Dr. Justin Northeim Medical Director€¦ · 2. Shall be extended to any EMT-P student directly...

________________________________Medical Director

________________________________Chief

________________________________Protocol Effective Date

________________________________Department License Expiration Date

Dr. Justin NortheimMedical Director

Table of Contents..........................................................Section One: General Information! 7

• Run Review Process: 7• Ongoing Skills and Competencies: 7• Medical Control: 7• Standing Orders: 7• Medical Control Orders: 7• Out of City Response: 8• Unknown Health Care Professional at Scene: 8• Scope of Practice: 8• Transportation Guidelines: 9• Aero-‐medical Transport Guidelines: 11• Consent/Refusal of Treatment DeJinitions: 11• Consent/Refusal of Treatment Policies: 11• EMS Patient Care Report: 14• Inter-‐Hospital Emergency Transfers: 15• Resuscitation Guidelines: 15• Cessation of Efforts DeJinition: 16• Do Not Resuscitate (DNR): 16• Controlled Substances: 18• Infectious Disease: 18• Immobilization Standards: 20• Mass Casualty Incident: 22• Restraint Policy: 24• Physical Restraint Guidelines: 24• Chemical Restraint Guidelines: 25

........................................................Section Two: Patient Assessment! 27• Scene Size-‐Up: 27• Triage: 27• Patient Movement: 28• Extrication: 28• Initial Patient Assessment: 28• History and Physical—Medical Patient: 29• History and Physical—Trauma Patient: 29• Detailed Physical Exam (Secondary Exam): 30• Triage Special Notes: 32

! ! ! ! ! ! ! ! ! ! ! ! ! ! 1*These protocols are not to be copied or distributed without written consent from Dr. Justin Northeim

*Paper copies of the protocols are always to be treated as default Revision 2014

• Neurological Assessment: 33• Vital Signs: 34• Capnography: 34• Twelve Lead EKG: 35• Intravenous Access/Fluids: 35• FACES Pain Scale: 36

.........................................................Section Three: Medical Protocols! 38• Pain Management: 38• Nausea and Vomiting: 39• Non-‐Traumatic Shock: 40• Sepsis/Septic Shock: 41• Altered Mental Status (AMS): 42• Mild and Moderate Allergic Reactions: 43• Severe Allergic Reaction: 44• Hypertensive Crisis: 45• Intracranial Bleed/CVA/TIA: 46• Diabetic Emergencies-‐-‐Hyperglycemia: 47• Diabetic Emergencies-‐-‐Hypoglycemia: 48• Environmental Emergencies-‐-‐Hyperthermia: 49• Environmental Emergencies-‐-‐Hypothermia: 50• Hyperventilation: 51• General Obstetrics Call: 52• Obstetrical Complications: 53• Obstetrical Delivery: 54• Pre-‐eclampsia/Eclampsia: 55• Opthalmic Emergencies: 56• Hyperkalemia/Renal Dialysis: 57• Overdose/Poisoning: 58• Psychiatric/Behavioral Emergencies: 60• TASER Barb Removal: 61• Respiratory Distress (Mild and Moderate): 62• Respiratory Distress (Severe): 63• Seizures: 64• Syncope: 65• Carbon Monoxide/Cyanide Poisoning: 66• Snake Bites: 68

..........................................................Section Four: Cardiac Protocols! 70• Chest Pain: 70• Congestive Heart Failure (CHF): 71• Cardiogenic Shock: 72• Atrial Fibrillation/Atrial Flutter with Rapid Ventricular Response: 73



• Adult Bradycardia: 74• Adult Tachycardia: 75• Adult Cardiac Arrest: 76• ROC Research Guidelines: 78• Adult Treatable Causes: 79• Hypothermic Protocol after ROSC: 80

.........................................................Section Five: Pediatric Protocols ! 82• Pediatric Pain Management: 83• Pediatric Nausea and Vomiting: 84• Pediatric Hyperventilation: 85• Pediatric Altered Mental Status (AMS): 86• Pediatric Mild and Moderate Allergic Reactions: 87• Pediatric Severe Allergic Reaction: 88• Pediatric Diabetic Emergencies-‐-‐Hyperglycemia: 89• Pediatric Diabetic Emergencies-‐-‐Hypoglycemia: 90• Pediatric Environmental Emergencies-‐-‐Hyperthermia: 91• Pediatric Environmental Emergencies-‐-‐Hypothermia: 92• Pediatric Seizures: 93• Pediatric Overdose/Poisoning: 94• Pediatric Respiratory Distress (Mild To Moderate): 95• Pediatric Respiratory Distress (Severe): 96• Pediatric Bradycardia: 97• Pediatric Tachycardia: 98• Pediatric Cardiac Arrest: 99• Pediatric Treatable Causes: 100

...........................................................Section Six: Trauma Protocols! 102• General Trauma Recommendations: 102• Amputations: 103• Burns/Electrical: 104• Head/Spinal Cord Injury: 106• Musculoskeletal: 107• Drowning/Near-‐Drowning: 108• Thoracic/Abdominal/Pelvic: 109

...........................................................................Section Seven: Skills! 111• Bandaging: 111• Tourniquet: 111• Splinting: 111• Traction Splinting: 112• Spinal Immobilization-‐Supine: 112• Spinal Immobilization-‐With Protective Clothing/Devices: 112



• Spinal Immobilization-‐Seated: 112• Bronchodilator Administration: 112• Peripheral Venipuncture: 113• Intramuscular Drug Injection: 113• Intravenous Drug Administration: 114• Intranasal Drug Administration: 114• External Jugular Vein Access: 114• Endotracheal Drug Administration: 114• Piggyback Drug Administration: 115• PICC Line/Central Line Access: 115• Dialysis Catheter Access: 115• Medi-‐port Access: 116• Umbilical Vein Cannulation: 116• Intraosseous Insertion: 116• Transcutaneous Pacing: 118• Cardioverson: 118• DeJibrillation: 118• AED: 119• Needle Decompression: 119• Aids To Airway/Breathing: 120• Oxygen: 120• Nasopharyngeal Airway: 120• Oropharyngeal Airway: 120• Bag Valve Mask: 120• Suctioning: 120• Mouth to Mask: 121• Chronic Tracheostomy: 121• Rapid Sequence Intubation: 121• RSI Chart: 123• Endotracheal Intubation: 124• Oral Gastric Tube Placement: 125• I-‐Gel: 126• CPAP: 127• Open Crichothyrotomy: 128• Needle Crichothyrotomy: 129• Vagal Maneuvers: 129• EKG: 130

..............................................Section Eight: Medications/Equipment! 132• Adenosine (Adenocard) 132• Albuterol (Proventil) (Ventolin) 132• Alcaine 132• Amiodarone (Cordarone) 132• Aspirin 132



• Atropine 133• Calcium Gluconate 133• Cyanokit (Hydroxocobalamin) 133• Dextrose 50%/25%/Paste 133• Diltiazem (Cardizem) 134• Diphenhydramine (Benadryl) 134• Epinephrine 1:1,000 134• Epinephrine 1:10,000 134• Epinephrine (Push Dose Pressor) 135• Epinephrine (Racemic) 135• Etomidate 135• Fentanyl 135• Glucagon 136• Haloperidol (Haldol) 136• Hydromorphone (Dilaudid) 136• Ipatropium (Atrovent) 136• Ketamine 137• Labetalol 137• Lidocaine 137• Magnesium Sulfate 137• Metoclopramide (Reglan) 138• Midazolam (Versed) 138• Morphine 138• Naloxone (Narcan) 138• Nitroglycerin (Nitro Spray) 138• Nitrous Oxide 139• Ondansetron (Zofran) 139• Oxygen (O2) 139• Promethazine (Phenergan) 139• Rocuronium (Zemuron) 139• Sodium Bicarbonate 140• Succinylcholine 140• Thiamine (Vitamin B1) 140• Vasopressin 140• Vecuronium (Norcuron) 141



Section One: General Information



Section One: General Information

Run Review Process:

It is the responsibility of each department to maintain a thorough, ongoing run review process. As part of their risk management and quality assurance obligations, the Medical Director will randomly audit the performance of the EMS personnel. This audit will be used for the following reasons:

1. To assure that the standards of patient care are being met, as are generally outlined in the following protocols

2. To assure that refusal and trip destination policies are being adhered to3. To identify areas in which continuing education is necessary

Ongoing Skills and Competencies:

It is the responsibility of each department to maintain the overall skills and competencies of their EMS personnel. This includes annual check offs related to the skills within the EMS personnel’s scope of practice. All EMS personnel functioning under these protocols will be required to pass the protocol exam after each revision. The departments should maintain records of the above stated. Continuing education will be the responsibility of the EMS personnel and their department.

Medical Control:

1. Shall be extended to any EMS entity that is functioning in the EMS system (EMS agencies under this protocol)

2. Shall be extended to any EMT-P student directly involved with your department through an approved EMS training program that is functioning in the EMS system

3. Shall be extended to any EMS entity of your department functioning in a stand-by capacity at a special event as part of the EMS system

4. Shall be utilized in the following situations:a. Whenever the EMS entity wishes to utilize Medical Controlc. When the protocol indicates Medical Control orders onlyd. When the patient’s complaint does not match a protocole. When the paramedic wishes to deviate from a protocol

Standing Orders:

1. Standing orders shall be utilized only after assessment has been performed and clinical indications are present to initiate the orders

2. Standing orders are approved and authorized orders by the EMS Medical Director and require no base contact or direct medical control to implement, when they are utilized, the EMS entity shall contact the receiving hospital with a verbal report prior to arrival

Medical Control Orders:

1. Shall only be given by State of Texas licensed physicians 2. Once an order is given, it is applicable to all EMS entities involved in the care of the patient 3. All physician directed orders shall be documented in the patient care report 4. The agency should contact their Medical Director or the hospital which provides Medical Control as described in the contract



Out of City Response:

At the scene of an emergency, when dispatched by a dispatch center for mutual aid request, and when an EMS entity is responding as part of their normal course of duty and is equipped to their scope of practice, an individual may render care according to these protocols. The EMS entity may transfer care to the first EMS responder from local area. Patients will only be transferred to equal or higher medical authority. Please document all patient care in your patient care report.

Unknown Health Care Professional at Scene:

If a bystander at an emergency scene identifies himself/herself as a healthcare professional (i.e. doctor, RN, PA, etc.) they may assist within their scope of practice, under their professional license and under their own liability. If there are any issues surrounding this circumstance, Medical Control should be contacted. In the event of conflict, Medical Control’s orders always prevail.

Scope of Practice:

EMT-BPatient Assessment/Physical SurveyCPROxygen administrationSuctioningOral/nasal airwaysAutomated External Defibrillator (AED)Bandaging/splintingSpinal immobilization/clearanceVaginal deliveryPhysical restraintEpinephrine (auto-injector)Assist patient with their own bronchodilator administration (metered dose inhaler-MDI)GlucometerOral glucose Assist patient with their own nitroglycerinTourniquetsI-GelTASER barb removalSingle attempt to reduce dislocated/fractured extremity with absent distal pulseCPAPAspirin administrationAlbuterol/atrovent administrationIntraosseous access

EMT-IAll of the above skills plus:

Peripheral intravenous access (including external jugular)Endotracheal intubation (nasal and oral)Magill forcepsNarcan administrationDextrose administration (non-oral route)



EMT-PAll of the above skills plus:

Needle/Surgical AirwaysDefibrillationCardioversionTranscutaneous pacingVagal maneuversEKG interpretationMedication administration (IV, IO, IM, IN, SL, PO, Ocular, Nebulized)Needle decompressionChemical restraintInduced hypothermia

Critical Care Paramedic or Critical Care Skill Proficient Paramedic (*Optional-Department Dependent)All of the above skills plus:

Intravenous pump managementVentilator managementContinuation of advanced IV dripsContinuation of advanced lines/chest tubes

Transportation Guidelines:

Appropriate Receiving Facilities:

The term “Appropriate Facility” means that a patient will be transported to a hospital that will best address their medical needs.

Adult Trauma Patients:

Patients meeting trauma criteria shall be transported to the most appropriate Trauma Center either by ground transportation or aero-medical transport (see Aero-Medical Guidelines), unless unstable, in which case they will be transported to the nearest Emergency Department for stabilization. See hospital specific activation criteria to determine activation levels and trauma criteria.

Burn Center Transport Criteria (Parkland):

Partial/Full thickness burns (> 20% Adult BSA, > 10% Peds BSA, facial, inhalation, genitalia)

Pediatric Trauma Patients:

Pediatric patients meeting trauma criteria shall be transported to the most appropriate Trauma Center either by ground transportation or aero-medical transport (see Aero-Medical Guidelines), unless unstable, in which case they will be transported to the nearest Emergency Department for stabilization. See hospital specific activation criteria to determine activation levels and trauma criteria.

If less than 14 years of age: Cook Children’s Medical Center-Fort Worth Children’s Medical Center-Dallas

Those not meeting trauma criteria shall be transported to the facility of choice (in compliance with Fire Department policy) as determined by the family member giving consent, or to the nearest emergency department if a preference is not expressed.



Unstable Trauma Patients:

Patients with the following injuries should be transported to the nearest Emergency Department for stabilization:

1. Tension pneumothorax2. Obstructive airway3. Massive facial and neck injury compromising airway4. Traumatic arrest with ongoing CPR5. Burn patients with potential airway compromise6. Patients necessitating emergent blood transfusion

Non-Critical Trauma Patient:

A patient meeting none of the above trauma criteria should be transported to the hospital of choice with due consideration of the Emergency Departments status (open or closed), EMS system operational status, and the facility where patient routinely obtains medical care for continuity of care.

Unstable medical patients:

A patient with an unstable hemodynamic status will always be transported to the nearest appropriate emergency department.

Patients presenting with any or all of the following factors are considered unstable:

1. Altered mental status (unless normal for patient)2. Symptomatic bradycardia or tachycardia3. Severe difficulty breathing4. An airway obstruction that cannot be relieved5. Symptomatic hypotension6. Suspected high-risk obstetrical patient7. Any patient with an existing condition that may deteriorate or may not tolerate an extended transport time to an alternate receiving facility, which may result in an unfavorable outcome

Stable Medical Patients:

If the patient does not meet the above criteria, the patient will be considered hemodynamically stable; but, if the patient stability is in question, the primary paramedic should consult with the Medical Control for guidance. These patients will be transported to a local destination of their choice and if there is no preference, then to the nearest Emergency Department.

Medical Patients With Unique Circumstances:

Acute Stroke Patients Transported to the nearest stroke approved facility (consider facility with neurosurgery coverage if strong suspicion of non-traumatic intracranial hemorrhage). Recommend checking with specific facilities to determine their stroke timing criteria and treatment abilities.

STEMI Transport to closest facility with 24/7 Interventional Cardiology availability.

CPR with ROSC Transport to the nearest hypothermia capable facility with 24/7 Interventional Cardiology availability.

Premature DeliveryIf fetus is less than 37 weeks gestation, transport to facility with NICU (Neonatal Intensive Care Unit) capabilities unless the patient or mother is unstable, then transport to the nearest Emergency department for stabilization. Contact Medical Control for assistance in destination selection for NICU.



ObstetricsIf patient is < 20 weeks, take patient to the closest facility or patient preferred facility if patient is stable.If patient is > 20 weeks, take patient to the closest facility with a Labor and Delivery unit.

Depending on the case and complaint, the patient may either go directly to Labor and Delivery or first be seen in the Emergency Department to rule out non-OB emergent issues. Aero-medical Transport Guidelines:

1. The ground ambulance crew may request a scene response by a helicopter air ambulance under the criteria listed below.2. Contact Medical Control for proper disposition if the patient falls outside of the criteria listed in this section. 3. Once an air ambulance is en-route to the scene, only the pilot or medical personnel in attendance with the patient at the scene may cancel the air ambulance response.4. Scene response requests will be reviewed by the medical director as part of the EMS quality assurance program.

Criteria for Aero-Medical Transport:

1. Patient located in remote or off-road area not readily accessible to ground ambulance2. Ground resources exhausted or exceeded3. Special environmental conditions which affect potential patient outcome or prohibit ground access to hospital4. Patients with greater than 20 minute extrication time5. When ground transport times exceed 45 minutes to an appropriate facility6. The scene commander feels that the benefits outweigh the risks

Consent/Refusal of Treatment Definitions:

A. Person: Any person that Emergency Medical Care Personnel encounters, who does not demonstrate any known/suspected illness/injury after an evaluation, may be released

B. Patient:• Any individual who activates EMS for themselves• Any individual for whom 911 is activated on their behalf and has a chief complaint or injury• Any individual with an injury or illness• Any individual with a medical or traumatic complaint• Any individual with a new altered level of consciousness• Any individual where EMT/Paramedic suspects injury due to mechanism

C. “Incapacitated”: Means lacking the ability, determined by reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of, and reasonable alternatives to, any proposed treatment decision.

Consent/Refusal of Treatment Policies:

A. The medical community believes:1. EMS entities are required by the public for anticipated or actual medical needs2. The public expects a prudent assessment for medical needs in all persons who may be suffering

from illness or injury3. The public expects timely treatment and transportation4. That certain members of the public, while suffering from an illness or injury, may decline all or

part of the indicated emergency treatments and/or transportation. These members have a right to refuse emergency treatment and/or transportation if the following factors are not present:a. Impaired capacity to understand the emergent nature of their medical condition due to,

but not limited to, alcohol, drugs or medications, mental illness, traumatic injury or grave disability



b. Legal minority (the state of being below the age at which applicable law considers a person to be an adult)

5. It is the responsibility of the EMS entity to render the indicated emergency treatment and transportation under the following conditions:

a. When it is medically indicatedb. When requested to render treatment and/or transportationc. When evidence for impaired capacity existsd. When not of legal majority (majority - legal age status at which full personal and civil

rights may be exercised)

B. The EMS entities are required to initiate and complete a Patient Care Report (PCR) for every patient contact with a chief complaint or injury. The PCR shall contain supporting documentation on treatment and/or transportation refused.

C. For the members of the public that are refusing part or all indicated emergency treatment and or transportation and in the EMS entity’s judgment, requires treatment and or transportation, the following steps may be taken:1. Have your partner offer treatment and/or transportation2. Consider involvement of law enforcement early if there is a threat to self, others or grave disability3. Have a supervisor assist you in offering transportation4. Contact Medical Control to assist in offering treatment and/or transportation 5. Communication with Medical Control shall be in close proximity to the patient, so that direct

communication between the physician and patient may occur

D. Physicians at base should decide the issues of patient competence and right to refuse treatment whenever necessary. Direct communication between the physician and the patient may resolve many questions. The following is an outline of legal principles which may help when no direct contact with a base physician

is possible.1. Consent:

a. The patient has the right to consent or to refuse treatment, if he/she is unable to do so, a responsible adult relative or legal guardian may have this right

b. When waiting to obtain lawful consent from the person authorized to make such consent would present a serious risk of death, serious impairment of health, or would prolong severe pain or suffering of the patient, treatment may be undertaken to avoid those risks without consent (IN NO EVENT SHOULD LEGAL CONSENT FOR PROCEDURES BE ALLOWED TO DELAY IMMEDIATELY REQUIRED TREATMENT)

c. In non-emergency cases, consent should be obtained from the patient or from a legally responsible party prior to undertaking any treatment

d. A patient must be 18 years of age or older, or between 16 and 18 years and "emancipated" (i.e., living apart from his/her parents, with or without written evidence of emancipation, female with baby/child, or a married person of either sex) to refuse or consent to treatment

e. The following persons may consent to medical, dental, psychological, and surgical treatment of a child when the person having the right to consent as otherwise provided by law cannot be contacted and that person has not given actual notice to the contrary:1. a grandparent of the child;2. an adult brother or sister of the child;3. an adult aunt or uncle of the child;4. an educational institution in which the child is enrolled that has received written

authorization to consent from a person having the right to consent;5. an adult who has actual care, control, and possession of the child and has written

authorization to consent from a person having the right to consent;6. a court having jurisdiction over a suit affecting the parent-child relationship of

which the child is the subject;



7. an adult responsible for the actual care, control, and possession of a child under the jurisdiction of a juvenile court or committed by a juvenile court to the care of an agency of the state or county; or

8. a peace officer who has lawfully taken custody of a minor, if the peace officer has reasonable grounds to believe the minor is in need of immediate medical treatment

f. The Texas Youth Commission may consent to the medical, dental, psychological, and surgical treatment of a child committed to it under Title 3 when the person having the right to consent has been contacted and that person has not given actual notice to the contrary

2. Consent to Treatment by Child:a. A child may consent to medical treatment if the child:

1. is on active duty with the armed services of the United States of America;2. is:

(a) 16 years of age or older and resides separate and apart from the child’s parents, managing conservator, or guardian, with or without the consent of the parents, managing conservator, or guardian and regardless of the duration of the residence; and(b) managing the child’s own financial affairs, regardless of the source of the income;

3. consents to the diagnosis and treatment of an infectious, contagious, or communicable disease that is required by law or a rule to be reported by the licensed physician or dentist to a local health officer or the Texas Department of Health, including all diseases within the scope of Section 81.041, Health and Safety Code;

4. is unmarried and pregnant and consents to hospital, medical, or treatment, other than abortion, and related to the pregnancy;

5. consents to examination and treatment for drug or chemical addiction, drug or chemical dependency, or any other condition directly related to drug or chemical use.

3. Mental Competence:a. A person is mentally competent if he/she:

• is capable of understanding the nature and consequences of the proposed treatment and implications of refusal of that treatment AND

• is awake, alert and fully oriented to time, person, place and situation AND• has no signs of injury or illness which may impair the ability to make an

informed decision AND• not suicidal and/or homicidal• a patient who has had recent alcohol or drug use is a high risk medical patient

and it should always be recommended to the patient that he/she be transported to the ER, if they are A&Ox4, understand the consequences of their condition and still refuse, then you must document completely and when pertains, try to find someone who will stay with the patient to help ensure safety

b. If the adult patient is comatose, incapacitated, or otherwise mentally or physically incapable of communication, an adult surrogate from the following list, in order of priority, who has decision making capacity, is available after a reasonably diligent enquiry, and is willing to consent to medical treatment on behalf of the patient, may consent to medical treatment on behalf of the:1. patient’s spouse,2. adult child of the patient who has the waiver and consent of all other

qualified adult children of the patient to act as the sole decision-maker,3. a majority of the patient’s reasonably available adult children,4. patient’s parents, or5. the individual clearly identified to act for the patient by the patient before the

patient became incapacitated, the patient’s nearest living relative, or a member of clergy



c. If the patient is not mentally competent and none of the above persons are available, the person should be treated and transported to the appropriate emergency department. It is preferable under such circumstances to obtain concurrence of a police officer in this course of action

d. If the patient is not competent to give consent and a legally responsible person is present, and if that responsible person is of age and competent, he/she has the same right to consent to or refuse treatment as the patient himself/herself, his/her wishes cannot be ignored in a non-life-threatening situation

e. If the patient is judged NOT competent to refuse transport:• Explain to patient (or parent or guardian) the need for transport• Reassure patient that no harm will result from transport but complications, up to

and including death may result from a delay in treatment4. Procedure for Refusal:

a. If a patient wishes to refuse treatment, examination, or transportation, and is competent, the following steps will be taken:

1. The EMT/Paramedic will complete documentation to include assessment of the patient's level of orientation, level of consciousness, whether there is a head injury, or whether the patient is under the influence of drugs and/or alcohol

2. It will be noted that Medical Control was contacted only if needed3. The patient will be advised whether medical treatment and evaluation are

needed, whether transportation is needed, whether further harm could result without treatment and evaluation, whether transport by means other than ambulance could be hazardous in light of the patient's injury or illness

4. The type of refusal that is involved should be documented, whether the patient has used all the EMS services, refused transport but accepted field treatment, refused field treatment but accepted transport, whether released in the custody of themselves, law enforcement agency, or others, any further comments should be documented, this will be signed by the EMT/Paramedic, timed, and dated

5. The willingness of EMS to transport the patient6. The patient should call their primary care physician immediately or seek medical

advice/council ASAP5. Document on a patient care report

a. All cases in which patients refuse care and have a chief complaint or injuryb. All cases where there is an assessment of competencyc. The name and phone number of the patient refusing cared. All pertinent information (i.e., who, what, why, etc.) should be clearly and concisely

written in the patient summary report.e. Authoritative witnesses should also be documented

EMS Patient Care Report:

The Patient Care Report (PCR) will be completed for every patient contact with a chief complaint or injury. The pre-hospital provider is responsible for maintaining a record of every dispatched response. The EMS PCR is a medical record and the primary source of information for continuous quality improvement review. Pre-hospital care personnel shall be responsible for providing clear, concise, complete and accurate documentation.



Inter-Hospital Emergency Transfers: (*Optional-‐Department Dependent )

1. All patients should be stabilized before transfer and the transferring physician must state that the patient is stable for transfer.

2. EMS personnel must receive an adequate summary of the patient's condition, current treatment/s, possible complications and other pertinent medical history.

3. The overall treatment plan and goals should be discussed with the RN and/or physician at the transferring facility prior to transfer.

4. The EMS personnel should work within their overall scope of practice noted in the protocols.5. Transfer papers (summary, lab work, x-rays, MOT, etc) shall be transferred with the patient.6. The receiving physician must be contacted by the transferring physician prior to transfer in order to gain

appropriate acceptance. 7. EMS personnel must receive a brief in-service regarding the medications and/or equipment being continued

by either a physician or RN prior to transfer.8. If changes occur during transport, please refer to the protocols for further interventions.9. If a patient becomes unstable during transport, stop at the closest Emergency Department for stabilization.10. If the EMS personnel feel that the patient is unstable for transfer, then a call to Medical Control should be

made for further assistance.11. When transporting a ventilator, be reminded of the DOPE acronym for failure (Dislodged, Obstructed,

Pneumothorax, Equipment); when in doubt, disconnect the ventilator and ventilate the patient manually. All patients should be transported with capnography in place.

Resuscitation Guidelines:

In all situations where there is a possibility that life exists, every effort will be made to resuscitate the patient and transport to the hospital.

A. Requirements:1. Visual examination of the body/remains (must view with sufficient proximity and lighting to

assure existence of the death determining condition)2. Physical examination of the body/remains (must touch the body and expose the area to sight as

necessary to determine the existence of the condition)3. Must be pulseless and apneic (must check for breathing and central pulse, carotid preferred or

femoral if unable for at least ten seconds)4. Cardiac monitoring (must be asystole on the monitor, running at least six second strips in two

different leads) B. Conditions when minimal confirming examination and assessment is necessary to determine death. These

apply only to the initial assessment and will determine whether or not cardiopulmonary resuscitation efforts will be initiated. In all cases when determination is considered, it is assumed that there is no response to stimuli, no breathing, and no pulse. If there is any doubt, initiate cardiopulmonary resuscitation.

1. Decapitation2. Incineration3. Decomposition4. Rigor Mortis5. Lividity6. Submersion greater than six hours

C. Once it is determined that the victim is, in fact, dead, the crew should move as rapidly as possible to transfer responsibility or management of the scene to the Law Enforcement Agency and/or Medical Examiners OfJice. The personnel should not leave the scene until responsibility for management of the scene has been transferred appropriately.



Cessation of Efforts Definition:(*Optional-‐Department Dependent)

When all of the following circumstances exist, resuscitation efforts may be stopped in the field: 1. Patient must be age > 18, not pregnant and not traumatic 2. Scene must be safe and situation appropriate

3. The patient’s initial EKG rhythm obtained by EMS must be asystole4. Fifteen minutes of ACLS must be performed with no change in rhythm (asystole)5. Should not be related to a hypothermic cause6. There must have been successful advanced airway placement (ET tube or I-Gel)7. There has been no return of pulse, spontaneous respirations, eye opening, motor response, or

improvement of neurologic activity 8. If all above exist, then the police/medical examiner should be called according to local protocols9. Either police, EMS personnel, or medical examiner must stay on scene with the deceased until

transported from the scene

NOTES: The purpose behind termination of ACLS in the field is to keep paramedic units in-service for emergencies instead of transporting non-salvageable patients under ACLS. This protocol provides a method for terminating ACLS in hopeless cases.

Do Not Resuscitate (DNR):

A. All patients shall be resuscitated following the above resuscitation guidelines, unless EMS is presented with:

1. An intact, unaltered, easily identifiable Texas DNR bracelet 2. An intact, unaltered Texas DNR form (a copy is allowed)

B. EMS may discontinue resuscitation if after the resuscitation was instituted, the above information is provided

C. The DNR order may be revoked at anytime by the person enacting the document either by destroying the DNR document, removing the identification device or by giving verbal revocation

D. If any questions, or dispute resolution will be handled by utilizing direct Medical Control for guidance

E. In the event the patient expires en route, continue to the destination hospital. If the patient expires during a transfer from facility to facility, transport the patient to the nearest emergency department for pronouncement

F. See below for commonly asked questions and a copy of the Texas DNR Form:

Q: What is Out-of-Hospital Do-Not-Resuscitate Order? A: An order that allows patients to direct health care professionals in the out-‐of-‐hospital setting to withhold or withdraw speciJic life-‐sustaining treatments in the event of respiratory or cardiac arrest.

Q: Who is a health care professional? A: The law deJines healthcare professionals as physicians, nurses, emergency medical personnel and physician’s assistants.



Q: What are those life-sustaining treatments that are prohibited? A: Cardiopulmonary resuscitation (CPR) Transcutaneous Cardiac Pacing DeJibrillation Advanced Airway Management ArtiJicial Ventilation

Q: Does this mean I can’t offer any comfort (palliative) measures? A: No. Comfort measures are speciJically allowed.

Q: Can a DNR be revoked? A: A DNR can be revoked at any time by the patient or the person who acted on behalf of the agent. Revocation can be in the form of communication to responding health care professionals, destruction of the form, or removal of devices.

Q: Is a copy of the form acceptable? A: You can make copies of the form before it’s Jilled out and after it’s Jilled out. Copies should be accepted like the originals.

Q: What happens if the patient is transported? A: A copy of the form or the device must accompany the patient.

Q: What if EMS begins treatment and is then presented with the form? A: After verifying the validity and correctness of the form, EMS should cease using CPR, transcutaneous cardiac pacing, deJibrillation, advanced airway management and artiJicial ventilation on the patient.



Controlled Substances:

A. Controlled substances are to be administered in accordance with the EMS treatment protocols

B. All controlled substances will be stored in a secure and accountable manner per DEA regulations

C. The storage container will be inspected at every shift change for breakage of the locks, if the lock is broken, then the contents will be checked and logged appropriately, both the oncoming EMT-Ps and off-going EMT-P will jointly count, date, time, and sign a Controlled Substance Signature Log, discrepancies will be reported immediately to the immediate supervisor

D. All controlled substances shall be re-supplied in accordance with the narcotic supply exchange policy

Infectious Disease:

A. When field personnel are treating a patient whom they suspect has a blood-borne infectious disease (i.e. hepatitis, HIV/AIDS, etc.) and medical intervention is anticipated to place field personnel at risk for contamination, then personal protection measures will be employed as appropriate to reduce the risk of contamination.

B. The personal protection measures available include use of:1. Disposable medical gloves2. Disposable surgical masks3. Plastic goggles4. Personal decontamination prophylaxis at conclusion of patient contact (i.e., hand washing, etc.)5. Restraint from non-essential invasive therapy

C. An employee is considered exposed when he/she is contaminated by any of the following routes:1. Patient secretions in an eye2. Needle stick from a contaminated needle3. Mouth-to-mouth contact during resuscitation4. Prolonged contact with patient's blood or other body fluids through field personnel's abraded or

open skin5. Respiratory contact with airborne infected individual (i.e TB)

D. In the event that exposure, as defined above, occurs, the exposed employee should:1. Notify the Emergency Department Physician at the receiving hospital of such exposure and

request that the patient be evaluated for the presence of a blood-borne infectious disease including appropriate corroborative blood tests as deemed necessary by the physician

2. Obtain the following patient information:a. Patient's name

b. Date of birthc. Address of incidentd. Time of incidente. Receiving hospitalf. Incident number

3. Contact appropriate EMS supervisor to obtain and complete an incident form





OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER TEXAS DEPARTMENT OF STATE HEALTH SERVICES

This document becomes effective immediately on the date of execution for health care professionals acting in out-of-hospital settings. It remains in effect until the person is pronounced dead by authorized medical or legal authority or the document is revoked. Comfort care will be given as needed.

Person's full legal name Date of birthMaleFemale

A. Declaration of the adult person: I am competent and at least 18 years of age. I direct that none of the following resuscitation measures be initiated or continued for me: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.

Date

B. Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication:

I am the: legal guardian; agent in a Medical Power of Attorney; OR proxy in a directive to physicians of the above-noted person who is incompetent or otherwise mentally or physically incapable of communication.

Based upon the known desires of the person, or a determination of the best interest of the person, I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.

Date Printed name

E. Declaration on behalf of the minor person: I am the minor's: parent; legal guardian; OR managing conservator.

Printed name

Date

TWO WITNESSES: (See qualifications on backside.) We have witnessed the above-noted competent adult person or authorized declarant making his/her signature above and, if applicable, the above-noted adult person making an OOH-DNR by nonwritten communication to the attending physician.

Printed name

Printed name

PHYSICIAN'S STATEMENT: I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.

Printed name

Date

License #

Date

Date

F. Directive by two physicians on behalf of the adult, who is incompetent or unable to communicate and without guardian, agent, proxy or relative: The person's specific wishes are unknown, but resuscitation measures are, in reasonable medical judgment, considered ineffective or are otherwise not in the best interests of the person. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.

Printed nameDate

DatePrinted name

All persons who have signed above must sign below, acknowledging that this document has been properly completed.

Second physician's signature

This document or a copy thereof must accompany the person during his/her medical transport.

Signature of second physician

Physician's electronic or digital signature must meet criteria listed in Health and Safety Code §166.082(c).

Person's signature

Witness 1 signature

Witness 2 signature

Attending physician's signature

Person's signature


Lic#

Lic#

Printed name

C. Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication: I am the above-noted person's:

spouse, adult child, parent, OR nearest living relative, and I am qualified to make this treatment decision under Health and Safety Code §166.088.

To my knowledge the adult person is incompetent or otherwise mentally or physically incapable of communication and is without a legal guardian, agent or proxy. Based upon the known desires of the person or a determination of the best interests of the person, I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.

Printed name Date

Notary's signature

Witness 1 signature Witness 2 signature

Guardian/Agent/Proxy/Relative signature

Physician's signature

Notary in the State of Texas and County of___________________. The above noted person personally appeared before me and signed the above noted declaration on this date:______________.

Signature & seal: _______________________________________________Notary's printed name:_______________________________________________ Notary Seal

[ Note: Notary cannot acknowledge the witnessing of the person making an OOH-DNR order in a nonwritten manner ]

A physician has diagnosed the minor as suffering from a terminal or irreversible condition. I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.

D. Declaration by physician based on directive to physicians by a person now incompetent or nonwritten communication to the physician by a competent person: I am the above-noted person's attending physician and have:

seen evidence of his/her previously issued directive to physicians by the adult, now incompetent; OR observed his/her issuance before two witnesses of an OOH-DNR in a nonwritten manner.

I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.

Lic#Printed nameDate


Signature

Signature

Signature

Figure: 25 TAC §157.25 (h)(2)

Immobilization Standards:

Immobilization criteria: A patient meeting ANY of the below criteria MUST have spinal immobilization:

1. Pediatric patients in which an appropriate exam/questioning is not able to be obtained

2. Language barrier in which an appropriate exam/questioning is not able to be obtained

3. ANY altered level of consciousness (GCS < 15) 4. Midline cervical spine pain 5. Neurological deficits (i.e. numbness, tingling, weakness)

6. Painful distracting injuries (injuries that could distract from the patient’s ability to perceive spine pain)

7. Intoxication (ETOH or drug)

8. Drowning patients

9. Pain with range of motion of cervical spine 45 degrees left, right, up and down

10. Age > 65 with injury above the clavicles

11. Penetrating trauma/injury with significant secondary traumatic injury (i.e. fall > 10 feet (Peds > 2x height)

EMS MAY CLEAR THE CERVICAL SPINE OF PATIENTS NOT MEETING THE ABOVE CRITERIA

WHEN IN DOUBT, ERROR ON THE SIDE OF CERVICAL IMMOBILIZATION

Have a high suspicion of cervical spine injuries in the following patients:

> 65 years old History of cervical spine injury History of osteoporosis Motorcycle accidents Axial loading injuries Automobile-pedestrian Ejection or significant vehicle damage Patients who are poor historians



Spinal immobilization options:

Patients meeting ANY of the immobilization criteria above should receive ONE of the following:

1. Cervical collar and stretcher Preferred method for:

Ambulatory patients Patients who are neurologically intact and able to stand/self-extricate Patients that can be moved to the stretcher with scoop stretcher or other 3 person log roll method

*The cervical collar should be placed immediately, the stretcher should be brought as close as possible to the patient, and EMS should assist the patient with pivoting and lying down

**The head of the stretcher may be elevated 30 degrees if needed

OR

2. Cervical collar, KED or scoop stretcher and stretcher Preferred method for:

Patients who are NOT neurologically intact or have significant midline thoracic/lumbar tenderness Patients should be moved via KED or scoop stretcher with as little movement to the spine as possibleIf patient is on the ground, a 3 person c-spine rolling technique must be utilizedKED may stay in place when patient is placed on stretcherScoop stretcher must be removed when patient is placed on stretcher

OR

3. Cervical collar with vacuum/soft type immobilization device

Preferred method for:

Any patient (for trauma arrest patients, a long hard spine board my be preferred)

*The head of the stretcher may be elevated 30 degrees if needed

**Consider a draw sheet between the patient and immobilization device to facilitate movement at the hospital

OR

4. Cervical collar with long hard spine board

Preferred method for:

Trauma arrests Air medical patients Can be utilized for situations involving rapid extrications/extractions (EMS personnel decision) Can be utilized for situations involving movement/lifting/space limitations (EMS personnel decision) Can be utilized for critically injured patients (EMS personnel decision)

IF THE PATIENT IS VOMITING OR PREGNANT, WITH ANY OF THE ABOVE OPTIONS, PATIENT MAY BE CAUTIOUSLY PLACED ON HIS/HER SIDE TO FACILITATE MAINTENANCE OF AIRWAY



Mass Casualty Incident:

A Mass Casualty Incident (MCI) will be defined as any incident in which the on-scene providers establish a treatment area to care for multiple victims. A MCI may overwhelm response capabilities and may or may not require assistance from outside agencies.

The six steps in the plan are: 1. Institute the Incident Command System (ICS) 2. Triage utilizing the START method 3. Establish appropriate Zones and Sectors 4. Contact Medical Control and appropriate facilities, including a request for EMS system notification as appropriate 5. Transport patient(s) to facilities as directed by the transportation officer 6. Debriefing and incident critique

Step One is to institute the ICS. The initial responding units are to assure scene safety and summon additional units. Scene management and access will also be part of this step.

Step Two is to triage using the START method. START allows emergency personnel at any training level to triage victims in sixty seconds or less depending upon three observations. It does not attempt to make a diagnosis, but selects victims in the greatest need of urgent care based upon simple basic assessments. It recognizes that there is neither the time nor resources available to perform techniques that are normally considered initial patient assessment. However, minimal intervention to stabilize the airway or to control hemorrhage is done at the same time as the initial triage. A copy of the START flowchart should be available with departmental MCI materials, and any MCI training should focus on this method.

The responsibility of the first arriving unit is to begin the simple triage and treatment process, moving as rapidly as possible through all the victims to determine which need immediate care to prevent death. Each is tagged into categories using the tag system adopted by the agency so that incoming units can begin providing medical treatment/transport to those most in need. The provider can use any simple triage tags that provide a clear, easily recognizable method of identifying victims and their status. Minimally there should be a category of patients that can received delayed care because of their stability, a category of patients needing urgent or immediate care to prevent death or serious degradation of condition, and a category of patients that are either dead or have injuries so severe that their treatment will use resources that will are better served with other patients. Ambulatory patients may be further separated from the “delayed” category patients. This initial screening must be rapid and efficient. This will allow for the greatest number of victims to be screened for urgent, life threatening conditions.

It will be the responsibility of the second wave of rescuers to locate the victims designated as "Immediate" “Delayed” or "Minor" and proceed with more definitive treatment. Step Three is to establish Zones and Divisions. Each MCI has the potential to be a HAZMAT or Biohazard event. The initial units should consider this possibility, and may establish hot, warm, and cold zones per their HAZMAT training.

Several Divisions should be considered depending on the size and scope of the incident. Other than Incident Command, these are optional depending on the decisions and guidelines of the department. Possible Divisions include Treatment, Transportation, Staging, and Rehab. A Safety Officer is also essential, and a Liaison Officer is very helpful. The assignment of these Divisions should be flexible with each specific incident, assigning the appropriate numbers and expertise as indicated and available. Normally, Transportation will keep up with the destination of patients and the facility availability. Access to EMS system can facilitate this with the establishment of an “Event” by the primary receiving facility, Medical Control, the EMS Coordinator, or possibly Communications.

Incident Command (IC) will have ultimate command of the entire MCI. In addition, identification of personnel and areas are crucial to an organized MCI. A PASS system or some other method of keeping up with responders and their assignments is necessary for IC. In addition, the various Division commanders should be easily identifiable by vests or another acceptable method. The various sectors should be easily identified with flags, cones, tarps, or another acceptable method. Exits and



entrances should be apparent. The Incident Command post should be identified with a green emergency light or another easily identified green marker.

Step Four is to notify Medical Control and the other appropriate facilities. This step will be performed by the Transportation Officer or someone assigned to this duty. Using EMS system as described above with early notification of the primary receiving facility will help reduce delays and put units back in service quicker. It also allows the receiving hospital(s) to prepare for the MCI and helps keep other non-urgent ambulance traffic from entering the region.

Step Five is to transport the patient or patients to the facility assigned by the Transportation Officer. Any deviation should be reported back to that sector commander.

Step Six is to debrief the MCI and critique the events. This will be scheduled after the entire event has been completed. Consideration should be given to a critical incident stress defusing and/or debriefing, and inclusion of all involved parties.

Hazardous Materials Incident:

EMS personnel are urged to be alert for hazardous materials when responding to calls. Hazardous materials may be obvious, but often are not. If a vehicle has a diamond shaped placard or an orange panel on its side or rear, assume the cargo to be hazardous. Consult the Hazardous Materials Identification guidebooks carried on each unit. Not all hazardous materials will be clearly identified or marked. Common sense dictates that each pre-hospital provider assumes a hazardous material is present unless proven otherwise.

Park uphill and upwind from suspected hazardous materials unless directed otherwise by a competent authority, such as the Senior Fire Officer or Incident Commander.

Do not drive or walk through any suspected hazardous material.

If EMS is the first arriving agency, establish zones (hot, warm, and cold). Do not approach the victim without proper protective equipment and training! DO NOT BECOME A VICTIM!If the appropriate agency is already on the scene, report to staging.

Contamination Precautions: 1. Insure the patient has been decontaminated and clothing and belongings have been removed (clear with HAZMAT Team) 2. Implement department approved isolation techniques for MICU 3. Treat patients that are symptomatic with appropriate protocol 4. Contact Medical Control for further guidance as necessary

Transport: 1. Assure crew safety first 2. Record all product information and transport with victim 3. Obtain advice for further decontamination of vehicle or personnel from HAZMAT Team 4. Provide name of chemical/agent to Emergency Department staff prior to hospital arrival 5. Double bag any contaminated clothing, equipment, sheets or blankets 6. Delay patient unloading until cleared by Emergency Department staff 7. Implement any secondary decontamination procedures for vehicle or personnel, if necessary



Restraint Policy:

All patients who are transported via stretcher will have lap belt at all times.

All patients who are ambulatory but being transported by ambulance must have standard seat belt restraints at all times (cab or patient care area).The decision to restrain a violent patient should be made carefully. Once the decision has been made then it should be done swiftly and completely. If a patient demonstrates behavior which must be contained, EMS personnel may use “reasonable force” to restrain the patient.

Physical Restraint Guidelines:

1. Use the minimum physical restraint required to accomplish necessary patient care and ensure safe transportation:

! Soft restraints may be sufficient! If law enforcement or additional personnel are needed, call for it prior to attempting

restraint procedures! Do not endanger yourself or your crew

2. Avoid placing restraints in such a way as to preclude evaluation of the patient’s medical status (airway, breathing, and circulation), consider whether placement of restraints will interfere with necessary patient care activities or will cause further harm

3. Ensure sufficient personnel are present to control the patient while restraining him/her; USE LAW ENFORCEMENT ASSISTANCE WHEN AVAILABLE

4. Make sure the patient is always face up 5. Secure ALL extremities in a manner that ensures patient and EMS personnel safety

6. If necessary, use cervical spine precautions (CID) to control violent head or body movements7. Place padding under patient’s head and wherever else needed to prevent the patient from further

harming him/herself or restricting circulation8. Law Enforcement may place a patient in restraints with a lock that requires a key to unlock, Law

Enforcement MUST ride with you and the patient and be in possession of the key with capability of immediate release of the restraint if necessary



Chemical Restraint Guidelines:

1. Sedative agents may be used to provide a safe, humane method of restraining the violently combative patient who presents a danger to themselves or others and to prevent the violently combative patient from further injury while secured by physical restraints

2. These patients may include but are not limited to the following:! Alcohol and or drug-intoxicated patients! Restless, combative head-injury patients! Mental illness patients! Physical abuse patients (more humane than physical restraint)

3. Assess the possibility of using physical restraint first; evaluate the personnel needed to safely attempt to restrain the patient

4. Have sedative medication prepared for injection, prepare for possible hypo-tensive side effects 5. Follow the Psychiatric/Behavior Emergency Protocol

6. Vital signs should be assessed within the first five minutes and thereafter as appropriate7. The violently combative patient stands a lesser chance of injury when sedated8. Patients who are physically restrained and aggressively fighting their restraints and head injury

patients who are combative and compromising their airway and C-spine may be candidates for sedation

9. Document the following:a. In what manner was your patient violent? Record patient’s comments verbatim.b. Did you feel threatened? Why?c. Were you concerned about your patient’s outcome without emergency medical

interventions? Why?d. Could you treat your patient appropriately without the use of restraints?e. What law enforcement officer was present?f. Who was the Medical Control physician?g. Document the frequency of respiratory and mental status change assessments.



Section Two: Patient Assessment



Section Two: Patient Assessment

Scene Size-Up:

A. Body substance isolation review1. Gloves2. Eye protection if necessary3. Gown if necessary4. Mask if necessary

B. Scene Safety1. Definition - an assessment to assure the well-being of the EMS providers2. Personal Protection - is it safe to approach the patient?

a. Crash/rescue scenesb. Toxic substances - low oxygen areasc. Crime scenes - potential for violenced. Unstable surfaces- slope, ice, water

3. Protection of the patient - environmental considerations4. Protection of bystanders - if appropriate, help the bystander avoid becoming a patient5. If the scene unsafe, make it safe, otherwise, do not enter

C. Mechanism of injury/nature of illness1. Medical

a. Nature of illness - determine from the patient, family or bystanders why EMS was activated

b. Determine the total number of patients, if there are more patients than the responding unit can effectively handle, initiate a mass casualty plan(a) Obtain additional help prior to contact with patients: law enforcement, fire,

rescue, ALS, utilities(b) Begin triage

2. Traumaa. Mechanism of injury - determine from the patient, family or bystanders and inspection of

the scene what is the mechanism of injuryb. Determine the total number of patients

(a) If there are more patients than the responding unit can effectively handle, initiate a mass casualty plan(1) Obtain additional help prior to contact with patients(2) Begin triage

(b) If the responding crew can manage the situation, consider spinal precautions and continue care.

Triage:

A. Assign one medical person to control medical scene

B. Complete primary survey on all patients before management

C. Categorize patients according to priority and assign personnel to complete assessment and treatment on that basis (START):1. Deceased: dead or mortally wounded, no care required2. Immediate: immediate care, life threatening3. Delayed: urgent care, can delay up to one hour

4. Minor: delayed care, can delay up to three hours



Patient Movement:

A. Do primary and secondary assessment before patient movement (unless grave threat to patient)B. Monitor airway and cervical spine carefully while movingC. Roll as a unitD. Splint prior to movement if possibleE. Perform a smooth and safe transfer to transport device (board or vehicle)F. Use proper body mechanics as rescuerG. Minimize patient movement with modification for environmental hazards

Extrication:

A. Survey scene for potential hazards, number of patients, need for specialist helpB. Call for medical or technical backup as neededC. Protect rescuers first: treat gas spills, remove power lines, etc.D. Stabilize vehicle prior to entryE. Perform primary survey and treat airway difficulties, severe bleeding firstF. If patient has no pulse or respirations, extrication is necessary before CPR can be providedG. Triage patients and assign to available medical personnelH. Apply cervical collar, immobilize spine prior to extricationI. Perform quick secondary survey as possible: splint extremity fractures if possibleJ. Expedite safe extrication by specialists after management of life-threatening problemsK. Perform or repeat complete secondary survey once patient extricated

Initial Patient Assessment:

A. General impression of the patient1. Definition:

a. The general impression is formed to determine priority of care and is based on the EMS provider’s immediate assessment of the environment and the patient’s chief complaint

b. Determine if medical or trauma etiologyc. Aged. Gender

2. Assess patient and determine if the patient has a life threatening conditiona. If a life threatening condition is found, treat immediatelyb. Assess nature of illness or mechanism of injury

B. Assess patient’s mental status (maintain spinal immobilization if needed)

1. Levels of mental status (AVPU)a. A-Alertb. V-Verbal stimulus-Patient responds toc. P-Painful stimuli-Patient responds tod. U-Unresponsive-no gag or cough

C. Assess the patient’s airway status1. Responsive patient - Is the patient talking or crying?

a. If yes, assess for adequacy of breathingb. If no, open airway

2. Unresponsive patient - Is the airway open?Open the airway(1) For medical patients, perform the head-tilt chin-lift

a. Clearb. Not Clear - Clear the airway



(2) For trauma patients or those with unknown nature of illness, the cervical spine should be stabilized/immobilized and the jaw thrust maneuver performed

a. Clearb. Not Clear - Clear the airway

(3) To clear airway, consider BLS choking maneuvers or Magill forcep removal if indicated

D. Assess the patient’s breathing1. If breathing is adequate and the patient is responsive, maintain pulse ox greater than 94% (92%

COPD patients) and consider capnography for further assessment2. All responsive patients with respiratory distress or respiratory depression should be given oxygen

to maintain pulse ox greater than 94% (92% COPD patients), capnography should be utilized and nasal airway considered

3. If the patient is unresponsive but breathing, place appropriate airway device, maintain pulse ox greater than 94% (92% COPD patients) and capnography should be utilized to guide therapy

4. If the patient is not breathing, place appropriate airway device, maintain pulse ox greater than 94% (92% COPD patients) and capnography should be utilized to guide therapy

E. Assess the patient’s circulation1. Assess the patient’s pulse and apply the AED or cardiac monitor when indicated

F. Proceed to the appropriate focused history and physical examination (trauma versus medical)

History and Physical—Medical Patient:

A. Responsive Medical Patients1. Assess complaints and signs or symptoms

a. O-P-Q-R-S-T(1) O-Onset(2) P-Provocation(3) Q-Quality(4) R-Radiation(5) S-Severity(6) T-Time

b. Obtain SAMPLE Historyc. Perform rapid assessmentd. Assess baseline vital signs

B. Unresponsive Medical Patients1. Position patient to protect airway 2. Perform rapid assessment3. Assess baseline vital signs 4. Obtain pertinent information from bystander, family, friends prior to leaving

History and Physical—Trauma Patient:

A. Consider mechanism of injury (refer to Level I and II Criteria)B. Perform rapid trauma assessment on patients to determine life-threatening injuriesC. Continue spinal stabilization (Spinal Immobilization and Immobilization Standards)D. Consider transport decisions (hospital capabilities, air vs. ground transport)E. Assess baseline vital signs



Detailed Physical Exam (Secondary Exam):

A. Detailed Physical Exam 1. Perform a detailed physical examination on the patient to gather additional information

a. As you inspect and palpate, look and/or feel for the following examples of injuries or signs of injury: (DCAP-BTLS)(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling

b. Assess the head, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling

c. Assess the face, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling

d. Assess the ears, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Drainage

e. Assess the eyes, inspect for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Discoloration(10) Unequal pupils(11) Foreign bodies(12) Blood in anterior chamber



f. Assess the nose, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Drainage (10) Bleeding

g. Assess the mouth, inspect for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Teeth (10) Obstructions(11) Swollen or lacerated tongue(12) Odors(13) Discoloration

h. Assess the neck, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Jugular vein distention (10) Crepitus

i. Assess the chest, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Crepitus (10) Paradoxical motion(11) Breath sounds in the apices, mid-clavicular line, bilaterally and at the bases,

mid-axillary line, bilaterally.(a) Present(b) Absent(c) Equal

j. Assess the abdomen, inspect and palpate for injuries or signs of injury: (1) D-Deformities(2) C-Contusions(3) A-Abrasions



(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Firm(10) Soft(11) Distended

k. Assess the pelvis, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) If the patient does not complain of pain or is unresponsive, gently flex and

compress the pelvis to determine stabilityl. Assess all four extremities, inspect and palpate for injuries or signs of injury:

(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling(9) Distal pulses(10) Sensation(11) Motor function

m. Roll with spinal precautions and assess posterior aspect of body, inspect and palpate for injuries or signs of injury:(1) D-Deformities(2) C-Contusions(3) A-Abrasions(4) P-Punctures/penetrations(5) B-Burns(6) T-Tenderness(7) L-Lacerations(8) S-Swelling

Triage Special Notes:

A. Do not let gathering of information distract you from management of life-threatening problemsB. Appropriate questioning can provide valuable information while establishing your authority, competence

and rapport with patientC. History is commonly obtained while performing secondary survey. Assistant is often used for gathering

information from patient or bystandersD. DO NOT FORGET TO USE BYSTANDERS to confirm information obtained from patient and to provide

facts when patient cannot. History from the scene is invaluable; you are the only one who can obtain thisE. Over-the-counter medications (including aspirin and birth control pills) are frequently overlooked by

patient and rescuerF. Consider medical causes for trauma, particularly in single-person accidents



Neurological Assessment:

Management of patients with head injury or neurologic illness depends on careful assessment of neurologic function. Changes in neurologic status are particularly important. The first observations of neurologic status in the field provide the basis for monitoring sequential changes. It is therefore important that the first responder accurately observe and record neurologic assessment, using these parameters which will be followed throughout the patient's hospital course.

The following are the important observations to be made as part of neurological assessment in the field.

A. Vital Signs:Observe particularly for adequacy of ventilation; depth; frequency and regularity of respirations

B. Level of Consciousness (GCS):

C. Eyes:1. Direction of gaze2. Size and reactivity of pupils

D. Movement:Observe whether all four extremities move equally well

E. Sensation:Observe for absent, abnormal or normal sensation at different levels if cord injury suspected



Vital Signs:

Vital signs including pulse, blood pressure, respirations, pulse oximetry, and temperature should be assessed prior to transport (within five minutes of patient contact) and reassessed during transport. Vital signs will be assessed as indicated by protocol and after each pharmacological intervention. Confirm all abnormal blood pressures with manual method. Reassessment of temperature is not required if the patient’s initial reading is within normal limits. A final set of vital signs documenting the patient’s condition upon arrival at the ED will be documented. All vital sign assessments will be documented completely in the patient care report.

Capnography:

If capnography is available, it should be used on all high acuity medical/trauma patients. When it is used, the readings should be documented at the same interval as the patient’s vital signs. The general goal for pCO2 should be in the range of 35-45 mmHg. In head injury patients, follow the guidelines outlined in the head injury section of these protocols.



Twelve Lead EKG:

**If patient meets below indication for EKG, then must be performed as soon as possible (Goal <5 minutes)**

Indication: 12-Lead acquisition is mandated by the EMS Medical Director on the following (if equipment is available):

1. Paramedic suspects cardiac etiology2. Previous cardiac history and symptoms3. Chest pain4. Dyspnea5. Syncope, dizziness and/or new onset seizure6. Bradycardia7. Tachycardia9. Abdominal pain (non-traumatic) (Age >35)10. Nausea and vomiting (Age >35)11. Diaphoresis12. Weakness (Age >35)13. Altered Mental Status14. Overdose/ingestion

Procedure:See EKG Skill

Precautions: A “normal” EKG does not definitively rule out cardiac etiology, nor should it be justification for non-treatment/transport

Reporting:1. The prehospital provider should relay significant 12-lead EKG changes to the receiving hospital’s ER2. All 12-lead EKG’s should be transmitted to the receiving hospital’s ER3. A copy of the 12-lead EKG will be left at the receiving hospital’s ER

Intravenous Access/Fluids:

A saline lock (with 10 ml NS flush) may be placed for prophylactic venous access and medication delivery. Normal Saline is an appropriate fluid when volume resuscitation is indicated. Volume resuscitation is generally best provided via 250-1000 cc bolus (Peds 20 cc/kg) followed by frequent reevaluation and potential re-bolus if needed depending on response. Use caution in patients with acute CHF and renal failure. A history of renal failure and/or CHF does not preclude a patient from receiving fluids. Refer to specific protocols where indicated.

Intraosseous access is warranted when a critical condition exists, the condition will rapidly worsen without medication and/or fluid administration, and intravenous access proves unsuccessful after two attempts or 90 seconds. May also consider external jugular venous access. IV medications can be given via the IO route. See Intraosseous Skill and External Jugular Skill



FACES Pain Scale:



Section Three: Medical Protocols



Section Three: Medical Protocols

Pain Management:

1. Initial therapy:

Refer to the Patient Assessment Section

2. Consider possible causes; below may be used for all types of pain (including abdominal pain)

3. Treatment options (may use a combination of TWO of the below medications): Morphine Sulfate 2-10 mg IV/IO; may repeat every 5 minutes (maximum 3 doses); 2-10 mg IM; may repeat every 15 minutes (maximum 3 doses) (may use if SBP > 100) OR Dilaudid 1-2 mg IV/IO; may repeat every 10 minutes (maximum 3 doses); 1-2 mg IM; may repeat every 15 minutes (maximum 3 doses) (may use if SBP > 100) OR

Ketamine 5-10 mg IV/IM/IO/IN; may repeat every 5-10 minutes (maximum 3 doses) (treatment of choice for hypotensive patient) OR

Fentanyl 1 mcg/kg IV/IO (max dose 100 mcg) or 2 mcg/kg IN (max dose 150 mcg); may repeat every 3-5 minutes (maximum 3 doses); 1 mcg/kg IM (max dose 100 mcg); may repeat every 15 minutes (maximum 3 doses) (may use if SBP > 90) OR Nitrous Oxide Apply and deliver until patient drops the mask

5. Consider capnography monitoring for patients receiving pain medications, especially with respiratory depression

**Pain medications should be used with caution in pregnancy and the risks/benefits should be explained to the patient. Pain medications should not be withheld from patients during pregnancy if the patient is in pain and understands the risks.

Contact Medical Control for further guidance if necessary



Nausea and Vomiting:

1. Initial therapy:


2. Consider possible causes

3. Treatment plan:

Zofran 4-8 mg slow IV/IM/IN/IO/PO OR

Reglan 5-10 mg slow IV/IM/IO OR Phenergan 12.5 mg IV/IO (in 100 or 250 cc bag of NS given slowly) or 25 mg IM (make sure this is given through IV site with low risk of extravasation)

If persistent nausea/vomiting symptoms despite Zofran, Reglan or Phenergan, may give a dose of another agent If patient develops a dystonic reaction with Reglan, may give Benadryl 25-50 mg IV/IM/IO

4. Consider IV access and NS fluid bolus for patient with prolonged symptoms or signs of dehydration (dry mucosa, tachycardia and/or hypotension




Non-Traumatic Shock:

1. Initial therapy:


2. If there is an unclear etiology of non-traumatic shock (SBP < 100 mmHg) then give a 500 cc NS fluid challenge

3. If the patient’s blood pressure does not improve with the fluid challenge, evaluate for cardiogenic shock (refer to Cardiogenic Shock Protocol)

4. If there is no evidence of cardiogenic shock and SBP remains < 100 mmHg, then repeat NS fluid bolus as needed

5. Consider the other causes of non-traumatic shock: a. Hemorrhage not associated with trauma (i.e. GI bleeding) b. Hypovolemia (i.e. dehydration) c. Septic shock d. Anaphylactic shock

6. Septic shock should be treated as per Sepsis Protocol

7. Anaphylactic shock should be treated as per Severe Allergic Reaction Protocol

8. Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg, if not responding to fluid bolus




Sepsis/Septic Shock:

1. Initial therapy:


2. Prehospital Criteria:

a. Presumed source of infection (most common include lung, skin, urine, abdomen, and CNS) b. Two or more of the following (SIRS Criteria): Temp > 101 or < 96.8 HR > 90 RR > 20 Altered Mental Status (from baseline) Glucose > 120 mg/dl (non-diabetic) 3. Large bore IV access (two if able), 12-lead EKG, O2 to keep sats > 94% (COPD > 92%), capnography and cardiac monitoring

4. IV fluids are the mainstay of pre-hospital EMS treatment, give 30 cc/kg NS bolus (For dialysis patients or patients in active pulmonary edema, IV NS fluid boluses should be administered in 250 cc amounts to maintain SBP > 100 mmHg; if increased respiratory distress with IV fluids, the fluids should be held) 5. If SBP < 100 mmHg then continue IV fluids bolus until SBP > 100 mmHg

6. Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg, if not responding to above fluid bolus (30 cc/kg) 7. Rapidly transport to the closest facility for continued treatment and IV antibiotics, notify ER staff of “Sepsis Alert”

**Septic shock is defined as persistent SBP < 90 after 30 cc/kg of fluids given




Altered Mental Status (AMS):

1. Initial therapy:


2. Consider possible causes of AMS: T - Trauma A - Alcohol

I - Infection E - Endocrine, Electrolyte P - Psychiatric I - Insulin

S - Stroke O - Overdose U - Uremia

3. Determine blood glucose level: If the blood glucose level is < 70 mg/dcl, refer to the Hypoglycemia Protocol If the blood gluocose level is > 250 mg/dcl, refer to the Hyperglycemia Protocol

4. IV access, 12-lead EKG, O2 to keep sats > 94% (COPD > 92%), capnography and cardiac monitoring

5. Consider Narcan 0.5-2 mg IV/IM/ET/IO or 2 mg IN if altered mentation with respiratory depression, may continue to repeat every 10 minutes if improvement

6. Refer appropriate protocol if indicated Overdose/Poisoning Protocol Sepsis Protocol CVA Protocol Trauma Protocol

7. IV NS fluid bolus to maintain SBP > 100 mmHg

8. Carefully monitor and document changes in LOC and vitals

9. If gag depressed, GCS < 8, and/or patient deemed to be unable to protect airway, then refer to Intubation/RSI protocol




Mild and Moderate Allergic Reactions:

Mild: Rash, itching, hives

Moderate: Dyspnea/wheezing/stridor, mild/moderate angioedema 1. Initial therapy:


2. Consider possible causes (i.e. medications, exposures)

3. Mild:

Consider IV access

Benadryl 25-50 mg IV/IM/IO

4. Moderate:

Obtain IV access Cardiac monitoring and consider capnography Consider NS fluid bolus Benadryl 50 mg IV/IM/IO Consider nebulized Albuterol 2.5 mg and Atrovent 500 mcg (Duoneb) if wheezing/dyspnea, may repeat 2 times Consider Solumedrol 125 mg IV/IO/IM 5. If no improvement and/or continued decompensation, proceed to Severe Allergic Reaction Protocol




Severe Allergic Reaction:

Severe: Severe dyspnea, severe angioedema, hypotension, altered mental status

1. Initial therapy:

Refer to the Patient Assessment Section:


3. Treatment plan: Consider airway intervention early Intubation/RSI protocol or Surgical Airway Skills Obtain IV access, capnography, cardiac monitoring and consider 2nd IV Racemic Epinephrine 0.5 ml for upper airway involvement and/or stridor Epinephrine 1:1,000 0.5 mg IM or administer one Adult Epinephrine Pen for upper airway involvement and/or stridor

May repeat Epinephrine every 5-10 minutes if needed

Administer NS fluid bolus to maintain SBP > 100 mmHg

Administer Benadryl 100 mg IV/IM/IO

Nebulized Albuterol 2.5 mg and Atrovent 500 mcg (Duoneb) if wheezing, may repeat 2 times

Administer Solumedrol 125 mg IV/IO/IM

Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg, if not responding to fluid bolus




Hypertensive Crisis:

1. Initial therapy:


2. IV access, 12-lead EKG and cardiac monitoring

3. Consider pharmacological interventions if patient’s systolic blood pressure is > 190 or diastolic blood pressure is > 100 with any or all of the following: acute pulmonary edema, hypertensive encephalopathy, headache, nausea and vomiting, chest pain, blurred vision, and/or altered mental status

4. Aim for a 25% decrease in blood pressure over the first hour and/or improvement of symptoms

5. Always consider pain as a reason for hypertension, refer to Pain Management Protocol

6. Treatment plan:

Administer Nitroglycerin 0.4 mg sublingual or Nitrospray Repeat every 5 minutes to reach above goals Avoid Nitroglycerin in patients with right ventricular infarct or CVA symptoms

OR Administer Labetalol 10-20 mg slow IV push; if needed may double the initial dose and give after 10 minutes Recommend Labetalol for patients with suspected intracranial hemorrhages or CVA (If high suspicion for intracranial hemorrhage, goal blood pressure of < 140/90)

7. Monitor for seizure, see Seizure Protocol

8. Rapid transport and patient reassurance




Intracranial Bleed/CVA/TIA:

1. Initial therapy:


2. Attempt to determine the last time patient known to be normal, IV access, consider capnography, 12-lead EKG and cardiac monitoring; place head of bed > 30 degrees if able

3. Determine blood glucose level: If the blood glucose level is < 70 mg/dcl, refer to the Hypoglycemia Protocol If the blood glucose level is > 250 mg/dcl, refer to the Hyperglycemia Protocol

4. Complete Cincinnati Stroke Scale (below):

5. Transport to the closest stroke center, make sure that the ER is notified as soon as possible

6. Reassure patient if conscious, remember that the patient may understand and hear all conversation even though they appear to be comatose or confused

7. Carefully monitor and document changes

8. For ischemic stroke patients, if BP is greater than 200/100 on two consecutive measurements, consider Labetalol 10-20 mg slow IV push; if needed may double the initial dose and give after 10 minutes (goal blood pressure of 185/110 is acceptable in ischemic CVA patients)

9. If high suspicion for non-traumatic intracranial hemorrhage/subarachnoid hemorrhage, consider Labetalol 10-20 mg slow IV push; if needed may double the initial dose and give after 10 minutes (goal blood pressure < 140/90)

10. Always consider Intubation/RSI protocol if airway is not intact




Diabetic Emergencies--Hyperglycemia:

1. Initial therapy:


2. Determine blood glucose level: If the blood glucose level is < 70 mg/dcl, refer to the Hypoglycemic Protocol If the blood glucose level is > 250 mg/dcl, follow below

3. Obtain IV access, consider capnography and 12-lead EKG

4. Give 1-2 L of NS and then administer fluid bolus to maintain SBP > 100 mmHg if needed

5. Pertinent history to obtain: Diabetic? If so, taking medications/insulin? Fever? Nausea/Vomiting? Polydipsia? Polyuria?




Diabetic Emergencies--Hypoglycemia:

1. Initial therapy:


2. Determine blood glucose level: If the blood sugar level is < 70 mg/dcl, then consider level of consciousness

3. Patient is able to control airway: Administer one tube of Oral Glucose Repeat as needed

4. Patient has altered mentation: Obtain IV access Consider Thiamine 100 mg IV/IM/IO (patient is malnourished or a suspected alcoholic)

Administer Dextrose 50% 25 grams IV May repeat up to 2 times if subsequent blood samples reveal a reading less than 70 mg/dcl

If unable to establish IV access, administer Glucagon 1 mg IM or 2 mg IN, then transport to emergency department

If Glucagon is unsuccessful, establish IO and put Dextrose 50% 25 grams into 1 L NS bag and run as a bolus

5. Carefully monitor and document changes in LOC and respirations

6. If the patient remains unresponsive to therapy, refer to the Altered Mental Status Protocol

**Patients who are going to be by themselves, take oral diabetes medications or are not responding to treatment, should always be

transported to the hospital for further evaluation/treatment




Environmental Emergencies--Hyperthermia:

Hyperthermia is defined as a core temperature greater than 102ºF

Heat stroke is defined as hyperthermia with hypotension, altered mental status, hypotension and/or tachycardia

1. Initial therapy:


2. Obtain IV access, cardiac monitoring, consider capnography and 12-lead EKG

3. Move to a cooler environment, remove excess clothing

4. Apply tepid compresses to forehead, neck, extremities

5. Administer 2 L NS fluid bolus, may repeat boluses to maintain SBP > 100 mmHg

6. In heat stroke, perform aggressive cooling with wet sheets and cold packs to the neck, axilla, and femoral regions

7. For active seizures, follow Seizure Protocols




Environmental Emergencies--Hypothermia:

Hypothermia is defined as a core temperature less than 95°F

1. Initial therapy:


2. Systemic: Refer to the appropriate dysrhythmia protocol as indicated by cardiac monitoring Carefully remove wet clothing (cut away, do not pull clothing off) Insulate from the cold, keep vehicle warm Wrap patient in warm blankets Apply heat packs to head, neck, chest, axilla, and groin Use IV re-warming units if available Provide gentle handling and transport ASAP Consider 12-lead EKG, cardiac monitoring and capnography depending on severity

3. Localized (Frostbite): Gently remove clothing from the affected area (cut away, do not pull clothing off) Protect area from pressure or friction (do not rub frost bite areas) Rewarm with blankets and body heat Assess for systemic hypothermia

Note: If the body temperature is less than 86°F, the heart may not respond to cardiac medications. Only one course of ACLS drugs should be given prior to the time the patient is warmed to 92°F




Hyperventilation:

1. Initial therapy:


2. Consider possible causes: Diabetic Ketoacidosis Metabolic Acidosis Carbon Monoxide Pulmonary Embolus Pneumothorax Aspirin Overdose Toxic Alcohol Poisoning

3. Pulse oximetry, consider cardiac monitoring 12-lead EKG and capnography

4. Coach respiratory rate and rhythm

5. If sufficient improvement is not seen in 5 minutes of coached breathing: Re-evaluate respiratory function Ensure adequate oxygenation (pulse ox) Determine blood glucose level Establish IV

6. If the patient is known to be hyperventilating from anxiety: Versed 1-2.5 mg IV/IO or 2.5 mg IN may repeat every 2-3 minutes (maximum three doses); 2.5 mg IM may repeat every 10-15 minutes (maximum two doses)




General Obstetrics Call:

1. Initial therapy:


2. Obtain relevant OB history: Number of previous pregnancies (Gravida) Number of times a viable fetus has been delivered (Para) Estimated date of conception Length of labor during previous pregnancy Frequency of contractions Maternal urge to push Crowning Prenatal care Number of babies in current gestation Are there any complications of this pregnancy or previous pregnancies

3. Conditions requiring immediate transport: Premature Rupture Of Membranes (PROM) Abnormal presentation, breech or transverse

4. Consider O2, IV access, fluid bolus (to keep SBP > 100 mmHg) and cardiac monitoring for any patient with abnormal vitals

For complications of delivery, refer to the Obstetrical Complications Protocol




Obstetrical Complications:

1. Initial therapy:


2. Obtain IV access and RAPID TRANSPORT

3. Possible Presentations:

Breech - Avoid delivery, if possible, and elevate mother's hips. If unavoidable, assist with delivery. If head will not deliver and spontaneous respirations occur, insert gloved hand with palm toward the infant's face. Form a "V" and gently push the vaginal wall away from the face to create an airway.

Prolapsed Cord - Avoid delivery, if possible. Insert two fingers of gloved hand to raise the presenting part of the fetus off of the cord, do not attempt to push the cord back, place the mother in a "knee/chest position".

Multiple Births - Deliver babies as directed in the Obstetrical Delivery Protocol, keep babies warm, consider an additional MICU

Uterine Rupture - Pain control, IV access, NS fluid bolus to maintain SBP > 100 mmHg; refer to Non-Traumatic Shock Protocol if needed

Uterine Inversion - Cover uterus with moist sterile dressing, pain control, IV access, NS fluid bolus to maintain SBP > 100 mmHg; refer to Non-Traumatic Shock Protocol if needed

Placenta Abruption/Placenta Previa - Pain control, IV access, NS fluid bolus to maintain SBP > 100 mmHg; refer to Non-Traumatic Shock Protocol if needed

Ectopic Pregnancy - Pain control, IV access, NS fluid bolus to maintain SBP > 100 mmHg; refer to Non-Traumatic Shock Protocol if needed

Shoulder Dystocia - Flex the patient’s thighs up to her abdomen, have your partner apply downward pressure to the pubic symphysis while you are applying downward traction on the fetus

For cardiac arrest, refer to the Pediatric Cardiac Arrest Protocol

If IV access needed, refer to the Intraosseous Insertion Skill or Umbilical Vein Cannulation Skill




Obstetrical Delivery:

1. Initial therapy:


2. Prepare for delivery; place mother in a supine position with head of bed at 30 degrees

3. Instruct the mother when it is appropriate to push

4. Apply gentle pressure to the baby's head to prevent explosive delivery

5. As soon as head delivers, suction the mouth and nose with a bulb suction device

6. Ensure that the cord is not around the neck (if it is, gently slip over the head, if possible, if it is too tight to slip over the head, apply two umbilical clamps and cut the cord)

7. Allow the infant's body to deliver

8. Note the time of birth

9. Clamp the cord four inches from the infant and place a second clamp two inches distal from the first clamp. Cut the cord between the clamps

10. Clean, dry, warm, position, and stimulate infant

11. Maintain the infant's body temperature with an insulating blanket

12. Record APGAR scores at 1 and 5 minutes

Element 0 Points 1 Point 2 Points SCOREAppearance(Skin Color)

Body and Extremities blue, pale

Body pink, hands/feet blue

Completely pink

Pulse rate absent < 100/min. ≥ 100/min.

Grimace(Irritability)

No response Grimaces Cough, sneeze, cries

Activity(Muscle tone)

Limp Some flexion of extremities

Active motion

Respiratory effort

None Slow and irregular Strong cry

TOTAL SCORE = TOTAL SCORE = TOTAL SCORE = TOTAL SCORE = TOTAL SCORE =

13. Allow placenta to deliver and place in a clean container for physician inspection

14. Massage the uterine fundus in a circular motion

15. Administer NS fluid bolus to maintain SBP > 100 mmHg; refer to Non-Traumatic Shock Protocol if needed

For complications of delivery, refer to the Obstetrical Complications ProtocolContact Medical Control for further guidance if necessary



Pre-eclampsia/Eclampsia:

1. Initial therapy:


2. Confirm history of pregnancy > 20 weeks

3. Position on left side and handle gently

4. Determine blood glucose level: If the blood glucose level is < 70 mg/dcl, refer to the Hypoglycemic Protocol If the blood glucose level is > 250 mg/dcl, refer to the Hyperglycemia Protocol

5. Establish IV access

6. PRE-ECLAMPSIA: (Abdominal pain, mental or visual status change, pitting edema, hyper-reflexia, BP > 140/90 ) If SBP > 160 mmHg and/or DBP > 110 mmHg and/or symptomatic: Magnesium Sulfate 4 grams IV/IO given over 5-10 minutes (may mix in 100 ml NS over 5-10 min) If after Magnesium Sulfate, SBP still > 160 mmHg and/or DBP > 110 mmHg and/or symptomatic: Labetalol 10-20 mg slow IV push; if needed may double the initial dose and give after 10 minutes 7. If nausea/vomiting, see the Nausea and Vomiting Protocol

8. ECLAMPSIA: (If actively seizing) Versed 2.5-5 mg IV/IO or 5 mg IN may repeat every 2-3 minutes (maximum three doses); 5 mg IM may repeat every 10-15 minutes (maximum two doses) Magnesium Sulfate 4-6 grams IV/IO given over 5-10 minutes (may mix in 100 ml NS over 5-10 min) Labetalol 10-20 mg slow IV push; if needed may double the initial dose and give after 10 minutes (If SBP > 160 mmHg and/or DBP > 110 mmHg)





Opthalmic Emergencies:

1. Initial therapy:


2. Treatment plan: Administer Alcaine 1-2 drops in affected eye(s) Do not use when laceration or global penetrations are present or suspected Do not allow the patient to rub their eyes once anesthetized as this may exacerbate existing injuries Slowly irrigate, if necessary, using NS with IV tubing or sterile water or saline flush Do not attempt to remove foreign bodies, if large, stabilize in position




Hyperkalemia/Renal Dialysis:

1. Do not take blood pressure or attempt IV sticks in the same area as a dialysis access 2. If IV initiation is unsuccessful after several attempts and emergent, you may consider initiating IV in a dialysis access (see Dialysis Catheter Access Skill)

3. These patients are predisposed to hyperkalemia, therefore always obtain a 12-lead EKG and continue cardiac monitoring

4. If the patient is in a brady-arrhythmia with wide QRS complex and pulse:

Administer Calcium Gluconate 1 gram IV/IO

Administer Sodium Bicarbonate 1 mEq/kg IV/IO, may repeat every 5 minutes

Administer Albuterol 2.5 mg (may also use Duoneb) via nebulizer, may repeat every 5 minutes

Consider Transcutaneous Pacing if above fails 5. If the patient is in cardiac arrest:

Calcium Gluconate 1 gram IV/IO

Sodium Bicarbonate 1 mEq/kg IV/IO, may repeat every 5 minutes

Albuterol 2.5 mg (may also use Duoneb) via ET tube, may repeat every 5 minutes

Follow Cardiac Arrest Protocols




Overdose/Poisoning: (Poison Control 1-800-222-1222)

1. Initial therapy:



3. If external contamination, then protect medical and rescue personnel. remove contaminated clothing, and brush off any solid material from skin


5. IV access, 12-lead EKG, capnography and cardiac monitoring

6. Consider Narcan 0.5-2 mg IV/IM/ET/IO or 2 mg IN if altered mentation with respiratory depression, may continue to repeat every 10 minutes if improvement



9. Specific Poison Therapies:

Cholinergic (Organo-Phosphate Insecticides): Salivation/Lacrimation/Urination/Defecation/G.I.Distress/Emesis = “SLUDGE” syndrome Atropine 2-3 mg IV/ET/IO, repeat every 5 minutes until secretions diminished Suction as needed For seizures, refer to Seizure Protocol

Tricyclic Antidepressants: Increased HR-first warning sign, increased BP-worsening, decreased BP (with possible ectopy, seizures, and cardiac arrest) Hyperventilate in assisting respiration Treat hypotension with fluid challenge per protocol. If tachycardia, dysrhythmias or widening QRS (> 0.1sec), administer Sodium Bicarbonate 1 mEq/kg IV/IO Intubate if needed for unstable vitals or for protection of airway For seizures, refer to Seizure Protocol

Common Tricyclic Antidepressants: Amitriptyline (Elavil, Tryptizol, Laroxyl) Amitriptylinoxide (Amioxid, Ambivalon, Equilibrin) Butriptyline (Evadyne) Clomipramine (Anafranil) Demexiptiline (Deparon, Tinoran) Desipramine (Norpramin, Pertofrane) Dibenzepin (Noveril, Victoril) Dimetacrine (Istonil, Istonyl, Miroistonil) Dosulepin/Dothiepin (Prothiaden) Doxepin (Adapin, Sinequan) Imipramine (Tofranil, Janimine, Praminil)



http://en.wikipedia.org/wiki/Amitriptyline

http://en.wikipedia.org/wiki/Amitriptyline

http://en.wikipedia.org/wiki/Amitriptylinoxide

http://en.wikipedia.org/wiki/Amitriptylinoxide

http://en.wikipedia.org/wiki/Butriptyline

http://en.wikipedia.org/wiki/Butriptyline

http://en.wikipedia.org/wiki/Clomipramine

http://en.wikipedia.org/wiki/Clomipramine

http://en.wikipedia.org/wiki/Demexiptiline

http://en.wikipedia.org/wiki/Demexiptiline

http://en.wikipedia.org/wiki/Desipramine

http://en.wikipedia.org/wiki/Desipramine

http://en.wikipedia.org/wiki/Dibenzepin

http://en.wikipedia.org/wiki/Dibenzepin

http://en.wikipedia.org/wiki/Dimetacrine

http://en.wikipedia.org/wiki/Dimetacrine

http://en.wikipedia.org/wiki/Dosulepin

http://en.wikipedia.org/wiki/Dosulepin

http://en.wikipedia.org/wiki/Doxepin

http://en.wikipedia.org/wiki/Doxepin

http://en.wikipedia.org/wiki/Imipramine

http://en.wikipedia.org/wiki/Imipramine

Imipraminoxide (Imiprex, Elepsin) Lofepramine (Lomont, Gamanil) Melitracen (Deanxit, Dixeran, Melixeran, Trausabun) Metapramine (Timaxel) Nitroxazepine (Sintamil) Nortriptyline (Pamelor, Aventyl, Norpress) Noxiptiline (Agedal, Elronon, Nogedal) Pipofezine (Azafen/Azaphen) Propizepine (Depressin, Vagran) Protriptyline (Vivactil) Quinupramine (Kevopril, Kinupril, Adeprim, Quinuprine) Cocaine: Hypertension, hyperthermia, mental status changes, seizures, agitation, chest pain, diaphoresis Treat symptoms with:

Versed 1-2.5 mg IV/IO or 2.5 mg IN may repeat every 2-3 minutes (maximum three doses); 2.5 mg IM may repeat every 10-15 minutes (maximum two doses) Beta-Blocker or Calcium Channel Blocker: call medical control for further guidance

Common Calcium Channel Blockers: Common Beta Blockers: Cardene Lopressor Verapamil Metoprolol Nicardipine Labetalol Cardizem Toprol Diltiazem Propanolol Norvasc Atenolol Procardia Sotalol Amlodipine Timolol Nifedipine Coreg Carvedilol

Contact Medical Control or Poison Control for further guidance if necessary



http://en.wikipedia.org/wiki/Imipraminoxide

http://en.wikipedia.org/wiki/Imipraminoxide

http://en.wikipedia.org/wiki/Lofepramine

http://en.wikipedia.org/wiki/Lofepramine

http://en.wikipedia.org/wiki/Melitracen

http://en.wikipedia.org/wiki/Melitracen

http://en.wikipedia.org/wiki/Metapramine

http://en.wikipedia.org/wiki/Metapramine

http://en.wikipedia.org/wiki/Nitroxazepine

http://en.wikipedia.org/wiki/Nitroxazepine

http://en.wikipedia.org/wiki/Nortriptyline

http://en.wikipedia.org/wiki/Nortriptyline

http://en.wikipedia.org/wiki/Noxiptiline

http://en.wikipedia.org/wiki/Noxiptiline

http://en.wikipedia.org/wiki/Pipofezine

http://en.wikipedia.org/wiki/Pipofezine

http://en.wikipedia.org/wiki/Propizepine

http://en.wikipedia.org/wiki/Propizepine

http://en.wikipedia.org/wiki/Protriptyline

http://en.wikipedia.org/wiki/Protriptyline

http://en.wikipedia.org/wiki/Quinupramine

http://en.wikipedia.org/wiki/Quinupramine

Psychiatric/Behavioral Emergencies:

1. Initial therapy:


2. Non-Violent Patient: No evidence of immediate danger Approach patient in a calm manner Show self-confidence and convey concern for patient Reassure patient that they should and will be taken to a hospital where there are people who are interested in helping Transport the patient as quickly as possible to an appropriate facility without causing harm If the patient appears to have a significant mental disorder and is refusing transport, consider police assistance Never stay alone with a psychiatric patient One crew member should establish rapport and deal with the patient

3. Violent and/or Suicidal/Homicidal Patient: Immediate danger to patient and/or EMS personnel Protect patient, yourself and others at the scene Always have enough help to restrain the violent patient Summon law enforcement for assistance when necessary 4. Determine blood glucose level: If the blood glucose level is < 70 mg/dcl, refer to the Hypoglycemic Protocol If the blood glucose level is > 250 mg/dcl, refer to the Hyperglycemia Protocol

5. Violent patients judged as unsafe for transport (possibility for injury to patient or EMS personnel) may be considered for physical/chemical restraints (Refer to the Physical/Chemical Restraint Protocol)

6. Medication options:

Versed 2.5-5 mg IV/IO or 5 mg IN may repeat every 2-3 minutes (maximum three doses); 5 mg IM may repeat every 10-15 minutes (maximum two doses) If the patient continues to be violent, Haldol 2-5 mg IV/IM/IN/IO (patient should be placed on cardiac monitor if Haldol given)

7. Always consider Intubation/RSI protocol if airway is not intact or if patient at high risk of injuring him/herself and/or staff despite above treatments




TASER Barb Removal:

1. Confirm that the TASER has been shut off and the barb cartridge has been disconnected from the TASER device

2. Initial therapy:

Refer to the Patient Assessment Section 3. Consider reasons for violent and combative behavior include intoxication, psychosis, hypoxia, hypoglycemia, overdose, or CNS infection

4. 12-lead EKG (if age over 40)

5. Treat trauma, hypoxia, hyper/hypoglycemia, cardiac etiologies and seizures, if applicable

6. Evaluate the anatomical location of the barb’s puncture zone(s). High-risk/sensitive zones will require transport to a medical facility for removal. Do not attempt to remove the barb(s) if they are lodged in the: a. Face or neck b. Groin/Genitals c. Spinal column d. Imbedded in a bone or joint

7. Barb Removal: a. Utilize appropriate PPE (gloves) b. Inform all caregivers of the intent to remove the contaminated sharp c. Remove one barb at a time d. Stabilize the skin surrounding the TASER barb e. Firmly grasp the barb and with one smooth hard jerk, remove barb from patient’s skin f. Visually examine the barb tip to ensure it is fully intact g. If any part of the barb remains in the subject, transport the patient to a medical facility for removal h. The TASER barb is considered a sharp and EMS personnel should take all precautions to avoid needle sticks i. Ensure the barb is placed in an appropriate container and return the barb/container to the law enforcement officer j. Provide wound care by cleansing the affected area with antiseptic and cover with an adhesive bandage k. Inform subject of basic wound care and the need to seek additional care in the event that signs of infection l. The subject will need a tetanus shot if he or she has not received one within the previous 5 years m. The subject must be transported to the hospital if he or she meets any of the following criteria: 1. Barb lodged in any of the above listed areas 2. Subject has a previous cardiac history 3. Subject appears intoxicated or non-compliant with direct instructions 4. If patient has any symptoms, abnormal vitals or abnormal 12-lead EKG (age over 40) 5. If patient does not meet Consent/Refusal of Transport Guidelines

n. Complete medical documentation is required whether or not EMS transports the subject

o. If emergency department evaluation is necessary, transport to the closest appropriate hospital




Respiratory Distress (Mild and Moderate):

Mild: Shortness of breath, wheezes, cough, tachypnea, increased respiratory effort, decreased air movement, normal O2 saturations (> 94%); normal capnography

Moderate: Abnormal O2 saturations (90-94%), capnography CO2 < 50 mmHg, accessory muscle use/retractions, difficult to complete sentences

1. Initial therapy:


2. Consider obtaining IV access, 12-lead EKG, capnography and cardiac monitoring

3. Always consider upper airway obstruction, if that is the case, use BLS choking maneuvers or Magill forcep removal

4. If clinical picture suggests CHF, then refer to CHF Protocol

5. If clinical picture suggests asthma or COPD, wheezing or poor air movement, then: Nebulize Albuterol 2.5 mg with Atrovent 500 mcg (Duoneb), may repeat 2 times Consider Solumedrol 125 mg IV/IO/IM If patient improves, maintain sats > 94% (COPD > 92%) with supplemental oxygen Consider 500 cc IV NS fluid bolus if no CHF suspicion, then TKO If no improvement, proceed to Severe Respiratory Distress Protocol




Respiratory Distress (Severe):

Severe: Impending respiratory failure, abnormal O2 saturations (< 90%), capnography CO2 > 50 mmHg, 1-3 syllable phrases, cyanosis, decreased LOC, hypotension (SBP < 100)

1. Initial therapy:


2. Obtain IV access, 12-lead EKG, capnography and cardiac monitoring


4. If clinical picture suggests CHF, then refer to CHF Protocol

5. If clinical picture suggests asthma or COPD, wheezing or poor air movement, then:

Nebulize Albuterol 2.5 mg with Atrovent 500 mcg (Duoneb), may repeat 2 times

Administer Solumedrol 125 mg IV/IO/IM

Consider starting CPAP (refer to CPAP Skill)(Albuterol/Atrovent (Duoneb) may also be given inline)

500 cc IV NS fluid bolus if no CHF suspicion, then TKO or NS bolus to maintain SBP > 100

6. Consider Racemic Epinephrine 0.5 ml for respiratory distress with stridor

7. If symptoms continue, then:

Magnesium Sulfate 2 grams slow IV/IO over 20 minutes (may mix in 100 ml NS over 20 min)

Epinephrine 1:1,000 0.5 mg IM (use ONLY for asthma, age < 50 and no history of cardiac disease) May repeat Epinephrine once in 10 minutes if no change 8. If still no improvement and above interventions have failed, then refer to the Intubation/RSI Skill




Seizures:

1. Initial therapy:


2. Obtain IV access, cardiac monitoring, capnography when able and 12-lead EKG if new onset seizure or age > 40


4. If pregnancy related, refer to Pre/Eclampsia Protocol

5. Consider possibility of head injury, overdose, fever, hypoxia or recurrent seizure and refer to appropriate protocol 6. Consider spinal immobilization (refer to Spinal Immobilization procedure and Immobilization Standards section)

7. Ensure patients experiencing febrile seizures are not excessively dressed

8. If still seizing: Versed 2.5-5 mg IV/IO or 5 mg IN may repeat every 2-3 minutes (maximum three doses); 5 mg IM may repeat every 10-15 minutes (maximum two doses)





Syncope:

1. Initial therapy:


2. Obtain IV access, 12-lead EKG and cardiac monitoring

3. Consider IV NS fluid bolus to maintain SBP > 100 mmHg, use caution with clinical picture of CHF


5. Refer to the appropriate dysrhythmia protocol as indicated by cardiac monitoring

6. Consider most common causes: a. Dysrhythmias b. Decreased cardiac output c. Hypovolemia d. Vagal response e. Orthostasis

7. Obtain pertinent history including: a. Circumstances of occurrence (patient’s position) b. Duration of episode c. Any symptoms before the episode d. Other associated symptoms e. Previous episodes of syncope f. Past medical history




Carbon Monoxide/Cyanide Poisoning:

Causes: Space heaters/stoves, water heaters, grills, house fires, cigarette smoke, gas/propane exhaust fumes, paints/solvents/degreasers

Symptoms: Tachycardia, hyper/hypotension, tachypnea, headache, dizziness, nausea/vomiting, pallor/”cherry-red skin”, pulmonary edema, memory disturbances/amnesia/confusion, seizures

1. Initial therapy:


2. Evacuate patient from surroundings

3. If cardiac monitor equipped, check the initial CO level of the patient 5-15% Mild--headache, dyspnea on exertion, dizziness 15-25% Moderate--fatigue, visual changes, nausea/vomiting, palpitations, tinnitus >25% Severe--altered mental status, angina/MI, seizures

4. Determine blood glucose level (if altered mentation): If the blood glucose level is < 70 mg/dcl, refer to the Hypoglycemic Protocol If the blood glucose level is > 250 mg/dcl, refer to the Hyperglycemia Protocol

5. Non-rebreather mask at 15 lpm (100% O2)

6. If symptoms not significantly improved with high-flow oxygen, consider cyanide toxicity, especially if cyanide detected on fire-scene, manufacturing facility, drug-house (meth-lab): Cyanokit Administration Hydroxocobalamin (see diagram below) 1. Place vial in an upright position 2. Add 200 ml of NS to the vial using the transfer spike, fill to line 3. Invert/rock vial for 60 seconds (do not shake) 4. Infuse 5 grams IV over 15 minutes (Pediatric Dose 70 mg/kg)



7. IV NS fluid bolus to maintain SBP > 100 mmHg 8. Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg, if not responding to fluid bolus

9. Consider Transcutaneous Pacing if needed

10. Consider 12-lead EKG/cardiac monitoring for patients with chest pain, dyspnea or altered mental status

11. For seizures, see Seizure Protocol

12. For nausea/vomiting, see Nausea/Vomiting Protocol

13. Transport all symptomatic CO poisonings to the closest appropriate hospital

** “Cherry-red skin” is often a late and un-reliable sign of CO poisoning, pulse oximetry is un-reliable and often misleading**




Snake Bites:

1. Initial therapy:


2. Obtain rapid/pertinent history (type of snake, any field treatment, previous anti-venom exposure)

3. Remove all jewelry and keep patient calm

4. Obtain IV access and maintain SBP > 100 mmHg with NS fluid bolus

5. Mark the wound size with the time of marking, and keep wound clean

6. Rapid transport

7. Manage pain with Adult Pain Management and Peds Pain Management protocols

**Do not use ice, wrap, tourniquet or apply suction to the wound**




Section Four: Cardiac Protocols



Section Four: Cardiac Protocols

Chest Pain:

1. Initial therapy:


2. Consider serious causes: a. Acute pericarditis/myocarditis b. Aortic dissection c. Pulmonary embolism d. Esophageal rupture e. Angina/MI f. Spontaneous pneumothorax

3. Obtain IV access (2 large bore for STEMI), O2 to keep sats > 94% (COPD > 92%), cardiac monitoring and 12-lead EKG

4. Beware of anginal equivalent symptoms such as nausea, indigestion, back pain, diaphoresis, dyspnea, etc.

5. If 12-lead EKG shows signs of STEMI, notify the accepting cardiac facility immediately to activate the cath lab

6. If your 12-lead EKG shows ST elevation or depression, obtain a 15-lead EKG to determine if there is right ventricular (V4R) or posterior wall (V8, V9) involvement (label your EKG accordingly)

7. Aspirin 324/325 mg PO (do not give if patient has history of GI bleeding in past 24 hours)

8. If right ventricular infarct is suspected on 15-lead EKG, DO NOT GIVE NITROGLYCERIN OR MORPHINE and instead administer NS fluid bolus to maintain SBP > 100 mmHg

9. If suspected cardiac chest pain and SBP > 100 mmHg, administer Nitroglycerin 0.4 mg SL or Nitrospray May repeat Nitroglycerin every 5 minutes (if improving the symptoms) (although IV access and 12 lead EKG are preferred prior to Nitroglycerin administration, a single Nitroglycerin dose may be given without IV access if SBP > 110) 10. For residual pain, Morphine Sulfate 2-4 mg IV; may repeat every 5 minutes as needed for pain (maximum three doses)

11. For nausea, refer to the Nausea/Vomiting Protocol

12. Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg, if not responding to fluid bolus

13. If chest pain caused by cocaine ingestion, consider: Versed 1-2.5 mg IV/IO or 2.5 mg IN may repeat every 2-3 minutes (maximum three doses); 2.5 mg IM may repeat every 10-15 minutes (maximum two doses)




Congestive Heart Failure (CHF):

1. Initial therapy:


2. Obtain IV access, 12-lead EKG, capnography and cardiac monitoring (if STEMI, notify accepting cardiac facility)

3. Place in seated position

Consider starting CPAP early (refer to CPAP Skill)

If CPAP not tolerated or contraindicated, then refer to the Intubation/RSI Skill

Consider Aspirin 324/325 mg PO (do not give if patient has history of GI bleeding in past 24 hours)

Nitroglycerin 0.4 mg SL or Nitrospray every 5 minutes until SBP < 140 mmHg

Lasix 40-80 mg IV after SBP < 140 mmHg and if SBP > 100 mmHg

If SBP < 90 mmHg, may use 250-500 ml NS bolus

Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg, if not responding to fluid bolus **Studies show that neb treatments in acute CHF patients may lead to higher rates of intubation, please use with caution; may consider in patients with wheezing and a history of asthma or COPD (please follow Respiratory Distress protocol for dosages)




Cardiogenic Shock:

1. Initial therapy:


2. Obtain IV, 12-lead EKG, capnography and cardiac monitoring (if STEMI, notify accepting cardiac facility)

3. Consider causes: a. Volume problem b. Rate problem c. Pump problem

4. If volume problem, consider NS fluid bolus to maintain SBP > 100 mmHg

5. If rate problem, refer to the appropriate protocol (Tachycardia or Bradycardia Protocol)

6. If pump problem, consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg




Atrial Fibrillation/Atrial Flutter with Rapid Ventricular Response:

1. Initial therapy:


2. Obtain IV access, 12-lead EKG, consider capnography and continue cardiac monitoring (if STEMI notify accepting cardiac facility)

3. For unstable patients, cardioversion should be performed (refer to the unstable portion of the Tachycardia Protocol)

4. For stable, narrow complex, irregular rhythm (rate > 110 bpm) Cardizem 10-20 mg slow IV push If rate still > 110 bpm after 5 minutes, may repeat dose




Adult Bradycardia:(HR < 50)

1. Initial therapy:Refer to the Patient Assessment Section

2. Always consider Treatable Causes

3. Support ABC’s, give oxygen, attach monitor/defibrillator, consider capnography and obtain 12-lead EKG

4. Is bradycardia still causing cardiorespiratory compromise (hypotension, AMS, shock, ischemia, CHF)? 5. If NO, continue to support ABC’s, give oxygen as needed, observe cardiac activity and transport 6. If YES: Atropine 0.5-1 mg IV/IO/ET, may repeat every 3-5 minutes (max 3 mg) If resistant, consider Transcutaneous Pacing (some blocks may be resistant to Atropine, especially if wide complex; may proceed to Transcutaneous Pacing) 7. Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg after above interventions 8. If patient improves, continue to support and transport

9. If patient develops pulseless cardiac arrest, refer to the Adult Cardiac Arrest Protocol




Adult Tachycardia:(HR > 150)



3. Support ABC’s, give oxygen, attach monitor/defibrillator, consider capnography and obtain 12-lead EKG

4. Is tachycardia still causing cardiorespiratory compromise (hypotension, AMS/ischemia with severe chest pain/SOB)?

5. If YES, Synchronized Cardioversion Consider sedation with Etomidate 0.1 mg/kg IV/IO Narrow Regular-- 50-100 J Narrow Irregular--120-200 J Biphasic Wide Regular--100 J Wide Irregular--Defibrillation Dose, Not Synchronized

6. If NO, evaluate the QRS duration

7. Is it a WIDE QRS (>= 0.12 sec)?

8. If YES, Amiodarone 150 mg IV/IO over 10 minutes (may mix in 100 ml NS over 10 min) If patient converts with Amiodarone, observe and transport, contact ER to notify to have Amiodarone drip prepared May repeat Amiodarone as above if patient returns to initial tachycardic rhythm If resistant to Amiodarone and still stable, then Adenosine 6 mg rapid IV bolus (with 20 cc NS bolus) May repeat with 12 mg rapid IV bolus (with 20 cc NS bolus) If patient converts with Adenosine observe and transport

9. If NO, Consider vagal maneuvers Adenosine 6 mg rapid IV bolus (with 20 cc NS bolus) May repeat with 12 mg rapid IV bolus (with 20 cc NS bolus) If resistant at any time appears irregular, may consider Cardizem 10-20 mg slow IV push

10. If patient develops pulseless cardiac arrest, refer to the Adult Cardiac Arrest Protocol




Adult Cardiac Arrest:


2. Perform CPR (100-120 compressions/min, hard and fast allowing full recoil) for 2 minutes

3. Ventilate via BVM with oxygen, attach monitor/defibrillator, establish IO/IV, establish advanced airway after 600 compressions (there are no trials to show clear benefit of IV fluids during cardiac arrest unless hypovolemia suspected; if suspected would give 1-2 L of NS)

4. Always consider Treatable Causes (may consider Sodium Bicarbinate 1 meq/kg IV/IO for all patients with unwitnessed arrests, prolonged downtime, dialysis patients or persistent PEA)

5. Shockable Rhythm?

6. If Shockable (VF/VT) (ALWAYS CONSIDER THE HIGHEST DEFIBRILLATION AMOUNT AVAILABLE)

Give 1 SHOCK (200-360 J Biphasic or AED) Resume CPR immediately (5 cycles/2 minutes) Shockable Rhythm?--if not refer to Unshockable (Asystole/PEA) Give 1 SHOCK (200-360 J Biphasic or AED) Resume CPR immediately (5 cycles/2 minutes) Epinephrine 1:10,000 1 mg IV/IO/ET (ET=2x IV/IO dose) (repeat every 3-5 minutes) Vasopressin 40 units IV/IO/ET (can replace 1st or 2nd Epinephrine dose, then continue with Epinephrine after 5 minutes)

Shockable Rhythm?--if not refer to Unshockable (Asystole/PEA) Give 1 SHOCK (200-360 J Biphasic or AED) Resume CPR immediately (5 cycles/2 minutes) Amiodarone 300 mg IV/IO; may repeat with 150 mg IV/IO once Consider Magnesium 2 grams IV/IO bolus for Torsades de Pointes Shockable Rhythm?-- continue Epinephrine/Vasopressin, Amiodarone, SHOCK and CPR If hypothermic, withhold Amiodarone until patient is warmed above 92 degrees If patient converts with Amiodarone, observe and transport, contact ER to notify to have Amiodarone drip prepared If return of spontaneous circulation (ROSC), continue supportive care Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg Refer to the Hypothermic Protocol after ROSC Protocol



7. If Unshockable (Asystole/PEA)

Epinephrine 1:10,000 1 mg IV/IO/ET (ET=2x IV/IO dose) (repeat every 3-5 minutes) Vasopressin 40 units IV/IO/ET (can replace 1st or 2nd Epinephrine dose, then continue with Epinephrine after 5 minutes) Resume CPR immediately (5 cycles/2 minutes) Shockable Rhythm?, refer to Shockable (VF/VT) Unshockable Rhythm?, continue Epinephrine/Vasopressin and CPR If return of spontaneous circulation (ROSC), continue supportive care Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < 90 mmHg Refer to the Hypothermic Protocol after ROSC Protocol

*Capnography goals should be 35-45 mmHg ideally; < 10 mmHg = inadequate CPR/ventilation/poor outcome




ROC Research Guidelines:

- 18 years and older- Must be non-traumatic cardiac arrest (i.e. no hangings, MVA’s, drownings, GSW/stabbings, etc.)- May use automatic CPR assist device after 10 minutes of manual CPR- Place pads on patient within first minute; keep monitor on paddle mode- First dose of Epinephrine/Vasopressin within 10 minutes- 600 compressions (6 minutes of CPR) before advanced airway (I-gel/ET Tube)- Avoid stopping CPR during advanced airway placement- Switch compression provider every 2 minutes- Do not move patient for first 10 minutes (concentrate on quality CPR)- 100-120 compressions per minute (use metronome)- 8-10 respirations per minute- Continuous chest compressions- Compressions must occur > 75% of the patient contact time- <5 second pre-shock pause- <5 second post-shock pause- Overall goal is never to be off the chest for > 10 seconds, unless moving the patient- Start hypothermia with ROSC- If EMS witnessed arrest with pads on the patients, then shock without delay

The overall goal is to perform quality CPR for the first 6 minutes, establish airway and then move the patient after 10 minutes.

**If the scene is unsafe in anyway, then do what is necessary to keep the crew and patient safe



Adult Treatable Causes:HypovolemiaHypoxia or ventilation problemsHydrogen ion (acidosis)Hypo/HyperkalemiaHypoglycemiaToxinsTamponade (cardiac)Tension pneumothoraxThrombosis (coronary or pulmonary)Trauma (hypovolemia, increased ICP)



Hypothermic Protocol after ROSC:

Indications:1. Adult (age > 18) medical cardiac arrests2. Persistent coma3. Less then one hour from collapse to ROSC4. Unable to follow simple commands (hold up one finger, wiggle toes, answer simple yes/no questions, etc)

Contraindications:1. Traumatic/hemorrhagic related arrests2. Apparent pregnancy3. Refractory cardiogenic shock (SBP<90)4. Initial temperature less than 34°C (93°F)5. Refractory ventricular arrhythmias6. Underlying terminal Illness

Procedure:1. Remove Clothing (undergarments may remain for patient privacy)2. Place ice packs into axilla and groin directly on skin for maximum cooling3. Rapidly infuse 30 mL/kg IV/IO cold saline (33-39°F) (maximum 2 L) via pressure infuser4. If patient begins to shiver, move or awaken, then: Versed 2.5-5 mg IV/IO or 5 mg IN may repeat every 2-3 minutes (maximum three doses); 5 mg IM may repeat every 10-15 minutes (maximum two doses)

Considerations:1. Transport should not be delayed for cooling2. If able, obtain initial temperature 3. If able, monitor patient temperature (goal temperature is 90°F - 93°F)4. Discontinue cooling if temperature is below 90°F.5. Avoid hyperventilation (keep ETCO2 levels around 40 mmHg)6. Chilled saline infusion takes precedence over ROSC drips7. Both liters of chilled saline may be given simultaneously8. Transport patient to facility who is able to continue the hypothermic treatment




Section Five: Pediatric Protocols



Section Five: Pediatric Protocols(Chart below is to be used for general references only, refer to protocols for exact dosages and medications carried)



Peds Dosing Resp/Allergic CardiacAmiodarone Adenosine Atropine Epi 1:1000 Epi 1:10,000 Mag Sulfate Mag Sulfate

Age (Approx) Lbs Kg 5 mg/kg 0.1 mg/kg 0.02 mg/kg 0.01 mg/kg 0.01 mg/kg 25 mg/kg 40 mg/kgTerm 7.5 3.4 17 0.35 0.1 0.04 0.04 85 135

6 Months 15 6.8 34 0.7 0.1 0.07 0.07 170 2751 Year 22 10 50 1 0.2 0.1 0.1 250 4003 Years 33 15 75 1.5 0.3 0.15 0.15 375 6006 Years 44 20 100 2 0.4 0.2 0.2 500 8008 Years 55 25 125 2.5 0.5 0.25 0.25 625 100010 Years 66 30 150 3 0.6 0.3 0.3 750 120011 Years 77 35 175 3.5 0.7 0.3 0.35 875 140012 Years 88 40 200 4 0.8 0.3 0.4 1000 160014 Years 99 45 225 4.5 0.9 0.3 0.45 1125 1800

Sodium Bicarb Narcan D 25% D 50% Fluid Bolus BenadrylAge (Approx) Lbs Kg 1 meq/kg 0.1 mg/kg 4 ml/kg (0-2 yrs) 2 ml/kg (>2 yrs) 20 cc/kg 1 mg/kg

Term 7.5 3.4 3.5 0.35 14 7 70 3.56 Months 15 6.8 7 0.7 28 14 150 7

1 Year 22 10 10 1 40 20 200 103 Years 33 15 15 1.5 60 30 300 156 Years 44 20 20 2 80 40 400 208 Years 55 25 25 2 100 50 500 2510 Years 66 30 30 2 120 60 600 3011 Years 77 35 35 2 140 70 700 3512 Years 88 40 40 2 160 80 800 4014 Years 99 45 45 2 180 90 900 45

Zofran Reglan Fentanyl Fentanyl Dilaudid Morphine Ketamine KetamineAge (Approx) Lbs Kg 0.1 mg/kg 0.1 mg/kg 1 mcg/kg 2 mcg/kg 0.015 mg/kg 0.1 mg/kg 0.1 mg/kg 0.5 mg/kg

Term 7.5 3.4 0.35 0.35 3.5 7 0.1 0.35 0.35 1.76 Months 15 6.8 0.7 0.7 7 14 0.1 0.7 0.7 3.5

1 Year 22 10 1 1 10 20 0.2 1 1 53 Years 33 15 1.5 1.5 15 30 0.2 1.5 1.5 7.56 Years 44 20 2 2 20 40 0.3 2 2 108 Years 55 25 2.5 2.5 25 50 0.4 2.5 2.5 1010 Years 66 30 3 3 30 60 0.5 3 3 1011 Years 77 35 3.5 3.5 35 70 0.5 3.5 3.5 1012 Years 88 40 4 4 40 80 0.6 4 4 1014 Years 99 45 4 4.5 45 90 0.7 4.5 4.5 10

Versed Versed Solumedrol Defibrillation Defibrillation Cardioversion CardioversionAge (Approx) Lbs Kg 0.1 mg/kg 0.2 mg/kg 2 mg/kg 2 J/kg 4 J/kg 0.5 J/kg 1 J/kg

Term 7.5 3.4 0.35 0.70 7 7 14 2 36 Months 15 6.8 0.7 1.5 14 14 27 3 7

1 Year 22 10 1 2 20 20 40 5 103 Years 33 15 1.5 3 30 30 60 8 156 Years 44 20 2 4 40 40 80 10 208 Years 55 25 2.5 5 50 50 100 13 2510 Years 66 30 3 5 60 60 120 15 3011 Years 77 35 3.5 5 70 70 140 18 3512 Years 88 40 4 5 80 80 160 20 4014 Years 99 45 4.5 5 90 90 180 23 45

Age (Approx) Lbs Kg ET Tube Suction Cath HR Resp Rate Sys BpPreterm 3 1.4 2.5, 3.0 140 40-60 50-60

Term 7.5 3.4 3.5 8 Fr 125 40-60 60-706 Months 15 6.8 3.5 8 Fr 120 24-36 60-120

1 Year 22 10 4.0 8 Fr 120 22-30 65-1253 Years 33 15 4.5 8 Fr 110 20-26 1006 Years 44 20 5.5 10 Fr 100 20-24 1008 Years 55 25 6.0 10 Fr 90 18-22 10510 Years 66 30 6.5 10 Fr 90 18-22 11011 Years 77 35 6.5 10 Fr 85 16-22 11012 Years 88 40 7.0 10 Fr 85 16-22 11514 Years 99 45 7.0 10 Fr 80 14-20 115

Pediatric Pain Management:

1. Initial therapy:

Refer to the Broselow Pediatric Emergency Tape for determination of patient weightRefer to the Patient Assessment Section/See Pediatric Dosing Chart

2. Consider possible causes; below may be used for all types of pain (including abdominal pain)

3. Treatment options (may use a combination of TWO of the below medications): Morphine Sulfate 0.1 mg/kg IV/IO (max dose 10 mg); may repeat every 5 minutes (maximum 3 doses); 0.1 mg/kg IM (max dose 10 mg); may repeat every 15 minutes (maximum 3 doses) (may use if SBP > 100) OR Dilaudid 0.015 mg/kg IV/IO (max dose 2 mg); may repeat every 10 minutes (maximum 3 doses); 0.015 mg/kg IM (max dose 2 mg); may repeat every 15 minutes (maximum 3 doses) (may use if SBP > 100) OR Fentanyl 1 mcg/kg IV/IO (max dose 100 mcg) or 2 mcg/kg IN (max dose 150 mcg); may repeat every 3-5 minutes (maximum 3 doses); 1 mcg/kg IM (max dose 100 mcg); may repeat every 15 minutes (maximum 3 doses) (may use if SBP > 90) OR Ketamine 0.1-0.5 mg/kg (max dose 10 mg) IV/IM/IO/IN; may repeat every 5-10 minutes (maximum 3 doses) (treatment of choice for hypotensive patient) OR

Nitrous Oxide Apply and deliver until patient drops the mask

5. Consider capnography monitoring for patients receiving pain medications, especially with respiratory depression




Pediatric Nausea and Vomiting:

1. Initial therapy:



3. Treatment plan: Zofran 0.1 mg/kg (up to 4 mg) IV/IM/IN/IO/PO OR

Reglan 0.1 mg/kg (up to 10 mg) IV/IM/IO

If persistent nausea/vomiting symptoms despite Zofran or Reglan may give a dose of the other agent

If patient develops a dystonic reaction with Reglan, may give Benadryl 1 mg/kg IV/IM/IO (50 mg maximum)

4. Consider IV access and NS fluid bolus (20 cc/kg) for patient with prolonged symptoms or signs of dehydration




Pediatric Hyperventilation:

1. Initial therapy:


2. Consider possible causes: Diabetic Ketoacidosis Metabolic Acidosis Carbon Monoxide Pulmonary Embolus Pneumothorax Aspirin Overdose Toxic Alcohol Poisoning

3. Pulse oximetry, capnography, cardiac monitoring and consider 12-lead EKG

4. Coach respiratory rate and rhythm

5. If sufficient improvement is not seen in 5 minutes of coached breathing: Re-evaluate respiratory function Ensure adequate oxygenation (pulse ox) Determine blood glucose level Establish IV

6. If the patient is known to be hyperventilating from anxiety:

Versed 0.1 mg/kg IV/IO (max dose 2.5 mg) or 0.2 mg/kg IN (max dose 2.5 mg) may repeat every 5 minutes (maximum two doses); 0.2 mg/kg IM (max dose 2.5 mg) may repeat every 10-15 minutes (maximum two doses)




Pediatric Altered Mental Status (AMS):

1. Initial therapy:


2. Consider possible causes of AMS: T - Trauma A - Alcohol

I - Infection E - Endocrine, Electrolyte P - Psychiatric I - Insulin

S - Stroke O - Overdose U - Uremia

3. Determine blood glucose level: If the blood glucose level is < 80 mg/dcl, refer to the Pediatric Hypoglycemic Protocol If the blood glucose level is > 250 mg/dcl, refer to the Pediatric Hyperglycemia Protocol

4. IV access, 12-Lead EKG, capnography and cardiac monitoring

5. Consider Narcan 0.1 mg/kg (up to 2 mg) IV/IM/ET/IO/IN if altered mentation with respiratory depression, may continue to repeat every 10 minutes if improvement

6. Refer to Pediatric Overdose/Poisoning Protocol if indicated

7. Consider arrhythmia and trauma (refer to Trauma Protocols or Pediatric Cardiac Related Protocols)

8. Carefully monitor and document changes in LOC and vitals

9. If gag depressed, GCS < 8, and/or patient deemed to be unable to protect airway, then refer to Intubation/RSI Skill




Pediatric Mild and Moderate Allergic Reactions:

Mild: Rash, itching, hives

Moderate: Dyspnea/wheezing, mild/moderate angioedema 1. Initial therapy:



3. Mild: Consider IV access Benadryl 1 mg/kg IV/IM/IO (25 mg maximum)

4. Moderate:

Obtain IV access Cardiac monitoring and consider capnography

Consider 20 cc/kg NS fluid bolus

Benadryl 1 mg/kg IV/IM/IO (50 mg maximum)

Consider nebulized Albuterol 2.5 mg and Atrovent 500 mcg (Duoneb) if wheezing/dyspnea, may repeat 2 times (If age < 1, use half dose Albuterol/Atrovent or half dose Duoneb)

Consider Solumedrol 2 mg/kg (125 mg maximum) IV/IO/IM

5. If no improvement and/or continued decompensation, proceed to Pediatric Severe Allergic Reaction Protocol




Pediatric Severe Allergic Reaction:

Severe: Severe dyspnea, severe angioedema, hypotension, altered mental status 1. Initial therapy:



3. Treatment plan: Consider airway intervention early Intubation/RSI protocol or Surgical Airway Skills Obtain IV access, capnography, cardiac monitoring and consider 2nd IV Racemic Epinephrine 0.05 ml/kg (0.5 ml maximum)(< 4 years old), 0.5 ml (> 4 years old) for upper airway involvement and/or stridor Epinephrine 1:1,000 0.01 mg/kg IM (0.3 mg maximum) or administer one Pediatric Epinephrine Pen for upper airway involvement and/or stridor May repeat Epinephrine every 5-10 minutes if needed Administer 20 cc/kg NS fluid bolus and maintain SBP > (70 + 2x Age) Benadryl 1 mg/kg IV/IM/IO (50 mg maximum)

Nebulized Albuterol 2.5 mg and Atrovent 500 mcg (Duoneb) if wheezing, may repeat 2 times (If age < 1, use half dose Albuterol/Atrovent or half dose Duoneb)

Administer Solumedrol 2 mg/kg (125 mg maximum) IV/IO/IM

Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < (70 + 2x Age), if not responding to fluid bolus

4. If no improvement, consider intubation (early intubation is paramount as laryngeal edema and spasm can progress rapidly)




Pediatric Diabetic Emergencies--Hyperglycemia:

1. Initial therapy:


2. Determine blood glucose level: If the blood glucose level is < 80 mg/dcl, refer to the Pediatric Hypoglycemic Protocol If the blood glucose level is > 250 mg/dcl, follow below

3. Obtain IV access, consider capnography and administer NS fluid bolus (20 cc/kg) and repeat to maintain SBP > (70 + 2x Age)

4. Pertinent history to obtain: Diabetic? If so, taking medications/insulin? Fever? Nausea/Vomiting? Polydipsia? Polyuria?




Pediatric Diabetic Emergencies--Hypoglycemia:

1. Initial therapy:


2. Determine blood glucose level: If the blood sugar level is < 80 mg/dcl, then consider level of consciousness

3. Patient is able to control airway:

Administer one tube of Oral Glucose Repeat as needed

4. Patient has altered mentation:

Obtain IV access

Thiamine (> 12 yo) 10-25mg IV/IM/IO (if the patient is malnourished)

Dextrose 25% 4 ml/kg IV/IO (0-2 years old); Dextrose 50% 2 ml/kg IV/IO (> 2 years old) May Repeat Dextrose up to two times if needed to keep blood glucose > 80 mg/dl

If unable to establish IV access, give Glucagon 0.5 mg IM or 1 mg IN (< 20 kg), 1 mg IM or 2 mg IN (> 20 kg) and transport to the hospital 5. Carefully monitor and document changes in LOC and respirations

6. If the patient remains unresponsive to therapy, refer to the Pediatric Altered Mental Status Protocol

**Patients who are going to be by themselves, take oral diabetes medications or are not responding to treatment, should always be

transported to the hospital for further evaluation/treatmentContact Medical Control for further guidance if necessary



Pediatric Environmental Emergencies--Hyperthermia:

Hyperthermia is defined as a core temperature greater than 102ºF

Heat stroke is defined as hyperthermia with hypotension, altered mental status, hypotension and/or tachycardia

1. Initial therapy:


2. Obtain IV access, cardiac monitoring, consider capnography and 12-lead EKG

3. Move to a cooler environment, remove excess clothing

4. Apply tepid compresses to forehead, neck, extremities

5. In heat stroke, administer NS fluid bolus (20 cc/kg) NS and repeat to maintain SBP > (70 + 2x Age)

6. In heat stroke, perform aggressive cooling with wet sheets and cold packs to the neck, axilla, and femoral regions

7. For active seizures, follow Seizure Protocols




Pediatric Environmental Emergencies--Hypothermia:

Hypothermia is defined as a core temperature less than 95°F

1. Initial therapy:


2. Systemic: Refer to the appropriate dysrhythmia protocol as indicated by cardiac monitoring Carefully remove wet clothing (cut away, do not pull clothing off) Insulate from the cold, keep vehicle warm Wrap patient in warm blankets Apply heat packs to head, neck, chest, axilla, and groin Use IV re-warming units if available Provide gentle handling and transport ASAP Consider 12-lead EKG, cardiac monitoring and capnography depending on severity

3. Localized (Frostbite): Gently remove clothing from the affected area Protect area from pressure or friction Rewarm with blankets and body heat Assess for systemic hypothermia

Note: If the body temperature is less than 86°F, the heart may not respond to cardiac medications. Only one course of PALS drugs should be given prior to the time the patient is warmed to 92°F




Pediatric Seizures:

1. Initial therapy:


2. Obtain IV access, cardiac monitoring, capnography when able and 12-lead EKG if new onset seizure


4. Consider possibility of head injury, overdose, fever, hypoxia or recurrent seizure and refer to appropriate protocol 5. Consider spinal immobilization (refer to Spinal Immobilization procedure and Immobilization Standards section)

6. Ensure patients experiencing febrile seizures are not excessively dressed

7. If still seizing: Versed 0.1 mg/kg IV/IO (max dose 5 mg) or 0.2 mg/kg IN (max dose 5 mg) may repeat every 2-3 minutes (maximum three doses); 0.2 mg/kg IM (max dose 5 mg) may repeat every 10-15 minutes (maximum two doses)




Pediatric Overdose/Poisoning: (Poison Control 1-800-222-1222)

1. Initial therapy:



3. If external contamination, then protect medical and rescue personnel. remove contaminated clothing, and brush off any solid material from skin


5. IV access, 12-lead EKG, capnography and cardiac monitoring

6. Treat hypotension with NS fluid bolus to maintain SBP > (70 + 2x Age) Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < (70 + 2x Age), if not responding to fluid bolus

7. Consider Narcan 0.1 mg/kg IV/IM/ET/IO/IN if altered mentation with respiratory depression, may continue to repeat every 10 minutes if improvement


9. If gag depressed and patient deemed to be unable to protect airway, then establish and protect airway

10. Specific Poison Therapies:

Cholinergic (Organo-Phosphate Insecticides): Salivation/Lacrimation/Urination/Defecation/G.I.Distress/Emesis = “SLUDGE” syndrome Atropine 0.02 mg/kg IV/ET/IO, repeat every 5 minutes until secretions diminished Suction as needed For active or repetitive seizures, refer to Pediatric Seizure Protocol

Tricyclic Antidepressants: Increased HR-first warning sign, increased BP-worsening, decreased BP (with possible ectopy, seizures, and cardiac arrest) Hyperventilate in assisting respiration If tachycardia, dysrhythmias or widening QRS (> 0.1sec), administer Sodium Bicarbonate 1 meq/kg IV/IO See adult Overdose/Poisoning Protocol for common tricyclic medications

Cyanide Poisoning (Odor of bitter almonds): See Carbon Monoxide/Cyanide Protocol

Beta-Blocker or Calcium Channel Blocker: call medical control for further guidance See adult Overdose/Poisoning Protocol for common Beta-Blocker and Calcium Channel Blocker medications

Contact Medical Control or Poison Control for further guidance if necessary



Pediatric Respiratory Distress (Mild To Moderate):

Mild to Moderate: Shortness of breath, wheezes, cough, tachypnea, increased respiratory effort, mild retractions, decreased air movement, normal to slightly abnormal O2 saturations (> 94-100%), able to complete long phrases/sentences, normal capnography

1. Initial therapy:


2. Consider obtaining IV access, capnography and cardiac monitoring if patient moderate or worsening


4. If clinical picture suggests asthma/bronchiolitis and/or wheezing/poor air movement:

Nebulized Albuterol 2.5 mg and Atrovent 500 mcg (Duoneb) May repeat Albuterol/Atrovent twice (If age < 1, use half dose Albuterol/Atrovent or half dose Duoneb)

Consider Solumedrol 2 mg/kg (125 mg maximum) IV/IO/IM

If patient improves, maintain sats > 94% with supplemental oxygen

Consider NS fluid bolus (20 cc/kg)

If no improvement, proceed to Pediatric Respiratory Distress (Severe) Protocol




Pediatric Respiratory Distress (Severe):

Severe: Impending respiratory failure, grunting, severe retractions/accessory muscle use, abnormal O2 saturations (< 93%), capnography CO2 > 50 mmHg, 1-3 syllable phrases, cyanosis, decreased LOC, hypotension (SBP < 70 mmHg or 70 + 2x Age)

1. Initial therapy:


2. Obtain IV access, capnography and cardiac monitoring


4. If clinical picture suggests asthma or bronchiolitis with wheezing and/or poor air movement, then:

Nebulized Albuterol 2.5 mg and Atrovent 500 mcg (Duoneb) May repeat Albuterol/Atrovent twice (If age < 1, use half dose Albuterol/Atrovent or half dose Duoneb)

Administer Solumedrol 2 mg/kg (125 mg maximum) IV/IO/IM

Consider CPAP if age appropriate (CPAP Skill)(Albuterol/Atrovent (Duoneb) may also be given inline)

Administer NS fluid bolus (20 cc/kg)

5. Consider Racemic Epinephrine 0.05 ml/kg (0.5 ml maximum)(< 4 years old), 0.5 ml (> 4 years old) for respiratory distress with stridor

6. If symptoms continue, then:

Magnesium Sulfate 25-40 mg/kg IV/IO (2 g maximum) over 20 minutes (may mix in 100 ml NS over 20 min)

Epinephrine 1:1,000 0.01 mg/kg IM (0.3 mg maximum) May repeat Epinephrine once in 10 minutes if no change 7. If still no improvement and above interventions have failed, then refer to the Intubation/RSI Skill




Pediatric Bradycardia:

1. Initial therapy:



3. Support ABC’s, give oxygen, consider capnography and attach monitor/defibrillator

4. Is bradycardia still causing cardiorespiratory compromise? If NO, continue to support ABC’s, give oxygen as needed, observe and transport If YES:

Perform CPR (100/min, hard and fast allowing full recoil) if HR < 60/min

Epinephrine 1:10,000 0.01 mg/kg IV/IO or 1:1000 0.1 mg/kg ET (repeat every 3-5 minutes)

If resistant, consider Atropine 0.02 mg/kg IV/IO/ET (max 1 mg)

If resistant, consider Transcutaneous Pacing 5. If patient improves, continue to support and transport

6. If patient develops pulseless cardiac arrest, refer to the Pediatric Cardiac Arrest Protocol




Pediatric Tachycardia:

1. Initial therapy:

Refer to the Broselow Pediatric Emergency Tape for determination of patient weightRefer to the Patient Assessment Section/See Pediatric Dosing Chart2. Always consider Treatable Causes3. Support ABC’s, give oxygen, consider capnography and attach monitor/defibrillator4. Unstable tachycardia if causing cardiorespiratory compromise (hypotension, AMS)5. Obtain 12-lead EKG6. Evaluate the QRS duration7. Is it a NARROW QRS (<= 0.09 sec)?

Is it Sinus Tachycardia? - P waves present/normal - Variable R-R, constant P-R - Infants: Rate usually < 220/min - Children: Rate usually < 180/min - Search for and treat cause (dehydration, fever, ingestion, etc) If Sinus Tachycardia: Consider 20 cc/kg NS bolus If fever, consider up-wrapping child If suspicion of ingestion, see Pediatric Overdose/Poisoning protocol Is it SVT? - Does patient have history of SVT? - P waves absent - Heart rate not variable - Infants: Rate usually > 220/min - Children: Rate usually > 180/min If SVT: Consider vagal maneuvers If stable, Adenosine 0.1 mg/kg (max 6 mg) rapid IV bolus (with 10 cc NS bolus) If resistant, may double first dose (max 12 mg) If still resistant, Amiodarone 5 mg/kg IV/IO over 20 minutes If unstable, Synchronized Cardioversion 0.5-1 J/kg If resistant and still unstable, increase to 2 J/kg Consider sedation with Etomidate 0.1 mg/kg IV/IO

8. Is it a WIDE QRS (>= 0.09 sec)? If possible V-Tach: If stable, Amiodarone 5 mg/kg IV/IO over 20 minutes If patient converts with Amiodarone, observe and transport, contact ER to notify to have Amiodarone drip prepared If patient returns to initial rhythm, may repeat Amiodarone 5 mg/kg IV/IO over 20 minutes If still stable and resistant to Amiodarone, attempt Adenosine 0.1 mg/kg (max 6 mg) rapid IV bolus (with 10 cc NS bolus) If unstable, Synchronized Cardioversion 0.5-1 J/kg If resistant, increase to 2 J/kg Consider sedation with Etomidate 0.1 mg/kg IV/IO9. If patient develops pulseless cardiac arrest, refer to the Pediatric Cardiac Arrest Protocol




Pediatric Cardiac Arrest:

1. Initial therapy:


2. Perform CPR (100-120 compressions/min, hard and fast allowing full recoil)

3. Support ABC’s, give oxygen, attach monitor/defibrillator, establish IO/IV, establish airway after 600 compressions

4. Always consider Treatable Causes (may consider Sodium Bicarbinate 1 meq/kg IV/IO for all patients with unwitnessed arrest, prolonged downtime or persistent PEA)

5. Shockable Rhythm?

6. If Shockable (VF/VT)

Give 1 SHOCK (Manual 2 J/kg or AED > 1 year of age) Resume CPR immediately (5 cycles/2 minutes) Shockable Rhythm?--if not refer to Unshockable (Asystole/PEA) Give 1 SHOCK (Manual 4 J/kg or AED > 1 year of age) Resume CPR immediately (5 cycles/2 minutes) Epinephrine 1:10,000 0.01 mg/kg IV/IO or 1:1000 0.1 mg/kg ET (repeat every 3-5 minutes) Shockable Rhythm?--if not refer to Unshockable (Asystole/PEA) Give 1 SHOCK (Manual 4 J/kg or AED > 1 year of age) Resume CPR immediately (5 cycles/2 minutes) Amiodarone 5 mg/kg IV/IO; may repeat same dose once Consider Magnesium 25-50 mg/kg IV/IO bolus (maximum 2 g) for Torsades de Pointes Shockable Rhythm?-- continue Epinephrine, Amiodarone, SHOCK and CPR If hypothermic, withhold Amiodarone until patient is warmed above 92 degrees If patient converts with Amiodarone, observe and transport, contact ER to notify to have Amiodarone drip prepared If return of spontaneous circulation (ROSC), continue supportive care Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < (70 + 2x Age) 7. If Unshockable (Asystole/PEA) Epinephrine 1:10,000 0.01 mg/kg IV/IO or 1:1000 0.1 mg/kg ET (repeat every 3-5 minutes) Resume CPR immediately (5 cycles/2 minutes) Shockable Rhythm?, refer to Shockable (VF/VT) Unshockable Rhythm?, continue Epinephrine and CPR If return of spontaneous circulation (ROSC), continue supportive care Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP < (70 + 2x Age)

**Capnography goals should be 35-45 mmHg ideally; < 10 mmHg = inadequate CPR/ventilation




Pediatric Treatable Causes:

HypovolemiaHypoxia or ventilation problemsHydrogen ion (acidosis)Hypo/HyperkalemiaHypoglycemiaToxinsTamponade (cardiac)Tension pneumothoraxThrombosis (coronary or pulmonary)Trauma (hypovolemia, increased ICP)



Section Six: Trauma Protocols



Section Six: Trauma Protocols

General Trauma Recommendations:

1. Initial therapy:


2. Large bore IV access x 2, cardiac monitor, pulse ox, O2 to maintain sats > 94%, and capnography when indicated

3. Spinal immobilization (refer to Spinal Immobilization procedure and Immobilization Standards section)

4. Adults--2 L NS fluid bolus to maintain SBP > 90 mmHg

5. Pediatrics--NS fluid bolus (20 cc/kg) to maintain SBP > (70 + 2x Age)

6. Consider Epinephrine Push Dose Pressor 0.5-2 ml every 2-5 minutes IV for SBP goal of 90 mmHg (Peds=SBP < (70 + 2x Age)), if not responding to adequate trauma fluid resuscitation

7. Manage nausea and vomiting with Adult Nausea/Vomiting and Peds Nausea/Vomiting protocols

8. Manage pain with Adult Pain Management and Peds Pain Management protocols

9. If altered mentation, refer to the Adult AMS and Pediatric AMS protocols (some trauma may have been caused by a medical event)

10. If intubation/RSI indicated, refer to the Intubation/RSI Skill

11. Establish Trauma Designation and transport as soon as possible to the most Appropriate Facility and notify them

12. All blunt trauma arrests should be transported the closest facility; all penetrating trauma arrests should be transported to the closest appropriate Trauma Center

13. All pregnant trauma patients should be have appropriate spinal immobilization and placed left lateral as best as possible

14. Refer to below sections for specific information: a. Amputations b. Burns/Electrical c. Head/Spinal Cord d. Musculoskeletal e. Drowning/Near Drowning f. Opthalmic g. Thoracic/Abdominal/Pelvic



Amputations:

1. Refer to General Trauma Recommendations

2. Recover all amputated parts, if possible

3. Gently dress in sterile dressing, place in a zip lock bag (if possible), or wrap in a towel, and store in a cool location

4. Do not apply ice pack or ice directly

5. Do not delay transport if there is a delay in amputated part recovery

6. If unable to stop bleeding with compression, utilize hemostatic dressing

7. If still unable to stop bleeding, utilize Tourniquet Skill, do not remove after application and document application time




Burns/Electrical:


2. General Rules: Remove clothing (if clothing stuck to burn, do not remove that area) Superficial thickness burns may be rinsed with sterile water or saline Rinse partial/full thickness burns that are less than 20 percent body surface area with sterile water or saline Do not rinse partial/full thickness burns larger than 20 percent body surface area; cover with dry sterile dressings Rinse chemical burns for 30-60 minutes after dusting dry contents off (bring name of chemical if able) If burns involve the eyes, rinse with sterile water or saline (remove contacts, if pertains) Maintain normal body temperature (blankets, exterior climate)

3. Obtain 12-lead EKG for electrical burns/electrocution patients

4. If burn is greater than 10 percent body surface area, give IV NS fluids: 1-2 liters NS bolus (Adults) 20-40 cc/kg NS bolus (Peds)

5. If probable airway burn, intubate early to secure airway using Intubation/RSI Skill, if unable to intubate, divert to the closest ER for airway stabilization

6. Refer to Rule of Nines:



7. Types of burns:




Head/Spinal Cord Injury:


2. Keep head of bed elevated > 30 degrees

3. Overall capnography goal is to maintain pCO2 of 35-39 mm Hg, avoid unwarranted hyperventilation

4. Signs/symptoms of cerebral herniation syndrome (Cushing’s Triad): a. Hypertension b. Bradycardia c. Irregular respirations

5. If unequal pupils, posturing and/or signs of Cushing’s Triad, hyperventilate to goal of pCO2 30-35mm Hg 6. Adjust respiratory rate to capnography goal

7. Patient with head trauma, who is paralyzed to intubate, monitor for seizure, dilated pupils or tachycardia may indicate seizure, refer to Adult Seizure and Pediatric Seizure protocols




Musculoskeletal:


2. Never remove a foreign body, stabilize in position

3. Refer to Bandaging and Splinting Skill


5. Flush open fracture wound with 1 L of sterile water or saline and apply soaked gauze

6. Continue to monitor circulation, sensation and motor distal to the injury

7. If extremity is pulseless, an attempt to reduce the fracture in order to regain a pulse is acceptable

8. See indications for Tourniquet Skill

9. Consider pelvic binding with sheet if unstable pelvic fracture suspected




Drowning/Near-Drowning:


2. Warm patient and refer to Adult Hypothermic or Pediatric Hypothermic protocols

3. Make every effort to transport these patients, some patients are stable shortly after an initial recovery period, a “Secondary Drowning” (post immersion syndrome) can occur within 12 to 72 hours after submersion

4. Post immersion syndrome is probably a form of acute respiratory distress syndrome (ARDS) caused by pulmonary injury

5. All drowning patients should receive spinal immobilization

6. If the body temperature is less than 86°F, the heart may not respond to cardiac medications, only one course of ACLS drugs should be given prior to the time the patient is warmed to 92°F

7. May consider Sodium Bicarbonate 1 meq/kg IV/IO for prolonged submersion




Thoracic/Abdominal/Pelvic:


2. Control external hemorrhage with compression, cover eviscerated bowel with moist saline and secure, do not remove any impaled objects (stabilize and secure) when encountered

3. Closely monitor for JVD, tracheal alignment, subcutaneous emphysema and/or hypotension, consider Needle Decompression Skill, if indicated (consider bilateral needle decompressions if traumatic cardiac arrest)

4. Seal all penetrating chest wall defects with pressure relief occlusive dressing as needed

5. Stabilize any flail segments, avoid circumferential dressings





Section Seven: Skills



Section Seven: Skills

Bandaging:

1. Check circulation, motor function, and sensation distal to injury before bandaging2. Cover dressing using aseptic technique3. Secure dressing using appropriate pressure with no excessive movement4. Use bandaging technique appropriate to injury5. Check circulation, motor function, and sensation distal to injury after bandaging6. Document all assessment findings and patient’s response to procedure.

Tourniquet:

Rationale:

Use of a tourniquet is appropriate when upper or lower extremity hemorrhage cannot be controlled by applying direct pressure or a pressure dressing to the site of bleeding.

Procedure:

1. Always use personal protective equipment (PPE) appropriate for potential blood exposure 2. Visually inspect injured extremity and avoid placement of a tourniquet over joint, angulated, or open fracture, stab or gunshot wound sites, or the lower arm or leg (occlusion of the arterial supply may not be possible if applied there) 3. Assess and document circulation, motor and sensation distal to injury site 4. Apply tourniquet to the upper arm or leg four finger breadths proximal to wound 5. Tighten tourniquet incrementally to the least amount of pressure required to stop bleeding 6. Cover wound with an appropriate sterile dressing and/or bandage 7. Do not cover tourniquet (keep tourniquet visible) 8. Re-assess and document circulation, motor and sensation distal to tourniquet 9. Ensure receiving facility staff are aware of tourniquet placement and time tourniquet placed

Documentation:

1. Estimated blood loss 2. Vital signs, assessment of circulation, motor, and sensation distal to injury site before and after tourniquet application 3. Time tourniquet is applied

Splinting:

1. Check circulation, motor function, and sensation distal to injury before splinting2. Immobilize injury with appropriate device3. Check circulation, motor function, and sensation distal to injury after splinting4. Elevate the extremity



Traction Splinting:**Should never be applied to an open fracture

1. Check circulation, motor function, and sensation distal to injury before applying splint2. Apply and maintain traction, elevation, and gentleness3. Apply traction splint according to manufacturer guidelines/instructions4. Monitor circulation, motor function and sensation distal to injury after procedure is completed

Spinal Immobilization-Supine:

1. Direct partner to establish and maintain neutral spinal alignment2. Check circulation, motor function, and sensation in all four extremities3. Apply cervical collar4. Move patient carefully without compromising integrity of spine5. Place patient onto stretcher, soft/vacuum immobilization device or long board according to the spinal immobilization protocol6. Check circulation, motor function, and sensation in all four extremities7. Do not compromise or impede respirations

Spinal Immobilization-With Protective Clothing/Devices:

1. Helmet face masks should always be removed prior to transport 2. Recreational helmets should be removed while maintaining inline spinal immobilization and cervical collar applied3. Sports helmets and shoulder pads can be removed while maintaining inline spinal immobilization4. If personnel chooses to remove the helmet and shoulder pads, both should be removed, not just one of them, to maintain proper inline immobilization of the spine Spinal Immobilization-Seated:

1. Direct partner to establish and maintain neutral spinal alignment2. Check circulation, motor function, and sensation in all four extremities3. Apply cervical collar4. Position short device5. Secure short spinal device to patient's torso according to manufacturer’s recommendations6. Secure short spinal device to patient's head to assure neutral cervical spine alignment7. Check circulation, motor function, and sensation in all four extremities8. Do not compromise or impede respirations9. Patient should be removed from the short spinal device when able according to the spinal immobilization protocol

Bronchodilator Administration:

1. Inform patient of order for medication and inquire about allergies and recent doses of other bronchodilators2. Verbalize check of medication for contamination and expiration date3. Add appropriate volume of medication to the nebulizer4. Assemble nebulizer according to the manufacturer’s standard (or local protocol) and connect to oxygen regulator5. Adjust oxygen liter flow as ordered or per manufacturer’s recommendations and allow mist to fill breathing tube or mask6. Position nebulizer device on patient



Peripheral Venipuncture:

1. Avoid contamination of equipment2. Confirm order (solutions and rate)3. Inform patient of order for IV access and/or fluid therapy4. Select and prepare equipment5. Select correct IV solution and verbalize check for contamination and expiration date6. Connect tubing to solution and clear air7. Apply constricting band and check distal pulse8. Select site below constricting band9. Cleanse skin with alcohol prep using a circular motion working outward10. Inspect catheter and needle for defects without advancing catheter over the needle11. Perform steps 4-10 before venipuncture12. Perform venipuncture (no more than three attempts); consider IO if needed13. Attach tubing to the catheter hub14. Remove constricting band before attempting to verify flow15. Verify flow by opening flow control16. Secure catheter and tubing and dress site17. Adjust drip rate as ordered18. Dispose of contaminated equipment

Intramuscular Drug Injection:

1. Avoid contamination of equipment2. Confirm order (medication, dosage, and route)3. Inform patient of order for medication and inquire about allergies4. Select correct medication5. Check medication for contamination and expiration date6. Prepare correct amount of medication for administration7. Expel air from syringe8. Recheck medication9. Select appropriate site (prefer thigh > gluteal > deltoid)10. Recheck medication label11. Prepare injection site by cleansing with alcohol12. Perform needle insertion13. Aspirate for absence of blood return14. Inject the medication15. Withdraw needle and apply pressure16. Dispose of contaminated equipment



Intravenous Drug Administration:

1. Avoid contamination of equipment2. Confirm order (dosage, medication, and route)3. Inform patient of order for medication and inquire about allergies4. Select correct medication5. Check medication for contamination and expiration date6. Prepare correct amount of medication for administration7. Expel air from syringe8. Select medication port closet to IV site9. Prepare port for injection by cleansing with alcohol10. Recheck medication11. Insert the needle into the medication port/ attach syringe into stopcock12. Ensure patent IV line (aspirate for blood or check for infiltration and a check for IV flow)13. Occludes flow above medication port14. Recheck medication15. Inject the medication16. Remove needle/syringe and flush tubing17. Adjust flow rate to appropriate drip rate18. Dispose of contaminated equipment19. Unless during cardiac arrest or Adenosine, all drugs should be slow IV push (over 3-5 minutes)

Intranasal Drug Administration:

1. Calculate drug dosage2. Draw up the medication and attach atomizer3. Aspirate the proper volume of medication (an extra 0.1 ml of medication should be drawn up to account for the dead space within the atomizer at the end of the procedure) (ideal volume 0.2 to 0.3 ml per nostril, maximum volume 1 ml per nostril)4. Using your free hand to hold the crown of the head stable, place the tip of the atomizer snugly against the nostril aiming slightly up and outward (towards the top of the ear on same side as nostril ear)5. Briskly compress the syringe plunger to deliver half of the medication into the nostril6. Move the device over to the opposite nostril and administer the remaining medication into that nostril

External Jugular Vein Access:

1. Place the patient in a supine, head down position, turn patient’s head slightly to the side opposite the intended venipuncture site2. Cleanse site with alcohol prep3. Align catheter in the direction of the vein, with the point aimed toward the shoulder on the side of venipuncture4. Stabilize above and below intended puncture site5. Puncture midway between the angle of the jaw and the mid-clavicular line.6. Proceed the same as with peripheral cannulation, using caution not to allow air to enter the catheter7. Secure catheter carefully; without taping around the patient’s neck.

Endotracheal Drug Administration:(Approved Epinephrine, Vasopressin, Narcan, Atropine, Albuterol, Atrovent, Duoneb)

1. Avoid contamination of equipment2. Confirm order (medication, dosage, and route)3. Inquire about medication allergies4. Select correct medication and supplies5. Check medication for contamination and expiration date6. Prepare correct amount of medication for administration (double the IV dose per protocol)



7. Recheck medication8. Instruct partner to hyperventilate patient9. Recheck medication10. Administer the medication11. Instruct partner to hyperventilate patient12. Dispose of contaminated equipment

Piggyback Drug Administration:

1. Avoid contamination of equipment2. Confirm order (medication, dosage, and route)3. Inquire about allergies4. Select correct medication and administration equipment5. Check medication for contamination and expiration date6. Prepare correct amount of medication for administration7. Recheck medication label8. Inject medication into secondary IV bag and mix solution9. Label medicated IV bag with name of drug and amount added10. Connect IV tubing and needle to solution and expel air11. Insure patency of original IV line (lower original bag to observe blood return or check for infiltration and IV flow)12. Cleanse medication port13. Connect piggyback solution by inserting needle into medication port14. Recheck medication label15. Begin infusion and adjust flow rate16. Tape needle securely17. Dispose of contaminated equipment

PICC Line/Central Line Access:

1. Identify site of PICC line2. Prep port with sterile technique (Chloraprep swab and sterile gloves)3. Aspirate and then flush the system with 10 cc normal saline to confirm that fluid flows through the system4. If unable to aspirate blood, STOP the procedure5. Infuse IV fluid/medication

**PICC lines should always be flushed with a minimum of 10 cc normal saline when finished using the line

Dialysis Catheter Access:

**THIS IS ONLY TO BE DONE IN AN EMERGENT SITUATION AND UNABLE TO ACCESS IV/IO**

1. Identify site of dialysis catheter line2. Prep port with sterile technique (Chloraprep swab and sterile gloves)3. Aspirate and then flush the system with 10 cc normal saline to confirm that fluid flows through the system4. If unable to aspirate blood, STOP the procedure5. Infuse IV fluid/medication



Medi-port Access:

1. Identify site of medi-port2. Prep area with sterile technique (Chloraprep swab and sterile gloves)3. Connect extension set tubing to a 10 cc, or larger, syringe filled with normal saline4. Expel all air and clamp shut5. Locate medi-port again6. Insert the non-coring needle through the skin and portal septum at a ninety degree angle7. Secure needle with tape or a transparent dressing8. Tape all connections9. Release clamp, aspirate and then flush the system with normal saline to confirm that fluid flows through the system10. If unable to aspirate blood, STOP the procedure and remove the needle11. Clamp extension set tubing and remove the syringe12. Attach IV solution to extension set13. Release clamp and infuse IV fluid

**Medi-ports should ALWAYS be flushed with Heparin at the ER when they are finished being used

Umbilical Vein Cannulation:

Indications:1. Newborn infant requiring resuscitation with intravenous fluid and/or intravenous medication

Contraindications: None

Procedure:1. Trim the infant’s umbilical cord with scalpel just proximal to the clamp to provide a fresh end2. Clean the umbilical cord end with Chloraprep swab3. Locate the umbilical vein (in the umbilical cord, there are three vessels, the two umbilical arteries are small and have thick walls, the single umbilical vein is the largest vessel and has thin walls)4. Place an 16 or 18 gauge angiocath (without the needle) into the umbilical vein, providing constant manual stabilization of the umbilical cord; aspirate for blood return; if no blood return, reposition the catheter5. Attach 3 way stopcock/extension set and flush with 10 cc NS6. Use umbilical tape to secure the catheter in place; use enough pressure to secure but also to allow fluid to flow

Intraosseous Insertion:

Indications:

For intraosseous access anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases.

Sizes:

15mm (3–39 kg) (pink)25mm (40 kg and over) (red) 45mm (40 kg and over with excessive tissue) (yellow)

Sites:

Proximal tibiaProximal humerus



Contraindications:

Fracture of the bone selected for IO infusion (consider alternate sites)Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate sites)Previous significant orthopedic procedures (IO within 24 hours, prosthesis - consider alternate sites)Infection/burn at the site selected for insertion (consider alternate sites)

Considerations:

1. Ensure the administration of a rapid and vigorous 10ml flush with normal saline prior to infusion “NO FLUSH = NO FLOW”2. A pressure bag will facilitate the infusion of fluids through the IO3. Consider cardiac lidocaine prior to the flush for anesthetic4. Tie arms across chest if humeral IO placed

Procedure:1. If the patient is conscious, explain procedure 2. Apply non-sterile latex free gloves 3. Cleanse site using alcohol swab4. Allow to air dry thoroughly 5. Connect appropriate needle set to driver 6. Stabilize site (position arm across chest for humeral IO)7. Remove needle cap8. Insert IO needle into the selected site: Keep hand and fingers away from needle set Position the driver at the insertion site with the needle set at a 90-degree angle to the bone surface Gently pierce the skin with the needle set until it touches the bone Penetrate the bone cortex by squeezing driver’s trigger and applying gentle, consistent, steady, downward pressure Do not use excessive force, in some patients insertion may take greater than 10 seconds Release the driver’s trigger and stop the insertion process when a sudden “give or pop” is felt upon entry Remove IO driver from needle set while stabilizing the catheter hub Remove stylet from catheter by turning counter-clockwise and immediately dispose in biohazard sharps container 9. Secure site10. Connect primed tubing to exposed hub 11. Flush the catheter with 10 ml of normal saline 12. If the patient is responsive to pain, may consider 2 ml of 2% lidocaine (cardiac lidocaine) prior to the flush13. Assess for potential IO complications14. Disconnect 10 ml syringe from the catheter set15. Begin infusion utilizing a pressure bag delivery system16. Continue to monitor extremity for complications



Transcutaneous Pacing:

1. Confirm presence of dysrhythmia and patient’s hemodynamic status, including copy of 12-lead EKG strip2. Explain procedure to patient3. Establish IV, if not already performed4. Consider sedation with Etomidate 0.1 mg/kg IV/IO or Ketamine 1 mg/kg IV/IO if SBP < 905. Adjust EKG size so machine can sense intrinsic QRS activity6. Apply peacemaker electrodes, using either the anterior-posterior or anterior-anterior approach7. Turn monitor/defibrillator to “on” position and select proper lead8. Plug pacing cable into connector9. Select desired pacing rate (60-70 usually)10. Observe monitor for a “sense” marker on each QRS complex, if none present, increase QRS size11. Once sensing, depress “start” button and observe for pacer spikes12. Increase current (mA) slowly while observing for evidence of electrical capture13. Once electrical capture seen, turn current down to lowest possible 14. Assess patient’s perfusion15. Record EKG and document procedure

Cardioverson:

1. Place EKG leads2. Place monitor in “Lead 2” position3. Confirm rhythm by looking at monitor4. Check pulse5. Apply defibrillation pads or EKG gel6. Set cardioverter to the appropriate level for first cardioversion7. Activate synchronizer8. Charge cardioverter9. Instruct all personnel to “Clear” and confirm that personnel are clear10. Reconfirm rhythm by looking at the monitor and perform synchronized cardioversion11. Confirm rhythm by looking at the monitor12. Check pulse

Defibrillation:

1. Turn on monitor and set to "paddles" or the appropriate setting for hands free defibrillator2. Properly place paddles/pads on patient3. With proper paddle/pad placement confirm rhythm by looking at monitor4. Determine pulselessness5. Set defibrillator to the proper energy setting for the first defibrillation6. Charge defibrillator7. Instruct personnel to clear and confirm that all personnel are clear8. With proper paddle/pad placement reconfirm rhythm by looking at monitor and defibrillate9. With proper paddle/pad placement confirm rhythm by looking at monitor10. Check pulse. Repeat sequence as indicated by protocol



AED:

1. Direct rescuers to stop CPR2. Check pulse3. Direct rescuers to continue CPR if necessary4. Turn on power to AED5. Attach pads to cables6. Properly place pads on patient7. Direct rescuers to stop CPR and to “Clear”8. Initiate analysis of rhythm9. Confirm personnel are clear10. Deliver shock11. Repeat steps 8, 9, & 10 until three shocks have been delivered or patient has ROSC12. Check pulse13. Direct rescuers to continue CPR if necessary

Needle Decompression:

Indications:

1. Patient with signs of tension pneumothorax: a. Jugular vein distention b. Tracheal deviation - away from the affected side c. Hypotension - with narrowing pulse pressure d. Decreased breath sounds - on the affected side e. Dyspnea 2. Traumatic CPR’s with high suspicion of underlying chest injury (especially patients in PEA)3. Intubated patient that is becoming increasingly difficult to ventilate with signs of tension pneumothorax

Procedure:

1. Identify the need for pleural decompression2. Use anterior approach only3. Locate the second or third intercostal space in the mid-clavicular line4. Prep area with Chloraprep swab5. Insert the large bore needle over the rib into the pleural space (you should feel a popping sensation)6. Withdraw the needle from the catheter7. Secure pleural decompression device with tape8. Continuously monitor breath sounds and respiratory rate and effort 9. Repeat as needed

Age Appropriate Catheter Sizes

Age (years) Size (kg) Needle Size0-5 0-20 18g5-12 21-40 16g>12 >40 14g



Aids To Airway/Breathing: Oxygen:

1. Prepare and assemble equipment2. Assemble regulator to tank3. Check tank pressure4. Adjust liter flow to desired flow5. Pre-fill reservoir bag if applicable6. Apply and adjusts cannula or mask to the patient’s face7. Remove the cannula or mask prior to discontinuation of oxygen flow8. Shut off regulator

Nasopharyngeal Airway:1. Select proper size2. May be used in responsive patients with gag reflex3. Use effective method of insertion4. Continue to monitor patients vitals and oxygen saturations

Oropharyngeal Airway:

1. Select proper size2. Check for unresponsiveness3. Use effective method of insertion4. Monitor for gag reflex5. Continue to monitor patients vitals and oxygen saturations

Bag Valve Mask:

1. Position mask properly and open airway2. Maintain adequate seal around mouth and nose3. Begin effective ventilation (chest or lung inflation) within 30 seconds4. Perform effective ventilations for one (1) minute at a rate of 10-20 ventilations per minute5. Connect BVM to oxygen source and adjust liter flow6. Resume ventilations within 15 seconds and continue effective ventilations for 30 seconds at a rate of 10-20 ventilations per minute

Suctioning:

1. Position patient to prevent aspiration by turning patient's head to side or turning the patient to the side as a unit2. Prepare suction device3. Insert appropriate sized suction catheter4. Apply suction for 5-10 seconds5. Stop suctioning and remove the suction catheter



Mouth to Mask:

1. Connect one way valve to mask2. Position mask properly and open airway3. Establish and maintains a proper mask-to-face seal4. Begin effective ventilations within 30 seconds5. Perform effective ventilations for one (1) minute at rate of 10-20 ventilations per minute6. Connect mask to oxygen source and adjust liter flow7. Resume ventilations within 15 seconds and continue effective ventilations for 30 seconds at a rate of 10-20 ventilations per minute

Chronic Tracheostomy:

If a patient has a chronic tracheostomy and it is not functional/clogged and patient is not maintaining his/her oxygen saturations, then you may remove the tracheostomy and place a similar size ET tube in the opening, gently inflate the balloon and use Ambu bag for ventilation to maintain normal oxygen saturations

Rapid Sequence Intubation:

Consider RSI if one of the following conditions exist:

1. Respiratory burns with impending respiratory failure2. Combative head trauma patients where behavior threatens life3. Possible cervical spine injury where immobilization is not possible due to delirium4. Impending respiratory arrest which warrants immediate intubation 5. A patient with a GCS score of 8 or less who warrants immediate intubation 6. Penetrating neck trauma, before there is swelling that compromises the airway7. Loss of gag reflex



Procedure:

**All intubations are to be performed using a bougie unless video laryngoscope being utilized, then bougie is optional**See RSI CHART below for dosage calculations

1. If suspicious for head injury or increased ICP, consider Lidocaine 1 mg/kg IV/IO (unless heart block present)2. If 5 years old or less, administer Atropine 0.02 mg/kg IV/IO3. If patient is unresponsive and mouth able to be opened with no gag reflex, then proceed right to Endotracheal Intubation4. Choose induction medication: Etomidate 0.3 mg/kg IV/IO; may repeat once after 2-3 minutes if inadequate sedation - preferred agent for tachycardic or hypertensive patients

OR Ketamine 1 mg/kg IV/IO; may repeat once after 2-3 minutes if inadequate sedation

- preferred agent for acute asthma/COPD exacerbation patients- preferred agent for hypotensive patients (SBP < 90 mmHg)

- preferred agent for septic patients

5. If patient is able to be intubated without paralytics, may proceed right to Endotracheal Intubation6. If patient is unable to be intubated with induction agent alone, then make sure patient is able to be ventilated effectively and administer Succinylcholine 1-1.5 mg/kg IV/IO7. If contraindication to Succinylcholine, use Rocuronium 1 mg/kg IV/IO or Vecuronium 0.1 mg/kg IV/IO (please note that both Rocuronium and Vecuronium are long acting paralytics and it is very important that you are able to ventilate the patient effectively before giving these medications)8. Perform Endotracheal Intubation9. If relaxation inadequate after 60-120 seconds, repeat dose of paralytic used above and reattempt intubation 10. For sedation during intubation, may use: Versed 0.1 mg/kg IV/IO every 5-10 minutes if SBP > 100 OR Ketamine 0.5 mg/kg IV/IO every 5-10 minutes

11. For pain management during intubation, may use: Fentanyl 1 mcg/kg IV/IO every 3-5 minutes if SBP > 90 OR Ketamine 0.5 mg/kg (max dose 10 mg) IV/IO every 5-10 minutes

12. Only when adequately sedated can further paralytics be used: Rocuronium 1 mg/kg IV/IO OR Vecuronium 0.1 mg/kg IV/IO



RSI Chart:



RSISuccinylcholine Succinylcholine Etomidate Ketamine Vecuronium Rocuronium Atropine Lidocaine

Weight (Lbs) Weight (Kg) 1 mg/kg 1.5 mg/kg 0.3 mg/kg 1 mg/kg 0.1 mg/kg 1 mg/kg 0.02 mg/kg 1 mg/kg3 1.4 1.5 2 0.4 1.5 0.1 1.5 0.1 1.57.5 3.4 3.5 5 1 3.5 0.3 3.5 0.1 3.515 6.8 7 10 2 7 0.7 7 0.1 722 10 10 15 3 10 1 10 0.2 1033 15 15 23 4.5 15 1.5 15 0.3 1544 20 20 30 6 20 2 20 0.4 2055 25 25 38 7.5 25 2.5 25 0.5 2566 30 30 45 9 30 3 30 0.6 3077 35 35 53 10.5 35 3.5 35 0.7 3588 40 40 60 12 40 4 40 0.8 4099 45 45 68 13.5 45 4.5 45 0.9 45110 50 50 75 15 50 5 50 1 50121 55 55 83 16.5 55 5.5 55 1 55132 60 60 90 18 60 6 60 1 60143 65 65 98 19.5 65 6.5 65 1 65154 70 70 105 21 70 7 70 1 70165 75 75 113 22.5 75 7.5 75 1 75176 80 80 120 24 80 8 80 1 80187 85 85 128 25.5 85 8.5 85 1 85198 90 90 135 27 90 9 90 1 90209 95 95 143 28.5 95 9.5 95 1 95220 100 100 150 30 100 10 100 1 100231 105 105 158 31.5 105 10.5 105 1 105242 110 110 165 33 110 11 110 1 110253 115 115 173 34.5 115 11.5 115 1 115264 120 120 180 36 120 12 120 1 120275 125 125 188 37.5 125 12.5 125 1 125286 130 130 195 39 130 13 130 1 130297 135 135 203 40.5 135 13.5 135 1 135308 140 140 210 42 140 14 140 1 140319 145 145 218 43.5 145 14.5 145 1 145330 150 150 225 45 150 15 150 1 150

Endotracheal Intubation:

Indications:1. Inadequate oxygen exchange or depressed ventilatory state 2. Need to provide airway protection in obtunded patient with a depressed gag reflex 3. Prophylactically in the patient suspected having suffered inhalation injuries

Procedure:1. Instruct partner to ventilate/oxygenate the patient; if able oxygenate to 100% O2 sat2. Determine Mallampati score (see below)3. Assemble and check appropriate equipment; choose appropriate size ET tube (Adult=7.0-8.0)(Peds=(Age/4) + 4)4. Instruct partner to stop ventilations and remove mask5. Remove oral airway if in place6. Place patient's head in sniffing position or in-line position (if c-spine injury possible)7. Insert laryngoscope and lift without using the teeth as fulcrum; place bougie into trachea (no bougie required if using video laryngoscope)8. Place ET tube over the bougie and into trachea; remove the bougie 9. If unable to place tube successfully in 30-60 seconds, then ventilate/oxygenate the patient, and when effectively ventilated/oxygenated, attempt one more time (total of 2 attempts); if unable to place ET tube after 2 attempts, then proceed to I-Gel Skill10. If unable to ventilate patient, refer to Surgical Airway Skills11. Upon successful intubation, inflate cuff to 10 cc and remove syringe 12. Confirm placement by direct visualization of the cords, condensation in the tube, auscultation of the bilateral lung fields and epigastric area, positive ET CO2 detection, improved pulse ox and capnography13. Secure tube in place, noting the depth of the ET tube (teeth or lip line measurement acceptable)14. Insure that the tube is held in place throughout transport process and apply cervical collar to reduce chances of displacement15. Reconfirm tube placement often and document in your report, continue patient assessment and document any changes16. Monitor pulse ox, capnography and vitals signs throughout patient transport and on movement to ER bed (document well)



Oral Gastric Tube Placement:

(*Optional-Department Dependent)

Indications:1. Age >= 162. Patient intubated3. Gastric distension present

Contraindications:1. Age <162. Active upper GI bleeding presumed to be caused by esophageal varices3. Significant airway/pharyngeal trauma

Procedure:1. Assemble supplies: 16 Fr tube, water soluble lubrication, suction and Toomey syringe2. Measure tube for placement starting with the distal tip of the tube lying over the left upper quadrant of the patient’s abdomen and then following an imaginary line up the center of the chest and the side of the patient’s face and terminating at the corner of their mouth3. Once measured, you should mark with tape to identify terminal point of insertion4. Coat distal tip of OG tube with water soluble lubricant5. Attach syringe filled with 50-60 cc of air to suction port of OG tube6. Insert the tube into the patient’s mouth and advance tube posteriorly down the esophagus7. When tube is placed and inserted to desired, pre-measured length, confirm epigastric placement by using a stethoscope to auscultate over the epigastrium, while injecting the syringe full of air in a rapid fashion8. Placement is confirmed with auscultation of air in the stomach as well as return of gastric contents by aspirating the syringe9. Once placement is verified, secure in place with tape and continue intermittent suction as needed to decompress the stomach



I-Gel:

Indication:The I-Gel is an airway device designed to provide ventilations/oxygenation to the apneic or unresponsive patient without a gag reflex. Contraindications:1. Responsive patients with an intact gag reflex

Procedure for Insertion:1. Prepare including gloves, mask, and eye protection2. Assemble the equipment while continuing ventilations3. Choose the correct tube size based on the patient’s weight4. Apply lubricant to the gel portion of the device taking care to avoid introduction of lubricant in or near the ventilatory openings5. Position the head in slight extension; if cervical spine injury, insert in neutral position only6. Insert the I-Gel with dominant hand using a steady, continuous force until the patient’s teeth are in line with the black line7. Deliver breaths with the bag-valve-mask and confirm proper placement as follows: a. Auscultate the chest bilaterally checking for the presence of equal, bilateral lung sounds b. Observe for symmetrical chest rise and fall with each breath8. Tie the tube in place with the provided strap9. Ventilate the patient with the bag-valve-mask supplied with 100% oxygen10. Re-confirm airway placement after the device is secured, after every patient movement and at regular intervals11. Application of a cervical collar will help to prevent movement of the airway12. If gastric suction is needed, a suction catheter may be placed in the gastric port (do not advance further than the I-Gel length13. Monitor pulse ox, capnography and vitals signs throughout patient transport and on movement to ER bed (document well)14. Adjust ventilation rate to capnography readings (normal pCO2 35-45)



CPAP:

Inclusion Criteria (2 or more of the following):- Retractions or accessory muscle use- Respiratory Rate > 24/min- Pulse Ox < 94% - Age 7 or Above

Exclusion Criteria:- Pneumothorax- Unable to follow commands- Apnea- Vomiting or active GI bleed- Major Trauma

Conditions Indicated For:- Congestive Heart Failure- COPD- Asthma- Pneumonia

Procedure:1. Gather the appropriate equipment2. Assess vital signs, attach pulse oximeter and attach cardiac monitor3. Make sure patient does not have a pneumothorax4. Explain procedure to the patient5. Connect the CPAP to a 50 PSI oxygen outlet6. Ensure adequate oxygen supply to ventilate device (100% when starting and then maintain sats > 94% (COPD >92%))7. Select a sealing face mask and ensure that the mask fits comfortably, seals the bridge of the nose, and fully covers the nose and mouth8. Attach the breathing circuit to the CPAP, insert and align the locking bayonet outlet adapter to the unit and turn clockwise until securely engaged9. Attach end-tidal CO2 measurement prior to delivering pressure10. Secure the mask to the patient with provided straps or the other provided devices11. Obtain and record an end-tidal CO2 measurement prior to delivering pressure12. Prior to setting the pressure always observe that the airway pressure gauge needle indicator is at the zero (0) value with the CPAP adjustment knob in the fully counterclockwise position and the breathing circuit is connected (to set continuous positive airway pressure, turn the CPAP adjustment clockwise to the “6-O’Clock” position and observe the needle indicator on the airway pressure gauge)13. Turn the CPAP adjustment clockwise in ¼ turn (9, 12, 3, 6 O’Clock) increments gradually until needle indicates 5-15 cm H2O pressure14. Check for air leaks15. Monitor and document the patient’s respiratory response to the treatment16. Continue to coach patient to keep mask in place and readjust as needed17. Evaluate vital signs and end-tidal CO2 every 5 minutes18. If respiratory status deteriorates, remove device and consider bag valve mask ventilation or intubation19. Notify receiving hospital of CPAP

Removal Procedure:1. CPAP therapy needs to be continuous and should not be removed unless the patient cannot tolerate the mask or experiences continued or worsening respiratory failure.

Pediatric Considerations:1. CPAP should not be used in children under 7 years of age



Special Notes:1. Advise receiving hospital as soon as possible so they can be prepared for patient2. Do not remove CPAP until hospital therapy is ready to be placed on patient3. Watch patient for gastric distention4. Reassessment of the patient’s status is critical and should be performed every 5-10 minutes5. Inline nebulized treatments may be given (may use “T” piece attachment from standard nebulizer set-up)

Open Crichothyrotomy:

Indications:1. Age >= 10 or >= 40 kg2. Unable to ventilate patient with standard techniques3. Upper airway obstruction and unable to ventilate patient or remove the obstruction4. Head/facial trauma making it impossible to ventilate with standard techniques

Contraindications:1. Anytime a less invasive maneuver would allow ventilation of the patient 2. Age < 10 or < 40 kg 3. Tracheal transection4. Fractured larynx or significant damage to the cricoid cartilage or larynx

Procedure:1. Assemble and prepare equipment2. Position the patient supine, with the neck in a neutral position3. Clean the patient’s neck in a sterile fashion using Chloraprep swab6. Locate the cricothyroid membrane anteriorly between the thyroid and cricoid cartilage7. Stabilize the trachea with the left hand until the trachea is intubated8. Make a 2- to 3-cm midline vertical incision through the skin from the caudal end of the thyroid cartilage to the cephalic end of the cricoid cartilage9. Make a 1- to 2-cm transverse incision through the cricothyroid membrane with a scalpel10. Insert the scalpel handle into the trachea11. Insert a bougie into the opening over your scalpel and place a size 6.0 ET tube over the bougie into the trachea; when ET tube in place, remove bougie12. Inflate cuff to 10 cc and remove syringe 13. Confirm placement of tube auscultation of the bilateral lung fields and epigastric area, positive ET CO2 detection and stable pulse ox and normal capnography 14. Secure tube in place15. Insure that the tube is held in place throughout transport process and if able apply cervical collar to reduce chances of displacement16. Reconfirm tube placement often and document in your report17. Continue patient assessment and document any change18. Monitor pulse ox, capnography and vitals signs throughout patient transport and on movement to ER bed (document well)19. If cervical immobilization is needed and unable to place collar, may need to use manual stabilization instead20. Adjust ventilation rate to capnography readings (normal pCO2 35-45)



Needle Crichothyrotomy:

Indications:1. Pediatric patient (< 10 years old or < 40 kg)2. Unable to ventilate patient with standard techniques3. Upper airway obstruction and unable to ventilate patient or remove the obstruction4. Head/facial trauma making it impossible to ventilate with standard techniques

Contraindications:1. Anytime a less invasive maneuver would allow ventilation of the patient 2. Tracheal transection

Procedure:1. Assemble and prepare equipment2. Position the patient supine, with the neck in a neutral position3. Clean the patient’s neck in a sterile fashion using Chloraprep swab4. Assemble a 16-18 gauge over-the-needle catheter to a 10-mL syringe5. Locate the cricothyroid membrane anteriorly between the thyroid and cricoid cartilage6. Stabilize the trachea with the thumb and forefinger of one hand7. Using the other hand, puncture the skin in the midline with the needle over the cricothyroid membrane (a small incision with a scalpel may be made first to facilitate passage of the needle 8. Direct the needle at a 45° angle caudally while applying negative pressure to the syringe9. Maintain needle aspiration as the needle is inserted through the lower half of the cricothyroid membrane, aspiration of air signifies entry into the tracheal lumen10. Remove the syringe and needle while advancing the catheter to the hub, reattach the syringe and attach ET tube adapter to syringe11. Attach to BVM, ventilate, check for chest rise and breath sounds12. Secure the device13. Monitor pulse ox, capnography and vitals signs throughout patient transport and on movement to ER bed (document well)14. If cervical immobilization is needed, may need to use manual stabilization instead of a collar15. Adjust ventilation rate to capnography readings (normal pCO2 35-45)

Vagal Maneuvers:

1. Continuous cardiac monitoring must be in place before vagal maneuvers are performed2. “Bearing Down” a. Have the patient bear down like they are having a bowel movement b. May be repeated as needed3. “Straining against a closed glottis” a. Have the patient cough and keep their airway closed b. May repeat as needed



EKG:

1. For indications, see 12 Lead EKG Section of patient assessment

2. Lead placement, precordial leads: a. V-1, fourth intercostal space just to the right of the sternum b. V-2, fourth intercostal space just to the left of the sternum c. V-3, in between V2 and V4 d. V-4, fifth intercostal space mid clavicular line e. V-5, anterior axillary line level with V4 f. V-6, mid axillary line level with V4 and V5 g. V4R, fifth intercostal space in right mid-clavicular line (label on EKG) h. V8, fifth intercostal space, mid-scapular line (label on EKG) i. V9, fifth intercostal space, between V8 and spine (label on EKG)

3. What each lead sees: a. Leads I, AVL, V5, V6 lateral wall, left ventricle b. Leads II, III, AVF inferior wall, left ventricle c. Leads V1, V2 septal wall, left ventricle d. Leads V3, V4 anterior wall, left ventricle e. Lead V4R right ventricle f. Leads V8, V9 posterior wall



Section Eight: Medications/Equipment



Section Eight: Medications/Equipment

Adenosine (Adenocard)Class: AntiarrhythmicActions: Slows AV conductionIndications: TachycardiaContraindications: Hypersensitivity to drug, second or third-degree heart block, sick-sinus syndromePrecautions: Blood pressure, pulse, and EKG should be monitoredSide Effects: Facial flushing, headache, shortness of breath, dizziness, and nauseaDosage: See protocolsRoutes: IV, IO

Albuterol (Proventil) (Ventolin)Class: Sympathomimetic (ß2 selective)Actions: BronchodilationIndications: Reversible bronchospasm associated with COPD or asthmaContraindications: Hypersensitivity to drug, symptomatic tachycardiaPrecautions: Blood pressure, pulse, and EKG should be monitored use caution in patients with known heart diseaseSide Effects: Palpitations, anxiety, headache, dizziness, and sweatingDosage: See protocolsRoutes: Inhalation, ET

AlcaineClass: Topical anestheticAction: Anesthetizes globe of eyeball, onset thirty seconds, duration fifteen minutesIndications: Prior to irrigation to remove foreign objects, burns, and eye pain secondary to injuryContraindications: Hypersensitivity to drug or "caine" drugs, lacerations or global penetrations are present or suspectedSide Effects: Stinging and irritationDosage: See protocolsRoutes: Eye

Amiodarone (Cordarone)Class: AntiarrhythmicActions: Prolongs action potential and refractory period, slows the sinus rate, increases PR and QT intervals, decreases peripheral vascular resistanceIndications: Life-threatening cardiac arrhythmiasContraindications: Hypersensitivity to drug, severe sinus node dysfunction, sinus bradycardia, second and third degree block, hemodynamically significant bradycardiaSide Effects: Hypotension, nausea, anorexia, malaise, fatigue, tremors, pulmonary toxicity, ventricular escape beatsDO NOT SHAKE THIS MEDICATIONDosage: See protocolsRoutes: IV, IO

AspirinClass: Platelet inhibitor/anti-inflammatoryActions: Blocks platelet aggregationIndications: Cardiac chest pain, AMI, signs and symptoms suggestive or recent CVAContraindications: Hypersensitivity to drug, significant ulcers disease, GI bleedingPrecautions: Avoid head injury patients, possible hemorrhagic CVA or those with potential sites of bleedingSide Effects: Heartburn, nausea and vomiting, wheezingDosage: See protocolsRoutes: PO/PRPediatric: Not recommended



AtropineClass: Para-sympatholytic (anticholinergic)Actions: Blocks acetylcholine receptors, increases heart rate, decreases gastrointestinal secretionsIndications: Hemodynamically-significant bradycardia, hypotension secondary to bradycardia, organophosphate poisoning, pediatric RSIContraindications: Hypersensitivity to drugPrecautions: None when used in the emergency settingSide Effects: Palpitations and tachycardia, headache, dizziness, and anxiety, dry mouth, pupillary dilation, and blurred vision, urinary retentionDosage: See protocolsRoutes: IV, ET, IO

Calcium GluconateClass: ElectrolyteActions: Increases cardiac contractilityIndications: Acute hyperkalemiaContraindications: Patients receiving digitalisPrecautions: IV line should be flushed between calcium and sodium bicarbonate administration, extravasation may cause tissue necrosisSide Effects: Arrhythmias (bradycardia and asystole), hypotensionDosage: See protocolsRoutes: IV, IO

Cyanokit (Hydroxocobalamin)Indications: Treatment of known or suspected cyanide poisoningContraindications: Use caution in the management of patients with known anaphylactic reactions to hydroxocobalamin or cyanocobalaminSide Effects: Chromaturia, allergic reaction, erythema, rash (acneiform), nausea, headache, decreased lymphocyte percentage, hypertension, chest tightness, edema, and injection site reactions Precautions: Pregnancy Category C and should be used during pregnancy only if the potential benefit justifies the potential risk, usage may interfere with some clinical laboratory evaluations, and due to potential photosensitivity patients should avoid direct sun until erythema resolvesDosage: See protocolsUsage may interfere with some clinical laboratory evaluations. Due to potential photosensitivity patients should avoid direct sun until erythema resolves.Routes: IV, IO

Dextrose 50%/25%/PasteClass: CarbohydrateActions: Elevates blood glucose level rapidlyIndications: HypoglycemiaContraindications: None in the emergency settingPrecautions: A blood sample should be drawn before administering 50% dextroseSide Effects: Local venous irritationDosage: See protocols; (D 25% can be made by wasting 1/2 of the amp of D 50% and filling rest of syringe with NS)Routes: IV, IO, Oral form in tube of glucose paste



Diltiazem (Cardizem)Class: Calcium channel blockerActions: Slows conduction through the AV node, causes vasodilation, decreases rate of ventricular response, decreases myocardial oxygen demandIndications: To control rapid ventricular response associated with atrial fibrillation/flutter flutter and narrow complex tachycardiaContraindications: Hypersensitivity to drug, hypotension, Wolff-Parkinson-White SyndromePrecautions: Should not be used in patients receiving intravenous ß blockers, hypotensionSide Effects: Nausea, vomiting, hypotension, and dizzinessDosage: See protocolsRoutes: IV, IO

Diphenhydramine (Benadryl)Class: AntihistamineActions: Blocks histamine receptors, has some sedative effectsIndications: Anaphylaxis, allergic reactionsContraindications: Hypersensitivity to drug, asthma, nursing mothersPrecautions: Hypotension, sedationSide Effects: Sedation, dries bronchial secretions, blurred vision, headache, palpitationsDosage: See protocolsRoutes: IV, IM, IO

Epinephrine 1:1,000Class: SympathomimeticActions: BronchodilationIndications: Severe asthma, severe allergic reactions, anaphylactic shock, cardiac arrest (ET)Contraindications: Patients with underlying cardiovascular disease, hypertension, pregnancy, patients with tachy-arrhythmiasPrecautions: Should be protected from light, blood pressure, pulse, and EKG must be constantly monitoredSide Effects: Palpitations and tachycardia, anxiousness, headache, tremorDosage: See protocolsRoutes: IM

Epinephrine 1:10,000Class: SympathomimeticActions: Increases heart rate and automaticity, increases cardiac contractile force, increases myocardial electrical activity, increases systemic vascular resistance, increases blood pressure, causes bronchodilationIndications: Cardiac arrest, anaphylactic shockContraindications: Epinephrine 1:10,000 is for intravenous or endotracheal use; it should not be used in patients who do not require extensive resuscitative effortsPrecautions: Should be protected from light, can be deactivated by alkaline solutionsSide Effects: Palpitations, anxiety, tremulousness, nausea and vomitingDosage: See protocolsRoutes: IV, ET, IO



Epinephrine (Push Dose Pressor)Class: SympathomimeticActions: Increases heart rate and automaticity, increases cardiac contractile force, increases myocardial electrical activity, increases systemic vascular resistance, increases blood pressure, causes bronchodilationIndications: ShockPrecautions: Should be protected from light, can be deactivated by alkaline solutionsSide Effects: Palpitations, anxiety, tremulousness, nausea and vomitingDosage: See protocolsRoutes: IV, IOMixing:1. Take a 10 ml syringe with 9 ml of Normal Saline2. Into this syringe, draw up 1 ml of Epinephrine 1:10,0003. Now you have 10 ml of Epinephrine (10 mcg/ml)

Epinephrine (Racemic)Class: SympathomimeticActions: Increases heart rate and automaticity, increases cardiac contractile force, increases myocardial electrical activity, increases systemic vascular resistance, increases blood pressure, causes bronchodilationIndications: Stridorous respirations related to allergic reactions and upper respiratory causesContraindications: Epiglottis and patients with underlying cardiovascular disease, hypertension, pregnancy, patients with tachy-arrhythmiasPrecautions: Should be protected from light, can be deactivated by alkaline solutionsSide Effects: Palpitations, anxiety, tremulousness, nausea and vomitingDosage: See protocolsRoutes: Inhalation

EtomidateClass: HypnoticActions: Short-acting hypnotic used to induce anesthesiaIndications: Used for sedation and for the induction of anesthesia prior to paralytic use in Rapid Sequence IntubationContraindications: Hypersensitivity to the drug or sepsisSide Effects: Myoclonic jerking, usually brief and self-limited, respiratory suppressionDosage: See protocolsRoutes: IV, IO

FentanylClass: NarcoticActions: CNS depressant, causes peripheral vasodilation, decreases sensitivity to painIndications: Pain, pulmonary edemaContraindications: Hypersensitivity to drug, respiratory insufficiencies, asthma, bronchospasm, intracranial or intraspinal pressure, head injuries, altered mental status or hypotensionPrecautions: Respiratory depression (Narcan should be available), hypotension, nauseaSide Effects: Dizziness, altered level of consciousness, hypotension, respiratory depression, nauseaDosage: See protocolsRoutes: IV, IM, IN, IO



Furosemide (Lasix)Class: DiureticActions: Inhibits reabsorption of sodium chloride, promotes prompt diuresis, vasodilationIndications: Congestive heart failure, pulmonary edemaContraindications: Hypersensitivity to drug, pregnancy, dehydrationPrecautions: Should be protected from light, dehydrationSide Effects: Few in emergency usageDosage: See protocolsRoutes: IV, IO

GlucagonClass: Hormone Actions: Causes breakdown of glycogen to glucose, inhibits glycogen synthesis, elevates blood glucose level, increases cardiac contractile force, increases heart rateIndications: Hypoglycemia without IV access and unable to take oralContraindications: Hypersensitivity to the drugPrecautions: Only effective if there are sufficient stores of glycogen within the liver, use with caution in patients with cardiovascular or renal disease, obtain blood glucose before administrationSide Effects: Few in emergency situationsDosage: See protocolsRoutes: IM, IN

Haloperidol (Haldol)Class: Major tranquilizerActions: Blocks dopamine receptors in brain responsible for mood and behavior has antiemetic propertiesIndications: Acute psychotic episodesContraindications: Hypersensitivity to drug, patients with prolonged QTPrecautions: Orthostatic hypotensionSide Effects: Physical and mental impairment, extra-pyramidal reactions have been known to occur (can reverse with Benadryl)Dosage: See protocolsRoutes: IV, IM, IN, IO

Hydromorphone (Dilaudid)Class: NarcoticActions: CNS depressant, causes peripheral vasodilation, decreases sensitivity to painIndications: PainContraindications: Hypersensitivity to drug, respiratory insufficiencies, asthma, bronchospasm, intracranial or intraspinal pressure, head injuries, or hypotensionPrecautions: Respiratory depression (Narcan should be available), hypotension, nauseaSide Effects: Dizziness, altered level of consciousness, hypotension, respiratory depressionDosage: See protocolsRoutes: IV, IM, IO

Ipatropium (Atrovent)Class: AnticholinergicActions: Causes bronchodilation, dries respiratory tract secretionsIndications: Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysemaContraindications: Hypersensitivity to drug, should not be used as primary agent in acute treatment of bronchospasmPrecautions: Blood pressure, pulse, and EKG must be constantly monitoredSide Effects: Palpitations, dizziness, anxiety, tremors, headache, nervousness, dry mouthDosage: See protocolsRoutes: Inhalation, ET



KetamineClass: NMDA receptor antagonistActions: Affects catecholaminergic transmissionIndications: For the induction of anesthesia prior to Rapid Sequence IntubationContraindications: Hypersensitivity to drugSide Effects: Hypertension, tachycardia, involuntary muscle movements, sedation, emergence reactions, vomitingDosage: See protocolsRoutes: IV, IO, IN, IM

LabetalolClass: Sympathetic blockerActions: Selectively blocks alpha receptors and non-selectively blocks beta receptorsIndications: Hypertensive crisisContraindications: Hypersensitivity to drug, bronchial asthma, congestive heart failure, heart block, bradycardia, hypotensionPrecautions: Blood pressure, pulse, and EKG must be constantly monitoredSide Effects: Bradycardia, heart block, congestive heart failure, bronchospasm, hypotensionDosage: See protocolsRoutes: IV, IO

LidocaineClass: Antiarrhythmic, AnestheticActions: Suppresses ventricular ectopic activity, increases ventricular fibrillation threshold, reduces velocity of electrical impulse through conductive system, anesthetic, thought to decrease ICPIndications: Premedication prior to rapid sequence induction (decreases ICP)Contraindications: Hypersensitivity to drug, heart blocks, PVCs in conjunction with bradycardiaPrecautions: Dosage should not exceed 300 mg/hr, monitor for CNS toxicity, dosage should be reduced by 50% in patients older than 70 years of age or who have liver disease in cardiac arrest, use only bolus therapySide Effects: Anxiety, drowsiness, dizziness, and confusion, nausea and vomiting, convulsions, widening of QRSDosage: See protocolsRoutes: IV, ET, IO

Magnesium SulfateClass: Anticonvulsant/Antiarrhythmic/Reduces BronchospasmActions: CNS depressant, anti-convulsant, anti-arrhyhmic, anti-spasmotic (bronchial)Indications: Eclampsia, Torsades de Pointes, severe asthmaContraindications: Shock, heart blockPrecautions: Caution should be used in patients receiving digitalis, hypotension, calcium gluconate should be readily available as an antidote if respiratory depression ensues, use with caution in patients in renal failureSide Effects: Respiratory depression, drowsinessDosage: See protocolsRoutes: IV, IO

Methylprednisolone (Solumedrol)Class: Anti-inflammatory glucocorticoidActions: Decreases inflammation Indications: Allergic reactions, COPD, asthma, airway inflammationContraindications: Hypersensitivity to drugSide Effects: HyperglycemiaDosage: See protocolsRoutes: IV, IO, IM



Metoclopramide (Reglan)Class: Anti-emetic (dopamine)Actions: Blocks dopamine receptors in the CNS, increases upper GI motility, sensitizes tissues to AChIndications: Active nausea and vomiting and as an adjunct to prevent nausea and vomiting associated with narcotic analgesicsContraindications: Hypersensitivity to drug, bowel obstruction/perforation, GI bleedSide Effects: Extrapyramidal symptoms (can be treated with Benadryl), fatigue, sedation, restlessnessDosage: See protocolsRoutes: IV, IM, IO

Midazolam (Versed)Class: BenzodiazepineActions: Hypnotic, sedative Indications: Seizure, sedationContraindications: Hypersensitivity to drug, narrow-angle glaucoma, respiratory depression, hypotensionPrecautions: Emergency resuscitation equipment should be available, respiratory depression Side Effects: Drowsiness, hypotension, amnesia, respiratory depression, apneaDosage: See protocolsRoutes: IV, IM, IN, IO

MorphineClass: NarcoticActions: CNS depressant, causes peripheral vasodilation, decreases sensitivity to painIndications: Pain, pulmonary edemaContraindications: Hypersensitivity to drug, respiratory insufficiencies, asthma, bronchospasm, intracranial or intraspinal pressure, head injuries, altered mental status or hypotensionPrecautions: Respiratory depression (Narcan should be available), hypotension, nauseaSide Effects: Dizziness, altered level of consciousness, hypotension, respiratory depression, nauseaDosage: See protocolsRoutes: IV, IM, IO

Naloxone (Narcan)Class: Narcotic antagonistActions: Reverses effects of narcoticsIndications: Narcotic overdoses, to rule out narcotics in coma of unknown originContraindications: Hypersensitivity to the drugPrecautions: Should be administered with caution to patients dependent on narcotics as it may cause withdrawal effects, short-acting, should be augmented every 5 minutesSide Effects: NoneDosage: See protocolsRoutes: IV, IM, IO, IN, ET

Nitroglycerin (Nitro Spray)Class: NitrateActions: Smooth-muscle relaxant, decreases preload, dilates coronary arteries, causes vasodilationIndications: Angina, chest pain associated with myocardial infarctionContraindications: Hypersensitivity to drug, hypotension, bradycardia, head injury, CVA, erectile dysfunction medicationsPrecautions: IV access, constantly monitor vital signs, syncope/hypotension can occurSide Effects: Dizziness, hypotension, headacheDosage: One spray/sublingual administered under the tongue; may be repeated in 5 minutes; no more than three sprays/sublinguals in a 15-minute periodRoutes: Sprayed under tongue on mucous membrane or sublingual



Nitrous OxideClass: Sedative/AnalgesicActions: Exact actions not completely understood, central nervous system depressantIndications: PainContraindications: Hypersensitivity to drug, pregnancy, pneumothorax, bowel obstruction, hypoxia, COPDPrecautions: Patient must be alert, able to follow instructions and able to hold the mask on faceSide Effects: Nausea, lethargy and dizziness (can be relieved with 100% O2)Dosage: Via delivery device/mask until patient’s mask falls downRoutes: Inhaled

Ondansetron (Zofran)Class: Anti-emetic (5-HT3 antagonist)Actions: Causes interruption of the Serotonin 5-HT3 receptors responsible for vomiting in the brainIndications: Active nausea and vomiting and as an adjunct to prevent nausea and vomiting associated with narcotic analgesicsContraindications: Hypersensitivity to drugSide effects: Headache, constipation and dizziness are the most commonDosage: See protocolsRoutes: IV, IM, IN, IO, PO

Oxygen (O2)Class: GasActions: Necessary for cellular metabolismIndications: HypoxiaContraindications: NonePrecautions: Use cautiously in patients with COPD, humidify when providing high-flow ratesSide Effects: Drying of mucous membranesDosage: See protocolsRoutes: Inhalation

Promethazine (Phenergan)Class: AntihistamineActions: Blocks histamine receptors, has some sedative effectsIndications: Active nausea and vomiting and as an adjunct to prevent nausea and vomiting associated with narcotic analgesicsContraindications: Hypersensitivity to drugPrecautions: Hypotension, sedation, must be diluted and slow IV push as can cause vein damageSide Effects: Sedation, dry mouth, restlessnessDosage: See protocolsRoutes: IV, IM, IO

Rocuronium (Zemuron)Class: Neuromuscular blocking agent (non-depolarizing)Actions: Paralyzes skeletal muscles including respiratory musclesIndications: To achieve paralysis to facilitate endotracheal intubation/ventilationContraindications: Hypersensitivity to the drugPrecautions: Should not be administered unless persons skilled in endotracheal intubation are present, endotracheal intubation equipment must be available, oxygen equipment and emergency resuscitative drugs must be available, paralysis occurs within 1-2 minutes and lasts for approximately 30-60 minutesSide Effects: Prolonged paralysis, tachycardiaDosages: See protocolRoutes: IV, IO



Sodium BicarbonateClass: Alkalinizing agentActions: Combines with excessive acids to form a weak volatile acid, increases pHIndications: Late in the management of cardiac arrest, if at all, tricyclic antidepressant overdose, severe acidosis refractory to hyperventilation, dialysis patients for acidosisContraindication: Hypersensitivity to drug, alkalotic statesPrecautions: Correct dosage is essential to avoid overcompensation of pH, can deactivate catecholamines, can precipitate with calcium preparations, delivers large sodium loadSide Effects: AlkalosisDosage: See protocolsRoutes: IV, IO

SuccinylcholineClass: Neuromuscular blocking agent (depolarizing)Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory musclesIndications: To achieve paralysis to facilitate endotracheal intubationContraindications: Hypersensitivity to drug, muscle myopathies/wasting, malignant hyperthermia (personal or family history), burns and hyperkalemiaPrecautions: Should not be administered unless persons skilled in endotracheal intubation are present, endotracheal intubation equipment must be available, oxygen equipment and emergency resuscitative drugs must be available, paralysis occurs within 1 minute and lasts for approximately 8 minutesSide Effects: Prolonged paralysis, hypotension, bradycardiaDosage: See protocolsRoutes: IV, IO

Thiamine (Vitamin B1)Class: VitaminActions: Cofactor/coenzymes in glucose metabolismIndications: Coma of unknown origin, alcoholism, malnutritionContraindications: None in the emergency settingPrecautions: Rare anaphylactic reactions have been reportedSide Effects: RareDosage: See protocolsRoutes: IV, IM, IO

VasopressinClass: Posterior pituitary hormone (ADH)Actions: Potent peripheral vasoconstrictorIndications: Cardiac ArrestContraindications: Hypersensitivity to drugSide Effects: No significant in cardiac arrestDosage: See protocolsRoutes: IV, IO, ET



Vecuronium (Norcuron)Class: Neuromuscular blocking agent (non-depolarizing)Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory musclesIndications: To achieve paralysis to facilitate endotracheal intubationContraindications: Hypersensitivity to drugPrecautions: Should not be administered unless persons skilled in endotracheal intubation are present, endotracheal intubation equipment must be available, oxygen equipment and emergency resuscitative drugs must be available, paralysis occurs within 1 minute and lasts for approximately 30 minutesSide Effects: Prolonged paralysis, hypotension, bradycardiaDosage: See protocolsRoutes: IV, IO



Equipment List: (Minimum Amount Listed)

IMMOBILIZATION AND TRANSPORT

2 each Cervical Collars (Adult and Pediatric)

2 Spinal Immobilization Devices With Appropriate Accessories

1 Seated Spinal Immobilization Device

1 Pediatric Spinal Immobilization Device

1 Scoop Style Stretcher

1 Multilevel Stretcher

2 each Splint Devices (Small, Medium and Large)

2 Blankets

6 Sheets

1 each Traction Splints (Adult and Pediatric)

AIRWAY AND OXYGENATION

1 Portable Suction Unit (With Tubing and Rigid Suction Tip)

2 each BVM (Adult, Pediatric and Infant)

2 sets Oropharyngeal Airways (50, 60, 70, 80, 90, 100)

2 sets Nasopharyngeal Airways (24, 26, 28, 30)

2 each Oxygen Masks (Adult, Pediatric, Infant)

2 Oxygen Nasal Cannulas

2 Oxygen Nebulizers

2 Portable Medical Grade Oxygen Cylinders

1 Onboard Medical Grade Oxygen Cylinder

1 Oxygen Regulator for Cylinder

1 each Suction Catheters (8 Fr, 10 Fr, 12 Fr)

1 each I Gels (1.0, 1.5, 2.0, 2.5, 3.0, 4.0, 5.0)

2 each Endotracheal Tubes (2.5-8.0)

2 each Stylets (Adult, Pediatric)

2 Laryngoscope Handles and Batteries

1 set Laryngoscope Blades (1-4 Miller, 1-4 Macintosh)

1 each Magill Forceps (Adult, Pediatric)

2 Bougies

2 End Tidal CO2 Detector Devices

1 Surgical/Needle Cricothyrotomy Kit (Chloraprep, Scalpel, Bougie, Size 6.0 ET Tube, 10 cc Syringe, 16 and 18 Gauge 1.25 Inch Angiocatheters)

1 Needle Decompression Kit (Chloraprep, 2-14 Gauge (3.25 Inch), 2-16 Gauge (2 Inch) and 2-18 Gauge (2 Inch) Angiocatheters

4 Waveform Capnography Device (With Nasal Cannula)

1 CPAP Delivery Device

1 Pulse Oximeter Device with Probes

IV / IO / IN Access

4 Macro Drip Intravenous Administration Sets

5 each IV Catheters- (14,16,18, 20, 22, 24 Gauge)

2 Saline Locks

1 box Alcohol Cleaning Pads

3 IV Start Tourniquets

1 Pressure Infusion Bag

1 Non-Coring (Huber type) Needles

1 Intra-osseous Driver

2 each Intra-osseous Needles (Adult, Long, and Pediatric)

2 each Syringes (1 ml, 3 or 5 ml, 10 ml)

4 Needles

1 Intranasal Atomizer Device

CARDIAC

1 Adult/Pediatric Defibrillator

2 sets each Defibrillation/Pacing Pads (Adult, Pediatric)

2 rolls EKG Paper

6 sets EKG Electrodes

WOUND CARE

2 Multi Trauma Dressings

40 Sterile Gauze 4x4’s

12 Soft Roller Adhering Bandages

4 Sterile Abd Pads

4 rolls Adhesive Tape

4 Sterile Burn Sheets

12 Triangular Bandages

1 box Bandaids

1 Liter Total Sterile water or saline bottles

3 Hemostatic Dressings

2 Combat Application Tourniquet

GLUCOSE DETERMINATION

1 Blood Glucose Determination Device

5 Lancets for Blood Glucose Determination

5 Blood Glucose test strips

OB

1 Sealed Obstetrics Kit

1 Umbilical Vein Kit (Chloraprep, Scalpel, 16 and 18 Gauge Angiocatheters, 10 cc NS Saline Flush, 3-Way Stopcock, Umbilical Tape)

1 Non-porous Infant Insulating Device

MISC

2 Trauma Shears

1 each Sphygmomanometers (Adult, Pediatric, Infant)

1 set Soft Restraints

2 Stethoscopes

1 Benzoin Tincture

2 Chloraprep Swabs

2 Penlights

1 Thermometer

1 Razor or Shaver

2 Heat Packs

6 Cold Packs

1 Refrigeration Device

PERSONAL PROTECTION DEVICES

2 Protective Goggles

1 box Gloves

2 packs Sterile Gloves

2 Protective Gowns

5 N-95 Respirator Masks

5 Masks with Face Shield

1 Biohazard Waste Disposal Bag

1 Biohazard Waste System for Sharps

1 Cleaning/Disinfectant Solution

REFERENCES

1 Mass Casualty Incident Triage Kit

1 Broselow Pediatric Emergency Tape

1 copy Hazmat Reference Guide

1 copy Field Treatment Protocols

SAFETY/COMMUNICATION

1 Emergency Warning Devices (Triangles and/or Flares)

1 5 lb Fire Extinguisher

1 No Smoking Signs (Cab and Patient Compartment)

1 2 Way Radio/Mobile Phone

1 Flashlight

OPTIONAL EQUIPMENT

1 Nitrous Oxide Administration Device

1 AED (BLS Units)

1 Antiperspirant Stick

1 Automatic CPR Device

1 Ventilator

1 Video Laryngoscope

1 Ring Cutter

1 In-Line Nebulizer

1 Spit Hoods

1 Pediatric O2/Nebulizer Bear Device

1 Pillow

1 Buretrol Set

1 Water Soluble Lubricant

1 16 Fr Oral Gastric Tube

1 Toomey Syringe

Medication List:Quantity Medication How Supplied

(Substitutions allowed according supplier availability)

5 Adenosine (Adenocard) 6 mg (6 mg/2ml)***

6 Albuterol (Proventil) 2.5 mg/3ml *

1 Alcaine (Opthaine) 15 ml bottle 0.5%

3 Amiodarone (Cordarone) 150 mg/3ml

12 Aspirin 81mg tablets

4 Atropine 1 mg (0.1mg/ml)

2 Calcium Gluconate 1 gram (100 mg/ml)

3 Dextrose 50% 25 grams (500 mg/ml)

1 Diltiazem (Cardizem) 50 mg (5 mg/ml)

2 Diphenhydramine (Benadryl) 50 mg (50 mg/ml)

2 Epinephrine 1:1,000 1 mg (1mg/ml)

10 Epinephrine 1:10,000 1 mg (0.1mg/ml)

2 Racemic Epinephrine 2.25% per 0.5 ml

3 Etomidate 40 mg (2 mg/ml)

4 Fentanyl 50 mcg/ml (2 ml vial)

4 Furosemide (Lasix) 40 mg (10 mg/ml)

2 Glucagon 1 unit in powder form = 1mg/ml when reconstituted

2 Glucopaste 15 gram tubes

2 Haloperidol (Haldol) 5 mg (5 mg/ml)

2 Hydromorphone (Dilaudid) 2 mg (2 mg/ml)

6 Ipatroprium (Atrovent) 500 mcg/3 ml*

2 Ketamine 10 mg/ml

*Albuterol and Atrovent may be carried as Duoneb (Total 6) (Albuterol 2.5 mg/Atrovent 500 mcg/3ml)**It is required to carry 30mg of Adenosine

2 Ketamine 50 mg/ml

2 Labetalol 20 mg (5 mg/ml)

2 Lidocaine (Xylocaine) 100 mg (20 mg/ml)

2 Magnesium Sulfate 5 grams/10 ml

2 Methylprednisolone (Solumedrol) 125 mg/2 ml

3 Midazolam (Versed) 10 mg (10 mg/2 ml)

4 Morphine 10 mg (10 mg/ml)

4 Naloxone (Narcan) 2 mg (1 mg/ml)

10 Nitroglycerin 0.4 mg tablets or spray

2 Ondansteron (Zofran) 4 mg (2 mg/ml)

1 Oxygen Cylinder

2 Promethazine (Phenergan) 25 mg (25 mg/ml)

4 Rocuronium (Zemuron) 100 mg (10 mg/ml)

2 Sodium Bicarbonate 50 miliequivalents (1 Meq/ml)

4 Succinylcholine 200 mg (20 mg/ml)

2 Thiamine (Vitamin B1) 200 mg (100 mg/ml)

6 Normal Saline 0.9% 1000 ml (2 chilled for hypothermia)

2 Normal Saline 0.9% 100 ml

4 Normal Saline 0.9% 10 cc flushes

Quantity Medication How Supplied(Substitutions allowed according

supplier availability)

Optional Medications

________________________________Medical Director

______________________________Chief

_______________________Date

*Due to medication shortages the way that the above medications are packaged may vary

1 Cyanokit (hydroxocobalmin) 5 grams/vial

1 Nitrous Oxide Cylinder

1 Epinephrine Pen (Adult) 0.3 mg

1 Epinephrine Pen (Peds) 0.15 mg

2 Vasopressin 20 U (20 u/ml)



2 Ondansteron ODT (Zofran) 4 mg

2 Metoclopramide (Reglan) 10 mg (5 mg/ml)

4 Vecuronium (Norcuron) 10 mg in powder form

Dr. Justin Northeim Medical Director€¦ · 2. Shall be extended to any EMT-P student directly...

Documents

Transcript of Dr. Justin Northeim Medical Director€¦ · 2. Shall be extended to any EMT-P student directly...