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STROKE GUIDELINE
- 1. UNIVERSAL PATIENT CARE GUIDLELINE
- 2. IV Access >= 18g
- 3. Check Blood Glucose Level
- 3b. If Blood Glucose < 70 mg/dcl then Admin 25G of D50
- 4. Cincinnati Prehospital Stroke Scale
- 4a. Assess for new unilateral arm or leg weakness
- 4b. Assess speech - slurred or inappropriate words?
- 4c. Assess for new facial droop?
- 5. Transport Patient to appropriate receiving facility
- 6. Contact Medical Control
- 6a. Contact receiving hospital for "Acute Stroke Alert"
- 1) Time of sympton onset
- 2) Description of neurologic deficits (Cincinnati stroke scale)
- 3) Blood glucose level
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UNIVERSAL PATIENT CARE GUIDLELINE
- 1) Scene Safety/BSI
- 2a) Initial Assessment
- 2b) Adult or Pediatric
- 2c) C-Spine stabilization if indicated
- 2A) Cardiac Arrest -> Cardiac Arrest Guideline (Adult of Pediatric)
- 3a) Vital Signs (including temp & pain severity)
- 4) Airway Guideline (Adult or Pediatric)
- 5) Consider Pulse Oximetry
- 6) Consider Cardiac Monitor & 12 Lead EKG
- 7) Appropriate Guideline -> If patient doesn't fit a guideline Contact Medical Control
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ANAPHYLAXIS
- 1. Unstable Hemodynamics w/ hypotoensive pt or impending upper airway obstruction; stridor; severe wheezing &/or respitory distress.
- 2. UNIVERSAL PATIENT CARE GUIDLELINE
- 3. AIRWAY MANAGEMENT GUIDELINE
- 4. Oxygen
- 5. Epinephrine 1:1000 0.3mg SQ *
- 6. IV Ringers Lactate or Normal Saline titrated to a BP > 100 systolic
- 7. Cardiac monitoring
- 8. If patient remains unstable hemodynamically, adminitster Epinephrine 1:10,000 0.1mg Slow (over 3 minutes) IV or IO (ET if no vascular access), to a maximum of 0.3mg, titrated to effect. Repeat in 2 min prn.
- 9. Benadryl 1mg/kg Slow IVP (max. 50mg)
- 10. Albuterol 2.5mg via nebulizer for respiratory distress
- 11. Establish Medical Control -> possible physician orders: Dopamine Drip, Repeat doses of Epinehphrine (or Epi-Pen for EMTs)
- * (EMT protocal: Epinephrine 1:1000 0.3mg SQ [Epi-Pen autoinjector] Unstable anaphylaxis patients must meet all the following criteria for EMTs: 1)Unstable Hemodynamics w/ hypotension (SBP < 90mmHg) 2)Difficulty in breathing and severe wheezing 3)Hives & Itching 4)Patient has been exposed to known allergen 5)Difficulty in swallowing)
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High-Risk Conditions That Merit Paramedic Care (mostly)
- 1. primary complaint of chest pain, chest discomfort, palpitations, or syncope in pt's of any age
- 2. complaint of shortness of breath or difficulty breathing
- 3. pt's w/ a new neurological deficit or presentation of stroke
- 4. pt's w/ an initial diagnostic finding of blood glucose <60 ro >400
- 5. pt's who meet the physiologic or anatomic triage criteria for transport to a level 1 or 2 trauma center
- 6. pt's for whom the transporting service reqeuests the presence of the Paramedic
- 7. pt's for whom Paramedic treatment (not assessment only) has been initiated
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12-Lead ECG Indications
- (after initial set of vitals)
- 1. chest pain, presure or discomfort
- 2. radiating pain to neck or left arm. also right arm, shoulder or back
- 3. dyspnea
- 4. CHF
- 5. cardiac arrhythmias
- 6. syncope/near syncope
- 7. profound weakness
- 8. epigastric discomfort
- 9. hyperglycemia in diabetic pt's
- 10. sweating incongruent w/ enviroment
- 11. nausea, vomiting
- 12. previous cardiac history or other cardiac factors
- 13. presence of anginal equivalents
- 14. overdoses
- 15. altered mental status
- DO NOT DELAY SCENE TIME > 4 MIN TO PERORM 12-LEAD ECG
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PEDIATRIC BURN PT (<13y/o)
- 1. PEDIATRIC PT ASSESSMENT GUIDELINE
- 2. OXYGEN
- 3. IV LACTATED RINGERS (in non affected area of burn if possible) [IO ACCESS IF INDICATED]
- 4. TYPE OF BURN
- a) THERMAL
- b) CHEMICAL
- c) OPTHALMIC
- d) ELECTRICAL
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PEDIATRIC BURN PT (<13y/o)
THERMAL BURNS
- 1. COVER BURNS w/ CLEAN, DRY DRESSING (< 10% & superficial or partial thickness you may moisten towels/sheets w/ sterile NS for comfort.)
- 2. IF > 20% BSA, BEGIN FLUID RESUSCITATION @ 250-500 ML FLUID BOLUS & TITRATE BP > 100 SBP
- 3. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
- 4. ESTABLISH MEDICAL CONTROL (possible orders: additional MS, Intubation.
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PEDIATRIC BURN PT (<13y/o)
CHEMICAL BURNS
- 1. CONSIDER ANY CHEMICAL BURN SITUATION AS A HAZMAT SITUATION
- a) if potential hazmat situation exists, notify receiving hospital ASAP
- b) identify chemical if possible
- 2. REMOVE AFFECTED CLOTHING & JEWELRY
- 3. FLUSH w/ COPIOUS AMOUNTS OF WATER OR SALINE (unless contraindicated). IRRIGATE BURNS TO EYES w/ MIN OF 1L LACTATED RINGERS. ALKALINE BURNS SHOULD RECEIVE CONTINUOUS IRRIGATION THROUGHOUT TRANSPORT. CONSIDER MORGAN LENS FOR EYE IRRIGATION IF > 6 y/o. BRUSH OFF DRY POWDER
- 4. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
- 5. ESTABLISH MEDICAL CONTROL (possible orders: additional MS)
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PEDIATRIC BURN PT (<13y/o)
OPTHALMIC BURNS
- 1. IMMEDIATE/CONTINUOUS FLUSHING OF THE AFFECTED EYE w/ LACTATED RINGERS. IF CONTACT LENSES ARE KNOWN TO BE IN THE PT'S EYES, AN ATTEMPT SHD/ BE MADE TO REMOVE THEM & CONTINUE FLU. SHING.
- 2. INSTILL 1/2 DROPS OF OPHTHALMIC ANESTEHESIA (unless contraindicated). PLACE MEDICATION ONTO THE LOWER LID.
- 3. PLACE MORGAN LENS (if pt > 6 y/o) IN THE AFFECTED EYE(S) CONTINUOUSLY FLUSH w/ LACTATED RINGERS WHILE ENROUTE TO THE HOSPITAL. RUN 2L OF FLUID WIDE PER EYE, THEN ADMINISTER KVO RATE.
- 4. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
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PEDIATRIC BURN PT (<13y/o)
ELECTRICAL BURNS
- 1. SUSPECT SPINAL INJURY 2NDARY TO TETANIC MUSCLE CONTRACTION. IMMOBILIZE PT. ASSESS FOR ENTRANCE & EXIT WOUNDS.
- 2. IV NS
- 3. CARDIAC MONITOR. TREAT ANY CARDIAC RHYTHM DISTURBANCES PER QUIDELINE.
- 4. CONTROL PAIN (refer to Pediatric Pain Control Guideline)
- 5. ESTABLISH MEDICAL CONTROL
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CINCINNATI PREHOSPITAL STROKE SCALE
- 1. FACIAL DROOP: Have pt show teeth or smile
- 2. PRONATOR DRIFT: Have pt close eyesy & extends both arms straight out, palms up, for 10 seconds. Normal: Both arms move the same, or both do not move at all. Abnormal: 1 arm either does not move, or 1 arm drifts downward (pronator drift) compared to the other.
- 3. SPEECH: Have pt repeat "The sky is blue in Cincinnati". Abnormal: slurs, says wrong words or is unable to speak.
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PEDIATRIC GCS "CHILD"
- EYE OPENING
- 4 opens spontaneously
- 3 opens to speech
- 2 opens to pain
- 1 none
- VERBAL RESPONSE
- 5 oriented
- 4 confused
- 3 inappropriate words
- 2 incomprehensible words
- 1 none
- MOTOR RESPONSE
- 6 obeys commands
- 5 localizes pain
- 4 withdrawl to pain
- 3 flexion (pain)
- 2 extention (pain)
- 1 none
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PEDIATRIC GCS "INFANT"
- EYE OPENING
- 4 opens spontaneously
- 3 opens to speech
- 2 opens to pain
- 1 none
- VERBAL RESPONSE
- 5 coos & babbles
- 4 irritable cry
- 3 cries in pain
- 2 moans in pain
- 1 none
- MOTOR RESPONSE
- 6 spontaneous movement
- 5 withdrawls to touch
- 4 withdrawls to pain
- 3 flexion (pain)
- 2 extention (pain)
- 1 none
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EMERGENCY CHILDBIRTH
- 1. UNIVERSAL PT CARE GUIDELINE
- 2. O2
- 3. ESTABLISH IV NS KVO
- 4. CROWNING OR URGE TO PUSH - VISUAL INSPECTION (if no crowning or urge to push Transport to OB facility)
- 5. PREPARE FOR CHILD BIRTH
- 6. CONTROL DELIVERY w/ PALM OF HAND SO INFANT DOES NOT "EXPLODE" OUT OF VAGINA. SUPPORT INFANTS HEAD AS IT EMERGES & SUPPORT THE PERINEUM w/ GENTLE HAND PRESSURE.
- 7. SUPPORT & ENCOURAGE MOTHER TO CONTROL THE URGE TO PUSH.
- 8. TEAR THE AMNIOTIC MEMBRANE, IF STILL INTACT & VISIBLE OUTSIDE THE VAGINA. CHECK FOR CORD AROUND THE NECK.
- 9. GENTLY SUCTION MOUTH & NOSE (w/ BULB SYRINGE) OF INFANT AS SOON AS HEAD DELIVERED
- 10. NOTE PRESENCE OF ABSENCE OF MECONIUM STAINING. (if meconium is present & infant has a HR<100, poor respiratory effort or poor muscle tone intubate & suction prior to stimulating breathing. ventilate w/ BVM after suctioning.)
- 11. AS SHOULDERS EMERGE, QUIDE HEAD & NECK SLIGHTLY DOWNWARD TO DELIVER ANTERIOR SHOULDER, THEN THE POSTERIOR SHOULDER.
- 12. REST OF INFANT SHOULD DELIVER w/ PASSIVE PARTICIPATION. GET FIRM HOLD ON THE BABY.
- 13. REPEAT GENTLE SUCTIONING THEN PROCEED TO POSTPARTUM CARE OF INFANT & MOTHER.
- 14. DRY & KEEP INFANT WARM. IF POSSIBLE SKIN SKIN TO SKIN CONTACT w/ THE MOTHER WHILE COVERING THE INFANT w/ A BLANKET.
- 15. ESTABLISH DATE & TIME OF BIRTH & RECORD, DO APGAR @ 1 & 5 MIN.
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AEIOU-TIPS
- General Causes of Reduced LOC
- 1. Alcohol
- 2. Epilepsy
- 3. Insulin (Hypo/Hyperglycemia)
- 4. Over Dose
- 5. Uremia
- 6. Trauma
- 7. Infarctions (Cardiac or Cerebral)
- 8. Poisoning, Phychological
- 9. Sepsis
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PEDIATRICS ANAPHYLAXIS
- 1. Pediatric Assessment Guide
- 2. Oxygen & Pediatric Airway Guide
- 3. Epi (1:1000) 0.01 mg/kg IM
- 4. IV/IO access Fluid Bolus 20 ml/kg of NS or LR
- 5. If bronchospasm admin 2.5mg Albuterol via Neb, Benedryl 1mg/kg (50mg max) IV/IO over 1 min (IM if no IV/IO). If no improvement Epi 1:10,000 .0.01 mg/kg (max 0.3mg) slow IV/IO push.
- 6. Establish Medical Control
- Possible Physician Orders1. Repeat Epi IM or IV doses q 52. Epi infusion 0.1 - 0.3 mcg/kg/min increasing to 1.0 mcg/kg/min as necessary3. Fluid Bolus 20 ml/kg of NS or LR
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NEONATAL RESUSCITATION
- 1. UNIVERSAL PATIENT GUIDELINE
- 2. POST PARTUM CARE FOR INFANTS GUIDELINE
- 3. Position infant on his/her back w/ head down. Check for Meconium
- 4. If thick Meconium, w/ HR < 100, weak respiratory effort, or poor muscle tone, aggressively suction until clear using ET Tube immediately following birth. Ventilate w/ BVM after suctioning.
- 5. Suction mouth & nose w/ bulb syringe. Dry infant & keep warm.
- 6. Stimulate infant by rubbing his/her back or flicking the soles of the feet. If the infant show decreased LOC, mottling or cyanosis, &/or presents w/ a HR < 100 BPM.
- a. Breathing, HR > 100
- b. Breathing, HR > 100 but cyanotic
- c. Apneic or HR < 100
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NEONATAL RESUSCITATION
Breathing, HR > 100
1. observe
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NEONATAL RESUSCITATION
Breathing, HR > 100 but cyanotic
- 1. admin supplemental O2
- 2. if after 30 sec, persistent cyanosis admin positive pressure ventilation
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NEONATAL RESUSCITATION
Apneic or HR < 100
- 1. positive presure ventilation
- 2. if after 30 sec, HR < 60, admin positive presure ventilat ion & chest compressions
- 3. if after 30 sec, HR < 60, admin EPINEPHRINE 0.01 mg/kg (1:10,000) IV/IO; 0.1 mg/kg (1:1,000) ET. consider maternal condition including medications. NARCAN 0.1 mg/kg
- 4. IM/IV/IO/ET IV/IO access, 10-20 mg/kg NORMAL SALINE bolus
- 5. obtain BGL
- 6. ESTABLISH MEDICAL CONTROL Possible Physician Orders: repeat EPINEPHRINE, NARCAN. DEXTROSE 5% 5-10 ml/kg over 20 min other treatment options per consultation
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