patient care guidelineswcvems.com/uploads/3/4/9/5/34956237/2013_protocols.pdf · 2016. 2. 2. ·...

WALLER COUNTY EMS PATIENT CARE GUIDELINES VERSION 2013

PATIENT CARE GUIDELINES


TABLE of CONTENTS Introduction Required Supply Lists

ALS Supplies BLS Supplies

Standing Orders

Guidelines Transport Destination Hospital Capabilities

TSAQ Diversion Guidelines Medical / Legal Considerations

Duty to Act Consent/Refusal Documentation Physician Assistance Individuals on Scene Confidentiality

Out of Hospital Do-Not-Resuscitate (OOH DNR) General Protocols

Airway C-Spine Clearance Death in the Field Failed Airway IV Access Multiple Patient Triage Pain Management Police Custody Universal Patient


TABLE of CONTENTS Medical Protocols

Abdominal Pain Allergic Reaction Altered Mental Status Asystole / PEA Atrial Fibrillation with RVR Behavioral Bradycardia Cardiac Arrest Cerebrovascular Accident Chest Pain Diabetic Complications Excited Delirium Fever / Infection Control Hypertension Hypotension Induced Hypothermia Nausea / Vomiting Overdose / Toxic Exposures Post Resuscitation Pulmonary Edema Respiratory Distress Seizure Supraventricular Tachycardia Ventricular Tachycardia / PVC V-Fib / Pulseless V-Tach

Trauma Protocols

Bites / Stings Burns Drowning / Diving Head Trauma Hyperthermia Hypothermia Multiple Trauma Skeletal Trauma Traumatic Arrest

Pediatric / Obstetrical Protocol

Childbirth / Labor Newborn Obstetrical Emergency Pediatric Bradycardia Pediatric Respiratory Distress Pediatric Seizure


TABLE of CONTENTS

Procedures 12 Lead EKG AED Airway: Obstruction Airway: Surgical Cric Airway: CPAP Airway: King Tube Airway: Nasal Intubation Airway: Nebulizer Airway: Orotracheal Intubation Airway: Suctioning Assessment: Adult Assessment: Pediatric Auto Injector Blood Glucose Analysis Capnography Chest Decompression Childbirth Difficult Airway Evaluation External Pacing Gastric Tube Intranasal Administration Manual Defibrillation Pharmacological Assistance Intubation Pulse Oximetry Restraint Spinal Immobilization Splinting SQ and IM Injections Synchronized Cardioversion Taser Probe Removal Termination of Resuscitation Venous Access: Existing Catheter Venous Access: External Jugular Venous Access: Extremity Venous Access: Intraosseous Wound Care: General Wound Care: Tourniquet


TABLE of CONTENTS Medications

Activated Charcoal Adenosine (Adenocard) Albuterol Sulfate (Proventil) Aspirin Ativan (Lorazepam) Atropine Sulfate Atrovent (Ipratropium) Benadryl (Diphenhydramine) Calcium Chloride Cardizem (Diltiazem) Dextrose Dopamine (Intropin) Epinephrine (Adrenalin) Etomidate (Amidate) Fentanyl (Sublimaze) Ketamine (Ketalar) Labetalol (Normodyne) Lidocaine (Xylocaine) Magnesium Sulfate Morphine Sulfate Narcan (Naloxone) Nitroglycerine (spray and paste) Oral Glucose Rocuronium Sodium Bicarbonate Solumedrol (Methylprednisolone) Tylenol (Acetaminophen) Versed (Midazolam) Zofran (Ondansetron)

Charts and Formulas

Glasgow Coma Scale Infant Glasgow Coma Scale APGAR Score Dopamine Infusion Epinephrine Infusion Lidocaine Infusion Drug Calculations


Required ALS Supply List

ITEM QTY ITEM QTY All BLS Equipment Requirements As Listed Pedi IV Arm Board 2 BAAM 1 PEEP Valve 1 Cardiac Monitor with AED capabilities 1 Pre-Filled Saline Flush (optional) 4 Batteries (spare) 1 Saline Lock (optional) 4 EKG Paper 2 EKG Electrodes 15 Syringes (1cc, 3cc, 5cc, 10cc) 4 each Auto BP Cuff (XL , L, youth) 1 each Syringes (20cc, 60cc) 2 each Razor or equivalent 1 Adenosine 30mg Pulse Oximeter or equivalent 1 Ativan 8mg Chest decompression kit: Atropine 3mg 14g x 2” cath 2 Atrovent 1 dose one way valve 2 Benadryl 50mg ET Tube Securing Device (Pedi / Adult) 2 Calcium Chloride 1000mg CPAP Regulator 1 Cardizem 45mg CPAP Hose and Mask 2 Dextrose 25% 2.5G Cricothyrotomy Kit or equivalent 1 Dextrose 50% 50G Defibrillator Pads (Pedi/Adult) 2 each Dopamine 400mg Endotracheal Tube Inducer (Pedi / Adult) 1 each Epi 1:10,000 (or 1:1000 for dilution) 6mg ETCO2 (inline and sidestream) 1 each Epinephrine 1:1000 2mg ET Tubes or equivalent (2.5 - 8.5) 1 each Etomidate 40mg EZ-IO: or equivalent 1 Fentanyl 400mg Drill 1 Ketamine 500mg Needles (Pedi / Adult / Lg Adult) 2 each Labetalol 150mg Pressure Bag 1 Lidocaine 300mg Stabilizer 2 Lidocaine Premix 2000mg Injection Needles (18g, 25g) 4 each Magnesium Sulfate 6G IV Catheters: Morphine 20mg 14g x 1.25" 4 Narcan 4mg 14g x 2" 4 Nitroglycerine Paste 2 inches 16g, 18g, 20g, 22g, 24g 4 each Rocuronium 200mg IV Start Kits 4 Sodium Bicarb 4.2% 5mEq Laryngoscope Batteries (spare) 2 each Sodium Bicarb 8.4% 100mEq Laryngoscope Blades: Solumedrol 250mg Miller & Macintosh (1, 2, 3, 4) 1 each Versed 20mg Laryngoscope Handle (Pedi / Adult) 1 each Zofran 8 mg Maxi Drip (when no Multi-drip present) 6 Mini Drip (when no Multi-drip present) 6 Mucosal Atomization Device 2 Multi Drip (replaces Mini/Maxi when present) 6 Nasogastric Tube (14fr, 16fr) 2 each Normal Saline Bags: 100cc, 250cc 2 each 500cc and/or 1000cc 6000cc

The following is a minimum standard of supplies to be carried on all WCEMS ambulances while operating at ALS level or above. It is encouraged that all units consider increased supplies based on need and call volume. In some circumstances, the fluid and drugs on this page may be supplied in concentrations or amounts other than those listed. It is the ALS provider's responsibility to ensure all equivalent total amounts are present and that correct dosages are administered to patients. Medications may be supplied in generic or brand name, and are considered interchangeable.


Required BLS Supply List

ITEM QTY ITEM QTY 2 Way Communication 1 No Smoking Signs (cab and box) 1 each Adjustable C-Collars (Pedi / Adult) 4 each Non-Adhesive Non-Sterile Bandage 20 NRB (Pedi / Adult) 4 each Non-Adhesive Sterile Bandage 10 Traction Splint (Pedi / Adult) 1 each OB Kit 1 BVM (Adult) 2 Occlusive dressing or equivalent 2 Alcohol Preps or equivalent 20 NPA set 1 each Ammonia Inhalants or equivalent 2 OPA set 1 each Backboards 3 BVM (Pedi / Neonate or combination) 1 each Bandaging Roll or equivalent 10 Pedi SPO2 Probe or equivalent 1 Biohazard Bags 2 Penlight 1 Bite Block or equivalent 1 Personal Skin Cleanser 1 box BP Cuff (Child, Adult, Lg Adult) 1 each Portable O2 Bottle 2 Broselow Tape 1 Portable O2 Regulator 1 Burn Gel or equivalent 1 Protective Eyewear 2 Burn Sheet or equivalent 3 Protective Gowns 2 Splinting Material (various sizes) 2 each Protective Masks 2 Child Car Seat or equivalent 1 Rectal Thermometer Attachment 1 Colormetric Device or equivalent 2 Reflective Road Triangles 3 Tourniquet 1 Rigid Suction Device w/ Tubing 2 Disinfectant Spray or equivalent 1 Saline for Irrigation 2 bottles Emergency Blanket or equivalent 2 Scoop Stretcher 1 Emergency Response Guide 1 Sharps Container (mounted) 2 EpiPen©/ EpiPen Jr© or equivalent protocol 1 each Sharps Shuttle (portable) 1 Fire Extinguisher 1 Nebulizer 4 Flashlight 1 Soft Suction Catheter (8fr, 12fr, 14fr) 2 each Gloves (sm, med, lg, xl) 1 box each Stairchair 1 Glucometer 1 Sterile Water for Irrigation 2 bottles Glucometer Strips 5 Stethoscope 2 Head Blocks 4 Stretcher 1 Hot / Cold Pack 4 each Suction Canister 2 Hydrogen Peroxide 1 bottle Tape (1" and 2") or equivalent 2 each KED 1 Thermometer 1 King Tube(2.5, 3, 4, 5) or equivalent 1 each Thermometer Probes 5 Lancets or equivalent 5 Trauma Shears 1 Lubrication Gel or equivalent 2 Trauma Tape or equivalent 2 Map Book (Waller Co. / Harris Co.) 1 each Triangular Bandage 4 Mounted / Portable Suction 1 each Webbing or equivalent 4 Mounted Onboard O2 Cylinder 1 Tylenol 480mg Multi-Trauma Pad or equivalent 3 Activated Charcoal 100G Nasal Canula 4 Albuterol 4 doses

Aspirin 324 mg Nitroglycerin Spray 1.2 mg Oral Glucose 2 tubes

The following is a minimum standard of supplies to be carried on all WCEMS ambulances while operating at BLS level or above. It is encouraged that all units consider increased supplies based on need and call volume. In some circumstances, the fluid and drugs on this page may be supplied in concentrations or amounts other than those listed. It is the BLS provider's responsibility to ensure all equivalent total amounts are present and that correct dosages are administered to patients. Medications may be supplied in generic or brand name, and are considered interchangeable.


STANDING ORDERS GUIDELINES FOR UTILIZING STANDING ORDERS The following standing orders are meant to serve as guidelines for patient care. It is impossible to outline treatment sequences for every situation you will encounter. Each patient should be treated individually and appropriately, utilizing sound clinical judgment and these protocols as guidelines. The receiving hospital should be notified as soon as practical; however, this practice is a courtesy and should never interfere with patient care. If the clinical picture is clouded or complicated, on-line consultation with the receiving emergency department physician, on duty supervisor, clinical manager, or Dr. Messa should be utilized. Therapies are to be utilized at WCEMS protocol level, not state certification level. The following is a brief summary of skills allowed at each level. APPROVED ECA PROVIDERS can:

Scene survey and requesting additional resources Triage and assessment Basic airway management including O2 administration, suctioning, King Tube airway placement, and bag

valve mask assisted breathing CPR and AED use Basic patient assessment Assess vital signs, blood glucose levels and pulse oximetry Assist in delivery of the newborn Basic intervention in bleeding control/burn management Musculoskeletal movement restriction Vehicle rescue Documentation of patient care Verbal patient care reports to receiving hospital staff Rehabilitation of ambulance/infection control Wound care Assist advanced provider with skills as requested (within basic scope of practice)

APPROVED EMT-BASIC PROVIDERS can:

Perform all of the functions listed above for ECA providers Administer Aspirin, Albuterol, Nitroglycerine spray, and Oral Glucose, assist patient with self-

administration of an Epi-pen or metered dose inhaler Administer Tylenol PO Administer CPAP Administer Epinephrine 1:1000 IM for severe respiratory distress

APPROVED EMT-INTERMEDIATE PROVIDERS can:

Perform all of the functions listed above for EMT-Basic providers Administer Tylenol PR Intravenous cannulation and fluid administration including adult and pediatric IO Administration of Dextrose IV/IO/PR in hypoglycemic patients Administration of Epinephrine IV/IO in pulseless patients Endotracheal / Nasotracheal intubation Administration of Narcan IV/IO/IM/IN in patients suspected to be under the influence of narcotics Insertion of Nasogastric Tube


APPROVED EMT-PARAMEDIC PROVIDERS can:

Perform all of the functions listed above for EMT-Intermediate providers Apply and interpret electrocardiographic assessment (4, 12, and 15-lead) Administer appropriate pharmacological therapy for assessed conditions in symptomatic patients Intramuscular administration of all approved medications Intranasal administration of all approved medications Perform Pleural Needle Decompression Perform pain and sedation management with approved medications

APPROVED SENIOR PARAMEDICS / SUPERVISORS can:

Perform all of the functions listed above for EMT-Paramedic providers Perform Pharmacologically Assisted Intubations (P3) Perform Field Termination of Resuscitation (P4) Perform Surgical Cricothyrotomy (P3) Authorize extended transport destinations (P4) Administer loading dose of Ketamine in Excited Delirium (P4)

TRANSPORT DESTINATION CRITERIA

All Patients requesting ambulance transport will be transported by ambulance. The medical and/or surgical needs of the critically ill or injured patient are always the primary

consideration in determining transport destination. In general, critically ill medical and trauma patients should be transported to the closest appropriate facility

unless the patient’s condition can be best treated at another facility and the patient’s condition is stable enough for the longer transport distance.

Critically injured patients require rapid transport to the closest hospital capable of handling the multiple trauma patients. Determination of appropriate transport destination should be based upon the patient’s immediate condition, location of the call, possible traffic delays and the needs of the patient in the critical first hour of trauma. When in doubt, refer to TSAQ GUIDELINES.

Transport of the urgent and/or non-urgent patient shall be to the hospital of the patient’s choice with regards to current system status and the capabilities of the hospital. If the patient insists on being transported to a facility that is not capable of treating their injury/illness, they must sign a waiver stating they understand the risks of their decision. Should the system be stressed at the time of the transport, or the requested destination is outside of the normal transport area, consult the on-duty supervisor for further guidance.

See HOSPITAL CAPABILITIES.


CAPABILITIES

HOSPITAL ER Trauma Level STEMI

ROSC Hypo‐thermia

Stroke NICU Labor / Delivery

Adult ICU

Ortho‐ Pedics

CPAP Capable CT Sexual

Assault Dialysis Hyper‐ Barics

Methodist West N/A YES YES NO YES YES YES YES YES NO NO NO

Bellville St. Joseph N/A NO NO NO NO NO NO YES YES NO NO NO

Brenham‐Scott & White 3 NO NO NO YES YES NO YES YES NO NO NO

CyFair N/A YES YES NO YES YES YES YES YES NO YES YES

CyFair Stand Alone N/A NO NO NO NO NO NO YES YES NO NO NO

Katy‐Memorial Hermann N/A NO YES YES YES YES YES YES YES YES YES NO

Katy‐Christus St. Catherine N/A NO YES NO YES YES YES YES YES NO YES NO

Katy‐ Texas Childrens N/A NO NO NO YES NO YES YES YES NO NO NO

College Station Medical 3 YES YES NO YES YES YES YES YES YES YES YES

Navasota‐St. Joseph N/A NO NO NO NO NO NO YES YES NO NO NO

North Cypress N/A YES YES YES NO YES YES YES YES NO YES NO

Bryan‐St. Joseph 2 YES YES YES YES YES YES YES YES YES YES YES

St. Joseph Stand Alone N/A NO NO NO NO NO NO YES YES YES NO NO

Tomball N/A YES YES YES YES YES YES YES YES NO YES YES

These are the Hospitals that WCEMS staff are allowed to transport to without advance approval. Transport to an ER not on this list must be pre‐approved by the on‐duty Supervisor. Also keep System Status in mind when transferring to a listed hospital that is outside your present district. If in doubt, contact Supervisor. If you are transporting to a hospital not listed, or for reasons not listed, it is the crew's responsibility to contact that ER prior to initiating transport to verify their capabilities.


TSA-Q FACILITY DIVERSION GUIDELINES

SUBJECT: Diversion of Emergency Medical Services (EMS) traffic from emergency facilities. PURPOSE: To define uniform system guidelines for a hospital requesting diversion of EMS traffic to an alternate hospital. ACKNOWLEDGMENTS:

System hospital facilities, both Trauma Centers and non-Trauma Centers, should request diversion activation only when the resources and capabilities of that facility have been exhausted to the point that further ambulance traffic would jeopardize the care and treatment of patients at that facility as well as any subsequent patient transported to that facility by an ambulance.

It is recognized in advance that no diversion strategy can guarantee total compliance with these guidelines and it is likely that ambulances will deliver patients to hospitals which have requested diversion activation. It is further understood that a request for diversion activation is honored as a courtesy by the local EMS system.

Each facility is responsible for defining facility-specific policies and procedures for implementation of these guidelines. Diversion activation by a facility is understood to be a request applicable to all ambulance traffic regardless of a patient’s injury

or illness and regardless of the diversion activation rationale. It is understood that EMS personnel will not attempt to screen patients transported to a facility based upon the diversion categories identified hereunder.

DEFINITIONS: Transfer: Movement of a patient from one hospital to another based upon the patient’s need (inter-hospital transport) Bypass: Intentional movement of a patient from the scene to a specific hospital, not necessarily the nearest

hospital, based upon the patient’s medical need. Diversion: Intentional movement of a patient from the scene to an alternate hospital capable of providing appropriate

care at the request of the nearest hospital due to lack of available resource or capability. Appropriate Facility: A hospital, not necessarily the nearest hospital, with the resources and capability to care for a patient based

upon the patient’s medical needs. DIVERSION ACTIVATION CATEGORIES;

ED saturation ICU saturation OR saturation Internal disaster

AUTHORIZATION FOR DIVERSION STATUS IMPLEMENTATION AND DEACTIVATION:

Hospital administrator or designee; and Trauma Director or designee


COMMUNICATION OF DIVERSION STATUS A hospital must notify the local EMS system dispatch and on-line medical direction source of a request for diversion activation

and deactivation A hospital must provide the local EMS system with the applicable diversion activation category identified previously A hospital must provide the local EMS system dispatch and on-line medical direction source the names of the administrator or

designee and Trauma Director or designee authorizing diversion implementation and deactivation. TIME PERIOD FOR DIVERSION STATUS;

Diversion request will be in allotment up to eight (8) hours. A hospital may deactivate a diversion request at any time. A hospital must notify the local EMS system dispatch and on-line medical direction source to request an extension beyond each

eight (8) hour allotment. Neglect or failure of a hospital to notify the local EMS system dispatch and on-line medical direction source at the end of the

requested eight (8) hour allotment will result in automatic deactivation of that hospital’s diversion request. AUTHORIZATION FOR OVER-RIDE OF DIVERSION STATUS: The on-line medical direction source may over-ride a diversion status after consideration of the following:

Severity of the patient Distance and estimated time to an alternate appropriate facility Inclement weather conditions Resource availability and capability of the transporting pre-hospital provider All potential receiving facilities within a 15 minute radius of the patient location have requested diversion consideration Patient refuses transport to another designated facility.

SYSTEM MONITORING AND QI

Each hospital will be requested to document and report diversion activities to the SETRAC QI Committee on a quarterly basis. Each EMS system will be requested to document and report to the SETRAC QI Committee those situations where a diversion

request has not been honored or has been over-ridden by the on-line medical direction source.


MEDICAL / LEGAL CONSIDERATIONS DUTY TO ACT Waller County EMS (WCEMS) has a duty to respond to all calls for medical aid within the geographical boundaries of our service area and, when resources are available, to recognized mutual aid agencies. Once treatment is rendered, WCEMS personnel have a duty to care for that patient until there is a transfer of care to someone of appropriate medical training according to patient condition. PATIENT CONSENT / REFUSAL OF TREATMENT 1. If a patient (or legal patient representative) requests evaluation and treatment from WCEMS, they will be

actively encouraged to seek evaluation by a physician. If they consent, they will be transported to the appropriate acute care facility. Under no circumstances will WCEMS refuse or deny treatment to any patient who requests medical assistance.

2. Minor patients (under the age of 18 years old) shall not be permitted to decline/refuse medical care or EMS transport without obtaining an informed refusal from the parent, legal guardian, or other authorized family members or caregivers. If a minor with no injuries or illness wants to refuse, contact S1for permission to complete refusal. If the parent or legal guardian refuses needed medical care for their child, and EMS feels the child is in danger of losing life or limb, contact law enforcement and the on-duty supervisor.

3. Any patient, who appears to be impaired or have altered mental status, cannot be permitted to decline or refuse medical care or transportation. When orientation is questionable, opt for treatment and transport.

4. Patients who present with the following will be strongly discouraged from declining/refusing EMS transport: Chest pain or symptoms of ischemic heart disease. Dyspnea/respiratory distress Hypertension Abdominal pain with significant findings (orthostatic changes, guarding, rigidity, hematemesis,

melena, rebound tenderness, abdominal surgery within last year). Overdoses / Poisonings – accidental or intentional. Seizures Any complaint or abnormal finding possibly related to a known or suspected pregnancy including

abdominal pain of unknown etiology in a female of childbearing potential. Any evidence of injury to the head, spine, chest, abdomen or pelvis. Known or suspected abuse victims – child or adult. Contact CPS / APS, and law enforcement if care

is refused. Any patient that receives advanced and/or invasive treatment then refuses further care or transport.

This includes medications of any type. 5. Any patient refusing treatment or transport against medical advice will be informed of EMS findings and that

further harm could result without appropriate treatment. This will constitute an “informed refusal”, will be considered “Against Medical Advice” (AMA) and will be documented as such. The on-scene EMS providers have the option to request the on-duty supervisor to review a potential AMA refusal. All AMA refusals will be documented and completed thoroughly by the on-scene Paramedic in-charge.


DOCUMENTATION In all cases where an ambulance is dispatched, whether patient contact is established or not, a report will be completed detailing response to incident, patient contact, assessment, treatment, response to therapy and any events at the receiving facility. Records will include:

Dispatched complaint Actual C/C and reason EMS called. Level of consciousness including GCS (minimum of baseline and ending) Physical exam findings. Complete set of vital signs upon arrival on scene, during care, and upon discharge. (at least 2 sets), Any diagnostic findings (ECG, blood glucose, SpO2, etc.). Any attempts and number of attempts offering EMS transport including any outside assistance. Condition of patient at presentation and discharge. Reason patient is refusing and patient understands the risks of such a refusal. Patient’s plans for seeking physician evaluation. Names of people present who witnessed patient’s refusal and your attempt to encourage the patient to seek

follow-up care. All EKG tracings and Vital signs trending page. Pain scale if applicable (minimum of baseline and ending and after each pain management attempt) All applicable signatures. Hospital Face Sheet. Demographics and insurance information.

PHYSICIAN ASSISTANCE • PHYSICIAN ON SCENE

Occasionally a physician will attempt to provide assistance at the pre-hospital scene. When this occurs, if this physician is an emergency physician or a physician adequately trained in emergency medical care, every attempt should be made to utilize the physician appropriately. The following provides guidelines for a physician at the pre-hospital emergency scene.

• THE GOOD SAMARITAN PHYSICIAN This physician has no previous connection or relationship with the patient. The doctor should be courteously informed that you are functioning under delegated practice of a licensed physician Medical Director. To take control of the scene, the physician must: 1. Submit verification of physician status by proving proof of medical licensure or verifiable personal

identification by personnel on scene. If this status cannot be verified, assistance should be courteously declined. 2. The physician must be willing to assume responsibility for the patient at the scene, in transport and until

relieved by another physician in the emergency department. This physician must accompany the crew and patient to the hospital and sign the patient care report as the “in charge” health care provider.

3. WCEMS personnel will not perform any treatments or procedures that are not in their scope of practice.

• PHYSICIAN IN HIS/HER OFFICE OR OTHER MEDICAL FACILITY: 1. The physician in his/her office may elect to take charge and supervise the EMS management of the patient

provided they will be physically present in the transporting ambulance. 2. If the physician is not willing to be present during transport, EMS crews will revert to WCEMS protocols for

appropriate therapy.


INDIVIDUALS ON SCENE

• CERTIFIED/LICENSED INDIVIDUALS ON SCENE Individuals that possess a valid EMS certification and/or other healthcare license but are not members of WCEMS may be allowed to assist Waller County EMS personnel in rendering patient care under the following conditions: 1. The individual may only provide basic care under the direct supervision of a Waller County EMS In-charge or

Supervisor on scene 2. The individual may not administer any advanced or invasive treatment even if they possess an advanced

certification. • BYSTANDERS ON SCENE

Non-Certified bystanders may not render patient care. Bystanders whom are approved First Responders for Waller County EMS may render patient care within their

approved level and/or as deemed necessary by the on-scene WCEMS in-charge personnel.

• LAW ENFORCEMENT PERSONNEL ON SCENE Medically certified/licensed law enforcement personnel may assist WCEMS with basic care as deemed

necessary by the on-scene WCEMS in-charge personnel. Law Enforcement personnel whom are approved First Responders for Waller County EMS may render patient

care within their approved level and/or as deemed necessary by the on-scene WCEMS in-charge personnel.

• FIRE DEPARTMENT PERSONNEL ON SCENE Medically certified/licensed fire department personnel may assist WCEMS with basic care as deemed necessary

by the on-scene WCEMS in-charge personnel. Fire department personnel whom are approved First Responders for Waller County EMS may render patient

care within their approved level and/or as deemed necessary by the on scene WCEMS in-charge personnel. CONFIDENTIALITY All information regarding patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA). The exception to this is in the event that a criminal act has been committed or is confessed to the crew. In this case, law enforcement officials will be notified. Do not release a patient report to anyone except for the receiving ER. All others need to request a copy from the Executive Director in person. Ensure all reports are completed, synced from laptop, proofread for accuracy, locked, and faxed with all documents attached upon return to station.


OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDERS (OOH DNR)

IDENTIFYING OOH DNR FORM AND ID DEVICES There are two devices approved by Texas Department of Health to identify that a patient has an advanced directive in the form of a Do-Not-Resuscitate order:

Texas OOH-DNR Form An original Texas OOH DNR form can be identified by a red symbol in the shape of the State of Texas in the upper left hand corner with the word “STOP” imposed over it and the words “DO NOT RESUSCITATE” beside it. An original or photocopy of this form shall be honored by all WCEMS personnel. Photocopies of this form are to include page 2 (instructions) either copied onto the back of page 1 or attached to page 1. Page 2 does not have to be included for photocopy to be valid as long as page 1 appears to be properly completed. Texas OOH DNR ID Necklace or Bracelet The following shall be honored by WCEMS personnel in lieu of the original or copy of OOH DNR form:An intact, unaltered, easily identifiable plastic identification OOH DNR bracelet, with the word "Texas" (or a representation of the geographical shape of Texas and the word "STOP" imposed over the shape) and the words "Do Not Resuscitate”. OR An intact, unaltered, easily identifiable metal bracelet or necklace inscribed with the words, "Texas Do Not Resuscitate - OOH".

PROPERLY COMPLETED TEXAS OOH DNR The following sections must be completed in order for a Texas OOH DNR to be valid:

Section 1: Patient’s name and date of birth Section 2: Signatures, dates and appropriate boxes marked in either box A, B, or C (one only). Section 3: Witnesses signatures and dates signed. Witnesses signatures are not required if form is signed

by two physicians (Section 2, Box C completed). Section 4: Physician’s signature, printed or typed name, license number, date Section 5: Signatures of all persons who have signed the Texas OOH DNR in the above sections and the

date the order was issued. DOCUMENTATION OF OOH DNR ORDERS BY WCEMS PERSONNEL In the event of an OOH DNR order or identification device is encountered or if any other situations as noted above occur, the following information will be documented in addition to the standard demographic information:

1. History and assessment of the patient’s physical condition. 2. Name of the patient’s attending physician or physician on scene 3. Full name, address, telephone number, and relationship to patient of any witness used to identify the

patient. 4. Unique identification number on the DNR form or identification device. 5. Situations or conflict at scene and the resolution.


HONORING AN OOH DNR When presented with a patient who has Out of Hospital Do Not Resuscitate order, the protocol outlined below shall be followed.

Honoring an OOH-DNR in the presence of a pulseless, apneic patient: 1. Verify that the patient is the person named on the OOH-DNR form. If the patient is wearing an OOH-

DNR ID device, it shall be honored with or without the form being present. 2. Cease all resuscitation efforts. 3. Notify law enforcement of the patient’s death. 4. Attach a copy of the OOH-DNR to the call report.

Treatment to be withheld in the presence of an OOH-DNR form:

Cardiopulmonary resuscitation Advanced airway management Artificial ventilation Defibrillation External Pacing

Palliative Care If the patient is not in cardiac arrest, requires care, and has a properly completed OOH DNR form or ID device, provide care needed and transport both the patient and the OOH DNR form to the hospital. Out of state OOH DNR If an OOH DNR order is presented from another state, territory, or possession of the United States, WCEMS will honor only the original DNR form if there is no reason to question the authenticity of the order or device.

Do not honor an OOH-DNR if: 1. There is a suspicion of suicide, homicide or other non-natural cause of death. 2. The patient is known to be pregnant. 3. The OOH-DNR or ID device has been destroyed or revoked according to Texas Health and Safety Code

Sec. 166.092: a. A declarant may revoke an out-of-hospital DNR order at any time without regard to the

declarant’s mental state or competency. An order may be revoked by: 1. The declarant or someone in the declarant’s presence and at the declarant’s direction

destroying the order form and removing the DNR identification device, if any; 2. a person who identifies himself or herself as the legal guardian, as a qualified relative, or

as the agent of the declarant having a medical power of attorney who executed the out-of-hospital DNR order or another person in the person’s presence and at the person’s direction destroying the order form and removing the DNR identification device, if any;

3. the declarant communicating the declarant’s intent to revoke the order, or; 4. a person who identifies himself or herself as the legal guardian, relative, or the agent of the

declarant having a medical power of attorney who executed the out-of-hospital DNR order orally stating the person’s intent to revoke the order.

CONFLICT RESOLUTION PROCEDURE In the event the scene situation is unclear or conflict at the scene occurs, personnel will:

1. Initiate Basic Life Support procedures during the resolution process. 2. Consult with the family members to resolve the conflict. 3. WCEMS will transport with CPR in progress and full ALS skills if the conflict cannot be resolved.


GENERAL EMERGENCIES

Patient Care Guidelines


AIRWAY UNIVERSAL PATIENT PROTOCOL Assess ABCs

Rate, effort and adequacy Pulse Oximetry ETCO2 (as needed) If adequate

Give supplemental O2 with appropriate device as needed Reassess

If inadequate Continue with protocol

Open airway Head tilt-chin lift or jaw thrust

Insert adjuncts as needed OPA / NPA

Remove obstructions as needed AIRWAY: OBSTRUCTION PROCEDURE

Assist or ventilate with supplemental O2 using appropriate device as needed Reassess ABCs

If adequate Continue actions

If inadequate Continue with protocol

Blind Insertion Airway Device King Tube

Nasotracheal Intubation If breathing and has intact gag reflex

Orotracheal Intubation PHARMACOLOGICAL ASSISTED INTUBATION PROCEDURE as needed Bougie required

Consider gastric tube If 2 failed attempts at Orotracheal Intubation, or airway efficiency is still inadequate

FAILED AIRWAY PROTOCOL

NOTES • Capnography required with any / all intubations. Also include at least 4 other methods of

confirmation. • Any of the above airways are considered acceptable as long as they maintain ETCO2 at 35-45 and

pulse oximetry > 92%. • An intubation attempt is defined as any time the bougie passes the teeth or ETT is inserted into

the nares. • External Laryngeal manipulation (ELM) should be employed as needed on all intubations except

BIAD. Allow person intubating to guide your position and pressure. AIRWAY


C-SPINE CLEARANCE Altered Mental Status?

Any evidence of alcohol or drug use that is interfering with judgment?

Are there extremes of age that may be interfering with the patient’s judgment?

Does patient have any injuries that may be distracting them from other injuries?

This can be a more painful injury or an injury that is particularly grotesque or visible to the patient.

Any neurologic deficits noted?

Any point tenderness or pain during spinal assessment?

If NO to all of the above, complete Range of Motion Test. Any tenderness or pain?

If NO to all of the above

No immobilization required.

If YES to any of the above Spinal immobilization is required.

SPINAL IMMOBILIZATION PROCEDURE If patient refuses

• Refusal waiver signature required.

NOTES • Range of Motion Test includes look fully upwards, downwards and side to side without

assistance and without any spinal process pain. • The decision to NOT implement spinal immobilization is the responsibility of the

Paramedic. • If you feel spinal immobilization is needed, but patient refuses any/all of it, a waiver

must be signed before transport of patient that documents what is refused and releasing responsibility of WCVEMS crews of injuries caused by this refusal of care.

C-SPINE CLEARANCE


DEATH IN THE FIELD Does person meet any of the following criteria:

Decapitation Decomposition Rigor Mortis Dependent lividity, venous pooling Injuries incompatible with life Pulseless/Apneic with valid OOH-DNR Pulseless and/or Apneic in a MCI where EMS resources are required for stabilization

of living persons If patient meets criteria

Do not attempt resuscitation Document any / all criteria Contact supervisor and law enforcement Remain on scene until released

If patient does not meet criteria Attempt resuscitation following appropriate protocols

NOTES • Be mindful and aware of situations that may be considered a crime scene and

coordinate with Law Enforcement. • Honoring an OOH-DNR does not require asystole. It only requires the absence of

spontaneous respirations and/or pulse.

DEATH IN FIELD


FAILED AIRWAY AIRWAY PROTOCOL Total of (2) failed Orotracheal intubation attempts with at least 1 attempt by most proficient

member on team will constitute a failed airway SPO2 >90% with supplemental O2 via appropriate delivery device

continue actions SPO2 <90% and falling with supplemental O2 via appropriate delivery device or becomes

difficult to ventilate Blind Insertion Airway Device

SPO2 >90% Continue actions

SPO2 <90% and falling with reasons to believe another airway would improve patient See AIRWAY: SURGICAL CRIC PROCEDURE

Contact Supervisor for approval

NOTES • If first intubation attempt fails, make adjustments and consider the following;

o Different Blade o Different size tube o Change head position o Change person o ELM

• Continuous SPO2 and ETCO2 should be applied to all patients. • If SPO2 is low, but all indications show that ETT is patent, continue actions. • Notify Supervisor of Failed Airway immediately.

FAILED AIRWAY


IV ACCESS UNIVERSAL PATIENT PROTOCOL Assess need for IV access

Emergent or potentially emergent medical or traumatic condition Peripheral site

Upper extremities preferred but not mandatory External jugular site

Greater than 8 years of age For life threatening event

Intraosseous For life threatening event and/or unable to cannulate peripheral site on critical patient in 2

attempts Monitor lock Monitor infusion Monitor fluid bolus as needed.

Maximum 20ml/kg Monitor ABCs and lung sounds for signs of fluid overload

NOTES • Any fluids or medications approved for IV use may also be used IO. • All IVs should have a saline lock or set at a rate of TKO unless administering a fluid bolus. • In life threatening situations, only 2 IV attempts maximum allowed before using IO. • In life threatening situations, any pre-existing external venous catheter may be accessed. • In post-mastectomy patients, avoid IV, blood draws, injections or blood pressure analysis in

arm of affected side. IV ACCESS


YES

NO POSITION AIRWAY

YES

OBEYS COMMANDS (ADULT)"A", "V", OR "P" (PEDI)

DELAYED

< 30 (ADULT)15‐45 (PEDI)

PERFUSION

MENTAL STATUS

> 30 (ADULT)< 15‐45 (PEDI)

NO PALPABLE PULSE

RESPIRATORY RATE

POSTURING, "U" OR "P" (PEDI)DOESN’T OBEY COMMANDS (ADULT)

IMMEDIATE

IMMEDIATE

NO PULSE

APNEIC

DECEASED

BREATHING

MULTIPLE PATIENT TRIAGEABLE TO WALK? MINOR

BREATHING? BREATHING IMMEDIATE

NO

APNEIC

PEDI ADULT

PULSE

5 BREATHS


PAIN MANAGEMENT UNIVERSAL PATIENT PROTOCOL Patient care using appropriate protocols Pain scale < 4 of 10

Make patient comfortable Reassess

Pain scale > 4 of 10 EKG IV ACCESS PROTOCOL Treat pain appropriately

If IV access unsuccessful or hazardous FENTANYL IM / IN

If IV access successful FENTANYL (option) MORPHINE (option)

Repeat as needed for pain management Do not exceed medication maximum dosages

Reassess after each dose to determine need for additional doses NAUSEA/ VOMITING PROTOCOL

NOTES • Pain severity must be recorded pre and post analgesic administration. • Be cautious of narcotic use with hypotension, head injuries or respiratory distress. • Document all allergies prior to medication administration. • Document reasoning of any pain >4 of 10 that was not treated appropriately. • Vital signs must be documented within 15 minutes post administration. • Pain < 4 of 10 may be treated if you feel it is detrimental to patient or patient does not

understand pain scale. Document reasoning. PAIN MANAGEMENT


POLICE CUSTODY UNIVERSAL PATIENT PROTOCOL Evidence of traumatic injury or medical illness

Use appropriate protocol and transport as needed Pepper spray

Irrigate eyes Remove contaminated clothing. If patient is wheezing

RESPIRATORY DISTRESS PROTOCOL Transport as needed

Taser If significant injury from Taser probe, from fall after taser use, or patient complains

of chest pain with cardiac history Appropriate protocol Transport as needed

For probe removal TASER PROBE REMOVAL PROCEDURE

Excited Delirium EXCITED DELIRIUM PROTOCOL Transport

Jail Calls If life threatening emergency, transport patient immediately to closest appropriate

facility with jail staff or deputy onboard All other decisions to transport will be made by jail doctor Have jailers contact the jail doctor, give him your assessment findings over the

phone, and follow his directions for transport or refusal No orders for medicine will be taken from the doctor. Only the jailers or the nurse

are to take medication orders from jail doctor

NOTES • Any patient who is handcuffed or in custody by Law Enforcement and transported by

EMS must be accompanied by Law Enforcement during transport. • If patient with history of Asthma was pepper sprayed and released back to Law

Enforcement, ensure they understand to call EMS immediately if patient begins wheezing or develops difficulty breathing.

POLICE CUSTODY


UNIVERSAL PATIENT Scene survey PPE Be professional and courteous at all times Conduct appropriate assessments

ASSESSMENT: ADULT ASSESSMENT: PEDIATRIC

Consider C-SPINE CLEARANCE PROTOCOL Airway management including oxygen using appropriate devices

AIRWAY PROTOCOL Vital signs

Manual blood pressure Pulse rate, rhythm and quality Respiratory rate, rhythm and quality PULSE OXIMETRY PROCEDURE BLOOD GLUCOSE ANALYSIS PROCEDURE Temperature as needed CAPNOGRAPHY PROCEDURE as needed Glascow Coma Scale Pain scale EKG {3 lead and/or 12 lead} as needed

Treat per appropriate protocols Transport to closest appropriate facility

NOTES • Pediatric patient is defined by the length of the Broselow-Luten Tape. If the patient is

longer than the tape, they are considered an adult. • Temperature, EKG, and ETCO2 use are to be based on patient presentation, age,

history and complaint. UNIVERSAL PATIENT


Medical Emergencies



ABDOMINAL PAIN UNIVERSAL PATIENT PROTOCOL 12 lead EKG IV ACCESS PROTOCOL Consider NAUSEA/VOMITING PROTOCOL Consider PAIN MANAGEMENT PROTOCOL

NOTES • Document Vital signs and GCS prior to administering anti-emetics. • Consider the following in women of child bearing age;

o Abortion o Ectopic pregnancy (until proven otherwise) o Uterine Rupture o Abruptio Placenta o Ovarian Cyst o Mittleschmertz

ABDOMINAL PAIN


ALLERGIC REACTION UNIVERSAL PATIENT PROTOCOL If only hives and/or rash with no respiratory involvement

IV ACCESS PROTOCOL BENADRYL Continue to reassess airway

If signs of impending respiratory involvement or shock AIRWAY PROTOCOL 12 lead EKG as patient condition allows EPINEPHRINE 1:1000 IM IV ACCESS PROTOCOL BENADRYL ALBUTEROL SOLUMEDROL Reassess airway

Consider RESPIRATORY DISTRESS PROTOCOL PEDIATRIC RESPIRATORY DISTRESS PROTOCOL

If condition worsens

Repeat EPINEPHRINE 1:1000 IM EPINEPHRINE 1:10000 IV/IO (option)

Reassess airway

If Anaphylaxis refractory to above treatments EPINEPHRINE INFUSION

NOTES • The shorter the onset from cause to symptoms, the more severe the reaction is. • When giving Epinephrine to patients over 50 years, or patients with known cardiac

history, ensure 12 lead is completed prior to medication as time and severity allows. • Give Epinephrine IV if IM dose is ineffective or perfusion is severely diminished. The

effect of IV is faster, but IM is safer. • To administer Epinephrine by IV/IO, inject 1cc of 1:10,000 into 100cc saline and

administer through 60 gtts set.ALLERGIC REACTION


ALTERED MENTAL STATUS SCENE SAFETY!! UNIVERSAL PATIENT PROTOCOL C-SPINE CLEARANCE PROTOCOL IV ACCESS PROTOCOL If respirations are depressed

NARCAN Consider AEIOU-TIPS for cause of Altered Mental Status

Alcohol Epilepsy Insulin Complications Opiates / Oxygen Uremia Trauma Infection Poisons Shock / Stroke Use appropriate protocol based on findings

If patient becomes combative BEHAVIORIAL EMERGENCY PROTOCOL EXCITED DELIRIUM PROTOCOL

NOTES • SCENE SAFETY ABOVE ALL ELSE!!

• Don’t let alcohol or drugs affect your assessment, a medical problem may be causing the emergency and NOT the alcohol or drugs.

• Titrate narcan administration based on patient respirations, not on mental status.

ALTERED MENTAL STATUS


ASYSTOLE / PEA CARDIAC ARREST PROTOCOL Perform rhythm / pulse checks between cycles of CPR EPINEPHRINE

Every 3-5 minutes. Consider EXTERNAL PACING PROCEDURE early If asystole / PEA is refractory to treatments

Consider SODIUM BICARBONATE Consider FIELD TERMINATION PROCEDURE for Asystole

If rhythm changes at any time

use appropriate protocol

If return of spontaneous circulation at any time POST RESUSCITATION PROTOCOL INDUCED HYPOTHERMIA PROTOCOL

NOTES • Confirm Asystole in 2 leads and always verify lead placement. • Reassess and document intubation placement and ETCO2 frequently, after every move,

and at transfer of care. ASYSTOLE / PEA


ATRIAL FIBRILLATION with RVR UNIVERSAL PATIENT PROTOCOL IV ACCESS PROTOCOL Asymptomatic

Supportive care Reassess

Symptomatic with RVR > 140 bpm{chest pain, AMS, hypotension} CARDIZEM

Escalate dose in 10 minutes if no change SYNCHRONIZED CARDIOVERSION PROCEDURE

Repeat as needed. 12 lead EKG after rate control

NOTES • Monitor for hypotension after Cardizem use. • Document all rhythm changes and pre/post interventions. • To obtain slow push of Cardizem, consider injecting into 100cc bag thru 60 gtts at 50

ml/min. • For young patients with A-Fib and RVR with wide QRS, consider WPW, and do not

treat with Cardizem. Synchronized Cardioversion is treatment of choice. ATRIAL FIBRILLATION


BEHAVIORAL EMERGENCY Scene safety is of EXTREME importance

Ensure law enforcement on scene prior to entering UNIVERSAL PATIENT PROTOCOL Remove patient from stressful environment Talk calmly and develop a rapport with patient GCS on all patients If patient not alert and oriented and refuses care, or you would feel in danger during transport

RESTRAINT PROCEDURE IV ACCESS PROTOCOL

If needed and if possible Consider IM or IN medication route also

12 lead EKG Refer to appropriate protocol based on assessment

ALTERED MENTAL STATUS PROTOCOL DIABETIC COMPLICATIONS PROTOCOL HEAD TRAUMA PROTOCOL OVERDOSE / TOXIC EXPOSURE PROTOCOL EXCITED DELIRIUM PROTOCOL

NOTES • YOUR SAFETY IS FIRST! • Any patient who is handcuffed or restrained by Law Enforcement and transported by

EMS must be accompanied by Law Enforcement during transport. • Do not irritate patient with a lengthy exam. • Be sure to consider all medical and trauma causes for the behavioral problem. • All patients who receive either physical or chemical restraints must be continually

assessed by medical personnel.

BEHAVIORAL


BRADYCARDIA UNIVERSAL PATIENT PROTOCOL IV ACCESS PROTOCOL

Fluid bolus If glucose < 60 mg/dl

DIABETIC COMPLICATION PROTOCOL If Calcium Channel Blocker toxicity

CALCIUM CHLORIDE Asymptomatic

Monitor Reassess

Symptomatic {hypotension, AMS, chest pain, acute CHF, syncope, seizures} ATROPINE If refractory to treatment

EXTERNAL PACING PROCEDURE If hypotensive

HYPOTENSION PROTOCOL

NOTES • DO NOT TREAT IF ASYMPTOMATIC! • Treat rate before rhythm. • Use of Atropine in Myocardial Infarct can worsen heart damage. • Consider Hyperkalemia in wide complex slow rhythms.

BRADYCARDIA


CARDIAC ARREST UNIVERSAL PATIENT PROTOCOL Consider DEATH IN FIELD PROTOCOL Consider OOH-DNR POLICY Begin compressions If no ALS available

AED PROCEDURE If ALS available

Assess cardiac rhythm Treat per appropriate protocol

ASYSTOLE / PEA PROTOCOL V-FIB / PULSELESS V-TACH PROTOCOL

AIRWAY PROTOCOL IV ACCESS PROTOCOL If return of spontaneous circulation at any time

POST RESUSCITATION PROTOCOL INDUCED HYPOTHERMIA PROTOCOL

Assess and treat correctable causes Hypoxia Hypoglycemia Hypovolemia Hypothermia Acidosis Toxins Tension Pneumothorax Trauma

NOTES • Success is based on planning and execution. • Procedures require space. Make room to work. • Reassess and document intubation placement and ETCO2 frequently, after every move,

and at transfer of care. • Adequate compressions with timely defibrillation are the keys to success. • Refer to Broselow-Luten tape for pediatrics. • Pediatric survival is often dependent on airway management success. • For patients who are hypothermic, “they are not dead until warm and dead”. Refer to

HYPOTHERMIA PROTOCOL also. CARDIAC ARREST


CEREBROVASCULAR ACCIDENT (CVA) UNIVERSAL PATIENT PROTOCOL Verify CVA using Prehospital Stroke Screen AIRWAY PROTOCOL IV ACCESS PROTOCOL 12 lead EKG If glucose < 60 mg/dl

DIABETIC COMPLICATIONS PROTOCOL Consider

ALTERED MENTAL STATUS PROTOCOL SEIZURE PROTOCOL OVERDOSE / TOXIC EXPOSURE PROTOCOL

Blood pressure < 220 systolic and/or <120 diastolic Do not treat the hypertension directly

Blood pressure > 220 systolic and/or >120 diastolic LABETALOL

Titrate dosing to return patient to 220/120 range. Do not reduce further.

NOTES • Onset of symptoms is defined as the last witnessed time patient was symptom free. • AEIOU-TIPS listed in Altered Mental Status protocol should also be considered. • Hypoglycemia can present as a localized neurological deficit, especially in the elderly. • Do not use Nitroglycerin. • Post intubation paralytics may “mask” seizure activity.

CEREBROVASCULAR ACCIDENT (CVA)


CHEST PAIN UNIVERSAL PATIENT PROTOCOL If associated with trauma

Consider MULTIPLE TRAUMA PROTOCOL 12 lead EKG ASPIRIN IV ACCESS PROTOCOL NITROGLYCERIN

Spray or Paste If pain still present

MORPHINE (preferable) FENTANYL (option)

NAUSEA/ VOMITING PROTOCOL

If STEMI is identified Bilateral IV sites Transmit EKG to receiving ER (if available) Early notification to ER

NOTES • Serial 12 leads required. Minimum of 3. • Avoid Nitroglycerin in any patient who has taken Viagra or Levitra in the past 24 hours

or Cialis in the past 36 hours. • STEMI activation requires minimum 1mm ST segment elevation in 2 contiguous leads

or a new onset LBBB. • If inferior MI is identified, perform right side 12 lead EKG. • Diabetics, geriatrics and females may have atypical complaints.

CHEST PAIN / STEMI


DIABETIC COMPLICATIONS UNIVERSAL PATIENT PROTOCOL If glucose < 60 mg/dl and patient is conscious and able to follow commands

ORAL GLUCOSE If glucose < 60 mg/dl and patient is unconscious

IV ACCESS PROTOCOL DEXTROSE IV

If glucose < 60 mg/dl and patient is unconscious and unable to establish IV DEXTROSE PR

If glucose > 300 mg/dl and/or signs of DKA IV ACCESS PROTOCOL

Evaluate blood glucose level approximately 10 minutes after each medication intervention.

NOTES Consider household food items such as orange juice and peanut butter & jelly following

Oral Glucose to the conscious patient. Signs / symptoms of DKA are Kussmauls respirations, acetone breath, nausea, vomiting

and / or signs of dehydration.

DIABETIC COMPLICATIONS


EXCITED DELIRIUM SCENE SAFETY!! Ensure Supervisor and law enforcement on scene UNIVERSAL PATIENT PROTOCOL

Safety will take precedence over all individual procedures. Restrain patient manually as needed to provide safety for all involved Ensure all Taser activity (if deployed) is cancelled prior to contact KETAMINE IM

Loading dose Maintain manual restraint of patient until sedated After successful sedation

SPINAL IMMOBILIZATION PROCEDURE 4 point restraints

RESTRAINT PROCEDURE EKG and Vital signs AIRWAY PROTOCOL

Continuous ETCO2 and Pulse Oximetry monitoring mandatory IV ACCESS PROTOCOL

If 2 unsuccessful IV attempts • IO

KETAMINE IV/IO Maintenance dose as needed for continued sedation

1000cc chilled fluid bolus If patient experiences laryngospasm

OPA / NPA with BVM till spasm passes If prolonged laryngospasm

Give paralytic • AIRWAY: OROTRACHEAL INTUBATION PROCEDURE

Continue post intubation sedation • KETAMINE

NOTES • Signs/symptoms include

o Aggressive, threatening, combative behavior o Extreme agitation or excitement o Unusual strength o Sweating and tachypnea

• If a known pregnant patient falls under this protocol, continue as always. The safety of Ketamine is a category “C” and it is still the safest approach.

• Do not treat tachycardia during use of this protocol unless it becomes a non-sinus type tachycardia. Expect rates as high as 170.

EXCITED DELIRIUM


FEVER / INFECTION CONTROL UNIVERSAL PATIENT PROTOCOL Consider contact, droplet and/or airborne precautions If fever is > 101°F

TYLENOL PO/PR If pediatric and seizure develops

PEDIATRIC SEIZURE PROTOCOL

NOTES • Febrile seizures are the result of a rapid elevation in temperature. • Patients with a history of liver failure should not receive Tylenol. • Do not give Aspirin to a child. • Droplet Precautions include standard PPE plus a standard surgical mask for providers

and a surgical mask or NRB for the patient. This level should be used when influenza, meningitis, mumps, streptococcal or other illnesses spread via large particle droplets are suspected.

• Airborne Precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions. This level should be used when multi-drug resistant organisms (MSRA), scabies, zoster (shingles), or other illnesses spread by contact are suspected.

FEVER / INFECTION CONTROL


HYPERTENSION UNIVERSAL PATIENT PROTOCOL If systolic < 190 and/or diastolic < 110

Continue supportive care Treat accompanying signs / symptoms with appropriate protocol

If systolic > 190 and /or diastolic > 110 AND patient presents with at least one of the following; headache, nose bleed, blurred vision, altered mental status or dizziness

12 lead EKG IV ACCESS PROTOCOL LABETALOL

NITROGLYCERIN (option) • Paste or Spray

For hypertension associated with CVA symptoms CVA PROTOCOL

For pregnancy induced hypertension OBSTETRICAL EMERGENCY PROTOCOL

NOTES • Treating accompanying signs / symptoms may result in reduction of blood pressure. • Goal for treating Hypertension is 25% reduction maximum. • Avoid Nitroglycerin in any patient who has taken Viagra or Levitra in the past 24 hours

or Cialis in the past 36 hours. • Never treat Hypertension based on 1 set of vital signs.

HYPERTENSION


HYPOTENSION UNIVERSAL PATIENT PROTOCOL IV ACCESS PROTOCOL If glucose < 60 mg/dl

DIABETIC COMPLICATIONS PROTOCOL If trauma related

Use appropriate trauma protocol Fluid bolus

If cardiac related Use appropriate cardiac protocol If no rales present

Fluid bolus If non-cardiac and non-trauma related

Fluid bolus Always consider repeating fluid bolus If refractory to fluid bolus

DOPAMINE (option) EPINEPHRINE drip (option)

NOTES • Dopamine should only be started after fluid bolus with no improvement. • Consider all possible causes of shock and treat with appropriate protocol. • Consider possible allergic reaction or early anaphylaxis. • Decreasing HR and hypotension occur late in children and are signs of imminent

cardiac arrest.

HYPOTENSION


INDUCED HYPOTHERMIA INCLUSION CRITERIA

1. Viable unconscious patient with ROSC not related to trauma or hemorrhage 2. Minimum 18 years old 3. King Tube or ETT in place and confirmed 4. Initial temperature > 34°C 5. Not pregnant

If patient does not meet INCLUSION CRITERIA

Discontinue this protocol and use POST RESUSCITATION PROTOCOL only If patient meets INCLUSION CRITERIA

Continue POST RESUSCITATION PROTOCOL also Apply ice packs to axilla and groin Cold fluid bolus (max 2 liters) Reassess temperature every 15 minutes

If temperature < 34°C Discontinue this protocol and use only POST RESUSCITATION PROTOCOL

Transport to facility capable of continuing Induced Hypothermia If destination facility cannot continue this protocol, do not induce cooling.

NOTES • Do not delay transport to initiate cooling. • Patient may develop metabolic alkalosis. Do not hyperventilate. • If patient begins to shiver, contact Supervisor.

INDUCED HYPOTHERMIA


NAUSEA / VOMITING UNIVERSAL PATIENT PROTOCOL 12 lead EKG If glucose < 60 mg/dl

DIABETIC COMPLICATIONS PROTOCOL IV ACCESS PROTOCOL ZOFRAN IM/IV

NOTES • Zofran dose may be repeated x1 as needed.

NAUSEA / VOMITING


OVERDOSE / TOXIC EXPOSURE UNIVERSAL PATIENT PROTOCOL 12 lead EKG IV ACCESS PROTOCOL Consult Poison Control Center

(800)222-1222 If patient alert

CHARCOAL If confirmed Tricyclic ingestion with tachycardia or QRS widening

SODIUM BICARBONATE 5 minute slow push with fluid bolus

If Respiratory depression NARCAN

If Antipsychotic medication with signs / symptoms of dystonia BENADRYL

If Calcium Channel Blockers CALCIUM CHLORIDE

If Organophosphates ATROPINE

If suspected Alcohol DT or Stimulant use with anxiety (Cocaine, meth, etc) ATIVAN

Use appropriate protocols as needed Cardiac dysrhythmias protocols HYPOTENSION PROTOCOL ALTERED MENTAL STATUS PROTOCOL SEIZURE PROTOCOL BEHAVIORAL PROTOCOL RESTRAINT PROCEDURE

NOTES • Bring bottles, contents and emesis to ER. • Depressants

o Decreased HR, decreased BP, decreased temperature, decreased respirations. • Stimulants

o Increased HR, increased BP, increased temperature, dilated pupils, seizures. • Anticholinergic

o Increased HR, increased temperature, dilated pupils, mental status changes. • Cardiac medications

o Dysrhythmias and mental status changes. • Solvents

o Nausea, vomiting, coughing, mental status changes. • Insecticides

o Increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils.

OVERDOSE / TOXIC EXPOSURE


POST RESUSCITATION Repeat primary assessment Consider INDUCED HYPOTHERMIA PROTOCOL Continue AIRWAY PROTOCOL

Do not hyperventilate IV ACCESS PROTOCOL Vital signs 12 lead EKG Continue anti-dysrhythmic medication if ROSC was associated with its use If hypotensive

Fluid bolus DOPAMINE (if no change with fluid bolus)

If Bradycardic BRADYCARDIA PROTOCOL PEDIATRIC BRADYCARDIA PROTOCOL

Tachycardia (only if ventricular) VENTRICULAR TACHYCARDIA PROTOCOL

If arrest recurs Use appropriate protocol

NOTES • Hyperventilation is a significant cause of Hypotension and recurrence of cardiac arrest

in post resuscitation phase and must be avoided at all costs. • Most patients immediately post resuscitation will require ventilatory assistance. • Post resuscitation patient condition fluctuates rapidly and requires close monitoring. • Titrate Dopamine to maintain MAP > 90. (2x diastolic + systolic / 3)

POST RESUSCITATION


PULMONARY EDEMA UNIVERSAL PATIENT PROTOCOL Obtain pulse oximetry and ETCO2 if available AIRWAY PROTOCOL NITROGLYCERIN

Spray or Paste IV ACCESS PROTOCOL AIRWAY: CPAP PROCEDURE 12 lead EKG

NOTES • Pulse Oximetry and ETCO2 should be monitored continuously. • Avoid Nitroglycerin in any patient who has taken Viagra or Levitra in the past 24

hours, or Cialis in the past 36 hours. • Carefully monitor the level of consciousness, BP and respiratory status with the above

interventions. • If Nitro Paste is used, do not continue to use Nitroglycerin SL. • Allow patient to be in their position of comfort to maximize their breathing effort.

PULMONARY EDEMA


RESPIRATORY DISTRESS UNIVERSAL PATIENT PROTOCOL Obtain pulse oximetry and ETCO2 if available AIRWAY PROTOCOL Rales or signs of CHF

PULMONARY EDEMA PROTOCOL 12 lead EKG IV ACCESS PROTOCOL Consider AIRWAY: CPAP PROCEDURE If wheezing

ALBUTEROL Continue as needed

Follow with ALBUTEROL and ATROVENT (1x only) SOLUMEDROL

If refractory to treatment MAGNESIUM SULFATE

If patient has history of asthma or experiencing severe allergic reaction

EPINEPHRINE (1:1000) IM

For Stridor Nebulized saline Consider ALLERGIC REACTION PROTOCOL

NOTES • Pulse Oximetry and ETCO2 should be monitored continuously. • If patient has used Albuterol PTA without relief, you may go directly to the 1x dose of

Albuterol and Atrovent. • Respiratory status must be assessed after each dose of Albuterol to determine need for

additional doses. • When giving Epinephrine to patients > 50, with cardiac history, or HR > 150, a 12 lead

EKG should be performed first, based upon severity of patient. • A “silent chest” in respiratory distress is a pre-respiratory arrest sign.

RESPIRATORY DISTRESS


SEIZURE UNIVERSAL PATIENT PROTOCOL C-SPINE CLEARANCE PROTOCOL If glucose < 60 mg/dl

DIABETIC COMPLICATION PROTOCOL If currently seizing

AIRWAY PROTOCOL IV ACCESS PROTOCOL

Consider IM or IN administration ATIVAN (option) VERSED (option)

If post ictal Assess patient IV ACCESS PROTOCOL

If seizure recurs ATIVAN (option) VERSED (option)

If patient is > 20 weeks gestation or < 4 weeks post-partum OBSTETRICAL EMERGENCY PROTOCOL

NOTES • Grand mal (generalized) seizures are associated with LOC, incontinence and tongue

trauma. • Petit mal (focal) seizures only affect a part of the body and not usually associated with

LOC. • Jacksonian seizures start as a focal seizure and become generalized. • Assess possibility of trauma and/or substance abuse. • Consider Versed / Ativan IM or Versed IN for active seizure for safety.

SEIZURE


SUPRAVENTRICULAR TACHYCARDIA UNIVERSAL PATIENT PROTOCOL IV ACCESS PROTOCOL 12 lead EKG If patient is stable

Vagal maneuver ADENOSINE

If patient is unstable ADENOSINE (as time allows) SYNCHRONIZED CARDIOVERSION PROCEDURE

Repeat as needed If rhythm changes

Use appropriate protocol If QRS duration is > .12 seconds

VENTRICULAR TACHYCARDIA PROTOCOL

NOTES • Pediatric SVT generally considered > 220 in infant, and > 180 in child. • Adult SVT generally considered > 150 with no visible P-Waves. • Continually monitor Pulse Oximetry and ETCO2. • Adenosine may not be effective in unidentifiable A-Fib / A-Flutter, but it is not harmful.• Document all rhythm changes and rhythm after each intervention.

SUPRAVENTRICULAR TACHYCARDIA


VENTRICULAR TACHYCARDIA / PVC UNIVERSAL PATIENT PROTOCOL IV ACCESS PROTOCOL

Fluid bolus 12 lead EKG Stable vital signs

LIDOCAINE May repeat dose

If unstable vital signs SYNCHRONIZED CARDIOVERSION PROCEDURE

Repeat as needed LIDOCAINE

May repeat dose 12 lead EKG after conversion Continue Lidocaine drip if rhythm change was associated with its use

For PVC that are deemed detrimental to patient health LIDOCAINE

May repeat dose Continue Lidocaine drip if rhythm change was associated with its use

NOTES • For witnessed / monitored ventricular tachycardia, try having patient cough. • Polymorphic ventricular tachycardia (Torsades) may benefit from the administration

of Magnesium Sulfate. • Rate usually 150-180 bpm for sustained ventricular tachycardia. • QRS > .12 sec. • Calcium Chloride if hyperkalemia is suspected (renal failure).

VENTRICULAR TACHYCARDIA / PVC


V-FIB / PULSELESS V-TACH CARDIAC ARREST PROTOCOL MANUAL DEFIBRILLATION PROCEDURE x1

Resume CPR immediately without pulse check EPINEPHRINE

Every 3-5 minutes After 5 cycles of CPR

Check rhythm and pulse MANUAL DEFIBRILLATION PROCEDURE x1

Resume CPR immediately without pulse check LIDOCAINE Establish secondary IV site After 5 cycles of CPR

Check rhythm and pulse MANUAL DEFIBRILLATION PROCEDURE x1

Resume CPR immediately without pulse check MAGNESIUM SULFATE Consider EPINEPHRINE drip In refractory V-Fib / Pulseless V-Tach

SODIUM BICARBONATE Contact receiving ER and supervisor

If rhythm changes at any time use appropriate protocol

If return of spontaneous circulation at any time POST RESUSCITATION PROTOCOL

NOTES • Polymorphic V-Tach (Torsades) may benefit from Magnesium Sulfate. • Reassess and document intubation placement and ETCO2 frequently, after every move,

and at transfer of care. • Calcium Chloride and Sodium Bicarbonate if hyperkalemia is suspected (renal failure). • If arrest not witnessed by EMS, perform 5 cycles of CPR prior to 1st defibrillation. • Effective CPR and prompt defibrillation are the keys to successful resuscitation.

V-FIB / PULSELESS V-TACH


Trauma Emergencies



BITES / STINGS

UNIVERSAL PATIENT PROTOCOL Immobilize area or limb IV ACCESS PROTOCOL PAIN MANAGEMENT PROTOCOL Remove all rings and jewelry from affected extremity Consult Poison Control Center

(800)222-1222 If allergic reaction to bite or sting

ALLERGIC REACTION PROTOCOL If animal bite

Contact law enforcement If envenomation

Mark borders of inflammation / swelling and document time in 10 minute intervals to allow ER to track the rate of progression.

NOTES • Human bites have high infection rates due to normal mouth bacteria. • Carnivore bites are likely to become infected and all have risk of Rabies exposure. • Cat bites may progress to infection rapidly due to a specific bacteria (Pasteurella

multicoda). • Black Widow spider (black with red hourglass on belly) bites are minimally painful, but

develop muscular pain and severe abdominal pain over a few hours. Consider ATIVAN for muscular spasms / pain.

• Brown Recluse spider (brown with fiddle shape on back) bites are near painless. Little reaction is noted, but tissue necrosis develops over the next few days at bite area.

• Evidence of infection includes swelling, redness, drainage, fever, red streaks proximal to wound.

BITES / STINGS


BURNS

SCENE SAFETY!! UNIVERSAL PATIENT PROTOCOL AIRWAY PROTOCOL

Be mindful of singed nasal hairs, carbonaceous sputum and raspy voice Use Rule of Nines to calculate Total Body Surface Area (TBSA) burned IV ACCESS PROTOCOL

Give fluid bolus of 0.5ml/kg x TBSA (only if burns exceed 20% TBSA) PAIN MANAGEMENT PROTOCOL Use sterile covering on burned area Remove constricting items or jewelry If < 10% TBSA

Cool wound with normal saline In moderate to severe burns

Establish secondary IV access If electrical burn or lightning strike

EKG Identify all entry and/or exit sites

If chemical burn Identify safety of chemical reaction with normal saline

Flush area with normal saline for 15 minutes If minor burn, including sunburn

Burn Gel or equivalent

NOTES • Potential CO poisoning should be given 100% O2 and transported to facility with

hyperbaric chamber capabilities. • 2nd /3rd degree burns > 15% TBSA, burns involving hands/face/feet or electrical burns

should be treated at a burn center. • Always evaluate the possibility of abuse. • Normal saline or sterile water is preferred for flushing, but tap water is acceptable if

amount needed is unavailable. Perform final flushing with normal saline or sterile water.

• In electrical burns, do not contact patient until certain that source of the electrical shock has been disconnected.

• Attempt to identify nature of shock (AC/DC), amount of voltage and the amperage patient was exposed to prior to leaving scene, but do not delay transport.

BURNS


DROWNING / DIVING

UNIVERSAL PATIENT PROTOCOL C-SPINE CLEARANCE PROTOCOL AIRWAY PROTOCOL

Consider AIRWAY: CPAP PROCEDURE IV ACCESS PROTOCOL EKG Consider ALBUTEROL Monitor and reassess If patient unconscious

Consider PEEP

If associated with diving (decompression sickness) Transfer to facility equipped with hyperbaric chamber Contact Divers Alert Network

919-684-9111 Provide detailed history of dive

Depth Duration Number of dives Timing and onset of history

Collect and deliver dive computer or tables if possible

NOTES • With cold water and no time limit - attempt all resuscitations. • All victims should be transported for evaluation due to potential for worsening over the

next several hours, including delayed respiratory distress. • Drowning is a leading cause of death among would-be rescuers. Allow appropriately

trained rescuers to remove victims from areas of danger. • Most patients with decompression sickness seek medical attention within 12 – 24 hours

of last dive. • Signs and symptoms of decompression sickness

o Joint and abdominal pain o Fatigue o Paresthesias (“pins and needles”) o CNS disturbances

DROWNING / DIVING


HEAD TRAUMA

UNIVERSAL PATIENT PROTOCOL If poly-trauma including head trauma

MULTIPLE TRAUMA PROTOCOL also C-SPINE CLEARANCE PROTOCOL Obtain GCS

Continually monitor and reassess for GCS AIRWAY PROTOCOL IV ACCESS PROTOCOL Glucose < 60 mg/dl

DIABETIC COMPLICATION PROTOCOL If patient develops seizures

SEIZURE PROTOCOL Monitor Reassess

NOTES • Hyperventilate patient (adult:20 breaths/min, child:30, infant:35) only if ongoing

evidence of brain herniation (blown pupil, posturing, bradycardia, decreasing GCS). Goal is 30 – 35 ETCO2.

• Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushings Response).

• Limit IV fluids unless patient is hypotensive. • Concussions are periods of confusion associated with trauma which may resolve PTA.

Any prolonged confusion or mental status abnormality that does not return to normal or any documented loss of consciousness should be evaluated by a physician ASAP.

HEAD TRAUMA


HYPERTHERMIA UNIVERSAL PATIENT PROTOCOL EKG Document patient temperature Remove from heat source Remove clothing Cool patient appropriately IV ACCESS PROTOCOL

Fluid bolus Use appropriate protocol based on patient condition

NOTES • Extreme ages are more prone to heat emergencies (very young and very old). • Cocaine, amphetamines and salicylates may elevate body temperature. • Intense shivering may occur if patient is cooled too rapidly. • Sweating generally disappears as body temperature rises > 104°F. • Heat Cramps consist of benign muscle cramping secondary to dehydration and is not

associated with elevated body temperature. • Heat Exhaustion consists of dehydration, dizziness, fever, mental status changes,

headache, cramping, nausea, vomiting, tachycardia and hypotension. • Heat Stroke consists of dehydration, tachycardia, hypotension, temperature > 104°F,

and an altered mental status. HYPERTHERMIA


HYPOTHERMIA

UNIVERSAL PATIENT PROTOCOL EKG If temperature > 95°F

Use appropriate protocols based on symptoms If temperature < 95°F

Handle gently Remove any wet clothing Warm patient

Hot packs Blankets

IV ACCESS PROTOCOL Use appropriate related protocols

NOTES • Extreme ages are more prone to heat emergencies (very young and very old). • With temperatures less than 86°F, ventricular fibrillation is common cause of death.

Handling patient gently may prevent this. • Hypothermia may produce severe bradycardia, so take at least 45 seconds to palpate

pulse. • Do not place hot packs directly against skin. • Core body temperature may need to be restored prior to myocardium becoming

receptive. • If patient is < 86°F and defibrillation is required, only attempt x1. Withhold all further

attempts until temperature > 86°F. • If patient is < 86°F, antiarrhythmics may not work. If given, do so at reduced intervals. • If patient is < 86°F, pacing should not be attempted. • For patients who are hypothermic and pulseless, “they are not dead until warm and

dead”. Consider DEATH IN FIELD PROTOCOL. HYPOTHERMIA


MULTIPLE TRAUMA UNIVERSAL PATIENT PROTOCOL C-SPINE CLEARANCE PROTOCOL AIRWAY PROTOCOL Vital signs including GCS

Consider HEAD TRAUMA PROTOCOL WOUND CARE: GENERAL PROCEDURE

If uncontrollable hemorrhage WOUND CARE: TOURNIQUET PROCEDURE

IV ACCESS PROTOCOL PAIN MANAGEMENT PROTOCOL Continually reassess

If skeletal involved

SKELETAL TRAUMA PROTOCOL

If hypotensive HYPOTENSION PROTOCOL PEDIATRIC HYPOTENSION PROTOCOL

If tension pneumothorax

PLEURAL DECOMPRESSION PROCEDURE

If abdominal eviscerations Cover with saline soaked gauze Do not attempt to push organs back inside

If flail chest

Stabilize with large bulky dressing and tape.

NOTES • In prolonged extrications and serious trauma, consider air medical based on transport

times and destinations, and for the ability to give blood. • Do not overlook the possibility of child / elder abuse. • Scene time should not be delayed for procedures. These should be performed en route

when possible. • Do not remove impaled objects. Stabilize them in place.

MULTIPLE TRAUMA


SKELETAL TRAUMA

UNIVERSAL PATIENT PROTOCOL WOUND CARE PROCEDURE

If uncontrollable hemorrhage WOUND CARE: TOURNIQUET PROCEDURE

IV ACCESS PROTOCOL PAIN MANAGEMENT PROTOCOL SPLINTING PROCEDURE

NOTES • Peripheral neurovascular status is important. • In amputations, time is critical. Clean and wrap amputated part and place on ice if

available. Do not allow ice to directly contact part. • Open fractures should be covered with moist sterile gauze and padded prior to

bandaging. • Mark location of peripheral pulse with an “X” on extremity. Continuously monitor

during transport. • Hip / elbow / knee dislocations have high incidence of vascular compromise. • Urgently transport any injury with vascular compromise.

SKELETAL TRAUMA


TRAUMATIC ARREST

UNIVERSAL PATIENT PROTOCOL If pulseless patient has injury obviously incompatible with life

Do not attempt resuscitation If pulseless patient has traumatic injuries and asystole

Do not attempt resuscitation If pulseless patient has no traumatic injuries

Consider DEATH IN FIELD PROTOCOL Consider medical CARDIAC ARREST PROTOCOL

If pulseless patient has traumatic injuries and V-Fib, V-Tach or PEA Rapid transport to closest ER facility SPINAL IMMOBILIZATION PROCEDURE Control external hemorrhage AIRWAY PROTOCOL IV ACCESS PROTOCOL Bilateral chest decompression Use appropriate treatment protocols

If return of pulse at any time POST RESUSCITATION PROTOCOL

NOTES • For patients who are hypothermic with minimal obvious injuries, “they are not dead

until warm and dead”. Refer to HYPOTHERMIA PROTOCOL. TRAUMATIC ARREST


PEDIATRIC / OBSTETRIC

EMERGENCIES



CHILDBIRTH / LABOR UNIVERSAL PATIENT PROTOCOL Left lateral position unless crowning IV ACCESS PROTOCOL If hypertensive or abnormal presentation

OBSTETRICAL EMERGENCY PROTOCOL If patient is not crowning

Monitor and reassess Document frequency and duration of contractions

If patient crowning Supine position CHILDBIRTH PROCEDURE NEWBORN PROTOCOL

NOTES • Document all times (delivery, contraction, frequency and length). • After delivery, massaging the uterus (lower abdomen) will promote uterine contraction

and help to control post-partum bleeding. Allowing newborn to breast feed may help promote uterine contraction also.

• Some perineal bleeding is normal with any childbirth, but large quantities of blood or free bleeding is abnormal.

• Record APGAR at 1 minute and 5 minutes after birth. • If patient is in active labor, and hypertensive, do not treat the hypertension.

CHILDBIRTH / LABOR


NEWBORN UNIVERSAL PATIENT PROTOCOL (For Mother) Meconium present

AIRWAY: SUCTION PROCEDURE Insert laryngoscope for deep suctioning at vocal cords

AIRWAY: ORAL INTUBATION PROCEDURE (if needed) Stimulate, dry and keep warm Bulb suction mouth, then nose Assess 1 minute APGAR If heart rate < 100 during assessment

Ventilate at 50 breaths/minute with BVM and 100% oxygen for 30 seconds Reassess heart rate

Heart rate < 80 Begin chest compressions AIRWAY PROTOCOL IV ACCESS PROTOCOL Appropriate protocol per presentation

PEDIATRIC BRADYCARDIA PROTOCOL PEDIATRIC PULSELESS ARREST PROTOCOL

If glucose < 60 mg/dl DEXTROSE 10%

Consider NARCAN Heart rate 80-100

AIRWAY PROTOCOL IV ACCESS PROTOCOL If glucose < 60 mg/dl

DEXTROSE 10% Stimulate

Heart rate > 100 Monitor Assess 5 minute APGAR If glucose < 60 mg/dl

DEXTROSE 10%

NOTES • It is extremely important to keep infant warm. • Consider hypoglycemia in infant. Perform glucose stick in heel of foot. • If Dextrose 10% not available, dilute 1ml Dextrose 50% with 4ml normal saline.

NEWBORN


OBSTETRICAL EMERGENCY UNIVERSAL PATIENT PROTOCOL IV ACCESS PROTOCOL CHILD BIRTH / LABOR PROTOCOL (as needed) Left lateral position during transport unless otherwise noted For hypotension

Fluid bolus Prolapsed Umbilical Cord / Limb Presentation

Maintaining pulsatile cord is objective of care Elevate hips and place in knee/chest position Insert gloved fingers into vagina to alleviate pressure on cord. Do not remove until

ordered by ER doctor Keep cord moist with normal saline

Breech Birth If delivery of the body alone occurs, support the presenting part If newborn is attempting to breath prior to the head delivering, place gloved fingers

inside vagina and form a “V” around the mouth and nose Spontaneous Abortion

Emotional care Retain tissue for hospital

Pregnancy Induced Hypertension If patient complaint is headache or visual changes, and pressure exceeds 140/90

LABETALOL Seizures (20 weeks gestation to 4 weeks post-partum)

If post ictal Monitor Reassess

If actively seizing MAGNESIUM SULFATE

If seizing continues MAGNESIUM SULFATE

If seizing continues MAGNESIUM SULFATE

If seizing continues ATIVAN

If refractory to all above treatments Contact receiving ER and Supervisor

NOTES • Left lateral position minimizes risk of supine hypotension syndrome. • Ask patient to quantify bleeding severity – number of pads used per hour. • Any pregnant patient involved in MVA or related trauma should be seen immediately

by physician for evaluation and fetal monitoring. OBSTETRICAL EMERGENCY


PEDIATRIC BRADYCARDIA UNIVERSAL PATIENT PROTOCOL AIRWAY PROTOCOL IV ACCESS PROTOCOL

Fluid bolus If glucose < 60 mg/dl

DIABETIC COMPLICATION PROTOCOL If Calcium Channel Blocker toxicity

CALCIUM CHLORIDE Asymptomatic

Monitor Reassess

Symptomatic EKG EPINEPHRINE 1:10000 ATROPINE If refractory to treatment

EXTERNAL PACING PROCEDURE If infant heart rate < 60 bpm

Start CPR If hypotensive

HYPOTENSION PROTOCOL

NOTES • Use Broselow-Luten Tape. • Infant = 1 year old or less. • The majority of pediatric arrests are respiratory related. • Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia. • Minimum Atropine dose is 0.1 mg IV.

PEDIATRIC BRADYCARDIA


PEDIATRIC RESPIRATORY DISTRESS UNIVERSAL PATIENT PROTOCOL Obtain pulse oximetry and ETCO2 if available AIRWAY PROTOCOL Position patient for comfort IV ACCESS PROTOCOL

Fluid bolus If wheezing

ALBUTEROL Continue as needed

Follow with ALBUTEROL and ATROVENT (1x only) SOLUMEDROL

If refractory to treatment MAGNESIUM SULFATE

If patient is severe EPINEPHRINE (1:1000) IM

For Stridor Nebulized saline Consider ALLERGIC REACTION PROTOCOL

NOTES • Do not force a child into a position. They will protect their airway with their body

position. • The most important component of respiratory distress is airway control. • Croup- typically < 2 years. It is viral, possible fever, gradual onset, no drooling. • Epiglottitis- typically > 2 years. Bacterial, fever, rapid onset, possible stridor, patient

wants to sit up to keep airway open, drooling is common. Airway manipulation may worsen the condition.

PEDIATRIC RESPIRATORY DISTRESS


PEDIATRIC SEIZURE UNIVERSAL PATIENT PROTOCOL C-SPINE CLEARANCE PROTOCOL

SPINAL IMMOBILIZATION PROCEDURE AIRWAY PROTOCOL Glucose < 60 mg/dl

DIABETIC COMPLICATION PROTOCOL If history of or injury to the head

PEDIATRIC HEAD TRAUMA PROTOCOL If febrile

Begin cooling FEVER / INFECTION CONTROL PROTOCOL

If actively seizing IV ACCESS PROTOCOL

Consider IM or IN administration ATIVAN (option) VERSED (option)

If post ictal IV ACCESS PROTOCOL Continually reassess patient

If seizure recurs ATIVAN (option) VERSED (option)

NOTES • Status Epilepticus is defined as two or more successive seizures without a period of

consciousness or recovery. This is an emergency requiring rapid airway control, treatment and transport.

• In an infant, a seizure may be the only evidence of a closed head injury. • Grand mal (generalized) seizures are associated with LOC, incontinence and tongue

trauma. • Petit mal (focal) seizures only affect a part of the body and not usually associated with

LOC. • Jacksonian seizures start as a focal seizure and become generalized.

PEDIATRIC SEIZURE


PROCEDURES


12 LEAD EKG CLINICAL INDICATIONS

Suspected cardiac patient Electrical injuries Syncope Nausea/vomiting

PROCEDURE 1) Assess patient and monitor cardiac status. 2) Administer oxygen as patient condition warrants. 3) Expose chest and prep as necessary. 4) Apply chest and extremity leads.

RA – right arm LA – left arm RL – right leg LL – left leg V1 – 4th intercostal space just to the right of the sternum V2 – 4th intercostal space just to the left of the sternum V4 – 5th intercostal space at the mid-clavicular line V3 – 5th intercostal space midway between V3 and V4 V6 – 5th intercostal space at the min-axillary line V5 – 5th intercostal space between V4 and V6

5) Instruct patient to remain still. 6) Press appropriate button to acquire 12 lead. 7) If 12 lead indicates STEMI or consultation is required, transmit 12 lead EKG to appropriate

receiving hospital if capable. Contact receiving hospital to notify them a 12 lead EKG has been sent.

8) Monitor patient while continuing with treatment protocol. 9) Download data from monitor and/or attach copy of 12 lead to PCR. 10) Document procedure, time and interpretation on PCR.

MINIMUM CERTIFICATION LEVEL Paramedic

• Basic and Intermediate may attach leads, but may not interpret rhythm. 12 LEAD EKG


AED CLINICAL INDICATIONS

Patients in cardiac arrest (pulseless, non-breathing). Age < 8 years, use pediatric pads.

CLINICAL CONTRA-INDICATIONS Pediatric patients who are so small that the pads cannot be placed without touching one

another.

PROCEDURE 1) If multiple rescuers available, one rescuer should provide uninterrupted compressions while

AED is being prepared. 2) Apply defibrillator pads per manufacturer’s recommendations. Use alternative placement

when implanted devices (pacemakers, etc.) occupy preferred pad positions. 3) Connect defibrillator leads if needed. 4) Activate AED for analysis of rhythm. 5) Stop CPR and clear patient for rhythm analysis. Keep interruption in CPR as brief as

possible. 6) If shock is indicated:

Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with patient.

Defibrillate by depressing the “shock” button. 7) Resume CPR immediately after shock is delivered. 8) After 2 minutes (5 cycles) of CPR, analyze rhythm and defibrillate if indicated. Repeat this

step every 2 minutes. 9) If “No shock advised” appears, perform CPR for 2 minutes and then reanalyze. 10) Transport and continue appropriate protocol treatment.

NOTES Keep interruption of CPR as brief as possible. Adequate CPR is a key to successful

resuscitation. If pulse returns, use POST RESUSCITATION PROTOCOL.

MINIMUM CERTIFICATION LEVEL ECA

AED


AIRWAY: OBSTRUCTION CLINICAL INDICATIONS

Sudden onset of respiratory distress often with coughing, wheezing, gagging, or stridor due to a foreign-body obstruction of the upper airway.

Respiratory arrest where ventilation cannot be accomplished after repositioning of airway.

PROCEDURE 1) Assess the degree of foreign body obstruction.

Do not interfere with a mild obstruction. Allow the patient to clear their airway by coughing.

In severe foreign-body obstructions, the patient may not be able to make a sound. The victim may clutch his/her neck in the universal choking sign.

2) For an infant Deliver 5 back blows (slaps) followed by 5 chest thrusts repeatedly until the object is

expelled or the victim becomes unresponsive. 3) For a child

Perform the Heimlich Maneuver until the object is expelled or the victim becomes unresponsive.

4) For an adult Heimlich Maneuver should be used in rapid sequence until the obstruction is relieved. If ineffective, chest thrusts should be used.

Chest thrusts should be used primarily in morbidly obese patients and those in the late stages of pregnancy.

5) If the victim becomes unresponsive, begin CPR immediately but look in the mouth before administering any ventilations.

If visible, remove it. Do not perform blind finger sweeps in the mouth and posterior pharynx. This may push the object farther into the airway.

6) In unresponsive patients, EMT-Intermediate and above should visualize the posterior pharynx with a laryngoscope to potentially identify and remove the foreign-body using Magill forceps. 7) Document the methods used and result of these procedures in the PCR.

MINIMUM CERTIFICATION LEVEL ECA – except where higher level is noted

AIRWAY: OBSTRUCTION


AIRWAY: SURGICAL CRIC CLINICAL INDICATIONS

Surgical Airway as indicated by the FAILED AIRWAY PROTOCOL.

PROCEDURE 1) Pre-oxygenate patient when possible. 2) Assemble all available additional personnel. 3) Locate cricothyroid membrane at the inferior portion of the thyroid cartilage (with head in

neutral position, membrane is approximately 3 finger widths above the sternal notch). 4) Hold or have assistant hold skin taut over membrane and locate the midline. 5) Prep area with betadine or alcohol solution. 6) Make a 1.5 – 2 cm vertical incision through the skin overlying the cricothyroid membrane. 7) Dissect the skin and fatty tissue overlying the trachea to visualize the cricothyroid

membrane. 8) Make a horizontal incision through the membrane into the trachea. 9) Insert gloved finger into the incision to enlarge and hold open. 10) Insert tracheal hook into the incision to elevate thyroid cartilage towards the head and hold

open. 11) Insert bougie and advance to confirm presence of the Carina and verify correct placement. 12) Slide appropriately sized ETT over the bougie to appropriate depth and inflate the cuff. 13) Remove bougie. 14) Attach BVM with supplemental oxygen. 15) Verify placement with minimum of 5 confirmation devices, including ETCO2. 16) Secure ETT. 17) Document procedure, time and result on PCR.

MINIMUM CERTIFICATION LEVEL EMT-Paramedic P3

AIRWAY: SURGICAL CRIC


AIRWAY: 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.

In asthmatic patients, continuous monitoring is required to reduce the risk of respiratory depression or arrest.

CLINICAL CONTRA-INDICATIONS Respiratory or Cardiac Arrest Agonal respirations Persistent nausea/vomiting Inability to control airway Penetrating chest trauma / pneumothorax

PROCEDURE 1) Ensure adequate oxygen supply to ventilation device. 2) Explain the procedure to the patient. 3) Consider placement of a nasopharyngeal airway. 4) If the Positive End Expiratory Pressure (PEEP) is adjustable on the CPAP device, adjust the

PEEP beginning at 0 cmH2o of pressure and slowly titrate to achieve a positive pressure as follows: ( or insert proper valve into disposable CPAP)

5) 5-10 cmH2O for pulmonary edema, near drowning, possible aspiration or pneumonia 6) 3-5 cmH2O for COPD 7) Place the delivery mask over the mouth and nose. Oxygen should be flowing through the

device at this point. 8) Secure the mask with provided straps starting with the lower straps until minimal air leak

occurs. 9) Evaluate the response of the patient assessing breath sounds, oxygen saturation, and general

appearance. 10) Titrate oxygen levels to the patient’s response. 11) Encourage the patient to allow forced ventilation to occur. Observe closely for signs of

complications. 12) If patient cannot tolerate procedure

ATIVAN (option) VERSED (option) KETAMINE (option)

13) Document time and response on PCR.

NOTES Do not initiate this therapy if patient is lying flat. Stretcher must be at a minimum of 30 degrees.

MINIMUM CERTIFICATION LEVEL EMT-Basic EMT-Paramedic (in unable to tolerate procedure)

AIRWAY: CPAP


AIRWAY: KING TUBE CLINICAL INDICATIONS

Cardiac arrest where initial BLS airway management has been completed per protocol or sufficient personnel are present to perform without interruption in the other cardiac arrest care.

Non-cardiac arrest patient without a gag reflex for whom at least one failed intubation attempt has occurred OR the King Tube can be placed more rapidly or with less interruption to care.

Appropriate intubation is impossible due to patient access or difficult airway anatomy.

CLINICAL CONTRA-INDICATIONS Obstructive facial trauma.

PROCEDURE 1) Prepare, position and oxygenate the patient with 100% Oxygen if needed. 2) Choose King tube size per package recommendations. 3) Check the cuffs for proper inflation and deflation. 4) Apply chin lift and introduce device to corner of mouth. 5) Advance tip between tongue and soft palate rotating tube to midline. 6) Without excessive force, advance tube until base of connector aligns with teeth or gums. 7) Inflate the cuff per the manufacturer’s recommendations until a seal is obtained. 8) Connect the King tube to the BVM, ventilate, and slowly withdraw tube until ventilation

becomes easy and free flowing (normal tidal volume with minimal airway pressure.) 9) Confirm placement with minimum of 5 confirmation methods, including ETCO2. 10) If necessary, adjust cuff inflation pressure to maximize seal. 11) Secure King tube and apply c-collar to help limit movement of patient’s head. 12) Re-verify King tube placement after every move and upon arrival in the ED. 13) Document procedure, time, and result on the PCR.

NOTES THIS AIRWAY MAY NOT PREVENT ASPIRATION OF STOMACH CONTENTS. This airway is considered an “alternate intubation” for all WCEMS protocol purposes.


AIRWAY: KING TUBE


AIRWAY: NASAL INTUBATION CLINICAL INDICATIONS

A spontaneously breathing patient in need of intubation (inadequate respiratory effort, evidence of hypoxia or CO2 retention, or need of airway protection).

Rigidity or clenched teeth prohibiting other airway procedures. CLINICAL CONTRA-INDICATIONS

Non-breathing or near apneic patient. Known or likely fracture / instability of mid-face secondary to trauma.

PROCEDURE 1) Prepare, position and oxygenate patient with 100% oxygen. 2) Choose proper ET tube (about 1mm less than for oral intubation). 3) Lubricate ET tube generously water soluble lubricant such as Lidocaine Jelly or similar. 4) Pass the tube thru largest nostril with the beveled edge against the nasal septum and

perpendicular to the facial plate. 5) Use forward, lateral back and forth rotating motion to advance the tube. Never force the

tube. 6) Continue to advance the tube noting air movement through it. Consider the BAAM whistle

to assist with this. 7) Advance the tube quickly past the vocal cords during inspiration. 8) Inflate the cuff. 9) Attach BVM. 10) Confirm placement with minimum of 5 confirmation methods including ETCO2. 11) Secure tube and apply c-collar to help limit movement of patient’s head. 12) Re-verify tube placement after every move and upon arrival in the ED. 13) Document procedure, time, and result on the PCR.

NOTES Use of ELM may assist procedure.

MINIMUM CERTIFICATION LEVEL EMT-Intermediate

AIRWAY: NASAL INTUBATION


AIRWAY: NEBULIZER THERAPY CLINICAL INDICATIONS

Patients experiencing bronchospasms. As defined in Respiratory Protocols.

PROCEDURE 1) Gather necessary equipment. 2) Assemble the nebulizer kit. 3) Instill the premixed drug into the reservoir well of the nebulizer.

ALBUTEROL ALBUTEROL / ATROVENT combination.

4) Nebulizer may be handheld thru mouthpiece, attached to NRB or BVM , or to CPAP inlet. 5) Connect nebulizer device to oxygen supply at adequate flow pressure to produce a steady,

visible mist. 6) The treatment should last until the solution is depleted. 7) Monitor the patient for medication effects. This should include an assessment of the

response to the treatment and reassessment of vital signs, EKG, and breath sounds. 8) Document treatment, dose and route on the PCR.

MINIMUM CERTIFICATION LEVEL EMT-Basic EMT-Paramedic (Atrovent)

AIRWAY: NEBULIZER THERAPY


AIRWAY: OROTRACHEAL INTUBATION CLINICAL INDICATIONS

Inability to adequately ventilate a patient with BVM mask Transport distance requires a more advanced airway. Unconscious patient without a gag reflex who is apneic or is demonstrating inadequate

respiratory effort. PROCEDURE 1) Prepare, position and oxygenate the patient with 100% oxygen. 2) PHARMACOLIGICAL ASSISTED INTUBATION PROCEDURE as needed. 3) Select and prepare equipment.

Proper size ETT Bougie Suction Etc.

4) Using laryngoscope, visualize vocal cords (use BURP to assist you). 5) Visualize bougie passing through the vocal cords and ensure “holdup” is felt. 6) Without losing sight of vocal cords, have assistant slide ETT over bougie. 7) Take control of ETT as assistant holds bougie in place. 8) Visualize ETT passing over bougie and through the vocal cords. 9) Limit each intubation attempt to 30 seconds, maintaining SAO2 between attempts. 10) Remove laryngoscope. 11) Inflate cuff. 12) Attach BVM. 13) Confirm placement with minimum of 5 confirmation methods including ETCO2. 14) Secure tube and apply c-collar to help limit movement of patient’s head. 15) Re-verify tube placement after every move and upon arrival in the ED. 16) Document ETT size, time, result, and placement depth at patient’s teeth on the PCR. Also

document all devices used for confirmation. 17) Consider placing an NG or OG tube to clear stomach after the airway is secured.

NOTES Consider King Tube if orotracheal intubation attempts are unsuccessful. Determine pediatric tube sizes based on Broselow-Luten tape. If tube is too small to fit over bougie, use stylet inside ETT if appropriate.

MINIMUM CERTIFICATION LEVEL EMT-Intermediate (for intubation) EMT-Paramedic P3 (for PAI Procedure)

AIRWAY: OROTRACHEAL INTUBATION


AIRWAY: SUCTIONING CLINICAL INDICATIONS

Obstruction of the airway (secondary to secretions, blood or any other substance) in a patient currently being assisted by an airway adjunct such as nasotracheal tube, endotracheal tube, King tube, tracheostomy tube or cricothyrotomy tube.

Obstruction of the airway (secondary to secretions, blood or any other substance) in a patient who cannot maintain or keep their airway clear.

PROCEDURE 1) Ensure suction device is working. 2) Pre-oxygenate as possible. 3) If suctioning thru a pre-applied airway adjunct:

a. Attach suction catheter to suction device. b. Using the suprasternal notch and the end of the airway that suction will pass

through as your guides, measure the depth of insertion of the suction catheter (judgment must be used for depth on cricothyrotomy or tracheostomy tubes).

c. Remove ventilation devices as needed. d. With thumb port of catheter uncovered, insert tip into airway device. e. Once desired depth is reached, occlude thumb port and remove slowly. f. A small amount of normal saline may be used to loosen secretions.

4) If suctioning oropharynx only: a. Attach rigid catheter to suction device. b. Explain procedure to patient if needed. c. Inspect for anything that may occlude airway if dislodged by catheter (false teeth,

etc.) d. Use catheter to remove all secretions. e. The alert patient may assist with this procedure.

5) Reattach any ventilation devices that were removed. 6) Record time and result of suctioning on PCR.

MINIMUM CERTIFICATION LEVEL EMT-Basic

AIRWAY: SUCTIONING


ASSESSMENT: ADULT CLINICAL INDICATIONS

Any patient requesting assistance that is too large to be measured with a Broselow-Luten Tape.

PROCEDURE 1) Scene size up, including universal precautions, scene safety, environmental hazards, need

for additional resources, bystander safety, and patient and family interaction. 2) Initial assessment includes a general impression, as well as status of patient’s ABCs. 3) Control major hemorrhage and assess overall priority of the patient. 4) Assess mental status (AVPU) and disability (GCS). 5) Perform focused history and physical based on patient’s chief complaint while making

efforts to protect patient privacy and modesty. 6) Assess need for critical interventions. If none are anticipated, downgrade or cancel

additional responding units as appropriate. 7) Complete critical interventions and perform complete secondary exam to include a baseline

set of vital signs. 8) Maintain an ongoing assessment throughout transport, to include patient response, possible

complications of interventions, need for additional interventions and assessment of evolving patient complaints / condition.

9) Document all findings and information associated with the assessments, procedures performed, and medications administered on the PCR.


ASSESSMENT: ADULT


ASSESSMENT: PEDIATRIC CLINICAL INDICATIONS

Any child that can be measured with a Broselow-Luten Tape. PROCEDURE 1) Scene size up, including universal precautions, scene safety, environmental hazards, need

for additional resources, bystander safety, and patient and family interaction. Take reasonable steps to protect privacy and modesty.

2) Assess patient using the pediatric triangle of ABCs. Airway and appearance:

speech/cry, muscle tone, inter-activeness, look/gaze, movement of extremities.

Work of breathing: absent or abnormal airway sounds, use of accessory muscles, nasal flaring, body positioning.

Circulation to skin: pallor, mottling, cyanosis

3) Establish spinal immobilization if suspicion of spinal injury. 4) Establish responsiveness appropriate for age (AVPU, GCS, etc.). 5) Color code using Broselow-Luten tape. 6) Assess disability

Pulse, motor function, sensory function, pupillary reaction. 7) Perform a focused history and physical exam. Pediatric patients unable to verbalize their

own complaint should be fully exposed for assessment. 8) Record vital signs. 9) Include immunizations, allergies, medications, past medical history, last meal and events

leading up to injury or illness. 10) Treat chief complaint per protocol.

NOTES Pediatric patients easily experience hypothermia and should not be left uncovered any

longer than necessary to perform an exam. MINIMUM CERTIFICATION LEVEL

ECA ASSESSMENT: PEDIATRIC


AUTO-INJECTOR CLINICAL INDICATIONS

Patients experiencing severe airway compromise secondary to anaphylaxis or asthma. PROCEDURE 1) Attempt to remove irritant. 2) Ensure proper size auto-injector for patient.

Adult – 0.3 mg Pediatric – 0.15 mg

3) Ensure medication is not expired and not discolored. 4) Remove safety cap. 5) Place tip of auto-injector against the lateral aspect of the patient’s thigh, midway between

waist and knee. 6) Push firmly against thigh until auto-injector activates. 7) Hold auto-injector in place for 10 seconds to allow all medication to be expelled. 8) Properly dispose of device. 9) Reassess and continue treating per appropriate protocol. 10) Document procedure, time and patient response on PCR.


AUTO-INJECTOR


BLOOD GLUCOSE ANALYSIS CLINICAL INDICATIONS

Patients with suspected hypoglycemia or hyperglycemia (diabetic emergency, change in mental status, bizarre behavior, etc.).

PROCEDURE 1) Gather and prepare equipment. 2) Place correct amount of blood on reagent strip or site on glucometer per the manufacturer’s

instructions. 3) Time the analysis as instructed by the manufacturer. 4) Document the glucometer reading and treat the patient as indicated by the analysis and

protocol. 5) Repeat glucose analysis as indicated for reassessment after treatment and as per protocol.

NOTES Blood samples for analysis should be obtained through a finger stick. Venous blood

samples may produce artificially high blood glucose values and should be avoided due to this and the increased risk of needle stick.


BLOOD GLUCOSE ANALYSIS


CAPNOGRAPHY CLINICAL INDICATIONS

Capnography shall be used as soon as possible in conjunction with any airway management adjunct, including orotracheal, nasotracheal, cricothyrotomy, Blind Insertion Airway Device (BIAD) or BVM.

Capnography should also be used on all patients treated with CPAP, Magnesium and/or Epinephrine for respiratory distress.

Use as needed on appropriate patients for diagnosing possible hypoxemia. PROCEDURE 1) Attach appropriate capnography sensor to monitor and adjunct as needed. 2) Note ETCO2 level and waveform changes. These will be documented on each respiratory

failure, cardiac arrest, or respiratory distress patient. 3) The capnometer shall remain in place with the airway and be monitored throughout the pre-

hospital care and transport. 4) Any loss of CO2 detection or waveform indicates an airway problem and should be

investigated, corrected and documented. 5) The capnogram should be monitored as procedures are performed to verify or correct the

airway problem. 6) Document the procedure and results on the PCR.

NOTES This procedure includes inline and sidestream capnography. In all patients with a pulse, an ETCO2 >20 is anticipated. In the post-resuscitation patient, no effort should be made to lower ETCO2 by

modification of the ventilatory rate that exceeds 12/minute. MINIMUM CERTIFICATION LEVEL

EMT-Basic CAPNOGRAPHY


CHEST DECOMPRESSION CLINICAL INDICATIONS

Suspected tension pneumothorax in pre-arrest patient presenting with clinical signs of shock and at least one of the following:

Jugular vein distention. Tracheal deviation away from side of injury. Absent or decreased breath sounds on affected side. Increased resistance when ventilating patient.

Patients in traumatic arrest with chest or abdominal trauma for whom resuscitation is indicated. These patients may require decompression even in the absence of the signs above.

CLINICAL CONTRA-INDICATIONS Bilateral decompression without positive pressure ventilations.

PROCEDURE 1) Administer high flow oxygen. 2) Identify and use alcohol or iodine solution to prep the site.

Locate 2nd intercostal space, mid-clavicular line on the same side as suspected pneumothorax.

Alternatively, as a last resort, lateral placement may be used at the 4th ICS mid-axillary line.

3) Insert the catheter into skin over 3rd rib and direct it just over the top of the rib into the ICS. 4) Advance the catheter through the parietal pleura until a “pop” is felt and air or blood exits

under pressure through the catheter, then advance catheter only to chest wall. 5) Remove the needle, leaving the plastic catheter in place. 6) Secure the catheter hub to the chest wall. 7) Attach a one-way valve to catheter hub to control air flow.

NOTES If one way valve is not available:

Attach the cutoff finger from an exam glove to the glove to act as a “flutter” valve.

Attaching a ½ filled syringe of normal saline to catheter prior to insertion will allow a visible means of seeing effectiveness of air release.

Remove syringe after insertion. MINIMUM CERTIFICATION LEVEL

EMT-Paramedic CHEST DECOMPRESSION


CHILDBIRTH CLINICAL INDICATIONS

Imminent delivery with crowning. PROCEDURE 1) Delivery should be controlled so as to allow a slow, controlled delivery of the infant. This

will prevent injury to the mother and infant. Placed folded sterile towel to perineum and hold slight pressure to prevent tearing.

2) Consider additional resources as there will be two potential patients. 3) Support the infant’s head as needed. 4) If the umbilical cord is surrounding the neck, slip it over the head. If unable to free the cord

from the neck, double clamp the cord and cut between the clamps. 5) Suction airway with a bulb syringe. 6) Grasping the head with hands over the ears, gently pull down to allow delivery of the

anterior shoulder. 7) Gently pull up on the head to allow delivery of posterior shoulder. 8) Slowly deliver the remainder of the infant. 9) Clamp the cord 2 inches from the abdomen with 2 clamps and cut between the clamps. 10) Record APGAR scores at 1 and 5 minutes. 11) Follow NEWBORN PROTOCOL for further treatment. 12) The placenta will deliver spontaneously. Do not force the delivery. 13) Massaging the uterus may decrease bleeding by facilitating uterine contractions.


CHILDBIRTH


DIFFICULT AIRWAY EVALUATION CLINICAL INDICATIONS

Between 1-3% of patients who require endotracheal intubation have airways that make intubation difficult. Recognizing these patients allows the paramedic to proceed with caution and keep as many options open as possible. It also allows the paramedic to prepare additional equipment (such as cric kit) that may not ordinarily be part of a standard airway kit. The pneumonic LEMON is useful in evaluating patients for signs that may be consistent with a difficult airway and should raise the paramedic’s index of suspicion.

PROCEDURE 1) LOOK externally

External indicators of either difficult intubation or difficult ventilation include: Presence of a beard or mustache Abnormal facial shape Extreme cachexia (loss of body mass from Cancer, AIDS, etc.) Edentulous mouth (toothless) Obesity Large front teeth Short neck

2) EVALUATE (3-3-2 rule) 3 fingers between the patient’s upper and lower teeth (with mouth open) 3 fingers between tip of jaw and beginning of the neck (under the chin) 2 fingers between thyroid notch and floor of mandible (top of the neck)

3) MALLAMPATI Patient in sitting position, head in neutral position, mouth open, tongue protruding

Class I (Easy) = visualization of the soft palate, uvula, fauces and pillars Class II = visualization of soft palate, fauces and uvula Class III = visualization of soft palate and base of uvula Class IV(difficult) = soft palate not visible at all

4) OBSTRUCTION Besides the obvious difficulty if the airway is obstructed with a foreign body, the

provider should also consider other obstructions such as tumor, abscess, or expanding hematoma

5) NECK MOBILITY Ask the patient to place their chin on their chest and to tilt their head backward as

far as possible. Obviously, this will not be possible in the immobilized trauma patient


DIFFICULT AIRWAY EVALUATION


EXTERNAL PACING CLINICAL INDICATIONS

Patients with symptomatic bradycardia (less than 60 per minute) with signs and symptoms of inadequate cerebral or cardiac perfusion such as:

Chest pain, hypotension, pulmonary edema, AMS, ventricular ectopy. Patients in asystole (must be done early to be effective). Patients in PEA, where the underlying rhythm is bradycardic and correctable causes have

been treated. PROCEDURE 1) Attach standard 4 lead monitoring leads. 2) Apply defibrillation / pacing pads. 3) Select pacing option. 4) Adjust HR to 70 BPM for adult and 100 BPM for child. 5) Note pacer spikes on EKG screen. 6) Slowly increase output until capture of electrical rhythm on the monitor. 7) If unable to capture while at maximum current output, stop pacing immediately. 8) If capture observed on monitor, check for corresponding pulse and assess vital signs. 9) Consider use of sedation if patient is uncomfortable.

KETAMINE (option) VERSED (option) ATIVAN (option)

10) Document the dysrhythmia and the response to external pacing with appropriate EKG strips on the PCR.

MINIMUM CERTIFICATION LEVEL EMT-Paramedic

EXTERNAL PACING


GASTRIC TUBE CLINICAL INDICATIONS

Gastric decompression in patients with advanced airways placed or anticipated. PROCEDURE 1) Choose appropriate size tube. 2) Estimate insertion length by superimposing the tube over the body from the nose to the

stomach. 3) Flex the neck, IF NOT CONTRAINDICATED, to facilitate esophageal passage. 4) Lubricate distal end of tube and pass thru the patient’s nostril along the floor of the nasal

passage. Do not orient the tip UPWARDS, as this will pass tube into turbinates and increase difficulty and cause bleeding.

Alternatively, the tube may be passed thru the gastric lumen of the King tube if this has been utilized.

5) In the setting of an unconscious, intubated patient or a patient with facial trauma, oral insertion of the tube may be considered or preferred.

6) Continue to advance the tube gently until appropriate depth is reached. 7) Confirm placement by injecting 60cc of air and auscultate for the “swish” of air over the

stomach. Additionally, aspirate gastric contents to confirm placement. 8) Secure the tube. 9) Decompress the stomach of air and contents by connecting the tube to suction or manually

aspirating with a large catheter tip syringe. 10) Document the procedure, time, and result on the PCR.

NOTES Decompressing the stomach improves the effectiveness of CPR.


GASTRIC TUBE


INTRANASAL ADMINISTRATION CLINICAL INDICATIONS

Administration route for approved medications into the patient’s nasal mucosa when other routes are unavailable, deemed unsafe to attempt, or would delay patient treatment.

CLINICAL CONTRA-INDICATIONS Nasal trauma. Nasal discharge / congestion will reduce medication effectiveness. All medication contraindications still apply to IN use.

PROCEDURE 1) Draw up total desired dose of approved medication into appropriate syringe. 2) Remove needle from syringe and attach atomization device per manufacturer’s instructions. 3) Insert into nare and rapidly deliver ½ of total dose into each nare. 4) Document medication, time, dose, route and effectiveness on PCR.

NOTES Approved medications are :

VERSED FENTANYL NARCAN

Desired amount for IN is ¼ to ½ cc per nare. Up to 1cc is acceptable, but effects may be lessened due to runoff from nare.

MINIMUM CERTIFICATION LEVEL EMT-Intermediate (Narcan) EMT-Paramedic (Versed / Fentanyl)

INTRANASAL ADMINISTRATION


MANUAL DEFIBRILLATION CLINICAL INDICATIONS

Cardiac arrest with V-Fib or Pulseless V-Tach. CLINICAL CONTRA-INDICATIONS

Patient has a pulse. No EMT-Paramedic on location.

PROCEDURE 1) Ensure chest compressions are adequate and interrupted only when absolutely necessary. 2) Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation. 3) Apply hands-free pads per manufacturer’s instructions. Use alternative placement when

implanted devices (pacemakers, etc.) occupy preferred pad positions. 4) Charge the defibrillator

Adult - 360 joules. Pediatric - 2 joule/kg

Repeat at 4 joule/kg for all further attempts 5) Hold compressions, assertively state “CLEAR” and visualize that no one, including yourself,

is in contact with patient. 6) Deliver the shock by depressing the shock button. 7) Immediately resume CPR. After 2 minutes, analyze rhythm and check for pulse only if

appropriate for rhythm. 8) Repeat this procedure every 2 minutes as indicated by patient response and EKG rhythm.

NOTES Keep interruption of CPR as brief as possible. Adequate CPR is a key to successful

resuscitation. If pulse returns, use POST RESUSCITATION PROTOCOL.


MANUAL DEFIBRILLATION


PHARMACOLOGICAL ASSISTED INTUBATION (PAI)

CLINICAL INDICATIONS Patients with a gag reflex requiring sedation/paralysis to facilitate endotracheal intubation.

CLINICAL CONTRA-INDICATIONS Any circumstance where there is a high likelihood of intubation or mechanical ventilation

failure. PROCEDURE 1) Gather and prepare equipment. Ensure all equipment needed for procedure and additional

equipment for difficulties that may be encountered are readily available and within reach. 2) Attach EKG and pulse oximetry. 3) Preoxygenate patient using NRB with 100% oxygen.

Withhold BVM ventilations to prevent gastric inflation unless SPO2 saturations fall below 95% and cannot be raised with NRB use.

4) Sedate patient. ETOMIDATE (option) KETAMINE (option)

5) Paralyze patient. ROCURONIUM

6) After successful paralysis AIRWAY: OROTRACHEAL INTUBATION PROCEDURE

7) If ETOMIDATE was used for sedation FENTANYL for pain VERSED for continued sedation

8) If KETAMINE was used for sedation KETAMINE - Maintenance dose as needed

9) Post intubation paralytic is rarely needed, but may be used when medically appropriate ROCURONIUM

10) Continue appropriate protocol. 11) Document procedure, time, medications and result on the PCR.

NOTES Neuromuscular blockers should never be administered without proper sedation. For pediatric patients, Atropine is to be given after completion of PAI if bradycardia

persists. MINIMUM CERTIFICATION LEVEL

EMT-Paramedic P3 PHARMACOLOGICAL ASSISTED INTUBATION


PULSE OXIMETRY CLINICAL INDICATIONS

Patients with suspected hypoxemia. PROCEDURE 1) Apply probe to patient’s finger or any other site as recommended by the device

manufacturer. 2) Allow machine to register saturation level. 3) Record time and initial saturation percent on room air on PCR. 4) Verify pulse rate on machine with actual manual pulse. 5) Monitor critical patients continuously until arrival at ER. 6) Document percent of saturation every time vital signs are taken and in response to therapy

for correcting hypoxemia. 7) In general, normal saturation is 97-99% and requires no further oxygen intervention. Below

94%, suspect respiratory compromise and treat appropriately. 8) Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data

provided by the device. 9) Factors which may reduce the reliability of the pulse oximetry reading include:

Poor peripheral circulation (blood volume, hypotension, hypothermia). Excessive motion. Fingernail polish. Carbon monoxide. Irregular heart rhythms. Jaundice. Placement of BP cuff on same extremity.


PULSE OXIMETRY


RESTRAINT CLINICAL INDICATIONS

Any patient who may harm themselves or others may be gently restrained to prevent injury. This restraint must be in a humane manner and used only as a last result.

CLINICAL CONTRA-INDICATIONS Other means available for safely transporting patient.

PROCEDURE 1) Attempt least restrictive means of managing the patient. 2) Request law enforcement assistance. 3) Ensure there are sufficient personnel available to physically restrain the patient safely. 4) Restrain patient in a lateral or supine position. No devices such as backboards, splints, or

other devices will be on top of the patient. The patient will never be restrained in the prone position.

5) The patient must be under constant observation by the EMS crew at all times. This includes direct visualization as well as cardiac, ETCO2 and pulse oximetry monitoring.

6) The extremities that are restrained will have a PMS check at least every 10 minutes. The first of these checks will occur as soon as possible after placement of restraints. These MUST be documented in PCR.

7) Documentation on PCR will include reason for restraints, type of restraint used and time restraints were placed.

8) If the above actions are unsuccessful, or if patient is resisting the restraints, consider administration of medications to assist in restraint based on combativeness of patient.

VERSED (option) ATIVAN (option) KETAMINE (option)

9) Consider reasons for behavior, and follow appropriate protocol ALTERED MENTAL STATUS PROTOCOL BEHAVIORAL EMERGENCY PROTOCOL HEAD TRAUMA PROTOCOL DIABETIC COMPLICATION PROTOCOL EXCITED DELIRIUM PROTOCOL

NOTES If patient is restrained by law enforcement personnel with handcuffs or other devices

that cannot be removed by EMS, an officer must accompany the patient to the ER in the transporting vehicle.

MINIMUM CERTIFICATION LEVEL EMT-Paramedic (due to cardiac monitoring)

RESTRAINT


SPINAL IMMOBILIZATION CLINICAL INDICATIONS

Need for spinal immobilization as determined by C-SPINE CLEARANCE PROTOCOL. PROCEDURE 1) Gather backboard, webbing, c-collar and head rolls or other appropriate equipment based on

patient’s size and needs. 2) Explain procedure to patient. 3) Place c-collar while maintaining in-line stabilization.

This stabilization, provided by 2nd rescuer, should not involve traction or tension. 4) Once collar is secure, 2nd rescuer should still maintain their position to ensure stabilization. 5) Logroll patient into position on backboard, checking status of patient’s back during

maneuver. If unable to logroll onto backboard due to space restraints, such as inside vehicle,

patient is to be moved into supine position on backboard using safest method available.

6) Stabilize the patient with webbing and head rolls or other similar device. Tape will NOT be used for anything other than emergency extrication and webbing will be applied as soon as possible thereafter.

7) Patient’s body must be secured to backboard prior to securing head. 8) Once the patient’s head is secured to the backboard, the 2nd rescuer may release manual

stabilization. 9) Document the time of procedure and materials used in the PCR.

NOTES Some patients, due to size or age, will not be able to be immobilized with standard

methods. Never force a patient into position to immobilize them. Such situations may be so extreme that a rescuer may be required to maintain manual stabilization throughout the transport to the ER.


SPINAL IMMOBILIZATION


SPLINTING CLINICAL INDICATIONS

Immobilization of an extremity for transport due to suspected fracture, sprain or injury. PROCEDURE 1) Assess and document PMS prior to splinting.

a. If no pulse present and fracture suspected, consider 1 attempt at reduction of fracture to attempt to establish pulses.

b. If unsuccessful at attempt, transport rapidly. 2) Remove all clothing from the extremity. 3) Attempt to splint in correct anatomical position. 4) Select a site to secure the splint both proximal and distal to area of suspected injury. 5) Do not secure splint directly over the injury. 6) Place the splint and secure with appropriate bandage material. 7) Document PMS after placement. If any of the 3 parameters has declined, remove splint and

reassess. 8) If a femur fracture is suspected and there is no evidence of pelvic fracture or instability, the

following procedure may be followed for placement of traction splint. a. Place ankle device. b. Place proximal end of traction splint on the posterior side of the affected extremity,

being careful to avoid placing too much pressure on genitalia or open wounds. Make certain the splint extends proximal to the suspected fracture. If the splint will not extend in such a manner, reassess possible involvement of the pelvis.

c. Extend the distal end of the splint at least 6 inches beyond the foot. d. Attach ischial strap. e. Attach ankle device to traction crank. f. Pull traction and maintain it by tightening ankle device to crank device. g. Attach all remaining straps to secure splint. h. Reassess PMS. If any of the 3 parameters has declined, remove splint and reassess.

9) Document time, type of splint, pre and post assessment of PMS in the PCR.


SPLINTING


SQ and IM INJECTIONS CLINICAL INDICATIONS

When medication administration is necessary and the medication must be given via the SQ (not auto-injector) or IM route or as an alternative route in selected medications.

CLINICAL CONTRA-INDICATIONS Medication not prescribed for SQ or IM route.

PROCEDURE 1) Confirm medication and routes are appropriate. 2) Prepare equipment and medication. 3) Expel air from syringe. 4) Explain procedure to patient and reconfirm allergies. 5) The most common site for SQ injection is the arm.

Injection volume should not exceed 1cc. 6) Possible IM injection sites include the upper arm, buttocks and thigh.

Injection volume should not exceed 1cc for the arm. Injection volume should not exceed 2cc for thigh or buttock. For pediatric patients, the thigh should be utilized and volume should not exceed

1cc. 7) Expose the selected area and cleanse the injection site with alcohol. 8) Insert the needle into the skin with a smooth, steady motion.

SQ – 45 degree angle with skin pinched. IM – 90 degree angle with skin flattened.

9) Aspirate for blood. 10) Inject the medication. 11) Withdraw quickly and dispose of needle properly. 12) Apply pressure to the site. 13) Monitor the patient for desired effect as well as any possible side effects. 14) Document the medication, dose, route and time on the PCR.

MINIMUM CERTIFICATION LEVEL EMT-Basic (Epinephrine 1:1000 IM for severe respiratory distress) EMT-Intermediate (dependent on medication being given) EMT-Paramedic (dependent on medication being given)

SQ and IM INJECTIONS


SYNCHRONIZED CARDIOVERSION CLINICAL INDICATIONS

Unstable patient with a tachydysrhythmia (A-Fib with RVR, SVT, V-Tach). CLINICAL CONTRA-INDICATIONS

Pulseless patient. PROCEDURE 1) Ensure patient is attached properly to a monitor / defibrillator capable of synchronized

cardioversion. 2) Have all equipment prepared for defibrillation in case patient fails synchronized

cardioversion and condition worsens. 3) Consider the use of sedation medications.

VERSED ATIVAN

4) Set monitor / defibrillator to synchronized cardioversion mode. 5) Charge the defibrillator

Adult - 360 joules. Pediatric - 1 joule/kg

Repeat at 2 joule/kg for all further attempts 6) Make certain all personnel are clear of patient. 7) Press and HOLD the shock button until energy is delivered. Stay clear of patient until you are

certain the energy has been delivered. 8) Note patient response and perform immediate defibrillation if the patient’s rhythm has

deteriorated into a pulseless shockable rhythm (V-Fib, Pulseless V-Tach). 9) If the patient’s condition / rhythm is unchanged, repeat steps 2-8 above. 10) Repeat until efforts succeed. If unsuccessful after 3 attempts, consider consulting with

receiving ER or Supervisor. 11) Note procedure, response, and time in the PCR.

NOTES It may take the monitor / defibrillator several cardiac cycles to “synchronize”, so there

may be a delay between activating the cardioversion and the actual delivery of energy. MINIMUM CERTIFICATION LEVEL

EMT-Paramedic SYNCHRONIZED CARDIOVERSION


TASER PROBE REMOVAL CLINICAL INDICATIONS

Patient with Taser probes embedded subcutaneously in non-sensitive areas of skin. CLINICAL CONTRA-INDICATIONS

Patients with probes that have penetrated vulnerable areas of body as mentioned below should be transported for further evaluation and probe removal.

Probes embedded in skin above the clavicle level, female breasts, or genitalia. Suspicion that probe may be embedded in bone, blood vessel, or other sensitive structure.

PROCEDURE 1) Ensure patient properly restrained by law enforcement. 2) Ensure wires are disconnected from weapon. 3) Stabilize skin around probe using non-dominant hand. 4) Grasp probe by metal body using dominant hand. 5) Remove probe in single, quick motion. 6) Wipe wound with antiseptic wipe and apply dressing.

NOTES Taser probes are barbed metal projectiles that may embed themselves up to 13mm into

the skin. MINIMUM CERTIFICATION LEVEL

EMT-Basic TASER PROBE REMOVAL


TERMINATION of RESUSCITATION CLINICAL INDICATIONS

Resuscitation efforts may be terminated if patient meets ALL following criteria: 18 years or older. Cardiac arrest not associated with sudden external source:

Overdose / Toxic exposure. Hypo/Hyperthermia. Submersion. Electrocution. Burns. Trauma. Airway obstruction.

Must have successful intubation confirmed. King Tube is acceptable

Successful IV/IO with standard ALS procedures and medications applied. Resuscitation efforts applied for minimum of 30 minutes with no change from

asystolic rhythm. CLINICAL CONTRA-INDICATIONS

Persistent V-Fib / Pulseless V-Tach. Presence of any positive neurological sign (eye movement, etc.). Arrest witnessed by WCVEMS personnel. ROSC at any time during care.

PROCEDURE 1) If patient remains unresponsive to ALS measures and meets all Clinical Indications and none

of the Contraindications: a. EMT-Paramedic should approach family about termination of the efforts.

2) If approval to terminate is acknowledged by family: a. Tie off and knot all established IV lines. b. Remove IV fluid bag and other supplies from the site. c. Leave all IV/IO catheters and endotracheal/King tube in place along with any other

invasive procedure supplies. d. Notify communications center of termination and request law enforcement.

3) Remain attentive to the psychological needs of the family and provide support as needed.

MINIMUM CERTIFICATION LEVEL EMT-Paramedic (P4)

TERMINATION of RESUSCITATION


VENOUS ACCESS: EXISTING CATHETER CLINICAL INDICATIONS

Inability to obtain adequate peripheral venous access or intraosseous access. Access of an existing venous catheter for medication or fluid administration for life

threatening emergencies. PROCEDURE 1) Using sterile technique, withdraw 10cc of blood from port and discard syringe. 2) Using 5cc saline, access port and gently attempt to flush the saline. 3) If there are any difficulties, do not use port. 4) If there is no resistance, no infiltration, and no pain experienced by the patient, then port is

acceptable for use. 5) Begin administration of fluids or medications as required by appropriate protocol. 6) Continually observe area for infiltration. 7) Record procedure, any complications, and all fluids and/or medications administered on the

PCR.

NOTES Indwelling (under the skin) catheters are NOT to be accessed due to special equipment

involved for proper use. Maintain minimum drip rate of KVO to prevent clotting.


VENOUS ACCESS: EXISTING CATHETER


VENOUS ACCESS: EXTERNAL JUGULAR CLINICAL INDICATIONS

Critically ill patient >8 years of age who requires IV access and in whom an extremity vein or IO is not obtainable.

Can be attempted initially in life threatening events where no obvious extremity site is rapidly noted and IO access is contraindicated or undesirable.

CLINICAL CONTRA-INDICATIONS Other suitable site is readily available. Situation is not life threatening.

PROCEDURE 1) Place patient in supine, head down position. This helps distend the vein and prevents air

embolism. 2) Turn head to opposite side if no risk of cervical injury. 3) Prep the site with alcohol. 4) Align the catheter with the vein and aim towards the same side shoulder. 5) Puncture the vein midway between angle of jaw and the clavicle and cannulate the vein. 6) Attach IV and secure catheter. Avoid circumferential dressing or taping. 7) Document the procedure, time, and result on the PCR.


VENOUS ACCESS: EXTERNAL JUGULAR


VENOUS ACCESS: EXTREMITY CLINICAL INDICATIONS

Any patient where intravenous access is indicated. PROCEDURE 1) Saline locks may be used as an alternative plan to IV tubing and IV fluid in every protocol at

the discretion of the ALS professional. 2) Intraosseous access may be used where a threat to life exists as provided for in VENOUS

ACCESS: INTRAOSSEOUS PROCEDURE. 3) Use the largest catheter bore necessary based upon patient condition and vein size. 4) Fluid and setup choice is preferably:

Macro drip (10 gtt/cc) for trauma, hypovolemia or medical conditions. Micro drip (60 gtt/cc) for infusions and pediatric patients.

5) Inspect IV solution for expiration date, cloudiness, discoloration, leaks, or presence of particles.

6) Connect IV tubing to solution in sterile manner. Fill drip chamber ½ full and then flush tubing, bleeding all air bubbles from the line.

7) Place a tourniquet around extremity to restrict venous flow only. 8) Select a vein and appropriate gauge catheter. 9) Prep the skin with antiseptic solution. 10) Insert needle with the bevel up into the skin with a steady, deliberate motion until the bloody

flashback is visualized in the catheter. 11) Advance the catheter into the vein. Occlude catheter and remove needle. NEVER reinsert the

needle thru the catheter. Dispose of needle properly. 12) Attach saline lock and/or IV tubing. 13) Remove the tourniquet. 14) Open the IV to assure free flow of the fluid and then adjust the flow rate as clinically

indicated. 15) Cover the site with a sterile dressing and secure the IV and tubing. 16) Document procedure, time, and result on PCR.


VENOUS ACCESS: EXTREMITY


VENOUS ACCESS: INTRAOSSEOUS CLINICAL INDICATIONS

As the initial access in cardiac arrest. Patients where rapid, regular IV access is unavailable with any of the following:

Multisystem trauma with severe hypovolemia. Severe dehydration with vascular collapse and/or loss of consciousness. Respiratory failure / respiratory arrest.

CLINICAL CONTRA-INDICATIONS Fracture proximal to proposed IO site. History of Osteogenesis Imperfecta. Current or prior infection at proposed IO site. Previous IO insertion or joint replacement at the selected site.

PROCEDURE Humeral head

Place the patient palm on their umbilicus and elbow on the ground or stretcher. Use your thumb to identify humeral shaft, slide thumb towards humeral head with firm pressure. Locate tubercule by prominent bulge. Use the opposite hand to pinch inferior and anterior humerus ensuring you are midline on the humerus.

Proximal Tibia Identify anteromedial aspect of the proximal tibia (bony prominence below the knee

cap). The insertion location will be 1-2 cm (2 finger widths) below this. Distal Tibia

If patient >12 years of age, identify the anteriomedial aspect of the distal tibia (2cm proximal to the medial malleolus).

1) Don PPE. 2) Prepare appropriate intraosseous insertion device and other needed equipment. 3) Prep the site with antiseptic solution. 4) Insert IO needle following manufacturer’s instructions. 5) Attach syringe and flush the needle. 6) Attach IV line and adjust flow rate. A pressure bag may enhance flows. 7) Stabilize and secure the needle. 8) You may administer lidocaine in patients who experience infusion-related pain. 9) Always flush IO line with 10cc saline after any medication administration. 10) Document procedure, time, and result on the PCR.

MINIMUM CERTIFICATION LEVEL EMT-Intermediate EMT-Paramedic (Lidocaine)

VENOUS ACCESS: INTRAOSSEOUS


WOUND CARE: GENERAL CLINICAL INDICATIONS

Protection and care for open wounds prior to and during transport. PROCEDURE 1) Don PPE. 2) If active bleeding

a. Elevate wound if possible b. Hold direct pressure

3) Once bleeding is controlled a. Irrigate contaminated wounds

• This may have to be avoided if bleeding was difficult to control. 4) Consider pain management. 5) Cover wounds with sterile gauze / dressings.

a. Monitor PMS. 6) Monitor dressings during transport for bleeding. 7) Document wound and assessment and care on the PCR.


WOUND CARE: GENERAL


WOUND CARE: TOURNIQUET CLINICAL INDICATIONS

Life threatening extremity hemorrhage that cannot be controlled by other means. CLINICAL CONTRA-INDICATIONS

Non-extremity hemorrhage. Proximal extremity location where tourniquet application is not practical.

PROCEDURE 1) Place tourniquet 2 inches proximal to the wound. 2) Tighten per manufacturer’s instructions until hemorrhage stops and/or distal pulses in

affected extremity disappear. 3) Secure the tourniquet in place per manufacturer’s instructions. 4) Note time of tourniquet application and communicate this to receiving care providers. 5) Dress wounds per WOUND CARE: GENERAL PROCEDURE.

NOTES Once tourniquet is applied, do not remove it.


WOUND CARE: TOURNIQUET


MEDICATIONS



ACTIVATED CHARCOAL

TYPE: Suspension containing activated charcoal and Sorbitol INDICATIONS:

Ingestions of poisons or excessive amounts of certain medications Especially useful in treatment of aspirin, amphetamine, strychnine, Dilantin and

phenobarbital overdose CONTRAINDICATIONS:

Cyanide poisoning Ingestion of syrup of ipecac Of no value in poisoning due to methanol, corrosive substances, iron tablets and

organophosphates DOSAGE and ROUTES:

Adult 1 gram/kg PO Usual dose 25-50 grams

Pediatric

1 gram/kg PO Usual dose 10-30 grams

MINIMUM CERTIFICATION LEVEL: EMT-Basic

ACTIVATED CHARCOAL


ADENOSINE ADENOCARD

TYPE: Antiarrhythmic (rapid acting) INDICATIONS:

Narrow complex tachycardia CONTRAINDICATIONS:

2nd degree / 3rd degree AV block Caution in:

Pregnancy Wheezing

SIDE EFFECTS: Transient dysrhythmias, facial flushing, headache, dyspnea, hypotension, vertigo, nausea. Short lasting 1st, 2nd, 3rd degree AV blocks.

These effects should be self-limiting. Any prolonged effects should be treated with appropriate protocol.

DOSAGE and ROUTES: Give as rapid bolus over 1-2 seconds followed by rapid flush with 10cc flush.

Adult: IV/IO

Initial dose: 6 mg Subsequent dose: 12 mg (may repeat 1x) Max single dose: 12 mg Max total dose 30 mg

Pediatric: IV/IO

Initial dose: 0.1 mg/kg (max 6 mg) Subsequent dose: 0.2 mg/kg (max 12 mg) Max single dose: 12 mg Max total dose: 18 mg

MINIMUM CERTIFICATION LEVEL: EMT-Paramedic

ADENOSINE


ALBUTEROL PROVENTIL

TYPE: Beta 2 adrenergic bronchodilator INDICATIONS:

Wheezing Respiratory distress Inhaled irritant exposure Asthma Anaphylaxis

CONTRAINDICATIONS: Use cautiously in the following

Cardiovascular disorders Cardiac dysrhythmias Hypertension

SIDE EFFECTS: Palpitations Tachycardia Hypertension Body tremors

DOSAGE and ROUTES: 2.5 mg via nebulizer

Repeat as needed

NOTES: Accurate documentation of pulse rate, before, during and after treatment must be

noted. MINIMUM CERTIFICATION LEVEL:

EMT-Basic ALBUTEROL


ASPIRIN

TYPE: Anti-thrombotic INDICATIONS:

Non-traumatic chest pain CONTRAINDICATIONS:

Known hypersensitivity SIDE EFFECTS:

Prolonged bleeding time Gastric irritation Nausea and Vomiting

DOSAGE and ROUTES: Adult

324 mg PO

NOTES: Aspirin should be given regardless of daily use by Patient.


ASPIRIN


ATIVAN LORAZEPAM

TYPE: Benzodiazepine INDICATIONS:

Seizures Behavioral emergencies Anxiety Sedation

CONTRAINDICATIONS: Hypersensitivity to Benzodiazepines.

SIDE EFFECTS: Anterograde amnesia Sedation Weakness Confusion Hypotension Blurred vision Nausea and Vomiting


0.5 – 4mg slow IV/IO/IM Maximum 8 mg total dose

Pediatric 0.1mg/kg slow IV/IO/IM


ATIVAN


ATROPINE

TYPE: Parasympatholytic Anticholinergic INDICATIONS:

Symptomatic Bradycardia Organophosphate poisoning with heart rate < 60 bpm

CONTRAINDICATIONS: Heart rate >60 bpm Known history of Glaucoma

SIDE EFFECTS: Pupil dilation Dry mouth Thirst Headache Tachycardia

DOSAGE and ROUTES: Bradycardia

Adult 0.5 mg IV/IO

• Q 5 min until desired heart rate achieved Max total dose 3 mg

Pediatric 0.02 mg/kg IV/IO

• Minimum single dose 0.1 mg • Max single dose 0.5 mg

May repeat one time Organophosphate poisoning

Adult 2mg IV/IO/IM

• q 15 min until heart rate stabilizes Pediatric

0.05 mg/kg IV/IO • q 15 min until heart rate stabilizes

NOTES: A dose less than 0.5 mg in an adult or less than 0.1 mg in pediatrics or any dose given

too slowly may decrease rather than increase heart rate. May precipitate V-Tach or V-Fib, therefore, should be used in caution in the setting of

an AMI. MINIMUM CERTIFICATION LEVEL:

EMT-Paramedic ATROPINE


ATROVENT IPRATROPIUM BROMIDE

TYPE: Parasympatholytic Anticholinergic INDICATIONS:

Respiratory distress to assist Albuterol CONTRAINDICATIONS:

Glaucoma Allergy to soy products or peanuts

SIDE EFFECTS: Palpitations Anxiety Headache Nervousness Dry mouth Dizziness

DOSAGE and ROUTES: Only to be used in combination with Albuterol via nebulizer for 1x dose

< 10 kg 0.25 mg

> 10 kg 0.5 mg

NOTES: Single dose only. Do not administer without Albuterol.


ATROVENT


BENADRYL DIPHENHYDRAMINE

TYPE: Antihistamine INDICATIONS:

Allergic reaction Phenergan overdose

CONTRAINDICATIONS: Asthma

SIDE EFFECTS: Drowsiness Dry mouth Wheezing Blurred vision


12.5 – 50 mg IV/IO/IM Pediatric

1 mg/kg IV/IO/IM Max single dose

• 25 mg

NOTES: Should be used as an adjunct to epinephrine and other standard measures after the

acute symptoms of anaphylaxis have been controlled.


BENADRYL


CALCIUM CHLORIDE

TYPE: Salt solution INDICATIONS:

Calcium Channel Blocker overdose Cardiac arrest in renal failure patient

CONTRAINDICATIONS: Avoid use in patients taking Digoxin


500 – 1000 mg slow IV/IO Pediatric

20 mg/kg slow IV/IO

NOTES: Give as slow IV/IO push. Can cause V-Fib if given rapidly. Infiltration will cause necrosis. Do not give IM / SQ. Precipitates when mixed with Sodium Bicarbonate.


CALCIUM CHLORIDE


CARDIZEM DILTIAZEM

TYPE: Calcium Channel Blocker INDICATIONS:

Narrow complex ventricular rate control CONTRAINDICATIONS:

Newborns 2nd / 3rd degree AV block Hypotension or Cardiogenic shock IV Beta Blockers in last 24 hours Patients with A-Fib associated with WPW and short PR syndrome

SIDE EFFECTS: 2nd / 3rd degree AV block Hypotension Transient, benign PVCs


Initial dose 0.25 mg/kg slow IV/IO

• Maximum 20 mg Subsequent dose

0.35 mg/kg slow IV/IO • Maximum 25 mg

NOTES: May cause burning or itching at injection site. Consider ½ dose and titrating to effect for patients > 70 years old. Consider injecting desired dose into 100cc bag of saline and run at 50 ml/min with 60

gtts administration set.


CARDIZEM


DEXTROSE

TYPE: Simple monosaccharide sugar INDICATIONS:

Hypoglycemia CONTRAINDICATIONS:

Hyperglycemia SIDE EFFECTS:

Necrosis due to infiltration. DOSAGE and ROUTES:

Adults D50%

25 grams IV/IO/PR • Repeat based on blood glucose analysis

Pediatrics (> 3 kg to 36 kg) D25%

0.5gram/kg IV/IO/PR • Repeat based on blood glucose analysis

Newborn D10% (Dilute 1ml D50% into 4 ml saline)

0.5gram/kg IV/IO/PR • Repeat based on blood glucose analysis

NOTES: D50% is a thick solution and is easier to administer through a large bore catheter. Ensure IV/IO line in patent, Dextrose is extremely necrotic. Consider Dextrose PR if no IVaccess.

MINIMUM CERTIFICATION LEVEL: EMT-Intermediate

DEXTROSE


DOPAMINE INTROPIN

TYPE: Vasopressor INDICATIONS:

Shock or hypotensive states CONTRAINDICATIONS:

Hypoperfusion associated with trauma where intravascular volume depletion may be present. SIDE EFFECTS:

Hypertension Tachycardia Many side effects are dose related.

DOSAGE and ROUTES: 5 – 20 mcg/kg/min

Chart is based upon 1600mcg/ml Patient weight in kg Mcg/kg/min 2.5 5 10 20 30 40 50 60 70 80 90 100

5 * 1 2 4 6 8 9 11 13 15 17 19 10 1 2 4 8 11 15 19 23 26 30 34 38 15 1.4 3 6 11 17 23 28 34 39 45 51 56 20 2 4 8 15 23 30 38 45 53 60 68 75

Renal Dose 2 – 5 mcg/kg/min Beta Dose (Cardiac) 5 – 15 mcg/kg/min Alpha Dose (Vasopressor) > 15 mcg/kg/min Onset 2 – 4 minutes Duration 10 – 15 minutes

NOTES: May be deactivated by Sodium Bicarbonate. MAOIs and Bretylium may potentiate the effects. Do not use in traumatic hypovolemic conditions.


DOPAMINE


EPINEPHRINE ADRENALIN

TYPE: Vasopressor Sympathomimetic INDICATIONS:

Severe respiratory distress Cardiac arrest Bradycardia

SIDE EFFECTS: Palpitations / Tachycardia Anxiety / Tremors Hypertension

DOSAGE and ROUTES: Cardiac Arrest ( repeat every 3-5 minutes)

Adult 1 mg IV/IO (1:10,000)

Pediatric (max single dose 1mg) 0.01 mg/kg IV/IO (1:10,000)

Respiratory distress / Allergic reaction (May repeat q15 minutes to maximum dose of 1.2mg)

Adult 0.3 mg IM (1:1000) 0.1 mg IV/IO (1:10,000)

• Inject 1cc into 100cc saline to obtain slow push Pediatric (max single dose 0.3mg)

0.01 mg/kg IM (1:1000) Bradycardia

Adult 2 – 10 ug/minute

• See INFUSION RATE CHART Pediatric (max single dose 0.5mg)

0.01 mg/kg IV/IO (1:10,000) • Repeat every 3 – 5 minutes

NOTES: Dose may be administered IV/IO (1:10,000) versus IM (1:1000) in diminished perfusion

secondary to anaphylaxis. IV/IO injection produces an immediate and intensified response.

MINIMUM CERTIFICATION LEVEL: EMT-Basic – 1:1000 IM for severe respiratory distress EMT-Intermediate – Cardiac Arrest EMT-Paramedic

EPINEPHRINE


ETOMIDATE AMIDATE

TYPE: Sedative / Hypnotic INDICATIONS:

Pharmacological Assisted Intubation CONTRAINDICATIONS:

< 2 year old < 10 kg

SIDE EFFECTS: Hypotension Arrhythmias

DOSAGE and ROUTES: 0.3 mg/kg slow IV/IO

Duration 3 – 10 minutes

NOTES: Used as an alternative to Ketamine in PAI. 20 mg is an acceptable dose in the average adult patient.

MINIMUM CERTIFICATION LEVEL: EMT-Paramedic P3

ETOMIDATE


FENTANYL SUBLIMAZE

TYPE: Narcotic analgesic INDICATIONS:

Pain management CONTRAINDICATIONS:

Bradycardic arrhythmias Hypotension

SIDE EFFECTS: Hypotension Arrhythmias Hypoventilation Chest wall rigidity Nausea Vomiting

DOSAGE and ROUTES: 1-2 mcg/kg IV/IO/IM/IN

Repeat as needed

NOTES: Beware of over sedation. Be prepared to ventilate with BVM. Effects can be reversed with narcan.


FENTANYL


KETAMINE KETALAR

TYPE: Anesthetic Sedation agent

INDICATIONS: Sedation agent for:

Excited Delirium Pharmacological Assisted Intubation Life saving procedures which are being hindered due to patient anxiety (such as

entrapment or CPAP mask tolerance).

CONTRAINDICATIONS: Patients in whom a significant elevation of blood pressure would constitute a serious hazard Age > 60, or < 16

SIDE EFFECTS: Hypertension and/or tachycardia Laryngospasms Tonic/Clonic motions resembling seizures

DOSAGE and ROUTES: Pharmacological Assisted Intubation

Initial dose - 2 mg/kg IV/IO Maintenance dose – 1 mg/kg IV/IO

Excited Delirium Initial dose - 5 mg/kg IM Maintenance dose – 1 mg/kg IV/IO

Dissociative doses for procedures 0.5 mg/kg IV/IO

Repeat as needed Titrate to patient tolerance of procedure

NOTES: All IV/IO dosing should be administered slowly over 60 seconds. Rapid administration

will cause respiratory depression. Do not mix with other sedation / pain management medications.

MINIMUM CERTIFICATION LEVEL: EMT-Paramedic P4 – Initial dose for Excited Delirium EMT-Paramedic P3 – Pharmacological Assisted Intubation EMT-Paramedic P2 – All other situations

KETAMINE


LABETALOL NORMODYNE

TYPE: Beta Blocker INDICATIONS:

Symptomatic Hypertension Hypertension associated with CVA

CONTRAINDICATIONS: Asthma CHF 2nd or 3rd degree AV blocks Bradycardia Cardiogenic shock Any patient who has received IV Beta Blockers within the last few hours

SIDE EFFECTS: CHF Bradycardia Hypotension Dyspnea Weakness Sweating Nausea

DOSAGE and ROUTES: 10 mg slow IV/IO

May repeat or double dose every 10 minutes Total max of 150mg if no decrease in BP

NOTES: Monitor cardiac and respiratory status during administration. Keep patient supine during administration if possible.


LABETALOL


LIDOCAINE XYLOCAINE

TYPE: Anesthetic Antidysrhythmic INDICATIONS:

Ventricular Tachycardia. To prevent recurrence of V-Tach / Pulseless V-Tach / V-Fib after successful conversion. To reduce the pain associated with pressure infusion of fluids into the marrow space. PVC

CONTRAINDICATIONS: Bradycardia 2nd / 3rd degree AV block

SIDE EFFECTS: Decreased cardiac output Decreased blood pressure Reduce dose in patients > 70 years old presenting with CHF or shock.

DOSAGE and ROUTES: Ventricular Tachycardia / V-Fib / Pulseless V-Tach / PVC

Adult and Pediatric Initial dose

• 1 – 1.5 mg/kg IV/IO Subsequent doses

• 0.5 – 0.75 mg/kg Total max dose

• 3 mg/kg IO anesthetic

Adult 20 mg slow IO push

• Do not flush for at least 30 seconds Pediatric

0.2 mg/kg slow IO push • Total max 20 mg

Infusion 2 – 4 mg/minute of a 4 mg/ml solution using a 60 gtts administration set

Mg/min 2 3 4 Gtts/min 30 45 60

NOTES: If patient is bradycardic, treat rate first according to appropriate protocol before

administering Lidocaine. MINIMUM CERTIFICATION LEVEL:

EMT-Paramedic LIDOCAINE


MAGNESIUM SULFATE

TYPE: Electrolyte salt solution INDICATIONS:

Refractory V-Fib / Pulseless V-Tach Torsades de Pointes Eclampsia Refractory respiratory distress

SIDE EFFECTS: Hypotension Flushing, sweating and hypothermia Flaccid paralysis Depressed reflexes

DOSAGE and ROUTES: Refractory respiratory distress (over 10 minutes)

Adult 2 grams IV/IO

Pediatric 25 – 50 mg/kg IV/IO (maximum 2 grams)

All other indications (over 2 minutes)

Adult 2 grams IV/IO

Pediatric

25 – 50 mg/kg IV/IO (maximum 2 grams)

NOTES: Side effects are from too rapid administration. Do not give faster than 1 gram/minute. Consider mixing dosage into 100cc saline to prevent rapid administration.


MAGNESIUM SULFATE


MORPHINE SULFATE

TYPE: Narcotic analgesic INDICATIONS:

Pain management Anxiety

CONTRAINDICATIONS: Hypotension

SIDE EFFECTS: Itching, rash, urticaria Respiratory depression Disorientation Bradycardia Nausea / Vomiting


2 – 5 mg IV/IO Repeat every 5 – 10 minutes

• Total max 20 mg Pediatric

0.1 mg/kg IV/IO (max 5 mg) Single dose only

NOTES: For burn patients requiring transport to burn center, maximum adult dose can be

increased to 50 mg. If allergic reaction occurs, treat with Benadryl. If respiratory depression occurs, treat with Narcan.


MORPHINE SULFATE


NARCAN NALOXONE

TYPE: Synthetic narcotic antagonist INDICATIONS:

Narcotic overdose Reversal of respiratory depression associated with narcotic administration


0.5 – 2 mg IV/IO 1 – 2 mg IM/IN

Pediatric 0.01 mg/kg IV/IO/IM/IN

NOTES: Rapid administration may cause:

Projectile vomiting. Ventricular dysrhythmias. Death.

Titrate dosage based on patient’s respiratory condition, not their mental status. Some narcotics may outlast Narcan, so repeated dosing may be required. If respirations are being maintained with Narcan, there is no maximum dose.

MINIMUM CERTIFICATION LEVEL: EMT-Intermediate

NARCAN


NITROGLYCERIN SPRAY OR PASTE

TYPE: Vasodilator INDICATIONS:

Non-traumatic chest pain Hypertension Pulmonary edema

CONTRAINDICATIONS: Patients who have taken Viagra or Levitra in the past 24 hours or Cialis in the past 36 hours. Hypotension CVA signs/symptoms Use cautiously in right sided AMI

SIDE EFFECTS: Headache Dizziness Orthostatic hypotension Syncope Nausea Vomiting

DOSAGE and ROUTES: Spray

1 metered dose spray (0.4 mg) SL Q 5 min

• Total maximum 3 sprays Paste

½ - 2 inches according to systolic BP

• ½ inch 110 – 140 • 1 inch 141 – 180 • 1 ½ inch 181 – 200 • 2 inch >200

NOTES: If patient shows relief with SL spray but symptoms reappear after 3-5 minutes,

consider paste for sustained relief. Nitroglycerin should be given to patients while in an upright position or semi-reclined. Give only number of doses necessary for effective relief. If hypotension occurs remove paste and wipe area clean.

MINIMUM CERTIFICATION LEVEL: EMT-Basic (spray) EMT-Paramedic (paste)

NITROGLYCERIN


ORAL GLUCOSE

TYPE: Hypoglycemic Medication INDICATIONS:

Hypoglycemia CONTRAINDICATIONS:

Hyperglycemia Inability to swallow or protect airway

SIDE EFFECTS: None if used correctly

DOSAGE and ROUTES: Oral

1 tube by mouth Repeat as needed based on BGL and mental status

NOTES: Consider household food items such as orange juice and peanut butter & jelly following

Oral Glucose to the conscious patient.


ORAL GLUCOSE


ROCURONIUM ZEMURON

TYPE: Non-depolarizing neuromuscular blocker INDICATIONS:

Patients requiring Pharmacological Assisted Intubation paralysis Patients requiring post intubation paralysis

CONTRAINDICATIONS: Patient in which intubation will be extremely difficult or impossible Any patient that is not properly sedated

SIDE EFFECTS: Apnea Bradycardia

DOSAGE and ROUTES: Pre and Post intubation

1 mg/kg IV/IO

NOTES: Onset of paralysis is 1 – 3 minutes. Duration of paralysis is 30 – 60 minutes. Ensure proper sedation of patient during paralysis. May prolong the QTc in pediatric patients.

MINIMUM CERTIFICATION LEVEL: EMT-Paramedic P3

ROCURONIUM


SODIUM BICARBONATE NaHCO3

TYPE: Electrolyte Alkalinizer INDICATIONS:

Acidosis Tricyclic Overdose

CONTRAINDICATIONS: Patients who cannot tolerate an added salt load (CHF, etc) Hypokalemia

SIDE EFFECTS: Metabolic alkalosis Precipitates when mixed with Calcium Chloride May deactivate catecholamine Electrolyte imbalances Fluid retention

DOSAGE and ROUTES: Adults and children

8.4% solution 1 mEq/kg IV/IO

Infants 4.2% solution

1 mEq/kg IV/IO

NOTES: Adequate ventilations with effective CPR are the major “buffer agents” in cardiac

arrest. Sodium Bicarbonate is a Class III intervention (not useful or effective) in cardiac arrest

without proper intubation. Not recommended for routine use in cardiac arrest patients.


SODIUM BICARBONATE


SOLUMEDROL METHYLPREDNISOLONE

TYPE: Glucocorticoid Steroid INDICATIONS:

Allergic reaction Respiratory distress

CONTRAINDICATIONS: CHI CVA signs/symptoms

SIDE EFFECTS: Headache Hypertension Alkalosis Sodium and water retention


125 mg IV/IO Pediatric

2 mg/kg IV/IO Max total dose 125 mg

NOTES: For Act-o-vial use push down on top until fluid escapes into powder, swirl well to re-

constitute powder, draw into syringe, then administer. MINIMUM CERTIFICATION LEVEL:

EMT-Paramedic SOLUMEDROL


TYLENOL ACETAMINOPHEN

TYPE: Analgesic Antipyretic INDICATIONS:

Pediatric fever SIDE EFFECTS:

Gastric irritation DOSAGE and ROUTES:

Based on bottled concentration Confirm concentration on bottle prior to using chart

Concentration: 160mg/5ml (32mg/ml)

AGE WEIGHT DOSAGE 0 – 3 Months 6 – 11 Pounds 40 mg (1.25ml) 4 – 11 Months 12 – 17 Pounds 80 mg (2.5ml) 12 – 23 Months 18 – 23 Pounds 120 mg (3.75ml)

2 – 3 Years 24 – 35 Pounds 160 mg (5ml) 4 – 5 Years 36 – 47 Pounds 240 mg (7.5ml) 6 – 8 Years 48 – 59 Pounds 320 mg (10ml) 9 – 10 Years 60 – 71 Pounds 400 mg (12.5ml)

11 Years 72 – 95 Pounds 480 mg (15ml)

NOTES: Do not administer if last dose was less than 4 hours ago. Hepatic damage begins at overdoses of approximately 150 mg/kg.

MINIMUM CERTIFICATION LEVEL: EMT-Basic (PO) EMT-Intermediate (PR)

TYLENOL


VERSED MIDAZOLAM

TYPE: Benzodiazepine INDICATIONS:

Sedation Behavioral emergencies Anxiety Seizures

CONTRAINDICATIONS: Shock Hypotension

SIDE EFFECTS: Respiratory depression Apnea Hypotension Amnesia Drowsiness AMS


2 - 5 mg IV/IO 5 mg IM/IN

If unable/unsafe to establish IV/IO • Total max 20 mg

Pediatric 0.05 – 0.2 mg/kg IV/IO/IM/IN (max total dose 5mg)

NOTES: Emergency resuscitation equipment must be available when administering Versed. Dosing may need to be titrated based on vital signs.


VERSED


ZOFRAN ONDANSETRON

TYPE: Antiemetic INDICATIONS:

Nausea Vomiting

CONTRAINDICATIONS: Long Q-T Syndrome

SIDE EFFECTS: Anxiety and agitation Bradycardia Dizziness Shivering Skeletal muscle weakness/pain


4 mg slow IV/IO/IM May repeat x1

Pediatric < 40 kg

0.1 mg/kg slow IV/IO • May repeat x1

> 40 kg 4 mg IV/IO

• May repeat x1

NOTES: Do not administer Zofran IM to pediatric patients as it may cause extreme muscular

skeletal pain. MINIMUM CERTIFICATION LEVEL:

EMT-Paramedic ZOFRAN


GLASGOW COMA SCALE

Eye Opening Verbal Response Motor Response 4 Spontaneously 5 Oriented 6 Obey Commands 3 To Command 4 Confused 5 Localizes Pain 2 To Pain 3 Inappropriate Words 4 Withdraws from Pain 1 No Response 2 Incomprehensible 3 Flexion (Decorticate) 1 No Response 2 Extension (Decerebrate) 1 No Response

INFANT GLASGOW COMA SCALE

Eye Opening Verbal Response Motor Response 4 Spontaneously 5 Coos, Babbles 6 Spontaneous 3 To Command 4 Irritable Cries 5 Localizes Pain 2 To Pain 3 Cries to Pain 4 Withdraws from Pain 1 No Response 2 Moans, Grunts 3 Flexion (Decorticate) 1 No Response 2 Extension (Decerebrate) 1 No Response

APGAR SCALE (1 and 5 minutes post-birth)

Score 0 Points 1 Point 2 Points

Heart Rate Absent < 100 > 100

Respiratory Effort Absent Slow, Irregular Strong Cry

Muscle Tone Flaccid Some Flexion Active Motion

Reflex Irritability No Response Some Motion Vigorous Cry

Color Blue/Pale Body Pink/Extrs Blue Fully Pink


Renal Dose: 2 - 5mcg/kg/min

Beta Agonist dose: 5 – 15 mcg/kg/min Alpha Agonist dose: >15 mcg/kg/min

Pediatric Infusion at 0.1 mcg/kg/minute for initial, and titrate to effect at 0.1 – 1.0 mcg/kg/min

Dopamine Infusion 5-20mcg/kg/min using 60 gtts set

400mg into 250cc saline = 1600mcg/ml Patient Weight in kg

mcg/kg/min 2.5 5 10 20 30 40 50 60 70 80 90 100 5 mcg * 1 2 4 6 8 9 11 13 15 17 19 10mcg 1 2 4 8 11 15 19 23 26 30 34 38 15 mcg 1.4 3 6 11 17 23 28 34 39 45 51 56 20 mcg 2 4 8 15 23 30 38 45 53 60 68 75

Epinephrine Infusion 2-10 ug/min using 60 gtts set

1 mg (1:1000) / 250cc = 4mcg/ml Ug/min 2 3 4 5 6 7 8 9 10

Gtts/min 30 45 60 75 90 105 120 135 150

Lidocaine Infusion 1 – 4 mg/min using 60 gtts set

2000mg into 500cc saline = 4mg/ml mg/ml 1 2 3 4

Gtts/min 15 30 45 60


DRUG CALCULATIONS

Drug Dosage for Injection

Drug Dose Ordered x Volume of Stock Solution = ml of Medication to be Administered Dose on Hand

Drip Rates

ml to be Infused x gtts/ml of Infusion Set = Drops per Minutes Total time of Infusion in Minutes

Note: When a factor of 60 is used, the drop-per-minute rate will always equal the ml/hour infusion rate

Infusions

Prescribed Dose x Administration Set Drop Factor = Drops per Minute

Concentration of Drug Note: When a factor of 60 is used, the drop-per-minute rate will always equal the ml/hour infusion rate

patient care guidelineswcvems.com/uploads/3/4/9/5/34956237/2013_protocols.pdf · 2016. 2. 2. ·...

Documents