BASIC LIFE SUPPORT - Grand Bank / Fortune Ambulance

70 Pages·2012·1.15 MB·English

BASIC LIFE SUPPORT

Patient Care Protocols

BLS
Patient Care Protocols

FIELD GUIDE

Provincial Medical Oversight Program

Provincial Medical Oversight

2012 Edition Newfoundland & Labrador
ACKNOWLEDGEMENT

OFFICE OF THE
PROVINCIAL MEDICAL OVERSIGHT PROGRAM

Paramedicine & Medical Transport - Eastern Health
St. Clare's Mercy Hospital
RM SM343
154 LeMarchant Road
St. John's NL, Canada, A1C 5B8

709 – 777 – 5209
709 – 777 – 5940 FAX
www.pmtnl.ca
[email protected]

OLMC 1-877-709-3535

This OL MC line is only to be used for medical advice when actively engaged in patient care

© All Rights Reserved: No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval system, without
permission in writing from the Provincial Medical Oversight Program.
If found, please return to address above.
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AUTHORIZATION FOR PROTOCOLS

OVERVIEW
These protocols were developed for the following reasons:
1. To provide the EMS provider with a quick field reference
2. As written standards of care which are consistent throughout the Province
of Newfoundland & Labrador. Users of these protocols are to have
knowledge of more detailed and basic patient management principles
found in EMS textbooks and literature appropriate to the EMS provider’s
level of training and licensure.
3. All users must have strict adherence to these protocols.

POLICY
Practitioners will work within their scope of practice specifically guided by
procedures and protocols as authorized by the Provincial Medical Director or the
Assistant Provincial Medical Director.

SCOPE
Emergency Medical Responders and Primary Care Paramedics actively
registered with the Provincial Medical Oversight Program (PMO) and who are on
duty with a public ambulance service that is recognized by the Department of
Health and Community Services.
These protocols can be used by Advanced Care Paramedics or Critical Care
Paramedics if they are working for a BLS service in the role of a BLS provider.

PURPOSE
The Procedures and Protocols will be based on current best practice and
evidence. These protocols are issued by the Provincial Medical Director and the
Assistant Provincial Medical Director and will be supported by Regional Medical
Control Physicians. These protocols govern the practice of EMS Providers who
are registered with the Provincial Medical Oversight Program by the authority of
Department of Health and Community Services.

REVIEW
These protocols will be subject to annual review. New or revised protocols will be
issued as applicable changes occur. If there are errors or omissions, please
contact PMO.

_________________________ _____________________________
Dr. Doug Baggs MD, FRCP(EM) Dr. Rose Mengual MD,FRCP(EM)
Provincial Medical Director Assistant Provincial Medical Director
Paramedicine & Medical Transport Paramedicine & Medical Transport
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TABLE OF CONTENTS

Standards of Care 5

Airway Emergencies
Difficult Airway 7
Pediatric Respiratory Distress with Inspiratory Stridor 8

Breathing Emergencies
Adult Respiratory Distress with Bronchospasm 9
Pediatric Respiratory Distress with Bronchospasm 10
Adult Anaphylaxis 11
Pediatric Anaphylaxis 12

Circulation Emergencies
Ischemic Chest Pain 13
Symptomatic Arrhythmias 14
Pulmonary Edema 15
Cardiogenic Shock 16
Acute Stroke 17

Cardiac Arrest
Cardiac Arrest 19
Post Arrest Care 20
Traumatic Cardiac Arrest 21

Death in the Field
Obvious Death 22
Do Not Resuscitate (DNR) 23
Termination of Resuscitation (TOR) 24
Determination of Death 25

Trauma Emergencies
Burns 26
Spinal Assessment 27
Trauma Alert 29

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Medical Emergencies
Sepsis 30
Shock Not Yet Diagnosed 31
Symptomatic Hypoglycemia 32
Treat and Release Protocol for Hypoglycemia 34
Symptomatic Hyperglycemia 35
Convulsive Seizures 36
Toxins 37

Obstetrics / Gynecology
Child Birth 38
Complications of Delivery 39
Neonatal Assessment and Resuscitation 40

Reference Material
12 Lead ECG Acquisition 42
Fluid Therapy 44
PCP/ACP Intercept 45
Non-EMS Medical Personnel On-Scene 46
Refusal of Care / Refusal of Transport 47
Potential Communicable/Quarantinable Disease 48
Mass Casualty Incident (MCI) Management 49
MCI Triage - Adult 50
MCI Triage - Pediatric 51
Communications 52
Definitions surrounding DNR, TOR, Determination of Death 53
Pediatric Reference 54
Rule of Nines 55
Glasgow Coma Scale (Adult and Pediatric) 56
Oxygen Tank Duration Charts 57
IV Rate Conversion Chart 60
Metric Conversion Chart 61
Acronyms / Abbreviations 62
Formulary 63

4
GENERAL STANDARDS OF CARE

Gene ral standards of care should be performed if indicated and as necessary with all

patients based on the registered level scope of practice for the clinician as defined by the

Na tional Occupational Competency Profiles and PMO Policies for Paramedicine.

Scene assessment (Safety issues, MOI, # of Pts, need for resources)
Application of PPE including universal precautions
Assess LOC, Airway, Breathing, Circulation
C-spine immobilization
Airway management
Administer oxygen
Establish effective ventilation
Obtain detailed history
Perform physical exam
Vital signs
Determine blood glucose level
Pulse oximetry (before and after oxygen administration if possible)
Cardiac monitor
12 lead ECG
Establish vascular access
Spinal immobilization
Perform CPR as per Heart & Stroke Guidelines
Consider differential diagnosis
Consider PCP or ACP intercept for EMR/EMR crew
Consider ACP intercept for PCP/EMR or PCP/PCP crew
Standards of trauma care to follow guidelines of International Trauma
Life Support (ITLS)
Frequent reassessment, particularly after intervention
Notify receiving hospital

DOCUMENTATION

Ensure complete and thorough documentation of patient care activities.

Patient c are reports should contain enough detail so that it is easily apparent why specific
treatmen ts were offered or decisions were made. Careful documentation is especially important
when doc umenting cases including but not limited to:

Traumatic Cardiac Arrest

Obvious Death

Do -Not-Resuscitate (DNR)
Te rmination of Resuscitation (TOR)
De termination of Death
Sp inal Assessment
Re fusal of Care

If a patient care report is reviewed, your documentation should present a logical train of thought

that is easily followed through the appropriate protocol or algorithm.

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GENERAL STANDARDS OF CARE Cont’d

To use these protocols as they were intended, it is necessary to know the
philosophy, treatment principles, and definitions, which guided the physicians and
other EMS providers who drafted these protocols:

1. Assessment and treatment should very RARELY delay transport!
IV’s should be started en route except in those situations where treatment
at the scene of an out-of-hospital emergency is in the patient’s best interest
such as hypoglycemia, or cardiac arrest, and cardiac arrhythmia when full
ACLS care is available. Delays in transport should be discussed with
OLMC.

2. Inability to establish voice contact with OLMC.
There are rare situations where the patient is unstable and delay in
treatment threatens the patient’s life or limb. If, after good-faith attempts,
the practitioner cannot contact OLMC, then the practitioner is authorized
to use any appropriate treatment protocols as standing orders. Continue
attempts to contact OLMC and document these attempts on the patient
care record.

3. Treatments/drugs should be given in the order specified.
PMO recognizes that often treatments are delivered simultaneously and
more than one protocol may be used. OLMC may request treatments/drugs
out of sequence for medical reasons.

EMS providers may contact OLMC in any situation in which advice is

needed, not only in situations as directed by these written protocols.

Medical Authority

Medical authority is determined by the individual’s level of training. Personnel with the

highest level of training shall have medical authority during ambulance responses.

Personnel with the same level of training shall have medical authority determined by the

amount of experience at that training level. The person with the most experience

performing at that training level shall be granted medical authority.

Personnel who have the same training level and same experience at that training level

shall determine the course of treatment for the patient by mutual agreement.

If persons with the same training level and experience can not mutually agree on the

course of treatment they shall contact the on line medical control physician for direction.

Failing the above, if there is a disagreement on scene, regardless of training or

experience, practitioners must contact OLMC for direction.

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DIFFICULT AIRWAY
(with/without obstruction)

EMR & PCP

1. Manage airway as needed (airway maneuver and/or suction and/or
adjunct).
Follow current Heart & Stroke guidelines for respiratory arrest
procedure.
Utilize 100% O with assisted ventilation (PPV) if necessary.
2
Use the foreign body obstructed airway procedure as necessary.
2. Request ACP intercept if available

PCP ONLY
3. Continuous cardiac and SpO monitoring
2
4. IV during transport
5. Maintain adequate tidal volumes and ventilatory rates by monitoring chest
rise and SpO
2

Difficult Bag Mask Ventilation

Predictors of Difficult Bag Approach to Difficult BMV

Mask Ventilation
1) Reposition airway – exaggerated head tilt or

exaggerated jaw thrust. Consider adding pillow under
BOOTS

head. If obese, position using the ear to sternum

(ramping) technique (see picture below)
Beard
2) Insert oral and/or nasal airway
Obese
3) Two-person bag-mask ventilation
Older
4) Consider alternative mask size
Toothless
5) Consider foreign body
Snore/Stridor
6) If cricoid pressure being applied, ease up on or release

cricoid pressure

Ramping for obese patients

Figure A shows obese patient positioned without ramping. Figure B shows the patient ramped
so that her sternum and ear line up. This position should improve ventilation.
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PEDIATRIC RESPIRATORY DISTRESS WITH INSPIRATORY STRIDOR
(Laryngotracheitis/Croup)

EMR & PCP
1. Keep child as comfortable as possible, agitation may worsen condition
2. Humidified O , with upright posture
2
Blow by O acceptable if child refuses mask
2
3. If needed, assist ventilations with PPV using 100% O
2
4. EMR’s should request PCP or ACP intercept if available

PCP ONLY

5. Continuous cardiac and SpO monitoring
2
6. Consider nebulized epinephrine 1:1000 if indications present as per
dosing guidelines below:

Age Dose
Less than 1 year and less than 5 kg 0.5 mg (0.5mL) in 2 mL 0.9% NaCl

Less than 1 year and equal to or
2.5 mg (2.5 mL)
greater than 5 kg

Greater than or equal to 1 year 5 mg (5 mL)

In dications for epinephrine:

Severe respiratory distress

AND

Cu rrent history of upper respiratory infection with a “barking cough”, stridor at rest,
an d suprasternal retractions with severe respiratory distress

C ontact OLMC for consideration of:

S econd dose of epinephrine 1:1000

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ADULT RESPIRATORY DISTRESS WITH BRONCHOSPASM
(COPD, Emphysema, Chronic Bronchitis, Asthma)

EMR & PCP
1. Manage airway as needed
2. O via NRB during acute distress
2
If needed, assist ventilations with PPV
3. EMR’s should request PCP or ACP intercept if available

PCP ONLY
4. IV access during transport
5. Continuous cardiac and SpO monitoring
2
6. Administer:

Salbutamol
4-8 puffs via MDI with aerochamber* every 5 minutes as needed to maximum of 3
administrations
AND
Ipratropium Bromide
4-8 puffs via MDI with aerochamber* every 5 minutes as needed to maximum of 3
administrations

OR

Salbutamol
5 mg nebulized with O every 5 minutes as needed to maximum of 3 doses
2
AND
Ipratropium Bromide
500 mcg nebulized with O every 5 minutes as needed to maximum of 3 doses
2

* each puff must be followed by at least 4 breaths

7. If confirmed COPD (Emphysema or Chronic Bronchitis) only and
respiratory status has improved to patient’s baseline after treatment:
Consider replacing NRB with Venturi Mask or nasal cannula to
maintain SpO 90-92% if prolonged transport
2
If there is continued respiratory distress continue O via NRB
2

In cases such as status asthmaticus, where bronchospasm is not
alleviated with salbutamol + ipratropium bromide, the PCP should
contact OLMC to administer further salbutamol or to administer
epinephrine 1:1000 0.3 mg IM

NOTES:
Patients should be treated with MDI and aerochamber unless it is deemed
ineffective or patient cannot tolerate
Salbutamol or ipratropium bromide may be administered singularly if the
patient has a hypersensitivity to one of the medications.
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