SO WE TREATED HIM OUTSIDE OUR SCOPE OF PRACTICE, WHOS GOING TO KNOW?

California

Skills, procedures and administration of

medications allowed by California regulations

Local

(Must be approved by the state)

Skills procedures or administration of medications

approved for EMTs by the Los Angeles County EMS Agency Medical Director

 The

Los Angeles County EMT Scope of Practice was developed to:

Address special needs of patients prior to the

arrival of an ALS Unit and during interfacility transport Expedite care of patients in acute distress

 Protocols

allowing for utilization of BLS procedures and the EMT Local Scope of Practice prior to ALS arrival
EMTs may assist patients with certain medications

prior to the arrival of an ALS Unit. An ALS Unit must be enroute or the patient must be transported immediately to the nearest emergency department appropriate for the needs of the patient if ALS response is not available or is delayed.

health care facility that is staffed, equipped, and prepared to administer emergency and/or definitive care appropriate for the needs of the patient. Facilities EMTs should consider are:
Most Accessible Receiving (MAR) Closest Emergency Department Approved For

Pediatrics (EDAP) Closest Perinatal Center Closest Trauma Center

 Assisting

patients with administration of physician prescribed emergency medications Transporting patients with various tubes and indwelling vascular access lines Transporting patients with certain medication additives in intravenous solutions Transporting patients with specific patient operated medication pumps

 The

EMT must be:

Currently certified as an EMT in California and

working in Los Angeles County Trained and tested in the knowledge and performance of procedures and skills included in the local scope of practice
All EMTs must be trained and tested in the LA County Scope of Practice by December 31, 2013

 Oral

Glucose preparations Oxygen

 Actions Immediate source of glucose Indications Conscious diabetic patient with s/s of

hypoglycemia
Signs and Symptoms of hypoglycemia Cool, moist skin, bizarre or combative behavior,

anxiety, restlessness, appearance of intoxication May also have signs similar to a stroke(slurred speech and staggering gait, or weakness on one side)

 Contraindications

Unresponsive patients Patients unable to swallow or have a diminished

gag reflex Patients complaining of nausea

Adverse

Effects

Gastrointestinal: vomiting aspiration, Respiratory:

obstructed airway

 Administration: Solution 75-100g (10g/oz) PO, sipped slowly. Paste/Gel 1 tube of paste/gel swallowed or 1 inch

placed between cheek and gum.

Pediatric Solution 1g/kg PO, sipped slowly Paste/Gel Not recommended for prehospital use Onset: Within 20 minutes
Duration:

Depends on the degree and cause of hypoglycemia

 Precautions Patients must be able to hold the bottle and drink

without assistance or Patients must be able to swallow if administering paste/gel

Risk of airway obstruction, vomiting, and/or aspiration if patient is unable to swallow or has a diminished gag reflex.
Note: The entire amount does not need to be

administered if the patient's condition improves.

 Normal

metabolic function requires oxygen Do not withhold oxygen from patients in respiratory distress.
Oxygen may decrease the respiratory drive in

patients with COPD (CO2 retaining)

Observe for any changes in respiratory and mental status and be ready to assist ventilations if necessary.

 Delivery

Adjuncts Allowed in Los Angeles

Nasal Cannula (Do not give more than 6/l) Face Mask Bag-valve-mask with O2 reservoir

Endotracheal Tube (ALS)

King Tube (ALS)

 Ventilate

advanced airway adjuncts

Endotracheal tube Esophageal-tracheal airway device Perilaryngeal airway device (King LTS-D)

Tracheostomy tube or stoma

Suction

a tracheostomy tube or stoma

 ET

Tube tube

Esophageal-tracheal

(combi-tube)
Not currently used in LA County
Perilaryngeal

airway (King Tube) tube or Stoma

Tracheostomy

 Avoid

excessive ventilation and limit tidal volume to achieve chest rise Problems due to excessive ventilation
Impedes venous return leading to decreased

cardiac output, cerebral blood flow, and coronary perfusion by increasing intrathoracic pressure Causes air trapping and barotrauma in patients with small airway obstruction Increases the risk of regurgitation and aspiration

 Each

breath should be given over 1 second Each breath should make the chest rise
When you see the chest rise-stop squeezing
Avoid

delivering too many breaths or breaths that are too forceful

Hyperventilation is now considered harmful

 Without

CPR (Respiratory Arrest Only)

10-12 breaths per minute (once every 5-6

seconds) for adults 12-20 breaths per minute (approx once every 3-5 seconds) for infant or child
With

CPR

After advanced airway, 8-10 breaths per minute

(once every 6-8 seconds)Do not pause compressions when giving the breath
Both adult and child

Seven pigs Hyperventilated

Seven pigs Ventilated correctly

Survival: 1/7 (14%)

Survival: 6/7 (86%*)

 Report

immediately if chest rise is not observed Assess breath sounds after moving the patient Report immediately if compliance is decreasing (it becomes harder to bag) Ensure that the bag is attached to supplemental O2

 Connect

BVM to the tracheostomy tube

Sometimes air may escape through the nose and

mouth leading to inadequate ventilation

Seal mouth and nose with one hand to prevent air escape
If

unable to ventilate the tube

through the mouth and nose while sealing the stoma

Suction

If suctioning doesnt help, attempt to ventilate

 Total

laryngectomy laryngectomy

No airflow from the mouth and nose

Partial

May still have some airflow from the mouth and

nose

 Suction

to clear stoma of any foreign

matter Keep patients head straight and shoulders slightly elevated

No need to perform head-tilt, chin-lift
Use

a child or infant mast, that fits securely over the stoma and can be sealed against the neck
continued

 Squeeze

bag and watch for adequate chest rise and fall

If the chest does not rise, suspect a partial

laryngectomy
For

partial laryngectomy

Pinch nose with fingers while using the palm to

seal the mouth

 EMTs

are required to suction:

Tracheostomy tubes Stomas

 INDICATIONS:

To maintain a patent airway in patients with a tracheostomy tube or stoma.

Rattling mucus sound from tracheostomy (noisy

respirations) Bubbles of mucus in trachea Coughing up secretions Patient requests to be suctioned Respiratory distress due to airway obstruction.

 COMPLICATIONS

Hypoxia
Bronchospasm Cardiac dysrhythmias

Hypotension
Tracheal trauma Infection/sepsis

Cardiac arrest

 Nasogastric

(NG) tube Gastrostomy tube Saline/Heparin lock Foley Catheter Tracheostomy tube Ventricular assist device Surgical drains Medical Patches
Excluded are thoracostomy (chest) tubes

 Nasogastric

(NG) tube

Clamp tubing Secure the tube and avoid tension or kinks in the

tubing
Gastrostomy

tube (GT)

Clamp tubing Secure the tube and avoid tension or kinks in the

tubing

 Heparin/saline

locks

Monitor for dislodgement and bleeding Ensure locks are taped securely prior to transport
Foley

catheter

Keep bag below level of the bladder Secure the tube and avoid tension or kinks in the

tubing Empty the drainage bag prior to transport

Document the amount emptied

 Tracheostomy

tube

Monitor for secretions - if necessary, suction Monitor for adequate air exchange - place in

position to facilitate air exchange (semi or high Fowlers.) Ensure that an obturator or new trach tube accompanies the patient - needed in case of dislodgement. Check to see that the trach ties are secure, have hospital personnel/caregiver adjust if necessary

 Tracheostomy

tube

If secretions are present, suction patient

 Ventricular

Assist Devices

VADs are implanted devices that is a pump that

may partially or completely replace the function of the heart

All

VAD patients have a VAD team member who is available 24 hours a day.
The contact number is listed on a sticker on the

patients controller

 Ventricular

Assist Devices: Assessment and Treatment

Depending on the device, a pulse or BP may not

be obtainable
Use other means to assess the patient.

These patients are on anticoagulants and are

prone to bleeding. If patient is in cardiac arrest: DO NOT start compressions, it may dislodge the VAD
Call the VAD team member for further instructions

 Ventricular

Assist Devices

Take ALL equipment to the hospital. The patients family receive training in the specific VAD that the patient may have and are good resources which should be utilized if possible.
Take them in the ambulance when ever you can

 Surgical

Drains

Drains pus, blood & other fluids Use clean technique around drain to prevent

introducing bacteria Ensure drain apparatus is secured to prevent accidental dislodgement of drain Keep gravity drains at the appropriate level for proper functioning

Common Surgical Drains

Jackson-Pratt drains -- clear plastic bulb that

creates suction when emptied of fluid and air. Used in abdominal, breast, mastectomy and thoracic surgery.

continued

Common Surgical Drains

Hemovac wound suction device that provides

negative suction pressure when compressed.

continued

Common Surgical Drains

Penrose drain -- soft rubber tube which is placed

in a wound to prevent the build-up of fluid.

continued

Common Surgical Drains

Negative pressure wound therapy
Also called topical negative pressure, subatmospheric pressure dressings or vacuum sealing technique. Is an enclosed foam dressing and suction device used to promote healing in acute or chronic wounds and burns A vacuum source is used to create subatmospheric pressure in the wound.

 Medication

Patches

Prevent touching the adhesive surface or getting

the medication on your hands

Medication can be absorbed if you come into contact with it

Place a loose patch in a plastic closed container

and transport with the patient

All patches contain residual medication that could harm unprotected individuals

 Allow

patient to self-administer prescribed medications in the presence of BLS providers Assist patient in taking prescribed medications if patient has difficulty with self-administration Administer prescribed medication to the patient if patient is physically incapable of administering the medication

 Medication

is for emergency treatment Medication is prescribed by a physician Medication is prescribed for the patient Meets indication for administration No contraindications are present
EMTs may only assist with physician prescribed emergency medications for the relief of acute symptoms or a current emergency condition

 Administration

of these medications is for emergency supportive therapy only and not a substitute for immediate medical care If medication assistance is rendered, an ALS unit must be enroute or the patient must be transported immediately to the most appropriate receiving facility

 Verify

the patients prescription (prescribed for the patient) Check name of medication Check dose and route of medication Check the expiration date Check integrity of container Check the condition of the medication; clarity of solution, impurities, or intact tablet

 Repeat

initial assessment Repeat vital signs Assess response to medication Assess for adverse/side effects

 EMTs

may assist with include but are not limited to:

Nitroglycerin tablets or spray Up to 3 doses if blood pressure is maintained at 100mmHg(includes any patient self-administered doses) Bronchodilator Inhaler or nebulizer (one dose) If patient is alert enough to use inhaler Epinephrine Auto-Injector as prescribed for s/s of

severe allergic reactions or asthma (one dose)

 Trade

Names: Nitrolingual Spray, Nitrobid, Nitrostat, ect Classification:

Vasodilator
Actions

Dilates blood vessels and coronary arteries Decreases the workload of the heart
Indications

Chest pain

 Contraindications

Blood pressure below 100 systolic Patient has taken 3 doses prior to the arrival of

EMTs Sexually enhancing/erectile dysfunction drugs taken within 48 hours

 Adverse

effects

Cardiovascular: hypotension, bradycardia, reflex

tachycardia, rebound hypertension Neurological: headache dizziness/faintness, confusion, blurred vision Gastrointestinal : nausea/vomiting General: flushed skin, dry mouth, sublingual burning

 Administration

EMTs are not authorized to carry NTG, but may

assist patients with their own physician prescribed medication. Tablet 1 tablet (1/150gr or 0.4mg) SL Spray 1 spray (0.4mg) SL or TM (transmucosal)
Do Not Shake container shaking alters the dose
Onset

1-3 minutes

 Directions

for Administering Nitroglycerin

Tablets
Place or have patient place tablet under tongue Instruct patient not to swallow, but to allow tablet

to dissolve under tongue. Retake blood pressure and pulse after 5 minutes. If hypotension develops, place patient in shock position.

 Directions

for Administering Nitroglycerin

Aerosol
DO NOT shake container. Administer or have patient spray on or under the

tongue. Retake blood pressure and pulse after 5 minutes. If hypotension develops, place patient in shock position.

 Trade

Names: Proventil, Ventolin, Bronchometer, Bronkosol, Alupent, Metaprel Actions

Dilates bronchioles Reduces airway resistance

 Indications

Bronchospasm caused by: Acute asthma Near drowning COPD Drug overdose Bronchitis Pulmonary edema Toxic gas inhalation Crush syndrome, Suspected hyperkalemia,

Crush force > 4 hours

 Contraindications

Maximum prescribed inhalation dose already

taken by patient Inhaler not prescribed for patient

Adverse

Effects:

Cardiovascular: tachycardia, hypertension Neurological: ,headache, tremors, nervousness,

dizziness Respiratory: cough, wheezing

 Administration

EMTs may only add a unit dose to the nebulizer

when assisting the patient with preparing a nebulizer

May NOT draw up medication from a multi-dose vial to add to the nebulizer

 Administration:

1 spray inhaled using the metered dose inhaler

with or without a spacer device. May repeat 1 spray in 3-5 minutes one time. Pediatric
< 12 years Not recommended for prehospital use > 12 years Same as adult
Onset

Within 5 minutes

 Precautions:

Hypoxic patients may experience dysrhythmias.

Monitor pulse periodically for irregularity. Administer supplemental O2 before and after treatment to decrease hypoxemia.

 Shake

container vigorously several times. Instruct patient to:

Exhale deeply and place lips around mouthpiece. Take a slow, deep breath and depress the medication

canister while patient inhales. Remove mouthpiece and hold breath for as long as possible. Exhale slowly through pursed lips.
Replace

O2 and reevaluate breath sounds. Repeat procedure one time if needed.

Shake container vigorously several times. Remove cap from spacer and attach spacer to inhaler. Instruct patient to:

Exhale deeply and place lips around mouthpiece. Depress the medication canister to fill the spacer chamber. Take several slow, deep breaths to inhale medication in spacer. (Whistling sound may be present if patient inhales too rapidly.) Remove mouthpiece and hold breath for as long as possible. Exhale slowly through pursed lips.

Replace O2 and reevaluate breath sounds. Repeat procedure one time if needed.

EPIPEN AUTO-INJECTOR

 Trade

Name: Adrenalin Actions

Dilates bronchioles and constricts blood vessels
Indications:

Severe asthma Signs and symptoms of anaphylaxis (severe

allergic reaction)
Flushed skin, tachycardia, thready or unobtainable pulse, hypotension, wheezing, stridor, dyspnea, itching, rash or hives and generalized edema

 Contraindications:

Patient unconscious
Adverse

effects

Cardiovascular: tachycardia, hypertension, chest

pain, ventricular fibrillation Neurological: seizures, cerebral hemorrhage, headache, Tremors, dizziness Gastrointestinal: anxiety, nausea/vomiting

 Administration

EMTs are not authorized to carry, but may assist

patients with their own prescribed device. EpiPen Auto-Injector (0.3mg) IM in the upperouter thigh. No repeat. Pediatric: EpiPen Jr. Auto-Injector (0.15mg) IM in the upper-outer thigh. No repeat.
Onset:

5-10 minutes

 Precautions

DO NOT INJECT INTO BUTTOCKS, HANDS,

FEET, OR ADMINISTER INTRAVENOUSLY.

Injection into buttocks, hands or feet may result in loss of blood flow to the affected area and tissue necrosis. Result in delayed absorption Intravenous injection may result in an acute myocardial infarction or cerebral hemorrhage.

 Precautions

Outdated Epipen may be chemically altered and

may lose its potency or result in muscle damage.

Note

The EpiPen contains 2ml (2mg) of epinephrine.

The Auto-Injector delivers 0.3ml (0.3mg); approximately 1.7ml remains in the pen after activation.

 Pull

off gray safety cap. Cleanse site with alcohol swab.** Place black tip on the upper-outer thigh, at right angle to the leg. Press hard into thigh until Auto-Injector activates and hold in place for several seconds. Massage the injection site for 10 seconds with alcohol swab.

 Glucose

Solutions Normal Saline Lactated Ringers Solution In Los Angeles County, ONLY these solutions may be transported by EMTs; all other solutions require ALS transport.

 IV

solutions must be either TKO or at a preset rate EMTs may re-adjust rates in case the IV flow changes from preset rate. If signs of infiltration occur during transport, the infusion should be turned off EMTs are NOT allowed to discontinue IV catheters.

 Flow

rate may either slow significantly or stop IV site becomes cool and hard to the touch IV site or extremity may become pale & swollen Patient may complain of pain, tenderness, burning or irritation at the IV site There may be noted fluid leakage around the site

 Pre-Existing

Vascular Access Device Peripheral Inserted Central Catheter (PICC) lines Excluded are central venous catheter (CVP) monitoring devices, arterial lines and Swan Ganz catheters

 Is

inserted into a central vein for long term IV therapy and/or hemodialysis
Use clean technique around the catheter to

prevent infection of site Ensure that device is secured to prevent accidental dislodgement Common pre-existing access devices:
Hickman catheter Broviac catheter Groshong catheter

 Used

for administration of chemotherapy or other medications, withdrawal of blood for analysis and some types are used mainly for dialysis

 Similar

to a Hickman and used for the same purpose, but has a smaller lumen and is used for children

 Similar

to a Hickman and Broviac catheter. It has a three-way valve which opens outward during infusion, and opens inward during blood aspiration. When not being accessed, the valve remains closed.

 Long

catheter inserted in a peripheral vein and advanced through increasingly larger veins, toward the heart until the tip rests in the superior vena cava.

 Used

for long term infusion (up to 6 months) to infuse chemotherapy, medications, blood products, fluids and IV nutrition. Use clean technique around the catheter to prevent infection of site Ensure that PICC line is secured to prevent accidental dislodgement

 Central

Venous Pressure (CVP) monitoring

device
CVP manometer must be disconnected prior to

transport. The manometer may be dislodged or connections loosened during transport resulting in bleeding and possible air emboli. Removing the CVP manometer converts the IV line to an indwelling vascular access line.
Continued

 Arterial

lines and Swan Ganz catheters

These are placed in patients who are medically

unstable and require close monitoring. These patients require a nurse transport team.
Chest

tubes

Chest tubes whether to suction or clamped may

pull out or develop clots which may result in a tension pneumothorax or hemothorax. Therefore, this transport is an ALS transport.

 Folic

acid - 1mg/1000ml Multivitamins - 1 vial/1000ml Magnesium Sulfate-2 gms/1000ml and only in conjunction with multivitamins Thiamine - 100mg/1000ml

 These

additives are nutritional supplements used to correct vitamin and mineral deficiencies Several of these additives may be mixed in one IV bag; check bag for additives and appropriate concentrations for each additive.

 Potassium

chloride - 20mEq/1000ml Total Parenteral Nutrition (TPN)

 These

additives/solutions may not be transported without an infusion pump and specific precautions followed.
All rates must be preset by hospital/home health

personnel whether the pump is supplied by BLS provider, hospital, or from home. If the pump is supplied by the hospital or from home, the hospital/home health personnel must instruct EMTs in the operation of the pump in case of infiltration or fluid overload.

 Any

prescribed medication with an automated or patient operated pump Any prescribed pain medication via a patient controlled analgesia (PCA) pump Most common
Insulin Meperidine HCL (Demerol) Morphine Sulfate

 Pumps

may be either implanted or external. PCA pumps must be on a locked setting and may only be activated by the patient or caregiver. EMTs are NOT allowed to activate or adjust rates for these IV delivery systems.

 Pregnant

or nursing mothers should defer patient care to partner Protective clothing should be worn when caring for patient
Exposure to chemotherapeutic agents places the

provider at risk for developing cancer, genetic damage and may cause birth defects Protective clothing consist of: latex or nitrile gloves that are at least 0.007 inch thick and gown; lintfree, low permeability fabric, closed front, long sleeves and tight-fitting cuffs

 Exposure

places the provider at risk for developing cancer, genetic damage, and may cause birth defects.
Pregnant or nursing mothers should defer patient

care to partner.
Protective

clothing should be worn when caring for patient

Latex or nitrile gloves that are at least 0.007 inch

thick and gown; lint-free, low permeability fabric, closed front, long sleeves and tight-fitting cuffs

 Immediate

first aid treatment is required for

exposure
Contact with some chemotherapeutic agents may

cause irritation, burning and tissue destruction. Skin -- wash immediately with soap and water Eyes-- flush with normal saline solution for 5 minutes
***All exposures must be reported and evaluated by a physician*** Chemotherapy Spill on Hand

 All

soiled linens, dressings and absorbent padding must be disposed of separately and not placed in regular waste containers
Chemotherapeutic agents are excreted in body

fluids.

 Use

either the Los Angeles County EMS Report form to document medications administered by the patient or the EMT, IV solution with medication additives, and if on an infusion pump.

 Document

in the Comments Section of the form, including vital signs that are pertinent for medication administration. DO NOT document in the Drugs/EKG section.

 Patient

Problem (indication) Vital Signs Name of the medication, dose, concentration and route of administration and describe the injection site.
Document if patient self-administered the

medication or if the patient required assistance with the medication.

Patients

response to the medication

 Type

of IV solution infusing Medication and concentration of additive Flow rate of solution Complications and treatment, if pertinent

 Type

of infusion pump Medication and concentration of medication Preset flow rate Complications and treatment, if pertinent