Medical
- Allergic Reaction - REACTION Format
- Hypoglycemia - Maryland Format
- Diabetic Emergency
- Cardiac Arrest - NC Format
- Pain Management - James Format
- Epistaxis
- Abuse / Neglect
Allergic Reaction - REACTION Format
This policy applies to: Patients whose chief complaint is itching, rash or allergic reaction.
Exclusion Criteria: None
Recognize
- Itching, hives, flushing, angioedema
- Coughing, wheezing, stridor, or respiratory distress
- Chest or throat constriction
- Difficulty swallowing
- Difficulty phonating
- Nausea / vomiting
- Altered Mental Status
- Hypotension or shock
- Edema
Evaluate
- Onset and trajectory of symptoms
- Anatomic and situational location of exposure
- Insect sting or bite
- Known allergies: food, environmental, medication, other
- Known or suspected exposure: past occurrences and current event
- Known history of sensitivity or allergic reaction
- Past medical and medication history
- New clothing, soap, or detergent
- New medications
Administer Treatment
- Remove allergy trigger if known and present
- Prioritize interventions based on clinical presentation and severity of reaction
- Supplemental oxygen PRN for goal SpO2
- Attentive and prompt airway assessment and management
- Airway Management if indicated per Airway Management PCG (P1)
- If patient has suspected or known exposure and exhibits signs of any: respiratory distress, airway
restriction, altered mental status or shock, treat accordingly-
- Epinephrine Auto-Injector 0.3 mg IM if available
- Vascular access per Vascular Access PCG
- Consider crystalloid fluid bolus 500 mL IV/IO to support hemodynamics, repeat PRN
- Diphenhydramine (Benadryl) 50 mg IM/IV/IO
- Epinephrine (1mg/1mL) 0.3 mg IM or Epinephrine (1mg/10mL) 0.1 mg IV/IO q 3 min PRN for
MORE SEVERE REACTION-
- Consider Epinephrine infusion 0.01 mcg/kg/min IV/IO, titrate to max 0.1 mcg/kg/min
as an alternative to repeat IM or IV/IO doses - Monitor ECG rhythm closely, Epinephrine may potentiate arrhythmias, especially in
patients over the age of 40
- Consider Epinephrine infusion 0.01 mcg/kg/min IV/IO, titrate to max 0.1 mcg/kg/min
-
- Methylprednisolone (Solu-Medrol) 125 mg IV/IO
- Albuterol (2.5 mg/3 mL) nebulized for wheezing or shortness of breath
-
Consider Differentials
- Urticaria (rash only)
- Anaphylaxis (severe systemic effect)
- Shock (severe vascular effect)
- Angioedema (drug induced or infection)
- Aspiration / airway obstruction
- Vasovagal event
- Asthma or COPD
- Infection (ex: retropharyngeal abscess, bacterial tracheitis, croup, epiglottitis, strep)
- Pulmonary edema or CHF
- Metabolic disorders
Transport Considerations
- During transport, maintain astute airway, breathing, circulation and mental status assessment with
prompt intervention as needed. Stability can quickly change to instability in these patients. - Consider early airway management, reference Airway Management PCG (P1)
Information
- Typically, the shorter the interval from exposure to symptoms, the more severe the reaction
- Hemodynamic instability may recur up to 24 hours after initial stabilization
Other Populations
- Neonatal/ Pediatric drug dosing:
-
- Pediatric Epinephrine Auto-Injector JR dose is 0.15 mg for patients 15-30 Kg
- Diphenhydramine (Benadryl) 1 mg/Kg IM/IV/IO over 5 min max dose 50 mg
- Epinephrine (1mg/1mL) 0.01 mg/Kg IM/IV/IO q3 min until stable or infusion started
-
- Max 0.5 mg per dose (Intentionally larger than adult dosing)
- Epinephrine infusion 0.01 mcg/Kg/min IV/IO, titrate to max 1 mcg/kg/min
-
- Methylprednisolone (Solu-Medrol) 2 mg/Kg IV/IO max dose 125mg
- Albuterol for 15 Kg or more, use adult dose
- Albuterol for less than 15 Kg (1.25mg/ 3ml) nebulized with O2 at 6 lpm
-
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References
Campbell, Ronna. “Anaphylaxis: Emergency Treatment.” UpToDate, January 2022.
Sicherer, Scott. “Prescribing Epinephrine for Anaphylaxis Self-Treatment.” UpToDate, January 2022.
“U.S. Army Medevac Critical Care Flight Paramedic Standard Medical Operating Guidelines.” Jan. 2020.
Hypoglycemia - Maryland Format
Applies to: Blood glucose less than 70 mg/dL or greater than 300 mg/dL
- Patient-reported low or high blood glucose
- Diabetic patients with other medical symptoms (e.g., vomiting)
- Altered mental status
- Alcohol intoxication, suspected
- Seizure
- Stroke symptoms
- Unresponsive patients
- Cardiac arrest
BLS
- Check blood glucose level
- If blood glucose is less than 70 mg/dL, administer 10-15 grams of oral glucose between the patient’s gum and cheek.
- Administer additional dose of 10-15 grams of oral glucose if not improved after 10 minutes.
ALS
- HYPOglycemia: If blood glucose is less than 70 mg/dL, administer 10% dextrose in 50 mL (5 gram) boluses, 1 minute apart, to a maximum of 250 mL OR 25 grams of 50% dextrose IVP, until:
- the patient has a return to normal mental status, and
- the patient’s blood glucose is at least 90 mg/dL
- If patient has persistently altered mental status and blood glucose less than 90 mg/dL despite treatment, repeat dosing regimen above.
- If unable to initiate an IV and blood glucose is less than 70 mg/dL, administer glucagon 1 mg IM/IN.
- If the patient has persistently altered mental status and blood glucose less than 90
mg/dL at 15 minutes, transport to the hospital should not be delayed.
- If the patient has persistently altered mental status and blood glucose less than 90
- HYPERglycemia: If blood glucose is greater than 300 mg/dL, administer 10 mL/kg Lactated Ringer’s bolus unless rales, wheezing, pedal edema, or history of renal failure or CHF is present.
MC
- Not Applicable
Diabetic Emergency
Applies to: Blood glucose less than 70 mg/dL or greater than 300 mg/dL and
- Patient-reported low or high blood glucose
- Diabetic patients with other medical symptoms (e.g., vomiting)
- Altered mental status
- Alcohol intoxication, suspected
- Seizure
- Stroke symptoms
- Unresponsive patients
- Cardiac arrest
Exclusion Criteria: None
History
- Past medical history
- Medications
- Drug allergies
- Last Meal
- Last BGA check
Signs and Symptoms
- Altered mental status
- Combative / irritable
- Diaphoresis
- Seizures
- Abdominal pain
- Nausea / vomiting
- Weakness
- Dehydration
- Deep / rapid breathing
Differentials
- Alcohol / drug use
- Toxic ingestion
- Trauma; head injury
- Seizure
- CVA
- Altered baseline mental status
Pearls
- Patient’s refusing transport to medical facility after treatment of hypoglycemia:
- Blood sugar must be ≥ 80, patient has ability to eat and availability of food with responders on scene.
- Patient must have known history of diabetes and not taking any oral diabetic agents.
- Patient returns to normal mental status and has a normal neurological exam with no new neurological deficits.
- Must demonstrate capacity to make informed health care decisions. See Universal Patient Care Protocol UP-1.
Otherwise contact medical control.
- Hypoglycemia with Oral Agents:
- Patient’s taking oral diabetic medications should be encouraged to allow transportation to a medical facility.
They are at risk of recurrent hypoglycemia that can be delayed for hours and require close monitoring even after
normal blood glucose is established. - Not all oral agents have prolonged action so Contact Medical Control or NC Poison Control Center for advice.
Patient’s who meet criteria to refuse care should be instructed to contact their physician immediately and
consume a meal.
- Patient’s taking oral diabetic medications should be encouraged to allow transportation to a medical facility.
- Hypoglycemia with Insulin Agents
- Many forms of insulin now exist. Longer acting insulin places the patient at risk of recurrent hypoglycemia even
after a normal blood glucose is established. - Not all insulins have prolonged action so Contact Medical Control for advice.
- Patient’s who meet criteria to refuse care should be instructed to contact their physician immediately and
consume a meal.
- Many forms of insulin now exist. Longer acting insulin places the patient at risk of recurrent hypoglycemia even
- Congestive Heart Failure patients who have Blood Glucose > 250:
- Limit fluid boluses unless patient has signs of volume depletion such as, dehydration, poor perfusion,
hypotension, and/ or shock.
- Limit fluid boluses unless patient has signs of volume depletion such as, dehydration, poor perfusion,
- In extreme circumstances with no IV / IO access and no response to glucagon, D50 can be administered rectally,
Contact Medical Control for advice.
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References
Protocols
Pharmacology
- Dextrose 10%
- Dextrose 50%
- Glucagon
- Glucose
Procedures
- Vascular Access
Cardiac Arrest - NC Format
Protocols Referenced
Medications Referenced
Naloxone
Procedures Referenced
Pain Management - James Format
Applies to: Patient presents with a painful condition that would benefit from treatment with an analgesic. This
includes DNR/MOLST patients and patients being pre-medicated for a painful procedure.
Exclusion Criteria: Medication specific hypersensitivity/allergy. Active Labor.
History
- Age
- Location
- Duration
- Severity (1 - 10)
- If child use Wong-Baker faces scale
- Past medical history
- Medications
- Drug allergies
Signs and Symptoms
- Severity (Pain scale)
- Quality
- Radiation
- Relation to movement
- Respirations
- Reproducible
- Increased upon palpation
Differentials
- Per the specific protocol
- Musculoskeletal
- Visceral (abdominal)
- Cardiac
- Pleural/ Respiratory
- Neurogenic
- Renal (colic)
Pearls
- Do not administer Acetaminophen to patients with history of liver disease or known to have consumed large amounts of ETOH.
- Fentanyl, Morphine and Ketamine should be reserved for acute pain.
- For patients in Moderate pain for instance, you may use the combination of an oral medication and parenteral if no contraindications are present.
- Ketamine
- May use Ketamine in combination with opioids to limit total amount of opioid administration
- Avoid in patients who have cardiac disease or uncontrolled hypertension.
- Avoid in patients with increased intraocular pressure such as glaucoma.
- Avoid use in combination with benzodiazepines due to depressed respiratory drive
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References
Protocols
- Nausea / Vomiting
Pharmacology
- Fentanyl
- Morphine
- Ketamine
- Acetaminophen
- Ofirmev
- Ibuprofen
Procedures
- Vascular Access
- Pain Assessment
Epistaxis
This policy applies to: Patients whose chief complaint is severe or prolonged bleeding from the nose.
Exclusion Criteria: Patients with respiratory compromise may first require airway control and mechanical ventilation. Patients with hemodynamic compromise may first require volume and blood product resuscitation.
Recognize
- Severity of Bleeding
- Airway patency
- Distress or Anxiety
- Blood Thinners / Coagulopathies
- Hemodynamic status
- Facial trauma
- Environmental factors
Evaluate
- Medical History and Medications
- Airway patency
- Circulatory status
- Bleeding disorders
- Estimate Blood Loss
- Pain
Administer Treatment
- Patient positioning
- Place patient in an upright sitting position with a forward lean to prevent ingestion or aspiration of blood.
- Apply direct pressure to the soft part of the nose.
- Provide oral suctioning as needed.
- Manage hypovolemia / shock as indicated.
- Manage airway as indicated
- Consider Zofran IV/IO for nausea associated with blood ingestion. Avoid PO administration.
- Consider analgesia.
- Consider mild sedation due to risk of increased bleeding from anxiety associate hypertension.
- If bleeding unresolved via direct pressure consider nasal packing.
- Prepare mixture of:
- 1ml Epinephrine 1:1000
- 1ml Lidocaine HCl 2%
- For patients with Cardiovascular disease or uncontrolled hypertension:
- Apply TXA as needed to soft rolled gauze or a commercial nasal packing device till wet.
- Begin packing affected nares.
- For all else:
- Administer 1ml of mixture to each affected nare via nasal atomizer. Using gauze to prevent leaking after administration.
- Begin packing affected nares either with moistened soft rolled gauze or a commercial nasal packing device.
- Administer 1ml of mixture to each affected nare via nasal atomizer. Using gauze to prevent leaking after administration.
- Consider IV/IO opioids for pain management. Avoid PO administration.
- Prepare mixture of:
Consider Differentials
- Facial Fractures
- Uncontrolled Hypertension
- Illicit drug use
- Bleeding Disorders
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References
Protocols
Medications
Procedures
Resources
Abuse / Neglect
This policy applies to: Patients who are suspected of being victims of abuse or neglect.
Exclusion Criteria: None
Recognize
- Injuries or burns in a pattern suggestive of intentional infliction.
- Injuries in various stages of healing or injuries scattered over multiple areas of the body.
- Patient, parent, or caregiver responding in an inappropriate manner to the situation.
- Malnutrition of extreme lack of cleanliness of the patient or environment.
- Infants: bulging of fontanels and altered mental status.
Evaluate
Administer Treatment
- Stabilize and treat injuries according to the appropriate protocol.
- Discourage patient from washing if sexual abuse is suspected.
- Document:
- All statements made by the patient, parent or caregiver.
- Any abnormal behavior on the part of the patient, parent or caregiver.
- The condition of the environment.
- Time and name of contact when reported to Adult Protective Services.
- Report all suspected cases of abuse / neglect to protective services. Do not initiate report in front of the patient, parent or caregiver.
Consider Differentials
- Not applicable
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References
Protocols
Medications
Procedures
Resources
Adult Protective Services phone: 1-800-252-5400