AIRWAY OBSTRUCTION

BLS / ALS

1. Determine responsiveness and ability to speak.

2. Position patient to open airway:

• If unconscious: use head tilt/chin lift.
• If possible c-spine injury: use modified jaw thrust.

3. Assess breathlessness/degree of airway impairment.

4. Monitor for:

• Cardiac dysrhythmia and/or arrest.

5. Complete Initial Medical Care:
Do not interfere with patient's own attempts to clear airway.

5.	5 abdominal thrusts (Heimlich maneuver) with patient standing or sitting. 5 chest thrusts if patient in 2nd-3rd trimester of pregnancy or morbidly obese. 5 back blows with head down, and 5 chest thrusts in infants < 1 year of age. REPEAT IF NO RESPONSE.

6. If successful: complete Initial Medical Care and transport.

7. Still obstructed:
While enroute to the hospital, continue any of the steps in 5 you are reasonably able to perform.

Note: Any time the efforts to clear the airway are successful, complete Initial Medical Care and transport.

8. Attempt to ventilate. If obstructed:

• Attempt to clear airway by using the finger sweep method unless contraindicated (consider suction)
• If still obstructed and unconscious, repeat above steps until airway is clear.

9. Visualize airway with laryngoscope and attempt to clear using forceps and/or suction.

10. Still obstructed: Attempt forced ventilation.

11. Still obstructed: INTUBATE and push foreign body into right mainstream bronchus, then pull back tube and ventilate left lung.

12. Still obstructed: Perform cricothyroidotomy.

Transport and ventilate with 100% oxygen/BVM

CONSCIOUS SEDATION - VERSED

ALS

1. Initial Medical Care. The following are situations which may require use of this protocol prior to intubation:

• Glasgow Coma Score < 8.
• Imminent respiratory arrest.
• Imminent tracheal/laryngeal closure due to severe edema secondary to trauma or allergic process.
• Severe flail chest and/or severe open chest wounds with cyanosis and a respiratory rate > 30 or < 10.

ALWAYS HAVE CRICOTHYROIDOTOMY EQUIPMENT AVAILABLE

2. Prepare patient and equipment for procedure:

• Position patient in sniffing position unless contraindicated (c-spine).
• Have suction with tonsilar (Yankauer) or other rigid tip ready.
• Prepare all intubation and cricothyroidotomy equipment per procedure manual.
• Ventilate patient prior to procedure.

• Continue to assist ventilations during this procedure.
• Spray posterior pharynx with BENZOCAINE (1-2 second spray, 30 seconds apart x 2 )
• VERSED 4 mg IVP, followed by VERSED 2 mg IVP increments up to 10 mg total until sedation achieved.
• Depress and hold cricoid ring (Sellick’s maneuver.)
• Attempt oral or oral in-line intubation via System protocol.
• Once intubation has occurred, check breath and epigastric sounds carefully.
• ETCO₂ detector / positube per system policy
• Secure ETT and reassess breath sounds.
• VERSED in 2 mg IVP increments up to 10 mg total as necessary for post-intubation sedation

PEDIATRICS

• Continue to assist ventilations during this procedure
• Spray posterior pharynx with BENZOCAINE (1-2 second spray, 30 seconds apart x 2 )
• VERSED 0.05 mg/kg slow IVP q 2 min. to a max of 0.2 mg/kg. If no IV give VERSED 0.2 mg/kg IM x 1
• Depress and hold cricoid ring (Sellick’s maneuver.)
• Attempt oral or oral in-line intubation via System protocol.
• Once intubation has occurred, check breath and epigastric sounds carefully.
• ETCO₂ detector
• Secure ETT and reassess breath sounds.
• VERSED in 0.05 mg/kg slow IVP increments up to 10 mg total to a max of 0.2 mg/kg as necessary for post — intubation sedation

PEDIATRIC RESPIRATORY ARREST

BLS / ALS

1. Initial Medical Care.

2. Secure and maintain patent airway using:

• jaw thrust or head tilt/chin lift.
• suction.
• oropharyngeal airway.

3. C-spine immobilization as indicated.

4. If airway obstructed, refer to Airway Obstruction SOP.

5. If breathing resumed, refer to appropriate SOP.

6. If not breathing: administer 100% O₂ with BVM. Observe for increase in heart rate and improved color.

ALS

• If no improvement, secure airway as appropriate (i.e., intubation/needle cricothyroidotomy as indicated).

7. Establish vascular access via IV/IO. Obtain glucose level — If Blood sugar < 60 or signs and symptoms of Insulin Shock/Hypoglycemia - follow Diabetes/Glucose Emergencies Protocol as needed.

ACUTE ASTHMA
COPD WITH WHEEZING

BLS / ALS

1. Initial Medical Care

• If mild distress: O₂ at 4-6 L/NC.
• If moderate/severe distress: 100% oxygen/NRB mask or BVM.
• BLS: If patient has prescribed inhaler, obtain time of last dosage. If appropriate, assist patient with inhaler.
• BLS: Reassess patient’s respiratory status and begin transport
• BLS: At discretion of medical control, additional doses of inhaler may be given.

2. Consider possibility of CHF / pulmonary edema in wheezing patient if patient has history of CHF, and/or pulmonary edema. If so, treat per Pulmonary Edema SOP.

ALS AGE > 8 YEARS:

3. ALBUTEROL 2.5 mg (3 cc) or XOPENEX 1.25 mg (3 cc) via nebulizer.

4. Partial response: repeat ALBUTEROL or XOPENEX immediately.

5. If no response to ALBUTEROL or XOPENEX or patient in severe distress AND age < 50 and patient has no cardiac history:
EPINEPHRINE (1:1,000) 0.3 mg SQ.

• If > 50 and/or cardiac history is present, contact Medical Control.

6. If imminent respiratory arrest, INTUBATE and use in-line ALBUTEROL 2.5 mg (3 cc) or XOPENEX 1.25 mg (3 cc)

REACTIVE (LOWER) AIRWAY DISEASE
PEDIATRIC WHEEZING
(< 8 yrs of age)

BLS/ALS

1. Initial Medical Care; special considerations

• If minimal-to-moderate distress: O₂ at 4-6 L/nasal cannula or pediatric mask.
• If severe distress: 100% O₂ with NRB or BVM at 10 liters/min.
• BLS: If patient has prescribed inhaler, obtain time of last dosage. If appropriate, assist patient with inhaler.
• BLS: Reassess patient's respiratory status and begin transport.
• BLS: At discretion of medical control, additional doses of inhaler may be given.

ALS

2. ALBUTEROL 2.5mg (3 cc) or XOPENEX 1.25mg (3 cc) via nebulizer.

3. Partial response: repeat ALBUTEROL or XOPENEX immediately.

4. No response to ALBUTEROL or XOPENEX, or patient in severe distress:
EPINEPHRINE 1:1,000

< 10kg =	0.1 mg or 0.1cc SQ
11 - 20kg =	0.2 mg or 0.2 cc SQ
21 - 30kg =	0.3 mg or 0.3 cc SQ

5. If imminent arrest, INTUBATE and use in-line ALBUTEROL 2.5mg (3 cc) or XOPENEX 1.25 mg (3 cc)

PARTIAL (UPPER) AIRWAY OBSTRUCTION
CROUP / EPIGLOTTITIS

ALS

1. Initial Medical Care; special considerations:

• Do not place anything in mouth to visualize pharynx.
• Do not start IV unless child presents in impending arrest.
• Monitor ECG for changes in heart rate. Bradycardia signals deterioration.

2. Prepare intubation/cricothyroidotomy/suction equipment.

STABLE: No cyanosis, mild respiratory distress, no retractions.

3. NS 6 cc in nebulizer by mask or aim mist at child's face.

4. If wheezing: ALBUTEROL 2.5 mg (3cc) or XOPENEX 1.25 mg (3 cc) via nebulizer mouthpiece, mask, or aiming mist at child's face. Oxygen at 6 L. Do not delay transport waiting for a response.

UNSTABLE: Cyanosis, marked stridor, or respiratory distress, evidence of inadequate airway exchange.

3. Consider possibility of epiglottitis and treat per Epiglottitis SOP.

4. EPINEPHRINE (1:1,000) 3 ml (3 mg) via nebulizer mask or aim mist at child's face with oxygen at 6 L.

STABLE: No cyanosis, effective air exchange. Administer oxygen by having caregiver hold mask near patient.

3. EPINEPHRINE (1:1,000) 3 ml (3 mg) via nebulizer mask or aim mist at child's face.

UNSTABLE: Bradycardic, altered mental status, marked stridor/ventilatory distress, retractions, ineffective air exchange, and/or actual or impending respiratory arrest.

3. Position supine in sniffing position. Ventilate with 100% oxygen/Peds BVM using slow compressions of bag. If unable to ventilate: temporarily stop ambulance and attempt one oral endotracheal intubation.

4. If intubation unsuccessful: Perform Needle Cricothyroidotomy.

ALLERGIC REACTION / ANAPHYLAXIS

BLS / ALS

1. Initial Medical Care:

2. Apply ice/cold pack to bite or injection site.

3. BLS: Consider the administration of one dose, EPINEPHRINE auto-injector

ALLERGIC REACTION (localized signs)

	Adult:	Peds:
4.	BENADRYL 50 mg IM or slow IVP	BENADRYL 1 mg/kg IM or slow IVP
5.	If history of systemic reaction or airway compromise:
	EPINEPHRINE 1:1,000 0.3 mg SQ may repeat x 1 after 15 minutes if minimal response.	EPINEPHRINE 1:1,000 < 10 kg = 0.1 mg or 0.1 cc SQ 11 - 20 kg = 0.2 mg or 0.2 cc SQ 21 - 30 kg = 0.3 mg or 0.3 cc SQ
6.	If wheezing, consider ALBUTEROL 2.5 mg or(3 cc) or XOPENEX 1.25 mg (3cc) per Asthma SOP	If wheezing, consider ALBUTEROL 2.5 mg (3 cc) XOPENEX 1.25 mg (3 cc) per Pediatric Wheezing SOP

ANAPHYLAXIS (Multisystem reaction with altered mental status or signs of hypoperfusion)

	Adult:	Peds:
4.	If signs of hypoperfusion, IV FLUID CHALLENGES in 200cc increments.	If signs of hypoperfusion, IV FLUID BOLUS NS 20cc/kg.
5.	EPINEPHRINE 1:10,000 0.5 mg IVP or IVP/IO or 1 mg ET or EPINEPHRINE 1:1,000 EPINEPHRINE 0.5 mg injected SL. May repeat q. 3 min.	EPINEPHRINE 1:10,000 0.01 mg/kg 1:1,000 0.02 mg/kg ET. If no IV/IO, 1:1,000 0.01 mg/kg injected SL.
DO NOT DELAY TRANSPORT WAITING FOR A RESPONSE
6.	BENADRYL 50 mg slow IVP. If no IV, give IM.	BENADRYL 1 mg/kg slow IVP. If no IV, give IM.
7.	If wheezing; ALBUTEROL 2.5 mg (3 cc) or XOPENEX 1.25 mg (3 cc) neb per Asthma SOP.	If wheezing, ALBUTEROL 2.5 mg (3 cc) or XOPENEX 1.25 mg (3 cc) via nebulizer.

 

• Flush all IV / IO meds with 5 cc NS
• Flush or dilute all ET meds with 2 cc