiac arrest registry. b. The QI should be coordinated with local PSAP/dispatch centers to review opportunities to assure optimal recognition of possible cardiac arrest cases and provision of dispatch- assisted CPR (including hands-only CPR when appropriate). Adult Post-ROSC (Return Of Spontaneous Circulation) Care Aliases None noted Patient care goals The immediate ROSC period is critical in stabilizing patients and preparing for transport. The goal is therefore to maximize survival and optimize neurologic and cardiovascular function following a return of spontaneous circulation by the following steps: Secure airway Obtain vascular access Maximize blood pressure Identify ST-elevation myocardial infarction (STEMI) or reversible causes of arrest Recognize pending re-arrest Consider appropriate destination choice Patient presentation Inclusion criteria Patient returned to spontaneous circulation following cardiac arrest resuscitation. Exclusion Criteria None noted Patient management Assessment, treatment, and interventions 1. Perform general patient assessment attempting to identify cause of cardiac arrest. 2. Support life-threatening problems associated with airway, breathing, and circulation. a. For example, most of the pediatric cardiac arrest occurs due to non-cardiac causes such as respiratory failure (hypoxemia) or shock (hypovolemia). 3. Monitor closely for recurrence of cardiac arrest using clinical and adjunctive criteria such as cardiac monitoring [acquire/transmit EMR-O, INT-R; interpret INT-R], EtCO2 monitoring [EMR-O, INT-R], and physical signs of perfusion. 4. Administer oxygen as appropriate with a target of achieving 94–98% saturation. [EMR-O, EMT-R; HFNC PARA-O] Do not hyperoxygenate. 5. Do not hyperventilate. Maintain a ventilation rate of 8–10 breaths per minute, targeting an EtCO2 of 35–45 mmHg. 6. For hypotension (SBP less than 90 mmHg or MAP less than 65 in adults) see Shock Guideline. 7. Perform serial 12-lead EKGs to assess for evidence of reversible cause of arrest such as STEMI or electrolyte derangement (e.g., hyperkalemia) [acquire/transmit EMR-O, INT-R; interpret INT-R]. 8. Post-cardiac arrest patients with evidence or interpretation consistent with ST elevation myocardial infarction (STEMI/acute MI) should be transported preferably to a facility capable of emergent cardiac catheterization or, as a secondary option, to a STEMI receiving facility based upon local resources and system of care. 9. Check blood glucose. a. If hypoglycemic, treat per Hypoglycemia Guideline. b. If hyperglycemic, notify hospital on arrival. 10. If patient seizes, treat per Seizures Guideline. 11. Consider transporting patients to an age-appropriate facility which offers specialized adult or pediatric post-resuscitation care. Patient safety considerations 1. Avoid hyperthermia (temperature greater than 37.5° C or 99.5° F) by avoiding excessive environmental heat exposure, warm blankets, etc. a. Beyond interventions to prevent hyperthermia or fever, prehospital initiation of therapeutic hypothermia (targeted temperature management) is not routinely recommended. Notes and educational pearls Key considerations 1. Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase and must be avoided. Similarly, hypoventilation (suggested by an EtCO2 greater than 40–45) contributes to worsening acidosis and may precipitate re-arrest. 2. Most patients are comatose immediately after resuscitation and will require airway management and ventilatory assistance. 3. Many patients experience “stunning” of the cardiac muscle after ROSC. Hypotension is common, and volume resuscitation or vasopressor support is often required. Refer to the [Shock Guideline] for further recommendations. Anticipate and prepare for subsequent cardiac arrest. 4. Common non-cardiac causes of post-resuscitation hypotension include hyperventilation, hypovolemia, and traumatic pneumothorax from chest compressions. 5. The condition of post-resuscitation patients fluctuates rapidly and continuously requiring close monitoring. A significant percentage of post-ROSC patients will re- arrest. 6. Current research has demonstrated that care of patients with ROSC at specialized centers is associated with both decreased mortality and improved neurologic outcomes. 7. Maintain mechanical CPR device in place in preparation for re-arrest. 8. A moderate number of adult post-ROSC patients may have transient ST-elevation on EKG Consider performing serial EKGs. Post-ROSC patients should preferentially be transported to centers capable of managing STEMI, whenever possible. Pertinent assessment findings Assess post-ROSC rhythm, lung sounds, and for signs of hypoperfusion. Determination of death/withholding resuscitative efforts Aliases None noted Patient care goals All clinically dead patients will receive all available resuscitative efforts including cardiopulmonary resuscitation (CPR) unless contraindicated by one of the exceptions defined below. Patient presentation A clinically dead patient is defined as any unresponsive patient found without respirations and without a palpable carotid pulse. Inclusion/exclusion criteria: 1. Resuscitation should be started on all patients who are found apneic and pulseless unless the following conditions exist (does not apply to victims of lightning strikes, drowning, or hypothermia): a. Medical cause or traumatic injury or body condition clearly indicating biological death (irreversible brain death), limited to: i. Decapitation: the complete severing of the head from the remainder of the patient’s body ii. Decomposition or putrefaction: the skin is bloated or ruptured, with or without soft tissue sloughed off. The presence of at least one of these signs indicated death occurred at least 24 hours previously iii. Transection of the torso: the body is completely cut across below the shoulders and above the hips through all major organs and vessels. The spinal column may or may not be severed iv. Incineration: 90% of body surface area with full thickness burns as exhibited by ash rather than clothing and complete absence of body hair with charred skin v. Injuries incompatible with life (such as massive crush injury, complete exsanguination, severe displacement of brain matter) vi. Futile and inhumane attempts as determined by agency policy/protocol related to “compelling reasons” for withholding resuscitation vii. In blunt trauma, if the patient is apneic, pulseless, and without other signs of life upon EMS arrival including, but not limited to spontaneous movement, EKG activity, or pupillary response viii. Nontraumatic arrest with obvious signs of death including dependent lividity or rigor mortis OR b. A valid Wisconsin DNR order (form, card, bracelet) is present, and it: i. Conforms to the Wisconsin state specifications for color and construction. ii. Is intact: it has not been cut, broken, or shows signs of being repaired. iii. Displays the patient’s name and, if required by state law or regulation, the physician’s name. Patient management Assessment Assess for dependent lividity with rigor mortis and/or other inclusion criteria. Treatment and interventions 1. If all the components above are confirmed, no CPR is required. 2. If CPR has been initiated but all the components above have been subsequently confirmed, CPR should be discontinued, and medical direction contacted as needed. 3. If any of the findings are different than those described above, clinical death is not confirmed, and resuscitative measures should be immediately initiated or continued. The Termination of Resuscitative Efforts Guideline should then be implemented. • Do Not Resuscitate (DNR) order) with signs of life: a. If there is a DNR bracelet or DNR transfer form and there are signs of life (pulse and respirations), provide standard appropriate treatment under existing protocols matching the patient’s condition. b. To request permission to withhold treatment under these conditions for any reason contact medical direction. c. If for any reason an intervention that is prohibited by an advanced directive is being considered, contact medical direction. Patient safety considerations In cases where the patient's status is unclear and the appropriateness of withholding resuscitation efforts is questioned, EMS personnel should initiate CPR immediately and then contact medical direction. Notes and educational pearls Key considerations 1. For scene safety and/or family wishes, clinician may decide to implement CPR even if all the criteria for death are met. 2. At a likely crime scene, disturb as little potential evidence as possible. Pertinent assessment findings None noted Do Not Resuscitate Status/Advance Directives/Health Care Power Of Attorney (POA) Status Aliases Comfort care Do Not Resuscitate (DNR) Patient care goals To acknowledge and understand patient goals about cardiopulmonary resuscitation or end-of- life decision making. Patient presentation Inclusion/exclusion criteria 1. Meets the criteria established by Wisconsin law (Wis. Stat. Ch. 154, Advanced Directives) Patient management Assessment If the patient has a valid exclusion to resuscitation, then no CPR or airway management should be attempted, however this does not exclude comfort measures as appropriate. 1. If CPR has been initiated and a valid exclusion to resuscitation has been subsequently verified, CPR may be discontinued, and medical direction contacted as needed. Treatment and interventions 1. If there is a valid exclusion to resuscitation and there are signs of life (pulse and respirations), EMS clinicians should provide standard appropriate treatment under existing protocols according to the patient’s condition. 2. The patient should receive full treatment per protocols except for any intervention specifically prohibited in the patient’s valid exclusion to resuscitation. 3. If for any reason an intervention that is prohibited by an advanced directive is being considered, medical direction should be contacted. Patient safety considerations In cases where the patient's status is unclear and the appropriateness of withholding resuscitation efforts is questioned, EMS personnel should initiate CPR immediately and contact medical direction. Notes and educational pearls Key considerations 1. Special Consideration: For scene safety and/or family wishes, the EMS clinician may decide to implement CPR even if all the criteria for death are met. Pertinent assessment findings None noted Termination of resuscitative efforts Aliases Call the code Patient care goals 1. When there is no response to prehospital cardiac arrest treatment, it is acceptable and often preferable to cease futile resuscitation efforts in the field. 2. In patients with cardiac arrest, prehospital resuscitation is initiated with the goal of returning spontaneous circulation before permanent neurologic damage occurs. 3. CPR that is performed during patient packaging and transport is much less effective than CPR done at the scene. Additionally, EMS clinicians’ risk physical injury while attempting to perform CPR in a moving ambulance while unrestrained. In addition, continuing resuscitation in futile cases places other motorists and pedestrians at risk, increases the time that EMS crews are not available for another call, impedes emergency department care of other patients, and incurs unnecessary hospital charges. Lastly, return of spontaneous circulation is dependent on a focused, timely resuscitation. The patient in cardia arrest should be treated as expeditiously as possible, including quality, uninterrupted CPR and timely defibrillation as indicated. 4. When cardiac arrest resuscitation becomes futile, the patient’s family should become the focus of the EMS clinicians. Families need to be informed of what is being done and that transporting all cardiac arrest patients to the hospital is not supported by evidence. This practice also inconveniences the family by requiring a trip to the hospital where they must begin grieving in an unfamiliar setting. Most families understand the futility of the situation and are accepting of ceasing resuscitation efforts in the field. 5. Consider potential for organ donation if feasible. Patient presentation Patient in cardiac arrest Inclusion criteria 1. Any cardiac arrest patient that has received resuscitation in the field but has not responded to treatment. 2. When resuscitation has begun, and it is found that the patient has a DNR order. Exclusion criteria Consider continuing resuscitation for patients in cardiac arrest associated with medical conditions that may have a better outcome despite prolonged resuscitation, including hypothermia. Patient management Resuscitation may be terminated under the following circumstances: 1. Non-traumatic arrest (all circumstances a-f below): a. Patient is at least 18 years of age b. Patient is in cardiac arrest at the time of arrival of advanced life support (ALS) i. No pulse ii. No respirations iii. No evidence of meaningful cardiac activity (e.g., asystole or wide complex PEA less than 60 BPM, no heart sounds) c. ALS resuscitation is administered appropriate to the presenting and persistent cardiac rhythm. i. Resuscitation may be terminated in asystole and slow wide complex PEA if there is: 1. No return of spontaneous circulation after 20 minutes in the absence of hypothermia. AND 2. The EtCO2 is less than 20 mmHg. ii. Narrow complex PEA with a rate above 40 or refractory and recurrent ventricular fibrillation/ventricular tachycardia: 1. Consider resuscitation for up to 60 minutes from the time of dispatch. 2. Termination efforts may be ceased before 60 minutes based on factors including, but not limited to, EtCO 2 less than 20 mmHg, age, co- morbidities, distance from, and resources available at the closest hospital. Termination before this timeframe should be done in consultation with online medical direction. d. There is no return of spontaneous pulse and no evidence of neurological function (non- reactive pupils, no response to pain, no spontaneous movement). e. No evidence or suspicion of hypothermia. f. All EMS clinicians involved in the patient’s care agree that discontinuation of the resuscitation is appropriate. g. Consider contacting medical direction before termination of resuscitative efforts. 2. Traumatic arrest a. Patient is at least 18 years of age. b. Resuscitation efforts may be terminated in any blunt trauma patient who, based on thorough primary assessment, is found apneic, pulseless, and asystolic on an EKG or cardiac monitor upon arrival of emergency medical services at the scene. c. Resuscitation efforts may be terminated in any penetrating trauma patient who, based on thorough primary assessment, is found apneic, pulseless, and asystolic on an EKG or cardiac monitor and demonstrates no signs of life after life -saving interventions (airway, breathing and circulation interventions). i. If resuscitation is not terminated, transport is indicated. ii. Cardiopulmonary arrest patients in whom mechanism of injury does not correlate with clinical condition, suggesting a non -traumatic cause of arrest, should have standard ALS resuscitation initiated. d. All EMS personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate. e. Consider contacting medical direction before termination of resuscitative efforts. Assessment 1. Pulse 2. Respirations 3. Neurologic status assessment [See Appendix VII. Neurologic Status Assessment; purposeful movement, pupillary response] 4. Cardiac activity (cardiac auscultation, cardiac monitoring, and/or, if available, ultrasonography) 5. Quantitative capnography Treatment and interventions 1. Focus on continuous, quality CPR that is initiated as soon as possible [EMR-R]. 2. Focus attention on the family and/or bystanders. Explain the rationale for termination. 3. Consider support for family members such as other family, friends, clergy, faith leaders, or chaplains. 4. For patients that are less than 18 years of age, consultation with medical direction is recommended. Patient safety considerations All patients who are found in ventricular fibrillation or whose rhythm changes to ventricular fibrillation should in general have full resuscitation continued on scene. Notes and educational pearls Key considerations and pertinent assessment findings 1. Recent evidence has shown that, to capture over 99% of potential survivors from medical cardiac arrest (especially VF and pulseless VT arrests), resuscitation should be continued for approximately 40 minutes. This does not imply, however, that all resuscitations should continue this long (e.g., asystolic rhythms). 2. In remote or wilderness situations, EMS clinicians should make every effort to contact medical direction, but resuscitation may be terminated in the field without contacting medical direction when the following have occurred: a. There has been no return of pulse despite greater than 30 minutes of CPR (this does not apply in the case of hypothermia). b. Transport to an emergency department will take greater than 30 minutes (this does not apply in the case of hypothermia). c. EMS clinicians are exhausted, and it is physically impossible to continue the resuscitation. 3. Logistical factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 4. Survival and functional neurologic outcomes are unlikely if ROSC is not obtained by EMS. It is dangerous to crew, pedestrians, and other motorists to attempt to resuscitate a patient during ambulance transport. 5. Quantitative EtCO 2 measurements of less than 10 mmHg or falling greater than 25% despite resuscitation indicates a poor prognosis and provide additional support for termination. Resuscitation in traumatic cardiac arrest Aliases Traumatic Cardiac Arrest (TCA) Patient care goals 1. Return of spontaneous circulation. 2. Treatment and resolution of the underlying pathophysiology leading to the traumatic cardiac arrest. 3. When appropriate, transport to the closest and most capable hospital within the defined trauma system. Patient presentation Inclusion criteria Patients suffering blunt or penetrating trauma with cardiac arrest after arrival of EMS clinicians or while under the care of EMS clinicians (witnessed arrest or recent arrest with continued signs of life). Exclusion criteria 1. When the mechanism of injury does not correlate with the clinical condition, suggesting a nontraumatic cause of cardiac arrest, standard resuscitative measures should be followed. In such cases, refer to the Resuscitation Section . 2. In victims of blunt or penetrating trauma with pulses or other signs of life on EMS clinician assessment refer to the General Trauma Management Guideline. 3. In victims of blunt or penetrating trauma with rigor mortis, lividity, or evidence of injuries incompatible with life (including decapitation, hemicorporectomy). In such cases, refer to Determination of Death/Withholding Resuscitative Efforts Guideline. 4. Resuscitation efforts may be withheld in any blunt trauma patient who, based on thorough primary assessment, is found apneic, pulseless, and asystolic on an EKG or cardiac monitor upon arrival of emergency medical services at the scene. In such cases, refer to the Determination of Death/Withholding Resuscitative Efforts Guideline. 5. Resuscitation efforts may be withheld in victims of penetrating trauma found apneic, pulseless, and without other signs of life including pupillary reflexes, respiratory effort, spontaneous movement, response to pain, and electrical activity on EKG. In such cases, refer to the Determination of Death/Withholding Resuscitative Efforts Guideline. Patient management Assessment 1. Management of traumatic cardiac arrest requires a balance of rapid, focused evaluation followed by prompt treatment of reversible life threats, including management of massive hemorrhage, airway management, decompression of tension pneumothorax, and resuscitation. 2. Assess for signs of life, including pulses, respiratory effort, and evaluation of other signs of life. 3. Assess for evidence of massive hemorrhage. a. Including evidence of massive external hemorrhage b. Evidence of pelvic injury (such as instability) 4. Assess the patient’s airway. 5. Assess the patient’s respiratory effort, if present, or for evidence of tension pneumothorax. 6. Assess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment). Treatment and interventions 1. Manage massive hemorrhage. Refer to General Trauma Management Guideline for complete list of therapies for the treatment of massive hemorrhage, including the following: a. Place tourniquets for wounds amenable to tourniquet placement [EMR-R]. b. Use a combination of wound packing [EMR-O, EMT-R]and direct pressure [EMR-R] for junctional wounds or junctional tourniquets if available. c. Place a pelvic binder [EMR-O, PARA-R]on all patients with blunt or blast trauma suffering traumatic arrest. 2. Manage the patient’s airway. Refer to the Airway Management Guideline. 3. Perform bilateral, rapid chest decompression [INT-R]. 4. Establish intravenous access [AEMT-R]. 5. Initiate volume resuscitation [AEMT-R] and adjunctive hemorrhage control measures (such as tranexamic acid (TXA)) [PARA-O]. Patient safety considerations None noted Notes and educational pearls Key considerations 1. Survival from traumatic cardiac arrest requires careful coordination between rapid prehospital assessment, EMS clinician treatment of reversible causes of traumatic cardiac arrest and transport that is rapid, but also allows maintenance of necessary therapies in a manner that is effective for patients as well as safe for EMS clinicians. 2. Evidence for the benefit of CPR in traumatic cardiac arrest is limited. Treatment priorities should initially focus on control of massive hemorrhage (including management of pelvis fractures), airway management, and consideration of bilateral needle thoracostomy. 3. Unless there is an immediate and correctable cause, patients suffering penetrating traumatic cardiac arrest have the best chance for survival when arrival time to a trauma center hospital is within 10 to 15 minutes from the loss of pulses. 4. If transport is initiated, patients should be transported to the closest appropriate hospital within the defined trauma system. 5. To reduce on-scene time, consider IV/IO access and initiation of resuscitation during transport. 6. Optimal choices for resuscitation are (in descending order as available) as follows: whole blood, balanced blood products (red blood cells (RBC), plasma), packed red blood cells alone, liquid, or freeze-dried plasma alone, no fluid resuscitation. Excessive crystalloid and colloid have little to no value and may in fact be harmful in hemorrhagic shock. 7. Consider the duration of resuscitation and transport, contact online medical direction if available to discuss. If termination of resuscitation is advised, refer to the Termination of Resuscitation Efforts Guideline. Pertinent assessment findings 1. Evidence of injuries incompatible with life 2. Evidence of signs of life Pediatric-Specific Guidelines Brief Resolved Unexplained Event (BRUE) & acute events in infants Aliases Apparent Life-Threatening Event (ALTE) Patient care goals 1. Recognize patient characteristics and symptoms consistent with a BRUE. 2. Promptly identify and intervene for patients who require escalation of care. 3. Choose proper destination for patient transport. Patient presentation Inclusion criteria 1. Suspected BRUE: An event in an infant less than 1 year old reported by a bystander as sudden, brief (less than 1 minute), unexplained, and completely resolved upon EMS arrival that includes one or more of the following: a. Breathing change (absent, decreased, or irregular) b. Color change (central cyanosis or pallor) c. Marked change in muscle tone (hyper- or hypotonia) d. Altered level of responsiveness (increased, irritability, or decreased) Exclusion criteria 1. Any signs or symptoms suggestive of underlying or acute illness or injury present upon EMS evaluation, such as: a. Abnormal vital signs for age (including fever). b. Vomiting. c. Signs of trauma. d. Noisy or labored breathing. 2. Identifiable cause for the event, such as: a. Gastric reflux (spitting up). b. Swallowing dysfunction. c. Nasal congestion or excessive secretions from the nose and/or mouth. d. Periodic breathing of the newborn. e. Breath-holding spell. f. Change in tone associated with choking, gagging, crying, feeding. g. Seizure (e.g., eye deviation, nystagmus, tonic-clonic activity). h. Hypoglycemia. i. Significant past medical history (e.g., congenital heart disease, pulmonary disease, VP shunt, or seizure disorder). j. Need for IV medication administration. 3. History or exam concerning for child abuse or neglect. 4. Color change that involved only redness (e.g., in the face) or isolated hands/feet cyanosis. Patient management Assessment 1. History a. History of circumstances and symptoms before, during, and after the event, including duration, interventions done, as well as patient color, tone, breathing, feeding, position, location, activity, and level of consciousness. b. Other concurrent symptoms (e.g., fever, congestion, cough, rhinorrhea, vomiting, diarrhea, rash, labored breathing, fussy, less active, poor sleep, poor feeding). c. Prior history of BRUE (ever, including past 24 hours). d. Past medical history (e.g., prematurity, prenatal/birth complications, gastric reflux, congenital heart disease, developmental delay, airway abnormalities, breathing problems, prior hospitalizations, surgeries, or injuries). e. Family history of sudden unexplained death or cardiac arrhythmia in other children or young adults. f. Social history: those living at home, recent household stressors, exposures to toxins/drugs, sick contacts. g. Considerations for possible child abuse (i.e., multiple/changing versions of the story or reported mechanism of injury does not seem plausible, especially for child’s developmental stage) [See Abuse and Maltreatment Guideline ]. 2. Exam a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) b. General assessment: i. Signs of respiratory distress or increased work of breathing (e.g., tachypnea, grunting or other abnormal breath sounds, nasal flaring, retracting, or head bobbing) ii. Color, both central and peripheral (pallor, cyanosis, redness, or normal), capillary refill iii. Mental status (alert, tired, lethargic, unresponsive, or irritable) c. Head to toe exam, including: i. Physical exam for signs of trauma or neglect. ii. Pupillary response and anterior fontanelle. Treatment and interventions 1. Monitoring (all patients with possible BRUE) a. Continuous cardiac monitor [acquire/transmit EMR-O, INT-R; interpret INT-R] b. Continuous pulse oximetry [EMR-O, EMT-R] c. Serial observations during transport for change in condition d. Check point-of-care (POC) blood glucose and treat symptomatic hypoglycemia [See Hypoglycemia Guideline] [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R] 2. Airway a. Give supplemental oxygen for signs of respiratory distress or hypoxemia — escalate from a nasal cannula to a simple face mask to a non-rebreather mask as needed [See Airway Management Guideline] [EMR-O, EMT-R; HFNC PARA-O]. b. Suction excessive secretions from the nose and/or mouth (using bulb syringe or suction catheter) [See Pediatric Respiratory Distress (Bronchiolitis) Guideline] [EMR-R]. 3. Utility of IV placement and fluids a. Routine IVs should not be placed on all suspected BRUE patients. b. IVs should be placed [AEMT-R] only for clinical concerns of shock or to administer IV medications. 4. Transport the patient to the appropriate facility even if they appear well or have returned to their baseline. Patient safety considerations 1. Regardless of the patient’s well appearance, all infants with a history of signs or symptoms suggestive of BRUE should be transported for further evaluation. a. By definition, infants who are not completely well-appearing at EMS evaluation do not meet the definition of possible BRUE and should be treated and transported according to local guidelines. 2. Destination considerations a. All patients should be transported to facilities with at least baseline pediatric readiness, i.e., appropriate equipment, resources, and trained staff capable of providing initial emergency care and stabilization to pediatric patients prior to hospital admission or interfacility transfer, if feasible. b. Consider transport to a facility with pediatric critical care capability for patients with any. High-risk criteria: Notes and educational pearls Key considerations 1. BRUE is a group of symptoms, not a disease process. 2. If the infant is not completely well upon EMS arrival, this excludes possible BRUE event: a. Treat and transport according to local guidelines. 3. Avoid using “BRUE”, “ALTE”, “SIDS” (sudden infant death syndrome), or “near-miss SIDS” terminology with parent/guardian. 4. EMS clinicians play a unique and important role in obtaining an accurate history soon after the event and in observing, documenting, and reporting environmental, scene and social indicators that may point to an alternate diagnosis. 5. High-risk patients with a possible BRUE have worse outcomes and may require emergency department (ED) or inpatient testing, intervention, and/or follow-up. 6. The determination of a BRUE is made only after hospital evaluation, not in the field: a. A few of these infants will die even after hospital evaluation and treatment. 7. All patients should be transported to an ED. Less than 2 months of age History of prematurity (less than or equal to 32 weeks gestation) More than one BRUE, now or in the past Event duration greater than 1 minute CPR or resuscitation by caregivers or trained rescuers 8. Contact medical direction if parent/guardian is refusing medical care and/or transport, especially if any high-risk criteria are present. Pediatric respiratory distress (Bronchiolitis) (Adapted from an evidence-based guideline created using the National Prehospital Evidence- Based Guideline Model Process) Aliases None noted Patient care goals 1. Alleviate respiratory distress. 2. Promptly identify respiratory distress, failure, and/or arrest, and intervene for patients who require escalation of therapy. 3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress. Patient presentation Inclusion criteria Child less than 2 years of age typically with diffuse rhonchi and/or wheezing with a viral or other undifferentiated illness characterized by rhinorrhea, cough, fever, tachypnea, and/or respiratory distress. Exclusion criteria 1. Anaphylaxis 2. Croup 3. Epiglottitis 4. Foreign body aspiration 5. Submersion/drowning 6. Asthma Patient management Assessment 1. History a. Onset of symptoms b. Concurrent symptoms (e.g., fever, cough, rhinorrhea, tongue/lip swelling, rash, labored breathing, foreign body aspiration) c. Sick contacts d. History of wheezing e. Respiratory and other treatments given f. Number of emergency department visits in the past year g. Number of admissions in the past year h. Number of intensive care unit (ICU) admissions ever (including pediatric ICU (PICU) and neonatal ICU (NICU)) i. History of prematurity j. Family history of asthma, eczema, or allergies k. Change in feeding patterns and/or number of wet diapers 2. Exam a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) temperature, and O2 saturation b. Air entry (normal vs. diminished) c. Breath sounds (wheezes, crackles, rales, rhonchi, diminished, clear) d. Signs of distress (grunting, nasal flaring, retracting, accessory muscle use) e. Weak cry or inability to speak full sentences (sign of shortness of breath) f. Color (pallor, cyanosis, normal) g. Mental status (alert, tired, lethargic, unresponsive) h. Hydration status (+/- sunken eyes, delayed capillary refill, mucous membranes (moist vs. tacky), fontanel (flat vs. sunken)) Treatment and interventions 1. Pulse oximetry and end-tidal capnography (EtCO2) should be routinely used as an adjunct to other forms of respiratory monitoring [pulse oximetry EMR-O, EMT-R; end tidal capnography EMR-O, INT-R]. 2. Perform EKG only if there are no signs of clinical improvement after treating respiratory distress [acquire/transmit EMR-O, INT-R; interpret INT-R]. 3. Airway a. Give supplemental oxygen – escalate from a nasal cannula to a simple face mask to a non- breather mask as needed, to maintain normal oxygenation (goal SpO 2 94–98%) [EMR-O, EMT-R; HFNC PARA-O]. b. Suction the nose and/or mouth (via bulb or suction catheter) particularly if excessive secretions are present [EMT-R]. 4. Inhaled medications – nebulized epinephrine 5 mg (5 mL of 1 mg/mL solution) should be administered to children in severe respiratory distress with bronchiolitis in the prehospital setting if other treatments (e.g., suctioning, oxygen) fail to result in clinical improvement; if immediate reassessment after treatment does not demonstrate clinical improvement, airway management should be escalated as necessary ( see below and refer to Airway Management Guideline)[ EMT-O]. 5. Utility of IV placement and fluids [AEMT-R]. IVs should only be placed in children with respiratory distress for clinical concerns of dehydration, or when administering IV medications. Otherwise, IV access is not routinely needed in bronchiolitis. 6. Steroids are not efficacious and should not be given. 7. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts. a. High flow nasal cannula (HFNC) [PARA-O] or continuous positive airway pressure (CPAP) [EMT-O, AEMT-R]can be administered, when available, for severe respiratory distress. b. Bag-valve-mask ventilation should be utilized in children with respiratory failure or impending respiratory failure [EMR-R]. 8. Supraglottic devices and intubation a. Supraglottic devices and intubation should be utilized only if bag-valve-mask (BVM) ventilation fails [non-visualized airway EMR-O, EMT-R; intubation INT-O, PARA-R]. b. The airway should be managed in the least invasive way possible. Patient safety considerations Routine use of lights and sirens is not recommended during transport. Notes and educational pearls Key considerations 1. Suctioning can be a very effective intervention to alleviate distress since infants are obligate nose breathers. 2. Heliox should not be routinely administered to children with respiratory distress. 3. Insufficient data exist to recommend the use of inhaled steam or nebulized saline. 4. Although albuterol and steroids have previously been a consideration, the most recent evidence does not demonstrate a benefit in routine use of albuterol or steroids for bronchiolitis. 5. Ipratropium and other anticholinergic agents should not be given to children with bronchiolitis in the prehospital setting. 6. Although nebulized hypertonic saline has been shown to decrease hospital length of stay when used for bronchiolitis, it does not provide immediate relief of distress and should not be administered to children in respiratory distress in the prehospital setting. Pertinent assessment findings Frequent reassessment is necessary to determine if interventions have alleviated signs of respiratory distress. Pediatric respiratory distress (Croup) (Adapted from an evidence-based guideline created using the National Prehospital Evidence- Based Guideline Model Process) Aliases None noted Patient care goals 1. Alleviate respiratory distress. 2. Promptly identify respiratory distress, respiratory failure, respiratory arrest, and intervene for patients who require escalation of therapy. 3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress. Patient presentation Inclusion criteria Suspected croup (history of stridor or history of barky cough) Exclusion criteria 1. Presumed underlying cause that includes one of the following: a. Anaphylaxis b. Asthma c. Bronchiolitis (wheezing in a patient less than 2 years of age) d. Foreign body aspiration e. Submersion/drowning f. Epiglottitis Patient management Assessment 1. History a. Onset of symptoms (history of choking) b. Concurrent symptoms (fever, cough, rhinorrhea, tongue/lip swelling, rash, labored breathing, foreign body aspiration) c. Sick contacts d. Treatments given e. Personal history of asthma, wheezing, or croup in past 2. Exam a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) temperature, and O2 saturation b. Presence of stridor at rest or when agitated c. Description of cough d. Other signs of distress (grunting, nasal flaring, retracting, use of accessory muscles) e. Color (pallor, cyanosis, normal) f. Mental status (alert, tired, lethargic, unresponsive) Treatment and interventions 1. Monitoring a. Pulse oximetry and EtCO2 should be routinely used as an adjunct to other forms of respiratory monitoring [pulse oximetry EMR-O, EMT-R; end tidal capnography EMR-O, INT-R]. 2. Airway a. Give supplemental oxygen as needed and tolerated to avoid agitating patient. Escalate from a nasal cannula to a simple face mask to a non- breather mask to SPO2 94-98% [EMR-O, EMT-R]. b. Suction the nose and/or mouth (via bulb or suction catheter) if excessive secretions are present [EMR-R]. 3. Inhaled medications should be administered to all children with croup in respiratory distress with signs of stridor at rest—these medications should be repeated at this dose with unlimited frequency for ongoing respiratory distress. a. Epinephrine 5 mg (5 mL of 1 mg/mL solution) [EMT-O]nebulized (may repeat in 20 minutes as needed), or b. Racemic epinephrine 0.5 mL of 2.25% solution mixed in 2.5 mL NS (may repeat in 20 minutes as needed) [EMT-O]. c. Humidified oxygen or mist therapy is not indicated. 4. Dexamethasone 0.6 mg/kg oral, IV, or IM to maximum dose of 16 mg should be administered to patients with suspected croup [PARA-O]. 5. Utility of IV placement and fluids. IVs should only be placed in children with respiratory distress for clinical concerns of dehydration or when administering IV medications [AEMT-R]. 6. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts. a. Continuous positive airway pressure (CPAP) should be administered for severe respiratory distress [EMT-O, AEMT-R]. b. BVM ventilation should be utilized in children with respiratory failure [EMR-R]. 7. Supraglottic devices and intubation — should be utilized only if BVM ventilation fails. The airway should be managed in the least invasive way possible [non- visualized airway EMR-O, EMT-R; intubation INT-O, PARA-R]. Patient safety considerations 1. Routine use of lights and sirens is not recommended during transport. 2. Patients who receive inhaled epinephrine should be transported to definitive care. Notes and educational pearls Key considerations 1. Upper airway obstruction can have inspiratory, expiratory, or biphasic stridor. 2. Foreign bodies can mimic croup, it is important to ask about a possible choking event. 3. Impending respiratory failure is indicated by: a. Change in mental status such as fatigue and listlessness. b. Pallor. c. Dusky appearance. d. Decreased retractions. e. Decreased breath sounds with decreasing stridor. 4. Without stridor at rest or other evidence of respiratory distress, inhaled medications may not be necessary. Pertinent assessment findings 1. Respiratory distress (retractions, wheezing, stridor, accessory muscle use) 2. Decreased oxygen saturation 3. Skin color 4. Neurologic status assessment 5. Reduction in work of breathing after treatment 6. Improved oxygenation after breathing Neonatal resuscitation Aliases None noted Patient care goals 1. Plan for resources based on number of anticipated patients (e.g., mother and newborn or multiple births). 2. Provide routine care to the newly born infant. 3. Perform a neonatal assessment. 4. Rapidly identify newly born infants requiring resuscitative efforts. 5. Provide appropriate interventions to minimize distress in the newly born infant. 6. Recognize the need for additional resources based on patient condition and/or environmental factors. Patient presentation Inclusion criteria Newly born infants Exclusion criteria Documented gestational age less than 20 weeks (usually calculated by date of last menstrual period). If any doubt about accuracy of gestational age, initiate resuscitation. Patient management Assessment 1. History a. Date and time of birth b. Onset of symptoms c. Prenatal history (prenatal care, substance abuse, multiple gestation, placenta and head positions if know, maternal illness) d. Birth history (maternal fever, presence of meconium, maternal bleeding, difficult delivery (e.g., shoulder dystocia, prolapsed or nuchal cord, breech)) e. Estimated gestational age (may be based on last menstrual period) 2. Exam a. Respiratory rate and effort (strong, weak, or absent; regular or irregular) b. Signs of respiratory distress (grunting, nasal flaring, retractions, gasping, apnea) c. Heart rate (fast, slow, or absent) i. Precordium, umbilical stump, or brachial pulse may be used (auscultation of chest is preferred since palpation of umbilical stump is less accurate) d. Muscle tone (poor or strong) e. Color/appearance (central cyanosis, acrocyanosis, pallor, normal) f. APGAR score (Appearance, Pulse, Grimace, Activity, Respiratory effort) — may be calculated for documentation, but not necessary to guide resuscitative efforts g. Estimated gestational age (term, late preterm, premature) h. Pulse oximetry should be considered if resuscitative efforts are initiated or if supplemental oxygen is administered Treatment and interventions 1. If immediate resuscitation is required and the newborn is still attached to the mother, clamp the cord in two places and cut between the clamps. If no resuscitation is required, warm/dry/stimulate the newborn, and then cut/clamp the cord after 60 seconds or the cord stops pulsating. 2. Dry, warm, and stimulate a. Wrap infant in dry towel or thermal blanket to keep infant as warm as possible during resuscitation; keep head covered if possible. b. If strong cry, regular respiratory effort, good tone, and term gestation, infant should be placed skin-to-skin with mother and covered with dry linen. 3. If weak cry, signs of respiratory distress, poor tone, or preterm gestation then position airway (sniffing position) and clear airway as needed. If signs of respiratory distress with airway obstruction, suction mouth then nose; routine suctioning is not recommended [EMR-R]. 4. Apply cardiac monitor, if available [acquire/transmit EMR-O, INT-R; interpret INT-R]. 5. If heart rate greater than 100 BPM a. Monitor for central cyanosis — provide blow-by oxygen as needed. b. Monitor for signs of respiratory distress. If apneic or in significant respiratory distress: i. Ventilate: BVM ventilation with room air at 40–60 breaths per minute. 1. Positive pressure ventilation (PPV) with bag-mask device may be initiated with room air (21% oxygen) in term and late preterm babies; otherwise use 100% oxygen [EMR-R]. 2. Goal: SPO2 at 10 minutes is 85–95%. ii. Consider endotracheal intubation per local guidelines [INT-O, PARA-R]. 6. Evaluate: If heart rate less than 100 BPM: a. Initiate BVM ventilation with room air at 40–60 breaths per minute for 90 seconds with room air[PARA-R]. i. Primary indicator of effective ventilation is improvement in heart rate. ii. Evaluate heart rate every 30 seconds. iii. Rates and volumes of ventilation required can be variable, only use the minimum necessary rate and volume to achieve chest rise and a change in heart rate; can control rate and volume by saying “squeeze, release” – squeeze the bag just until chest rise is indicated then release to allow for exhalation. b. If no improvement after 90 seconds, change oxygen delivery to 30% FiO 2 (fraction of inspired oxygen) if blender available, otherwise 100% FiO2 until heart rate normalizes [EMR-O, EMT-R]. c. Consider endotracheal intubation or supraglottic airway per local guidelines if BVM ventilation is ineffective [supraglottic EMR-O, EMT-R; intubation INT-O, PARA-R]. 7. Resuscitate: If heart rate less than 60 BPM: a. Ensure effective ventilations with supplementary oxygen and adequate chest rise. b. If no improvement after 30 seconds, initiate chest compressions — two-thumb- encircling- hands technique is preferred [EMR-R]. c. Coordinate chest compressions with positive pressure ventilation (3:1 ratio, 90 compressions and 30 breaths per minute). d. Consider endotracheal intubation or supraglottic airway per local guidelines [non- visualized airway EMR-O, EMT-R; intubation INT-O, PARA-R]. e. Administer epinephrine (0.1 mg/mL) 0.01 mg/kg IV/IO (preferable if access obtained) or 0.1 mg/kg via the ETT (if unable to obtain access) q 3–5 minutes if heart rate remains less than 60 BPM [INT-R]. 8. Consider checking a blood glucose for ongoing resuscitation, maternal history of diabetes, ill appearing or unable to feed [glucose check EMR-O, EMT-R; oral glucose EMR-O, EMT-R; IV dextrose AEMT-R]. 9. Administer 20 mL/kg normal saline IV/IO for signs of shock or post-resuscitative care [AEMT-R]. Patient safety considerations 1. Hypothermia is common in newborns and worsens outcomes of nearly all post-natal complications. a. Ensure heat retention by drying the infant thoroughly, covering the head, and wrapping the baby in dry cloth. b. When it does not encumber necessary assessment or required interventions, “kangaroo care” (i.e., placing the infant skin-to-skin directly against mother’s chest and wrapping them together) is an effective warming technique. c. Newborn infants are prone to hypothermia which may lead to hypoglycemia, hypoxia, and lethargy. Aggressive warming techniques should be initiated including drying, swaddling, and warm blankets covering body and head. When available, radiant warmers or other warming adjuncts are suggested for babies who require resuscitation, especially for preterm babies. Check blood glucose and follow Hypoglycemia Guideline as appropriate. 2. During transport, neonate should be appropriately secured (e.g., secured to mother with approved neonatal restraint system, car seat or isolette) and mother should be appropriately secured. Notes and educational pearls Key considerations 1. Approximately 10% of newly born infants require some assistance to begin breathing at birth and 1% require resuscitation to support perfusion. 2. Most newborns require only drying, warming, and stimulating to help them transition from fetal respiration to newborn respiration. The resuscitation sequence can be remembered as Dry, Warm, and Stimulate – Ventilate – Evaluate – and Resuscitate . Table 1. Assessments that are used to initiate BMV and chest compressions INTERVENTION INDICATED Blow-by Oxygen Bag-Mask- Ventilation (BVM) BVM and Chest compressions ASS ESS MEN T Heart Rate (BPM) > 100 60–100 < 60 Respiratory Distress/Apnea No Yes Central Cyanosis Present Yes Yes/No 3. Deliveries complicated by maternal bleeding (placenta previa, vas previa, or placental abruption) place the infant at risk for hypovolemia secondary to blood loss. 4. Low birth weight infants are at high-risk for hypothermia due to heat loss. 5. Measuring the pulse oximetry on the right hand provides the most accurate oxygen saturation (SpO2) in infants that are transitioning from fetal to normal circulation. At 60 seconds, 60% is the target with an increase of 5% every minute until 5 minutes of life when pulse oximetry is 80–85%. Table 2. Projected Pulse Oximetry in Infants Over Time Time Since Birth Projected Increase in Pulse Oximeter Over Time 1 minute 60–65% 2 minutes 65–70% 3 minutes 70–75% 4 minutes 75–80% 5 minutes 80–85% 10 minutes 85–90% 6. Both hypoxia and excess oxygen administration can result in harm to the infant. If prolonged oxygen use is required, titrate to maintain an SPO 2 of 85–95%. 7. While not ideal, a larger facemask than indicated for patient size may be used to provide BVM ventilation if an appropriately sized mask is not available. Avoid pressure over the eyes as this may result in bradycardia. 8. Increase in heart rate is the most reliable indicator of effective resuscitative efforts. 9. A multiple gestation delivery may require additional resources and/or clinicians. 10. There is no evidence to support the routine practice of administering sodium bicarbonate for the resuscitation of newborns. 11. APGAR scoring is not critical during the resuscitation, although it may be prognostic after 20 minutes if the APGAR Score remains “0” despite resuscitation. Table 3. APGAR Score Sign 0 1 2 Appearanc e: Blue, Pale Body pink, Extremities blue Completely pink Pulse: Absent Slow (less than l00) ≥ 100 Grimace: No response Grimace Cough or Sneeze Activity: Limp Some flexion Active motion of extremities Respiration s: Absent Slow, Irregular Good, Crying Source : The Apgar Score. www.acog.org Pertinent assessment findings 1. It is difficult to determine gestational age in the field – if there is any doubt as to viability, resuscitation efforts should be initiated. 2. Acrocyanosis, a blue discoloration of the distal extremities, is a common finding in the newly born infant transitioning to extrauterine life – this must be differentiated from central cyanosis. OB/GYN Childbirth Aliases Birth Delivery Labor Patient care goals 1. Obtain necessary history to plan for birth and resuscitation of the newborn. 2. Recognize imminent birth. 3. Plan for resources based on number of anticipated patients (e.g., mother and child or multiple births). 4. Assist with uncomplicated delivery of term newborn. 5. Recognize complicated delivery situations (e.g., nuchal or prolapsed umbilical cord, breech delivery, shoulder dystocia) and plan for management and appropriate transport destination. 6. Apply appropriate techniques when an obstetric complication exists. Patient presentation Inclusion criteria Imminent delivery with crowning Exclusion criteria 1. Vaginal bleeding in any stage of pregnancy [See Obstetrical/Gynecological Conditions Guideline] 2. Emergencies in first or second trimester of pregnancy [See Obstetrical/Gynecological Conditions Guideline ] 3. Seizure from eclampsia [See Obstetrical/Gynecological Conditions Guideline and Eclampsia/Pre-Eclampsia Guideline] Patient management Assessment: 1. Signs of imminent delivery: a. Crowning or other presentation in vaginal opening b. Urge to push c. Urge to move bowels d. Mother’s sense of imminent delivery 2. Signs of active labor a. Contractions b. Membrane rupture c. Bloody show Treatment and interventions 1. If patient in labor but no signs of imminent delivery, transport to appropriate receiving facility [EMT-R]. 2. Delivery should be controlled to allow a slow controlled delivery of infant – This will prevent injury to mother [EMR-R]. a. Support the infant’s head as needed and apply gentle counterpressure to help prevent the head from suddenly popping out [EMR-R]. 3. Check for nuchal cord (i.e., around the baby’s neck) [EMR-R]. a. If present, slip it over the head [EMR-R]. b. If unable to free the cord from the neck, double clamp the cord and cut between the clamps [EMR-R]. 4. Do not routinely suction the infant’s airway (even with a bulb syringe) during delivery [EM