Upper airway obstruction pediatric

Massachusetts Department of Public Health

Office of Emergency Medical Services

This document format is released in compliance with ADA requirements, and contains the complete text of this protocols, compatible with screen readers, and is not designed for use in the field or reference. This does not have the formatting and color direction of the PDF protocols. If printing or making protocols available to field providers, please use the PDF format, for easy reference.

Massachusetts Department of Public Health Office of Emergency Medical Services Statewide Treatment Protocols Version 2019.2

Legend Definition

First Responder (FR) -- Found only in protocols 2.2A, 2.2P, 2.9, and 2.14 Emergency Medical Technician (EMT)
Advanced Emergency Medical Technician (AEMT)
Paramedic
(RED FLAG) CAUTION – Red Flag topic

These protocols are developed and approved by the Department of Public Health, based on the recommendations of Emergency Medical Care Advisory Board (EMCAB) and its Medical Services Committee (MSC). For the latest corrections or addenda, see the OEMS website at
http://www.mass.gov/dph/oems

These are Massachusetts Statewide Treatment Protocols; they are the standard of EMS patient care in Massachusetts.

Massachusetts Pre-Hospital Statewide Treatment Protocols 2019.2 Table of Contents

(Alphabetical order by section) Protocol ID

Massachusetts Pre-Hospital Statewide Treatment Protocols 2019.2- Table of Contents

(Alphabetical order by section) Protocol ID

Massachusetts Pre-Hospital Statewide Treatment Protocols 2019.2- Table of Contents

(Alphabetical order by section) Protocol ID

Massachusetts Department of Public Health Office of Emergency Medical Services Statewide Treatment Protocols Version 2019.2

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PATIENT CARE

Statewide Treatment Protocols

NOTE: This protocol applies to all EMS calls.

RESPOND TO SCENE IN A SAFE MANNER:
 Review dispatch information.

Number of patients. 
 Determine need for additional resources.

 Utilize Mass Casualty Incident (MCI) and/or Incident Command System (ICS) procedures as necessary. Determine mechanism of injury/illness.

 Begin assessment and care at the side of the patient; avoid delay.

 Bring all necessary equipment to the patient in order to function at your level of certification and up to the level of the ambulance service license.

 Determine patient’s hemodynamic stability, symptoms, level of consciousness, ABCs, vital signs.

Maintain an open airway and assist ventilations as needed.
 Apply the cardiac monitor and obtain a 12-lead ECG tracing as soon as possible when clinically appropriate and within your scope of practice.

compromised, or have the potential to become compromised. For pediatric patients, a 20mL/kg fluid

bolus if applicable.

should also have IV access established if possible to do so.

ASSESSMENT AND TREATMENT PRIORITIES (CONTINUED)

 Ventilation rates are to be titrated to goal ETCO2 recommendations.

 Use quantitative, recordable waveform capnography for all patients with advanced airway

detrimental and to ensure quality ventilation and oxygenation. In general this means that capno-

ETCO2 values should be kept between 35-40 mm Hg in these patients; specific exceptions should be

 Obtain a complete medical history (S-A-M-P-L-E).

 Obtain venous blood samples according to the receiving hospital policies.

may include repeat doses of medications within the standing orders.

 Follow service or regional policies for all radio or communication failures.

Statewide Treatment Protocols Version 2019.2

 If no palpable, distal pulse is present following suspected extremity fracture, position injured extremity in correct anatomic position, and apply gentle traction along the axis of the extremity distal to the injury until the distal pulse is palpable and immobilize in place. Note: This does not apply to dislocations.

 If patient care requires the removal of any of the restraining straps, re-secure them as soon as practical to do so.

 Pediatric patients are to be transported in a properly secured child transport device/seat if spinal injury is not suspected (See 7.4 Pediatric Transport for more).

 Additional data elements may be collected at the request of your Affiliate Hospital Medical Director.

This data may pertain to, but is not limited to; trauma, cardiac arrest, stroke and infectious disease processes.

 Securely maintain and store all medications and fluids at the appropriate temperatures as designated by manufacturer’s recommendations and in accordance with all Drug Control Program regulations. Pharmaceutical shortages and supply chain issues have become more frequent. The Department will issue Advisories addressing these shortages and outlining alternative therapies when needed.

 All EMTs and service providers must adhere to all advisories, memos and administrative requirements issued by the Department regardless of the topic.

 On occasion, good medical practice and the needs of patient care may require deviations from these protocols, as no protocol can anticipate every clinical situation. In those circumstances, EMS personnel deviating from the protocols should only take such actions as allowed by their training and only in conjunction with their on-line medical control physician.

 Any such deviations must be reviewed by the appropriate local medical director, but for regulatory purposes are considered to be appropriate actions, and therefore within the scope of the protocols, unless determined otherwise on Department review by the State EMS Medical Director.

 All patients with an advanced airway in place must have recordable waveform capnography documented.

 Documentation on the patient care report must include at least three evidence based methods of verification of tube placement (one being capnography) and must include at least three separate times

 Transport to the nearest appropriate treatment facility as defined in EMS regulations. In rare

circumstances, delayed transport may occur when necessary treatment cannot be performed during

regulations and Department-approved point-of-entry (POE) plans.

 There are currently Department-approved condition-specific POE plans for trauma, stroke and STEMI,

 EMS personnel may call medical control if they have a question about POE.

 Notify receiving facility as early as possible.

require that hospital physicians providing medical direction must be knowledgeable in the

communication system and its usage and must know the Statewide Treatment Protocols for each level

 Ambulance services with their medical directors must develop and implement a comprehensive and

dynamic quality assurance program in accordance with the ambulance service’s affiliation agreement.

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Massachusetts Department of Public Health Office of Emergency Medical Services

 Perform 2 minutes cycles of uninterrupted chest compressions

 Interrupt chest compressions only after each 2 minute cycle

 1.0 Routine Patient Care -with focus on HQCPR

 Immediate chest compressions at a rate of 100-120 per minute

ADVANCED EMT STANDING ORDERS

 Consider placement of a supraglottic airway device

 Provide manual defibrillation as indicated after each 2 minute cycle

 After 4 cycles (8 minutes):

 Rate of 8-12 breaths per minute

 Tidal volume 300-500mL

minutes after start of resuscitation even if ROSC has occurred.

PEARLS:

 Minimize interruptions in chest compression, as pauses rapidly return the blood pressure to zero and stop perfusion to the heart and brain.

 Recognizing the goal of immediate uninterrupted chest compressions, consider delaying application of mechanical CPR devices until after the first four cycles (8 minutes). If applied during the first 4 cycles, the goal is to limit interruptions. Mechanical devices should only be used by services that are practiced and skilled at their application.

Statewide Treatment Protocols Version 2019.2

2.1 Adrenal Insufficiency/Adrenal Crisis - Adult and Pediatric EMT STANDING ORDERS—Adult & Pediatric

 Obtain vascular access, if appropriate.

Massachusetts Department of Public Health Office of Emergency Medical Services

methylprednisolone 125mg IV/IO/IM.

 Pediatric: History of adrenal insufficiency; administer hydrocortisone 2mg/kg, to a maximum of 100mg

repeat stress dose orders:

o Nausea, vomiting, weakness, dizzy, abdominal pain, muscle pain, dehydration, hypotension,

o Normalize body temperature.

Clinical notes:

 Congenital or acquired disorders of the adrenal gland.

 Congenital or acquired disorders of the pituitary gland.

Clinical notes:

A “stress dose” of hydrocortisone should be given to patients with known chronic adrenal insufficiency

 Fever >100.4°F and ill-appearing.

 Multi-system trauma.

 Respiratory distress.

 2nd or 3rd degree burns >5% BSA.

FIRST RESPONDER/EMT STANDING ORDERS

 1.0 Routine Patient Care

 Albuterol 2.5mg via nebulizer. Repeat every 5 minutes up to 4 doses.

 If approved, epinephrine 1:1,000 0.3 mg IM-ONLY

 Diphenhydramine 25-50 mg IV/IO/IM

MEDICAL CONTROL MAY ORDER

90mmHg.

Epinephrine for BLS Providers.

NOTE: Mild Distress is defined by: itching, urticaria, nausea, and no respiratory distress.