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[FIRST RESPONDER PROTOCOLS] [These Protocols are for all Fire Departments that are associated with Cheatham County that provide First Responder Service to the stakeholders of their prospective zones or when providing mutual aid to another department.]

Cheatham County Emergency Medical Services

Emergency Medical Technician

& Emergency Medical Responder

Protocols May 2014

EMR & EMT First Responder Protocols Page 1 of 41

TABLE OF CONTENTS INTRODUCTION……………………………………………………………………………………….. 2 FIRST RESPONDER GENERAL ORDERS…………………………………………………………. 3 AIRWAY, CIRCULATION. AND ILLNESS Altered Mental Status……………………………………………………………………………4 Behavioral Emergency…………………………………………………………………………..5 Cardiac Compromise…………………………………………………………………………….6 AED……………………………………………………………………………………………..7-8 Heat Exposure……………………………………………………………………………………9 Hypothermia…………………………………………………………………………………….10 Local Cold Emergencies……………………………………………………………………….11 Respiratory Emergencies……………………………………………………………………...12 Seizures…………………………………………………………………………………………13 INJURY External and Internal Bleeding………………………………………………………………. 14 Bone or Joint Injuries…………………………………………………………………………...15 Burns…………………………………………………………………………………………….. 16 Head Injuries……………………………………………………………………………………. 17 Shock (Hypoperfusion)………………………………………………………………………… 18 Specific Traumatic Injuries……………………………………………………………………..19 Spine Injuries…………………………………………………………………………………… 20 CHILDBIRTH, CHILDREN, AND GERIATRICS Childbirth…………………………………………………………………………………….21-22 Assessment of Infants and Children (PAT)………………………………………………….23 Common Problems in Infants and Children……………………………………………...24-26 Geriatric Emergencies…………………………………………………………………………27 Abuse and Neglect……………………………………………………………………………..28 Physician Orders of Scope of Treatment POST…………………………………………….29 APPENDICES Appendix 1: POST Form………………………………………………………………………..30-31 Appendix 2: Normal Vital Signs……………………………………………………………………32 Appendix 3: Oxygen Delivery………………………………………………………………………33 Appendix 4: Documentation………………………………………………………………………..34 Appendix 5: START Triage…………………………………………………………………………35 Appendix 6: Common Medical Abbreviations…………………………………………………….36 Appendix 7: Pediatric Assessment Quick Reference Chart…………………………………….37 Appendix 8: APGAR Scale…………………………………………………………………………38 Appendix 9: Glucose, Aspirin, & Nitroglycerin (EMT)……………………..…………………….39 Appendix 10: Albuterol & Epinephrine (EMT)……………..……………………………………….40 Appendix 11: Document History…………………………………………………………………….41


INTRODUCTION These protocols were developed by Cheatham County EMS based on the DOT Emergency Medical Responder (EMR) and Emergency Medical Technician (EMT) Curriculum. They represent the consolidation of medical procedures for emergency pre-hospital patient care from many local and national sources. The term “Role of the First Responder” applies to EMR’s and EMT’s. No person may provide any treatment for which they are not trained to provide AND for which they are not certified by the Tennessee Department of Health at the EMR or EMT Level. The assessment information in the General Orders is intended to be considered with all protocols. In addition, the General Medical Assessment should be considered with all medical protocols, the General Trauma Assessment should be considered with all trauma protocols, and the Pediatric Assessment should be considered with all pediatric protocols. These protocols are intended to: 1. Provide direction for the use of appropriate emergency medical care procedures, based on the DOT EMR curriculum training modules to be used by certified EMR personnel while working under the direction of the Cheatham County EMS and the Medical Director. Cheatham County Fire Departments may also utilize the EMR & EMT treatments as long as the personnel are licensed in the state of Tennessee as an EMR or EMT and are members in good standing with the Cheatham County Fire Departments. Any Advanced Emergency Medical Technician (AEMT) or Paramedic with the Cheatham County Fire Departments may function to level of their license since this is the highest equipped first responder level of the Cheatham County Fire Departments. The AEMT and Paramedic First Responders will follow the current Cheatham County EMS Protocols. 2. Provide the standardization of medical first response in Cheatham County; 3. Provide Cheatham County EMS personnel, base hospital physicians and nurses with an understanding of what aspects of patient care have been stressed to First Responders and what their treatment capabilities may be; 4. Provide First Responder personnel with a framework for pre-hospital care; and 5. Provide the basic framework on which Medical Control can conduct quality improvement programs. 6. They are not intended to interfere with the wishes of the patient or family. 7. The protocols within this document are intended to be used as a guideline for the treatment of the sick and injured by state certified First Responders working or volunteering for CCEMS or Cheatham County Fire Departments. They will be reviewed annually and approved by the following signatories. The protocols enclosed may be utilized as standing orders.


FIRST RESPONDER GENERAL ORDERS I. Complete the EMR/EMT Assessment

A. Scene size-up/assessment 1. Ensure body substance isolation per agency exposure control program. 2. Secure scene safety.

B. Initial patient assessment 1. Evaluate alertness (responds to verbal stimulus, responds to painful stimulus, unresponsive) 2. Assess Airway — Breathing - Circulation. (If POST form intact, follow protocol for POST, see page 29-31.)

C. Physical exam 1. Perform patient and injury specific examination. 2. Perform physical examination. 3. Protect the patient’s modesty and privacy.

D. History - SAMPLE 1. Record all pertinent information.

2. Include information such as signs and symptoms, allergies, medications, past pertinent medical history, last oral intake, and events leading to illness or injury.

E. Ongoing assessment 1. Repeat and record Initial patient assessment, including time 2. Reassess mental status. 3. Maintain open airway and monitor breathing for rate and quality. 4. Reassess pulse for rate and quality. 5. Monitor skin color and temperature. 6. Re-establish patient priorities. 7. Reassess and record vital signs, include time. 8. Repeat first responder physical exam pertaining to patient complaint or injuries. 9. Check interventions. 10. Comfort, calm, and reassure the patient. II. Communications

A. Radio report to next level of care 1. Identify EMS service unit. 2. Identify patient’s age, sex, and primary complaint or problem. 3. Identify physical assessment findings, including, vital signs and level of consciousness. 4. Identify pertinent history as needed to clarity problem (medications, illnesses, allergy, mechanism of injury). 5. Identify treatment given and patient’s response.

B. Verbal and written report (See page 35.) 1. Provide verbal report to next level of care. 2. Provide written report.

C. Consider critical incident stress debriefing as necessary. Ill. Transportation

A. Arrange and assist with Pt. transportation as necessary. B. Continue ongoing assessment and patient care while waiting on EMS arrival.

IV. Do Not Transport (DNT) no EMR/EMT will cancel EMS due to a Pt. not wanting treatment. Determination for DNT will be by the responding Paramedic, Shift Supervisor for EMS or EMS Chief’s. Letting EMS determine the DNT releases the responding department of liability of Pt. care. Scene Command needs to conduct a risk analysis prior to canceling the response of EMS.


ALTERED MENTAL STATUS I. General Orders (See page 3.) II. Signs and Symptoms

A. Use AVPU mnemonic to determine level of responsiveness. 1. Alert and oriented 2. Responsiveness to verbal stimuli 3. Responsiveness to painful stimuli 4. Unresponsiveness

B. Attempt to determine cause of altered mental status, if possible, overdose, medical condition by SAMPLE history or trauma assessment.

1. Signs and symptoms 2. Allergies 3. Medications 4. Pertinent past history 5. Last oral intake 6. Events leading to the injury or illness

Ill. Role of the First Responder

A. Provide oxygen and/or ventilatory assistance as necessary, if not done during Initial Patient Assessment. (See Oxygen Delivery, page 33.)

B. Do not leave patient unattended.

IV. EMT C. Check glucose D. Administer oral glucose if the patient has a gag reflex. V. Other Considerations

A. Attempt to determine cause; i.e., hypoglycemia, poisoning, post seizure, infection, head trauma, hypoperfusion, etc.

VI. For Pain Use OPQRST. A. Onset (what made you call?) B. Provocation (what makes the symptom worse? what makes it better?) C. Quality (how would you describe the pain?) OPEN ENDED QUESTIONS D. Radiation (where do you feel the pain? where does the pain go?) E. Severity (how bad is the symptom? rate the pain on scale of 1-10) F. Time (how long have you had the symptom?)


BEHAVIORAL EMERGENCY CAUTION: Be alert Patient behavior may change rapidly, and the scene may become unsafe. General Orders (See page 3.) I. Causes, Signs and Symptoms

A. Situational stresses B. Mind altering substances - alcohol and drugs C. Psychiatric problems D. Psychological crises E. Bizarre thinking and behavior F. Danger to self C. Danger to others

II. Role of the First Responder

A. Identify yourself and let the person know you are there to help. B. Inform person of what you are doing. C. Ask questions in a calm, reassuring voice. D. Maintain a comfortable, safe distance. E. Encourage the patient to state what is troubling him/her. F. Do not make quick moves. G. Respond honestly to patient’s questions. H. Do not threaten, challenge, or argue with disturbed patients. Tell the truth. Do not lie to the patient. J. Do not “play along” with visual or auditory disturbances of the patient. K. Involve trusted family members or friends. L. Be prepared to stay at scene for a long time, always stay with the patient. M. Avoid unnecessary physical contact. N. Use good eye contact. O. Restraining patients:

1. Restraint should be avoided unless patient is a danger to self and others. 2. When using restraints, if possible, have police present; get approval from medical

control; and avoid unreasonable force P. Safety of all personnel should be a high priority!!

Q. Treat any injuries as indicated.


CARDIAC COMPROMISE I. General Orders (See page 3.) II. Signs and Symptoms A. Squeezing, dull pressure chest pain often radiating down the arms or to the jaw B. Sudden onset of sweating, or diaphoresis (This in and of itself is a significant finding.) C. Difficulty breathing (dyspnea), shortness of breath D. Anxiety, irritability E. Feeling of impending doom F. Abnormal pulse rate (may be irregular) C. Abnormal blood pressure H. Epigastric pain I. Nausea/vomiting J. Change in skin color Note: It is possible to have heart failure with no chest pain. Ill. Role of the First Responder A. Circulation - pulse absent I. CPR with AED (See AED, page 7-8.) a) Less than 1 year old - CPR only b) If POST form intact, follow POST protocol for no CPR c) Over 1 year old - CPR with AED 2. Provide supplemental oxygen and/or ventilatory assistance as necessary, if not done during the Initial Patient Assessment (See Oxygen Delivery, page 33.) B. Responsive patient with a known history - cardiac I. Place patient in position of comfort.

2. Provide supplemental oxygen and/or ventilatory assistance with OPA as necessary, if not done during the Initial Patient Assessment. (See Oxygen Delivery, page 33.)

3. Assess O-P-Q-R-S-T.

IV. EMT A. Administer a total of four (4) baby aspirin for 324 mg as soon as possible B. For ASA see Appendix 9. C. Use of Zoll Auto Pulse with additional training

Note: Unresponsive patient with a pulse present, refer to the Altered Mental Status protocol (See page 4.)


AED I. General Orders (See page 3.)

II. Signs and Symptoms

A. Use American Heart Association Guidelines to determine the following: 1. Unresponsiveness 2. Breathlessness 3. Pulselessness

B. If un-witnessed adult cardiac arrest and on call to arrival time is greater than 5 minutes deliver 5 cycles (about 2 minutes) of CPR should be performed before attaching and using the AED.

C. If a child suffers un-witnessed cardiac arrest deliver 5 cycles (about 2 minutes) of CPR should be performed before attaching and using the AED.

Ill. Role of First Responder

A. Begin CPR with high flow O2/BVM, Monitor Vitals B. Continue CPR while waiting for AED C. Apply AED and analyze (STOP CPR)

(First evaluation) NO Shock advised O Continue CPR and oxygenation O After 2 minutes of CPR Reanalyze (if AED permits) Shock advised O Ensure all providers are clear of patient contact O Deliver I shock O Oral airway, 100% oxygen via BVM or pocket mask O CPR for two minutes (Second evaluation) NO Shock advised O Continue CPR and oxygenation O After 2 minutes of CPR Reanalyze (if AED permits) Shock advised O Ensure all providers are clear of patient contact O Deliver I shock O Continue CPR O Consider non-cardiac causes of arrest, Go to appropriate protocol O Prepare the patient for transport (Third Evaluation) NO Shock advised


O Continue CPR and oxygenation O After 2 minutes of CPR Reanalyze (if AED permits) Shock advised O Ensure all providers are clear of patient contact O Deliver I shock O Continue CPR Note: If no shock is needed and after any shock delivery, resume CPR beginning with chest compressions. AED NOTES • Continue to follow the AED instructions until ALS unit arrives on scene. • The Zoll AED plus pads connector will plug directly into the NI series cardiac monitor/defibrillator cable from the EMS units. • Limit the amount of time not doing CPR if victim is in cardiac arrest. Limit hands off chest to a maximum of 10 seconds at a time if possible. • Adult pads should be used on all adults. If pediatric pads are available use the pads for the pediatric patients. If no pediatric pads are available, you may use adult pads. • The AED should be taken to the patient (if immediately available) along with a medical response bag. This ensures the needed emergency equipment is available at the patients’ side. • For every minute of cardiac arrest the victim’s chance of survival decreases 7-10%, thus the importance of taking the AED to the patient. • Reanalyze after 5 cycles (about 2 minutes) of CPR. • If a BLS ambulance arrives on scene DO NOT disconnect the AED and reconnect to the ambulances AED. Keep the initial AED in place and transport it with the patient to the emergency department. If the AED has delivered a shock(s) it needed it will re-shock at the correct level, if place on a new unit it will start all over.


HEAT EXPOSURE I. General Orders (See page 3.) II. Signs and Symptoms A. Muscular cramps B. Weakness or exhaustion C. Dizziness or faintness D. Rapid heart rate E. Altered mental status (See page 4.) Ill. Role of the First Responder A. Remove patient from heat environment. B. Cool patient by fanning, but may be ineffective in high humidity. C. Place in recovery position. D. Remove clothing as needed. (Protect modesty)


HYPOTHERMIA I. General Orders (See page 3.) II. Signs and Symptoms A. Obvious exposure B. Subtle exposure 1. Underlying illness 2. Overdose/poisoning/Alcohol/Drugs 3. Ambient temperature decreased (e.g., cool home of elderly patient) C. Cool/cold skin temperature D. Shivering E. Decreasing mental status or motor function - correlates with the degree of

hypothermia 1. Poor coordination/dizziness 2. Memory disturbances/confusion 3. Reduced or loss of touch sensation 4. Mood changes 5. Less communicative and speech difficult F. Stiff or rigid posture and muscular rigidity G. Poor judgment - patient may actually remove clothing H. Complaints of joint/muscle stiffness Ill. Role of the First Responder

A. Assess pulses for 30-45 seconds (If no pulse, start CPR) B. Remove the patient from the cold environment. C. Protect the patient from further heat loss.

1. Cover the patient with a blanket. 2. Remove any wet clothing. 3. Protect the patient’s modesty and ask bystanders to leave the area.

D. Handle the patient gently. E. Do not allow the patients to walk or exert themselves.

F. Do not put anything in the patient’s mouth, except as necessary to assure patient’s airway. G. Do not allow the patient to eat or drink stimulants or to smoke. H. Do not massage extremities.


LOCAL COLD EMERGENCIES I. General Orders (See page 3.) II. Signs and Symptoms A. Early or superficial injury

1. Blanching of the skin - palpation of the skin in which normal color does not return 2. Loss of feeling and sensation in the injured area 3. Skin feels soft. 4. If rewarmed, tingling sensation

B. Late or deep injury 1. White, waxy skin 2. Firm to frozen feeling upon palpation 3. Swelling may be present. 4. Blisters may be present.

5. If thawed or partially thawed, the skin may appear flushed with areas of purple and blanching or may be mottled and cyanotic. Ill. Role of the First Responder A. Remove the patient from the environment. B. Protect the cold - injured extremity from further injury. C. Remove wet or restrictive clothing and jewelry D. If early or superficial injury: 1. Manually stabilize the extremity. 2. Cover the extremity. 3. Do not rub or massage. 4. Do not re-expose to the cold. F. If late or deep cold Injury: 1. Cover with dry clothing or dressings 2. Do not break blisters. 3. Do not rub or massage area. 4. Do not apply heat. 5. Do not rewarm. 6. Do not allow the patient to walk on the affected extremity.


RESPIRATORY EMERGENCIES I. General Orders (See page 3.) II. Signs and Symptoms A. Anxious/restless B. Decreased breathing rate/Shortness of Breath (SOB) or increased breathing rate (gasping, grunting) C. Skin color changes (cyanotic, pale/clammy, redness/flushing) D. Abnormal airway noises (stridor, ineffective cough, wheezing, gurgling, snoring) E. Increased breathing effort (gasping, grunting) F. Inadequate chest wall motion G. Slow heart rate associated with slow respirations III. Role of the First Responder & EMT’s A. Patient c/o SOB/inadequate respirations 1. Remove obstruction, if any.

2. Provide supplemental oxygen and/or ventilatory assistance as necessary, if not done during Initial Patient Assessment. (See Oxygen Delivery, page 33.)

3. Allow patient to achieve position of comfort (POC). (Consider parents lap for pediatric patient.) B. Pediatric Considerations - Airway obstruction 1. Use infant/child foreign body airway procedures if complete obstruction. 2. If incomplete obstruction: a) Do not agitate patient. b) Provide supplemental oxygen and/or ventilatory assistance as necessary, if is done during Initial Patient Assessment. (See Oxygen Delivery, page 33.) c) Allow patient to achieve position of comfort (parent’s lap pm, except during C. The responder may need to assist the patient with their breathing medication, either nebulized or aerosol.

Note: Do not attempt to visualize Oropharynx.


SEIZURES

I. General Orders (See page 3.)

II. Signs and Symptoms/Causes A. Chronic medical conditions B. Fever C. Infections D. Poisoning, including drugs and alcohol E. Low blood sugar F. Head injury G. Decreased levels of oxygen H. Brain tumors I. Complications of pregnancy J. Pro-cardiac arrest K. Unknown causes

Note: Support the patient Do not worry about determining the cause of the seizure unless a hazardous materials scene indicates otherwise.

Ill. Role of the First Responder A. Protect the patient from the environment. B. Protect modesty - ask bystanders to leave the area. C. Provide oxygen and ventilatory assistance as necessary, if not done during Initial Patient Assessment. (See Oxygen Delivery, page 33.) D. After the seizure, place patient in the recovery position if no possibility of spine trauma. E. Never restrain the patient. F. Do not put anything in the patient’s mouth, except as necessary to assure patency of airway. G. Have suction available, suction as necessary. H. Describe the seizure activity to the next level of care. IV. EMT A. Check glucose B. If the glucose is less than 80 refer to Appendix 9. C. Attempt to determine the cause of the seizure.

Note: Refer to pediatric seizures. (See page 27)


BLEEDING EXTERNAL BLEEDING I. General Orders (See page 3.) II. Signs and Symptoms A. Arterial 1. The blood spurts from the wound. 2. The blood is bright, red oxygen rich. B. Venous I. The blood flows as a steady stream. 2. The blood is dark, oxygen poor. C. Capillary 1. The blood oozes from a capillary and is dark red in color. 2. The bleeding often clots spontaneously. Ill. Role of the First Responder

A. Provide oxygen and ventilatory assistance as necessary, if not done during Initial Patient Assessment. (See Oxygen Delivery, page 33.)

B. Control bleeding. 1. Direct pressure 2. Application of a Tourniquet INTERNAL BLEEDING I. General Orders (See page 3.) II. Signs and Symptoms A. Discolored, tender swollen or hard tissue B. Increased respiratory and pulse rates C. Pale, cool skin D. Nausea and vomiting E. Thirst F. Mental status changes G. Unexplained signs and symptoms of shock Ill. Role of the First Responder


B. Manage external bleeding, if present. C. Place in a position of comfort.(consider trauma, take spinal precautions if indicated) D. Treat for shock. (See Shock, page 18.)


BONE OR JOINT INJURIES I. General Orders (See page 3.) II. Signs and Symptoms A. Deformity or angulation B. Pain and tenderness C. Grating D. Swelling E. Bruising (discoloration) F. Exposed bone ends G. Joint locked into position Ill. Role of the First Responder

A. Provide supplemental oxygen and/or ventilatory assistance as necessary, if not done during the Initial Patient Assessment. (See Oxygen Delivery, page 33.)

B. After life threats have been controlled, manual stabilization. C. Apply cold pack to area of painful, swollen, deformed extremity to reduce swelling. IV. EMT Extremity stabilization splinting.

A. Only splint injuries in preparation for transport when EMS arrives unless special circumstances exist.

B. Splint – traction C. Elevate the extremity after splinting.


BURNS I. General Orders (See page 3.) II. Classification A. Superficial involves only the outer layer of the skin B. Partial thickness involves the outer and middle layer of the skin C. Full thickness extends through all layers of the skin Ill. Role of the First Responder A. Stop the burning process initially with water or saline. Limit to 1 minute. B. Remove smoldering clothing and jewelry. 1. Be aware that some clothing may have melted to the skin. 2. If resistance is met when removing the clothing, it should be left in place. 3. Protect modesty - ask bystanders to leave the area. C. Provide oxygen and ventilatory assistance as necessary, if not done during Initial Patient Assessment. (See Oxygen Delivery page 33.) D. Continuously monitor the airway for closure or difficulty breathing. E. Cover the burned area with a DRY, sterile dressing. F. Do not use any type of ointment, lotion, or antiseptic. G. Do not break blisters. H. Monitor continuously for shock and treat as necessary. (See Shock, page 18) I. Special considerations: 1. Chemical burns a) Ensure scene safety. b) Wear gloves and eye protection. c) Brush off dry powder. d) Flush with copious amounts of water. e) Consider eye burns if splash injury. 2. Electrical bums a) Ensure scene safety. b) Be aware that these are often more severe than external indications. c) Monitor the patient closely for respiratory or cardiac arrest. 3. Infant and child considerations: Greater surface area in relation to the total body size results in greater fluid and heat loss.


HEAD INJURIES I. General Orders (See page 3.) II. Signs and Symptoms A. Open injuries may present with bleeding B. Closed injury may present 1. Swelling 2. Depression of skull bones 3. Increased brain pressure (See Altered Mental Status, page 4.) 4. Scalp may bleed excessively because of the large number of blood vessels in the scalp.

C. Injury to the brain - Injury of brain tissue or bleeding inside the skull may increase pressure on the brain.


A. Initial assessment with cervical and spinal immobilization should be done on-scene wit a complete detailed physical exam en route. If EMS is delayed and personnel permit this may be done on scene by the first responder. B. Provide supplemental oxygen and/or ventilatory assistance as necessary, if not done during the Initial Patient Assessment. (See Oxygen Delivery, page 33.)

C. Closely monitor the airway, breathing, pulse, and mental status for deterioration. D. Control bleeding. (See External Bleeding, page 14.) 1. Do not apply pressure to an open or depressed skull injury. 2. Dress and bandage open wound as indicated in the treatment of soft tissue injuries.


SHOCK (HYPOPERFUSION) I. General Orders (See page 3.) II. Signs and Symptoms A. Extreme thirst B. Restlessness, anxiety C. Rapid, weak pulse D. Rapid, shallow respirations E. Mental status changes F. Palo, cool, moist skin Ill. Role of the First Responder


B. Prevent further blood loss. (See Bleeding, page 14) C. Keep patient calm, in position of comfort. D. Protect the patient from heat loss. 1. Remove wet clothing, if any. 2. Protect modesty - ask bystanders to leave the area. 3. Cover with blanket. E. Do not give food or drink. F. Provide care for specific injuries. C. Elevate lower extremities if no possibility of spinal trauma.


SPECIFIC TRAUMATIC INJURIES I. General Orders (See page 3.) II. Types A. Abrasion B. Laceration C. Penetration/puncture III. Role of the First Responder

A. Provide supplemental oxygen and/or ventilatory assistance as necessary, if not done during the Initial Patient Assessment. (See Oxygen Delivery, page 33.)

B. Management of open soft tissue injuries 1. Expose the wound. 2. Control the bleeding. 3. Prevent further contamination. 4. Apply sterile dressing to the wound and bandage securely in place. C. Special treatment considerations 1. Chest injuries a) An occlusive dressing should be applied to open wounds and sealed on three sides or Asherman Chest Seal. b) Place in position of comfort if no spinal injury suspected. 2. Impaled objects a) Do not remove the impaled object unless it is through the cheek or it would interfere with airway management or chest compressions, b) Manually secure the object, c) Expose the wound area. d) Control bleeding. e) Utilize a bulky dressing to help stabilize the object. 3. Eviscerations a) Open injury with protruding organs. b) Do not attempt to replace protruding organs. c) Cover with thick moist sterile dressing. 4. Amputations a) Involves the extremities and other body parts b) Massive bleeding may be present or bleeding may be limited. c) Locate and preserve the amputated part.

(1) Wrap severed part in a MOIST sterile dressing. (2) Place the part in a plastic bag. (3) Keep cool. a. Place the plastic bag containing the part in a larger bag or container with ice and water. b. Do not use ice alone.

c. Do not use dry ice.


SPINE INJURIES


II. Signs and Symptoms Note: The ability to walk, move extremities or feel sensation; or lack of pain to spinal column does not rule out the possibility of spinal column or cord damage. A. Tenderness in the area of injury B. Pain associated with moving C. Tell the patient not to move while asking questions. D. Pain independent of movement or palpation I. Along spinal column 2. Lower legs 3. May be Intermittent E. Obvious deformity of the spine upon palpation F. Soft tissue injuries associated with trauma 1. Head and neck to cervical spine 2. Shoulders, back or abdomen - thoracic, lumbar 3. Lower extremities - lumbar, sacral G. Numbness, weakness or tingling in the extremities H. Loss of sensation or paralysis below the suspected level of injury Loss of sensation or paralysis in the upper or lower extremities I. Incontinence J. Consider Mechanism of injury Ill. Role of the First Responder

A. Establish and maintain in-line immobilization until directed otherwise by arriving EMS unit.

B. Perform initial assessment. 1. Assess pulse, motor and sensation in all extremities. 2. Assess the cervical region and neck. IV. EMT Spinal Immobilization A. Apply Cervical collar

B. Place Pt. on Long Spine Board C. Manual stabilization D. Seated Pt. KED E. Rapid manual extrication


CHILDBIRTH I. General Orders (See page 3.) II. If Crowning Is Present, Prepare For Delivery, DO NOT attempt move the Pt. out of the

house, only move to gain access to the Pt. for crews on scene and arriving EMS. Ill. Role of the First Responder A. Use body substance isolation B. Do not touch vaginal areas except during delivery and when your partner is present. C. Do not let the mother go to bathroom. D. Do not hold mother’s legs together. E. If the head is not the presenting part, this may be a complicated delivery. 1. Tell the mother not to push. 2. Update responding EMS resources. 3. Calm and reassure the mother. F. Delivery procedures 1. Have mother lie on her back with knees drawn up and legs spread apart 2. Place absorbent, clean materials (sheets, towels, etc.) under the patient’s buttocks. 3. Elevate buttocks with blankets or pillow. 4. When the infant’s head appears, place the palm of your hand on top of the delivering baby’s head and exert very gentle pressure to prevent explosive delivery. 5. If the amniotic sac does not break or has not broken, tear it with your fingers and push it away from the infants head and mouth. 6. As the infant’s head is being born, determine if the umbilical cord is around the infants neck.

a) Attempt to slip the cord over the baby’s head. b) If unsuccessful, attempt to alleviate pressure on the cord.

7. After the infant’s head is born, support the head. 8. Suction the mouth and then the nostrils two or three times with the bulb syringe.

a) Use caution to avoid contact with the back of the baby’s mouth. b) If a bulb syringe is not available, wipe the baby’s mouth and then the nose

with gauze. 9. As the torso and full body are born, support the infant with both hands. 10. Do not pull on the infant 11. As the feet are delivered, grasp the feet.

a) Keep the infant level with the vagina. b) You may place the infant on the mother’s abdomen for warmth.

12. When the umbilical cord stops pulsating, it should be tied with gauze between the mother and the newborn, and the infant may be placed on the mother’s abdomen. 13. Wipe blood and mucus from the baby’s mouth and nose with sterile gauze, suction mouth, then the nose again. 14. Dry the infant. 15. Rub the baby’s back or flick the soles of Its feet to stimulate breathing. 16. Wrap the infant in a warm blanket and place the infant on its side, head slightly lower than trunk.


CHILDBIRTH (CONTINUED)

17. There is no need to cut the cord in a normal delivery. Keep the infant warm and wait for additional EMS resources who will have the proper equipment to clamp and cut the cord. 18. Record time of delivery and APGAR scores (Appendix 8: APGAR Scale Pg. 38) 19. If there is a chance of multiple births, prepare for second delivery. 20. Observe for delivery of placenta. This may take up to 30 minutes. 21. If the placenta is delivered, wrap it in a towel with 3/4 of the umbilical cord, place in a plastic bag, and keep the bag at the level at the infant. 22. Place sterile pad over vaginal opening, lower mother’s legs, and help her hold them together. 23. Post-delivery care of the mother

a) Keep contact with the mother throughout the process. b) Monitor respirations and pulse. c) Keep in mind that delivery is an exhausting procedure. d) Replace any blood soaked sheets and blankets while awaiting transport G. Vaginal bleeding following delivery

I. Up to 300-500 ml blood loss is well tolerated by the mother following delivery but with continued blood loss, massage the uterus. a) Use hand with your fingers fully extended. b) Place the palm of your hand on lower abdomen above the pubis. c) Massage (knead) over area. 2. If bleeding continues, check massage technique. IV. Initial Care of the Newborn

A. Assessment of infant (See APGAR Scale Appendix 8, page 38) B. Position, dry, keep warm, and stimulate the newborn to breathe. C. Wrap newborn in blanket and cover its head. D. Repeat suctioning if necessary. E. Continue to stimulate newborn if not breathing.

1. Flick soles of feet. 2. Rub infant’s back.

F. If newborn does not begin to breathe or continues to have breathing difficulty after one minute, the First Responder must consider the need for additional measures. G. Provide oxygen and ventilatory assistance as necessary, if not done during Initial

Patient Assessment. (See Oxygen Delivery, page 33.) 1. Ventilate at a rate of 40 breaths per minute.

2. Reassess after one minute. If heart rate is less than 80 beats per minute, a second rescuer should perform chest compressions.

V. Breech or Limb Presentation 1. ABC’s, 02 2. Place mother in knee-chest position 3. Allow infant to deliver spontaneously while supporting it. 4. If head delivers, ensure that cord is not wrapped around the neck. If so, gently slip two fingers underneath cord and attempt to slip cord overhead. Gently extract legs downward until buttocks are delivered, then rotate upward until both shoulders deliver. 5. If the head does not deliver within 3 mm, insert a gloved hand into the vagina and create an airway between the face and vaginal wall. Avoid placing excessive pressure on infants’ eyes


ASSESSMENT OF INFANTS AND CHILDREN (Pediatric Assessment Triangle)


II. The initial approach to pediatric resuscitation begins with a general assessment of the child. This must be rapidly performed and can often be difficult when the child is critically ill. The goal of the general assessment is to quickly form an impression of the child's overall physiological state and to help answer one of the most basic questions in emergency medicine: "sick or not sick?"

III. The Pediatric Assessment Triangle (PAT) is considered to be an integral part of the general assessment of a sick child. The triangle is designed to be a quick and simple approach to evaluating a child based on visual and auditory clues. It is broken down into the following 3 elements:

• Appearance • Work of breathing • Circulation

1. These 3 elements are further broken down into certain characteristics that help the healthcare provider determine the child's level of severity

as well as help identify the underlying physiological abnormality. a). Appearance is assessed as follows:

• Tone • Interactivity • Consolability • Look/gaze • Speech/cry

b). Work of breathing assessment includes the following: • Abnormal breath sounds • Abnormal positioning • Retractions • Flaring

c). Circulation assessment includes the following: • Pallor • Mottling • Cyanosis • Bleeding

IV. The visual and auditory clues of the pediatric assessment triangle allow the healthcare

provider to quickly form a general impression of the child and make two determinations. First, the provider must determine if the child is "sick" or "not sick," which means determining whether the child has an apparent life-threatening condition or not. This determination prompts the provider to begin life-saving interventions immediately or continue with a systematic assessment of the child. Secondly, the pediatric assessment triangle helps determine the underlying physiological abnormality.

V. These abnormalities can be broken down into basic categories: respiratory distress,

respiratory failure, compensated shock, decompensated shock, cardiopulmonary arrest, primary brain dysfunction, or other systemic abnormality. The general assessment is a critical starting point for pediatric resuscitation, and using the pediatric assessment triangle helps healthcare providers make timely decisions based on the overall appearance of the child

Pediatric Assessment Triangle


COMMON PROBLEMS IN INFANTS AND CHILDREN PARTIAL AIRWAY OBSTRUCTION I. General Orders (See page 3.) II. Signs and Symptoms

A. Infant or child who is alert and sitting B. Stridor (high pitched inspiratory sound), crowing, or noisy C. Retractions on inspiration D. Pink E. Good peripheral perfusion F. Still alert, not unresponsive


A. Allow position of comfort. 1. Assist younger child to sit up. 2. Do not lay down 3. May sit on parents lap.

B. Encourage patient to cough if possible. C. Do not agitate child.

COMPLETE OBSTRUCTION


II. Signs and Symptoms

A. No crying or speaking and cyanosis B. Child’s cough becomes ineffective. C. increased respiratory difficulty accompanied by stridor (high pitched inspiratory sound) D. Patient loses responsiveness. E. Altered mental status


A. Clear airway using latest American Heart Association standards. B. Provide oxygen and ventilatory assistance as necessary, if not done during initial Patient Assessment. (See Oxygen Delivery, page 33.)

RESPIRATORY EMERGENCIES

I. General Orders (See page 3.) II. Signs and Symptoms

Precedes respiratory failure and is indicated by any of the following: A. Respiratory rate greater than 60 in infants B. Respiratory rate greater than 30/40 in children C. Nasal flaring D. Intercostal retraction (between the ribs), supraclavicular (neck muscles), subcostal retractions (below the margin of the rib)


COMMON PROBLEMS IN INFANTS AND CHILDREN (CONTINUED) E. Stridor (high pitched inspiratory sound) F. Cyanosis G. Altered mental status (combative, decreased mental status, unresponsive) H. Grunting Ill. Causes, Signs, and Symptoms of Respiratory Failure/Arrest A. Breathing rate less than 10 per minute in a child B. Breathing rate of less than 20 per minute in an infant C. Limp muscle tone D. Unresponsive E. Slower, absent heart rate F. Weak or absent distal pulses G. Cyanosis and a slow heart rate IV. Role of the First Responder A. Provide mouth-to-mask or barrier device ventilations. B. Observe heart rate. C. Provide oxygen and ventilatory assistance as necessary, if not done during Initial Patient Assessment. (See Oxygen Delivery, page 33.) V. EMT D. Administer Aerosol Medication (Appendix 10) CIRCULATORY FAILURE

I. General Orders (See page 3.) II. Signs and Symptoms A. Increased heart rate B. Unequal central and distal pulses C. Poor skin perfusion D. Mental status changes Ill. Role of the First Responder A. Provide supplemental oxygen and/or ventilatory assistance as necessary, if not done during the Initial Patient Assessment. (See Oxygen Delivery, page 33.) B. Observe for signs of cardiac arrest. C. Begin CPR if not provided during Initial Patient Assessment. If POST form intact, follow protocol for POST. (Page 29-31)


COMMON PROBLEMS IN INFANTS AND CHILDREN (CONTINUED)

SEIZURES I. General Orders (See page 3.) II. Role of the First Responder A. Protect the patient from the environment. B. Ask bystanders (except parents) to leave the area. C. Place patient in the recovery position if no possibility of spine trauma. D. Never restrain the patient. E. Do not put anything in the patients mouth, except as necessary to assure patency of airway. F. Have suction available. Suction as necessary. G. Report assessment findings to additional EMS responses. H. Patients who are actively seizing, bluish, and breathing inadequately should be ventilated. Provide supplemental oxygen and/or ventilatory assistance as necessary, if not done during the Initial Patient Assessment. (See Oxygen Delivery, page 33.) III. EMT I. Check glucose K. Treat hypoglycemia as indicated (Appendix 9) Note: Seizures (See page 13.)

ALTERED MENTAL STATUS

I. General Orders (See page 3.) II. Role of the First Responder A. Provide oxygen and ventilatory assistance as necessary, if not done during Initial Patient Assessment. (See Oxygen Delivery, page 33.) B. Have suction available. Suction as necessary C. Place in recovery position (if no trauma is suspected) III. EMT D. Check glucose E. Treat hypoglycemia as indicated (Appendix 9) Note: Seizures, including seizures caused by fever (febrile), should be considered potentially life-threatening.


GERIATRIC EMERGENCIES I. General Orders (See page 3.) II. Make Observations A. General cleanliness of the environment B. Availability of food and water C. Hazards in the home D. Observe for signs of physical abuse/neglect. (See page 28.) E. If any medications, take them or a fist of them to the hospital. III. Role of the First Responder A. Determinations 1. Establish quick and effective rapport with patient and family. 2. Level of function with his/her own function prior to problem

3. Past medical history to assess present condition and anticipate effect of one disease on another

4. If in long-term care, determine reason for their being there and present condition requiring EMS. B. Emergency Medical Care I. Medical a) Altered Mental Status (See page 4.) b) Behavioral Emergency (See page 5.) c) Cardiac Compromise (See page 6.) d) Heat and cold emergencies (See pages 9 and 11.) 2. Trauma a) Cause of trauma may be medical b) Age> 60 at higher risk for mortality and morbidity c) Treat according to trauma treatment protocols for specific injury. (See pages 14 to 20.)


ABUSE AND NEGLECT I. General Orders (See page 3.) II. Signs and Symptoms A. Multiple bruises in various stages of healing B. Injury inconsistent with mechanism described C. Patterns of injury 1. Cigarette burns 2. Whip marks 3. Hand prints D. Repeated calls to the same address E. Fresh burns I. Not just any burns a) Scalding b) Glove, dip pattern c) Burns inconsistent with the history presented d) Untreated burns F. Caregiver seem inappropriately unconcerned G. Conflicting stories H. Fear discussing how the injury occurred I. CNS injuries - shaken baby syndrome 1. Unresponsive/Seizure 2. Severe internal injuries 3. No evidence of external injuries Ill. Causes, Signs, and Symptoms of Neglect A. Lack of supervision B. Malnourished appearance C. Unsafe living environment D. Untreated chronic illness; e.g., asthmatic with no medications E. Untreated soft tissue injuries IV. Role of the First Responder A. Do not accuse in the field. I. Accusation and confrontation delays transportation. 2. Report objective information to the transporting unit. B. Reporting is required by state law. I. Local regulations 2. REMS in objective a) Report what you see and what you hear. b) Do not comment on what you think facts only! V. Need for First Responder Debriefing A. Especially in cases of abuse/neglect B. Serious injury/death of a child C. Principles for assessing behavioral emergency patients


PHYSICAN ORDERS OF SCOPE OF TREATMENT (POST) I. General Orders (See page 3.) II. Role of the First Responder

A. Confirm the presence of the POST form and the patient’s identity B. Determine scope of care as defined in the POST document C. Is it filled out correctly with the proper signatures on both sides. D. When in doubt begin resuscitative efforts until EMS arrives.

Ill. Notify EMS as soon as possible Note: Refer to page 30 and 31 for sample POST form


APPENDIX 1: PHYSICAN ORDERS OF SCOPE OF TREATMENT (SCOPE)


APPENDIX 1: PHYSICAN ORDERS OF SCOPE OF TREATMENT (SCOPE) (CONT)


APPENDIX 2: NORMAL VITAL SIGNS


PULSE, BLOOD PRESSURE, AND RESPIRATION – RANGES

NORMAL RANGES OF ARTERIAL BLOOD RRESSURES (mm/Hg Infant 70 6-12 Years 80-120

1-12 Months 90 20-40 Years 120/80 12-36 Months 70 to 100 41-60 Years 120/80

3-5 Years 80-110 61+ Years Health Depends Another Method of Determining Systolic Blood Pressure

Male Adult Systolic: Patient’s Age + 100 (Up to 140 mm/Hg)

Adult Female Systolic: Patient’s Age + 90 (Up to 140 mm/Hg)

Note: The systolic values given above may vary up or down from the mean significantly and still remain in the normal range as follows:

Newborn ………………+ or – 16 6 Mos – 4 Years ……...+ or – 25 4 Years – 10 Years …. + or – 16 10 Years -14 years ….. + or – 18

The diastolic values given above (for Newborn through 14 Years old) may vary up to + or – 24 mm/Hg from the mean and still remain in the normal range.

NORMAL PULSE RATES (HEART BEATS PER MINUTE) Newborn 140 – 160 13-18 Years 55 – 105 12-36 Months 80 – 130 20-40 Years 76 – 90 3-5 Years 80 – 120 41-60 Years 70 6-12 Years 70 – 110 61-Older Depends on

Health

NORMAL RESPIRATORY RATES (RESPIRATIONS PER MINUTE) Newborn 1-11 Months

40-60 within minutes 30-40

6-12 Years 14 – 22

12-36 Months 3-5 Years

20 – 30 Adolescent and Adult

12- 20

APPENDIX 3: OXYGEN DELIVERY


OXYGEN DELIVERY

OXYGEN ADMINSISTRATION REFERENCE CHART Method Flow Rate

(in Liters per Minute) % Oxygen Delivered

Room Air 21 Nasal Cannula

(prongs) 1 2 4

24 28 31

Nonrebreather Face Mask *(1)

12 15

80 90

Pocket Mask 10 15 30

50 80

100 *(2) Bag Valve Mask Room Air

12 21

40 – 90 *(3)

*(1) Delivery system of choice for patients with inadequate breathing and patients who are cyanotic, cool clammy, short of breath, or suffering chest pain, suffering severe injuries, or displaying an altered mental status, or being transported.

*(2) This is accomplished by occluding breathing port with thumb.

*(3) Depends on brand of bag valve mask and

provisions for occluding room air inlet.

NOTES: 1. Administration rates by nasal cannula of over 4 L/min. are uncomfortable. 2. Use humidified oxygen, when possible, on infants, children, suspected respiratory tract burns, and transports exceeding one hour duration. 3. Bag Valve Mask is not recommended for use in patients in transport situations. 4. Most hypoxic patients will feel better with an increase in delivered oxygen from 21% to 24%. 5. Percentages of delivered oxygen listed above are based on optimal conditions, Altitude, equipment, etc, may decrease percentages of delivered oxygen.

OXYGEN BOTTLE VOLUME AND FLOW

Bottle Size Volume in Liters

Time @ 5 L/min

Time @ 5 L/min

Time @ 5 L/min

D 360 1 hr. 12 min. 36 min. 24 min. E 625 2 hr. 5 min. 1 hr. 3 min. 42 min M 3,200 10 hrs. 5 hrs. 3 hrs. 20 min. G 5,300 17 hrs. 40 min. 8 hrs. 50 min. 5 hrs. 53 min. H 6,900 23 hrs. 11 hrs. 30 min. 7 hrs. 40 min.

1. The above values are based on full bottle (2,000 to 2,200 psi.) @ 70 degrees F. 2. Allow for pressure drop of 5 psi. for every 1 degree drop in temperature below 70 degrees F.

APPENDIX 4: DOCUMENTATION


I. General Guidelines A. Document legibly. B. Document completely. C. A report MUST be completed on all calls a first responder responds to. D. All (Patient Care Reports) PCR’s contain Protected Health Information (PHI), treat them accordingly to protect patient information. E. All PCR’s will be maintained under lock and key within the County Fire Departments. II. Turn in of PCR’s

A. PCR’s will be turned in to the Cheatham County EMS training captain at the end of the month. Preferably the report may be e-mailed or faxed ASAP after the call. You may fax your PCR’s to 615-792-2056

B. Turn in of PCR’s will be conducted by a Chief Officer of the Fire Department. III. Verbal Report to Responding Medic Unit upon arrival at scene.

1. Identify patient’s age, sex, and primary complaint or problem. 2. Identify physical assessment findings, including, vital signs and level of

consciousness. 3. Identify pertinent history as needed to clarity of problem (medications,

illnesses, allergy, mechanism of injury). 4. Identify treatment given and patient’s response.

Note: Some reports may not contain all information as requested due the short patient contact time or situation (cardiac arrest, awaiting police arrival, etc.). Document accordingly and follow documentation guidelines.

APPENDIX 5: START TRIAGE


Simple Triage And Rapid Treatment

1. RPM method of identifying immediate patients; • Respiration’s • Perfusion • Mental status 2. Triage Criteria A. Immediate (Red)

Respirations >30 per minute or absent until head repositioned, or Radial pulse absent or capillary refill> 2 seconds, or Cannot follow simple commands

B. Delayed (Yellow) Respirations present and <30 per minute, and Radial pulse present, and can follow simple commands. *The saying is 30-2- can do, represents a delayed patient.

C. Minor (Green) Anyone that can get up and walk when you instruct them to do so.

D. Deceased (Black) Anyone not breathing after you open the airway

3. This system is limited to use in the incident where needs exceed resources immediately available 4. Frequently reassess patients and perform a more in-depth triage as more rescuers become available APPENDIX 6: COMMON MEDICAL ABBREVIATIONS


↑ Increase(d) ↓ Decrease(d) Ø None ♀ Female ♂ Male < Lesser then > Greater then = Equal to + positive - negative ∆ Change @ at 1o primary, first degree 2o secondary, second degree 3o tertiary, third degree ā before α alpha A&O alert and oriented abd abdomen, abdominal AMA against medical advice AMI acute myocardial infarction Amt. Amount Ant. Anterior Approx approximately β beta Bilat. Bilateral BM bowel movement BP blood pressure Brady bradycardia BS blood sugar also breath sounds ĉ with c/o complaint of cc chief complaint, also cubic centimeter CHF congestive heart failure CO carbon monoxide CO2 carbon dioxide COPD chronic obstructed pulmonary disease CSF cerebrospinal fluid CVA cerebral vascular

accident cx chest D50 50% Dextrose D5W 5% Dextrose in Water dc discontinued DOA dead on arrival DTs delirium tremors Dx diagnosis Epi epinephrine ET endotracheal ETOH ethyl alcohol Fx fracture FBAO foreign body airway obstruction GCS Glasgow coma scale GI gastrointestinal GSW gunshot wound Hx history H/A headache HR heart rate Hr(s) hour, hours IM intramuscular IO intraosseous IV intravenous IVP IV push kg kilogram = 1,000 grams JVD jugular vein distention L liter, left LLQ left lower quadrant LOC level of consciousness LUQ left upper quadrant mcg microgram mEq milliequivalent mg milligram MI myocardial infarction min minute mL milliliter mm millimeter MVA motor vehicle accident N/V nausea & vomiting NKA no known allergies NKDA no known drug allergies

noc at night NPO nothing by mouth NS normal saline NSR normal sinus rhythm NTG nitroglycerine neg. negative O2 oxygen O2 sat oxygen saturation p after palp palpation PE pulmonary embolism ped pediatric PERRL pupils equal round reactive to light PMH past medical history PMS pulse, motor, sensory PO by mouth, orally prn as needed tachycardia Pt. Patient q every qid four times a day R right resp respirations RLQ right lower quadrant RUQ right upper quadrant Rx treatment ŝ without SIDS sudden infant death syndrome SL sublingual SNT soft, nontender SOB shortness of breath SQ subcutaneous tid three times a day TIA transient ischemic attack TKO to keep open VF ventricular fibrillation Vfib ventricular fibrillation VT ventricular tachycardia Vtach ventricular tachycardia WO wide open

APPENDIX 7: PEDIATRIC ASSESSMENT QUICK REFERENCE CHART


Age Group Respiratory Rate Heart Rate Systolic B/P New Born

Infant (1-12 mo.) Toddler (1-3 yr.)

Preschooler (3-5 yr.) School Age (6-12 yr.) Adolescent (13 + yr.)

30-50 20-30 20-30 20-30 20-30 12-20

120-160 80-140 80-130 80-120 70-110 55-105

50-70 70-100 80-110 80-110 80-120

100-120 Equation for estimating systolic B/P: 80+ (2 X Child’s age in years) = Systolic B/P Weight = (Age X 2) + 8 = weight in kg APPENDIX 8: APGAR SCORING SYSTEM

Airway patency • Able to maintain independently • Requires adjuncts/assistance

to maintain

Breathing • Rate • Mechanics

o Retractions o Grunting o Accessory muscles o Nasal flaring

• Air entry o Chest expansion o Breath sounds o Stridor o Wheezing o Paradoxical chest

movement Children: 6-8 ml/kg

• Color Liver function

• Engorgement Renal function

• Tear production • # of diapers • Avg. UOP=1-2 ml/kg per hr.

Circulation • Heart rate • Blood pressure

o Volume/strength of central pulses

• Avg. circulating blood volume o Neonates = 85 ml/kg o Infants = 80 ml/kg o Children = 75 ml/kg

• Peripheral Pulses

o Present/absent o Volume/strength

• Skin perfusion o Capillary refill time (Consider ambient temp.) o Temperature o Color o Mottling

• CNS Perfusion o Responsiveness o Awake o Responds to voice o Responds to pain o Unresponsive o Recognizes parents o Muscle tone o Pupil size o Posturing


Clinical Sign 0 Points 1 Point 2 Points

A – Appearance P – Pulse G – Grimace A – Activity R – Respiratory

Blue/Pale

Absent

No Response

Limp

Absent

Body Pink/ Extremities blue

Below 100

Grimace

Some flexion of Extremities

Slow/Irregular

Completely Pink

Above 100

Cries

Active Motion

Good Strong Cry

The APGAR score should be calculated after the delivery of the Infant. The five (5) clinical signs are evaluated according to the scoring system detailed above. Each sign is assigned points to be totaled. A total score of ten (10) indicates that the Infant is in the best possible condition. A score of 4-6 indicates moderate depression and a need for resuscitative measures. APPENDIX 9: GLUCOSE & ASPIRIN


You must check the medication that you may be administering for the 5 Right’s, Right Pt., Right Dose, Right Medication, Right Route, Right Time and is it Expired. Glucose Indications

Any patient with a decreased level of consciousness with or without a history of insulin or non-insulin dependent diabetes. Glucose Contraindications Any patient that is unresponsive, has no gag reflex or can’t control their own airway. Glucose Protocol The provider should administer one tube of oral glucose, if no response after 3 -5 minutes the provider may administer another tube of oral Glucose. Aspirin Indications When the patient presents with signs and symptoms that indicate the clinical picture of an acute myocardial infarction (dyspnea; substernal chest pain [radiating or nonradiating]; diaphoresis; nausea and vomiting). Aspirin Contraindications Any patient that is allergic to aspirin Aspirin Protocol The provider shall administer a total of four (4) baby aspirin. APPENDIX 10: ALBUTEROL & AUTO-INJECTOR EPINEPHIRNE PIN (EMT Only)


Albuterol Medication Indications If the patient if found to have wheezing, either inspiratory, expiratory or both and/or dyspnea and the Pt. is prescribed an Inhaler then the EMT can assist the Pt. with their inhaler or nebulized medication. You must check the medication for the 5 Right’s, Right Pt., Right Dose, Right Medication, Right Route, Right Time and is it Expired. Albuterol Medication Contraindications If the patient is found to be allergic, intolerant or hypersensitive to the medication, this will not be followed without contact with MEDICAL CONTROL. 1. Patient is unable or unwilling to cooperate or perform the appropriate breathing pattern the protocol will not be followed. 2. If the heart rate is above 150 in the resting adult or above 180 in the pediatric patient. 3. The procedure will be terminated if the heart rate increases by 20 beats per minute from the pretreatment level. 4. If the systolic blood pressure increases greater than 20 mm Hg from pretreatment levels, the procedure should be terminated Albuterol Protocol Adult: If the patient if found to have wheezing, either inspiratory, expiratory or both and/or dyspnea Auto Injector EPI Pen Adult having an allergic reaction that requires the use of Auto Injector EPI Pen, the Pt. must have the Auto Injector prescribed to them and in their possession. If they unable to Inject themselves with the Injector you can assist them with the pen. You must check the pen for the 5 Right’s, Right Pt., Right Dose, Right Medication, Right Route, Right Time and is it Expired. APPENDIX 11: DOCUMENT HISTORY


Effective Date 08/10/2014 Initial date of standing orders for Cheatham EMS First Responders. Revision Date Include_____________ Fire to utilize the standing orders. Revision Date Include _____________ Fire to utilize the standing orders so all first responders agencies in Cheatham County utilize the same standing orders, revise BLS to 2010 AHA Guidelines.

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