Environmental Emergencies

  • Allergic Reaction
    Adult
  • Allergic Reaction
    Pediatric
  • Drowning/Near Drowning
  • Hyperthermia
  • Hypothermia

Adult
Allergic Reaction

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Call for an ALS unit if patient has wheezing, stridor, or shows other signs of respiratory distress or nausea/vomiting.
  8.  

  9. If patient has a prescribed Epi auto-injector and displays signs of anaphylaxis, assist patient with or administer one dose of the patient’s own Epi auto-injector.
  10.  

  11. If patient does not have a prescribed Epi-auto injector and displays signs of anaphylaxis, administer epinephrine 1mg/mL (1:1000) at the following dose and route:
  12.  

    1. Adult (25kg or more) 0.3 mg IM in the anterolateral thigh

     

  13. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine, additional IM epinephrine can be repeated every 5-15 minutes at above noted doses.

 

ALS
IF suspected anaphylaxis, proceed directly to epinephrine administration

 

  1. Establish a saline lock or an IV with 0.9% NaCl. Titrate fluids to a SBP of 90 mmHg.
  2.  

  3. Apply cardiac monitor.
  4.  

  5. Medicate according to signs/symptoms as below.

 

Isolated Itchy Rash/Hives

 

    Administer Diphenyhdramine 25-50 mg IV or IM

 

Rash/Hives & Wheezing

 

  1. Administer 0.3 mg Epinephrine 1:1,000 IM.
  2.  

  3. Administer 2.5 mg nebulized Albuterol at a flow sufficient to produce of mist.
  4.  

  5. Administer Diphenhydramine 25-50 mg IV or IM.

 

Stridor &/or Hypotension

 

  1. Administer 0.3 mg Epinephrine 1:1,000 IM.
  2.  

  3. Administer 2.5 mg nebulized Albuterol.
  4.  

  5. Administer Diphenhydramine 25-50 mg IV or IM.
  6.  

  7. If condition remains unchanged or worsens after 3 minutes, administer additional dose of 0.3mg Epinephrine 1:1,000 IM.
  8.  

  9. If after 3 minutes and second dose of epinephrine condition remains unchanged, mix and infuse epinephrine drip at 5mcg/min. Contact medical control if need for titration.

 

Epinephrine drip: Inject 1mL of epinephrine 1:1000 (also known as epinephrine 1 mg/ml for anaphylaxis) into a 1-liter saline bag and mix.

 

This yields a final medication concentration of 1mcg epinephrine / 1mL fluid. You must label the medication “Epi Drip: 1mcg/mL”

 

Use of a 20 gtt drip set is preferred. A 20 gtt drip set allows for:
Adult dosing: Drip rate of 100 drops/min yields drug infusion rate of 5 mcg/min.
Drip rate can be easily calculated by counting number of drops over 15 seconds then multiply by 4.

Pediatric
Allergic Reaction

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration protocol.
  6.  

  7. Call for an ALS unit if patient has wheezing, stridor, or shows other signs of respiratory distress or nausea/vomiting.
  8.  

  9. If patient has a prescribed Epi auto-injector and is experiencing stridor and/or hypotension, assist patient with or administer one dose of the patient’s own Epi auto-injector.
  10.  

  11. If patient does not have a prescribed Epi-auto injector and displays signs of anaphylaxis, administer epinephrine 1mg/mL (1:1000) at the following dose and route:
  12.  

    1. Pediatric (less than 25kg) 0.15 mg IM in the anterolateral thigh

     

  13. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine, additional IM epinephrine can be repeated every 5-15 minutes at above noted doses.

 

ALS
IF suspected anaphylaxis, proceed directly to epinephrine administration

 

  1. Establish a saline lock or an IV with 0.9% NaCl. Titrate fluids to a SBP of 90 mmHg.
  2.  

  3. Apply cardiac monitor.
  4.  

  5. Medicate according to signs/symptoms as below.

 

Isolated Itchy Rash/Hives

 

    Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)

 

Rash/Hives & Wheezing

 

  1. Administer 0.01 mg/kg Epinephrine 1:1,000 IM. (Max 0.3 mg)
  2.  

  3. Administer 2.5 mg nebulized Albuterol at a flow sufficient to produce of mist.
  4.  

  5. Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)

 

Stridor &/or Hypotension

 

  1. Administer 0.01 mg/kg Epinephrine 1:1,000 IM. (Max 0.3 mg)
  2.  

  3. Administer 2.5 mg nebulized Albuterol.
  4.  

  5. Be prepared for emergent airway management.
  6.  

  7. Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)
  8.  

  9. If condition is unchanged after 3 min. or worsens, administer additional dose of 0.01mg/kg Epinephrine 1:1,000 IM.
  10.  

  11. If after 3 minutes and second dose of epinephrine condition remains unchanged, mix and infuse epinephrine drip at 0.25mcg/kg/min (max 5mcg/min). Contact medical control if need for titration.

 

Epinephrine drip: Inject 1mL of epinephrine 1:1000 (also known as epinephrine 1 mg/ml for anaphylaxis) into a 1-liter saline bag and mix.

 

This yields a final medication concentration of 1mcg epinephrine / 1mL fluid. You must label the medication “Epi Drip: 1mcg/mL”

 

Use of a 20 gtt drip set is preferred. A 20 gtt drip set allows for:
Adult dosing: Drip rate of 100 drops/min yields drug infusion rate of 5 mcg/min.
Drip rate can be easily calculated by counting number of drops over 15 seconds then multiply by 4.

 

Weight
(Estimated by
Broselow tape)
4 kg
6 kg
8 kg
10 kg
12 kg
16 kg
> 20 kg or
Adults
Drug
Infusion
Rate
1
mcg/min
1.5
mcg/min
2
mcg/min
2.5
mcg/min
3
mcg/min
4
mcg/min
5
mcg/min
10
gtt set
10
drops/min
15
drops/min
20
drops/min
25
drops/min
30
drops/min
40
drops/min
50
drops/min
15
gtt set
15
drops/min
23
drops/min
30
drops/min
38
drops/min
45
drops/min
60
drops/min
75
drops/min
20
gtt set
20
drops/min
30
drops/min
40
drops/min
50
drops/min
60
drops/min
80
drops/min
100
drops/min

Drowning/Near Drowning

  1. PROTECT YOURSELF! Do not enter a body of water unless you are certified in water rescue and have the appropriate equipment.
  2.  

  3. Administer high flow oxygen (See Oxygen Administration)
  4.  

  5. Immobilize cervical spine if potential exists for cervical injury.
  6.  

  7. Treat patients for problems as indicated by appropriate protocol.
  8.  

  9. If a cold water drowning exists consider hypothermia (See Hypothermia protocol). Standard termination protocol does not apply to cold water drowning unless drowning time >30 minutes for adults or >90 minutes for pediatric patients.
  10.  

  11. Transportation by ALS is preferred.
  12.  

  13. All near drowning patients, even if they regain consciousness, should be transported to a hospital—such complications such as pulmonary edema may be delayed.
  14.  

  15. If the patient is persistently hypoxemic (oxygen saturation <92% on non-rebreather), or in the judgment of the Paramedic, CPAP would be beneficial, refer to CPAP protocol.

Hyperthermia

 

  1. Administer high flow oxygen. (See Oxygen Administration).
  2.  

  3. Move patient to cool environment.
  4.  

  5. Remove clothing. Cool patient with cold packs around the abdominal, axillary, neck, and groin areas.
  6.  

  7. Do not allow patient to shiver during cooling. If shivering occurs, remove cold packs.
  8.  

  9. If patient presents with altered level of consciousness, (See Altered Level of Consciousness).
  10.  

    Note: Many athletic programs have instituted ice bath cooling for exertional heat stroke. Permit use of rectal thermometers by on-site medical personnel. If ice bath cooling has been initiated consider the following:

     

    1. Indications for ice bath cooling include altered mental status and elevated temperature.
    2.  

    3. Once initiated, patient may stay in the ice bath for up to 30 minutes.
    4.  

    5. When patient is in the ice bath, monitor vital signs, ECG, and start IV per protocol.
    6.  

    7. When possible, monitor temperature as best as possible. The most accurate method is a rectal temperature. Oral, axillary and tympanic temperatures may be falsely low during exertional heat stroke – continue cooling even if temperature readings appear normal but patient remains altered.
    8.  

    9. If at any point in time the patient becomes unstable, remove from ice bath and initiate rapid transport.
    10.  

    11. Patient may be removed from the ice tub once core temperature falls below 102 or they regain a normal mental status.

 

If patient appears unbstable:

 

BLS

 

    Request ALS if not already en route and initiate transport. Contact receiving facility for further orders if ALS is not on scene.
ALS

 

  1. Apply cardiac monitor.
  2.  

  3. Initiate an IV and titrate flow to a systolic BP of 90 mmHg.

Hypothermia

Any patient with a suspected core body temperature of 96 F or less. Hypothermic patients are considered viable until rewarmed and pronounced dead by a physician.

 

  1. Administer oxygen at 10-15 LPM per non-rebreather (See Oxygen Administration Protocol).
  2.  

    1. Assist ventilations with BVM as needed and avoid hyperventilation – rapid correction of acidosis may result in cardiac arrest. Refer to Airway Management Protocol as needed.

     

  3. On all patient procedures, handle gently. Do not let the patient walk.
  4.  

  5. Remove wet clothing. Cover patient with dry blankets. Do not rub patient's extremities.
  6.  

  7. Assess vital signs (Check pulse for one full minute).

 

Pulse Present

 

BLS
ALS

 

  1. If patient presents with altered level of consciousness, see Altered Level of Consciousness protocol

 

Pulse Absent

 

BLS

 

  1. Begin CPR and request ALS.

 

ALS

 

  1. If monitor shows an organized rhythm, do not initiate CPR.
  2.  

  3. Initiate CPR if the patient is found to be in asystole or ventricular fibrillation.