RESQDOC
06-16-02, 19:03
This is a DRAFT protocol I am looking at using for selected EMT's & RN's on my EMS services. We do not have advanced life support providers. Under common practice EMT-B's in wilderness/remote settings can provide some advanced care. Please tear into it, tear it up, and correct it, as needed. The settings out here could include transport delays back to the hospital of up to 24 hours due to weather, range fire, etc., and disaster response delays back to the hospital in excess of 72 hours.
Gordon Rescue/EMS
Respiratory Distress, Asthma Attack,
& Allergic Reaction In The
Wilderness, Remote, & Disaster Setting
Purpose:
This protocol has been developed for use by appropriately trained individuals to aid in the recognition, management, and treatment of respiratory distress, asthma exacerbations, and allergic reactions. It is based on principles defined by the United States Department of Transportation, State of Nebraska Department of Health & Human Services, the Wilderness Medical Society, and the National Association of EMS Physicians.
Scope:
This protocol is limited to the use of Gordon Rescue/EMS personnel and Gordon Memorial Hospital medical care staff while working in wilderness, remote, or disaster settings where immediate medical care is not available. Isolation due to weather conditions, loss of transportation and communications, and/or loss of road access is included in this definition. It is not for use when transport times are short, routine systems and services are not impaired, and access to medical care is readily available.
Application & Use:
This protocol may be employed if the following conditions are met:
1. The patient is in a wilderness, remote, or disaster setting where medical care is not immediately available, as defined in “Scope” above.
2. Those using this protocol have been trained, tested, and approved by the Gordon Rescue/EMS Medical Director, and will be re-certified every 6 months.
3. Every effort will be made to communicate with the Medical Director or receiving hospital medical control physician prior to initiating therapies given in this protocol, however if communication is not available therapy will be initiated and contact made as soon as is feasible.
Definition:
Respiratory distress is defined as increased work of breathing, respiratory rates too fast or too slow to support the patient for more than a few minutes, and/or inadequate oxygen intake. Asthma exacerbations or “attacks” are defined as severe constriction of the airways and respiratory distress, often caused by allergic reactions, heavy exercise, or both. Anaphylaxis and life threatening allergic reactions are defined as effects caused by toxin/allergen contact by any method or mechanism of exposure that produces shock and/or impaired circulatory, respiratory, neurologic, or metabolic bodily function to the extent that a patient’s health or life may be endangered.
General Principals:
1. Respiratory distress can develop from infection, cardiac failure, smoke or gas inhalation, asthma exacerbations, allergic reactions, and other causes. Allergic reactions may come from exposure to bites, stings, inhalation, ingestion, contact, or other mechanism. A specific source may not be identifiable. Treatment is initiated based on a patients signs and symptoms, not on the presence of an identified source of allergic reaction.
2. Early recognition & treatment may be essential to saving the patient’s life.
3. The triggering factor, toxin, or allergen may persist in the body longer than the therapy. Asthmatic reactions may also reoccur. Watch closely for reoccurring signs and symptoms and retreat as necessary
4. All patients requiring treatment are to be evacuated to the nearest medical facility
Signs & Symptoms:
Mild Distress - itching, shortness of breath but able to talk normally, metallic taste in mouth, minor rash or swelling, normal vital signs.
Moderate Distress - wheezing or stridor but able to talk in brief phrases or sentences, swelling, rash, hives, rapid heart rate, rapid & shallow respirations, tripod position.
Severe Distress – profound wheezing or stridor, unable to talk, a sense of doom, falling blood pressure, falling pulse, shock, loss of consciousness.
Treatment:
1. Perform CPR as needed, consistent with the SOP’s.
2. Offer calm reassurance & control to the patient.
3. Remove the patient from any source of respiratory irritation, such as smoke, fumes, & gases. Recall that high winds may place a large amount of dust and pollen in the air. For allergic reactions remove any insect stingers, plant oils, or other sources.
4. Secure the airway with patient positioning, nasal/oral airways, assisted ventilation, and intubation as needed.
5. Suction secretions as needed.
6. If available, give OXYGEN, high flow (8-15 liters/min.) for serious respiratory distress, smoke or carbon monoxide inhalation, or severe allergic reaction. For less serious patients low flow (2-6 liters/min.) may be adequate and will conserve your oxygen supply.
7. If available, give ALBUTEROL (Proventil, Ventolin) inhaler 2 puffs every five minutes, or nebulizer 1 unit dose vial every 15 minutes, until improvement in respiratory distress is seen and then every 1 hour as needed. A routine treatment every 4-6 hours may be helpful in preventing re-occurrence. Recall that albuterol can produce mild tachycardia, tremors, and distress in some patients, but these are not serious in the short term. Do not withhold this medicine if they are in severe respiratory distress.
8. For patients in severe respiratory distress, if available give the above plus:
EPINEPHRINE (Adrenaline) 0.3 ml under skin of upper arm or by auto-injector (Epi- Pen). For patients less than 80 pounds give 0.15 ml under the skin of the upper arm or use the pediatric auto-injector (Epi-Pen Jr.). The Epinephrine may be repeated every 5 - 15 minutes as needed if worsening or not improving. Recall that epinephrine can cause significant tachycardia, tremors, and even chest pain if the patient has an underlying cardiac condition. Do not withhold this medicine if they are in severe respiratory distress.
9. For patients in moderate or severe respiratory distress, if available, give the above plus: METHYLPREDNISOLONE (Solumedrol) 125 mg intra-muscular (IM) injection into upper arm or buttocks. For patients less than 80 pounds give 60 mg intra-muscular (IM) injection into upper arm or buttocks. This may be repeated every 6 hours for the first 24 hours if needed. Recall that methylprednisolone can produce insomnia and agitation in some patients, but these are not serious in the short term.
10. For any allergic reactions also give, if available, DIPHENHYDRAMINE (Benadryl) 50 mg oral or intra-muscular (IM) injection into upper arm every 6 hours for the first 24 hours. For patients less than 80 pounds give 25 mg. Recall that diphenhydramine can produce mild sedation and thickening of secretions, but these are not serious in the short term.
11. For mild and moderate distress encourage ORAL FLUID intake if the patient is able to swallow and protect their airway. For patients in severe distress, if available, give NORMAL SALINE or RINGERS LACTATE 1000 cc’s either intra-venous or dermoclysis (under the skin) over one hour, with additional fluids to be given per SOP as needed. For patients less than 80 pounds follow the fluid resuscitation SOP. Fluids are important to maintain an adequate intra-vascular volume and to thin pulmonary secretions.
12. Perform a complete assessment of the patient, evacuate immediately, treat any underlying causes such as infection, & monitor for reoccurrence of symptoms. Make contact with medical control as soon as possible.
Gordon Rescue/EMS
Respiratory Distress, Asthma Attack,
& Allergic Reaction In The
Wilderness, Remote, & Disaster Setting
Purpose:
This protocol has been developed for use by appropriately trained individuals to aid in the recognition, management, and treatment of respiratory distress, asthma exacerbations, and allergic reactions. It is based on principles defined by the United States Department of Transportation, State of Nebraska Department of Health & Human Services, the Wilderness Medical Society, and the National Association of EMS Physicians.
Scope:
This protocol is limited to the use of Gordon Rescue/EMS personnel and Gordon Memorial Hospital medical care staff while working in wilderness, remote, or disaster settings where immediate medical care is not available. Isolation due to weather conditions, loss of transportation and communications, and/or loss of road access is included in this definition. It is not for use when transport times are short, routine systems and services are not impaired, and access to medical care is readily available.
Application & Use:
This protocol may be employed if the following conditions are met:
1. The patient is in a wilderness, remote, or disaster setting where medical care is not immediately available, as defined in “Scope” above.
2. Those using this protocol have been trained, tested, and approved by the Gordon Rescue/EMS Medical Director, and will be re-certified every 6 months.
3. Every effort will be made to communicate with the Medical Director or receiving hospital medical control physician prior to initiating therapies given in this protocol, however if communication is not available therapy will be initiated and contact made as soon as is feasible.
Definition:
Respiratory distress is defined as increased work of breathing, respiratory rates too fast or too slow to support the patient for more than a few minutes, and/or inadequate oxygen intake. Asthma exacerbations or “attacks” are defined as severe constriction of the airways and respiratory distress, often caused by allergic reactions, heavy exercise, or both. Anaphylaxis and life threatening allergic reactions are defined as effects caused by toxin/allergen contact by any method or mechanism of exposure that produces shock and/or impaired circulatory, respiratory, neurologic, or metabolic bodily function to the extent that a patient’s health or life may be endangered.
General Principals:
1. Respiratory distress can develop from infection, cardiac failure, smoke or gas inhalation, asthma exacerbations, allergic reactions, and other causes. Allergic reactions may come from exposure to bites, stings, inhalation, ingestion, contact, or other mechanism. A specific source may not be identifiable. Treatment is initiated based on a patients signs and symptoms, not on the presence of an identified source of allergic reaction.
2. Early recognition & treatment may be essential to saving the patient’s life.
3. The triggering factor, toxin, or allergen may persist in the body longer than the therapy. Asthmatic reactions may also reoccur. Watch closely for reoccurring signs and symptoms and retreat as necessary
4. All patients requiring treatment are to be evacuated to the nearest medical facility
Signs & Symptoms:
Mild Distress - itching, shortness of breath but able to talk normally, metallic taste in mouth, minor rash or swelling, normal vital signs.
Moderate Distress - wheezing or stridor but able to talk in brief phrases or sentences, swelling, rash, hives, rapid heart rate, rapid & shallow respirations, tripod position.
Severe Distress – profound wheezing or stridor, unable to talk, a sense of doom, falling blood pressure, falling pulse, shock, loss of consciousness.
Treatment:
1. Perform CPR as needed, consistent with the SOP’s.
2. Offer calm reassurance & control to the patient.
3. Remove the patient from any source of respiratory irritation, such as smoke, fumes, & gases. Recall that high winds may place a large amount of dust and pollen in the air. For allergic reactions remove any insect stingers, plant oils, or other sources.
4. Secure the airway with patient positioning, nasal/oral airways, assisted ventilation, and intubation as needed.
5. Suction secretions as needed.
6. If available, give OXYGEN, high flow (8-15 liters/min.) for serious respiratory distress, smoke or carbon monoxide inhalation, or severe allergic reaction. For less serious patients low flow (2-6 liters/min.) may be adequate and will conserve your oxygen supply.
7. If available, give ALBUTEROL (Proventil, Ventolin) inhaler 2 puffs every five minutes, or nebulizer 1 unit dose vial every 15 minutes, until improvement in respiratory distress is seen and then every 1 hour as needed. A routine treatment every 4-6 hours may be helpful in preventing re-occurrence. Recall that albuterol can produce mild tachycardia, tremors, and distress in some patients, but these are not serious in the short term. Do not withhold this medicine if they are in severe respiratory distress.
8. For patients in severe respiratory distress, if available give the above plus:
EPINEPHRINE (Adrenaline) 0.3 ml under skin of upper arm or by auto-injector (Epi- Pen). For patients less than 80 pounds give 0.15 ml under the skin of the upper arm or use the pediatric auto-injector (Epi-Pen Jr.). The Epinephrine may be repeated every 5 - 15 minutes as needed if worsening or not improving. Recall that epinephrine can cause significant tachycardia, tremors, and even chest pain if the patient has an underlying cardiac condition. Do not withhold this medicine if they are in severe respiratory distress.
9. For patients in moderate or severe respiratory distress, if available, give the above plus: METHYLPREDNISOLONE (Solumedrol) 125 mg intra-muscular (IM) injection into upper arm or buttocks. For patients less than 80 pounds give 60 mg intra-muscular (IM) injection into upper arm or buttocks. This may be repeated every 6 hours for the first 24 hours if needed. Recall that methylprednisolone can produce insomnia and agitation in some patients, but these are not serious in the short term.
10. For any allergic reactions also give, if available, DIPHENHYDRAMINE (Benadryl) 50 mg oral or intra-muscular (IM) injection into upper arm every 6 hours for the first 24 hours. For patients less than 80 pounds give 25 mg. Recall that diphenhydramine can produce mild sedation and thickening of secretions, but these are not serious in the short term.
11. For mild and moderate distress encourage ORAL FLUID intake if the patient is able to swallow and protect their airway. For patients in severe distress, if available, give NORMAL SALINE or RINGERS LACTATE 1000 cc’s either intra-venous or dermoclysis (under the skin) over one hour, with additional fluids to be given per SOP as needed. For patients less than 80 pounds follow the fluid resuscitation SOP. Fluids are important to maintain an adequate intra-vascular volume and to thin pulmonary secretions.
12. Perform a complete assessment of the patient, evacuate immediately, treat any underlying causes such as infection, & monitor for reoccurrence of symptoms. Make contact with medical control as soon as possible.