EMT/Advanced EMT Standing Orders

• Routine Patient Care—initial steps identified in Newborn Care Protocol (73 Medical).
• Call for Paramedic intercept, if available. If not available, call for AEMT intercept.
• For premature infants, consider additional warming techniques, including a newborn heating pad or wrapping the torso and extremities of the baby in food-grade or medical-grade plastic wrap.
• If the mouth or nose is obstructed or heavy secretions are present, suction the oropharynx then nares using a bulb syringe or mechanical suction using the lowest pressure that effectively removes the secretions, not to exceed 120 mmHg.
• If ventilation is inadequate, if the chest fails to rise, or if the heart rate is less than 100, initiate positive pressure (bag-valve-mask) ventilations at 40 - 60 breaths per minute.
  • Note: Resuscitation should be initiated with room air. Use oxygen if the newborn is premature or low birth weight. If no response to resuscitation after 90 seconds, supplement with 100% oxygen.
• After 30 seconds of ventilations, assess heart rate:
  • Auscultate the apical beat with a stethoscope or palpate the pulse by lightly grasping the base of the umbilical cord.
• For heart rate < 100, reassess the ventilatory technique and continue ventilations.
• For heart rate < 60 after attempts to correct ventilation:
  • Initiate CPR at a 3:1 ratio (for a rate of 90 compressions/minute and 30 ventilations/minute). Minimize interruptions. Reassess every 60 seconds; if not improving, continue CPR with 100% oxygen until recovery of a normal heart rate, then resume room air.

AMET/Paramedic Standing Orders

• If bag valve mask ventilation is inadequate or chest compressions are indicated, intubate the infant using a 3.0 mm to 4.0 mm endotracheal tube. (For an infant born before 28 weeks gestation, a 2.5 mm endotracheal tube should be used.)
  • Meconium aspiration may be indicated if the airway is obstructed.
  • After direct visualization, improvement in heart rate and EtCO2 are the best indicators of whether the tube is properly placed in the trachea.
• Establish IV/IO access. Obtain a blood sample if possible.
  • If hypovolemia is suspected, administer 10 mL/kg bolus 0.9% NaCl over 5 - 10 minutes.
  • If the heart rate fails to improve with chest compressions, administer epinephrine (1:10,000) (0.1 mg/mL) 0.01 - 0.03 mg/kg IV (0.1 - 0.3 mL/kg).
  • IV/IO is the preferred route for epinephrine—if there is a delay in establishing access, may be administered via ETT 0.05 - 0.1 mg/kg (1:10,000) (0.1 mg/mL).
  • If glucose level is < 60 mg/dl: 3.3mmol/L
    • Administer dextrose per Pediatric Color Coded Appendix (Appendix 1).

PEARLS:

• ALS NOTES: Flush all meds with 0.5 to 1.0 mL 0.9% NaCl or follow all ETT meds with positive-pressure ventilation.