1-1. Continuous Positive Airway Pressure

(CPAP) Apply CPAP if ALL of the following conditions below are present and there are no contraindications:

1) The patient is awake and can cooperate with CPAP;

2) CPAP mask fits the patient;

3) The patient is able to maintain an open airway;

4) The patient exhibits two or more of the following:

a) RR > 20 breaths per minute.

b) O2 < 94% while on O2, or persistent dyspnea.

c) Accessory muscles are used during respiration.

d) Rales audible to auscultation are present.

5) If CPAP fails, — ET intubation, or BVM / BVM with SGA. Monitor O2 saturation and continuous waveform EtCO2, place on cardiac monitor, and establish IV access.

1-2. End Tidal Carbon Dioxide

(EtCO2) Use continuous wave EtCO2 with any critically ill patient, advanced airway or sepsis patients.

1-3. Intraosseous (IO)

1-3. Intraosseous (IO)

critically ill patients with urgent need for IV & no available veins for regular IV access. A careful skin prep is done and the proximal tibia is the preferred site for IO.

1-4. Oxygen Administration

based upon the pt presentation and guidelines:

1) No Supplemental O2 if:

a) No complaint and no appearance of SOB

b) “POX” ≥ 94%.

2) NC @ 2 LPM if:

a) complaint of SOB and no appearance of SOB

b) POX ≥ 94%

3) NRB @ 10- 15 LPM if ANY of:

a) Complaint of SOB; b) Appearance of SOB; c) “AMS”

AND

d) POX O2 < 94%.

4) Three diagnoses that are exceptions for high flow 15 LPM O2:

a) Barotrauma / decompression sickness;

b) Suspected carbon monoxide poisoning

c) Suspected cyanide exposure.

6) “BVM” @ 15 LPM if any of the following:

a) Complaint of SOB; b) Appearance of SOB; c) AMS

AND

d) Absent or inadequate ventilations.

1-5. Pain Reduction

isolated extremity trauma / significant burns. — selectively and cautiously, with goal of partial relief of pain while avoiding: over sedation, hypotension and obscuring head or torso injuries.

1) O2 / NS IV at TKO

2) If BP >100 mm Hg

a) Morphine Sulfate 2 mg IV; OR

b) Fentanyl 50 mcg IV.

If BP is still >100 mm Hg, may repeat:

For other severely painful conditions, commo.

If respiratory depression or difficulty after administration of pain medication, support respiration as needed, avoid a full reversal with Naloxone. If necessary give Naloxone 0.5 mg IV and repeat as needed up to a total dose of 2mg.

If the IV has been lost, administer Naloxone 2mg intranasal (IN) using an atomizer or mister device. You must use the higher concentration form when administering Naloxone IN.

1-6. Rapid Sequence Intubation

“RSI” or Paralytic Assisted Tracheal Intubation “PATI”

1-6-a. Indications

1) Inability to maintain oxygen saturation > 90% by any other more conventional means;

2) Inadequate ventilation; and,

3) Unable to protect airway.

As much as possible, hyper-oxygenation should be attempted pre-RSI, by administering high flow O2 by mask, and also by doing apneic oxygenation via nasal prongs at 15 LPM before and during RSI.

1-6-b. Preparation

1) Start / increase pre-oxygenation.

2) Assure suction is available and set up.

3) Establish and secure an IV or an IO.

4) Place cardiac monitor and POX on patient.

5) Prepare waveform capnography.

6) Ready intubation equipment and supplies.

7) Setup alternate airway adjuncts: SGA and BVM.

8) Restrain patient, as appropriate.

1-6-c. Medication and RSI perform these steps, in this order

1) Preoxygenate.

2) Administer Etomidate 0.3 mg/kg up to a max dose of 30 mg IV/IO.

3) If X Etomidate give Midazolam 0.1 mg/kg up to a maximum single dose of 10 mg IV/IO.

You may repeat the Midazolam 0.1 mg/kg if it is needed to a maximum total dose of 0.3 mg/kg.

4) Support ventilation to the extent needed after giving sedation, using BVM with attached supplemental high flow O2.

5) Administer Succinylcholine 1.5 mg/kg IV/IO up to a maximum single dose of 200 mg.

6) Apply backward, upward, rightward pressure to larynx (BURP maneuver) to facilitate intubation.

7) Intubate and assess ET tube placement.

8) Secure ET tube position and reassess tube placement.

9) Monitor continuous waveform capnography/EtCO2 to ensure ongoing correct tube placement.

10)Administer additional Midazolam, or add Midazolam after Etomidate, as needed for continued patient sedation up to a total of 0.3 mg/kg.

11)Any sedation should be administered by slow IV push.

12)If relaxation is inadequate to allow intubation after 1-2 minutes, recheck IV quality. If needed, start a new IV/IO, then repeat the same dose of Succinylcholine and sedation, and re-attempt tracheal intubation.

13)If unable to intubate the paralyzed patient, insert SGA.

14)If unable to insert SGA, use BVM assisted ventilation with maximal attention to technique.

15)Ventilation optimal rates: When bagging the intubated patient and/or setting the ventilator rate, consider the clinical situation pre-intubation and pick a respiratory rate that is appropriate.

a) Normal = 12 /minute with a tidal volume of 8 cc/kg;

b) Asthma = Slow, 8 /minute with a tidal volume of 6 cc/kg; and,

c) Acidosis = Fast, 20 /minute with a tidal volume of 8 cc/kg.

1-7. Shock / Hypovolemia

For systolic BP < 90 mmHg which is considered to be secondary to hypovolemia:

1) Administer supplemental oxygen as needed

2) Establish IV access with Normal Saline “NS” and infuse at a rapid rate.

3) If unable to start IV within 2 minutes, you may choose to obtain vascular access by IO

4) Do not delay transport

5) Establish second vascular access with NS while en-route: Infuse NS at a rapid rate until:

BP is ≥ 90 mmHg systolic (110 if a severe head injury is also present) - then reduce to a TKO rate and monitor VS

6) If BP does not improve:

check for signs of a cardiogenic cause on the ECG monitor

or signs of obstructive shock such as neck vein distention and if these signs are present, reduce IV/IO infusion rate to TKO

1-8. Spinal Motion Restriction

Consider immobilizing a patient with a significant mechanism of injury if:

1) GCS < 15?

2) Intoxication: Any evidence of alcohol or drug intoxication?

3) Neuro exam: Any focal motor or sensory deficit? Any transient deficit that has resolved?

4) Distracting injuries: Any painful injury that might distract the patient from the pain of a spinal injury?

5) Exam: Any tenderness or pain over the midline of the cervical spine?

6) Extremes of age: be extra cautious in those patients younger than 5 years or older than 65 years.

Apply a cervical collar and perform SMR as below:

1) Spinal motion restriction should be considered for any patient who has been subjected to mechanisms of injury that have a high index of suspicion for cervical, thoracic, lumbar or spinal cord injury.

2) Firmly secure the torso to EMS stretcher or conforming device (e.g., vacuum splint).

3) Use of a hard surface backboard should be avoided, but may be considered for cases in which:

a) The backboard is used for extrication from a scene / vehicle, but it should be removed after the patient is placed on the EMS stretcher.

b) Removal of the backboard would delay the transport of a critical patient.

c) The backboard is needed for CPR chest compressions.

1-9. Taser Dart Removal

Consider scene safety and medic safety, even with police present. The patient with embedded darts is at high risk for AMS, and for having injuries from an altercation or from a Taser-related fall. The darts are removed with a quick pull, the puncture wounds cleaned with alcohol and covered with band-aids. Do and document a good overall exam for injuries, ventilation, and mental status. Consider transporting the patient to ED for dart removal with darts embedded in eye, face, neck or genitals.

1-10. Termination of Resuscitation Cardiac Arrest

1) If cardiac arrest patient has had ALS resuscitation for ≥ 20 minutes and is in asystole, or no Return of Spontaneous Circulation / ROSC, the case should be considered for field pronouncement.

2) Consider transporting patients when there are concerns for scene safety, provider safety, or if the scene is in a very public place.

Traumatic Cardiac Arrest

1) If patients are in asystole after significant blunt trauma or penetrating trauma, strongly consider field pronouncement.

2) Consider transporting patients when there are concerns for scene safety, provider safety, or if the scene is in a very public place.

1-11. Needle Thoracostomy

Suspect tension pneumothorax in the patient who has decreased breath sounds unilaterally or throughout the lungs and persistent hypoxia with poor lung compliance. Particularly, at risk are patients with severe blunt trauma or penetrating trauma to the chest or abdomen who are receiving positive pressure ventilation. Note that additional signs of tension pneumothorax such as tracheal deviation and subcutaneous emphysema may be absent.

1) Establish an IV access and provide high flow oxygen.

2) Consider diagnostic mimics like improper endotracheal tube placement (ETT too deep) and hemothorax. Also consider your ETA to the ED, and time to communicate a possible diagnosis and trauma activation alert to the ED.

3) If the oxygen saturation cannot be maintained above 90% and there is either BP ≤ 80 mmHg systolic (impending cardiac arrest) or PEA, then perform a needle thoracostomy to decompress the suspected tension pneumothorax.

4) Do this at the midclavicular line at the 2nd intercostal space or at the anterior axillary line 5th intercostal space.

5) Use a special long and large catheter: 14 ga X 3 ¼” length.

6) Insert the needle into the chest wall perpendicular to the rib. Once the needle contacts the rib, then direct the needle over the rib into the target interspace.

7) Leave the catheter in place.

8) Post procedure: recheck VS, lung sounds, POX, and then report any changes to the ED.

1-12. Transport Interfacility

A paramedic will accept an order to transfer a patient by 911 ambulance from one medical facility to another (whether directly or as a segment of an air ambulance transfer) if ALL of the following conditions are met:

1) The order comes from a Hawaii Base Station Physician, on duty in the ambulance service region;

2) The paramedic is adequately informed of the patient’s diagnosis, condition, medications, allergies, and expected course during ambulance transport;

3) Also important to know is the patient’s Provider Orders for Life-Sustaining Treatment / POLST / Comfort Care Only / CCO / Do Not Resuscitate / DNR status; and,

4) There is an accepting physician at the destination facility, and the destination facility agrees to receive the patient. A request from a non-hospital medical facility should be treated as a 911 ambulance call rather than as an interfacility transfer. The paramedic may use Standing Orders during transfer, if indicated, and shall communicate with the receiving hospital if he / she does this.

1-13. Trauma / Bleeding Control

1) Extremity wounds

a) Apply direct pressure using a gloved hand or finger and very little gauze.

b) If direct pressure does not control the bleeding within 1-2 minutes, proceed quickly to a tourniquet (commercial tourniquet preferred).

c) Tourniquet should be placed proximally on the thigh or upper arm.

d) If 1st tourniquet does not stop the bleeding, apply an additional tourniquet close to the first one (proximally, if possible).

2) Wounds outside the chest and abdominal cavities (i.e. in the axilla or groin): do direct pressure first, then consider packing the wound by layering a roll of gauze into the wound, followed by application of direct pressure over the wound packing.