OC Medic Protocols

Allergic Reaction/Anaphylaxis

- Do not administer if history of cardiac disease; Epinephrine Auto-injector administered prior to arrival counts as one dose. - Do not administer if diphenhydramine taken prior to arrival. Reaction with only rash or urticaria and vital signs stable: - Pulse oximetry: if room air oxygen saturation less than 95%, manage as reaction includes hypoxia as described below. Reaction includes facial/cervical angioedema: - Epinephrine 0.5 mg IM lateral thigh area (1 mg/1 mL concentration) - one time dose. - Diphenhvdramine (Benadryl®) 50 mg IM or IV once Reaction includes wheezing or hypoxia (pulse oximetry <95% saturation): - Epinephrine 0.5 mg IM lateral thigh (I mg/ImL concentration), may repeat twice with 0.5 mg IM every 5 minutes for continued symptoms. - Albuterol, Continuous nebulization of 6 mL (5 mg) concentration as tolerated. - Diphenhydramine (Benadryl) 50 mg IM or IV once Reaction includes hypotension, respiratory distress, and/or impending airway obstruction: - Epinephrine 0.5 mg IM lateral thigh (I mg/ImL. concentration) - Normal Saline, infuse 250 mL IV or IO, repeat up to maximum I liter to maintain adequate perfusion - After initial IM epinephrine given as above, if continued symptoms after 5 minutes, repeat Epinephrine 0.5 mg IM lateral thigh or Epinephrine 0.3 mg IV / IO (0.1 mg/I mL concentration) - Diphenhydramine (Benadryl) 50 mg IM or IV once - Make base contact

Obviously Deceased Criteria

1. Incineration 2. Massive crush injury and/or evisceration of the heart or brain 3. Decapitation 4. Obvious fatal external exsanguination (massive blood loss) 5. Decomposition 6. Rigor mortis and meets the procedure described below in subsection IV, B 7. Post-mortem lividity and meets the procedure described below in subsection IV, B 8. Traumatic cardiopulmonary arrest and meets the procedure described below in subsection IV. B 9. It is determined that the person had an unwitnessed, non-trauma cardiopulmonary arrest with no bystander CPR or AED placement prior to EMS arrival and the person is found by cardiac monitor to be systolic in two leads and meets the procedure described below in subsection IV. B

Trauma Criteria Extremity Injuries

1. Penetrating injury to extremity above elbow or knee 2. Extremity injury w/poor circulation or without a pulse 3. Paralysis or paresthesia of arm or leg due to injury 4. Fracture of two or more long-bones (femur or humerus) 5. Pelvic rim pain or deformity on palpation 6. Amputation (partial or complete) above the wrist or ankle 7. Crushed, degloved or mangled extremity

Trauma Criteria Neck, Chest, Torso, Abd Injuries

1. Penetrating injury to neck, chest, abdomen, back or groin 2. Blunt chest injury with abnormal respirations (<12 or >30) 3. Seat belt bruising or abrasion of neck, chest or abdomen 4. Blunt abdominal injury with palpable tenderness in any # of quadrants 5. Reported or obviously pregnant woman w/blunt or penetrating abd inj. 6. Hanging

Trauma Criteria Head Injuries

1. Penetrating or open injury of the head 2. Depressed skull fracture 3. Blunt or penetrating head injury with observed loss of consciousness for any amt of time, focal neuro deficit, asymmetric pupils or vomiting 4. Blunt head injury with bruising in area of injury and taking blood thinners (excluding ASA), has hemophilia, or is on dialysis

Trauma Criteria Injury

1. Penetrating or open injury of the head 2. Depressed skull fracture 3. Blunt or penetrating head injury with observed loss of consciousness, focal neurologic deficit, asymmetric pupils, or vomiting 4. Penetrating (appears to penetrate all skin layers) injury to the neck, chest, abdomen, back, or groin 5. Penetrating (appears to penetrate all skin layers) injury to extremity above elbow or knee 6. Extremity injury with poor circulation or without a pulse 7. Paralysis or paresthesia of arm or leg due to injury 8. Blunt chest injury with abnormal respiration as defined above 9. Seat belt bruising or abrasion of neck, chest, or abdomen 10. Blunt abdominal injury with palpable tenderness 11. Fracture of two or more long bones (femur, humerus) 12. Pelvic rim pain or deformity on palpation 13. Amputation (partial or complete) above the wrist or ankle 14. Crushed, degloved, or mangled extremity (excluding only fingers or toes) 15. Reported or obviously pregnant woman with blunt or penetrating abdominal injury 16. Blunt head injury with bruising in area of injury and known to be taking anticoagulants or platelet inhibitors (blood thinners) excluding aspirin or to have hemophilia or to be a dialysis patient

Trauma Mechanism of Injury

Falls: 1. Adult/Adolescent: Greater than 15 feet (one story is equal to 10 feet) 2. Children: Greater than 10 feet or 2-3 times the height of the child 3. Adult/Adolescent/Child: Fall from a galloping horse High-Risk Auto Crash: 1. Passenger space intrusion greater than 12 inches where an occupant (who would be defined as a trauma victim) is sitting or any occupant in a passenger seat when there is greater than 18 inches intrusion at any site within the passenger space. 2. Ejection (partial or complete) from automobile. 3. Person who is in same passenger compartment in which a trauma death has occurred. Dive and shore break injuries with suspected spinal cord injury. Hanging. Auto vs. Pedestrian / Bicyclist who is thrown any distance, run over, or with significant (greater than 20 mph) impact. Unenclosed motorized vehicle crash (motorcycle, bike, scooter, etc) greater than 20 mph, including "laying bike down"

Ischemic Stroke

Give no fluids or solids orally Ischemic Stroke Suspected: 1. Last seen neurological baseline within the past 24 hours AND 2. Responds appropriately to verbal or visual stimuli or has spontaneous eye opening AND 3. Demonstrates ONE OR MORE of the following new onset neurological signs: - Arm drift or paralysis, asymmetric to right or left arm - Facial paresis or droop - Decreased grip strength, asymmetric to right or left hand

Hyperglycemia Protocol

If mental status, vital signs, and pulse oximetry normal AND: - Glucose less than 250 and no other complaint exists requiring ALS intervention/transport, may transport BLS. - Glucose greater than 250 but less than 400, and no other complaint exists requiring ALS intervention, may transport BLS if no other co-morbidities exist. Consider ALS transport if patient also has history of: 1. Active cancer 2. Active abdominal pain with vomiting 3. Renal Failure 4. Congestive Heart Failure 5. Liver disease 6. Organ transplant 7. Immunosuppression 8. Frail elderly - Glucose greater than or equal to 400, transport ALS. If patient has a blood glucose greater than 250 AND: - is confused/lethargic, OR - has a heart rate greater than 120, OR - has a respiratory rate greater than 20 and labored breathing, OR - has history of fever, OR - if oxygen saturation is less than 94%, Transport ALS and consider DKA.

Obviously Deceased Assessment Procedure

If rigor mortis, post-mortem lividity, traumatic cardiopulmonary arrest, or an un-witnessed cardiac arrest with no bystander CPR as criteria for "obviously dead" 1. Assessment of respiratory status by: - Assuring that the patient has an open airway, AND - Looking, listening, and feeling for respirations. This shall include auscultation of the lungs for a minimum of 30 seconds. 2. Assessment of cardiac status by: - Palpating for a central pulse for a minimum of 15 seconds, AND - Auscultation for the apical pulse for a minimum of 15 seconds. 3. Assessment of neurological reflexes by checking for: - Pupil response with a penlight or flashlight, AND - A response to painful stimuli. 4. If all three assessments are negative for signs of life, the patient meets criteria for obviously dead. 5. If there is uncertainty regarding any of the above findings or at EMS discretion, rhythm strips in two leads to confirm systole in support of the assessment of "obviously dead" may be obtained. 6. If there are signs of life based on any of the above assessment elements, resuscitative intervention is required unless a DNR or Health Care Directive is present. 7. If a patient meets "obviously dead" criteria while being transported to an ERC, do not initiate resuscitative measures or CPR. Continue transport to the original (ERC) destination. Notify the receiving ERC of the situation and to expect arrival of an "obviously dead" victim

Intracranial Hemorrhage

Intracerebral Hemorrhage Suspected: Sudden, severe headache with onset in the past 24 hours WITH ANY ONE OF: - Vomiting (repeated) OR - Neurological deficit (hemi-paresis or weakness, gaze to one side, or asymmetric pupils) OR - ALC - Marked BP elevation (diastolic >100 mm Hg)

Suspected Sepsis

Known or suspected source of infection: - Cough suggestive of pneumonia - Complaint of urinary tract problems in past or present - Skin infection - Known to be immune suppressed: 1. Taking oral steroids (such as prednisone) for chronic diseases such as asthma and arthritis. 2. Who have received organ transplants. 3. With a history of cancer 4. With history of diabetes 5. With history of renal failure 6. With history of HIV infection/AIDS AND If any two of the following three symptoms are present: 1. Altered Mental Status (GCS < 13) and/or 2. Systolic Blood Pressure < 100 mm Hg and/or 3. Respiratory rate > 22 / minute Other considerations increasing the risk of sepsis include: - Age > 50 - Acute or chronic altered mental status - History of stroke - Abdominal pain with fever - Resident of long-term healthcare facility - Dispatched as Nonspecific Illmess/Sick Person - Nonspecific weak/dizzy presentation

Base Hospital Contact Criteria Peds

Vital: Pulse (bpm): <60 or >200 Respirations (resp/min): <12 or > 50 Systolic blood pressure (mm Hg): <80 1. Respiratory distress or labored breathing manifested by: - Intercostal retractions, - Nasal flaring with inspiration, - Respirations less than approximately 12/min or more than approximately 50/min - Cyanosis (particularly of lips and central face area), - Complaint of difficulty breathing by child who can communicate - Paramedic judgment 2. Circulatory compromise manifested by: - Poor skin color (pallor, cyanosis) - Decreased capillary refill of hypothenar area (3 seconds or greater) - Altered mental status or confusion - Mottling of skin (darkened or lighter patches) - Pale lips or fingernail beds - Weak / thready pulse or heart rate less than 60/min or over 200/min - Paramedic judgement 3. Children with acute symptoms of a BRUE (ALTE) below, either observed by EMS personnel or reported by parent or caretaker, even when signs or symptoms are apparently resolved: - Apnea episode - Color change (cyanosis, pallor, erythema) episode - Marked change in muscle tone (limpness, flaccidity) episode - Choking or gagging spontaneous, unrelated to food or fluid intake 4. Children with BRUE (ALTE) symptoms when caretaker requests to sign out AMA for ALS or BLS transport. 5. Children who meet Trauma or Replant Criteria (see SO-T-15). 6. Child victims of suspected physical or sexual assault. 7. Pediatric cardiac arrest and ROSC 8. Pediatric drowning (fatal/non-fatal) 9.Burn Center (see SO-P-95) pediatric patients to determine which center is available for receiving acute cases and to assist with management.

Trauma Criteria Vitals

Vitals: 1. Failure to follow commands 2. Respiratory rate <12 or >30 per min 3. Systolic BP <90 (Adult/Adolescent) <80 (child)

Base Hospital Contact Criteria Adult

Vitals: Pulse (bpm): <50 or >130 Respirations (resp/min): <12 or > 26 Systolic blood pressure (mm Hg): <90 1. Patients for whom a 12-lead ECG is performed who request to sign out AMA for transport. 2. Mass Casualty Incidents (MCI) for receiving ERC/TC destination, unless the Orange County Communications Center (OCC) is determined by field protocol as communication point for destination assignments. 3. Cardiovascular Receiving Center (CVRC) patients to determine destination for an open cardiac catheterization laboratory. Indications for CVRC transport include: - Return Of Spontaneous Circulation (ROSC) - Automatic Implantable Cardioverter Defibrillator "firing" or defibrillating two or more times in less than fifteen minutes. - 12 lead EKG reading of acute MI - Patient with symptomatic bradycardia - Patient with a Left Ventricular Assist Device (LVAD) 4. Patients who meet Trauma or Replant Criteria (see SO-T-15). 5. Patients who meet Stroke-Neurology Center criteria 6. Burn Center (see SO-E-05) patients to determine which center is available for receiving acute cases. 7. Triage decisions in which Base Hospital contact may assist field personnel, such as ALS level refusal of care when there is a question of patient mental capacity. 8. Field transport by helicopter to an ERC