General Care Guidelines

  • Initial Medical Care
  • Airway Management
  • Oxygen Administration
  • Obstructed Airway - Conscious Infant
  • Obstructed Airway - Conscious Child/Adult
  • Obstructed Airway - Unconscious
  • Pain Management
  • Numeric Pain Scale
  • Wong-Baker Pain Scale
  • Wong Baker Pain Scale - Spanish
  • Infant Pain Scale
  • Nausea and/or Vomiting
  • Fever

Initial Medical Care

BLS

 

  1. Follow the Universal Precautions protocol.
  2.  

  3. Follow the Airway Management protocol to open and maintain a patent airway.
  4.  

  5. Follow the Oxygen Administration protocol when appropriate.
  6.  

  7. Loosen tight clothing and reassure the patient.
  8.  

  9. Place the patient in the position of comfort unless contraindicated by injuries and/or symptoms.
  10.  

  11. Completely assess the patient, including vital signs.
  12.  

  13. Obtain an appropriate history
  14.  

  15. Refer to appropriate protocol according to patient condition.
  16.  

  17. Reassess patient and record vital signs every 5-10 minutes as condition warrants. Transported patients must have at minimum 2 sets of complete vitals documented. Weight will be recorded in kilograms for all pediatric, overdose/poisoning, and any adult receiving medications.
  18.  

  19. Patient's body temperature should be preserved, especially infants, children, and the elderly
  20.  

    ALS

     

  21. Establish IV access:
  22.  

    1. to administer pre-hospital medications, or
    2. for fluid replacement, or
    3. if the patient’s condition is likely to deteriorate before arriving at the hospital.

     

  23. The IV solution is to be NORMAL SALINE unless otherwise stated. (See Vascular Access Procedures)
  24.  

  25. If an IV cannot be established and an urgent need for vascular access exists, establish IO access. (See Vascular Access Procedures)
  26.  

  27. Pre-existing vascular access devices (PVAD) may be used only if:
  28.  

    1. The patient is in cardiac arrest, or
    2. There is an emergent need to administer fluids or IV medications and a peripheral IV cannot be established and an IO is not appropriate due to the patient’s condition. (See Vascular Access Procedures)

 

Medical Alert Criteria

 

    Suspected acute MI
    Suspected Sepsis
    Acute neurological deficits of < 6 hours duration
    Inspiratory stridor

 

Physiological

 

    Systolic BP (SBP) < 90 mmHg or vital signs outside of physiologic ranges for pediatrics
    GCS < 13
    Respiratory rate < 10 or > 30 (adults), < 15 or > 45 (peds)
    Heart rate < 40 or > 120
    Temp < 92°F or > 105°F
      Usually determined in the transferring ED
    Oxygen saturation < 88%

     

    Healthcare provider discretion

Airway Management

BLS

 

  1. Open the airway by use of a chin-lift or jaw thrust without head tilt. Remember to protect the cervical spine at all times when the potential for cervical spine injury exists.
  2.  

  3. Suction is indicated in any patient whose airway is obstructed by liquid or solid material which may result in aspiration or interfere with respiration.
  4.  

  5. Use an oropharyngeal or nasopharyngeal airway device as needed to maintain a patent airway.
  6.  

  7. Assist ventilations as needed using a bag-valve device (BVM) and 100% oxygen. (Pediatric rate - 12 - 20 / min., newborns – 40 - 60 / min.) BVM use should include the two-hand mask-seal technique whenever possible. The volume of the ventilation should be enough to provide visible chest rise.
  8.  

  9. If a patient age 18 or older is in respiratory arrest with no gag reflex, insert an appropriately sized non-visualized airway, if available. See cardiac arrest protocol for cardiac arrest patients.

 

ALS

 

  1. If the above measures prove to be inadequate or there is risk of aspiration or vomiting in the unconscious patient, intubate adults with an endotracheal tube or non-visualized airway. The guidelines for intubation are as follows:
  2.  

  3. Bag-valve-mask ventilation is the preferred method of oxygenating and ventilating pediatric patients. If you cannot adequately ventilate with a BVM, attempt placement of a non-visualized airway if available. If non-visualized airway fails to provide adequate oxygenation, proceed to endotracheal intubation.
  4.  

  5. Apply ETCO2 capnography device to bag mask ventilation circuit to monitor ETCO2 levels and evaluate waveform. This is highly encouraged before advanced airway placement to obtain a baseline ETCO2 value.
  6.  

  7. Endotracheal intubation is the preferred advanced airway maneuver for adults. (See Verification of Endotracheal Tube (ETT) Placement – Procedure)
  8.  

  9. The use of the non-visualized airway should be reserved for those adults in whom an endotracheal tube cannot be placed.
    1. If unable to place an endotracheal tube after two attempts, place a non-visualized airway, if available.
    2. If the above are unsuccessful, maintain an airway via basic skills utilizing modified jaw thrust, OP airways, BVM, etc.

     

  10. Criteria for performance of cricothyrotomy are as follows:
  11.  

    1. If basic airway management, non-visualized airways, and intubation are unable to provide oxygenation and ventilation.
      1. Surgical cricothyrotomy is to be performed on the patient > /= 8 years old.
      2. Needle cricothyrotomy is to be performed on the patient < 8 years old
(See Procedures- Cricothyrotomy)

 

IF CRICOTHYROTOMY IS ATTEMPTED, A COPY OF THE PATIENT CARE REPORT MUST BE MADE AVAILABLE TO PROVIDER AGENCY SUPERVISORY PERSONNEL AND THE MEDICAL DIRECTOR WITHIN 24 HOURS OF THE RUN.

Oxygen Administration

BLS

 

  1. Any patient who has difficulty breathing or a SaO2 < 93% should be given oxygen.
  2.  

    1. Patients with mild respiratory distress (respiratory rate < 25, no cyanosis, and no use of accessory muscles) may be given oxygen by nasal cannula at 4-6 LPM to maintain an oxygen saturation of 94-99%
    2.  

    3. Patients with moderate respiratory distress (with or without cyanosis and/or using accessory muscles while breathing) should be given oxygen by a non-rebreather mask at 10-15 LPM. Liter flow should be enough to maintain inflation of the reservoir with oxygen and to maintain an oxygen saturation of 94-99%.
    4.  

        Infants and newborns should have oxygen administered by the blow-by method.

       

    5. Patients with severe respiratory distress should be assisted with ventilations by use of a bag-valve-mask with reservoir and supplemental oxygen (an oropharyngeal or nasopharyngeal airway should be inserted if tolerated). Oxygen should be set to 15 LPM.
    6.  

    7. Spontaneously breathing patients who are suspected to have been exposed to carbon monoxide or who are suspected of having a pneumothorax should receive oxygen by a non-rebreather mask at 10-15 LPM. Liter flow should be enough to maintain inflation of the reservoir with oxygen.

Pediatric
Obstructed Airway - Conscious Infant

BLS

 

  1. Determine complete airway obstruction.
  2.  

  3. Deliver cycles of alternating chest thrusts and back slaps until the obstruction is relieved or the patient becomes unconscious.
  4.  

  5. Do not perform blind finger sweeps.
  6.  

  7. If patient becomes unconscious, see Obstructed Airway - Unconscious.

Obstructed Airway - Conscious Child/Adult

BLS

 

  1. Determine complete airway obstruction.
  2.  

  3. Deliver abdominal thrusts until the obstruction is relieved or the patient becomes unconscious (Chest thrusts can be substituted in obese or pregnant patients.)
  4.  

  5. If patient becomes unconscious, see Obstructed Airway - Unconscious.

Obstructed Airway - Unconscious

BLS

 

  1. Stabilize cervical spine if potential for injury exists.
  2.  

  3. If the patient has no breathing or agonal gasps, begin CPR, starting with compressions.
  4.  

  5. Continue 2 minute cycles of CPR (30:2 for the adult, 15:2 for the infant and child with more than one rescuer).
  6.  

  7. Prior to giving respirations check for an obstructing object. If an object is visualized, remove it.
  8.  

  9. Attempt to ventilate.
  10.  

  11. If unable to ventilate, repeat above steps until material is dislodged. Suction the patient as needed.
  12.  

  13. If patient remains unconscious, transportation by ALS is preferred.
  14.  

  15. If the object is dislodged, assess airway, breathing, and circulation. Proceed with appropriate protocol.

 

ALS

 

  1. Use of the Magill forceps may be necessary to dislodge objects.

Pain Management

A pain assessment is considered standard of care on every patient, along with an initial set of vitals, and should be documented on the run report along with any pain management intervention and the patient’s response.

 

BLS

 

Attempt to place patient in position of greatest comfort

 

ALS

 

Paramedics should consider offering pain medication to any patient describing pain. Medications should be selected by paramedic judgment of pain severity (mild, moderate, severe) and is not necessarily limited to single pharmacologic agent.

 

Mild Pain
  1. Paramedics should consider offering patients describing mild pain acetaminophen for pain management.
  2.  

    1. Acetaminophen may be administered to patients > 15 years old and > 50 kg as 650 mg PO once
    2.  

      1. Unless the patient has:
      2.  

        1. An allergy to acetaminophen
        2. A history of liver dysfunction
        3. Active vomiting
        4. Acetaminophen use within last 4 hours

       

    3. Acetaminophen may be administered to patients older than 6 months and is able to take PO, administer 10mg/kg PO acetaminophen (max dose 650mg).
    4.  

      1. Unless the patient has:
      2.  

        1. An allergy to acetaminophen
        2. A history of liver dysfunction
        3. Active vomiting
        4. Acetaminophen use within last 4 hours

     

    Moderate Pain

     

  3. Paramedics should consider offering patients describing moderate to severe pain ketorolac (Toradol®) for pain management.
  4.  

    1. Ketorolac is administered in the following doses:
      For patients > 15 years old: 15 mg IV or 30 mg IM once.
    2.  

      1. Unless the patient has:
      2.  

        1. An allergy to ketorolac, aspirin, or other NSAIDS
        2. History of renal dysfunction
        3. History of GI bleed
        4. Active bleed or suspicion of active bleed
        5. NSAID use within last 6 hours
        6. Pregnancy

     

    Severe Pain

     

  5. Paramedics should consider offering patients describing severe pain fentanyl for pain management.
  6.  

    1. Fentanyl is administered in the following doses:
    2.  

        Patients > 15 years old and > 50 kg:

         

          Up to 100 mcg slow IV push or intra-nasal. Up to an additional 50 mcg may be administered every 5 minutes up to a maximum of 300 mcg prn pain > 3/10. Consider lower doses for patients > 65y/o or those with other comorbid conditions.

       

        Patients < 15 or < 50 kg:

         

          Up to 1mcg/kg slow IVP or 1-2 mcg/kg intra-nasal, can be repeated two more times every 5 minutes prn evidence of significant discomfort.

           

          1. Unless the patient has:
          2.  

            1. An allergy to fentanyl; OR
            2. A significantly altered level of consciousness (GCS < 14 or below baseline)

             

          3. Additional doses may be administered with approval of Medical Control.
          4.  

  7. Naloxone must be immediately available.
  8.  

    Breakthrough Pain

     

  9. After one dose of fentanyl, paramedics can consider augmenting pain control with intranasal ketamine if pain remains severe. Fentanyl using the Severe Pain protocol can still be administered after ketamine use.
  10. Source of pain must be due to serious traumatic injury, which includes, but is not limited to: extensive burns, open fractures, skeletal deformities, limb entrapment or amputation
  11.  

    1. Adults Patients Only (15 years and older): Intranasal ketamine is administered in the following dose
      0.5 mg/kg intranasal, max 50mg. This is a one time dose only.

     

    Patient's BP, HR, RR, GCS, and pain scale must be monitored regularly (at least once prior to and once after the dose(s) of medication) and documented on the patient care record. ETCO2 capnography must be applied if intranasal ketamine is used.

Numeric Pain Scale

 

0
 No Pain
1
 No Pain -> Little
2
 Little
3
 Little -> Moderate
4
 Moderate
5
 Moderate -> Quite Bad
6
 Quite Bad
7
 Quite Bad -> Severe
8
 Severe
9
 Severe -> Unbearable
10
 Unbearable

Wong Baker Pain Scale

0
No hurt
2
Hurts little bit
4
Hurts little more
6
Hurts even more
8
Hurts whole lot
10
Hurts worst

Wong Baker Pain Scale - Spanish

0
Muy contento;
sin dolor
2
Siente sólo un poquite de dolor
4
Siente un poco más de dolor
6
Siente aún más dolor
8
Siente mucho dolor
10
El dolor es el peor que puede imaginarse
(no tiene que estar llorandor para sentir este dolor tan fuerte)

Pediatric
Infant Pain Scale Assessment Tool

Behavior
Scoring
0
1
2
3
Facial
Neutral/smiling
Frowning/grimacing
Clenched teeth
Full cry expression
Body Movement
Calm, relaxed
Restless/fidgeting
Moderate agitation or moderate mobility
Thrashing, flailing, incessant agitation or strong voluntary immobility
Sleep
Sleeping quietly with easy respirations
Restless while asleep
Sleeps intermittently (sleep/awake)
Sleeping for prolonged periods of time interrupted by jerky movements or unable to sleep
Verbal/Vocal
No cry
Whimpering, complaining
Pain crying
Screaming, high pitched cry
Consolability
Neutral
Easy to console
Not easy to console
Inconsolable
Response to
Movement/Touch
Moves easily
Winces when touched/moved
Cries out when moved/touched
High-pitched cry or scream when touched or moved

Nausea and/or Vomiting

Assess for potential life-threatening causes of nausea and vomiting (such as myocardial infarction or shock) and initiate appropriate protocols.

 

ALS

 

If nausea and/or vomiting persists after initiating other indicated treatment protocols, and if no contraindication is present, you may administer ondansetron.

 

  1. Administer ondansetron:
  2.  

    1. Adults 50 Kg and over: 4-8 mg IV push or via oral-dissolving (ODT) tablet.
    2.  

    3. Less than 50 kg: 0.1 mg/Kg IV push or via an appropriate portion of an oral-dissolving (ODT) tablet (e.g., one-quarter or one-half…).

     

  3. If ondansetron is not immediately available or unsuccessful with relief of nausea
  4.  

    1. Adults 50 Kg and over: Offer opened alcohol swab to patient, request them to hold swab 1-2 cm from nostril and take inhalations as needed for up to 4 minutes

Fever

    Fever is defined in this protocol as 100.4 degrees F or higher (> 38°C).
    Temperatures taken by the patient or family with their own thermometer that documents fever is acceptable.
    Do not administer acetaminophen if any acetaminophen product has been given in the previous 4 hours.
    This protocol does not apply to environmentally induced cases of fever such as heat stroke.
    Acetaminophen does not improve survival in sepsis or serious infection and its administration should not delay transport.

     

    Adult Fever

     

    If patient is able to take PO, administer 650mg PO acetaminophen.

     

    Pediatric Fever

     

    If patient is older than 6 months and is able to take PO, administer 10mg/kg PO acetaminophen (max dose 650mg).