COVID-19 SPECIFIC PROTOCOLS 

  • Alternate Care
    Adult Flowchart
  • Alternate Care
    Adult Minor or Mild Symptoms
  • Alternate Care
    Adult Respiratory Symptoms
  • Alternate Care
    Pediatric Flowchart
  • Peds Vital Signs
  • Alternate Care
    Peds Minor or Mild Symptoms
  • Droplet Zero
  • Level Red

Adult
STAY AT HOME

STAGE 2: EMS facilitated Home Care for Respiratory Infection – Assumption: Severe impact to Hospitals. Goal: alternate care dispositions required to prevent further degradation of health services

 

Hospital Status: Severe Impact

 

Covid-19 Cases within Indiana: Extensive

 

 

Stay at Home Treatment
Minor or Mild Symptoms

 

You have received a medical assessment from Indianapolis EMS Paramedics. It appears you do not require immediate care in the Emergency Department. You should seek care by calling your doctor’s office and following the instructions below.

 

Prevent the spread of germs by covering your cough/sneezes and clean your hands often. Wash your hands with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food. Avoid touching your eyes, nose, and mouth with unwashed hands.

 

Plan to stay at home and rest for the next 2-3 days
Avoid cigarette smoke
Avoid close contact (<6 feet distance) with people who are sick
Use Tylenol (acetaminophen) for fever, sore throat, muscle aching and headache. See the medication handout for important information about these medications.
Drink plenty of fluids, such as water, orange/apple/grape juice, lemonade or sports drinks – up to eight to twelve eight-ounce glasses a day. You can also use an Oral Rehydration Solution.
Follow up with your primary care doctor if you are not better within a week

 

CALL 911 IF

 

Start coughing blood or have very heavy mucous
Have chest pain/discomfort or difficulty breathing
Have a severe headache or neck stiffness
Have a seizure
Start vomiting
Have diarrhea longer than a day, or your stools are red or black in color
Have severe abdominal pain
Develop a fever greater than 100.4 F or higher, not relieved by use of anti-fever medicine after 6 hours
Feel faint or think you are going to pass out

 

 

Name of Medicine
How to Take
Do Not Use Without First
Talking to a a Doctor if:
Acetaminophen
Tylenol
325 mg tablets

Adults: take 2 tablets every 4 to 6 hours while symptoms last
Do not take more than 10 tablets in 24 hours, unless directed by a doctor
Do not use for more than 10 days unless directed by a doctor
You have chronic liver orare using other products containing acetaminophen

Stay at Home Treatment
Respiratory Symptoms
Respiratory Illness + Fever, with or without nausea

 

You have received a medical assessment from Indianapolis EMS Paramedics. It appears you do not require immediate care in the Emergency Department. You should seek care by calling your doctor’s office and following the instructions below. You should restrict activities outside your home, except for getting medical care. Do not go to work, school, or public areas. Avoid using public transportation, ride-sharing, or taxis. Only leave your home after you have discussed your medical situation with your doctor.

 

Call EMS (9-1-1) back if you are not better in 24 hours for re-assessment or if you feel that you are worsening
Rest at home for the next 2-3 days- As much as possible, you should stay in a specific room and away from other people in your home. Also, you should use a separate bathroom, if available.
Prevent the spread of germs by wearing a facemask, cover your cough/sneezes and clean your hands often. Avoid close contact with other people (<6 feet distance)
Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food. If soap and water are not readily available, use an alcohol-based hand sanitizer. Soap and water are the best option if hands are visibly dirty. Avoid touching your eyes, nose, and mouth with unwashed hands.
Avoid cigarette smoke
Use Tylenol (acetaminophen) for fever, sore throat, muscle aching and headache. See the medication handout for important information about this medicine.
Drink plenty of fluids, such as water, orange/apple/grape juice, lemonade or sports drinks – up to eight to twelve eight-ounce glasses a day

 

CALL 911 IF

 

Start coughing blood or have very heavy mucous
Have chest pain/discomfort or difficulty breathing
Have a severe headache or neck stiffness
Have a seizure
Start vomiting
Have diarrhea longer than a day, or your stools are red or black in color
Have severe abdominal pain
Develop a fever greater than 100.4 F or higher, not relieved by use of anti-fever medicine after 6 hours
Feel faint or think you are going to pass out

 

 

Name of Medicine
How to Take
Do Not Use Without First
Talking to a a Doctor if:
Acetaminophen
Tylenol
325 mg tablets

Adults: take 2 tablets every 4 to 6 hours while symptoms last
Do not take more than 10 tablets in 24 hours, unless directed by a doctor
Do not use for more than 10 days unless directed by a doctor
You have chronic liver orare using other products containing acetaminophen

Pediatric
Stay at Home

STAGE 2: EMS Pediatric facilitated Home Care for Fever or Respiratory Infection – Assumption: Severe impact to Hospitals. Goal: reduce pediatric transport if possible for well appearing children

 

Hospital Status: Severe Impact

 

Covid-19 Cases within Indiana: Extensive

 

Pediatric
Vital Signs

VITAL SIGNS
FOR CHILDREN

Age Group

Respiratory Rate

Heart Rate

Systolic Blood Pressure

Newborn

30 - 60

120 -180

> 60

Infant
(1 - 12 months)

20 - 40

100 - 140

> 70

Toddler
(1 - 3 yrs)

20 - 34

90 - 130

> 75

Preschooler
(3 - 5 yrs)

20 - 30

80 - 120

> 80

School Age
(6 - 12 yrs)

18 - 30

70 - 110

> 80

Adolescent
(13+ yrs)

12-20

60 - 100

> 90

Pediatric
Stay at Home Treatment
Minor or Mild Symptoms

 

Your child has received a medical assessment from Indianapolis EMS Paramedics. During this current Public Health Emergency, you are advised to manage your child’s symptoms at home instead of going to the Hospital. This will limit your exposure to others who can get your child sick. Based on our assessment, your child does not need immediate care in the emergency department. You should seek care with your regular healthcare provider or doctor’s office.

 

IF YOUR CHILD WORSENS, YOU CAN CALL US BACK – DIAL 9-1-1

 

Plan to stay at home and rest for the next 2-3 days
Avoid cigarette smoke
Avoid close contact (<6 feet distance) with people who are sick
Use Tylenol (acetaminophen) for fever, sore throat, muscle aching and headache. See the medication handout for important information about these medications.

 

Acetaminophen
Tylenol
Do Not Use Without First
Talking to a a Doctor if:
Take every 4-6 hours if there is fever or pain
Your child is <12 weeks old
Your child has liver problems or is using other products containing acetaminophen

 

Weight
Syrup:
160 mg/5 ml
Chewable
80 mg
Chewable
160 mg
Adult
325 mg
Adult
500 mg
6-11 lbs
1.25 ml
---
---
---
---
12-17 lbs
2.5 ml
---
---
---
---
18-23 lbs
3.75ml
1.5 tabs
---
---
---
24-35 lbs
5 ml
2 tabs
1 tab
---
---
36-47 lbs
7.5 ml
3 tabs
1.5 tabs
---
---
48-59 lbs
10 ml
4 tabs
2 tabs
1 tab
---
60-71 lbs
12.5 ml
5 tabs
2.5 tabs
1 tab
---
72-95 lbs
15 ml
6 tabs
3 tabs
1.5 tab
1 tab
> 95 lbs
20 ml
8 tabs
4 tabs
2 tabs
1 tab

 

Drink plenty of fluids, such as water, orange/apple/grape juice, lemonade or sports drinks – up to eight to twelve eight-ounce glasses a day. You can also use an Oral Rehydration Solution.

 

Child's Weight

Amount of Pedialyte or other hydration fluid to work up gradually
10 lbs*
2 ounces (4 tablespoons) every hour
15 lbs*
2.5 ounces (6 tablespoons) every hour
20 lbs*
3.5 ounces (1/2 of a large glass) every hour
40 lbs
6.5 ounces (1 large glass) every hour
60 lbs
10 ounces (1.5 large glasses) every hour

 

Per the protocol, children <1 year should be transported instead of home care. The average 1 year old is about 25 lbs in weight.

 

Follow up with your primary care doctor if you are not better within a week

 

CALL 911 IF

 

Difficulty breathing
Signs of chest pain or abdominal pain
Severe abdominal pain
Confusion or you are unable to rouse your child
A seizure
Vomiting more than once or having several episodes of diarrhea
Develop a fever greater than 100.4 F or higher, not relieved by use of anti-fever medicine after 6 hours

 

Droplet Zero Protocol
March 23rd 2020

  1. Effective March 16th 2020, until suspended by medical direction, all EMS providers will adopt protocols (“Droplet Zero”) to limit the generation of droplets and aerosols during clinical interventions
  2.  

  3. The following procedures are defined as aerosol generating per the CDC:
  4.  

    1. Bag valve mask ventilation
    2. Oropharyngeal suctioning
    3. Endotracheal intubation
    4. Nebulizer treatment
    5. Continuous positive airway pressure (CPAP)
    6. Cardiopulmonary resuscitation

     

  5. If an aerosol generating procedure noted above is performed, the minimum PPE standard includes:
  6.  

    1. Gloves
    2. Gown
    3. Respirator (fit tested)
    4. Eye protection
    5. Face shield

     

  7. Nebulized Medications
  8.  

    1. Use should be avoided if possible – administer only if the patient is (1) hypoxic (SpO2 <92%), (2) has increased work of breathing or (3) has a shark-fin pattern on ETCO2
    2.  

    3. If a patient has their own Metered Dose Inhaler, its use is preferred over a nebulizer
    4.  

    5. If a nebulizer must be used:
    6.  

      1. First dose of nebulized medicine should be given on-scene (avoid delivery in back of ambulance of ambulance if possible)
      2. Do not use T-Piece nebulizer (unless anti-viral exhalation filter used), use only mask with flow rate 6lpm or less
      3. Use surgical face mask over nebulizer mask

       

  9. Oxygen administration equipment
  10.  

    1. Nasal cannula is preferred over a non-rebreather mask
    2. Place surgical facemask over any use of oxygen delivery devices (cannula, NRB or nebulizer mask)

     

  11. BVM Ventilation
  12.  

    1. Use HEPA filter in-line with mask or attached to BVM exhaust if available
    2. Maintain tight face seal.
    3. Avoid gastric insufflation and overly forceful ventilation

     

  13. Advanced Airway Management
  14.  

    1. The preferred 1st line advanced airway management is the use of an i-Gel with filter system attached during insertion
    2. Endotracheal intubation to be avoided whenever possible.

     

  15. Suctioning:
  16.  

    1. Unnecessary suctioning should be avoided
    2. The use of a droplet shield should be utilized if available.

     

  17. CPAP
  18.  

    1. The use of CPAP should be avoided when possible
    2. The use of CPAP devices with filters is preferred over non-filtered CPAP devices if CPAP must be used

     

  19. Cardiac Arrest
  20.  

    1. PPE as noted above should be worn for the management of cardiac arrest, including the provision of CPR

     

  21. Prior to Transport
  22.  

    1. If patient has any Metered Dose Inhalers, transport them with the patient
    2. If the patient has any home CPAP/BiPAP devices, transport them with the patient

     

  23. Transport
  24.  

    1. Avoid aerosol generating procedures performed inside the ambulance
    2. If intervention in the ambulance must be performed, minimize individuals in the patient compartment during any aerosol generating procedure
    3. Turn on fan to maximum compartment air flow

     

  25. At Hospital
  26.  

    1. Communicate with receiving hospital to ensure they are ready for patient arrival
    2. Discontinue any nebulizers and CPAP prior to entering hospital
    3. Transition to nasal cannula with surgical facemask over patient while moving from ambulance to patient room

     

  27. Pediatric Considerations
  28.  

    1. Use bag-valve-mask filter that does not increase dead space (i.e. an exhaust filter does not increase dead space)
    2. Bag Valve Mask with a filter should be used when it is clear the patient will need respiratory support but continues to have a gag reflex (ex. seizure, post-ictal patients, etc).
    3. A supraglottic airway with filter is the preferred airway management device in cases of respiratory arrest or cardiac arrest when it is clear the patient does not have a gag reflex.

Level Red
Clinical Protocols

Intent: To preserve the capacity of the EMS System in times of disaster or crisis
Implementation: Requires provider to complete training and familiarization of educational materials/handouts

 

Protocol Amendments:

 

  1. Droplet Zero
  2.  

    1. Providers are directed to follow Droplet Zero protocols to ensure appropriate protective measures are taken during aerosol generating procedures
    2. Nebulized treatments are only indicated if the patient is hypoxic (SPO2 <92%), has increased work of breathing or has a shark-fin pattern on ETCO2
    3. Providers should bring all home MDIs belonging to patient to hospital
    4. Provides should bring any home CPAP/BiPAP machine belonging to patient to hospital

     

  3. Alternate Treat-and-Release: Respiratory Illness
  4.  

    1. Providers are to utilize the Respiratory Illness Treat and Release Stage 2 Protocol
    2.  

      1. Adult patients with respiratory illnesses will be evaluated by checking for:
      2.  

        1. Vital Sign abnormalities
        2. Comorbid factors
        3. Current signs and symptoms

         

      3. Adult patients that meet the above criteria with only minor or no symptoms will not be transported. Paramedics are authorized to leave acetaminophen with the patient. Disagreements with this determination will be adjudicated by a District Lieutenant or Operational Medical Director (OMD).
      4.  

      5. Adult patients that meet the above criteria with only fever/nausea will be offered home treatment. If the patient is amenable, the paramedic may release the patient at home. The use of 1 dose of acetaminophen for fever/pain and 1 dose of ondansetron for nausea is authorized before release. Paramedics are authorized to leave acetaminophen with the patient. Providers may provide oral rehydration solution if available.
      6.  

      7. Pediatric patients with respiratory illness will be evaluated by checking for:
      8.  

        1. Pediatric Assessment Triangle abnormalities
        2. Age
        3. Abnormal vital signs, including pulse oximetry
        4. Comorbid factors

         

      9. Pediatric patients with fever may be treated with 1 dose of acetaminophen. If the patient can tolerate PO with has no other contraindications, treat-and-release at home may be recommended by providers if the parents are amenable. Providers may provide oral rehydration solution if available.

     

  5. Minor Injury/Condition Treat-and-Release
  6.  

    1. For minor first aid conditions (such as abrasions, bruises, minor headache, sore throat, etc.) providers may consider providing first aid interventions (ice, basic wound cleaning, education) and releasing on scene.
    2.  

    3. For open wounds, the patient should be transported if they have not have had a tetanus vaccination in the past 10 years.
    4.  

    5. For chronic minor complaints, lasting longer than 2 weeks (such as knee pain, wrist pain, chronic migraines), the provider may consider treat-and-release after approval from a District Lieutenant or Operational Medical Director. The approving authority name will be documented in the EMS medical record. A Community Paramedic referral through the DL/OMD can be considered.
    6.  

    7. For medication refills, discussion with a District Lieutenant or Operational Medical Director should be take place to determine alternatives. The consulting authority name will be documented in the EMS medical record. A Community Paramedic referral through the DL/OMD can be considered

     

  7. Cardiac Arrest
  8.  

    1. For Non-Traumatic Cardiac Arrest in which resuscitation is started on-scene:
    2.  

      1. Terminate resuscitation after 3 rounds of epinephrine with no ROSC OR after administration of 6th defibrillation shock with no ROSC
      2.  

      3. Exceptions include:
      4.  

        1. Pregnancy >24 weeks or palpable fundus at/above the level of umbilicus
        2. Lightning Strike
        3. Hypothermic cardiac arrest including cold water drowning
        4. Transport has already started

       

    3. For Traumatic Cardiac Arrest
    4.  

      1. Initiate resuscitation using traumatic cardiac arrest protocol only if the patient had initial Signs of Life when first encountered by public safety [Police, Fire, EMS] after injury prior to cardiac arrest (i.e. a witnessed traumatic cardiac arrest)
      2.  

      3. Signs of Life is defined as: pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure or extremity movement.

         

      4. Withhold traumatic cardiac arrest resuscitation if unwitnessed
      5.  

        1. Exceptions: Pregnancy >24 weeks or palpable fundus at/above the level of umbilicus
        2.  

        3. If a first responder prior to EMS arrival has already started resuscitation on an unwitnessed arrest, EMS providers are to ask about to surrounding circumstances to verify if there was signs of life before resuscitation was started. Resuscitation does not need to be continued if there were no signs of life before first responder arrival.

       

    5. There are NO changes in protocol for Pediatric Cardiac Arrest