SB202

• Maintain airway and administer Oxygen
• Allow patient to sit up in a position of comfort
• Apply cardiac monitor when available
• Monitor vital signs
• Consider CPAP
• If patient has chest pain suggestive of cardiac origin, dyspnea, no evidence of trauma, AND systolic BP <80, OR systolic BP 80-100 and HR>120, skin changes suggestive of shock, or altered mental status, GO TO CARDIOGENIC SHOCK – M401
• If the patient has a dysrhythmia, GO TO THE APPROPRIATE CARDIAC NON-ARREST PROTOCOL
• If the patient is unable to speak, airway obstruction, or possible foreign body aspiration, OR exhibits stridor lung sounds, GO TO OBSTRUCTION PROTOCOL – M402 or PEDIATRIC OBSTRUCTION – P606 or PEDIATRIC STRIDOR PROTOCOL – P605
• If the patient has a history of asthma, emphysema, or COPD AND complains of a worsening shortness of breath, GO TO ASTHMA-COPD – M403 or PEDIATRIC RESPIRATORY DISTRESS PROTOCOL – P605
• If the patient has a history of heart disease, a respiratory rate greater than 24 and a systolic blood pressure greater than 100 mm HG, GO TO CONGESTIVE HEART FAILURE – M404
• If the patient has hives, itching, or swelling, GO TO ALLERGIC REACTION/ANAPHYLAXIS – M409
• If pneumothorax is suspected be aware that this can develop into a tension pneumothorax and GO TO TENSION PNEUMOTHORAX DECOMPRESSION – T701
• If patient is in impending respiratory failure, apply any of the following that are within the provider’s scope of practice and appropriate for patient condition:
  • Head-tilt, chin-lift
  • Jaw thrust maneuver
  • Basic airway adjuncts such as NPA or OPA
  • Rescue airway device
  • Tracheal intubation (including RSI when available)
  • Surgical airway approved by EMS Medical Director

M403

• Albuterol (Proventil) or Duoneb via HHN. May repeat to a total of 3 treatments
• For first treatment may add ipratropium bromide or use Duoneb
• For asthma only, consider Epinephrine 1:1000 0.3 ml IM if patient is unable to breathe in HHN
• Consider CPAP if available
• Consider 60 mg Prednisone PO or Solumedrol 125mg IV

T701

• Expose chest and clean procedure area on skin
• Use commercial device or long, large bore IV catheter and needle (10-14 gauge; 3 inch 10 gauge preferred)
• Insert the device or IV needle and catheter over the top of the rib of the second or third intercostal space in the midclavicular line

OR

• Insert the device or IV needle and catheter over the top of the rib of the fifth or sixth intercostal space in the midaxillary line

• If a tension pneumothorax is present, a rush of air may be heard
• Remove the needle from the catheter and leave the plastic catheter in place
• Decompression may be supported with a large syringe, multiposition (3-way stopcock) valve, commercial attachment, or left to open air

M402

• Have victim cough forcefully if possible
• If victim cannot speak or cough, perform Heimlich maneuver until successful or patient unconscious;
• If unconscious, perform CPR and attempt BVM ventilations while preparing to intubate
• Use laryngoscope to visualize airway; if object visible, use Magill forceps or suction to remove
• If object not visible, intubate the airway; push object down the right mainstem bronchus to obstruct right lung and ventilate the left lung

M409

• Epinephrine 0.3ml 1:1000 IM if either hypotension or severe respiratory distress is present
• Albuterol (Proventil) 2.5mg in 2.5ml NS via HHN if wheezing or bronchospasm is present
• If hypotension infuse 1 liter NS IV WO rate.
• Benadryl 25-50mg IV/IM/PO; may be given without preceding Epinephrine in mild cases
• If hypotension persists, consider push dose epinephrine (5-20 mcg every 2-5 minutes; discontinue IM dosing)
• Persistent symptoms w/ known β blockers consider Glucagon IM/IV

M404

• CPAP if available
• Evaluate for contraindications to nitroglycerin:
  • Systolic BP <100 mmHg
  • Viagra/sildenafil in the last 24 hours
  • Levitra/vardenafil in the last 48 hours
  • Cialis/tadalafil in the last 72 hours
  • Medications for pulmonary hypertension (ex: Flolan, Revatio, Adcirca)
• Assess vitals, acquire 12-lead ECG and establish IV
• Consider Nitroglycerin administration as described below (If inferior MI evident on ECG, contact medical control prior to Nitroglycerin administration):
• 0.4 mg SL every 5 min X3 for MILD symptoms (HR<100, SBP 100-150, RR<25) or;
• 0.8 mg SL every 5 min X3 for MODERATE or SEVERE symptoms (HR>100, SBP >150, RR>25) or;
• Topical Nitroglycerin:
• 1″ for SBP 100-150
• 1.5″ for SBP 150-200
• 2″ for SBP >200
• Reassess blood pressure after each Nitroglycerin dose; do not readminister if SBP<100 mmHg
• Monitor LOC & respiratory status; do not readminister if status changes that cause concern for aspiration based on patient’s clinical status