Galveston Area Ambulance Authority Medical Protocols

Galveston Area Ambulance Authority

Medical Protocols

James Vincent M.D. Page 1

Medical Protocols

The Galveston Area Ambulance Authority(GAAA) Treatment Protocols are for the sole use of providers

that are providing care under the authority of GAAA or while deployed by GAAA in a disaster situation.

These protocols are valid from March 1, 2017 through March 31, 2018.

The GAAA protocols were written using the guidance of medical research and following accepted

national standards. The protocols were written by a committee of practicing paramedics at GAAA after

lengthy research and debate. The protocols were approved by Dr. James Vincent, medical director for

GAAA. This document is based upon current accepted medical practice and evidence. Due to the

evolving nature of medical standards this document is not a static piece of paper but is expected to be

used and revised as a dynamic document.

These protocols are a tool that providers will use with their assessment, knowledge, and experience to

provide exceptional patient care. Protocols are not meant to be blindly followed; instead providers

should understand the rationale behind the protocol pathways. All pathways are to be utilized only to

the degree that the patient requires. The pathways in the flowchart are used to facilitate the most

appropriate level of care for the patient. If a patient’s status does not require a certain pathway, it is

acceptable to omit or skip the treatment. Protocols are written for specific sets of symptoms and

conditions and can be combined in order to address the patient’s needs and complaints. The committee

and the medical director at GAAA recognize that in certain circumstances deviation from the protocols is

in the best interest of the patient. Protocol deviations should be a rare event and require detailed

documentation.

GAAA services a large area of Galveston County with multiple providers of various certification and

licensure levels. GAAA also utilizes first responders in the majority of our response districts and provides

non-emergency and emergency transfers originating in Galveston County and surrounding areas. With

the exception of Beach Patrol providers who are trained in the use of blind airway devices and basic first

aid, these protocols are not meant to provide authorization for providers outside of the GAAA system.

Any questions regarding who can practice under these guidelines should be referred to GAAA SOGs.

James Stephen Vincent M.D.

Medical Director


Medical Protocols

January 1, 2017

GAAA Field Staff:

I have been made aware of impending shortages of normal saline supplies, due to national shortages. In

the setting of limited supplies:

1. Do not give IV fluids indiscriminately or “reflexively” for any patient.

Consider holding IV fluids EXCEEPT for patients with a known or suspected volume-depleted

state.

2. Lactated Ringers (LR) may be used as a substitute for NS throughout the protocols when

indicated. As LR may be detrimental to patients in a shock or hypoperfusion state, carefully

weigh the risks of aggressive LR use, versus holding fluids and/or optimizing transport time to

the hospital, in these patients.

James Vincent, MD

Medical Director, GAAA

James Stephen Vincent M.D.

Medical Director


Medical Protocols

Fundamentals of Care

Patient Assessment 8

Documentation Guidelines 11

General System Guidelines 13

Air Medical Activation Guidelines 15

Specialty Care 17

On-Scene Medical Providers 18

Selected Age Definitions, Competency 19

Types of Consent 20

Treatment of Minors 21

Restraint / Transport against Patient Will 22

Refusals 23

Termination of CPR 24

Out of Hospital DNR 26

Hospice Patients 28

Scope of Practice 29

Inter-Facility Transfers 31

Expired Medications and Medication Shortages 34

Ebola Preparedness 35

Universal Treatment

Universal Treatment Guidelines 40

Rapid Sequence Induction 41

Failed Airway 42


Medical Protocols

Pain Management 43

Police Custody 44

Medical

Allergic Reaction 45

Anxiety 46

Behavioral Emergencies 47

Excited Delirium 48

COPD / Asthma 49

Diabetic Emergency 50

Hypotension 51

Nausea / Vomiting 52

Overdose 53

Respiratory Distress 54

Seizure 55

Stroke / CVA 56

Syncope 57

Cardiac

Acute Coronary Syndrome 58

Supra-Ventricular Tachycardia 60

A-Fib with RVR 61

Ventricular Tachycardia with a Pulse 62

Symptomatic Bradycardia 63

Adult Cardiac Arrest 64

Post Resuscitation 65

Post Resuscitation Induced Hypothermia 66


Medical Protocols

Hypertension 67

Congestive Heart Failure 68

Trauma

Selective Spinal Immobilization 69

Crush Injury 70

Major Trauma 71

Extremity Trauma 72

Extremity Hemorrhage or Amputation 73

Burns – Electrical / Chemical 74

Burns – Thermal 75

Marine Life Envenomation 76

Snake Bite 77

Drowning / Near Drowning 78

Pediatric

Active Labor 79

OB Emergencies 80

Neonatal Resuscitation 82

Pediatric Cardiac Arrest 83

Pediatric Diabetic Emergencies 84

Pediatric Pain Management 85

Pediatric Allergic Reaction 86

Pediatric Seizure 87

Pediatric Respiratory Distress 88

Pediatric Bradycardia 89

Pediatric Supra-Ventricular Tachycardia 90


Medical Protocols

Procedures

Capnography 91

Child Birth 94

CPAP 95

EZ-IO Intraosseous Infusion 96

Infection Control 98

Kendrick Extrication Device 99

King LTS Airway 100

Nasogastric / Orogastric Tube Insertion 101

Oral Tracheal Intubation 102

Needle Decompression 103

Spinal Immobilization 105

Taser Barb Removal 106

Injection: Subcutaneous / Intramuscular 107

Surgical Airway: Cricothyrotomy 109

Surgical Airway: Quick Trach 110

Tourniquet 111

Traction Splint 112

Transfers – Air Medical 113

Transfers – Trauma 114

Venti-Pac 117

Appendix A – Medication Formulary 118

Appendix B – Equipment List 159


Medical Protocols

EMT Basic Procedure-

EMT Basic Drug Administration-

EMT Intermediate Procedure-

EMT Intermediate Drug Administration-

Paramedic Procedure-

Paramedic Drug Administration-

See Protocol-

Important Note Regarding Protocol-

Pediatric Protocol Note-


Medical Protocols

Patient Assessment

A systematic approach to patient assessment allows for high quality and safe care that will be consistent

between providers and across a wide variety of patient encounters. The following outlines the expected

framework for the assessment, treatment, and communication which should occur for EVERY patient

encounter:

Primary Survey

1. Airway - is it patent? Identify and correct existing or potential obstruction, inclusive of advanced airway management as indicated.

2. Breathing - rate and quality. Identify and correct existing or potential compromising factors 3. Circulation – pulse, rate, quality, and location. Control external bleeding.

4. Determine level of consciousness (use AVPU system, Glasgow Coma Scale, or other system as indicated).

Secondary Survey

1. Reassure the patient and keep him/her informed about treatment. 2. Obtain a brief history from the patient, family and bystanders. Check for medical identification. 3. Perform a head-to-toe assessment.

4. Obtain and record vital signs as indicated by patient condition, to include heart rate, blood pressure (indicating patient’s position), respiratory rate, temperature (measured in degrees Celsius), skin color, cardiac monitor, blood glucose, SaO2 and ETCO2.

Treatment

Treat appropriately in order of priority. Refer to specific protocol.

Communications

1. Radio or telephone information protocol during transport. a. Identify transporting unit. b. Patient's age and sex. c. Chief complaint or problem. d. Pertinent history as needed to clarify problem (medications, illnesses, allergies, mechanism

of injury, etc.). e. Physical assessment findings. f. Vital signs and level of consciousness. g. Treatment given and patient's response. h. Estimated time of arrival (ETA).

2. Advise ED of changes in patient's condition during transportation.

3. Give a verbal report to ED nurse and/or physician on arrival.

4. Complete electronic patient care report (e-PCR). See following section for further details.


Medical Protocols

Cardiac Monitoring

1. Patients experiencing possible cardiac symptoms must have a 12 lead EKG within 5 minutes of patient contact whenever possible. Refer to the appropriate protocol for specific treatment. (12 lead EKG is appropriate prior to and post administration of medications, tracings should be

attached to the e-PCR)

Indications for 12 Lead Monitoring

Chest Pain or discomfort (radiating or non-radiating)

Congestive Heart Failure (CHF)

Syncope or near Syncope

Unconscious

Respiratory distress in patients >18 years of age

Chest Trauma (blunt or penetrating)

Non Traumatic GI bleeding

Overdose

CVA and or HTN

Female >50 years presenting with abdominal arm or neck pain.

Hypertension or Hypotension

Altered Mental Status

Post Resuscitation

2. Rhythms, dysrhythmias and 12-lead EKG's are to be documented and recorded as part of the patient’s record. A hard copy of the 12-lead EKG shall be made:

a. The 12 Lead ECG must be uploaded and attached to the patients ESO e-PCR when possible.

b. If/when electronic attachment is not possible due to technology failure, a paper copy must be made and routed to the Mid County Annex EMS office and filed in patient records.

c. The 12 lead must include;

i. The call run number

ii. Patient name

iii. Age

iv. Date of service

v. Receiving hospital


Medical Protocols

Respiratory Status Monitoring

Patients presenting with respiratory distress of any etiology should be assessed treated and monitored

throughout treatment and transport. End Tidal CO2 (ETCO2) monitoring is the gold standard and should

be utilized with these patients when available. SaO2 monitoring may be substituted when ETCO2

monitoring is not available.

The goal is to maintain ETCO2 between 35 - 45 mm/Hg and SaO2 at 97% or more.

Guidelines for Treatment of Respiratory Distress:

1. Oxygen Therapy. Consider limiting to 3 liters per minute in COPD or be prepared to actively support ventilation.

2. Consider intubation, CPAP, or bag valve mask/ventilation as indicated by the patient’s condition.

3. Obtain IV/IO access.

4. Position of comfort, generally sitting if adequate blood pressure.

5. See specific protocols for further details and interventions.

6. Special Considerations:

1. Rule out obstruction.

2. Listen to lung sounds for presence of:

a. Rales, rhonchi, or wheezes.

b. Accentuated or diminished lung sounds.

3. Obtain pre and post treatment ETCO2 and or SaO2 and document in e-PCR.


Medical Protocols

Documentation Guidelines

While our first and most important job is to provide patient care, all patient care and assessments must

be accurately recorded. This includes the patient s primary complaint; the patient’s presenting signs

and symptoms (assessment); and all treatments and interventions, both attempted and successful.

Deviations from protocol must also be documented, to include the reason the deviation occurred.

Protocol deviation narrative should also include the method used to notify supervising staff and/or the

medical director.

High-risk medicolegal situations require additional and thorough narrative, such as cases involving: an

unexpected death in the field or death of a young person; a prolonged resuscitation; a complex multi-

casualty incident with multiple patients and involvement of outside services; situations where law

enforcement personnel are also on scene due to violence or other civil disturbances; or cases when the

patient or family are visibly displeased with care provided. Additional details are useful to hospital-

based providers, are important during quality reviews, and may confer protection in the case of a

lawsuit.

All patient care reports (PCR’s) must be completed by the end of shift.

There are 5 main reasons to document EMS call Clinical, Legal, Operational, Financial, and Compliance.

10 items that must be in ePCRs

1. Times and dates: Make sure that all times and dates are recorded and correct.

2. Addresses of scene and destination: should include city and county.

3. Patient’s complaint on arrival: What was the patient’s primary complaint? Use patients own

words to describe the complaint when possible. Patient describes pain as “Crushing sensation in

the center of chest”.

4. Patient assessment: A primary assessment, including vital signs, must be completed on every

patient contact. This includes transports and patient refusals. All refusals’ need to 2 sets of vital

signs.

5. Patient demographics: Accurately record patient’s name, mailing address, DOB, SSN, and

telephone number. If unable to ascertain the patient’s name, state is requiring that UNKNOWN,

UNKNOWN for both last and first name.

6. Patient history, medications, and allergies: Obtain a list of the patient’s past medical history, all

medications taken by patients and list any allergies.

7. Treatments: A complete listing of all interventions and medications including time given. How

did patient response to treatment? Be sure to include both successful and unsuccessful

attempts. Including movement of patient. ( draw sheet, S.L.I.P., or bariatric equipment used)

8. Billing information: Every attempt should be made to obtain the patients insurance

information. Ask for a face sheet at the ER or get a copy made of insurance card.

9. Mileage: Total loaded mileage must be documented on every transport.


Medical Protocols

10. Signatures: A signature is required for all patients. If patient is unable to sign, a family member

of care giver can sign for patient. If a family member or care giver is not available, you will need

to note why patient is unable to sign, for example “patient is unable to sign due to AMS”.

ePCRs Specialty Patient Section

The following six sub-sections forward important data to GAAA QA and DSHS:

1. Cincinnati Stroke Scale 2. Obstetrical 3. Spinal Immobilization 4. Burns 5. CPR 6. Motor Vehicle Collision

Non-Emergency Transfers

In addition to the above guidelines, non-emergency transfers require additional documentation

specifying why the patient requires a stretcher. Relevant history, exam, and past medical history items

which support the patient’s condition as being bed-confined or non-ambulatory should be included. All

of the following must be attested and documented:

1. Unable to get up from bed without assistance, and

2. Unable to ambulate, and

3. Unable to sit in a chair or wheel chair,

4. Unable to maintain oxygenation without assistance.

Common Documentation Errors

Spelling and grammar (i.e. capital letters, punctuations, and complete sentences) are extremely

important components of the patient care narrative, both for professionalism and medicolegal reasons.

Do not use unapproved abbreviations. Most abbreviations are upper and lower case sensitive. If you are not sure whether an abbreviation is acceptable or not, write it out. Unacceptable Acceptable Abbreviation for PT Pt. Patient CC Write out Chief complaint AOS Write out Arrived on scene Cp CP Chest pain MSO MSO4 Morphine Sulfate

If you give treatment to a patient like a public assist, or bandage a wound you must fill out an ePCR.

All refusals must have 2 sets of vital signs, and document that you have explained the possible

consequences of the patient not seeking medical attention.


Medical Protocols

General System Guidelines

Transfer of Care to a Provider of a lower skill level

Leaving patients on-scene should not be a routine procedure. It is to be considered only when a patient requires immediate transport in order to maximize potential outcome.

The transport provider may transfer patient care to a provider of a lower skill level while

awaiting additional transport resources when transfer of established care is not beyond the

scope and/or training of the provider.

When a patient presents without need for MICU level care and a BLS/ALS unit is available,

patient care may be transferred at the discretion of the on-duty shift supervisor.

Mass and multi-casualty incident transport decisions will be made by the transport officer.

Cancellation or Alteration of a Response

Units may not respond non-emergency to a call for service for the sole reason that the caller

requests “No Lights and Sirens.”

Police, fire and other first responders can disregard responding units, but may not do so in order

to contact another transport provider.

Off-duty GAAA providers may downgrade or disregard responding units.

Dispatch may not disregard units when a caller requests EMS cancel their response; the

responding units must continue to the scene.

Mutual Aid:

When providers are requested to respond through an official channel for mutual aid; these

protocols remain in effect.

If a provider is dispatched on a radio channel separate from GAAA’s primary radio channel, the

responding unit must advise GAAA dispatch and the on-duty supervisor that they are responding

to a mutual aid request.

Level of Response to 9-11 Calls

Emergency traffic is the use of lights and sirens to respond to a location.

Non-emergency traffic is traveling without the use of emergency lighting or warning devices.

GAAA does not operate utilizing a tiered or EMD system.

When responding to emergency calls responders should use emergency traffic unless

downgraded or otherwise directed.

Providers may respond non-emergency to certain types of calls:

o Calls that are dispatched as a public assist without injuries

o Calls that require staging for scene safety and the provider can make the location in less

than 7 minutes driving non-emergency.

o Calls that are requested to incoming vessels or aircraft that have a known ETA that is


Medical Protocols

provided by dispatch and that the crew can make location prior to the arrival of the

vessel or aircraft.

o When directed to do so by the on duty supervisor.

On-Line Medical Consultation (OLMC): Providers have several options for OLMC:

Contact the receiving facility where the patient is being transported and speak with an ER

physician.

Contact the GAAA medical director, Dr. James Vincent.

At certain times it may be appropriate to contact the patient’s regular treating physician.

For inter-facility transports the provider should obtain written orders specific to the patient for

any treatments that are outside the provider’s standard scope of practice.

Nurses and other ancillary staff may not give providers treatment orders.

Once OLMC has been established the provider should follow the orders given by the physician that is

assuming care of the patient. However in cases that the provider feels the prescribed treatment would

violate accepted medical standards, supervisory guidance should be requested and the provider should

not follow those directives that may cause harm to the patient. In the event of a disaster situation or

other extreme circumstance, even if expressly directed by an OLMC physician, providers are prohibited

from performing field C-sections or field amputations.

Flight Operations: GAAA responds when dispatched to PHI out of Scholes field to provide medical care

to offshore locations such as ships and oil-rigs in the Gulf of Mexico. Providers may transport to a

variety of facilities along the US Gulf Coast.

For safety, GAAA providers are required to wear long pants and boots on all flights.

Additional equipment is located in the supply lockers at Scholes field in the PHI terminal.

Flight physiology will affect patient’s condition and require differing techniques to care for the

patient than ground based transport.

o Patients may require supplemental oxygen

o IV fluids will not flow in the absence of pressure infusers

o Entrapped air may expand in the patient’s body cavities.

OLMC is typically not available for providers responding off-shore; so Team Captains are

required on all flights.

If the shift supervisor is required to maintain system status by sending a non-team captain

paramedic on an offshore flight, that provider is permitted to utilize all treatment pathways,

including those at Team Captain level skills.


Medical Protocols

Air Medical Activation Guidelines

Overview: Air medical transport is an important adjunct to the overall care of the severely ill or injured patient. Air medical provider (AMP) resources should be utilized in accordance with the regional trauma plan. Purpose: These AMP activation guidelines are intended to provide a framework for each RAC to develop a standardized method for ground emergency medical service providers to request a scene response by an AMP, to reduce delays in providing optimal care for severely ill or injured patients, and to decrease mortality and morbidity. Decision Criteria: AMP activation/scene response should be considered when it can reduce transportation time for severely ill or injured patients meeting activation criteria. Should there be any question whether or not to activate regional AMP resources, on-line or receiving facility medical control should be consulted for a final decision. Guidelines for Activation:

1. The ground emergency medical service provider may, when one or more of the elements of the activation criteria exist, request a scene response by an AMP and assist with transportation to an appropriate acute care facility.

2. Ground emergency medical service providers should not remain on scene awaiting AMP arrival if ground transport time will be less than the combined arrival and return time of the AMP.

3. Ground emergency medical service providers should activate the AMP as early as possible, including prior to their arrival at the scene if the mechanism of injury or scene report meets criteria.

4. The EMS provider should comply with RAC-approved triage criteria (such as that listed below) to activate AMP transport.

5. Other factors that should be considered are: a) Location of incident b) Number of patients c) Age of patients d) The total AMP response time (response time+ scene time +transport time) will

result in delivery of the patient(s) to the most appropriate facility faster than transport by ground ambulance.

e) Weight of patients f) AMP activation will provide access to advanced life support interventions critical for

patient survival that are not available on scene (and more quickly than ground EMS can arrive at the nearest hospital).

g) Special circumstances & patient injuries (transport of suspected spinal injury over rough terrain) where patient outcome would be improved by AMP transport.

6. In all instances the available AMP that best meets the needs of the patient will be utilized.

Other considerations: Trauma patients meeting criteria for AMP dispatch should be transported to a Level I, II, or III Trauma Center. Severely ill medical patients should be transported to the nearest appropriate acute care facility.


Medical Protocols

Air Medical Activation Criteria:

1. Severely injured or ill patients located in a remote or off-road area not readily accessible to ground ambulance.

2. Ground resources with acceptable response time exhausted or exceeded in the region. 3. Reduction in transport time to a trauma center compared to ground transport for the

seriously injured trauma patient. 4. Motor vehicle collisions involving:

a. Ejection b. Rollover c. Death in same patient compartment d. Patient extrication of 20 minutes or greater

5. Falls from a distance of greater than 20 feet 6. Auto-pedestrian injury with significant impact (> 20 mph) 7. Physiologic:

a. Glasgow Coma Scale of less than 10 b. Systolic blood pressure of < 90 with signs/symptoms of shock

8. Anatomic: a) All penetrating injuries to the head, neck, torso, and/or extremities proximal to the

elbow and knee b) All penetrating injuries to the head, neck, torso, and/or extremities proximal to the

elbow and knee c) Flail chest d) Combination trauma with burns of 20% involving face or inhalation injuries e) Major burns including:

i. Inhalation ii. 2nd or 3rd degree burns > 20% BSA iii. Combination trauma with burns

f) Two or more proximal long-bone fractures g) Pelvic fractures h) Traumatic paralysis i) Amputation proximal to the wrist or elbow j) Depressed or open skull fractures

9. Multiple severely injured patients on scene 10. No available trauma center within one hour of ground transportation.


Medical Protocols

Specialty Care:

T r a n s p o r t decisions for specialty problems such as Trauma, Stroke, ACS/STEMI, Pediatric Care

and Burns will be made with attention to local hospital and regional protocols. Evidence-based

support fueling national quality initiatives to bring a patient to a certified/accredited specialty

center will be weighed against the need to bring a critically unstable patient to the closest

available facility.

Trauma: Patients with acute traumatic injuries will be transported to an appropriate

Trauma Center per RAC guidelines. (See “Transfers – Trauma” under Procedures Section).

Local Stroke Resources: Patients presenting with acute stroke symptoms less than 6 hours

in onset will be preferentially taken to a stroke center when possible. Air medical

transport may be considered for select patients with symptom onset less than 2 hours in

order to facilitate time-dependent lytic therapy.

ACS/STEMI: Patients experiencing acute STEMI are best managed in facilities with active

cath lab programs and should be preferentially taken to these centers. The receiving

hospital emergency department physician should be notified while en route. The field EKG

demonstrating the STEMI should be transmitted electronically to the receiving hospital

when possible, in order to facilitate activation of the cath lab before arrival when

appropriate.

Pediatric Care: Children with critical illness or injury and children with chronic underlying

medical conditions should be preferentially transported to a facility capable of caring for

the child’s critical illness or special needs. The parents should be enlisted to assist with

destination decisions whenever possible.

Burn Care: Patients fulfilling criteria for major burns (see burn care protocol) should be

transported to a burn center whenever possible.


Medical Protocols

On-Scene Medical Providers:

(Per the Texas State Board of Medical Examiners (TSBME), the licensing body for physicians in Texas.)

Control at the scene of a medical emergency shall be the responsibility of the individual in attendance

who is most appropriately trained and knowledgeable in providing prehospital emergency stabilization

and transport.

Physician On-Scene/General Guidelines The credentialed provider on-scene is responsible for management of the

patient(s) and acts as the agent of the medical director or OLMC. In order to participate in care physicians must present a valid Texas Board of

Medical Examiner’s License (all physicians are issued a wallet card) or be recognized as a physician by the provider.

Patient’s Personal Physician On-Scene If the patient's personal physician is present and assumes care, the provider

should defer to the patient’s personal physician. That physician shall provide the provider with written orders if they deviate from this document.

If there is a serious disagreement between the patient’s personal physician and

the system SOGs, the physician shall be placed in direct communication with

OLMC. If the patient’s personal physician and the on-line physician disagree on

treatment, the patient’s personal physician must either continue to provide

direct patient care and accompany the patient to the hospital, or must defer all

remaining care to the on-line physician. Intervener Physician On-Scene

If an intervener physician is present at the scene, has been satisfactorily identified as a licensed physician (by showing a valid copy of his/her Texas medical license), and expressed willingness to assume responsibility for care of the patient, OLMC should be contacted. The on-line physician has the option to:

manage the case exclusively work with the intervener physician allow the intervener physician to assume complete responsibility for the

patient If there is a disagreement between the intervener physician and OLMC, the

provider will take direction from the on-line physician and place the intervener physician in contact with the on-line physician.

The intervener physician must document his or her interventions and/or orders on the EMS patient care record.

The decision of the intervener physician to not accompany the patient to the hospital shall be made with the approval of the on-line physician.


Medical Protocols

Selected Age Definitions:

Adult: A patient that is over the age of 18 years of age.

Minor: A patient under the age of 18.

Pediatric patient: For treatment purposes only. Any patient that has not reached puberty or is able to fit on a Broselow tape

Competency: Mental competency: This is a legal definition and refers to the presumption that a patient is legally mentally competent unless a court of law has judged them to be incompetent. Present mental capacity: refers to a patient’s current mental ability to understand and appreciate the nature and consequences of his/her condition and to make rational treatment decisions. Determination of competency involves consideration of the following:

Adult patients.

Alert, able to communicate, and demonstrates appropriate cognitive skills for the circumstances of the situation.

Showing no indication of impairment by alcohol or drug use.

Showing no current evidence of suicidal ideations, suicide attempts or any indication that they may be a danger to themselves or others. Law enforcement must be requested for this patient population.

A law enforcement officer may arrest a patient who threatens or attempts suicide under Texas Health and Safety Code Section 573.001. The statute also covers other mentally ill patients and a similar statute allows an arrest for chemical dependency. Remember though, only a law enforcement officer can make these arrests.

Showing no current evidence of bizarre/psychotic thoughts and/or behavior, or displaying behavior that is inconsistent with the circumstances of the situation.

No physical finding or evidence of illness or injury that may impair their ability to understand and evaluate their current situation (for example, a patient with a head injury and an abnormal GCS, a patient with significant hypoxia or hypotension, etc.).

A patient that has NOT been declared legally incompetent by a court of law.

If a patient has been declared legally incompetent, his/her court appointed guardian has the right to consent to or refuse evaluation, treatment, and/or transportation for the patient.


Medical Protocols

Types of Consent

Informed Consent: This is the legal standard regarding the process in which the patient refuses or consents to medical care.

o The patient is competent and able to make a decision about their medical care. o The patient is given all the necessary information a reasonable person would require to

make the decision including: risks, benefits and alternatives o The patient is capable of deliberating and communicating their choice.

Implied Consent: This type of consent regards the legal standard for consent during a life-threatening emergency. Patients must be:

o Unable to communicate because of an injury, accident, illness, or unconsciousness and suffering from what reasonably appears to be a life-threatening injury or illness

o OR suffering from impaired present mental capacity o OR a minor who is suffering from what appears to be a life-threatening injury or illness

and whose parents, guardians or managing or possessory conservator are not present. o Patients who are not mentally competent or have an impaired present mental capacity.

The latter case will generally require law enforcement assistance.

Substituted Consent: When another person consents for the patient such as for minors, incapacitated patients, incarcerated patients and those who have been deemed by a court of law to be legally incompetent.


Medical Protocols

Consent and Treatment of Minors

A minor is able to consent or refuse medical care in a limited set of circumstances in Texas.

Emancipation: This requires a court order in the state of Texas.

Minors who are on active military duty with the US Military

When consenting to the diagnosis and treatment of an infectious, contagious, or communicable disease that is required by law or rule to be reported by the licensed physician or dentist to a local health officer or the Texas Department of State Health Services

Is consenting to examination and treatment for drug or chemical addiction, drug or chemical dependency, or any other condition directly related to drug or chemical use

A minor can consent to counseling for suicide prevention, chemical addiction or

dependency, or sexual, physical or emotional abuse Minors who are married are considered emancipated

Pregnancy:

Minors may consent or refuse medical care related to the care of their unborn child or for their pregnancy.

Minors may also consent or refuse medical care and treatment of their child if they have custody of that child.

Who other than the parents of a minor can consent to or refuse medical treatment? Per Texas Statutes- Family Code §32.001

Grandparent Adult brother or sister Adult aunt or uncle Any educational institution in which the minor is enrolled and has written

authorization from persons having power to consent Any adult who has actual care, control and possession of the minor and has written

authorization to consent for medical treatment. A court having jurisdiction over a suit affecting the parent-child relationship of which the child is

the subject

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

A managing or possessory conservator or guardian.

A provider may be denied access to minor children by a parent or guardian if there is no obvious

immediate life threat to the patient. However, in general, parents or guardians cannot refuse

life-saving therapy for a child based on religious or other grounds.

If the provider feels that the child is in immediate danger of a life threatening illness or injury

and the parent or guardian is refusing medical care, contact law enforcement for assistance in

treatment and transport.

In the event of an unaccompanied minor that requests refusal of medical care, consent may be obtained

via telephone by contacting the parent or guardian of the minor.


Medical Protocols

Restraint /Transport Against Patient Will:

Texas Penal Code § 573.001 and 573.002 places responsibility for management of patients with

psychiatric problems with local law enforcement. Pursuant to this law EMS crews will assess patients

with psychiatric problems for any medical problems which they may have. Patients with acute medical

issues will be treated and transported as appropriate for their medical condition. Persons with

psychiatric problems that have no acute medical problem will be left under the supervision of local law

enforcement authorities.

Patients who are mentally competent have the ability to refuse medical care even if the patient may

potentially suffer increased illness, injury, disability or death. However patients who do not meet the

definition for competency require treatment and transport to an Emergency Department.

1. Assess scene safety. Attempts to physically restrain a patient should be made (when possible) with law enforcement assistance.

2. Determine if the patient is mentally competent and able to consent to or refuse medical care.

3. Patients should never be restrained if they are legally able to refuse care in order to force medical care upon them.

4. If the patient is not mentally competent and the patient has a potentially significant injury or illness that requires medical care, GAAA providers will provide care when safe to do so.

5. Providers should attempt to de-escalate the situation with verbal techniques.

6. If verbal techniques fail or scene safety degrades in a way that becomes potentially dangerous for the providers, first responders, general public or the patient, then additional methods should be implemented.

7. Physical restraints should be safe & humane. At NO TIME should a patient be struck or managed in such a way as to impose pain. Restrain in a position of comfort and safety.

8. Inhumane or dangerous techniques of physical restraint including prone positioning, placing the patient between backboards or hogtieing are expressly prohibited.

9. Document the reason for restraint, the mental status exam, options attempted, and method of restraint on all patients.

10. Patients that are combative and who have been restrained should have chemical restraint unless contraindicated.

11. If chemical restraint is used; refer to the “Behavioral Emergency” protocol (page 47). Patients should be continuously monitored after implementing any degree of restraint.

12. At no time should the patient be left alone.


Medical Protocols

Refusals:

Any person, eighteen years of age or older, that is deemed to have the legal competency and present

mental capacity to consent, may consent to, or refuse evaluation, treatment, and/or transportation.

A provider may be denied access to personal property (land and home) by the property owner or

patient, if there is no obvious immediate life threat to a patient.

Patients that do not require transport by an Emergency ambulance:

Adult patients with less than <40BSA mild sunburn

Jellyfish envenomation successfully treated with first aid and in the absence of other complaints.

Patients who request transport for medication refills or doctor’s office visits, in the absence of any

complaints.


Medical Protocols

Termination of CPR

Termination of CPR is a difficult decision for clinicians. Termination of CPR should not be performed in public locations with the exceptions of hospitals, nursing home, assisted living facilities and other healthcare facilities. Termination may be performed in private residences and where the deceased and family’s privacy can be respected. Termination efforts involve the entire family if present and after a field termination care and guidance should be redirected to the family and friends present at the resuscitation.

Resuscitation should not be initiated when any of the following is noted:

Obvious appearance of death

Decomposition

Rigor mortis

Obvious mortal wounds (massive burn injuries, severe traumatic injuries with obvious signs of organ destruction such as brain, thoracic contents, etc.)

Severe extremity damage, including amputation, should not be considered an obvious mortal wound without coexistent injury/illness

Other circumstances

Patient submersion greater than 15 minutes after the arrival of first responders.

Patients who are submersed in cold water do not have a definitive time that resuscitation is futile and resuscitation should be initiated in the absence of other obvious signs of death.

Valid Out-Of-Hospital Do Not Resuscitate written order or device from any US State.

A valid licensed physician on scene or by telephone orders no resuscitation efforts.

Traumatic Cardiac Arrest:

o Arrival to the hospital time is greater than 10 minutes from time of arrest

o Asystole or PEA with a rate less than <40/minute. (Paramedic)

o This does not apply to isolated blunt traumatic arrest such as sudden blows to the chest

such as caused by a baseball or a strike with a fist. It does apply to severe crush injuries

to the torso.

o No evidence of signs of life

Any provider, in the following circumstances, may discontinue resuscitation efforts without OLMC:

Resuscitation efforts were inappropriately initiated when criteria to not resuscitate were present.

A valid OOH-DNR or advanced directive was discovered after resuscitative efforts were initiated.

As per the limited termination of resuscitation(TOR) protocol (see below)

For traumatic arrest only: when an EKG is applied after resuscitation is initiated and a PEA <40 or asytole is noted. (Paramedic)


Medical Protocols

Termination of appropriate Resuscitation Efforts Utilizing OLMC: There are instances when a provider

must contact OLMC when considering discontinuation of resuscitation efforts. These include but are not

limited to the following circumstances:

Attempts of 15 minutes or more using ACLS/PALS interventions with no return of spontaneous circulation (ROSC).

Patients who are found with presumed natural death and whose family request no interventions be performed but do not have a DNR.

If the decision to terminate resuscitation efforts is made:

Continue resuscitation while requesting an order to discontinue the resuscitative efforts.

Contact OLMC (recorded line preferred).

Document thoroughly per system and agency protocols.

Termination of appropriate Resuscitation Efforts without OLMC

This is permitted only by a Team Captain or higher level. This should not be performed if family is not able to accept the death. Prior to initiating this protocol the provider should speak with the family regarding the failed resuscitation efforts.

Team Captain or higher only

Adult patients

Cardiac arrests that were not witnessed by GAAA providers or first responders.

No bystander CPR

15 minutes or more of continued asystole

No defibrillation delivered during resuscitation and the patient is in asystole.

For offshore flights and no OLMC are available providers are permitted to cease resuscitation efforts when:

15 minutes of ACLS has been delivered without ROSC and in the presence of asystole

Provider fatigue

When the extrication time of the patient to the aircraft or to the provider would exceed 15 minutes and no bystander CPR has been delivered and the patient is confirmed to be pulseless and apneic.


Medical Protocols

Out of Hospital Do NOT Resuscitate (OOH DNR)

Patients have a legal right to consent to, or refuse, recommended medical procedures, including

resuscitative efforts. The decision to honor, or not to honor, an OOH DNR must be made quickly and

accurately. Remember, it is our obligation to carry out the patient’s appropriately designated medical

choices.

An OOH DNR order should NOT be honored and resuscitative efforts should be initiated in the

following circumstances:

o The patient or person who executed the order destroys the form and/or removes the identification device.

o The patient or person who executed the order directs someone in their presence to destroy the form and/or removes the identification device.

o The patient or person who executed the order tells the EMS providers or attending physician that it is his/her intent to revoke the order.

o The attending physician or physician’s designee, if present at the time of revocation, has recorded in the patient’s medical record the time, date, and place of the revocation and enters “VOID” on each page of the DNR order.

o The patient is known to be pregnant.

o In the event that there is a question as whether to honor or not honor an OOH DNR or

Advanced Directive, contact OLMC as needed.

Important Points to Remember

o Always rule out a non-traumatic etiology for what may be perceived as a traumatic arrest (for example, primary ventricular fibrillation resulting in a minor car crash).

o Anytime a DNR is not honored, the reason must be documented in the patient care record (PCR).

o An advanced directive does not imply that a patient refuses palliative and/or supportive care. Care intended for the comfort of the patient should not be withheld based on a medical power of attorney.

When an EMS provider honors an appropriately executed DNR order, the law provides protection against any charges of aiding in suicide 9Section 22.08 of the Penal Code -TAC 166.047.

When in doubt, always initiate resuscitative efforts. Later termination can be implemented if appropriate.


Medical Protocols


Medical Protocols

Hospice Patients

When a patient with a severe illness decides that curative measures are no longer appropriate or effective, the option of hospice care is a compassionate, dignified and cost-effective end-of-life care option. The address where a hospice patient resides will ideally be flagged from dispatch to allow for appropriate identification of these patients. While a patient or legal surrogate may reverse a hospice decision at any time, transport of these patients inappropriately to the hospital emergency room generally will trigger loss of funding for the patient. Our role when caring for a hospice patient includes:

Confirming hospice status

Providing comfort measures

Addressing family concerns

Coordinating care with the Hospice Team, which may include transport to the hospital as a direct admission

As end-of-life issues are difficult for patients and healthcare professionals alike, the shift Supervisor or Medical Director should be contacted immediately for assistance should any questions or concerns arise during the care of these patients.


Medical Protocols

Scope of Practice

The State of Texas does not have a state-mandated scope of practice. Each system determines the

providers’ scope of practice.

The following skills/interventions are authorized by credential level in our system:

Emergency Medical Technician- Basic (EMT-B) Credentials

Patient assessment

Spinal motion restriction

CPR/AED application

OPA/NPA

Oropharyngeal suction

Pulse Oximetry

BVM ventilations

Blood glucose assessment

Oral glucose administration

Bandaging/Splinting

Emergency Childbirth

Mark 1 Auto injector kits if available

Medication administration: all medications and routes as outlined in ECA and EMT-B level Patient Care Guidelines

12-lead acquisition if appropriately trained

Small volume nebulizer Members of Galveston Beach Patrol

CPAP

Combitube

Assist patient with prescribed medications

Oxygen administration: Titrate to an oxygen saturation of 92% or patient improvement by the use of NC, NRB, and BVM oxygen administration.

End-tidal CO2 monitoring and interpretation

CPAP


Medical Protocols

Emergency Medical Technician- Intermediate (EMT-I) Credentials

All EMT-B skills/interventions plus:

Medication administration: all medications and routes as outlined in EMT-B, and IM, PO, IV, IN, SQ, nebulized medications as directed in the protocols.

Peripheral intravenous access

Intraosseous access

Orotracheal intubation

Nasotracheal intubation

Tracheal suctioning

External jugular cannulation

EZ-IO

Non Team Captain Paramedics

All EMT-B, and EMT-I skills/interventions plus:

All routes of medication administration

(IV, IO, ET, SQ, SL, PR, IM and IN)

Obtaining and interpreting ECG &

12-leads.

All cardiac related medications in a

cardiac arrest situation.

Vagal maneuvers

Defibrillation / Cardioversion

External cardiac pacing

Gastric tube insertion

Any other skill as directed by Team

Captain.

Team Captain Paramedics

All skills listed above

Chest decompression

Surgical airway

Pharmacologically Assisted Intubation

Supervisor

All skills listed above

All Therapies within the protocols including extended medical authorization and other special procedural skills as developed.


Medical Protocols

Inter-facility Transfers:

When transferring a patient who requires transport to a higher level of care or for specialty services not available at the sending facility the following guidelines should be used:

Consult with the on-duty shift supervisor for any patient care issues that cannot be resolved through this document. If called to transport a patient that is potentially unstable for transport, assess and consult with the treating physician.

Consistent with the intent of EMTALA, the transfer of a patient not stabilized for transport may be preferable to keeping that patient at a facility incapable of providing stabilizing care. If the patient requires advanced treatment or interventions that are beyond the scope of prehospital providers the facility should provide appropriately trained staff to accompany the patient.

Additional staffing:

If the staff member is an RN, he or she will maintain patient care responsibility and function within his or her scope of practice and under the orders of the transferring physician. The GAAA provider(s) and the RN will work together to provide patient care. If the patient deteriorates en route the Paramedic will assume care outside the RN’s scope of practice.

If the additional staff member is an RT, he or she will manage ventilator settings and all treatment under his or her scope of practice. The paramedic will assist as needed and manage the comprehensive patient care.

If the additional staff member is a physician, then that physician will remain in charge of patient care. The GAAA provider will assist as required.

If the additional staff member is a flight paramedic, GAAA providers will assist as required and, unless requested, the patient will remain in the care of the flight paramedic.

Due to the unique nature of inter-facility transports, providers will encounter medications and invasive procedures that are not typically utilized in pre-hospital treatment. Providers should not monitor medications or devices that they are not familiar with. Providers should not take possession of any medication that is not from GAAA formulary to administer to the patient en route. Providers may monitor and transport an extended formulary but should not institute or titrate any medications or infusions not stated in this document. Limited titration can be performed by paramedics with written orders.

Dial-a-flows are not appropriate for medication and infusion monitoring on inter-facility transfers.

EMT- Basics are permitted to transport and monitor all patients as noted in GAAA protocols and:

Monitor only:

Peripheral lines with a saline lock.

Personal Insulin infusion pumps that are maintained by the patient.

Feeding tubes and TPN solutions on an infusion pump.

Established (greater than 2 week placement) of tracheostomy patients on home ventilators with

pre-set ventilator settings.


Medical Protocols

NG/OG tubes.

Internal pacemakers.

Spinal stimulators.

Foley catheters.

Central venous access lines without infusions excepting patient controlled devices.

EMT-Intermediates: All skills and medications listed above and:

Peripheral lines containing plain isotonic or glucose solutions without medications added. May

adjust per the patient’s condition and/or written orders from the sending facility.

IV antibiotics running at a KVO rate or on an infusion pump if the medication has been initiated

by the sending facility.

Ventilator patients that do not require sedation, paralysis, EKG monitoring or other advanced

procedure.

EMT-Paramedics: All skills and medications listed above

Non-Team captain Paramedics will require written orders to administer sedation or paralysis

for intubated patients on ventilators.

Administer but not initiate glucose or isotonic IV fluids that are not standard GAAA formulary.

May monitor and adjust IV solutions containing potassium less than 20mEq/L.

Medications that GAAA providers may monitor without titration and administered through an

infusion pump. In the event of an infusion pump malfunction, the infusion should be stopped

and the appropriate facility contacted for guidance.

Heparin Magnesium

Anticoagulants or Antiplatelet agents Solutions with >20mEq/L of KCL

Electrolyte preparations Insulin

Antibiotics Mannitol

Sedatives in an infusion dose Paralytics as a continuous infusion

Sodium Bicarbonate infusions TPN/PPN

Anesthetic infusions IV steroids


Medical Protocols

The following medications may be titrated with written orders from the sending facility :

Insulin Propranolol and other beta-blockers

IV Nitrates Anti-dysrhythmics

Vasopressors Anti-hypertensive continuous infusions

Lidocaine

NOTE: Although the sending facility may have initiated medication(s), Paramedics MUST be familiar with

the medications that the patient may be receiving at the time of transfer. Reminder: interfacility

medications are not to be initiated by Paramedics.

Paramedics may monitor:

Ventilators

PIC Lines

Bladder Irrigation

Chest tubes

Femoral lines

ICP monitoring devices that are not in active use.

Blood products may be monitored by providers.

Paramedics may transport patients with femoral sheaths that are not currently accessed. Patients that

have arterial line monitoring, active ICP monitoring devices or Intra-aortic balloon pumps require

additional trained personnel from the sending facility to monitor and manage those devices.


Medical Protocols

Expired Medications and Medication Shortages

In the setting of national medication shortages, when it is deemed to be in the patient’s best interest to

use an expired medication, as opposed to either an inferior alternative or no medication, an expired

medication may be used. Additionally, providers will not be responsible for giving medications in any

protocol in which the medicine is unavailable due to national shortages or supply issues. Clinically

appropriate pharmacologic substitutions may be authorized on a case-by-case basis and communicated

directly to field staff by the medical director.


Medical Protocols

Ebola Preparedness Procedure

Dispatch Decision Tree for Ebola Screening

Does the

patient have a

fever > 38*C or

100.4*F

NO Proceed with normal

call process

YES

Does the patient have severe

headache, muscle pain, vomiting,

diarrhea, abdominal pain or

unexplained bleeding?

NO Proceed with normal

call process

YES

In the past 21 days

has the patient been

in contact with blood

or body fluids of a

patient known to

have or suspected to

have Ebola?

In the past 21 days

handled bats or

nonhuman primates

from a disease

endemic area?

In the past 21 days

been in residence or

traveled to a country

where an Ebola

outbreak is

occurring?

Western Africa Countries:

Guinea, Liberia, Nigeria, Sierra Leone

If the answer to any of these questions is

YES notify the crew immediately for Person

under Investigation of Ebola


Medical Protocols

4.2 – Guidance for Emergency Medical Services (EMS) Systems for 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or suspected Ebola Virus Disease (EVD) Purpose To provide an integrated plan of operations between the University of Texas Medical

Branch (UTMB) Health System and any Emergency Medical Service in the safe transport and healthcare for patients with diagnosed or possible Ebola Virus Disease.

Audience Healthcare personnel in the UTMB Emergency Department (ED) and personnel in the EMS.

Policy and Procedures

I. Transport of patients with possible EVD based on 9-1-1 calls to the EMS A. When calls come in to the dispatcher requesting Transport of a patient with possible

EVD, the dispatcher should ask the following questions: 1. Do they or someone else with them have a fever of greater than 38*C or

101.5*F and if they have additional symptoms such as severe headache, muscle pain, vomiting diarrhea, abdominal pain or unexplained bleeding?

2. If the patient has symptoms of Ebola, then ask the patient about risk factors within the past 3 weeks before the onset of symptoms, including:

a. Has the patient had contact with blood or body fluids of a patient known to have or suspected to have EVD?

b. Has the patient had residence in-or traveled to a country where an Ebola outbreak is occurring?

a. Guinea b. Sierra Leone c. Liberia d. Nigeria

c. Has the patient handled bats or non-humans primates from the disease-endemic areas?

d. If the dispatcher has information from the above queries suggesting that the person may possibly have EVD, they should make sure that the EMS personnel are made confidentially aware of the potential for EVD so that responders can don appropriate PPE before they arrive at the scene.

II. Transport of cases of possible EVD from UTMB outlying Clinics to the UTMB ED A. Cases that present to UTMB Clinics with possible EVD will be screened using the

same screening protocol as that used by the UTMB ED.

Section: UTMB On-Line Documentation

Subject: Healthcare Epidemiology Policies and Procedures

Topic: 4.02 – Guidance for Emergency Medical Services (EMS) Systems for 9-

1-1 Public safety Answering Points (PSAPs) for Management of Patients with

Known or suspected Ebola Virus Disease (EVD)

4.02 – Policy

10.21.14

2014 - Author


Medical Protocols

B. When a patient in an outlying UTMB clinic meets the screening criteria for EVD or possible EVD, the clinic will call the EMS and request transfer to the UTMB ED. The clinic will notify the UTMB ED that the patient is being transferred.

III. PPE for EMS when transporting a case of EVD or possible EVD A. KleenGard suit B. Three pairs of gloves

1. Latex gloves 2. Middle pair of long puncture-resistant gloves taped to gown cuffs 3. Outer pair of latex or nitrile gloves 4. Surgical mask 5. Goggles or face shield 6. Shoe-leg covers

IV. Use caution when approaching a patient with Ebola. Illness can cause delirium, with erratic behavior that can place EMS personnel at risk of infection, e.g., flailing or staggering.

V. Pre-hospital resuscitation procedures such as endotracheal intubation, open suctioning of airways, and cardiopulmonary resuscitation frequently result in a large amount of body fluids, such as saliva and vomit. Performing these procedures in a less controlled environment (e.g., moving vehicle) increases risk of exposure for EMS personnel. If conducted, perform these procedures under safer circumstances (e.g. stopped vehicle, hospital destination).

A. During pre-hospital resuscitation procedures (intubation, open suctioning of airways, cardiopulmonary resuscitation).

1. In addition to recommended PPE above, respiratory protection that is at least as protective as a NIOSH-certified, fit-tested N95 filtering face piece respirator or higher should be worn (instead of a facemask).

2. Activities should be limited, especially during transport that increase the risk of exposure to infectious material (e.g., airway management, cardiopulmonary resuscitation, use of needles).

B. Limit the use of needles and other sharps as much as possible. All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers.

C. Phlebotomy procedures and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care.

D. If blood, body fluids, secretions, or excretions from a patient with suspected Ebola come into direct contact with the EMS provider’s skin or mucous membranes, then the EMS provider should immediately stop working. If eyes are involved, the EMS provider should flush eyes with large amounts of water. The EMS provider should wash the affected skin surfaces with soap and water and report exposure to an occupational health provider or supervisor for follow-up.

E. PPE should be worn upon entry into the scene and continue to be worn until personnel are no longer in contact with the patient.

F. PPE should be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials.

G. Re-useable PPE should be cleaned and disinfected according to the manufacturer’s reprocessing instructions and EMS agency policies.

H. Refer to all figures for instructions for putting on and removing PPE. I. Hand hygiene should be performed immediately after removal of PPE.


Medical Protocols

VI. Cleaning EMS transport vehicles after transporting a patient with suspected or confirmed Ebola.

A. EMS personnel performing cleaning and disinfection should wear recommended PPE (described above) and consider use of additional barriers (e.g., rubber boots or shoe and leg coverings) if needed.

B. Face protection (face mask with googles or face shield) should be worn since tasks such as liquid waste disposal can generate splashes.

C. Patient-care surfaces (including stretchers, railings, medical equipment, control panels and adjacent flooring, walls and work surfaces) are likely to become contaminated and should be cleaned and disinfected after transport.

D. A blood spill or spill of other body fluid or substance (e.g., feces or vomit) should be managed through removal of bulk spill matter, cleaning the site, and then disinfecting the site. For large spills, a chemical disinfectant with sufficient potency is needed to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant’s active ingredient.

E. An EPA-registered hospital disinfectant with instructions for cleaning and decontaminating surfaces or objects soiled with blood or body fluids should be used according to those instructions. After the bulk waste is wiped up, the surface should be disinfected as described in D. above.

F. Contaminated reusable patient care equipment should be placed in biohazard bags and labeled for cleaning and disinfection according to agency policies. Reusable equipment should be cleaned and disinfected according to manufacturer’s instructions by trained personnel wearing correct PPE. Avoid contamination of reusable porous surfaces that cannot be made single use.

G. Use only a mattress and pillow with plastic or other covering that fluids cannot get through. To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses as a regulated medical waste.

DONNING AND REMOVAL OF PERSONAL PROTECTIVE EQUIPMENT

PPE for EMS when transporting a case of EVD or possible EVD includes all of the items below:

Disposable KleenGard coverall

Three pairs of gloves o Latex gloves o Middle pair of long puncture-resistant o Outer pair of latex or nitrile gloves

Surgical mask

Goggles or face shield

Waterproof shoe-leg covers

For multiple pairs of gloves , (i.e. for EMS), carefully pull second puncture resistant gloves over first pair and tape cuffs of KleenGard coverall, sealing completely. Carefully pull third pair of gloves over the taped pair.


Medical Protocols

How to don a KleenGard suit:

Unfasten times/unzip zipper

Scrunch up the legs of the suit, making a space for your feet to go through to touch the ground

Step into the suit one leg at a time

Gently pull the suit over your legs and to your waist

One arm at a time, put on the upper portion of the suit

Zip the zipper

How to don shoe covers/leg covers:

Ensure that foot and leg protectors are fastened carefully outside the KleenGard suit legs

How to remove KleenGard suit:

Undo ties on foot-leg protectors and remove and discard in contaminated trash

Unfasten ties/unzip zipper on KleenGard suit

Peel suit away from neck and shoulder

Outer pair of gloves and middle pair of gloves taped to cuffs of KleenGard suit will be removed with the suit

Turn contaminated outside of suit toward the inside

Fold or roll into a bundle

Discard

REFERENCES

1. Centers for Disease Control and Prevention. Ebola Hemorrhagic Fever. Case Definition for Ebola Virus Disease (EVD). September 10, 2014.

2. Centers for Disease Control and Prevention. Ebola Hemorrhagic Fever. Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals. August 27, 2014.

3. Centers for Disease Control and Prevention. Ebola Hemorrhagic Fever. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals. August 30, 2014.

4. Centers for Diseases Control and Prevention. Ebola Hemorrhagic Fever. Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSARs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States. September 10, 2014.


Medical Protocols

UNIVERSAL TREATMENT GUIDLINES

Scene Safety

PPE As Needed

Initial Assessment

Cardiac Arrest

Cardiac Arrest

Protocol

CONSIDER DIAGNOSTIC ADJUNCTS:

Pulse oximetry if available

Consider BGL Measurement

Consider supplemental oxygen if O2 sat <92

Consider ETCO2 monitoring

RSI Protocol

Bring all necessary equipment to the patient

Heimlich Maneuver

Respiratory Failure

BVM Ventilation

Airway Obstructed Severe Neurologic

Disability

Suction Airway

OPA/NPA

Begin High Quality

Compressions

Excited

Delirium

Protocol

Seizure

Protocol

Secondary Survey

Detailed History

Proceed To

Appropriate Protocol Consider Establishing IV

COMMUNICATION

Document PCR

Obtain signatures AS NEEDED

Notify receiving hospital

Transmit ECG

Transmit pt. info

Notify supervisor

EXPECATIONS FOR EVERY

PATIENT ENCOUNTER:

- GCHD Badge displayed

- Appropriate dress code

- Highest degree of

professionalism

Consider cardiac monitor

Consider 12 Lead ECG


Medical Protocols

PREOXYGENATE PT 100% O2

VIA BVM FOR 30-90 SEC

ETOMIDATE 20MG

AND/OR

VERSED 5MG

INTUBATE PT

(CONSIDER KING VISION

WHEN AVAILABLE)

SUCCESSFUL

SUCCINYLCHOLINE

100 MG IV

YES

NO

OXYGENATE PT 100% O2 VIA

BVM FOR 30-90 sec. CONSIDER

ATTEMPT BY SECOND PERSON

INTUBATE PT WITH

PROPER SIZE ET TUBE

VERSED 5 mg IV

May Repeat X1 for

SYSTOLIC BP >90

FENTANYL

100 mcg IV

SUCCESSFUL NO YES

THREE

UNSUCCESSFUL

ATTEMPTS

NO

YES

Clinical Indications: Patients who require control of the airway due to airway compromise or the

potential for airway compromise.

RAPID SEQUENCE INDUCTION

RSI is not indicated for deeply comatose patients.

Monitor pulse oximetry when available. Ensure oxygen saturation remains > 90%.

A second medic should make the third attempt at intubation if 3 attempts are needed.

Documentation should include patient’s GCS prior to intubation, indication for intubation, and placement confirmation methods.

Paralyzing a patient without proper sedation is cruel and poor medical practice.

VECURONIUM

10 mg IV OR

ROCURONIUM

50 mg IV

INDICATORS OF SUCCESSFUL

INTUBATION

Visualization of tube going through cords

Audible and equal breath sounds

Lack of sounds over epigastrium

POSITIVE END-TIDAL CO2

Improvement in vital signs and color.

ASSESS ALL OF THE ABOVE AFTER EACH ATTEMPT

FAILED AIRWAY

Consider Add’l SUCC 50mg IV

PEDI DOSAGES

Etomidate

0.3 mg/kg

Succinylcholine

1 mg/kg

Rocuronium

1mg/kg

Versed

0.1 mg/kg

Vecuronium

0.1 mg/kg

KING VISION, when available:

- REQUIRED for C-spine immobilized patients

- STONGLY RECOMMENDED for all intubations

Yes to any item?

Patient will require spinal motion

restriction

MONITOR

ETCO2


Medical Protocols

FAILED AIRWAY Indications:

BVM fails to maintain SpO2 >90% or becomes difficult to ventilate.

Three failed total attempts at oral-tracheal intubation

Continuous pulse oximetry when available and ETCO2 monitoring should be used in all

patients with inadequate respiratory function.

Notify receiving Emergency Department ASAP about patients with failed air-way.

Place King Tube Surgical Airway

Facial Trauma or Swelling

NO YES

Announce over the Radio “Medic

______ Failed Air-way Protocol”

SpO2 <90%

YES NO

Continue To

ventilate with

BVM

SpO2 drops below <90% or

becomes difficult to ventilate

with BVM

Ventilate PT at a ≤ 12 / min,

keeping SpO2 above 90% SpO2 <90%

QuickTrach

YES


Medical Protocols

PAIN MANAGEMENT Clinical Indications:

Patients that need pain management and are unable to obtain adequate relief with non-

pharmaceutical measures

AND / OR

For sickle cell patients, also consider 1 liter of Normal saline.

For hemodynamically unstable patients, Fentanyl should be the first line treatment.

Morphine should be administered only with systolic pressure >90 and when the pt is not

presenting with signs of imminent circulatory collapse.

Morphine should not be used during active child birth.

Consider administration of Zofran early when administering Morphine.

(See Nausea Protocol)

In the elderly, patients with renal or severe liver disease reduce dosage by half.

Our goal is not complete cessation of pain, aim for 50% reduction of pain.

Fentanyl may be administered IV, IM, or IN.

This is not the necessarily the order of administration, use patient needs and presentation

as a guideline.

Consider 25 mcg IV dosages for elderly patients.

General Pain

Management

Morphine 2-5mg IV

May repeat X1

Fentanyl 50 – 100 mcg

IV/IM/IN May repeat X1


Medical Protocols

History:

Trauma

Drug Abuse

Foot Pursuit

Pepper Spray

Taser Evaluation

POLICE CUSTODY Signs and Symptoms:

External Trauma

Taser Barbs

Wheezing, SOB

AMS

Palpitations

Intoxication/Substance abuse

Differential:

Agitated Delirium

Traumatic Injury

Substance Abuse

Psychiatric Emergency

Traumatic brain injury

Asthma Exacerbation

Cardiac

Universal Treatment Guidelines

Suspected Traumatic Injury or

medical condition.

Pepper Spray Minor Laceration

or Abrasions?

Taser

Appropriate

Protocol

Irrigate Eyes and Face

w/ water. Remove

contaminated clothing

Wheezing

Appropriate wound

care.

YES

NO

Taser Barb

Removal Protocol

COPD/Asthma

Protocol & Transport

Coordinate disposition with LEO

and if necessary medical control

and the on-duty Supervisor.

Excited Delirium is a distinct syndrome that is marked by restlessness, combativeness, and hyperthermia. These patients are at high risk and should be transported by an ALS unit.

Patients who are in police custody retain their rights to medical care. This should be coordinated with the law enforcement officer (LEO). If any questions occurs whether the patient requires transport, contact the on-duty supervisor for guidance.

Sutures have a 6-8 hour window. Advise LEO and patient to obtain a Tetanus shot if the patient has not received one in more

than 10 years. If an asthmatic pt is exposed to pepper spray and is released to LEO or EMS care is refused

by LEO: all parties should be advised to contact EMS if wheezing or difficulty breathing occurs.


Medical Protocols

ALLERGIC REACTION Signs and Symptoms:

Stable: o Rash/ Hives / Urticaria o Stable Vital Signs

Unstable: Two or more of the following o Dyspnea o Wheezing o Cyanosis o Excessive Salvation o Edema to Eyelids, Lips, Hands,

Tongue

Differential:

Niacin Overdose

Angioedema due to ACE Inhibitors

Heat rash

Pulmonary Embolism

Foreign body obstruction

Unstable Stable

Benadryl 25-50 mg

SIVP or IM

Epinephrine 1:1000

0.3mg IM

May repeat X1 in 5 min

If Wheezing develops see

COPD/Asthma Protocol

The shorter the time from the patients exposure to the onset of symptoms, the more severe the reaction.

Apply cold packs. May be applied to bites and stings in order to reduce the swelling and slow blood flow from the affected are.

Famotidine is an antacid with H2 antagonist properties that has been shown to work well for hives and other allergic reactions.


Solumedrol 125mg

IV/IM

NS Bolus 1000 cc IV


Medical Protocols

History:

Behavioral or

psychiatric disorder

History of Anxiety

Recent trauma or

emotional distress

Differential:

Hypoxia

Head Trauma

Pulmonary Embolism

Signs and Symptoms:

Hyperventilation

Sensation of panic

Agitation

ANXIETY

Verbal Calming

Versed 1-2mg

IN/IM/IV may repeat

once

This Protocol is NOT to be implemented for patients who are refusing EMS care and are

legally mentally competent and able to refuse care.

The majority of patients that present with uncomplicated anxiety will not require

pharmacological management. Verbal calming and empathy is generally effective.

Consider midazolam 0.5 mg IV for elderly patients.

For pediatric patients < 13 y.o. contact medical control.



Medical Protocols

History:

Psychiatric Illness

Injury to self or

threats against others

Substance abuse or

Overdose

Diabetes

Differential Diagnosis:

Excessive Heat or Cold

Substance Abuse or

Intoxication

Head Trauma

Hypoxia

Hypoglycemia

CVA / Brain Tumor

CNS infection

Signs and Symptoms:

Anxious, tense, restless,

fidgeting

Hallucinations, or

delusional thoughts

Labile mood,

unpredictable, excitable

Combative or violent

Expression of suicidal or

homicidal ideation

BEHAVIORAL EMERGENCY

Verbal Calming

BGL, Any vital signs that can be

safely obtained.

Physical Restraints (see p.12)

Suspected Stimulant Overdose should be treated with Valium / Versed until pt is calmed or

systolic blood pressure of 100 is reached.

Do not restrain in the prone position. Physical restraints without chemical restraint can

increase the risk of Excited Delirium in susceptible patients.

For agitated or very combative patients do not restrain without adequate sedation to reduce

the risk of excited delirium.

Patients restrained using handcuffs in police custody must be transported with law

enforcement’s assistance.


legally able to do so.

If the patient is suspected of excited delirium and cardiac arrest ensues, Sodium Bicarbonate

and fluid bolus should be administered early in the arrest. If available cooled IV fluids should

be used. Consider passive cooling.

After restraint procedures are used the patient will require continuous monitoring.

For pediatric patients

< 13 y.o. contact

medical control.


Versed 5mg IN/IM

may repeat X 1

Valium 10mg IM

One dose OR


Medical Protocols

History:

Use of Bath Salts

Use of Synthetic

Marijuana

Use of LSD

Use of Cocaine

Signs and Symptoms:

Agitation

Aggressive or

threatening behavior

Amazing strength

Dilated Pupils

Sweating

Hot to the touch

Tachypnea


Excessive Heat or Cold

Substance Abuse or

Intoxication

Head Trauma

Hypoxia

Hypoglycemia

CVA / Brain Tumor

CNS infection

If Geodon is given IV, immediacy contact the medical director and notify the Clinical

Coordinator ASAP.

Do not restrain in the prone position. Physical restraints without chemical restraint can

increase the effects of Excited Delirium and are inhumane.

Patients restrained using handcuffs in police custody must be transported with law

enforcement’s assistance.


legally able to do so.

If the patient is suspected of excited delirium and cardiac arrest ensues Sodium Bicarbonate

and fluid bolus should be administered early in the arrest. If available cooled IV fluids should

be used. Consider passive cooling.


Cardiac Monitoring, 12 Lead EKG

Verbal Calming

Versed

5 mg IV/IM/IN

For pediatric patients

contact medical

control.

Benadryl 25-50 mg

IV/IM

FOR IMMINENT LIFE THREAT

TO PATIENT OR HARM TO

STAFF

CARDIAC ARREST

Sodium Bicarb

50-100 mEq IV Geodon

20 mg IM

GEODON SHALL ONLY

BE GIVEN IM

EXCITED DELIRIUM


Medical Protocols

COPD / ASTHMA


Cardiac Monitoring, 12 Lead EKG

Albuterol 2.5mg / Atrovent 0.5 mg

may repeat x2

Epinephrine (1:1000) 0.3mg IM

may repeat X1 in 5 min

Consider C-PAP

5cm H20

Solumedrol 125mg IV

Differential:

Pneumonia

Congestive Heart Failure

Anaphylaxis

Tuberculosis

Signs and symptoms:

Pursed Lips

Audible Wheezing

Decreased Breath Sounds

Inability to Complete Sentences

Prolonged Expiratory Phase

Magnesium Sulfate is recommended after 1 hour of treatment or for life-threatening asthma and should be given over 20 minutes. It should be used infrequently.

RSI Protocol

Albuterol 2.5mg nebs

continuously

Respiratory Distress Protocol

Bronchospasm most likely cause of distress

Life Threatening Asthma

Magnesium SO4 2G IV over 20 min

Apply ETCO2 Device

Obtain EKG


Medical Protocols

DIABETIC EMERGENCIES History:

Medication use

Endocrine Disorders

HX of cancer

Sepsis and Infection


CVA

ETOH abuse, overdose

Addison’s, Adrenal crisis

Pregnancy

Signs and Symptoms:

Thirst, malaise, nausea,

vomiting, irritability

AMS, Confusion,

Hallucinations, Bizarre

behavior

Focal Impairment and

seizures.

Unresponsive

BGL <70

Dextrose 50%

25 grams IV / IO

Thiamine 100 mg

IV/IM for chronically

malnourished pts.

Oral Glucose 15G

Obtain EKG

Pt refusals: If a hypoglycemic pt wishes to refuse transport after treatment, and the provider has no concerns about underlying medical conditions, or the ability of the person or care giver to manage their disease ensure the following conditions are met:

Adequate food available, advise pt to eat a meal containing complex carbohydrates Functional home glucometer Not on Sulfonylurea medications (i.e. Glyburide, Glipizide) Document removal of IV site and bandage Patients in a Hyperosmotic Nonketotic State (BGL >600) may present with altered mental

status and need for airway management.

Fluid Bolus up to 1 liter

NS over 30 min.

BGL >300

Treat associated

symptoms



Medical Protocols

HYPOTENSION Signs and Symptoms:

SYSTOLIC BP < 90 WITH SYMPTOMS Lightheaded, Dizziness Positive Tilt test Altered Mental Status Restlessness, Confusion Weak, rapid pulse Pale, cool, clammy skin Coffee ground emesis, Tarry Stool


Shock- Carcinogenic, Septic, Neurogenic, Anaphylactic

Pregnancy Ectopic Pregnancy Dysrhythmias Pulmonary Embolus Tension Pneumothorax Medication Effect / Overdose Vasovagal


CONSIDER SEPSIS IF ANY TWO ARE MET

1. Temperature >100.9 F or < 96.8

2. Heart rate > 90 Beats per minute;

3. Respiratory rate > 20 Breaths per min

4. Acutely altered mental status; or

5. Serum glucose < 120 mg/dL

(The Robson screening tool)

NON-TRAUMA NON-CARDIAC

(ex.: dehydration, GI bleed,

heat exhaustion, vagal event)

CARDIAC

(ex.: STEMI, CHF,

dysrhythmias,

bradycardia)

NS Bolus 500cc

repeat x 3

NS Bolus 500cc X1

Epinephrine 10 mcg = 1mL

Q 2-5 minutes

OR 5-20 mcg/min IV infusion

Titrate to SBP >90

Go to appropriate

protocol once etiology

determined

EPINEPHRINE FOR HYPOTENSION

Draw up 9 mL of NS in a 10mL syringe

Add 1 mL of cardiac Epi (1:10,000)

1 mL = 10 mcg = 1:100,000 epinephrine

Cardiac Monitor, 12 Lead EKG

NS Bolus 500cc,

Repeat until

30mL/kg given

Notify receiving hospital of

suspicion of sepsis (“Sepsis Alert”)

if hospital has a sepsis program

Norepinephrine

2-12 mcg/min IV

Target MAP 65


Medical Protocols

NAUSEA / VOMITING Signs and Symptoms:

Nausea Vomiting Dry lips, sunken eyes Tachycardia, hypotension

Differential:

Infection (viral, food-borne) Toxin, overdose, drugs, alcohol Increased intracranial pressure (stroke,

hemorrhage, trauma) Acute coronary syndrome


Zofran 4mg IV/IM

May repeat X1

Patients should be placed in an upright lateral recumbent position. Patients experiencing nausea or vomiting should not be allowed to ingest anything

by mouth while in EMS care. ALL nausea and vomiting patients should have a Blood Glucose Assessment.

6 mo to 4 yo:

Zofran 2 mg IV or IM

>4 yo:

Zofran 4 mg IV or IM

ADULT PEDIATRIC >6

months


Medical Protocols

Activated Charcoal

OVERDOSE

Signs and Symptoms:

Irregular or rapid respirations. Shallow respirations or apnea. Bradycardia Tachycardia Altered mental status.

Differential:

Head trauma Hypoglycemia Hyperglycemia Hypoxia


Cardiac Monitoring , 12 Lead EKG

Consider Activated

Charcoal 50 Grams

Sodium Bicarb

50 -100 mEq IV

For all medications / drugs contact Poison Control 1-800-764-7661

Max dose of Narcan 2mg.

Narcan is NOT to be given to conscious or breathing patients unless a decreasing LOC or decreasing

respiratory drive is noted.

Narcan is not to be used for diagnostic purposes.

Narcan is to be administered in 0.4 mg doses titrated to respiratory drive.

Activated Charcoal can be administered up to 2 hours after ingestion.

DO NOT administer Activated Charcoal for acids, alkali, or petroleum base products.

Signs of a Dystonic Reaction include: o Protruding or pulling sensation of tongue o Twisted neck, or facial muscle spasm o Roving or deviated gaze o Abdominal rigidity and pain o Spasm of the entire body

Calcium Channel Blocker

with symptomatic

hypotension

Known TCA & Wide QRS

Suspected

Stimulant Calcium Gluconate 10%

1 -2 grams IV over 10 min

= 10 -20 mL Behavioral Emergency Protocol

Suspected Opiate and apneic

Narcan 0.4 mg IV/IM/IN

May repeat X4 until

breathing

Max dose 2mg

Dystonic Reaction

Benadryl 25-50 mg

IV / IM


Medical Protocols

RESPIRATORY DISTRESS

Sign and Symptoms

Dyspnea / pursed breathing

Unable to speak full sentences

Increased respiratory rate and effort

Wheezing, stridor

Rales, rhonchi

Use of accessory muscles

Fever, cough

Tachycardia

Differential Diagnosis

Asthma

COPD / Chronic Bronchitis

Anaphylaxis

Pleural effusion

Pneumonia

Pulmonary embolus

Pneumothorax

Cardiac (ACS or CHF)

Pericardial tamponade

Anxiety / hyperventilation


12 Lead ECG / Cardiac monitor

Pulse Oximeter and ETCO2

Bronchospasm suggested by:

- History of asthma / COPD

- Use of inhalers chronically

- Smoking history

- wheezing on exam

Other Causes:

- Anxiety

- Allergic Reaction

- ACS

- Pain

- Pneumothorax

- Other

Pulmonary edema suspected:

- History of CHF

- Use of Lasix chronically

- Cardiac disease history

- Rales and leg edema on

exam

COPD / Asthma Protocol

Proceed to Appropriate Protocol

CHF Protocol

Apply Oxygen


Medical Protocols

SEIZURE History:

Reported / Witnessed Seizure activity.

Previous Seizure History

Medical alert tag Information

History of trauma

History of diabetes

History of pregnancy

Differential:

Head Trauma

Tumor

Metabolic, Hepatic, or Renal failure

Hypoxia

Medication non-compliance

Infection / Fever

Alcohol withdrawal

Eclampsia

Stroke

Hyperthermia

Hypoglycemia

Signs and Symptoms:

Decreased mental status

Sleepiness

Incontinence

Observed seizure activity

Evidence of trauma

Unconscious

Status Epilepticus Post-ictal

Blood Glucose

Diabetic Protocol

BGL < 60

Seizure Reoccurs


OR

Initial dose of IN Versed 5mg in 1 ml each nostril. Status Epilepticus is defined as 2 or more successive seizures without a period of consciousness or recovery. This

is a true emergency requiring rapid airway control, treatment, and transport. Grand mal seizures are associated with loss of consciousness, incontinence, and tongue trauma. Petit mal seizures effect only a part of the body and are not usually associated with a loss of consciousness. Jacksonian seizures are seizures which start as focal seizure and become generalized. Be prepared for airway problems and continued seizures. INTUBATION IS USUALLY NOT NEEDED. Attempt airway

positioning and nasopharyngeal airway during immediate post-ictal phase. Assess possibility of occult trauma and substance abuse. For any seizures in pregnant patient, follow the OB emergency protocols. Valium (Diazepam) is not effective when administered IM. It should be given IV or PR only.

Valium 10mg IV

Versed 5 mg

IN / IV / IM

May repeat X1

RSI Protocol Airway Positioning,

Nasopharyngeal airway, O2,

BVM Ventilations as needed

Consider ETCO2 Monitoring


Medical Protocols

CINCINNATI STROKE SCALE

1. Facial Droop

(Have patient show teeth and smile)

Normal: Both side of face move equally

Abnormal: One side of face does not move as well as other

2. Arm Drift

(Have pt close eyes and hold both arms straight out for 10 seconds)

Normal: Both arms move the same or not at all

Abnormal: One arm does not move or one arm drifts down

3. Abnormal Speech

(Have pt say “You can’t teach an old dog new tricks”)

Normal: Patient uses correct words with no slurring.

Abnormal: Pt slurs, uses wrong words, or cannot speak

Notify receiving Emergency Department of stroke alert as soon as possible.

Check glucose levels on all suspected CVA patients.

Ascertaining the exact time of onset of symptoms is key to definitive treatment.

Hypertension is an expected compensatory response and in general should NOT be treated.


Consider Labetalol ONLY for BP > 220/120

10-20 mg slow IVP, may repeat X1

12-lead ECG

Sign and Symptoms

Facial droop on one side

Slurred Speech / Aphasia

Weakness on effected side

Hemi paresis

Headache

Loss of coordination/Ataxia

Dysphasia / vision changes

Differential

Hypoglycemia

Migraines

Bell’s palsy

Multiple Sclerosis

Inner- ear problems

Vision disturbances

Brain tumors

STROKE / CVA


Medical Protocols

SYNCOPE Signs and Symptoms:

Loss of consciousness with recovery

Lightheadedness, dizziness

Palpations, slow or rapid pulse

Pulse irregularity Hypotension

Differential:

Orthostatic Hypotension

Psychiatric Stroke Hypoglycemia Seizure Shock Heat exhaustion Cardiac dysrhythmia

History:

Cardiac history, Stroke, Seizure

Occult blood loss (GI, Ectopic)

Fluid Loss: Nausea Vomiting, Diarrhea

Past medical history. Medications


Proceed to appropriate protocol as indicated

NS 500 to 1000 cc

Blood Glucose

Orthostatic Vital signs

Orthostatic vital signs must be assessed.

Assess for signs and symptoms of trauma if associated or questionable fall with syncope.

Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of

syncope.

A tilt test (orthostatic vital signs) is considered positive if the patient becomes dizzy, weak,

altered, pulse increase of 20bpm, or blood pressure decrease 10mm/hg

Obtain 12-lead ECG


Medical Protocols

ACUTE CORONARY SYNDROME Signs and Symptoms:

Non-Reproducible chest pain History of cardiac events Location (Substernal, Epigastric, Arm,

Neck, Shoulder) Radiation of pain Nausea, vomiting, or dizziness Dyspnea


Trauma vs. Medical Pulmonary Embolism Asthma / COPD Pneumothorax Aortic dissection or aneurysm Chest wall injury or pain GE reflux or Hiatal Hernia Overdose of Cocaine or

Methamphetamine


STEMI

NON-STEMI

Keep scene time <15 min.

Consider NS Bolus of 250-500cc

for suspected Inferior MI

Establish 2nd IV of at least 18

gauge while transporting

For continued pain see pain

management protocol

Consider Protocols as needed for, Hypotension,

HTN, Nausea / Vomiting, Dysrhythmias

Notify receiving Emergency Department as soon as possible for suspected STEMI. Patients with marginal Blood Pressure and concern for inferior Right sided STEMI, IV access is

preferred before the administration of Nitroglycerin. Avoid Nitroglycerin in any patient who has used Viagra or Levitra in the past 24 hours, or

Cialis in the past 36 hours. Diabetics, geriatric patients, and females may have atypical pain or only generalized

complaints. An IV is not required for administration of Nitroglycerin. BP drop is expected after receiving Nitro. Do not hold further doses unless SBP < 90.

Aspirin 324 mg PO chewed

12 lead EKG

Nitroglycerin Spray every

5 min X3 with SBP of >90

Transmit EKG to receiving hospital


Medical Protocols

ACUTE CORONARY SYNDROME


Medical Protocols

SUPRA-VENTRICULAR TACHYCARDIA

Adenosine 6mg

fast IVP

IV, NS Bolus 250-500 cc

Adenosine 12mg

fast IVP, may repeat X1

Synchronized cardioversion

50 joules


100 joules


150 joules

Signs and Symptoms:

Rapid Regular Pulse >150, palpitations

Feeling weak, light headed, or dizzy


Ventricular Tachycardia

A-Fib W/ RVR

Unstable is defined by severe hypotension, altered mental status and/or weak or absent

radial pulses.

Sedation should not be used with hemodynamically unstable pts.

SVT refractory to Adenosine can be treated with Diltiazem if not contra-indicated.

Vagal maneuvers are contraindicated if pt has a HX of CVA, carotid surgery or carotid bruits.

CONTINUOUS PRINT-OUT OF MONITOR TRACING DURING CONVERSION IS VERY HELPFUL

FOR RECEIVING HOSPITAL’S CARDIOLOGIST.


Diltiazem 10-20 mg

Repeat 25mg X1 in

10 min.

Consider Pain Management

and/or Anxiety Protocols

12 Lead EKG

STABLE

Amiodarone 150 mg

over 10 min

YES NO


Medical Protocols

A-FIB W/ RVR

Signs and Symptoms:

Rapid Irregular Pulse >150


Feelings of Palpations


Super Ventricular Tachycardia



12 Lead EKG

IV, NS Bolus 250-500 cc

STABLE NO




50 joules


100 joules


150 joules

YES

Diltiazem 10-20 mg

slow IV push

Diltiazem 10-20 mg

slow IV push

Unstable patients are ones with: severe hypotension, altered mental status and weak or

absent radial pulse.

Diltiazem requires a systolic blood pressure of at least 80-90 mm/Hg.

Sedation should be used with extreme caution on hemodynamically unstable patients.

Consider using the minimum dose.


Medical Protocols

VENTRICULAR TACHYCARDIA W/ PULSE

Signs and symptoms:

Runs or sustained Ventricular Tachycardia.

Conscious, rapid pulse

Chest Pain, Shortness of breath

Dizziness

QRS >0.12 sec.

Differential:

Artifact / Device Failure

Drugs

Pulmonary


Wide, regular rhythm with QRS >0.12 sec?

No

Pulse

YES

Cardiac

Arrest

Protocol

STABLE UNSTABLE

Synchronized Cardioversion

150 joules

May repeat as needed



For witnessed / monitored ventricular tachycardia try having the patient cough.

Polymorphic V-Tach (Torsade’s de Pointes) consider Magnesium Sulfate 2grams IVP

Notify receiving Emergency Department as soon as possible of the patient’s condition.

Brief episodes of ventricular ectopy do not require treatment (Formerly “Ventricular Ectopy”

protocol, which has been removed.)

Amiodarone 150mg

over 10 min

may repeat x1

SVT

Protocol

Narrow

Complex

Amiodarone 150mg

over 10 min

may repeat x1

12 Lead EKG


Medical Protocols

SYMPTOMATIC BRADYCARDIA Signs and Symptoms

Heart rate <60

Chest Pain

Hypotension (systolic >90)

Ventricular ectopy

Dyspnea


Seizures


Beta-blocker Overdose

Hypothermia

Digoxin Toxicity

Calcium Channel Overdose

Malnutrition

Increased ICP

TRANSCUTANEOUS PACING AT A RATE

OF 60 AT LOWEST MILLIAMP SETTING

THAT OBTAINS CAPTURE.

ATROPINE 0.5MG-1MG

MAY REPEAT q 3-5 MIN

MAX DOSE 3mg

IF HEART RATE >60 AND BP REMAINS <90 SYSTOLIC

SEE HYPOTENSION PROTOCOL

USE CAUTION: Atropine should be omitted for second degree Type ll or Third Degree AV

Heart blocks

DO NOT TREAT BRADYCARDIA IF PT HAS NORMAL BLOOD PRESSURE AND NO SYMPTOMS.




12 Lead EKG


Medical Protocols

ADULT CARDIAC ARREST

EMT B/I to use AED

for rhythm analysis

and shocks

EMT-I may use

Epinephrine 1mg

q3-5 min as in

diagram

EMT-I may

establish IO when

indicated


Medical Protocols

POST RESUSCITATION Signs and Symptoms:

Return of spontaneous circulation.


Continue to address specific differentials

associated with the original

dysrhythmia.


Hypotension

Normal Saline Fluid

Bolus 500cc

Significant Ectopy

Bradycardia

Ventricular

Tachycardia with a

pulse Protocol

Bradycardia

Protocol

Notify receiving emergency department as soon as possible.

Hyperventilation leads to negative patient outcomes and should be avoided.

Immediately post resuscitation patients should be treated conservatively. Remember the

negative side effects of cardiac drugs such as increasing myocardial oxygen demand.

Hypotension can be caused by injuries resulting from CPR, hypovolemia, pneumothorax and

medication reactions to ALS drugs.

PVC’s that present after resuscitation should rarely be treated until other causes have been

addressed. Remember that an anti-arrhythmic may suppress the ventricular response.

12 Lead EKG

Hypotension

Protocol If cardiac arrest reoccurs

resume appropriate

protocol

Watch for a drop in ETCO2

as an indicator of loss of

pulse


Medical Protocols

POST-RESUSCITATION INDUCED HYPOTHERMIA

Criteria

Post Cardiac Arrest with ROSC

Patient Comatose

Non-traumatic etiology

Transport to a facility that will continue procedure

Differential:

Continue to address specific differentials associated with the original dysrhythmia.

Arrests caused by drowning, hanging or asphyxiation can use this protocol.

Return of Spontaneous

Circulation

Criteria for Induced

Hypothermia and initial

temp >34c

Post Resuscitation

Protocol

NO

Advanced Airway NO RSI Protocol

Successful

Expose Patient, Apply Ice Packs

if available to Axilla and groin.

Reassess Temperature >34c and

Shivering <33C

Etomidate 20mg IV/IO Discontinue Cooling Measures

If no advanced airway can be obtained, cooling may only be initiated with online medical direction.

Do not delay transport to initiate cooling patient. Patients may develop metabolic alkalosis with cooling. Do not hyperventilate. Take care to protect patient’s modesty. Undergarments may remain in place during cooling.

Do not use in

Pediatric patients. If patients goes

into cardiac

arrest STOP

procedure and

resume

appropriate

protocol

Cold Saline Bolus 1-2 liters

(if available)

12 Lead EKG ACS Protocol as

needed.

Notify receiving

hospital if STEMI

present.


Medical Protocols

HYPERTENSION

History:

Hypertension

Stroke

Medication

Compliance

Pregnancy

Signs and Symptoms:

Systolic BP >180

OR Diastolic BP >110

With one of the following

Headache

Nausea / Vomiting

Chest Pain

Vertigo

Nose Bleed

Shortness of breath


Myocardial Infarction

Cushing’s Response-

Bradycardia with

Hypertension

Pre-eclampsia /

Eclampsia

Asymptomatic hypertension does not require treatment regardless of how high the blood

pressure is. Treatment may interfere with compensatory mechanisms and cause harm.

Target Systolic blood pressure should be two thirds of the initial blood pressure.

Do not use labetalol if HR < 60

Labetalol onset 5-10 min with a peak effect of 30 min.

Never treat Blood pressure based on one set of vitals.

Avoid Nitroglycerin in pt who has taken erectile dysfunction drugs in the past 48 hrs


Nitroglycerin 0.4 mg

spray

may be repeated X2 Labetalol 10-20mg

Slow IV push

Repeat q10 min X2

Neurologic or Other

(OB, renal, nosebleed)

Cardiac (angina, CHF) or

labetalol contraindicated

Enalapril 1.25 mg

Slow IV push

May repeat X1

12 Lead EKG

Nitro spray q5 min

for continued HTN


Medical Protocols

CONGESTIVE HEART FAILURE Signs and Symptoms:

Respiratory Distress Jugular Vein Distention Pink, Frothy Sputum Diaphoresis Hypertension,

Hypotension Chest Pain

History:


Medications, (Digoxin, Lasix, Viagra)

Cardiac History


Myocardial Infarction Asthma Aspiration COPD Pleural Effusion Pneumonia Pulmonary Embolus Pericardial Tamponade

Respiratory Distress, Alert

Oxygen , 12 Lead EKG, ETCO2 Monitor

Consider C-PAP

Systolic Blood

Pressure > 140

1 Nitro Spray q 3 min X 5

If systolic BP >140

Enalapril 1.25 mg slow IV push

May repeat X1

RSI Protocol

DO NOT administer Nitroglycerin to any patient who has used erectile dysfunction medications (Viagra, Cialas, Levitra, etc.) in the past 48 hours due to possible severe hypotension.

If patient has taken nitroglycerin without relief, consider potency of the medication. Nitroglycerin can be administered to a patient by EMS if the patient has already taken 3 of their own prior to

your arrival. Document it if the patient had any changes in their symptoms or a headache after taking their own. Document the expiration date of the patients prescribed nitroglycerin.

Diabetics and geriatric patients often have atypical pain, or only generalized complaints. Careful monitoring of LOC, BP, and respiratory status with above interventions is essential. Acute pulmonary edema may be a sign of acute cardiac ischemia, which may give rise to cardiovascular

collapse and hypotension as well as malignant atrial and ventricular arrhythmias. DO NOT withhold oxygen from hypoxic patients.


Respiratory Distress, Lethargic

Expect Hypotension

Give 250mL Bolus

and refer to

Hypotension

Protocol

ACS Protocol as

needed

Nitro spray q3 min

for SBP >140


Medical Protocols

Taser barb removal Taser barb rem Taser barb removal oval

VENTRICULAR ECTOPY SELECTIVE SPINAL IMMOBILIZATION

History:

Mechanism of injury Fall height Drugs or alcohol use Auto Pedestrian / Bicycle Accident Diving incidents

Signs and Symptoms:

Focal neurological deficit Any spinal tenderness.

The patient must be able to

look up, touch chin to the

chest and from side, to side

without spinal process pain.

Yes to any item?

Patient will require spinal

motion restriction

Focal Deficit?

Age <5 or >65?

Does the patient have altered

alertness?

Suspected or Known

Intoxication?

Distracting injury?

Spinal Exam: any point

tenderness to spine or with

range of motion?

The decision not to immobilize must be fully documented and include all of the above

historical and exam findings.

Palpate each spinous process to assess for tenderness. Only if no tenderness was elicited,

perform a range of motion exam.

Partial Immobilizations:

o At times securing a patient to a rigid spine board may worsen a spinal injury if

present or may otherwise harm the patient. These patients may be transported in

semi-recumbent position with a c-collar.

o Examples of patients who may not tolerate supine positioning: agitated patients and

patients with decompensated CHF or with kyphosis.

Dangerous mechanism? Ex: Fall > 3feet, mod to high speed MVA,

diving accident, ATV crash, auto-ped?


Medical Protocols

calcium gluconate 10% 10cc

CRUSH INJURY Signs and Symptoms:

Pain

Pallor

Pulselessness

Paralysis

Skin cool to the touch

History:

Entrapment of extremity or torso for prolonged

period of times.


Consider RSI Protocol

Sodium Bicarb 50-100 mEq IV to be administered immediately after removal from entrapment

Observe all crush injuries, even those who look well. Administer intravenous fluids before releasing the crushed body part. This step is especially

important in cases of prolonged crush >4 hours. Crush syndrome can occur in crush scenarios of <1 hour. Sodium Bicarbonate should only be given in instances of entrapment > 2hrs. Suspect hyperkalemia if T waves become peaked, QRS>.12seconds, and / or hypotension

develops. If cardiac arrest occurs after release of entrapment, give Sodium Bicarbonate 1mEq/kg

immediately and every 10 min during CPR.

Extremity Trauma or Amputation Protocols as needed

1-2 L NS



Calcium Gluconate 10%

1 -2 grams IV over 10 min =

10 -20 mL for arrhythmias


Medical Protocols

MAJOR TRAUMA SIGNS AND SYMPTOMS:

DETERMINE EVENTS LEADING TO TRAUMA AND MECHANISM OF INJURY

PAIN, SWELLING, DEFORMITY, BLEEDING, LESIONS

ALTERED MENTAL STATUS, UNCONSCIOUS

HYPOTENSION, SHOCK

DIFFERENTIAL:

TENSION PNEUMOTHORAX / HEMOTHORAX

FLAIL CHEST

PERICARDIAL TAMPONADE

OPEN CHEST WOUND

OPEN / CLOSED HEAD INJURY

SPINAL INJURY

PELVIC / HIP FRACTURE


CONTROL ALL

MAJOR

BLEEDING

VITAL SIGNS

TITRATE BLOOD

PRESSURE TO AT

LEAST 90 SYSTOLIC

with small NS

boluses 250mL

Consider RSI

Protocol

Consider Tourniquet

Protocol

SPLINT SUSPECTED

FRACTURES

Consider Pain

Management Protocol

GERIATIC PT SHOULD BE EVALUATED WITH A HIGH INDEX OF SUSPENSION.

MECHANISM IS THE BEST INDICATOR OF SERIOUS INJURY.

SCENE TIMES SHOULD NOT BE DELAYED FOR PROCEDURES; THESE SHOULD BE PERFORMED

DURING TRANSPORT WHEN POSSIBLE.

ON SCENE TIME OF 10 MIN OR LESS FOR THE UNSTABLE TRAUMA PT IS THE GOAL.

ALLOW PERMISSIVE HYPOTENSION TO PREVENT FURTHER HEMORRHAGE.

BILATERAL IV OR

IO ACCESS

Consider Needle

Decompression

O2 AS NEEDED DETERMINE

GCS

UNSTABLE

PATIENTS MUST

BE TRANSPORTED

IMMEDIATELY.

Goal Scene Time

< 10 minutes

CONTINUALLY REASSESS

ASSESS FOR

FOCAL NEURO

DEFICITS

AIRWAY AND

CERVICAL SPINE

CONTROL

BREATHING AND

OXYGENATION

CIRCULATION AND

HEMORRHAGE

CONTROL

DISABILITY

ASSESSMENT

EXPOSURE

Consider Antibiotic

Therapy for open long

bone fractures


Medical Protocols

Open long

bone fracture

EXTREMITY TRAUMA Signs and Symptoms:

Pain

Swelling

Deformity

Altered Sensation / Motor function

Diminished Pulse / Capillary refill

Decreased extremity temperature

Appropriate wound care.

Splint suspected Fractures

as necessary.

CONTROL ALL MAJOR BLEEDING


For patients with an amputation, time is critical. Transport and notify receiving hospital

immediately. (See Extremity Amputation Protocol)

Hip, knee and elbow fracture/dislocations have a high incidence of vascular compromise.

Urgently transport any injury with vascular compromise.

Lacerations must be evaluated for repair within 4 hours from the time of injury.

Consider Pain

Management Protocol


Consider Tourniquet

Protocol

Cefazolin

1-2g IV drip

1-2g IV

1


Medical Protocols

EXTREMITY HEMORRHAGE / AMPUTATION

Signs and Symptoms:

Amputation / Partial Amputation

Pain and Swelling

Deformity

Altered Sensations / Motor Function


Abrasion

Amputation

Contusion

Dislocation

Fracture

Laceration


Apply direct pressure to control hemorrhaging.

If unable to control with direct pressure, apply

indirect pressure using arterial pressure points and

elevating the affected limb if possible.


Protocol

If hemorrhage cannot be controlled by direct

pressure and the injury is life threatening consider

tourniquet application

Consider Tourniquet

Transport amputation victims rapidly, as successful replantation is time-dependent.

Hip dislocations, knee and elbow fracture / dislocations have a high chance of vascular

compromise.

Blood loss may be concealed or not apparent with extremity injuries.

Lacerations must be evaluated for repair within 4 hours.

Incomplete Amputation: Splint affected digit / limb in a physiological position.

Amputation:

o All retrievable tissue should be transported. (DO NOT DELAY TRANSPORT for tissue retrieval) o Rinse amputation with normal saline or sterile water. o Wrap amputation in sterile gauze that has been moistened with normal saline or sterile water. o Place in plastic bag or container; place container in separate container filled with ice. (if available) o DO NOT PLACE AMPUTATED PART IN DIRECT CONTACT WITH ICE.

Consider Antibiotic

Therapy for any open long

bone fractures without

amputation


Medical Protocols

BURNS CHEMICAL / ELECTRICAL

Signs and Symptoms:

Burns, pain, swelling Dizziness or Loss of consciousness Hypotension Airway Compromise Respiratory Distress / Wheezing Hypotension / Shock Signed Facial Hair or Nostril Hair

Differential:

Superficial (1st Degree) Painful and Red Partial Thickness (2nd Degree) Blistering Full Thickness (3rd Degree) Painless,

charred or leathery skin. Thermal Chemical Electrical

Chemical:

Flush the affected area as soon as possible with the cleanest and most readily available saline or tap water using copious amounts of fluid.

Utilize industrial decontamination equipment/showers and MSDS information when available.

ELECTRICAL:

Do not contact the patient until you are sure the electricity source is disconnected.

Attempt to locate contact points, both will generally be full thickness burns.

Anticipate Ventricular, or Atrial irregularity, V-Tach, V-Fib, Heart Blocks and other dysrhythmias.


Eye

Involvement

Continuously flush

the affected area

for 10-15 min.

Remove rings and other constricting items.

Remove clothing and expose affected area.

Apply sterile dressing to entry and exit site

of electrocution injuries.

Critical Minor

>10% TBSA 2nd/3rd Degree Burn Airway compromise,

Hypotension or GCS<14 TRANSPORT TO BURN CENTER

<10% TBSA 2nd OR <2% TBSA 3rd Not intubated, No Inhalation Injury, Normotensive. GCS 15

MAY BE TRANSPORTED TO LOCAL HOSPITAL


Consider Hypotension Protocol


Protocol

Cardiac Monitor and

12 lead EKG after electrical injury


Medical Protocols

BURNS - THERMAL Signs and Symptoms:

Burns, pain, swelling Dizziness or Loss of consciousness Hypotension Airway Compromise Respiratory Distress / Wheezing Hypotension / Shock Signed Facial Hair or Nostril Hair

Differential:

Superficial (1st Degree) Painful and Red Partial Thickness (2nd Degree) Blistering Full Thickness (3rd Degree) Painless,

charred or leathery skin. Thermal Chemical Electrical

Assure whatever caused the burn is no longer contacting the skin.

Early intubation is necessary for patients with significant inhalation injuries.

Burn patients are prone to hypothermia – NEVER cool or apply ice to the burned area.

Other burns ideally treated at a Burn Center: - Feet, hands, face, genital burns - Circumferential burns (due to

possible vascular compromise) - Any 3rd degree burn >2% TBSA - Burns with associated trauma - Nontrivial Pediatric burns - Burns in adults > 50, esp. with

underlying comorbid conditions


Critical Minor

>10% TBSA 2nd/3rd Degree Burn Airway compromise,

Hypotension or GCS<14 TRANSPORT TO BURN CENTER

<10% TBSA 2nd OR <2% TBSA 3rd Not intubated, No Inhalation Injury, Normotensive. GCS 15

MAY BE TRANSPORTED TO LOCAL HOSPITAL

Pain Management Protocol

Cool the wound with normal saline, cover burn with dry sterile dressing.

Remove rings, bracelets, and other constricting articles.


Assess Airway

Determine TBSA/depth of Burn

NS infusion < 6 yo 125 mL/hour IV 6-13 yo 250 mL/hour IV 14 + yo 500 mL/hour IV


Medical Protocols

MARINE LIFE ENVENOMATIONS History:

Type of bite or sting

Time, location and size of bite or sting.

Any prior reaction

Rabies and tetanus risk & status

Immunocompromised

Differential:

Snake Bite

Skin Infections

Infection risk

Rabies

Tetanus

Marine Life

Cellulitis

Transport patients with severe systemic response or allergic reaction to jellyfish stings. Jellyfish stings in the Galveston area are rarely serious despite the amount of pain. Rarely

toxic varieties can drift into the area and the patient will present in imminent collapse. Stingray envenomation require medical attention due to the high risk of infection and risk of

retained barbs or foreign mater in the wound. Transport and treat patients with high BSA % of jellyfish stings or patients with stings to the

mucosa due to the risk for infection, severe pain and cosmetic damage.

Signs and Symptoms:

Description of the injury

Rash: local or generalized

Hypotension

Respiratory Distress

Vomiting

Headache

JELLYFISH STINGRAY

Irrigate with copious

amounts of saline over

the wound.

Advise the Pt that if they

have mild pain after

treatment a topical

antihistamine may help.

If able immerse the

affected site in very hot

water or place hot packs

to the affected area.

Advise pt to allow EMS to

transport PT. for proper

wound care and to

ensure no foreign

material remains in the

wound.

Consider Pain

Management

Protocol

NOTE: Vinegar irrigation of jellyfish wounds is no longer recommended, (except in cases of Pacific box jellyfish or Atlantic Portuguese man-of-war stings, which are not endemic to Galveston.)


Medical Protocols

Consider Anaphylaxis and

Hypotension Protocols

SNAKE BITE History:

Type of bite or sting.

Time location and size of bite or sting.

Any prior reaction.

Rabies and tetanus risk & status.

Immunocompromised

Differential:

Animal or Human Bite

Skin Infections

Infection Risk

Rabies Risk

Tetanus Risk

Insect Bite

Marine Life

Signs and Symptoms:

Swelling

Allergic reaction

Hypotension or Shock

Difficulty Breathing

Signs of Systemic Response


Immediate transport to a trauma

center.

Keep pt movement to a minimum. Remove items that may constrict swelling tissue. Document size and time of edema near the injury site. When transporting from Moody Gardens bring anti-venin if available with the patient

and all the snake identification card and all records sent by Moody Gardens. If the patient is from Moody Gardens then choose the transport destination

requested by Moody Gardens staff based upon their training and knowledge.

Consider Pain

Management Protocol

DO NOT BRING DEAD OR LIVE SNAKES TO THE ER


Medical Protocols

DROWNING / NEAR-DROWNING

History:

Submersions in water regardless of depth

Possible trauma to c-spine

Temperature of water, possibility of hypothermia

Differential:

Trauma Pre-existing medical

problems Pressure injury

(diving) Post-immersion

syndrome

Signs and Symptoms:

Unresponsive Mental status changes Decreased or absent

vital signs Vomiting Coughing Apnea Stridor, Wheezing, Rales

Begin CPR if required.

Consider CPAP for

respiratory distress

Consider RSI if CPAP is

ineffective as indicated by

decrease in mental status.

Have a high index of suspicion for possible spinal injuries. Factors to consider are potential

underwater hazards, height of fall, neurological deficits or length of time missing.

With cold water drowning – resuscitate all. These patients have an increased chance of survival.

Some patients may develop delayed respiratory distress due to lung damage and capillary leak.

All victims should be transported for evaluation due to potential for worsening over the next

several hours.

Allow appropriately trained and certified rescuers to remove victims from areas of danger.

With pressure injuries (decompression / barotraumas), consider transport to a hyperbaric

chamber.

For SCUBA injuries contact Diver Alert Network 1-919-684-9111.


Immobilize C-spine


Medical Protocols

NO Crowing

ACTIVE LABOR Signs and Symptoms

Evident gravid uterus

Spasmodic pain

Vaginal discharge or bleeding

Crowning or the urge to push

Meconium


Prolapsed cord

Placenta Previa

Abruptio Placenta

Abnormal Presentation o Buttock o Hand o Foot


Left Lateral Position

Hypotension or Vaginal

Bleeding;

Abnormal Presentation

YES

OB Emergency

Protocol or

Difficult Child

Birth Protocol

NO Crowning

Crowning >36 Weeks

Crowning <36 Weeks,

or Multiple Gestation

Rapid Transport

Child Birth

Procedure

NO

Document all times. (Delivery, Contraction Frequency, and Length)

If Maternal Seizures occur, refer to OB Emergencies Protocol.

After delivery, massaging the uterus (lower abdomen) will promote uterine contractions and

help control post-partum bleeding.

Some perineal bleeding is normal with any child birth, large quintiles of blood or free

bleeding are not.

Record APGAR at 1 min. and 5 minutes after child birth.

Transport


Medical Protocols

Ectopic Pregnancy

Should be considered as a

possibility for patients with severe

abdominal/pelvic pain with known

pregnancy

Normal Saline 500-1000cc NS Bolus

Consider Pain Management Protocol

All of the following are considered priority symptoms and should be

transport to UTMB or CLRMC due to possible need for emergency surgery.

Abrupto Placenta

Should be considered for pregnant

patients complaining of severe

“ripping” pain with possible

hypotension.

High flow O2, position on left side

w/ padding;

NS Bolus 500-1000cc to maintain

SBP >100

OB EMERGENCIES

Eclampsia

Magnesium Sulfate 50% 2 gm

in 50 mL NS IV saline wide

open max 4 grams


Diazepam 5 mg IV for active

seizures refractory to

magnesium sulfate

Eclampsia is described as

seizures in a pregnant woman

that are not related to a

preexisting brain condition.


Medical Protocols

Placenta Previa

Should be considered when

the placenta delivers prior

to the fetus.

Treatment for Hypotension: high-flow O2;

Normal Saline 500-1000cc bolus to maintain

systolic BP >100; Position Patient on her left

side with padding under the abdomen.

Shoulder Dystocia

McRoberts Position

Inform the patient of need to assume

McRobert’s position and assist as

needed. Assert supra-pubic pressure

and tilt head towards posterior of

pelvis to allow for anterior shoulder

to clear pelvis. Then tilt the body

upwards towards anterior pelvis to

allow posterior shoulder to clear the

pelvis.

OB EMERGENCIES


Medical Protocols

NEONATAL RESUSCITATION


Delivery of Newborn

Term gestation?

Breathing or crying?

Good muscle tone?

Good color?

Breathing, HR >100,

but cyanotic

O2 By Mask or Blow-by

Persistent

Cyanosis

Apneic, Gasping

or HR <100

HR<60

Chest Compressions

Pediatric Cardiac

Arrest Protocol &

Transport

Prepare for RSI

Protocol if

apnea/cyanosis

persist

Observational Care &

Transport

Routine Care

Provide warmth

Clear airway if needed

Dry

Ongoing evaluation

Provide warmth

Position and clear the airway

Dry, stimulate, reposition

Evaluate HR, Respiration, Color

YES

10-15 rapid

ventilations with

BVM will often

stimulate

spontaneous

breathing

NO

Ventilate with PPV


Medical Protocols

Insert IO

EMT-I

may use

Epinephr

ine

ET Tube size Uncuffed Cuffed

0-1yr 3.5 3.0

1-2yr 4.0 3.5

>2yr 4+(age/4) 3.5+age/4)

Consider

advanced

airway

PEDIATRIC CARDIAC ARREST


Medical Protocols

PEDIATRIC DIABETIC EMERGENCIES

Dextrose Dilution Procedures D25 - Waste 25 ml D50W. Use pre-filled syringe (with remaining 25 ml) to withdraw 25 ml of NS from IV bag. Gently agitate syringe to mix solution. D10 - Waste 40 ml D50W. Use pre-filled syringe (with remaining 10 ml) to withdraw 40 ml of NS from IV bag.

Gently agitate syringe to mix solution

History:

Medication use

Endocrine Disorders

HX of cancer

Sepsis and Infection

Signs and Symptoms:

Thirst, malaise, nausea

vomiting, irritability

AMS, Confusion,

Hallucinations, Bizarre

behavior

Focal Impairment and

seizures.

Unresponsive


CVA

ETOH abuse, overdose

Addison’s, Adrenal crisis

Insulin pump malfunction

Oral Glucose 15G

BGL <60 BGL >300

D25

2 ml/kg

D10

5 ml/kg

1mo.-12yrs

EVERY ATTEMPT SHOULD BE MADE TO TRANSPORT THE PEDIATRIC DIABETIC

PATIENT.

Rapid or excessive fluid administration to children with DKA may increase risk of

cerebral edema and cause neurologic impairment.


NS 10-20cc/kg

over 30min <1mo. AND <45mg/dl

Obtain IO Access rapidly if PIV

unsuccessful with severe

lethargy and hypoglycemia


Medical Protocols

PEDIATRIC PAIN MANAGEMENT Clinical Indications:

Patients that need pain management and are unable to obtain adequate relief with non-

pharmaceutical measures

For sickle cell Patients also consider 5cc/kg bolus of Normal saline.

For hemodynamically unstable patients Fentanyl should be first line treatment.

Morphine should be administered only with systolic pressure >90 and pt is not presenting

with signs of imminent circulatory collapse.

Consider administration of Zofran early when administering Morphine.

Our goal is not complete cessation of pain, aim for 50% reduction of pain.

Monitor for respiratory depression.

Morphine 0.1 mg/kg

IV/IM

max dose of 5mg

General Pain

Management

OR

Fentanyl 1 mcg/kg

IV/IN/IM

May repeat X1


Medical Protocols

PEDIATRIC ALLERGIC REACTION

Signs and Symptoms:

Stable: o Rash/ Hives / Urticaria o Normal Vital Signs

Unstable: Two or more of the following o Dyspnea or wheezing o Cyanosis o Nausea, vomiting o Excessive Salvation o Edema to Eyelids, Lips, Hands,

Tongue

Differential:

Niacin Overdose

Angioedema due to ACE Inhibitors

Heat rash

Pulmonary Embolism

Foreign body obstruction

Unstable Stable

If Wheezing present see

Respiratory Distress Protocol


The shorter the time from the patients exposure to the onset of symptoms, the more severe the reaction.

Apply Cold Packs may be applied to bites and stings, in order to reduce the swelling and slow blood flow from the affected are.

Famotidine is an antacid with H2 antagonist properties that has been shown to work well for hives and other allergic reactions.

Epinepherine 1:1000

0.01 mg/kg IM

Max dose 0.3mg

may repeat 1 in 5 min

Benadryl 1mg/kg IV/ IM

Max dose 25mg

Solumedrol 2mg/kg IV/IM

Max dose 125mg

NS Bolus 20cc/kg

Max 1000cc


Medical Protocols

PEDIATRIC SEIZURE History:

Reported / Witnessed Seizure activity.

Previous Seizure History

Medical alert tag Information

History of trauma

History of diabetes

History of fever

Differential:

Head Trauma

Tumor

Metabolic, Hepatic, or Renal failure

Hypoxia

Drug medication, non-compliance

Infection / Fever

Alcohol withdrawal

Eclampsia

Stroke

Hyperthermia

Hypoglycemia

Signs and Symptoms:

Decreased mental status

Sleepiness

Incontinence

Observed seizure activity

Evidence of trauma

Unconscious

Status Epilepticus Post-ictal

Blood Glucose


Diabetic Protocol

BGL < 60

Seizure Reoccurs

OR

Initial dose of IN Versed should be divided evenly between each nostril. Status Epilepticus is defined as 2 or more successive seizures without a period of consciousness or recovery. This

is a true emergency requiring rapid airway control, treatment, and transport. Grand mal seizures are associated with loss of consciousness, incontinence, and tongue trauma. Petit mal seizures effect only a part of the body and are not usually associated with a loss of consciousness. Jacksonian seizures are seizures which start as focal seizure and become generalized. Be prepared for airway problems and continued seizures. Assess possibility of occult trauma and substance abuse. For any seizures in pregnant patient, follow the OB emergency protocols. Valium (Diazepam) is not effective when administered IM. It should be given IV or rectally only.

Valium 0.2mg/kg

IV Max dose 10mg

Versed 0.1mg/kg

IN/ IV/IM/buccal

Max dose 5 mg

May repeat X1

in 5 min


Airway Positioning,

Nasopharyngeal airway, O2,

BVM Ventilations as needed


Medical Protocols

PEDIATRIC RESPRITORY DISTRESS

Signs and symptoms:

Spasmodic Coughing

Pursed Lips

Grunting

Retractions / Accessory Muscle Usage

Audible Wheezing

Decreased Breath Sounds

Inability to Complete Sentences

Prolonged Expiratory Phase

Differential:

Pneumonia

Croup

Bronchiolitis


Anaphylaxis

Tuberculosis

A careful lung exam will reveal source of respiratory distress and can guide treatment decisions. Epinephrine IM is appropriate for use when respiratory failure is imminent, which in children is

signified by a sudden SLOWING in respirations and markedly DEPRESSED MENTAL STATE, (both indicators of carbon dioxide build-up).


Epinephrine 1:1000 Nebulized

0.5 mL diluted with 2.5 ml NS

Repeat X1 in 5 min

ASTHMA

Asthma History,

Normally > 1 yo

Wheezing on exam

Albuterol 2.5mg /

Atrovent 0.5 mg

may repeat x3

Solu-medrol 2mg/kg

IV/IM

Max Dose 125MG

Epinephrine (1:1000) 0.01mg/kg IM

Max dose 0.3mg IM

May repeat X1 in 5 min

BRONCHIOLITIS

Infant < 1yo

Wheezing, tight

cough, thick nasal

secretions

CROUP

Toddler

Barky cough,

stridor

Oxygen by Mask as Needed



Medical Protocols

PEDIATRIC BRADYCARDIA Signs and Symptoms

Heart rate <60

Chest Pain

Hypotension

Ventricular ectopy

Dyspnea


Seizures


Beta-blocker Overdose

Hypothermia

Digoxin Toxicity

Calcium Channel Overdose

Malnutrition

Increased ICP

Universal Treatment Guidelines Definition of Hypotension by Systolic Blood Pressure and Age.

Neonate 0 – 28 days <60 mm Hg

Infants 1 – 12 months <70 mm Hg

Children 1-10 years <70mm Hg + (age in years x2)

Children >10 years <90 mm Hg

Heart rates in pediatric patients.

AGE Awake Rate Sleeping Rate

Newborn to

3months 85 to 205 80 to 160

3 months to

2 years 100 to 190 75 to 160

2 to 10 years 60 to 140 60 to 90

>10 years 60 to 100 50 to 90

Respiratory rates in pediatric patients.

Age Rate

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-age child 18-30

Adolescent 12-16

Epinephrine 1:10 000

0.01mg/kg q 3-5 min.

Assess respirations. Apply O2 and

assist with BVM as necessary.

IF CARDIAC ARREST OCCURS SEE

PEDIATRIC ARREST PROTOCOL

Respiratory Compromise is the

leading cause of pediatric

bradycardia.

Respiratory care should be number

one priority in all pediatric patients.

Start compressions if pulse weak or

signs of lethargy present

Insert IO


Medical Protocols

Attempt Vagal maneuver

Adenosine 0.1 mg/kg

fast IVP max 6 mg

IV or Intraosseous Access

STABLE NO YES

Adenosine 0.2 mg/kg

max 12 mg


0.5 to 1 joule / kg


2 joules/ kg


2 joules/ kg

Signs and Symptoms:

Rapid Regular Pulse >180


Feelings of Palpations



A-Fib W/ RVR

Unstable is defined absence of a radial pulse, feeling light headed or dizzy.

Sedation should not be used on hemodynamically unstable pts.

Print a monitor strip during conversion if patient condition allows.

While a 12-lead EKG is ideal, a 3-lead tracing is adequate for small children, toddlers and infants

Amiodarone 5mg/kg

over 10 min


Adenosine 0.2 mg/kg

max 12 mg

PEDIATRIC SUPRAVENTRICULAR TACHYCARDIA

Consider Sedation with

Versed 0.1 mg/kg (max 2mg)

OR fentanyl 1mcg/kg


Medical Protocols

CAPNOGRAPHY (ETCO2) Indications:

Verification of ET tube placement

Continuous monitoring of ET tube during transport

Shortness of breath / hyperventilation

Status epilepticus

Unconsciousness / poor arousability

Pre and post treatment for asthma / COPD

Indicator of Return of Spontaneous Circulation during cardiac arrest

TECHNIQUE

For Verification of ET tube placement:

1. Visualize the ET tube passing through cords with King Vision (when available)

2. Assess for breath sounds high in the axilla, on the anterior chest, and over the

epigastrium

3. Apply the ETCO2 monitor. REQUIRED WITH ALL INTUBATED PATIENTS

4. Note the following ETCO2 information on the ePCR:

a. The initial ETCO2 value and presence or absence of a good waveform

b. A repeat ETCO2 value one minute or so later and quality of waveform

c. Successful intubation is indicated by:

i. ETCO2 of 5 or greater

ii. Good waveform

5. Continuously monitor waveform and ETCO2 value during transport as a sign of tube

dislodgement or loss of pulse.

For assessment of patients who are short of breath:

1. Apply nasal ETCO2 device

2. Document findings on the ePCR

For all patients, consider the following when ETCO2 is outside the normal range (35-45):

1. Tube dislodgement

2. Poor perfusion

3. Hyperventilation / Hypoventilation


Medical Protocols

CAPNOGRAPHY WAVE FORMS

Normal Capnography: A wave form is present; the wave form begins at the base line, raises steeply,

plateaus with a gradual upslope, and quickly returns to the baseline.

End Tidal CO2 normal range: 35-45 mmHg

Hyperventilation

Hypoventilation, Stroke, Seizure, Head Injury, CNS Depression

Asthma, COPD, CHF

ET CO2 monitoring on non-intubated patients - assess severity & effectiveness of treatment.

Bronchospasm will produce a “shark fin” wave form.

CPR with Return of Circulation (ROSC)

http://2.bp.blogspot.com/_FD2V12x--sQ/Sgemfl46aFI/AAAAAAAAAFs/Xx-pP5_xXZs/s1600-h/1146996481_hyper.jpg

http://2.bp.blogspot.com/_FD2V12x--sQ/SgenRAFsVdI/AAAAAAAAAF0/8XzLkjlqkYU/s1600-h/1165800022_seiz2.jpg

http://3.bp.blogspot.com/_FD2V12x--sQ/SgjL3G68M4I/AAAAAAAAAG8/31vRQKP8EJU/s1600-h/1146996505_copd.jpg


Medical Protocols

Apnea, Total Obstruction/Dislodged/Misplaced ET-Tube, Equipment Failure

Partial Tube Obstruction, Blood Loss, Pulmonary Embolism, Hypothermia

Sedation, Hypoventilation, Hypothermia, CNS depression

Hyperthermia, Bicarbonate Infusion

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Medical Protocols

CHILD BIRTH

NORMAL DELIVERY PROCEDURES

1. Attempt to prevent explosive delivery 2. As delivery of head occurs, suction mouth then nose. 3. If membranes are still intact, instruct the mother to stop pushing and

gently tear the membrane and immediately suction mouth, then nose.

4. Keep newborn warm and dry. 5. Keep newborn at the level of the vagina until the cord is clamped and

cut. 6. Once cord pulsations cease, place one clamp 6 inches from the

newborn and another clamp 9 inches from the newborn. Cut cord between the clamps.

7. Allow newborn to nurse. If multiple births, do not allow nursing until all have been delivered.

8. APGAR score at 1st minute and 5th minute after birth.

Indications:

Imminent Child Birth


Medical Protocols

CPAP

Clinical indications:

CPAP is indicated in patients for whom inadequate ventilation is suspected. This could be as

a result of pulmonary edema, pneumonia, COPD, asthma, etc.

PATIENT MUST BE BREATHING FOR PROPER USE OF CPAP.

In asthmatic patients, continuous monitoring is required to reduce the risk of respiratory

depression.

1. Ensure adequate oxygen supply to ventilation device.

2. Explain procedure to Pt.

3. Place the delivery mask over the nose and mouth. Oxygen

should be flowing through the device at this point.

4. Secure the mask with the provided straps starting with the

lower straps until minimal air leak occurs.

5. Adjust Positive End Expiratory Pressure (PEEP) on CPAP device

slowly starting at 0cmH2O until desired pressure is reached.

6. Evaluate the response of patient assessing breath sounds,

general appearance and oxygen saturation if possible.

7. Encourage patient to allow forced ventilation to occur.

8. Document time and response on patient care report.


Medical Protocols

EZ-IO INTRAOSSEOUS INFUSION

Indications:

First-line access for all cardiac arrests

Any ALS patient from whom immediate fluid or

medication treatment is indicated. In addition,

patients must have at least one of the following

1. Altered mental status

2. Respiratory compromise

3. Hemodynamic instability

Flow Rate may appear to be slower than those achieved with an IV catheter Ensure the administration of appropriate syringe bolus prior to infusion. NO FLUSH =NO FLOW Pain control for EZ-IO Insertion should be performed prior to initial syringe flush or infusion. Allow to work for

30-60 seconds prior to Syringe flush o For adults administer 40mg of Lidocaine = 2ml of 2% lidocaine for cardiac use. o For pediatric s administer 0.5 MG/KG= 0.05 ml/kg of 2% lidocaine for cardiac use. (20 kg child = 1 mL)

Be cautious of potential air embolism, subcutaneous infiltration, fracture, or osteomyelitis.

1. Prepare Equipment

2. Select insertion site

a. Adult proximal humerus (PREFERRED SITE)

b. Adult proximal tibia: Measure one finger width distal to tibial tuberosity, along,

along the flat aspect of the medial tibia.

c. Pediatric proximal tibia: One finger width distal to the tibial tuberosity OR if unable

to palpate tibial tuberosity; two fingers below the patella along the flat aspect of

the medial tibia.

d. Adult distal tibia: Two finger widths proximal to the medial malleolus and midline

on the medial shaft.

e. Pediatric distal tibia. One finger width proximal to the medial malleolus along the

flat aspect of the medial distal tibia.

3. Prepare the skin with alcohol and/or betadine.

4. Prepare IO driver and needle set; load needle set onto driver.

5. Hold the IO driver in one hand and stabilize the leg near the insertion site with the opposite

hand.

6. Position the driver at the insertion site with the needle at a 90 Degree angle to the surface of

the bone.

7. Before powering the driver, insert the needle through the skin. When you feel the needle is

hitting resistance from the bone, make sure the 5mm line is still visible above the skin.

Power the driver on while applying minimal pressure. Insert the needle until a change in

resistance is noted. Remove the driver from the needle set and the stylet from the catheter.

Attach the connection tubing.

8. Use syringe to rapidly infuse 10ml of NS. If no infiltration is seen, attach the IV line and infuse

fluids or medications as usual. (For adults the IV bag will need to be under pressure.) 9. Secure the needle by looping the tubing and taping it back to the skin.

Contraindications:

Pt with an available secure IV line adequate for

necessary treatment or in whom an IV line can be

placed in a timely fashion.

Pt’s that do not require immediate fluid or

medication therapy. IO SHALL NOT BE

PERFORMED FOR PROPHYLAXIS.

Fracture of bone selected for IO infusion.

Inability to identify landmarks for procedure.

Known previous orthopedic procedure or

preexisting medical disease (such as tumor of the

bone selected for IO infusion.

Severe Burn or infection at the site of insertion.


Medical Protocols

EZ-IO INTRAOSSEOUS INFUSION


Medical Protocols

ontact Droplet and Airborne Precautions

INFECTION CONTROL History:

Febrile Rash, Discharge or

Potential Exposure Immunocompromised Generalized vs. focal

seizure (toddlers)

Differential:

Sepsis Medication Reaction Hyperthyroid Heat Stroke Meningitis Simple febrile seizure

Signs and Symptoms:

Warm, flushed, sweaty Rash Headache Abdominal Pain Seizure type, duration

(for febrile seizures)


Droplet Precautions

PPE + HEPA Mask for Provider;

Surgical Mask for Patient

Airborne Precautions

Suspect TB, SARS, or drug

resistant pneumonia (MRSA/VRE)

Suspect Influenza, Mumps or

Meningitis

PPE + Surgical Mask for

Provider and Patient

For suspected Ebola Virus Disease patient, see dedicated

section under Fundamentals of Care, p 33


Medical Protocols

KENDRICK EXTRICATION DEVICE INDICATIONS:

Used to prepare patients with suspected spinal fracture for extrication and / or movement from a sitting to a supine position.

When a short spine board could not be used.

Application of patients into KED

1. Open KED and place it between the patient’s buttocks and the seat the

patient is sitting on.

2. Center the KED on the patient and position the KED snugly under the

patient’s armpits.

3. Fasten the chest straps, snug up the bottom and the middle straps.

4. Slide the leg straps under the patient’s legs, and around the tops.

5. Secure the leg straps to the same side of the KED.

Movement of the patient in the KED

1. Both rescuers grasp the side handles on opposite sides of the KED. Place other arms under the patient’s legs.

2. Locking their arms together under the patient, the rescuers lift the patient up (keeping the patients legs at a 45 degree angle).

3. Lower the patient onto the long spine board. 4. Undo the leg straps.


Medical Protocols

Indications:

Two failed attempts at oral tracheal intubation.

It appears additional attempts at oral tracheal intubation will fail.

Cardiac Arrest, respiratory arrest.

No Gag Reflex

No provider trained in oral tracheal intubation available.

KING LTS AIRWAY

1. Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near the ventilatory openings.

2. Position the head. (The ideal position for insertion is the “sniffing position”. 3. Hold the KING TUBE at the connector with the dominant hand. Hold the mouth

open with the non-dominant hand. 4. With the king tube rotated laterally 45-90 degrees such that the blue orientation

line is touching the corner of the mouth, introduce the tip into the mouth and advance behind base of the tongue. NEVER FORCE THE TUBE INTO POSITION.

5. As tube tip passes under the tongue, rotate tube back to midline. 6. Without excessive force, advance KING tube until proximal opening of gastric

access lumen is aligned with the teeth or gums. 7. Inflate the KING tube using the volume of air indicated by the manufacture. 8. Attach BVM to the King Tube, and gently ventilate the patient. 9. Check for chest rise; auscultate the epigastric area for absence of abdominal

sounds, and the lungs bilaterally for breath sounds. (If successful continue to

ventilate patient).

10. Secure the KING-tube using an appropriate method.

Contraindications:

Obvious Signs of death Conscious Patients Do-Not-Resuscitate order Gag Reflex Known esophageal disease (Cancer, varices, surgery) Known ingestion of caustic substance Larygenctomy patient with stoma

If after 2 attempts unable to successfully place KING

Tube see FAILED AIRWAY PROTOCOL.

o Yellow Connector: Height 4-5 feet King size3 o Red Connector: Height 5-6 feet King size 4 o Purple Connector: Height >6 feet King size 5


Medical Protocols

NASO/ORO GASTRIC TUBE INSERTION

1. Restrain patient as necessary. 2. Position Patient :

a. Conscious Patient: High fowlers with chin on chest. b. Unconscious Patient: Left lateral recumbent position, with slight

Trendelenburg. Airway must be protected with Intubation prior to NG/OG. 3. Measure length of ng tube from nose to earlobe and then to midway between the

xyphoid process and umbilicus, and mark with tape. 4. If inserting nasally, lubricate tip with water soluble lubricant. 5. Nasal insertion: Direct tube along the floor of nostril to the posterior pharyngeal then

direct the tube downward through the nasopharynx. Oral Insertion: Direct tube to the back of the tongue and then downward through the oropharynx.

6. If patient is conscious or old enough to follow instructions direct the patient to swallow to facilitate the placement of the tube in the stomach.

7. Continue advancing tube until tape is at the nostril and lip. 8. If tube meets resistance or the patient has respiratory distress, remove the tube.

Fogging of the tube accompanied by cough or respiratory distress indicated tracheal intubation.

9. If patient begins to vomit, suction around tube and leave in place. 10. Confirm placement of tube:

a. Aspirate gastric contents with a syringe. b. Injecting 5-20cc of air while auscultating over the stomach for a “swoosh” or

“burp” indicates gastric placement. c. Auscultate lung sounds.

11. Secure tube in place.

If tube is not placed properly remove immediately

DO NOT ATTEMPT PLACEMENT MORE THAN 3 TIMES.

For gastric lavage:

1. Connect to a closed system. 2. Instill 20-150ml boluses of solution to a maximum of 4 liters. 3. Repeat procedure until stomach contents return clear or maximum volume has been

reached.

NG/OG should only be performed when instructed by medical control or requested by the

patient.

Infants <6 months are nose breathers and an OG is preferred.

Nasogastric tubes can be used as orogastric tubes in the pediatric patient.

Contraindications:

Suspected fractures of the basilar skull. Facial trauma with suspected fractured. Known or suspected esophageal varices. Ingestion of caustic poisons, without

medial direction.

Indications:

To lavage the stomach. To decompress the stomach. Evacuation of Stomach contents.


Medical Protocols

OROTRACHEAL INTUBATION

Clinical indications:

Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport

distances requiring a more secure airway.

An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate

respiratory effort.

1. Assemble appropriate equipment (to include): o BVM o Oxygen with regulator o Suction o Appropriate size ETT and stylet o ETT securing device o Gas exchange indicator o Magill forceps o 10cc syringe o Laryngoscope with appropriate size blade o Cardiac monitor, ETCO2 monitor

2. Properly position the patient in the supine position and ventilate adequately as indicated by the

patient treatment protocol you are following.

3. With suction standing by and proper manpower to provide Slicks maneuver if indicated, take

the laryngoscope in your LEFT hand and insert into the RIGHT side of the patients mouth. In a

forward abducting motion pull the lower jaw up and away from the patient while moving the

laryngoscope blade to the LEFT in an attempt to visualize the glottic opening. When you see the glottic opening and can identify the landmarks of the glottic opening, insert the ETT through the

glottic opening and into the trachea until you are at approximately at 23-26cm at the lip line. 4. Ventilate the patient while checking for the standard "Earmarks" of a successful intubation,

those being: o Good waveform on ETCO2 monitor (MOST RELIABLE INDICATOR) o Condensation in the ETT o Chest rise and fall o Good BVM compliance o Good positive and equal breath sounds o Good gas exchange as indicated by the color change on the gas indicator o Negative gastric sounds

5. Advise the receiving ER of an intubated patient and transport A.S.A.P. during protocol. 6. Secure ET Tube to the patients face, using “tube tamer”, tape, or string. Do not be put off task by vomitus, in the absence of suction sometimes if you lift a little

higher you can see over the top of the vomit into the back of the oropharynx. If at all possible the patient should be placed on cardiac monitor at all times, to monitor for

bradycardia and cardiac rhythm. Limit attempts to 10sec each.


Medical Protocols

NEEDLE DECOMPRESSION

Indications:

Tension Pneumothorax

1. Asses Chest and respiratory exertion.

2. Apply O2 per non-rebreather mask or BVM with 100%

supplemental O2.

3. Identify second intercostal space, midclavicular line on the

affected side.

4. Prep the area.

5. Snugly attach a 14 or 16 gauge angiocath to a 10ml syringe or

use arrow kit.

6. Insert the needle into the skin over the rib into the 2nd

intercostal space in mid-clavicular line directly above the 3rd

rib.

7. Puncture the parietal pleura.

8. Aspirate air as necessary to relieve patient’s symptoms.

9. Leave the plastic catheter remaining but remove the needle.

10. Secure the catheter.

11. Connect the catheter to a one way valve.

12. Reassess ventilator status, jugular veins, tracheal position,

pulse, and blood pressure.

13. Document procedure and responses.

Contraindications:

No apparent signs and symptoms of a tension pneumothorax.

Indications of Tension Pneumothorax

Hemodynamic Compromise, Systolic BP < 90 with any of the following: o JVD o Asymmetrical Chest Movement o Tracheal Deviation o Absent/Decreased Breath Sounds o Increase Resistance with Ventilation


Medical Protocols

NEEDLE DECOMPRESSION


Medical Protocols

SPINAL IMMOBILIZATION INDICATIONS:

Possible C-Spine FX

Motor Vehicle Collision

Fall from greater than patient’s height.

Fall from standing with pt age >65.

Unconscious patients with high possibility of traumatic spine injury.

Combative patients with high possibility of traumatic spine injury.

Auto-pedestrian accident

Bicycle accident

Traumatic Injury for patients with osteoporosis.

Contraindications:

Some patients due to size or age will not be able to be immobilized through in-line

stabilization with standard backboards and c-collars.

See the spinal motion restriction protocol for alternate methods of partial immobilization.

1. Place the patient in the appropriately sized c-collar

2. Once the collar is secure a second rescuer should still maintain their

position to ensure stabilization.

3. Log roll the patient to one side, maintain c-spine control.

4. Check the back, legs and back of head for injuries.

5. Place the long spine board under the patient.

6. Roll the patient onto long spine board while still maintaining s-spine

control.

7. Place head blocks next to the patients head.

8. Secure the torso and legs to the long spine board using straps, webbing

or tape.

9. Secure the patients head to the long spine board.

NOTE: for the patients in a vehicle or otherwise unable to be place in the prone

or supine position, place them on a backboard by the safest method available

that maximizes maintenance of in-line spinal stability.

Never force a patient into a non-neutral position to immobilize them. Padding

below the neck may be necessary. The patient may also require alternate

means of neck immobilization, in these cases a “horse collar” made of a towel

may be necessary.


Medical Protocols

TASER BARB REMOVAL

Disposition:

Transport PT if: 1. The barb lodged in a high risk area. 2. Patient falls under another protocol. 3. Pt meets signs and symptoms of

excited delirium and requires chemical restraint.

Assess and Treat:

Psychosis Hypoxia Hypoglycemia Overdose Central Nervous System Infection Trauma or Seizure

Remove only one barb at a time. DO NOT attempt to remove barbs in the face, genitalia, neck, women’s breast, or any site

that your clinical judgment deems high risk. Patients that have been fighting and/or who have taken stimulant medications are at a risk

for excited delirium and may require treatment and transport if symptoms present. Ensure that the wires are disconnected from the Taser device. Obtain vital signs when safe to do so.

1. Stabilize the skin around the barb and use one hard jerk

to pull the barb out of the patient’s skin.

2. Ensure that the barb tips are intact.

3. Return Barbs to LEO. IF LEO does not take custody of the

barbs, dispose of them in a sharps container.

4. Provide proper wound care, clean and cover with a

bandage.

5. Inform patient and LEO that the patient will need to seek

medical attention if signs of infection later develop.

6. The subject will need a tetanus shot if they have not had

one in the last 10 years.


Medical Protocols

INJECTION: SUBCUTANEOUS

INTRAMUSCLAR Clinical Indications:

When medication is necessary and the medication is necessary and the medication must be

given via SQ (not auto –injector) or IM route or as an alternative route in selected

medications

1. Receive and confirm medication order, or perform according to

standing order.

2. Prepare equipment and medication, expelling air from the syringe.

3. Explain the procedure to the patient and reconfirm patient

allergies.

4. Expose the selected area and cleanse the injection site with

alcohol.

5. Insert the needle into the skin with a smooth, steady motion.

SQ:45-degree angle skin pinched

IM:90- degree angle skin flat

6. Aspirate for blood.

7. Inject the medication.

8. Withdraw the needle quickly, dispose of needle properly.

9. Apply pressure to the site.

10. Monitor the patient therapeutic effects as well as any possible

side effects.

11. Document the medication, dose, route, and time on/with the

Patient care report.

The thigh should be used for injections in pediatric patients and injection volume should not

exceed 1cc.

The most common site for subcutaneous injection is the arm

o Injection volume should not exceed 1cc.

The possible injection sites for subcutaneous injection include the arm, buttock, and thigh.

o Injection volume should not exceed 1cc for the arm.

o Injection volume should not exceed 2 cc for the thigh or buttock


Medical Protocols

INJECTION: SUBCUTANEOUS

INTRAMUSCLAR


Medical Protocols

SURGICAL AIRWAY: CRICOTHYROTOMY

Indications:

Unable to ventilate. Unable to intubate. Unable to ventilate with rescue airway. Severe Facial or nasal injuries that

prevent successful ventilation or airway placement.

Severe mid-tracheal injuries or anatomy that prevents intubation / ventilation.

Sever uncontrolled angioedema, anaphylaxis and certain types of inhalation injures.

Contraindications:

Inability to identify landmarks. Not trained in this procedure. Able to ventilate with less invasive

techniques Able to intubate

Notify the receiving Emergency Department of procedure as soon as possible during

protocol.

If bleeding occurs, use suction and proceed. Insertion and inflation of endotracheal tube

through the cricothyotomy site will protect the patient from blood entering the airway.

If using an endotracheal tube only advance 2 - 2.5cm to avoid right main stem intubation.

1. Assemble equipment a. Betadine prep swabs b. Scalpel c. Large curved hemostat, Bougie Tube, or Extra scalpel handle d. Tracheostomy or endotracheal tube e. Tape

2. Expose the neck. 3. Identify the thyroid cartilage. The space between the cricothyroid notch and the

thyroid cartilage is the location of the cricothyroid membrane. 4. Prep the area. 5. Stabilize the trachea by holding the thyroid cartilage between the thumb and

fingers. 6. Make a horizontal incision approximately ½ inch through the skin and cricothyroid

membrane. 7. Insert hemostat to dilate the incision. (Never remove scalpel or hemostat without

something in the incision space; the small incision will close.) 8. Turn the hemostat or scalpel handle until the opening is sufficient to allow the

passing of a small endotracheal tube. (6.0-7.0 mm 9. Pass the endotracheal tube about 1 – 1.5 inches into the trachea. 10. Inflate the cuff if using a cuffed tube and ventilate the pt with high flow oxygen. 11. Check breath sounds bilaterally and secure with tape. 12. Monitor patient condition and reassess frequently. 13. Control any bleeding and dress the wound.


Medical Protocols

SURGICAL AIRWAY: QUICK TRACH

Clinical Indications:

Surgical Airway as indicated by the failed airway protocol.

1. Pre-oxygenate patient when possible. 2. Assemble all available equipment. 3. Locate cricothyroid membrane at the inferior portion of the thyroid cartilage

(with the head in the neutral position, membrane is approx. 3 finger widths above the sterna notch).

4. Have assistant hold skin taunt over membrane and locate midline. 5. Prepare the area with betadine if possible. 6. Hold the needle bevel up at a 90 degree angle, aimed inferiorly as you

approach the skin. 7. Puncture the skin with the needle and continue with firm steady pressure

while aspirating for air with a syringe. 8. As soon as air is aspirated freely stop advancing the needle airway assembly. 9. Modify the angle to 60 degrees from the head and advance to level of the

stopper. 10. Remove the stopper while holding the needle /airway assembly firmly in

place. Do not advance the needle further. (NOTE: if the patient is obese and no air can be aspirated with the stopper in place you may remove the stopper and continue advancing until air is aspirated. Be aware that without the stopper, risk of perforating the posterior aspect of the trachea is greatly increased).

11. Hold the needle and syringe firmly and slide only the plastic cannula along the needle into the trachea until the flange rests on the neck. Carefully remove the needle and syringe.

12. Secure the cannula with the neck strap. 13. Apply the EtCO2 detector and to the tube and the bvm. 14. Confirm placement with the use of breath sounds, pulse ox, and Color-metric

change. 15. Ensure 100% supplemental Oxygen via BVM.

Notify the receiving Emergency Department of procedure as soon as possible during

protocol.


Medical Protocols

Contraindications:

Non-extremity hemorrhage

Proximal extremity location where tourniquet application is not practical.

1. Place tourniquet proximal to wound.

2. Tighten per manufacturer instructions until hemorrhage stops

and/or distal pulses in affected extremity disappear.

3. Secure tourniquet per manufacturer instructions.

4. Note Time of tourniquet application and communicate this to

receiving care providers.

5. Dress wounds appropriately.

6. If Delayed or prolonged transport and tourniquet application

time is more than 5 hours contact medical control.

Clinical Indications:

Life threatening extremity hemorrhage that cannot be controlled by other means.

Tourniquets should be used extremely infrequently

TOURNIQUET


Medical Protocols

TRACTION SPLINT Clinical Indications:

Deformity to the mid-shaft of the femur.

No pulses in the distal extremity.

Pale, cyanotic skin distal to the injury in the affected extremity.

Contraindications:

Pelvic fracture If positioning the traction splint would delay the transport in a trauma patient in imminent

risk of circulatory collapse.

Padding can be placed in the patients groin to add to the patients comfort when possible.

1. Place traction splint on the mid-line side of the

patient.

2. Secure the splint to the distal end of the extremity

and the proximal end of the extremity.

3. Expand the traction splint slowly until:

a. Patient fells relief of pain

b. Pulses return to the affected extremity

c. Capillary refill returns to normal in the

presence of pulses.


Protocol


Medical Protocols

TRANSFERS – AIR MEDICAL


Medical Protocols

TRANSFERS - TRAUMA


Medical Protocols

VentiPAC PORTABLE VENTILATOR

1. Connect the ventilator to the oxygen supply

2. Switch the ventilator on/off switch to on (you should hear the ventilator

begin to cycle)

3. Set the breathing parameters to suite the pt (obtain from the facilities

respiratory therapist when available)

4. Set air mix switch to 100% for

A CPR

B Respiratory arrest

C. Contaminated environments

5. Connect tubing to the patient

6. Ensure the settings are adequate for the patient by,

A. Monitoring the patient’s vital signs and physical condition (remember to

treat the patient not the monitor)

B. Confirm airway placement prior to and after each movement, suctioning,

when connecting or discounting the tubing from the patients airway device,

and when checking vital signs

7. If the ventilator fails to work properly at any point during the transport of a

patient, IMMEDIATELY DISCONNECT THE VENTILATOR FORM THE PATIENT

AND SWITCH TO A BVM

Typical Ventilator Settings for an Adult Patient

On/off (On), X100Pa (40)

Inspiratory Time (1.5)

Expiratory Time (3.0)

Air Mix (=50% O2)

Inspiratory Flow L/sec (0.50)


Medical Protocols

APPENDIX A: MEDICATION FORMULARY

Medication Quick Reference Dosage Page

Acetylsalicylic Acid 324 mg PO 121

Activated Charcoal 50 grams PO 122

Adenosine (Adenocard) 6/12/12 mg 123

Pedi 0.1/0.2/0.2 mg/kg

Albuterol 2.5 mg per neb 125

Amiodarone 300 then 150 mg for arrest 126

150 mg over 10 min for dysrhythmias

Pedi 5 mg/kg

Anectine (Succinylcholine) 100 mg IV/IO 127

3-4 mg/kg IM, (Max 150 mg)

Pedi 1 mg/kg IV/IO, (Max 100 mg)

Atropine 0.5 to 1 mg 128

Calcium gluconate 1 gram IV = 10ml 129

Cefazolin (Ancef) 1-2 gram(s) IV infusion in 50-250 mL 130

Diltiazem (Cardizem) 10-20 mg, then 25mg 131

Diphenhydramine (Benadryl) 25-50 mg IV/IM 132

Pedi 1 mg/kg IV, (Max 25mg)

Dextrose 50% 25 grams = “1 amp” 133

Pedi D10 5mL/kg, D25 2 mL/kg

Diazepam (Valium) 5-10 mg IV 134

Pedi 0.2 mg/kg

Enalaprilat (Vasotec) 1.25 mg IV 135


Medical Protocols


Epinephrine 1 mg IV for arrest 136

10mcg q2-5 min or 5-20 mcg/min

For hypotension

0.3 mg IM for allergy, asthma

Pedi 0.01 mg/kg, (Max 0.3 mg)

Epinephrine 1:1000 Nebulized 0.5 mL = 0.5 mg with 2.5 mL saline neb 138

Etomidate 20 mg IV 139

Pedi 0.3 mg/kg

Fentanyl 50-100 mcg IV/IM/IN 140

Pedi 1 mcg/kg

Geodon 20 mg IM for Excited Delirium 141

Ipratropium (Atrovent) 0.5 mg nebulized 142

Labetalol 10-20 mg IV 143

Lidocaine 100 mg IV 144

40mg IO = 2mL of 2% (for IO pain)

Pedi: 0.5 mg/kg = 0.05 mL/kg

Magnesium 2 grams in 50 mL NS 145

Methylprednisolone (Solu-Medrol) 125 mg IV/IM* 146

Pedi 2 mg/kg/IM*

*IM only for allergic reaction & dystonia

Midazolam (Versed) 1-2 mg IV/IM/IN for anxiety 147

5 mg IV/IM/IN for RSI, Seizure, Behav.

10 mg IV/IM for excited delirium

Pedi 0.1 mg/kg (Max 5mg)

Morphine 2-5 mg IV, Max 10mg 148

Pedi 0.1 mg/kg (Max 5mg)

Naloxone (Narcan) 0.4 mg IV/IM/IN, Max 2mg 149


Medical Protocols


Nitroglycerin 0.4 mg SL q5 min for ACS or HTN 150

0.4 mg SL q3 min for CHF

Norepinephrine (Levophed) 2-12 mcg/minute IV for hypotension 151

Pedi: not indicated

Ondansetron (Zofran) 4 mg IV/IM 152

Pedi 6mo to 4yr 2mg, >4 yr 4 mg

Oral Glucose 15 grams PO 153

Oxygen NC: 1-4 L, Neb: 8 L, Mask 10-15L/min 154

Rocuronium 50 mg IV 155

Pedi 1 mg/kg

Sodium Bicarbonate 50-100 mEq IV 156

Thiamine 100 mg IV/IM 157

Vecuronium 10 mg IV 158

Pedi 0.1 mg/kg


Medical Protocols

ACETYLSALICYLIC ACID (ASPRIN, ASA)

Class Platelet inhibitor, anti-inflammatory agent

Mechanism of Action Prostaglandin inhibition, prevents platelet aggregation

Indications Chest pain suggestive of acute myocardial infarction

Protocol: Acute Coronary Syndrome

Contraindications Hypersensitivity to ASA or nonsteroidal anti-inflammatory drugs (NSAIDS)

Gastrointestinal bleeding

Adverse Reactions Heartburn

Gastrointestinal bleeding

Nausea, vomiting

Wheezing in allergic patients

Prolonged bleeding

Dosage and Administrations Adult :

324mg PO

Pediatric: not recommended in pediatric population

Duration of Action Onset: 30-45 minutes

Duration: life of platelet (7-10 day)

Special Considerations/Drug Interactions Pregnancy safety: category D


Medical Protocols

ACTIVATED CHARCOAL (ACTIDOSE-AQUA) Class

Poison antidote

Mechanism of Action Binds and absorbs ingested toxins and inhibits the absorption of poisons

Indications Many oral poisonings, medication overdoses

Protocol: Overdose

Contraindications Ingestion of: turpentine, corrosives (lye and strong acids), caustics, or

petroleum distillates (kerosene, gasoline, paint thinner, cleaning fluid, furniture polish)

Adverse Reactions May indirectly induce nausea and vomiting May cause constipation

Dosage and Administrations Adult:

50 grams PO or NGT

Duration of Action Onset: Immediate

Duration: Continual while in GI tract

Special Considerations/Drug Interactions Is relatively insoluble in water May blacken feces Does not adsorb all drugs and toxic substances (for example, cyanide, lithium,

iron, lead and arsenic) Overdoses such as Phenobarbital, Carbamazepine, Theophylline, Phonation

and Digitalis, multiple doses of charcoal may be required to be effective Syrup of Ipecac is adsorbed by activated charcoal


Medical Protocols

ADENOSINE (ADENOCARD) Class

Antiarrhythmic

Mechanism of Action An endogenous purine nucleotide that slows conduction through the AV node,

interrupts the reentry pathways to the AV node and can restore normal sinus

rhythm in PSVT via modulation of K+ currents and blunting of catecholamine

response

Indications Conversion to sinus rhythm of Paroxysmal Supraventricular Tachycardia

(PSVT), including that associated (Wolff-Parkinson-White syndrome) To aid in the diagnosis of broad or narrow complex supraventricular

tachycardia Protocol: Supraventricular Tachycardia

Contraindications

Hypersensitivity to the medication 2nd or 3rd degree AV block (except in patients with a functioning artificial

pacemaker) Sick Sinus Syndrome where you see the accessory pathway conduct the atrial

impulses at rates > 220) Adverse Reactions

Non-cardiac: facial flushing, chest pain, dyspnea, headache, lightheadedness Cardiac: 1st, 2nd or 3rd degree heart block; transient asystole; varied atrial

and ventricular arrhythmias 1/2 life is 10 seconds. A brief period of asystole (up to 15 seconds) following

conversion, followed by resumption of NSR is common after rapid administration

Adverse reactions are generally transient, resolve within 1 minute of drug administration, and do not require intervention, nor are they an indication to not attempt a subsequent administration of a higher dose of the same medication.

Adult:

6mg FIVP with 10cc NS flush, wait 1-2 min if no conversion 12mg FIVP with

10cc NS flush , wait 1-2 minutes if no conversion 12mg FIVP with 10cc NS

flush (Max of 30mg)

Pediatric:

0.1 mg/kg (to a max of 6 mg) IV/IO with 10cc NS flush, wait 1-2 minutes.

If no conversion, 0.2 mg/kg (to a maximum of 12 mg) with a NS 10 ml flush.

Wait 1-2 minutes; if no conversion, 0.2 mg/kg (to a max of 12 mg) with a 10cc NS flush

(Total Max of 30mg)


Medical Protocols

Duration of Action Onset: < 60seconds

Peak : 60 seconds

Duration: 1-2 minutes

Special Considerations/Drug Interactions The effects of Adenosine are antagonized by methylxanthines, caffeine,

Theophylline (larger doses may be required to be effective) Direct IV rapid bolus (1 - 2 seconds), preferably via large bore EJ or AC site due

to short half-life and followed by NS 10 - 20 ml flush Must be administered quickly, preferably via large bore IV in the AC or EJ, may be

administered via IO.


Medical Protocols

ALUBTEROL SULFATE (PROVENTIL, VENTOLIN) Class

Beta2-adrenergic bronchodilator

Mechanism of Action A sympathomimetic that is selective for beta2-adrenergic receptors. It relaxes

smooth muscles of the bronchial tree and peripheral vasculature by stimulating

adrenergic receptors of the sympathetic nervous system.

Indications Relief of bronchospasm in patients with reversible obstructive airway disease

Protocol: Asthma, COPD, and Hyperkalemia

Contraindications Hypersensitivity to the medication

Cardiac dysrhythmias associated with tachycardia

Tachycardia caused by digitalis intoxication

Adverse Reactions Nervousness

Weakness

Tremors

Increased systemic effects (pulse, blood pressure)

Dosage and Administrations Adult: 2.5mg administered by inhalation via nebulizer

Pediatric:

2.5mg administered by inhalation via nebulizer

Duration of Action Onset: 5 – 15 minutes

Duration: 3-4 hours

Special Considerations/Drug Interactions It may potentiate diuretic induced hypokalemia

Beta-blockers antagonize the effects of Albuterol


Medical Protocols

AMIODARONE (CORDARONE) Class

Antidysrhtythmic

Mechanism of Action Prolongation of action potential

Non-competitive alpha and beta sympathetic blocking effects

Calcium channel block effects

Indications Ventricular fibrillation, ventricular tachycardia with or without a pulse

Protocol: Ventricular fibrillation, ventricular tachycardia with or without a pulse,

and A-fib/SVT refractory to Adenocard and Diltiazem

Contraindications Hypersensitivity to the medication

Bradycardia

Cardiogenic shock

Adverse Reactions Hypotension

Bradycardia

CHF


V-fib and pulseless V-tach- 300mg in 50cc’s of NS- initial dose wait ten

minutes, then administer 150mg in 50cc’s of NS x 3;

V-tach with a pulse or refractory A-fib/SVT – 150mg in 50ccs over 10

minutes.

Pediatric:

V-fib and pulseless V-tach- 5mg/kg (Max dose of 300mg);

SVT- 5mg/kg over 10 minutes


Peak effect: variable

Duration: long and variable

Special Considerations/Drug Interactions Incompatible with Sodium Bicarbonate- can precipitate

Caution with Beta Blockers- may increase hypotension and Bradycardia

Caution with Calcium Channel Blockers- hypotension and increase

inotropic/dromotropic effects

Hypotension associated with slow infusion rate


Medical Protocols

ANECTINE (SUCCINYLCHOLINE) Class

Depolarizing neuromuscular blocker; skeletal muscle relaxant Mechanism of Action

Ultra-short acting depolarizing agent that mimics acetylcholine as it binds with the

cholinergic receptors on the motor end plate, producing a phase I block as

manifested by fasciculations.

Indications Rapid Sequence Intubation

Contraindications Penetrating eye injuries Acute narrow angle glaucoma Malignant hyperthermia – personal of familial history After the acute phase of major burn or extensive trauma Muscular Myopathies (i.e.: Muscular dystrophy)

Adverse Reactions Anaphylaxis Hyperkalemia Malignant Hyperthermia Cardiac Dysrhythmias Bradycardia which may progress to asystole Rhabdomyolysis Increased intraocular pressure


100mg IV/IO

3-4mg/kg IM to max dose to 150mg

Pediatric:

1mg/kg to a max dose of 100mg IV/IO

Duration of Action Onset: 1 minute Duration: 5-10 minutes

Special Considerations/Drug Interactions Pregnancy Category C

Diazepam may reduce duration of action

Beta blockers and organophosphates may potentiate effects

Use with caution in hyperkalemic or possible hyperkalemic patients

Consider premedication with atropine, particularly in pediatric patients

Use with caution in pediatric patients


Medical Protocols

ATROPINE SULFATE Class

Anticholinergic Mechanism of Action

Atropine sulfate, a potent parasympatholytic, inhibits actions of acetylcholine at postganglionic parasympathetic neuroeffector sites. Small doses inhibit salivary and bronchial secretions; moderate doses dilate pupils and increase heart rate, and large doses decrease GI motility, inhibits gastric acid secretion. Blocked vagal effects result in positive chronotropic and positive dromotropic effects.

Indications Hemodynamically significant bradycardia Organophosphate poisoning Protocol: Bradycardia

Contraindications Tachycardia Hypersensitivity Unstable cardiovascular status in acute hemorrhage and myocardial ischemia Narrow-angle glaucoma

Adverse Reactions Tachycardia, palpations, dysrhythmias, headache, dizziness, nausea and vomiting Paradoxical bradycardia when pushed slowly or when used at doses less than 0.5

mg Anticholinergic effects (dry mouth or nose, photophobia, blurred vision, urine

retention; flushed, hot, dry skin ) Dosage and Administrations

Adult:

Bradycardia: 0.5-1.0 mg IV q 3-5 min as needed (max of 0.04 mg/kg) IV/IO

Pediatric:

Not indicated

Duration of Action Onset: Rapid

Duration: 2-6 hours

Special Considerations/Drug Interactions - Atropine Anticholinergic medications may increase vagal blockade. Potential adverse effects when administered in conjunction with digitalis,

cholinergic, neostigmine. The effects of atropine may be enhanced by antihistamines, Procainamide,

Quinidine, antipsychotics, antidepressants, and benzodiazepines.


Medical Protocols

CALCIUM GLUCONATE 10% Class

Minerals and electrolytes Mechanism of Action

Calcium is a positive inotrope Variable effect on systemic vascular resistance When used to prevent or treat negative calcium balance (e.g., osteoporosis), the

calcium in calcium salts moderates nerve and muscle performance and allows normal cardiac function

Indications Suspected Hyperkalemia in adult PEA/Asystole associated with renal patients

Antidote for calcium channel blocker overdose and magnesium sulfate toxicity

Hyperkalemia associated with adult crush injury

Protocol: Overdose, crush injury

Contraindications Patients with digitalis toxicity

Caution should be used with dehydrated patients

Adverse Reactions When given too rapidly or to someone on digitalis, can cause sudden death from

ventricular fibrillation


1 gram (= 10mL) over 10 minutes. May repeat X1

Duration of Action Onset: Immediate

Duration: 30 minute to 2 hours

Special Considerations/Drug Interactions Incompatible with Sodium Bicarbonate- IV line must be flushed with copious

amounts of saline Calcium may decrease the bioavailability of tetracycline’s, fluoroquinolones, iron

salts and salicylates, Atenolol, and sodium polystyrene sulfonate I.V. calcium may antagonize the effects of Verapamil; large intakes of dietary fiber

may decrease calcium absorption due to a decreased GI transit time and the formation of fiber-calcium complexes

Increased effect: I.V. calcium may increase the effects of Quinidine and digitalis


Medical Protocols

Cefazolin (Ancef) Class

Antibiotic - cephalosporin Mechanism of Action

Bactericidal agent that acts by inhibition of bacterial cell wall synthesis Indications

Open Skeletal fracture A break in the skin over a fracture site

Contraindications History of anaphylaxis (not a simple rash) to penicillin Known allergy to the cephalosporin group of antibiotics <1 year of age

Adverse Reactions Diarrhea Anaphylaxis Itching Skin rash

Dosage and Administration Adult:

1-2 gram IV infusion over 10-30 minutes Can administer 1 gram for patient <70kg Can administer 2grams for patients >70kg

After reconstituting medication, mix into a 50ml, 100ml or 250ml bag of Normal Saline

Preferred mixing dose is 50ml Normal saline for each 1mg of antibiotic

Duration of Action Duration unknown

Special Considerations/Drug Interactions Be alert for hypersensitivity reaction Pregnancy Category B Renal Impairment may require reduced dosage IV incompatible with Amiodarone Parenteral drug products should be shaken well when reconstituted and inspected

for particulate matter prior to administration Note that reconstituted solutions may range in color from pale yellow to yellow

without a change in potency.


Medical Protocols

DILTIAZEM (CARDIZEM) Class

Benzothiazepine, Calcium Channel Blocker, Cardiovascular agent

Mechanism of Action A slow calcium channel blocker that blocks calcium ion influx during depolarization

of cardiac and vascular smooth muscle. It decreases peripheral vascular resistance

and caused relaxation of the vascular smooth muscle resulting in a decrease of both

systolic and diastolic blood pressure

Indications Atrial arrhythmia

Protocol: Atrial Fibrillation

Contraindications Administration of intravenous beta-blockers within a few hours of intravenous

Diltiazem

Atrial fibrillation or flutter associated with an accessory bypass tract (Wolff-

Parkinson- White or short PR syndromes)

Hypotension

Sick sinus syndrome without a pacemaker

Adverse Reactions Bradyarrhythmia

Peripheral edema

CHF

Heart block

Myocardial infarction


10-20mg SIVP over 2 min

May repeat with a dose of 25mg SIVP over 2 min


Special Considerations/Drug Interactions Renal impairment can cause an increased risk of toxicity

Ventricular function, impaired

Hepatic or renal impairment, heart failure


Medical Protocols

DIPHENHYDRAMINE (BENADRYL) Class

Antihistamine

Mechanism of Action Antihistamines prevent histamines from reaching H1- and H2-receptor sites.

Antihistamine is specific for conditions in which histamine excess is present (for example, acute urticaria) but is adjunctive therapy in the treatment of anaphylactic shock because epinephrine is more effective.

Indications Allergic reactions

Anaphylaxis

Acute dystonic reactions

Protocol: Overdose, anaphylaxis, excited delirium

Contraindications Lower respiratory diseases such as asthma attacks Patients taking MAOIs Hypersensitivity Narrow-angle glaucoma

Adverse Reactions Dose-related drowsiness

Disrupted coordination

Hypotension

Palpitations

Tachycardia, bradycardia

Thickening of bronchial secretions


25-50 mg SIVP/ IM Pediatric:

1mg/kg SIVP/IM Max 25mg

Duration of Action - Diphenhydramine Peak: 1-3 hours Duration:6-12 hours

Special Considerations/Drug Interactions CNS depressants may increase depressant effects.

MAOIs may prolong and intensify Anticholinergic effects of antihistamines.


Medical Protocols

DEXTROSE 50% Class

Carbohydrate , hypertonic solution

Mechanism of Action The term dextrose is used to describe the six-carbon sugar d-glucose, the principal

form of carbohydrate used by the body. D50 is used in emergency care to treat hypoglycemia and to manage coma of unknown origin.

Indications Hypoglycemia

Protocol: Diabetic emergencies

Contraindications There are no significant contraindications for IV administration of 50% dextrose in

emergency care.

Adverse Reactions Warmth Pain and burning from medication infusion Thrombophlebitis Rhabdomyolysis


25 g slow IV Pediatric:

<1 mo AND < 45mg/dL D10 5mL/kg 1mo-12yr D25 2mL/kg

Duration of Action Onset: < 1 minute

Special Considerations/Drug Interactions Extravasations may cause tissue necrosis; use a large vein and aspirate occasionally

to ensure route patency. D50 sometimes precipitates severe neurological symptoms (Wernicke's

encephalopathy) in thiamine-deficient patients such as alcoholics. (This can be prevented by administering 100 mg of thiamine, IV.)


Medical Protocols

DIAZEPAM (VALIUM) Class

Benzodiazepine sedative-hypnotic, anticonvulsant Mechanism of Action

Diazepam acts on the limbic, thalamic, and hypothalamic regions of the CNS to potentiate the effects of inhibitory neurotransmitters, raising the seizure threshold in the motor cortex.

Indications Acute anxiety states Acute alcohol withdrawal Muscle relaxant Seizure activity Preoperative sedation Protocol: Behavioral emergencies, Seizures, Eclampsia

Contraindications Hypersensitivity to the drug Shock

Adverse Reactions Hypotension Reflex tachycardia Respiratory depression Ataxia Psychomotor impairment Confusion Nausea


Eclampsia: 5mg SIVP

Seizures/Behavioral: 10mg SIVP

Pediatric:

Seizures: 0.2 mg/kg IV; Max dosage of 10mg

Duration of Action Onset: (IV) 1-5 min (IM) 15-30 min

Duration: (IV) 15 min-1 hr (IM) 15 min-1 hr Special Considerations/Drug Interactions

May cause local venous irritation. Resuscitation equipment should be readily available

Rapid IV administration may be followed by respiratory depression and excessive sedation.

Though the drug is still widely used as an anticonvulsant, it is relatively weak and of short duration.


Medical Protocols

ENALAPRILAT (VASOTEC) Class

Enalaprilat is an angiotensin converting enzyme (ACE) inhibitor. Mechanism of Action

Inhibition of ACE results in decreased plasma angiotensin II, which leads to decreased vasopressor activity and to decrease aldosterone secretion.

Indications Hypertension associated with Congestive Heart Failure (CHF) Protocol: Congestive Heart Failure

Contraindications Patients with a history of angioedema related to previous treatment with an

angiotensin converting enzyme inhibitor and in patients with hereditary or idiopathic angioedema.

Hypersensitivity Adverse Reactions

Angioedema (severe swelling of tongue, face, lips, throat) Headache Hypotension Nausea

Dosage and Administrations Adult: 1.25mg SIVP over 5 minutes, may repeat X1

Duration of Action Onset: 15 minutes Peak:1-4 hrs Duration:4-6 hrs

Special Considerations/Drug Interactions Use caution when administering to renal patients May cause hyperkalemia Enalaprilat may potentiate the effect of diuretics causing a significant decrease in

blood pressure Lithium toxicity has been reported in patients receiving lithium concomitantly with

drugs which cause elimination of sodium, including ACE inhibitors


Medical Protocols

EPINEPHRINE (ADRENALINE) Class

Sympathomimetic

Mechanism of Action Epinephrine stimulates alpha-, beta1-, and beta2-adrenergic receptors in dose-

related fashion. It is the initial drug of choice for treating bronchoconstriction and hypotension resulting from anaphylaxis as well as all forms of cardiac arrest. Rapid injection produces a rapid increase in systolic pressure, ventricular contractility, and heart rate. In addition, epinephrine causes vasoconstriction in the arterioles of the skin, mucosa, and splanchnic areas and antagonizes the effects of histamine.

Indications Bronchial asthma Acute allergic reaction Cardiac arrest Anaphylaxis Protocol: V-Fib/Pulseless V-Tach, Asystole/PEA, Anaphylaxis, COPD/Asthma,

Bradycardia Contraindications

Hypersensitivity Hypovolemic shock Coronary insufficiency Hypertension

Adverse Reactions

Headache, nausea, restlessness, weakness, dysrhythmias, hypertension Dosage and Administrations Adult:

V-Fib/Pulseless V-Tach, Asystole/PEA – 1mg (1:10,000) IV/IO every 3-5 minutes Anaphylaxis – 0.3mg (1:1,000) IM every 5 minutes. May repeat x 1

COPD/Asthma - 0.3mg (1:1,000) IM. May repeat x 1 in 5 minutes. Hypotension – 10 mcg q 3 minutes, or 5-20 mcg/min (calculated from normal Dosage of 0.1-0.4 mcg/kg/min Pediatric:

V-Fib/Pulseless V-Tach, Asystole/PEA – 0.01mg/kg (1:10,000) IV/IO every 3-5 minutes Anaphylaxis – 0.01mg/kg (1:1,000) IM every 5 minutes, Max dose 0.3 mg. May repeat x 2

Asthma - 0.01mg/kg (1:1,000) IM every 5 minutes. May repeat x 1 Bradycardia - 0.01mg/kg (1:10,000) IV/IO every 3-5 minutes Duration of Action

Onset: (SQ) 5-10 min (IV) 1-2 min

Duration: 5-10 min


Medical Protocols

Special Considerations/Drug Interactions MAOI’s and Bretylium may potentiate the effect of Epinephrine.

Beta-adrenergic antagonists may blunt inotropic response.

Sympathomimetics and phosphodiesterase inhibitors may exacerbate dysrhythmia

response.

May be deactivated by alkaline solutions (Sodium Bicarbonate, Furosemide).

Syncope has occurred after epinephrine administration to asthmatic children.

May increase myocardial oxygen demand.


Medical Protocols

EPINEPHRINE NEBULIZED Class

Sympathomimetic

Mechanism of Action Acts as a bronchodilator that stimulates beta2 receptors in the lungs, resulting in

relaxation of bronchial smooth muscle. It alleviates bronchospasm, increases vital

capacity, and reduces airway resistance. It inhibits the release of histamine and is

useful in treating laryngeal edema.

Indications Bronchial asthma Prevention of bronchospasm Croup (laryngotracheobronchitis) Laryngeal edema Protocol: Pediatric Respiratory Distress : Brochiolitis and Croup

Contraindications Hypertension

Cardiovascular disease

Epiglottitis

Adverse Reactions Tachycardia

Dysrhythmia

Dosage and Administrations Pediatric:

Dilute 0.5ml of Epinephrine (1:1000) in 2.5ml of saline. Administer by

aerosolization

May repeat x 1 in 5 minutes.

Duration of Action Onset : within 5 minutes

Duration : 1-3 hours

Special Considerations/Drug Interactions - Epinephrine

May produce tachycardia and other dysrhythmias

Monitor vital signs closely

Excessive use may cause bronchospasm

MAOI’s and Bretylium may potentiate the effect of Epinephrine.

Beta-adrenergic antagonists may blunt inotropic response.

Sympathomimetics and phosphodiesterase inhibitors may exacerbate dysrhythmia

response.


Medical Protocols

ETOMIDATE (AMIDATE) Class

Etomidate is a hypnotic drug without analgesic activity Mechanism of Action

Etomidate is a hypnotic drug without analgesic activity Etomidate is a short-acting hypnotic, which appears to have gamma-aminobutyric acid (GABA)–like effects. Unlike the barbiturates, etomidate reduces subcortical inhibition at the onset of hypnosis while inducing neocortical sleep. Studies in animals suggest that a part of the action of etomidate consists of a depression of the activity and reactivity of the brain stem reticular formation.

Indications Induction of general anesthesia Protocol: Rapid sequence intubation, and post resuscitation induced hypothermia

Contraindications Patients who have known hypersensitivity

Adverse Reactions Etomidate may induce cardiac depression in elderly patients, particularly those with

hypertension Transient venous pain on injection and transient skeletal muscle movements,

including myoclonus Hyperventilation, hypoventilation, apnea of short duration (5 to 90 seconds with

spontaneous recovery), laryngospasm, hiccup and snoring. These conditions were managed by conventional countermeasures.

Hypertension, hypotension, tachycardia, bradycardia and other arrhythmias have occasionally been observed


20 mg IV/IO Pediatric:

0.3 mg/kg IV/IO, Max dose 20mg Duration of Action - Etomidate

Onset: within 1 minute Duration: 3 to 5 minutes

Special Considerations/Drug Interactions Risk benefit should be considered with Immunosuppression, sepsis or

Transplantation (potential effects on adrenal function) Etomidate can block the adrenal gland's production of cortisol and other steroid

hormones, possibly resulting in temporary adrenal gland failure. This may cause abnormal salt and water balance, lowered blood pressure, and, ultimately, shock.


Medical Protocols

FENTANYL Class

Synthetic narcotic Mechanism of Action

A potent, short-acting, rapid-onset opioid agonist that relieves pain by stimulating opioid receptors in CNS; also causes respiratory depression and peripheral vasodilation; inhibits intestinal peristalsis and sphincter of Oddi spasm; stimulates chemoreceptors that cause vomiting; increases bladder tone.

Indications Traumatic and Cardiac pain management, rapid sequence intubation Protocol: rapid sequence intubation, pain management,

Contraindications Hypersensitivity

Adverse Reactions

Bradycardia, more rapid and significant ventilation impairment in patients with

COPD and prolonged clinical effects in patients with hepatic or renal impairment. Severe muscular rigidity develops in patients if administered rapidly.


50-100mcg SIVP over 1-2 minutes; Max dose of 200mcg, May repeat X1 May be administered via IV/IM/IN

Pediatric: 1 mcg/kg SIVP over 1-2 minutes May repeat 1 mcg/kg X1

Duration of Action Onset: Immediately (IV); 7 to 8 min (IM). Duration: 30 to 60 min (IV); 1 to 2 h (IM).

Special Considerations/Drug Interactions Amiodarone: Profound bradycardia, sinus arrest, and hypotension may occur. Barbiturate anesthetics (e.g., thiopental) May have additive effects. Reduce

dosage of one or both agents. CNS depressants (e.g., alcohol, benzodiazepines [e.g., diazepam], general

anesthetics, hypnotics, other opioid, phenothiazines, sedating antihistamines, sedatives, skeletal muscle relaxants, tranquilizers) Concomitant use may produce increased depressant effects (e.g., hypotension, profound sedation, respiratory depression).

MAOIs (e.g., phenelzine) Fentanyl is not recommended for use in patients who have received MAOIs within 14 days.


Medical Protocols

Geodon Class

Antipsychotropic Mechanism of Action

It has been proposed that Geodon’s beneficial effects are achieved by blocking dopamine and serotonin receptors. Geodon also inhibits reuptake of serotonin and epinephrine in the brain.

Indications Psychosis where Excited Delirium is suspected.

Contraindications

Hypersensitivity to Geodon Adverse Reactions

Prolonged Q-T Interval Dosage and Administrations

Adult: Excited Delirium: 10-20mg IM

Duration of Action

Onset: Within 1 min Duration: 9-17 min

Special Considerations/Drug Interactions

Should not be given to patients with recent acute myocardial infarction, or known

history of QT prolongation.

Geodon should never be given intravenously.


Medical Protocols

IPRATROPIUM (ATROVENT) Class

Anticholinergic (parasympatholytic) agent Mechanism of Action

Atrovent inhibits interaction of acetylcholine at receptor sites on the bronchial smooth muscle, resulting in bronchodilation

Indications Patients with bronchospasm (asthma and COPD) may benefit from this medication.

Patients will typically present with wheezing or persistent cough. Remember with severe bronchospasm, the patient may not be moving enough air to have lung sounds auscultated

Protocol: COPD/Asthma Contraindications

The solution that is used for nebulization can be safely used in patients with a soy product allergy, but not if there is a known hypersensitivity to Ipratropium or atropine.

Adverse Reactions Palpitations Dizziness Anxiety Tremors Headache Nervousness Dry mouth


0.5mg mixed with Albuterol via aerosolization x 3 Pediatric:

0.5mg mixed with Albuterol via aerosolization x 3 Duration of Action

Onset:5-15 minutes Duration: 2-8 hrs

Special Considerations/Drug Interactions Can cause a paradoxical bronchospasm increasing the patient's respiratory

difficulties. Nebulizers can be attached to the ET tube and ventilated into patient with BVM.


Medical Protocols

LABETALOL Class

Alpha- and beta-adrenergic blocker Mechanism of Action

Labetalol is a competitive alpha1-receptor blocker as well as a nonselective beta-receptor blocker used to lower blood pressure in a hypertensive crisis. Because of alpha- and beta-blocking properties, blood pressure is reduced without reflex tachycardia, and total peripheral resistance is decreased without a significant alteration in cardiac output.

Indications Hypertension Protocol: Hypertension

Contraindications Bronchial asthma Congestive heart failure Second- and third-degree heart block Bradycardia Cardiogenic shock

Adverse Reactions Headache and facial flushing Ventricular dysrhythmias Hypotension and dizziness Dyspnea Diaphoresis


10-20 mg SIVP over 2 min. Repeat X2 q 10 min Duration of Action

Onset: Within 5 min Duration: 3-6 hr

Special Considerations/Drug Interactions Bronchodilator effects of beta-adrenergic agonists may be blunted by Labetalol.

Nitroglycerin may augment hypotensive effects. Observe for signs of congestive heart failure, bradycardia, and bronchospasm.

Labetalol should only be administered with the patient in a supine position.


Medical Protocols

LIDOCAINE (XYLOCAINE) Class

Antidysrhtythmic Mechanism of Action

Lidocaine decreases phase-4 diastolic depolarization and suppresses premature ventricular contractions. In addition, it is used to treat ventricular tachycardia and some cases of ventricular fibrillation. Lidocaine also raises the ventricular fibrillation threshold

Indications Protocol: IO pain management

Contraindications Hypersensitivity Stokes-Adams syndrome Second- or third-degree heart block in the absence of an artificial pacemaker

Adverse Reactions Lightheadedness, hypotension, confusion, blurred vision, cardiovascular collapse,

bradycardia CNS depression (altered level of consciousness, irritability, muscle twitching,

seizures) with high doses Dosage and Administrations

Adult: Intraosseous pain: 40 mg IV = 2 mL of 2% cardiac lidocaine

Pediatric: Intraosseous pain: 0.5 mg/kg of 2% cardiac lidocaine = 0.05 mL/kg,

10 kg = 0.5 mL, 20 kg = 1 mL, 30 kg = 1.5mL

Duration of Action Onset: 30-90 sec

Duration: 2-4 hr Special Considerations/Drug Interactions

Since Lidocaine is metabolized in the liver, elderly patients, patients with hepatic diseases, shock or congestive heart failure will not break down the drug rapidly. Consider one-half dose for boluses and drip rate in these patients.

Apnea induced with succinylcholine may be prolonged with large doses of Lidocaine.

If bradycardia occurs in conjunction with PVCs, always treat the bradycardia first with atropine or TCP. Exceedingly high doses of Lidocaine can result in coma or death.


Medical Protocols

MAGNESIUM SULFATE Class

CNS depressant Mechanism of Action

Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction.

Indications Seizures of eclampsia (toxemia of pregnancy) Torsade’s de pointes Severe asthma Protocol: Asthma, Eclamptic pregnancy

Contraindications Heart block

Adverse Reactions Diaphoresis Facial flushing Hypotension Depressed reflexes Hypothermia Reduced heart rate Circulatory collapse Respiratory depression


2 grams in 50 cc of NS over 10 minutes Duration of Action

Onset: Immediate Duration: 3-4 hr

Special Considerations/Drug Interactions CNS depressant effects may be enhanced if the patient is taking other CNS

depressants. Serious changes in cardiac function may occur with cardiac glycosides.

IV calcium gluconate or calcium chloride should be available as an antagonist to magnesium if needed.

Magnesium must be used with caution in patients with renal failure, since it is cleared by the kidneys and can reach toxic levels easily in those patients.


Medical Protocols

METHYLPREDNISOLONE (SOLU-MEDROL) Class

Glucocorticoid Mechanism of Action

Methylprednisolone is a synthetic steroid that suppresses acute and chronic

inflammation. In addition, it potentiates vascular smooth muscle relaxation by beta-

adrenergic agonists and may alter airway hyperactivity. A newer usage is for

reduction of posttraumatic spinal cord edema

Indications Anaphylaxis Bronchodilator for unresponsive asthma Shock (controversial) Acute spinal cord injury Protocol: COPD/Asthma, Anaphylaxis

Contraindications Use with caution in patients with, immuno-suppressed systems, GI bleeding and

diabetes mellitus. Adverse Reactions

Headache Hypertension Sodium and water retention Hypokalemia Alkalosis


125mg IV/IM

Pediatric:

2mg/kg IV/IM Max dose of 125 mg

Duration of Action Onset: 1-2 hrs Duration: 8-24 hr

Special Considerations/Drug Interactions Crosses the placenta and may cause fetal harm.

Ensure that the patient is not currently ill (pneumonia) or is currently taking

steroids.


Medical Protocols

MIDAZOLAM (VERSED) Class

Short-acting benzodiazepine CNS depressant Mechanism of Action

Midazolam HCl is a water-soluble benzodiazepine that may be administered for conscious sedation to relieve apprehension or impair memory before endotracheal or nasotracheal intubation.

Indications Premedication for tracheal intubation Seizures Protocols: Rapid sequence intubation, seizures, anxiety, behavioral, sedation prior

to cardioversion Contraindications

Hypersensitivity to Midazolam Glaucoma Shock Depressed vital signs Concomitant use of barbiturates, alcohol, narcotics, or other CNS depressants

Adverse Reactions Cough and/or hiccups Over-sedation Nausea and vomiting Headache and/or blurred vision Fluctuations in vital signs including hypotension Respiratory depression and/ or arrest


Anxiety: 1-2 mg IV/IM/IN RSI: 5mg IV/IM/IN, May Repeat X 1 Seizures, behavioral: 5mg IN/IV/IM, May repeat x 1 Excited Delirium: 10 mg/IV/IM

Pediatric: Seizures: 0.1 mg/kg IN/IV/IM Max 5mg Sedation: 0.1mg/kg Max 2mg

Duration of Action Onset: 1-3 min (IV); dose dependent Duration: 2-6 hr; dose dependent

Special Considerations/Drug Interactions Sedative effect of midazolam may be accentuated by concomitant use of

barbiturates, alcohol, or narcotics (it should therefore not be used in patients who have taken CNS depressants).

Administer immediately before the intubation procedure.


Medical Protocols

MORPHINE SULFATE Class

Opioid analgesic Mechanism of Action

Morphine sulfate is a natural opium alkaloid that increases peripheral venous capacitance and decreases venous return ("chemical phlebotomy"). It promotes analgesia, euphoria, and respiratory and physical depression. Secondary pharmacological effects of morphine include depressed responsiveness of alpha-adrenergic receptors (producing peripheral vasodilation) and baroreceptor inhibition. In addition, because morphine decreases both preload and afterload, it may decrease myocardial oxygen demand.

Indications Moderate to severe acute and chronic pain

Should be used with caution with pulmonary edema Protocol: pain management

Contraindications Hypersensitivity to narcotics Diarrhea caused by poisoning Hypovolemia Hypotension

Adverse Reactions Hypotension, tachycardia, bradycardia, palpitations, syncope, facial flushing,

respiratory depression, euphoria, bronchospasm, dry mouth Dosage and Administrations

Adult: 2-5 mg every 5 minutes Max 10 mg

Pediatric 0.1 mg/kg Max 5mg

Duration of Action Onset: Immediate Duration: 2-7 hr

Special Considerations/Drug Interactions CNS depressants may potentiate effects of morphine (respiratory depression,

hypotension, sedation). MAOl’s may cause paradoxical excitation. Narcotics rapidly cross the placenta. Use with caution in older adults, those with

asthma, and those susceptible to CNS depression. May worsen bradycardia or heart block in inferior myocardial infarction (vagotonic effect). Naloxone should be readily available.


Medical Protocols

NALOXONE (NARCAN) Class

Synthetic opioid antagonist Mechanism of Action

Naloxone is a competitive narcotic antagonist used in the management and reversal of overdoses caused by narcotics and synthetic narcotic agents. Unlike other narcotic antagonists, which do not completely inhibit the analgesic properties of opiates, naloxone antagonizes all actions of morphine.

Indications Decreased level of consciousness Coma of unknown origin For the complete or partial reversal of CNS and respiratory depression induced by

opioids: Narcotic agonist : Morphine sulfate, Heroin, Hydromorphone (Dilaudid), Methadone , Meperidine (Demerol) , Paregoric, Fentanyl citrate (Sublimaze), Oxycodone (Percodan), Codeine, Propoxyphene (Darvon)

Narcotic agonist and antagonist: Butorphanol tartrate (Stadol), Pentazocine (Talwin), Nalbuphine (Nubain)

Protocol: Overdose Contraindications

Hypersensitivity Adverse Reactions

Tachycardia and/or dysrhythmias Hypertension Nausea and vomiting Diaphoresis


0.4mg IV/IM/IN, Max of 2 mg Duration of Action

Onset: Within 2 min Duration: 30-60 min

Special Considerations/Drug Interactions Seizures have been reported (no causal relationship established). May not reverse hypotension. Caution should be exercised when administering

naloxone to narcotic addicts (may precipitate withdrawal with hypertension, tachycardia, and violent behavior).


Medical Protocols

NITROGLYCERIN Class

Vasodilator Mechanism of Action

It is now believed that atherosclerosis limits coronary dilation and that the benefits of nitrates and nitrites result from dilation of arterioles and veins in the periphery. The resulting reduction in preload and to a lesser extent in afterload decreases the work load of the heart and lowers myocardial oxygen demand. Nitroglycerin is very lipid soluble and is thought to enter the body from the GI tract through the lymphatics rather than the portal blood.

Indications Ischemic chest pain Congestive heart failure(CHF) Protocol: Acute coronary syndrome(ACS) , CHF

Contraindications Hypersensitivity Hypotension Do not administer NTG to male patients who have taken medication for erectile

dysfunction in the previous 48 hours. The combination of these meds with NTG may produce profound hypotension or cardiac arrest.

Adverse Reactions Transient headache Postural syncope Reflex tachycardia Hypotension Nausea and vomiting Muscle twitching Diaphoresis


ACS: 0.4 mg metered dose every 5 minutes until systolic BP of > 90 CHF: 0.4mg every 3 minutes x 5 Hypertension: 0.4mg X3

Duration of Action Onset:1-3 min Duration:20-30 min

Special Considerations/Drug Interactions Nitroglycerin decomposes when exposed to light or heat.


Medical Protocols

NOREPINEPHRINE (LEVOPHED) Class

Sympathomimetic

Mechanism of Action Norepinephrine alpha- and beta1-adrenergic receptors in dose-related fashion. It is

the initial drug of choice for treating hypotension refractory to IV fluids in the setting of sepsis. Continuous IV infusion results in increased contractility and heart rate as well as vasoconstriction, thereby increasing systemic blood pressure and coronary blood flow. Clinically, alpha effects (vasoconstriction) are greater than beta effects (inotropic and chronotropic effects).

Indications Hypotension refractory to 2L of IV fluids in the setting of sepsis Protocol: Hypotension

Contraindications Hypersensitivity Hypertension

Adverse Reactions

Headache, nausea, restlessness, weakness, dysrhythmias, hypertension Dosage and Administrations

Adult: Hypotension – 2-12 mcg/min NOTE: NOT WEIGHT BASED INFUSION Pediatric: Not used in prehospital setting due to need for extremely low

weight-based dose (0.05-0.1 mcg/kg/min) Special Considerations/Drug Interactions

Now considered first line vasoactive agent for septic shock, as dopamine was found

in a large clinical trial to have an unacceptably high occurrence of dysrhythmias

Large doses have been described in clinical trials 0.01-3 mcg/kg/minute

(0.7 to 200 mcg/min)


Medical Protocols

ONDANSETRON (ZOFRAN) Class

Antiemetic, Serotonin Receptor Antagonist, 5-HT3 Mechanism of Action

Antiemetic - The mechanism by which ondansetron works to control nausea and vomiting is not fully understood; it is believed that the antiemetic properties occur as a result of serotonin receptor antagonism.

Indications Nausea and vomiting due to chemotherapy. Prophylactic use prior to administration of pain management medication. Nausea and vomiting with moderate to severe dehydration or electrolyte imbalance. Protocol: nausea including nausea in a CVA patient

Contraindications History of allergic reaction to ondansetron or to any medicine similar to ondansetron,

including dolasetron (Anzemet), granisetron (Kytril), or palonosetron (Aloxi). Adverse Reactions

Constipation, diarrhea, dry mouth Headache, dizziness, drowsiness/sedation Anaphylaxis (rare) Fatigue, malaise, chills Cardiac dysrhythmia (rare), hypotension Bronchospasm Muscle pain


4mg IV/IM, may repeat X1 Pediatric:

6 months to 4 years: 2 mg IV/IM Greater than 4 years: 4 mg IV/IM

Duration of Action Onset: Immediate Duration 4-6 hours

Special Considerations/Drug Interactions Patients with a history, or family history, of Long QT syndrome; transient EKG changes

have been seen with IV administration including QT interval prolongation.


Medical Protocols

ORAL GLUCOSE Class

Monosaccharide Carbohydrate Mechanism of Action

After absorption of glucose in the GI tract, glucose is distributed in the tissues and provides a prompt increase in circulating blood sugar

Indications Hypoglycemic conscious pt w/ altered mental status

Protocol: Diabetic emergencies Contraindications

Unconscious

Patient hasn't taken insulin for days Adverse Reactions

Nausea Dosage and Administrations

Adult and Pediatric: 15 grams PO SL Preferred method of administration is between the cheek and gums

Duration of Action Onset: 15 minutes

Special Considerations/Drug Interactions Assure patient has the capabilities of swallowing and maintaining an airway Ensure that a BGL is checked prior to administration of Glucose in all patients,

especially ones that may have a suspected head injury Reassess BGL after administration of Glucose


Medical Protocols

OXYGEN Class

Naturally occurring atmospheric gas Mechanism of Action

Oxygen is odorless, tasteless, colorless gas that is present in room air at a concentration of about 21%. It helps oxidize glucose to produce ATP (Adenosine triphosphate).

Indications Confirmed or suspected hypoxia Ischemic chest pain Respiratory insufficiency Prophylatically during air transport Confirmed or suspected carbon monoxide poisoning and other causes of decreased

tissue oxygenation Protocol: Universal treatment guidelines

Contraindications Oxygen should not be withheld from any patients, even those with COPD.

Adverse Reactions High flow oxygen may cause decreased LOC and respiratory depression in patients

with COPD Dosage and Administrations

Adult and Pediatric: High concentration: 10-15 lpm via nonrebreather mask Low concentration: 1-4 lpm via nasal cannula Nebulizer: 8 lpm

Duration of Action Onset: Immediate Duration: less than 2 minutes

Special Considerations/Drug Interactions Oxygen vigorously supports combustion


Medical Protocols

ROCURONIUM

Class Non depolarizing neuromuscular blocker

Mechanism of Action Rocuronium bromide is a non-depolarizing skeletal muscle relaxant. Binding with

cholinergic receptor sites inhibits transmission of nerve impulses, antagonizing the action of acetylcholine. Has no analgesic properties and the patient maybe conscious, but unable to communicate by any means.

Indications

To maintain complete muscle relaxation with an intubated patient Protocol: rapid sequence intubation


Adverse Reactions Causes respiratory paralysis; supportive airway control must be continuous and under

direct observation at all times. Dosage and Administrations

Adult: 50mg IV

Pediatric: 1mg/kg (max 50mg)

Duration of Action Onset: 1-2 minutes Peak: 4 minutes Duration: 30 minutes

Special Considerations/Drug Interactions Myasthenia gravis and other neuromuscular diseases increase sensitivity to the drug.


Medical Protocols

SODIUM BICARBONATE Class

Buffer Mechanism of Action

Sodium bicarbonate reacts with hydrogen ions to form water and carbon dioxide and thereby can act to buffer metabolic acidosis. Increasing the plasma concentration of bicarbonate causes blood pH to rise.

Indications Tricyclic antidepressant (TCA) overdose Alkalinization for treatment of specific intoxications Protocol: Hyperkalemia, Crush injury

Contraindications In patients with chloride loss from vomiting and Gl suction Metabolic and respiratory alkalosis Hypocalcemia Hypokalemia

Adverse Reactions Metabolic alkalosis Hypoxia Rise in intracellular Pco2 and increased tissue acidosis Electrolyte imbalance (tetany) Seizures Tissue sloughing at injection site


Hyperkalemia/Crush injury: 50- 100mEq TCA: 50-100 mEq

Duration of Action Onset: 2-10 min Duration: 30-60 min

Special Considerations/Drug Interactions May precipitate in calcium solutions. Vasopressors may be deactivated. Bicarbonate administration produces carbon dioxide, which crosses cell membranes

more rapidly than bicarbonate, potentially worsening intracellular acidosis. May increase edematous or sodium-retaining states. May worsen congestive heart failure.


Medical Protocols

THIAMINE Class

Vitamin (B1) Mechanism of Action

Thiamine combines with ATP to form thiamine pyrophosphate coenzyme, a necessary component for carbohydrate metabolism. Most vitamins required by the body are obtained through diet, but certain states, such as alcoholism and malnourishment, may affect the intake, absorption, and use of thiamine. The brain is extremely sensitive to thiamine deficiency.

Indications Coma of unknown origin (before the administration of dextrose 50%, or Naloxone) Delirium tremens Beriberi (rare) / Wernicke's encephalopathy Protocol: Diabetic emergencies

Contraindications There are no significant drug interactions with other emergency medications

Adverse Reactions Hypotension (from rapid injection or large dose) Anxiety Diaphoresis Nausea and vomiting Allergic reaction (usually from IV injection; very rare)

Dosage and Administrations Adult: 100mg IV/IM

Duration of Action Onset: Rapid Duration: variable

Special Considerations/Drug Interactions Large IV doses may cause respiratory difficulties. Anaphylactic reactions have been reported.


Medical Protocols

VECURONIUM Class

Non depolarizing neuromuscular blocker Mechanism of Action

Vecuronium bromide is a non-depolarizing skeletal muscle relaxant. Binding with cholinergic receptor sites inhibits transmission of nerve impulses, antagonizing the action of acetylcholine. Has no analgesic properties and the patient maybe conscious, but unable to communicate by any means. First muscles affected include eyes, face, neck; followed by limbs, abdomen, chest; diaphragm affected last. Recovery usually occurs in the reverse order and may take longer than 60 minutes.

Indications

To maintain general anesthesia with an intubated patient Protocol: rapid sequence intubation


Adverse Reactions Causes respiratory paralysis; supportive airway control must be continuous and under

direct observation at all times. Dosage and Administrations

Adult: 10mg IV

Pediatric: 0.1mg/kg (max 10mg)

Duration of Action Onset: 30-60 seconds Peak: 3-5 minutes Duration: 30-60 minutes

Special Considerations/Drug Interactions Myasthenia gravis and other neuromuscular diseases increase sensitivity to the drug.

GAAA DAILY AMBULANCE CHECK LIST


911 Date __________________________

Truck # ________________________

Medic # ________________________

Personnel Printed Name

_______________________________


_______________________________

Supervisor _____________________

Tough Book # __________________

( ) Engine Oil Level

( ) Radiator Level

( ) Transmission Fluid

( ) Tires

Safety Sticker Expiration ________

Insurance Card Expiration________

DHSH Cert. Expiration __________

( ) GAAA Protocols - 1

( ) Emergency Response Guide - 1

( ) Triage Tags - 25

( ) Mounted Fire Extinguisher - 1

( ) Key Map Book – 1

( ) Flashlight - 1

EKG Monitor#__________ (MICU)

( ) Data Cable – (E-series) - 1

( ) USB thumb drive – (X-series) - 1

( ) V-Leads - 1

( ) Limb Leads - 1

( ) Electrodes - 1 pack

( ) Multi-function Pads Adult - 1

( ) Multi-function Pads Pedi – 1

( ) Capnography NC (Adult and Pedi ) –

1ea

Capnography ETT (Adult & Pedi) – 1ea

( ) Additional Battery - 1

NarcKit – MICU’s / M10

[ ] Diazepam 20mg x 1

[ ] Fentanyl 100mcg x 2

[ ] Versed 5 mg x 4

[ ] Morphine 10mg x 1

[ ] Geodon 20mg x 1

( ) Carpujet - 1

( ) MADD Nasal Atomizer – 1

( ) Knocks box key-1 (M-1,2,3,4 only)

( ) CPAP # _____________________

( ) CPAP Circuit - 1

( ) Portable Suction # ____________

( ) Disposable Canister - 1

( ) Suction Tubing – 1

( ) Yankuer – 1

( ) Suction Cath (6fr & 14fr) – 1ea

( ) ET Roll

( ) Laryngoscope Handle – 1

( ) Mac Blades-(1, 2, 3, 4) - 1ea

( ) Miller Blades-(0, 1, 2, 3, 4) -1ea

( ) ET Tubes-(2.5, 3, 3.5, 4, 5, 6, 6. 5, 9) -

1 ea

( ) ET Tubes (7.0, 7.5, 8.0) – 2 ea

( ) Stylet – (6fr, 10fr, 14fr) -1 ea

( ) ET Tube Holder / Ties – 1

( ) Capnography ETT (Adult & Pedi) – 1ea

( ) OPA’s (5 sizes) – 1 set

( ) Adult Magill Forceps – 1

( ) Pediatric Magill Forceps – 1

( ) Bougie ETT Introducer – 1

( ) ETT Tamer/Ties (Adult and Pedi) –

1 ea

( ) Surgilube - 1

( ) Syringe 10cc – 1


( ) C Batteries – 2

( ) Airway Bag

Oxygen Cylinder _____________psi

( ) CPAP Quick Connect – 1

( ) BVM (Adult, Child, Infant) - 1 ea

( ) ET Roll – 1

( ) King Tube (Sizes 3, 4, 5) – 1ea

( ) Quick Tach – 1

( ) Needle Decompression Kit - 1

( ) NRB Adult – 2

( ) NRB Pediatric - 1

( ) Nasal Cannula – 2

( ) Nebulizer - 1

( ) Hemostat – 1

( ) BP Cuff (Lg & Reg Adult, Child) 1ea

King Vision # ___________________

( ) King Vision Blade - 1

( ) Stethoscope – 1

( ) Pen Light - 1

( ) Trauma Shears – 1

( ) Kerlix Roll – 2

( ) Ace Wrap - 1

( ) Occlusive Dressing – 2

( ) 4 x 4 sterile – 4

( ) Triangular Bandage - 2

( ) Sam Splint - 1

( ) N95 Mask – 3

( ) Medication Kit

EZ IO Drill #___________________

( ) IO Needles (15, 25, 45mm) - 1ea

( ) Broselow Tape - 1

( ) IV Caths (16, 18, 20,22,24ga) 2ea

( ) Needles (20ga) - 2



( ) Syringe 10cc –3

( ) Tape 1” – 2

( ) Paper tape 1” - 1

( ) Alcohol Preps – 5

( ) Beta Dine Preps - 2

( ) Non sterile 4x4 - 10

( ) Saline Locks – 5

( ) Saline 10cc vial/syringe – 5

( ) Saline Bags (250 & 500 or 1000cc) –

1ea

( ) Select 3 Drip Sets – 1

( ) Glucometer – 1

( ) Strips and Lancets – 6 ea

Unit Equipment

Main O2 Cylinder ____________psi

Stretcher # _____________________

Stair chair # ____________________

Combi-Board or Scoop #-____________

( ) KED

( ) Sager Splint

( ) Air Splint(Sm, Med, Lg, & Torso)

( ) Air Splint Pump - 1

( ) Portable O2 - 3

( ) Traffic Safety Vest – 3

( ) Reflector Kit - 1

( ) Child seat (optional) – 1

( ) Back boards – 2

( ) Backboard webbing - 1

( ) C-Collars Adult – 6

( ) C-Collars (Pedi & Infant) – 4 ea

( ) Head Rolls – 6

( ) 2inch backboard tape – 1

( ) BP Cuff (Thigh, Lg. Adult, Reg.

Adult, Child, Infant) – 1ea


( ) ET Roll – 1

( ) AAA Batteries – 3

( ) King Vision Blade - 1

( ) ETT holder/Tie – 1

( ) ETCO2 detector ET tube -1

( ) ETCO2 detector ET tube -1

( ) Capnography NC Adult – 4


( ) NRB- Adult –5

( ) NRB – Pedi & Infant – 2 ea

( ) NC – 5

( ) Nebulizer – 5

( ) Yankuer/Suction Tubing - 3

( ) Suction Canister – 1 wall & 1 extra

( ) NGT- 18fr – 2

( ) Suction catheters (14fr & 6fr) 2ea

( ) EKG Electrodes - 1 pk


( ) Multi-function Pads Pedi - 1

( ) ECG Paper - 1

( ) OB Kit – 2



911 Unit Equipment Continued…

( ) Foil Blanket - 1

( ) Burn Sheet - 2

( ) Trauma Dressing – 2

( ) Abdominal Pads - 2

( ) Alcohol Preps – 1 bx

( ) Iodine Preps – 3

( ) Band Aids – 1 bx

( ) Bacitracin – 5 pk

( ) Tape – 1” – 4

( ) Paper Tape - 1

( ) Sterile Water - 2

( ) Rubbing Alcohol - 1

( ) Triangular Bandages - 4

( ) Kerlix – 4

( ) Ace Wrap – 2

( ) Commercial Tourniquet - 1

( ) Occlusive Dressing - 4

( ) 4x4 Sterile – 1 bx

( ) 4x4 Non sterile – 1 pk

( ) Cold packs- 5

( ) Hot Packs – 5


( ) Ring Cutter - 1

( ) Glucometer Strips – 10

( ) Lancets – 6

( ) Ammonia Inhalants – 5

( ) Select 3 – 6

( ) Buretrol set – 1

( ) Dial-a-flow-1


( ) Saline 50cc bag – 2


( ) Saline 500 or 1000cc bag – 6

( ) IV catheter (16, 18, 20) -6 ea

( ) IV catheter (22, 24) – 2 ea

( ) Needle 20ga – 5

( ) IO 15ga – 1

( ) Syringe 1cc- 2

( ) Syringe 3 cc – 5



( ) Sharps Container Lg – 1

( ) Sharps Container Sm – 1

( ) Biohazard Bags – 2

( ) Trash Bags – 2

( ) N95 Mask – 4

( ) Gowns- 4

( ) Safety Glasses- 3

( ) Gloves (Sm, Med, Lg, X-Lg) -1bx

( ) Hand Sanitizer – 1

( ) Cavicide Wipes/Spray- 1

( ) Thermometer

( ) Peroxide-1 btl

( ) stuffed animal x2

( ) odor neutralizer x1

MEDICATIONS

KIT UNIT

Activated Charcoal 50g [ ] x 1

[ ] x 5 Adenosine 6mg [ ] x 5

[ ] x 3 Albuterol 2.5mg [ ] x 6

[ ] x 2 Amiodarone 150mg [ ] x 4

Ancef (Cefazolin) 1g [ ] x 2

[ ] x 1 Aspirin 81mg - 1 btl [ ] x 1

[ ] x 3 Atropine 1mg [ ] x 3

[ ] x 1 Dextrose 50% 25g [ ] x 1

[ ] x 1 Diltiazem 25mg [ ] x 2

(Keep in cooler if available)________

[ ] x 1 Diphenhydramine 50mg [ ] x 1

[ ] x 1 Calcium Gluc. 10ml [ ] x 1

[ ] x 1 Enalaprilat 2.5mg [ ] x 1

[ ] x 1 Epinephrine (1:1) 1mg [ ] x 1

[ ] x 6 Epinephrine (1:10) 1mg [ ] x 6

[ ] x 1 Etomidate 20mg [ ] x 1

[ ] x 1 Glucose Oral 15g [ ] x 1

[ ] x 2 Ipratropium 0.5 mg [ ] x 3

[ ] x 1 Labetalol 40mg [ ] x 1

[ ] x 1 Lidocaine 2% 100mg [ ] x 1

[ ] x 2 Magnesium Sulfate 1g [ ] x 2

[ ] x 1 Narcan 2mg [ ] x 1

[ ] x 1 Nitroglycerin Spray Btl [ ] x 1

[ ] Norepinephrine 4mg [ ] x2

[ ] x 1 Ondansetron 4mg [ ] x 2

[ ] x 2 Sodium Bicarb 50mEq [ ] x 2

MEDICATIONS

KIT UNIT

[ ] x 1 Solu-Medrol 125mg [ ] x 1

[ ] x 1 Succinylcholine 200mg [ ] x 1

(Keep in cooler if available)________

[ ] x 1 Thiamine 200mg [ ] x 1

[ ] x 1 Vecuronium 10mg or [ ] x 1 Rocuronium 100mcg [ ] x1

(Keep In cooler if available_________)



NET Date __________________________

Truck # ________________________

Medic # ________________________


_______________________________


_______________________________

Supervisor _____________________

( ) Tough Book # ________________

( ) Engine Oil Level

( ) Radiator Level

( ) Transmission Fluid

( ) Tires

Safety Sticker Expiration ________

Insurance Card Expiration________

DHSH Cert. Expiration __________

( ) GAAA Protocols -1

( ) Emergency Response Guide - 1

( ) Triage Tags - 25

( ) Mounted Fire Extinguisher -1

( ) Key Map Book – 1

( ) Flashlight - 1

EKG Monitor/AED#_____________

( ) Data Cable - 1

( ) V-Leads - 1

( ) Limb Leads - 1

( ) Electrodes - 1 pack



( ) Additional Battery - 1

NarcKit – MICU’s / M10

[ ] Diazepam 10mg x 1

[ ] Fentanyl 100mcg x 2

[ ] Versed 5 mg x 4

[ ] Morphine 10mg x 1

[ ] Geodon 20mg x 1

( ) Carpujet - 1

( ) MADD Nasal Atomizer – 1

( ) Knoks box key1 (medic 10 only)

( ) CPAP # _____________________

( ) CPAP Circuit - 1

( ) Portable Suction # ____________

( ) Disposable Canister - 1

( ) Suction Tubing – 1

( ) Yankuer – 1

( ) Suction Cath (6fr & 14fr) – 1ea

( ) ET Roll

( ) Laryngoscope Handle – 1

( ) Mac Blades-(1, 2, 3, 4) - 1ea

( ) Miller Blades-(0, 1, 2, 3, 4) -1ea

( ) ET Tubes-(2.5, 3, 3.5, 4, 5, 6, 6.5, 9) - 1

ea

( ) ET Tubes (7.0, 7.5, 8.0) – 2 ea

( ) Stylet – (6fr, 10fr, 14fr) -1 ea

( ) ET Tube Holder / Ties – 1

( ) CO2 detector (Adult & Pedi) – 1ea

( ) OPA’s (5 sizes) – 1 set

( ) Adult Magill Forceps – 1

( ) Pediatric Magill Forceps – 1

( ) Bougie ETT Introducer - 1

( ) Surgilube - 1



( ) C Batteries – 2

( ) Airway Bag

Oxygen Cylinder _____________psi

( ) CPAP Quick Connect – 1


( ) ET Roll – 1

( ) King Tube (Sizes 3, 4, 5) -1

( ) Quick Trach - 1

( ) Needle Decompression Kit - 1

( ) NRB Adult – 1

( ) NRB Pediatric - 1

( ) Nasal Cannula – 2

( ) Nebulizer - 1

( ) BP Cuff (Lg & Reg. Adult) 1ea


( ) Pen Light - 1


( ) Kerlix Roll – 1

( ) Occlusive Dressing – 2

( ) 4 x 4 sterile – 2

( ) Triangular Bandage -2

( ) Sam Splint - 1

( ) N95 Mask – 3

( ) Medication Kit

EZ IO Drill #_________________

( ) IO Needles (15, 25, 45mm) - 1ea

( ) Broselow Tape - 1

( ) IV Caths (16, 18, 20, 22,24ga) 2ea

( ) Needles (20ga) – 2 ea




( ) Tape 1” – 2

( ) Paper Tape 1” - 1

( ) Alcohol Preps – 5

( ) Beta Dine Preps - 2

( ) Non sterile 4x4 - 5

( ) Saline Locks – 2


( ) Saline Bags (250cc & 500 or 1000cc)

1ea

( ) Select 3 Drip Sets – 1

( ) Glucometer – 1

( ) Strips and Lancets – 4 ea

Unit Equipment

Main O2 Cylinder ____________psi

Unit Equipment Continued…

Stretcher # _______________________

Stair chair # _______________________

Combi-Board or Scoop #____________

( ) KED

( ) Sager Splint

( ) Air Splint(Sm, Med, Lg, & Torso)

( ) Air Splint Pump - 1

( ) Portable O2 - 2

( ) Traffic Safety Vest – 3

( ) Reflector Kit - 1

( ) Child seat (optional) – 1

( ) Back boards – 1

( ) Backboard webbing - 1

( ) C-Collars Adult – 4

( ) C-Collars (Pedi and Infant) – 2 ea

( ) Head Rolls – 4

( ) 2inch backboard tape – 1

( ) BP Cuff (Thigh, Lg. Adult, Reg. Adult,

Child, Infant) – 1ea



( ) NRB- Adult – 3

( ) NRB – Pedi & Infant – 2 ea

( ) NC –3

( ) Nebulizer – 2

( ) Yankuer/Suction Tubing - 1

( ) Suction Canister – 1 wall

( ) NGT- 18fr – 1

( ) Suction catheters (14fr & 6fr) 1ea

( ) EKG Electrodes - 1 pk



( ) ECG Paper - 1

( ) OB Kit – 1

( ) Foil Blanket - 1

( ) Burn Sheet - 1

( ) Trauma Dressing – 1

( ) Abdominal Pads - 2

( ) Alcohol Preps – 1 bx

( ) Iodine Preps – 3

( ) Band Aids – 1 bx

( ) Bacitracin – 5 pk

( ) Tape – 1” – 2

( ) Paper Tape - 1

( ) Sterile Water - 1

( ) Rubbing Alcohol - 1

( ) Triangular Bandages - 2

( ) Kerlix –2

( ) Ace Wrap – 1

( ) Commercial Tourniquet - 1

( ) Occlusive Dressing - 2

( ) 4x4 Sterile – 1 bx



NET Unit Equipment Continued…

( ) 4x4 Non sterile – 1 pk

( ) Cold packs- 5

( ) Hot Packs – 5


( ) Ring Cutter - 1

( ) Thermometer -1

( ) Glucometer Strips – 5

( ) Lancets – 5

( ) Ammonia Inhalants – 2

( ) Select 3 – 2

( ) Buretrol set – 1

( ) Dial a Flow-1


( ) Saline 50cc bag –1


( ) Saline – 500 or 1000cc bag –2

( ) IV cath (16, 18, 20, 22, 24) -2 ea

( ) Needle 20ga –2

( ) IO 15ga – 1

( ) Syringe 1cc- 1

( ) Syringe 3 cc – 1


( ) Syringe 30cc –1

( ) Sharps Container Lg – 1

( ) Sharps Container Sm – 1

( ) Biohazard Bags – 2

( ) Trash Bags – 2

( ) N95 Mask – 4

( ) Gowns- 4

( ) Safety Glasses- 3

( ) Gloves (Sm, Med, Lg, X-Lg) -1bx

( ) Hand Sanitizer – 1

( ) Cavicide Wipes/Spray- 1

( ) SLIPP

( ) Peroxide-1 btl

( ) Stuffed animal x2

( ) odor neutralizer x1

MEDICATIONS- KIT ONLY

[ ] Activated Charcoal 50g x 1

[ ] Adenosine 6mg x 6

[ ] Albuterol 2.5mg x 6

[ ] Amiodarone 150mg x 4

[ ] Ancef (Cefazolin) 1g x 2

[ ] Aspirin 81mg - 1 bottle

[ ] Atropine 1mg x 3

[ ] Dextrose 50% 25g x 2

[ ] Diltiazem 25mg x 2

(Keep in cooler if available)

[ ] Diphenhydramine 50mg x 1

[ ] Calcium Gluconate 10ml x 2

MEDICATIONS - KIT ONLY

[ ] Enalaprilat 2.5mg x 1

[ ] Epinephrine (1:1) 1mg x 1

[ ] Epinephrine (1:10) 1mg x 6

[ ] Etomidate 20mg x 2

[ ] Glucagon 1mg – 10 x 2

[ ] Glucose Oral 15g x 2

[ ] Ipratropium 0.5 mg x 3

[ ] Labetalol 40mg x 1

[ ] Lidocaine 2% 100mg x 1

[ ] Magnesium Sulfate 1g x 4

[ ] Narcan 2mg x 1

[ ] Nitroglycerin Spray Btl x 1

[ ] Ondansetron 4mg x 2

[ ] Sodium Bicarb 50mEq x 2

[ ] Solu-Medrol 125mg x 1

[ ] Succinylcholine 200mg x 1

(Keep In cooler if available)

[ ] Thiamine 200mg x 1

[ ] Vecuronium 10mg x 1

Galveston Area Ambulance Authority Medical Protocols

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Transcript of Galveston Area Ambulance Authority Medical Protocols