BLS

 

1. Begin Initial Medical Care and call for ALS.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. Investigate for possible causes (medical history, medications, medic alert tag, recent trauma).

 

5. Perform Blood Glucose analysis if available. If hypoglycemic, administer oral glucose if patient can tolerate oral medication
   

 

6. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate BVM ventilation first, then administer intranasal naloxone. Wait 2 minutes before providing another dose of naloxone – ensure adequate BVM ventilation is being provided during this time.

 

ALS

 

1. Establish a saline lock or an IV with 0.9% NaCl or LR. Avoid LR in Pediatric Patients.

 

2. Apply cardiac monitor. Obtain a 12-lead electrocardiograph (ECG).

 

3. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

 

4. Perform blood glucose analysis.

BLS

 

1. Begin Initial Medical Care and call for ALS.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. Investigate for possible causes (medical history, medications, medic alert tag, recent trauma).

 

5. Perform Blood Glucose analysis if available. If hypoglycemic, administer oral glucose if patient can tolerate oral medication
   

 

6. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate BVM ventilation first, then administer intranasal naloxone. Wait 2 minutes before providing another dose of naloxone – ensure adequate BVM ventilation is being provided during this time.

 

ALS

 

1. Establish a saline lock or an IV with 0.9% NaCl or LR. Avoid LR in Pediatric Patients.

 

2. Apply cardiac monitor. Obtain a 12-lead electrocardiograph (ECG).

 

3. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

 

4. Perform blood glucose analysis.

 

BLS

ALS

 

1. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate ventilation using BVM, and administer 0.4 mg naloxone IVP.

 

1. If unable to administer IV, administer 2 mg of naloxone IN or IM
2. IN or IM auto-injector by EMT-B is permitted.

 

2. If respiratory depression persists after 2 minutes, repeat IV or IN via alternating nostrils until respirations are adequate or a total of 2 mg IV or 4mg IN of naloxone has been administered.

BLS

 

1. Begin Initial Medical Care and call for ALS.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. Investigate for possible causes (medical history, medications, medic alert tag, recent trauma).

 

5. Perform Blood Glucose analysis if available. If hypoglycemic, administer oral glucose if patient can tolerate oral medication
   

 

6. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate BVM ventilation first, then administer intranasal naloxone. Wait 2 minutes before providing another dose of naloxone – ensure adequate BVM ventilation is being provided during this time.

 

ALS

 

1. Establish a saline lock or an IV with 0.9% NaCl. Avoid LR in Pediatric Patients.

 

2. Apply cardiac monitor. Obtain a 12-lead electrocardiograph (ECG).

 

3. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

 

4. Perform blood glucose analysis.

    

   1. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate ventilation using BVM and administer 0.1 mg/kg (up to 2mg) Naloxone IVP or 0.1 mg/kg (up to 2mg) intra-nasally.

    

   2. If respiratory depression persists after 2 minutes, contact medical control for recommendations for any further dosing.

1. General approach

 

1. Violent behavior may be a manifestation of a medical condition such as head injury, drug or alcohol intoxication, metabolic disorders, hypoxia, stroke, or post-ictal state. Field personnel should consider these medical conditions first, and then consider psychiatric disorders in the approach to violent patients. Field personnel should obtain a detailed history from family members, bystanders, and law enforcement personnel, and make particular note of patient surroundings for clues to the cause of the behavior (e.g., drug paraphernalia, medication bottles).

 

2. EMS personnel shall attempt to de-escalate verbally aggressive behavior with a calm and reassuring approach and manner.

 

3. At all times, providers must act as an advocate for the safety, medical monitoring, and clinical care of the patient.

 

2. Physical Restraint Issues

 

1. Restrained patients shall be placed in a supine position, Fowler’s or semi-Fowler’s position. Patients shall not be transported in a prone position or “hog-tied.” Patients shall not be “sandwiched” between scoop stretchers, backboards, and/or mattresses during transport.

 

2. Four-point restraint is preferred; additional tethering of the thorax may be necessary. A surgical mask may be placed on the patient to prevent spitting.

 

3. The method of restraint must allow for adequate monitoring of pulse and respirations, and should not restrict the patient or rescuer’s ability to protect the airway should vomiting occur. EMS personnel must provide sufficient slack in the restraint device(s) to allow the patient to straighten the abdomen and chest and to take full tidal-volume breaths. The neck may not be compromised.

 

4. Once the patient has been restrained, he/she should never be left alone.

 

5. Restrained extremities should be monitored for circulation, motor function, and sensory function every 10 minutes and upon arrival at the hospital. It is recognized that the evaluation of motor and sensory status requires patient cooperation, and thus may be difficult or impossible to achieve.

 

6. Out-of-hospital documentation should include behavior, reason for restraint, that the restraints were “applied for the patient’s safety”, identification of personnel/agency applying restraint, other pertinent clinical information, vital signs, and documentation of monitoring of restrained extremities.

 

7. Unless mandated for emergency care, restraints are to be left in place until the patient is turned over to hospital ED staff and preparations are made for a smooth and safe transfer.

 

8. Metal handcuffs for initial restraint may only be applied by law enforcement personnel. Metal handcuffs may be replaced with another method of restraint (e.g., those listed above or hard plastic flex-cuffs) prior to transport. Metal handcuffs may only be used for restraint during transport when law enforcement personnel accompany the patient. Only law enforcement personnel may remove metal handcuffs.

 

Law enforcement responsibilities:

 

1. Law enforcement personnel are responsible for the capture and/or restraint of potentially violent patients. EMS personnel should obtain assistance from law enforcement to prepare patients for transport.

 

2. Law enforcement agencies retain primary responsibility for safe transport of patients under arrest or involuntary detention.

 

3. The hospital destination should be determined by the paramedic’s clinical decision and should not be directed by law enforcement.

 

4. Patients under arrest or involuntary detention shall be searched thoroughly by law enforcement personnel prior to being placed in the ambulance.

 

1. Patients under arrest must always be accompanied by law enforcement personnel.

 

2. EMS and law enforcement personnel should mutually agree on need for law enforcement assistance during transport of involuntary detention patients.
3. Transport Issues

 

1. If an unrestrained patient becomes violent during transport, EMS personnel shall request law enforcement assistance and make reasonable efforts to calm and reassure the patient

 

2. If the crew believes that their personal safety is at risk, they should not inhibit a patient’s attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. EMS personnel are to remain on scene until law enforcement arrives to take control of the situation.

Chemical restraint is to be used only where the patient can be adequately and repeatedly monitored by EMT-P providers. It is to be reserved for patients who cannot otherwise be restrained or restrained only at the risk of significant harm to the patient, law enforcement, or EMS providers or if provider has concern for excited delirium. Once applied, patients should be isolated and placed in an ALS ambulance as soon as possible. All patients who are administered midazolam or ketamine are required to be monitored with waveform EtCO₂ for adequate ventilation. All patients will be transported to closest appropriate facility for further evaluation.

 

Law enforcement directed use of chemical restraint is not authorized. The decision to use chemical restraint is solely the decision of the treating paramedic. Providers must not administer sedating medications to an individual to facilitate arrest or to assist law enforcement to take the individual into custody.

 

ALS

 

1. Consider other causes of combative or irrational behavior, including but not limited to hypoxia, seizure, head injury and hypoglycemia.

 

2. Indications for chemical restraint include

 

1. Violent, agitated patient who cannot be otherwise restrained or restrained only at the risk of significant harm to the patient, law enforcement, or EMS provider

 

3. Administer ONE of the following:

 

1. Midazolam IV, IM, or via intra-nasal spray. Preferred if known use of sympathomimetic drug such as cocaine or methamphetamine.

 

1. If patient > 50kg, administer 5 mg IV, IM or IN (2.5 mg in each nostril)
2. If patient < 50kg, administer 2.5 mg IV, IM, or IN
3. Consider lower dose if patient is elderly (> 65) or has serious comorbid medical conditions

 

2. Ketamine IM for patients 12 years of age or older.

 

1. If patient estimated > 50kg, administer 300 mg IM to lateral thigh or deltoid.
2. If patient estimated < 50kg, administer 150 mg IM to lateral thigh or deltoid
3. Use with caution in patients with history of coronary artery disease. If there is concern for an acute ischemic event such as a stroke or MI, do not administer ketamine
4. Larngyospasm is a rare, but serious adverse effect of ketamine administration. If patient develops stridor, apnea, or sudden loss of ETCO₂ after administration, suspect laryngospasm.

 

1. Apply airway maneuvers, such as jaw thrust or chin lift. Consider oral or nasal airway.

 

2. Assist with BVM at 100% O₂ to apply positive pressure.

 

3. If these methods prove to be inadequate and patient is not being ventilated, follow advanced airway protocols with the modification that only a single attempt to visualize the vocal cords should be made with direct laryngoscopy. If vocal cords can be seen and are open, then attempt to intubate with ET tube. If vocal cords are closed/spasming, DO NOT attempt to pass anything through vocal cords and proceed to cricothyrotomy.

 

4. DO NOT administer any further ketamine.

 

4. Patient should be isolated and placed in an ALS ambulance as soon as possible and all patients will be transported to the nearest appropriate facility for further evaluation and released to law enforcement thereafter. The hospital destination should be determined by the paramedic’s clinical decision and should not be directed by law enforcement.

 

5. After sedation is achieved

 

1. Treat any immediate life threatening injuries.

 

2. Airway, mental status, and vital signs (including pulse oximetry, waveform ETCO₂, and heart rhythm) must be examined and documented every 5 minutes.

 

1. All patients that receive midazolam or ketamine are required to be placed on nasal waveform capnography

 

3. Monitor for signs of hypoventilation such as decreased respiratory rate or increase in ETCO₂

 

1. Provide passive oxygenation via nasal cannula or nonrebreather
2. Attempt verbal and/or physical stimulation
3. If severe, apply BVM, and move onto advanced airway options per protocol if continued inadequate ventilation

 

4. Establish IV, initiate IVF therapy

 

5. Obtain blood glucose level

 

6. Keep patient in an upright position and allow for hyperventilation.

 

6. For situations in which chemical restraint has not been achieved:

 

If midazolam was previously given, can repeat dose 1 time after 15 minutes have elapsed since initial dose without needing additional orders. Inform receiving facility a second dose of midazolam has been given.


 

If ketamine was previously given, contact medical control for requests for additional medication or other orders


 

If medical control recommends additional doses of midazolam or ketamine, either in isolation or in combination, advanced airway preparation should be made, as there is an increased risk for respiratory depression.


 

7. If patient subsequently has a cardiac arrest, follow ALS protocol for cardiac arrest, but consider early administration of sodium bicarbonate 100 mEq IV push if patient initially presented with severe agitation or concerns for excited delirium.

 

8. If chemical restraint is used, a copy of the run record must be made available to the Medical Director through the CQI Coordinator within 24 hours.

 

If chemical restraint is used, a copy of the run record must be made available to the Medical Director through the CQI Coordinator within 24 hours

The use of Body Substance Isolation Procedures is especially important because of the possibility of exposure to blood and body fluids and the probability of dialysis patients being carriers of the hepatitis B virus. Treat any presenting problems according to the appropriate protocol and note the following modifications:

 

BLS

 

1. Do not take vital signs in an extremity containing a graft or fistula.

 

2. If the patient is on the hemodialysis machine, have the dialysis technician disconnect the patient from the machine. If the dialysis technician is not present, or is unable to disconnect the patient, turn off the machine.

 

1. Clamp off the access device and disconnect the patient from the machine.

 

2. Remove or have technician remove the needles. Apply pressure as the needle is removed so as to avoid cutting the access device.

 

3. If the patient is on continuous ambulatory peritoneal dialysis (CAPD), unclamp drainage tube and allow fluid in the peritoneal cavity to drain back into the bag.

 

4. Be alert for pathological fractures or fractures that might occur.

 

5. If a venous or arterial air embolus is suspected, immediately place the patient in Trendelenburg position on the left side.

 

6. If the site is persistently bleeding, apply direct pressure, using fingertip pressure if needed, and elevate the limb. Do NOT apply a tourniquet device.

 

ALS

 

1. Initiate an IV in an extremity containing a shunt or fistula only if an immediate life-threatening situation exists and there is no other IV site. NOTE: This does not mean that inserting an IV into the shunt or fistula is allowed – only that another IV site in that same arm is allowed.

 

2. For patients who may be hyperkalemic (with or without a missed dialysis) refer to Hyperkalemia Protocol.

BLS

 

1. Protect yourself from exposure to poisons.

 

2. Begin Initial Medical Care when safe to do so.

 

3. Obtain the following information:

 

1. Type of poison/medication.
2. Type of exposure - ingestion, injection, absorption, inhalation.
3. Time of exposure.
4. Amount of poison exposure (quantity, strength of agent(s)).
5. Time exposure took place.
6. If an ingestion, poison/medication taken with water/alcohol/etc.?
7. Time of last food and alcohol intake.
8. Weight of patient (in Kg).

 

4. Remove the patient from the source of contamination, if necessary, without endangering responders. Instruct patient to remove their own contaminated clothing, cutting away from body using shears if necessary. In the event of topical poisons, decontaminate the patient with copious amounts of water. If no water is immediately available, instruct patient to utilize any clean absorbent material (such as a trauma dressing) to perform dry decontamination by first blotting then rubbing surfaces for at least 10 seconds. Focus on the head, then face, then hands followed by any potentially exposed skin area. Brush away powdered substances prior to irrigation.

 

5. Categorize type of poison

 

1. Injected poisons - (e.g., bites, stings, or open wounds caused by an object contaminated with a poisonous substance) – apply a venous constricting band above the site of injection on an extremity, immobilize the extremity and keep it below the level of the heart. For stings, scrape stinger away, do not squeeze stinger.

 

2. Suspected allergic reactions (See Allergic Reaction Protocol)

 

3. Inhaled poisons - Administer high flow oxygen to all patients with poisoning by inhalation or who meet criteria for oxygen administration or airway management procedures. (See Administration of Oxygen Protocol and/or Airway Management Protocol)

 

6. If level of consciousness is decreased or vital signs abnormal, transportation by advanced life support is preferred. (See Altered Level of Consciousness Protocol)

 

7. Gather containers or remaining medications that can be taken to the hospital safely.

 

8. Consider contacting the Indiana Poison Center (IPC) on Med-1 or the IHERN for information on expected toxicity. The Poison Center may be used as a resource for information, NOT for orders for patient care. The IPC is also available at 317-962-2323, (800) 222-1222, on via the IHERN (EMS-M1).

 

ALS

 

1. Follow appropriate protocol for specific presentation/toxin.

 

Calcium Channel Blocker Overdose

 

Consider calcium chloride for calcium channel blocker OD with:

 

Bradycardia (HR < 60) AND

 

Hypotension (SBP < 90 mm Hg adult or SBP < 70 + 2 x age in years for pediatric patients )

 

Adult dose – Calcium Chloride 1 g slow IVP

 

Pediatric Dose – 0.2 ml/kg of 10% calcium chloride slow IVP (1 gram max)

Cyclic Antidepressant Overdose

 

Consider sodium bicarbonate for cyclic antidepressant OD with:

 

Wide QRS complex (≥ 0.12 sec ) OR

 

Hypotension (SBP < 90 mm Hg adult or SBP < 70 + 2 x age in years for pediatric patients )

 

Seizures

 

Adult dose and Pediatric – Sodium bicarbonate 1 mEq/Kg IVP

Organophosphate/Nerve Agent Poisoning

 

If unconscious, seizing, apneic, has flaccid paralysis, muscle fasciculations, nausea/vomiting, weakness, shortness of breath:

 

Administer atropine until decreased bronchial secretions/ wheezing


Adult dose – 2 mg IV/IO/IM every 5 minutes

 

Pediatric Dose – 0.02 mg/kg IV/IO/IM every 5 minutes

 

If seizing, proceed to seizure protocol after administration of first dose of atropine

Conscious Patient with Ongoing Epistaxis

 

1. Remove any packing already in nares placed by the patient.
2. Instruct the patient to blow each nostril separately to remove any clots.
3. Instruct the patient to firmly compress the nostrils together for 10 minutes and tilt head forward if tolerated.
4. If patient is unable to maintain nasal compression themselves, consider applying nostril compression device (see below).

 

If bleeding persists after 10 minutes:

 

1. Instruct patient to release the nostrils and blow their nose to clear of clots one nostril at a time.
2. Insert gauze into each nostril and instruct patient to compress the nostrils for another 10 minutes (the number of pieces of gauze placed needs to be documented per each nostril). If available, a total of 1 gram Tranexamic acid (TXA) may be used to soak the gauze prior to insertion into the nostril for topical treatment.

 

Criteria for ALS level care:

 

Current patient use of medication that may prevent blood clotting, including aspirin, clopidogrel (Plavix), warfarin (Coumadin), rivaroxaban (Xaralto), dabigatran (Pradaxa), Apixaban (Eliquis)

 

History of blood clotting disorder, such as hemophilia or thrombocytopenia (low platelet count)

 

Hypoxia (SpO₂ < 94%) or need for supplemental oxygen


 

Altered mental status, unconsciousness, hypotension or tachycardia. Note: Use of beta-blockers may mask vital sign abnormalities


 

Concern for massive epistaxis based on history

 

ALS

 

Establish large bore IV with 0.9% NaCl saline or LR. Titrate fluids to an SBP of 90 mm Hg

 

Continuous vital signs monitoring, including SpO₂

 

Unconscious Patient

 

Position patient to maintain airway

 

Avoid nasal airway insertion

 

Significant airway suctioning may be required, follow airway management protocol as required

To assemble a nostril compression device, tape 2 tongue blades together at one end at approximately 1/3 of the length. Consider taping a 4x4 gauze to each tongue blade at the opposite end. Apply directly to nose for continuous pressure.

 

ALS

 

1. Patient that are suspected to have, or are at risk of renal failure (such as dialysis patients or crush injury) should have an EKG performed. Hyperkalemia should be suspected if the patient exhibits a wide QRS (> 0.12 sec) or peaked T-waves.

 

2. If the patient with suspected hyperkalemia is hypotensive, has altered mental status or experiences cardiac arrest, give the following medications in this order:

 

1. Calcium chloride 1 g SLOW IV/IO push

 

2. Albuterol 5 mg nebs back-to-back/continuously for the spontaneously breathing patient or in-line with BVM if an advanced airway has been placed, and

 

3. If no change in patient condition, consider Sodium Bicarbonate, 100 mEq IV/IO push. Sodium bicarbonate may form a solid with calcium chloride – ensure line is properly flushed before administration.

 

Note: It is acceptable to use Lactated Ringers in patients with Hyperkalemia

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

 

2. Apply end-tidal capnography

 

3. Protect patient from injury while patient is seizing. DO NOT RESTRAIN PATIENT. DO NOT FORCE A BITE STICK INTO THE PATIENT'S MOUTH. Determine the duration of the seizure. Observe the type of seizure activity and what part(s) of the body it affects.

 

Not in Status Seizures

 

1. Initiate transport.

 

1. Adult patients who are no longer post-ictal may request not to be transported. You should consult with the hospital for authorization not to transport. (See Non-Transported Patient Protocol)

 

Status Seizures

 

Criteria: Continuous seizure activity for longer than 3 minutes or two or more consecutive seizures without regaining consciousness.

 

Focal seizure activity meeting the above criteria should also be considered status epilepticus

 

BLS

 

1. Assist ventilations and apply end-tidal capnography if available. (See Airway Management Protocol)

 

2. Contact receiving facility for further orders if ALS is not on scene. Request advanced life support.

 

3. Perform Blood Glucose analysis if available. If hypoglycemic, follow hypoglycemia BLS protocol in “Altered Level of Consciousness”.

 

ALS

 

1. Apply the cardiac monitor and pulse oximeter

 

2. Administer midazolam using IM/IN route FIRST:

 

1. If patient ≥ 50 kg, administer 10 mg IM/IN
2. If patient < 50 kg, administer 5 mg IM/IN

 

3. Perform blood glucose analysis. If blood glucose < 60 mg/dL, refer to hypoglycemia protocol in “Altered Level of Consciousness”.

 

4. If seizure continues for 5 minutes after initial administration of midazolam, then administer midazolam IM, IN, IO or IV:

 

1. Administer 5 mg IM/IN or 2.5 mg IV/IO

 

5. The EMS Administered maximum cumulative dose should not exceed 15mg total via all routes. Contact the receiving facility for further instructions or additional dosing if needed.

 

Note: Patient must be placed on nasal waveform capnography.

 

If the patient is pregnant in the 3^rd trimester, administer 4 grams magnesium IVP over at least 4 minutes

 

Adult Status Epilepticus

 

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

 

2. Apply end-tidal capnography

 

3. Protect patient from injury while patient is seizing. DO NOT RESTRAIN PATIENT. DO NOT FORCE A BITE STICK INTO THE PATIENT'S MOUTH. Determine the duration of the seizure. Observe the type of seizure activity and what part(s) of the body it affects.

 

Not in Status Seizures

 

1. Initiate transport.

 

1. Adult patients who are no longer post-ictal may request not to be transported. You should consult with the hospital for authorization not to transport. (See Non-Transported Patient Protocol)

 

Status Seizures

 

Criteria: Continuous seizure activity for longer than 3 minutes or two or more consecutive seizures without regaining consciousness.

 

Focal seizure activity meeting the above criteria should also be considered status epilepticus

 

BLS

 

1. Assist ventilations and apply end-tidal capnography if available. (See Airway Management Protocol)

 

2. Contact receiving facility for further orders if ALS is not on scene. Request advanced life support.

 

3. Perform Blood Glucose analysis if available. If hypoglycemic, follow hypoglycemia BLS protocol in “Altered Level of Consciousness”.

 

ALS

 

1. Apply the cardiac monitor and pulse oximeter

 

2. Administer midazolam using IM/IN route FIRST:

 

1. If patient ≥ 50 kg, administer 10 mg IM/IN
2. If patient < 50 kg give 0.2mg/kg of midazolam (up to a maximum of 5mg) IM/IN If IN, divide the dose so that each nares receives half

 

3. Perform blood glucose analysis. If blood glucose <60 mg/dL (Newborns <40 mg/dL), refer to hypoglycemia protocol in “Altered Level of Consciousness”.

 

4. If seizure continues for 5 minutes after initial administration of midazolam and the total dose has not yet exceeded 10 mg, then administer midazolam IM, IN, IO or IV

 

1. 0.2mg/kg of midazolam (up to a maximum of 5 mg) IM/IN. If IN, divide the dose so that each nares receives half

 

2. 0.1mg/kg of midazolam (up to a maximum of 2.5 mg) IV/IO

 

5. The EMS Administered maximum cumulative dose should not exceed 15mg total via all routes. Contact the receiving facility for further instructions or additional dosing if needed.

 

Note: Patient must be placed on nasal waveform capnography.

 

Pediatric Status Epilepticus

 

Any patient with altered mental status, weakness, or respiratory distress should be screened for inclusion in the sepsis protocol by reviewing a complete set of vital signs, including ETCO₂.

 

Patients with:

 

1. Suspected or possible infection AND
2. 2 or more of the following:

 

1. Heart rate > 90
2. Respiratory rate > 22
3. Temp > 38^oC (100.4^o F) or < 36^oC (96.8^oF) (if available)
4. ETCO₂ < 25

 

BLS

 

1. Minimize scene time

 

2. Call in Medical Alert – “suspected sepsis” to receiving facility

 

ALS

 

1. Alert receiving facility of Medical Alert – “suspected sepsis” prior to arrival including how much fluid has been administered.

 

2. Establish IV or IO access

 

3. Give 500ml bolus of NS

 

4. Repeat IVF bolus until SBP > 90, not to exceed 2L IVF.

 

5. If SBP < 90 after 2L IVF, call medical control and consider levophed at 2-4 mCg/min and titrate to SBP > 90, not to exceed 12 mCg/min.

 

How to mix a levophed drip:

 

Mix 4 ml in 500 ml bag of D₅W or NS or LR (8 mcg/ml concentration)
Start at 2-4 mcg/min and titrate to SBP > 90mm Hg. Max infusion 12 mcg/min.
Rates (using 60 drops/ml set):

 

mcg/ml	2	3	4	5	6	7	8	9	10	11	12
ggt/min	15	22	30	37	45	52	60	67	75	82	90

 

Consider epinephrine drip at 5 mcg/min if levophed (norepinephrine) infusion unavailable.

This protocol is intended to reduce the time to thrombolysis in the acute stroke patient. Patient with symptoms of less than 4 hours duration are considered “time-critical.” Other patients with symptom onset less than 24 hours should be considered urgent but not “time-critical”. Patients may present as having fallen, unable to walk, have new balance problems or with acute altered level of consciousness.

 

BLS

 

1. Administer oxygen as indicated. See Oxygen Administration protocol.

 

2. Perform blood glucose analysis. If blood glucose < 70 mg/dL, refer to hypoglycemia protocol in “Altered Level of Consciousness”

 

3. Evaluate any patient with suspected stroke using the Cincinnati Stroke Scale. If positive/abnormal, perform RACE Stroke Scale and determine, to the best of your ability, the time last known normal (neurologically).

 

4. Contact the receiving emergency department and include the following information: time of onset of signs/symptoms, RACE Stroke Scale findings, and blood glucose results. Document all results.

 

5. Identify a close family member or friend to accompany the patient to the hospital to provide information on baseline function, onset of symptoms, and possible consent for tPA. Include this information in your handover report. If a family member is unable to accompany the patient, obtain a phone number for a family member to provide the hospital with this same information.

 

6. If level of consciousness is decreased or vital signs abnormal, transportation by advanced life support is preferred.

 

ALS

 

1. Obtain a 12-lead EKG

 

2. Ensure blood glucose analysis has been performed. If blood glucose < 70 mg/dL, refer to hypoglycemia protocol in “Altered Level of Consciousness”
3. Do not treat hypertension

Cincinnati Prehospital Stroke Scale Facial Droop (have patient show teeth or smile): Normal – both sides of face move equally well Abnormal – one side of face does not move as well as the other side   Arm Drift (have patient close eyes and hold both arms out, palms up): Normal – both arms move the same or both arms do not move at all Abnormal – one arm does not move or one arm drifts down compared with the other   Speech (have the patient say “you can’t teach old dog new tricks”): Normal – patient uses correct words with no slurring Abnormal – patient slurs words, uses inappropriate words, or is unable to speak

 

RACE Stroke Scale

Facial Palsy	Absent	0
	Mild	+1
	Moderate/Severe	+2
Arm Motor Impairment	Normal/Minimal	0
	Moderate	+1
	Severe	+2
Leg Motor Impairment	Normal/Minimal	0
	Moderate	+1
	Severe	+2
Head and Gaze Deviation	Absent	0
	Present	+1
Left Hemiparesis Ask the patient: (1) While showing patient the paretic arm, “Whose arm is this?” (2) “Can you lift both arms and clap?”	Patient recognizes his/her arm and the impairment	0
	Does not recognize his/her arm or the impairment	+1
	Does not recognize his/her arm AND the impairment	+2
Right Hemiparesis Instruct the patient: (1) Close your eyes” (2) “Make a fist.”	Performs both tasks correctly	0
	Performs one task correctly	+1
	Performs neither task correctly	+2

BLS

 

1. If patient’s mental status remains altered, refer to Altered Level of Consciousness Protocol.

 

2. Place patient in position of comfort.

 

3. Perform Blood Glucose analysis if available. If hypoglycemic, follow hypoglycemia BLS protocol in Altered Level of Consciousness Protocol

 

4. Perform Cincinnati Prehospital Stroke Scale, if abnormal, refer to Suspected Stroke (CVA) Protocol.

 

Cincinnati Prehospital Stroke Scale Facial Droop (have patient show teeth or smile): Normal – both sides of face move equally well Abnormal – one side of face does not move as well as the other side   Arm Drift (have patient close eyes and hold both arms out, palms up): Normal – both arms move the same or both arms do not move at all Abnormal – one arm does not move or one arm drifts down compared with the other   Speech (have the patient say “you can’t teach old dog new tricks”): Normal – patient uses correct words with no slurring Abnormal – patient slurs words, uses inappropriate words, or is unable to speak

 

ALS

 

1. Apply the cardiac monitor

 

2. Obtain 12-lead EKG

 

3. If the patient’s mental status is not completely normal or there is a slow response to baseline, measure blood glucose.

 

1. If less than 60 mg/dL, refer to Altered Level of Consciousness.

    

2. Treat abnormal vital signs appropriately.