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ST. JOSEPH HEALTH CENTER
PRE-HOSPITAL CARE
&
PROCEDURES MANUAL
Updated January 5, 2005
PRE-HOSPITAL MEDICAL PROTOCOL FOR ALL UNITS
OPERATING UNDER THE MEDICAL AUTHORITY OF
ST. JOSEPH HEALTH CENTER
WARREN, OH 44484
MISSION STATEMENT: TO PROVIDE THE HIGHEST QUALITY PRE-HOSPITAL CARE TO THE CITIZENS OF TRUMBULL COUNTY AND SURROUNDING AREAS THROUGH SOUND MEDICAL DIRECTION, QUALITY EDUCATION, INNOVATION, AND CONTINUOUS PERFORMANCE IMPROVEMENT PROGRAMS
MEDICAL DIRECTOR, EMS
KATHRYN BULGRIN, D.O.
The contents of this document will be revised periodically as indicated by changing patient care and other medical standards. Revisions and modifications will be distributed to all pre-hospital units operating under medical authority of the Medical Director.
This pre-hospital medical protocol is for use ONLY by Emergency Medical Service squads operating under medical authority of St. Joseph Health Center and Dr. Kathryn Bulgrin, D.O.
MEDICAL AUTHORITY. Emergency Medical Technicians operating under this medical authority are required to follow this protocol unless an intervening physician licensed to practice medicine in the State of Ohio (M.D. or D.O.) accepts full responsibility for deviation from the provisions of this document and accompanies the patient to the receiving hospital. No squad or personnel of any particular squad is permitted to practice medicine beyond the scope of practice of their level of training as defined by the Department of Public Safety, Division of Emergency Medical Services, State of Ohio.
ALS ACTIVATION AND INTERCEPT. For any patient with serious illness and/or potentially life-threatening situations (chest pain/suspected myocardial infarction, respiratory distress, hypoglycemia, altered mental status, and/or other potentially life-threatening situations), all EMT-Basic and EMT-Intermediate units should immediately request assistance from the nearest ACLS (Paramedic) unit UNLESS the transport time is less than the rendezvous time with the Paramedic unit. EMT-Basic and EMT-Intermediate units' intervention on the patient's behalf should not exceed the scope of their practice and training.
All Emergency Medical Service units operating under the medical authority of St. Joseph Health Center are reminded that this protocol is for use in the pre-hospital setting only. This includes patient transports from:
Home to hospital
Accident scene to hospital
Extended care facility to hospital
Any other type of transport, i.e., inter-facility transport of critical care patients or inter-facility transport of any other type of patient is the responsibility of the sending facility, the respective physician, and the transporting agency. St. Joseph Health Center, including any of its signing physicians, WILL NOT accept liability or responsibility for these types of transports.
_______________________________
Kathryn Bulgrin, D.O.
HMHP St. Joseph Health Center
EMS Director
State of Ohio, County of Trumbull
Sworn to and subscribed to before me
On this _____ day of ______________________, 20 ___.
_______________________________
Notary Public
ST. JOSEPH HEALTH CENTER
EMERGENCY MEDICAL SERVICES
COLOR-CODED KEY TO PATIENT CARE GUIDELINES
All patient care algorithms are color coded to denote procedures which may be performed by each level of certification.
➢ EMT-Basics. EMT-Basics may perform any procedures in blue.
➢ EMT-Intermediate. EMT-Intermediates may perform all of the EMT-Basics procedures, as well as those color coded green.
➢ EMT-Paramedics. Paramedics may perform all of the EMT-Basic and EMT-Intermediate procedures, as well as those color coded red.
Any boxed procedures require on-line medical control direction
Higher levels of certification will perform lower level evaluations and procedures when interpreting the algorithms. No EMT is permitted to perform any procedures beyond his level of certification.
TABLE OF CONTENTS
I. ADULT PROTOCOLS
Abdominal Pain...................................................................................................... xx
Allergic Reactions.................................................................................................. xx
Altered Level of Consciousness............................................................................. xx
Anaphylactic Shock (See Shock)
Burns....................................................................................................................... xx
Cardiac Emergencies.............................................................................................. xx
- Angina/Chest Pain.................................................................................... xx
- Arrest........................................................................................................ xx
- Asystole........................................................................................ xx
- PEA.............................................................................................. xx
- Ventricular Fibrillation................................................................. xx
- Arrhythmias.............................................................................................. xx
- Bradycardia.................................................................................. xx
- Tachycardias................................................................................. xx
Childbirth................................................................................................................ xx
Diabetic Emergencies............................................................................................. xx
Eye Injuries............................................................................................................. xx
Glasgow Coma Scale / Revised Trauma Score...................................................... xx
Heat Exposure......................................................................................................... xx
Hypertension Management .................................................................................... xx
Hypothermia / Frostbite.......................................................................................... xx
Near-Drowning / Drowning.................................................................................... xx
Overdose / Poisoning.............................................................................................. xx
Respiratory Emergencies........................................................................................ xx
- Airway Obstruction.................................................................................. xx
- Asymmetric Breath Sounds...................................................................... xx
- Rales/Pulmonary Edema.......................................................................... xx
- Wheezing.................................................................................................. xx
Seizures................................................................................................................... xx
Shock....................................................................................................................... xx
- Anaphylactic............................................................................................. xx
- Cardiogenic / Neurogenic / Septic / Hypovolemic................................... xx
Stroke...................................................................................................................... xx
Thrombolytic Screening Checklist......................................................................... xx
Trauma Arrest......................................................................................................... xx
Trauma Emergencies.............................................................................................. xx
Trauma Triage........................................................................................................ xx
II. PEDIATRIC PROTOCOLS
Altered Level of Consciousness............................................................................. xx
Arrhythmias ........................................................................................................... xx
- Bradycardia.............................................................................................. xx
- Narrow complex tachycardia................................................................... xx
- Wide complex tachycardia....................................................................... xx
Cardiac Arrest......................................................................................................... xx
- Ventricular Fibrillation / Pulseless V-Tachycardia.................................. xx
- Asystole / PEA......................................................................................... xx
Child Abuse / Neglect............................................................................................ xx
Fluid and Drug Administration.............................................................................. xx
Medications – Reference Dosages.......................................................................... xx
Newborn Resuscitation........................................................................................... xx
Respiratory Distress................................................................................................ xx
- Upper Airway Obstruction....................................................................... xx
- Wheezing.................................................................................................. xx
Seizures................................................................................................................... xx
Shock...................................................................................................................... xx
- Anaphylactic............................................................................................. xx
- Cardiogenic / Neurogenic / Septic / Hypovolemic................................... xx
Vital Signs – Normal............................................................................................... xx
III. MEDICAL PROCEDURES
Automatic External Defibrillator (AED)................................................................ xx
Airway and Breathing:........................................................................................... xx
- Oxygen Therapy....................................................................................... xx
- Pulse Oximetry......................................................................................... xx
- Endotracheal Intubation........................................................................... xx
- Chest Decompression............................................................................... xx
- Cricothyrotomy........................................................................................ xx
Alternative Medication Routes............................................................................... xx
Assisting with Medication Administration............................................................. xx
C-Spine Immobilization.......................................................................................... xx
Conscious Sedation................................................................................................. xx
External Pacemaker................................................................................................ xx
Heimlich Maneuver................................................................................................ xx
Interosseus Infusions............................................................................................... xx
Intravenous Therapy................................................................................................ xx
Pain Management.................................................................................................... xx
Patient Assessment.................................................................................................. xx
IV. PHARMACEUTICAL PROTOCOL
Activated Charcoal (Actidose)............................................................................... xx
Adenocard (adenosine)........................................................................................... xx
Albuterol (Proventil / Ventolin)............................................................................. xx
Amiodarone (Cordarone)........................................................................................ xx
Aspirin.................................................................................................................... xx
Atropine Sulfate as Antidote for Poisonings.......................................................... xx
Atropine Sulfate as Cardiac Agent......................................................................... xx
Benadryl (diphenhydramine HCL)......................................................................... xx
Cordarone (amiodarone)......................................................................................... xx
Dextrose 50% (D50) and 25% (D25)..................................................................... xx
Diazepam (Valium)................................................................................................ xx
Diphenhydramine (Benadryl)................................................................................. xx
Dopamine HCL...................................................................................................... xx
Epinephrine (Adrenalin) (1:1000 and 1:10,000).................................................... xx
Furosemide (Lasix)................................................................................................. xx
Glucagon................................................................................................................. xx
Isuprel .................................................................................................................... xx
Ketorolac (Toradol)................................................................................................ xx
Lasix (Furosemide)................................................................................................. xx
Lidocaine (Xylocaine) 2% and 1%......................................................................... xx
Magnesium Sulfate................................................................................................. xx
Midazolam (Versed)............................................................................................... xx
Morphine Sulfate.................................................................................................... xx
Narcan (Naloxone).................................................................................................. xx
Nitroglycerin (Nitrostat)......................................................................................... xx
Oxygen (O2)........................................................................................................... xx
Pediatric Medications – Common Dosages............................................................ xx
Procainamide (Pronestyl)........................................................................................ xx
Proventil (Albuterol / Ventolin).............................................................................. xx
Sodium Bicarbonate 8.4% & 4.2%......................................................................... xx
Solu-Medrol............................................................................................................ xx
Thiamin HCL (Vitamin B-1/Biamine)................................................................... xx
Toradol (Ketorolac)................................................................................................ xx
Valium (Diazepam)................................................................................................. xx
Ventolin (Albuterol / Proventil).............................................................................. xx
Versed (midazolam) ............................................................................................... xx
Xylocaine (Lidocaine)............................................................................................ xx
V. ADMINISTRATIVE PROTOCOLS
Aeromedical Transport........................................................................................... xx
Communications / When to Call Medical Control................................................. xx
Coroner Death Notification.................................................................................... xx
Dead on Arrival (DOA).......................................................................................... xx
Do Not Resuscitate (DNR) Guidelines & Forms................................................... xx
Drug Box Exchange Guidelines............................................................................. xx
Linen Replacement................................................................................................. xx
Obtaining Individual Protocol................................................................................ xx
Patient Refusal or Withdrawal of Consent............................................................. xx
Physician at the Scene............................................................................................ xx
Restraint Policy....................................................................................................... xx
Termination of Resuscitation Efforts...................................................................... xx
Transfer Refusal...................................................................................................... xx
GENERAL PATIENT ASSESSMENT
1. ASSURE SCENE SAFETY
2. UNIVERSAL PRECAUTIONS SHALL BE OBSERVED TO PREVENT CONTACT
WITH BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIALS
3. INITIAL ASSESSMENT (Including ABCs)
This assessment is to discover and treat immediately life-threatening conditions.
a) Airway
– Open airway if needed
– Medical – head tilt chin lift
– Trauma – jaw thrust
– Look for airway obstructions: vomit, bleeding, facial trauma, etc.
– Identify and correct any existing or potential airway obstruction or problems
– Consider oxygen therapy at this time
– Consider Oropharyngeal Airway (OPA) or Nasopharyngeal Airway (NPA)
b) Breathing
– Check adequacy of ventilation – should be done by quickly observing chest rise/fall, approximate rate and listening to patient talk
– Expose chest and observe chest wall movement
– Consider oxygen therapy at this time
c) Circulation
– Palpate for pulse
– Radial pulse not present indicates systolic blood pressure < 80 mmHg
– Carotid pulse not present indicates systolic blood pressure < 60 mmHg
– Note skin temperature, color, and condition
– Note capillary refill in children
– Identify and treat life-threatening conditions or injuries and control bleeding, as needed
d) Disability:
Determine Level of Consciousness by:
– A – Alert
– V – Responds to Voice
– P – Responds to Pain
– U – Unresponsive
– Check pupils for size and reaction time
Form a General Impression of the Patient (age, sex, injury or illness, and immediate
environment)
4. FOCUSED HISTORY AND PHYSICAL EXAM
This section will identify any additional injuries or conditions that may also be life threatening.
Re-evaluate the mechanism of injury (trauma) or nature of illness (medical).
a) Trauma patients with significant mechanism of injury should be assessed as follows:
– Rapid head-to-toe assessment (inspect, palpate, and auscultate)
– Assess baseline vital signs to include:
a. Respirations
b. Pulse
c. Skin color, temperature, and condition
d. Pupils
e. Blood pressure
– Obtain SAMPLE History
Signs and Symptoms
Allergies
Medications (prescribed and over-the-counter)
Pertinent past medical history
Last oral intake
Events prior to injury
– Provide interventions (bandaging, splinting, boarding)
b) Trauma patients without significant mechanism of injury should be assessed as follows:
– Focused assessment (focuses primarily on injury site, rather than head to toe)
– Assess baseline vital signs (as listed above)
– Obtain SAMPLE history (as listed above)
c) Medical patients who are unresponsive should be assessed as follows:
– Rapid head-to-toe assessment
– Assess baseline vital signs (as listed above)
– Obtain SAMPLE history (as listed above)
d) Medical patients who are responsive should be assessed as follows:
– Assess patient's complaints (OPQRST)::
Onset (When and how did the symptoms begin?)
Provocation (What makes the symptoms worse?)
Quality (How would you describe the pain?)
Radiation (Where do you feel the pain?)
Severity (How bad is the pain?)
Time (How long have you had the symptoms?)
– Obtain a SAMPLE history (see above)
– Focused assessment (Assessment of specific complaint areas unless general "I don't feel well," which would require head-to-toe exam)
– Assess baseline vital signs
5. ONGOING ASSESSMENT
Reassess interventions.
I. ADULT PROTOCOLS
ABDOMINAL PAIN
EMT-Basic: 1. Confirm ALS en route, as indicated.
2. Administer oxygen 2 liters nasal cannula or higher
concentrations as indicated with shock or respiratory
distress
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Provokes, Quality, Radiation,
Severity, Time, Interventions, Associated Symptoms,
Allergies, Medications, Past Med/Surg History, Last Meal)
5. Perform complete assessment
6. Check blood sugar level (if < 80 or > 400,
refer to Diabetic Emergency Protocol)
7. Place patient in position of comfort
8. Give nothing by mouth
EMT-Intermed: 9. Reassess patient
10.Obtain IV access – normal saline at TKO
11. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
EMT-Paramedic: 12. Reassess patient
13. Apply cardiac monitor and treat per ACLS protocol
ALLERGIC REACTIONS
Mild Reaction: Rash, Itching, and/or Swelling
Moderate Reaction: Wheezing and/or Lightheadedness
Severe Reaction (Anaphylaxis): Respiratory Distress, Hypotension, and/or Decreased Responsiveness
EMT-Basic: 1. Confirm ALS en route, as indicated.
2. Administer oxygen 2 liters nasal cannula or higher
concentrations as indicated with shock or respiratory
distress
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Possible Exposures/New
Medications, Allergies, Associated Symptoms, Interventions,
Past Medical History)
5. Perform complete assessment
6. Assist patient in administering their own EPI-pen and/or
albuterol MDI as indicated by symptoms or history
7. Place patient in position of comfort
EMT-Intermed: 8. Reassess patient (monitor airway & respiratory status closely)
9. Obtain IV access – normal saline at TKO
10. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
11. Benadryl 25-50 mg IM or 25 mg IV slow over 3 minutes
12. Albuterol aerosol 2.5 mg prn for wheezing (may repeat x 2)
13. Epinephrine (1:1000) 0.3 mg SQ for severe
reactions/anaphylaxis
14. Intubate as indicated (Certified EMT-I only)
EMT-Paramedic: 15. Reassess patient (monitor airway & respiratory status closely)
16. Consider Solu-Medrol 125 mg IV
17. Apply cardiac monitor and treat per ACLS protocol
18. Intubate as indicated
19. Dopamine 5 mcg/kg/min titrated up to 20 mcg/kg/min in
symptomatic patient with SBP < 90 mmHg
ALTERED LEVEL OF CONSCIOUSNESS
EMT-Basic: 1. Confirm ALS en route.
2. Secure airway and consider cervical spine injury
3. Administer 100% oxygen by NRB mask (assist ventilation
with BVM with oral or nasal airway if indicated)
4. Apply pulse oximeter (if available)
5. Obtain relevant history (Onset, Circumstances, Past Medical
History-DM, Seizure, Drug Abuse, Head Injury, Medications,
Recent Illness, Associated Symptoms, and Allergies)
6. Thrombolytic Screening (for stroke patients)
7. Perform complete assessment
8. Document Glasgow Coma Scale
9. Check blood glucose of diabetic patients (If < 80 and patient
alert, give oral glucose 1 tube)
10. Place patient in position of comfort
EMT-Intermed: 11. Reassess patient
12. Obtain IV access – normal saline at TKO
13. D50 1 amp IV if blood sugar < 80 or not obtainable (or
Glucagon 1 mg IM)
14. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
15. Intubate as indicated (Certified EMT-I only)
EMT-Paramedic: 16. Reassess patient (manage airway)
17. Apply cardiac monitor and treat per ACLS protocol
18. Narcan 0.5-2 mg IV/ET for decreased responsiveness,
respiratory depression, or suspicion of narcotic overdose
(consider patient restraint prior to administration). May repeat
dose
19. Consider thiamine 100 mg IV/IM (especially with alcohol
history)
20. Intubate patient if indicated for airway protection/
ventilation (if no response to Narcan and/or D50)
ANAPHYLACTIC SHOCK
EMT-Basic: 1. Confirm ALS en route.
2. Administer oxygen 100% NRB mask (prepare to assist
ventilation)
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Possible Exposures/New
Medications, Allergies, Associated Symptoms, Interventions,
Past Medical History)
5. Perform complete assessment
6. Assist patient in administering their own EPI-pen as
indicated
7. Place patient in position of comfort
8. Transport immediately with ALS intercept
EMT-Intermed: 9. Reassess patient (monitor airway & respiratory status closely)
10. Obtain IV access – normal saline at TKO
11. Epinephrine (1:1000) 0.3 mg SQ (may repeat in 15 minutes if
no improvement)
12. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
13. Benadryl 25-50 mg IM or 25 mg IV slow over 3 minutes
14. Albuterol aerosol 2.5 mg prn for wheezing (may repeat x 2)
15. Intubate as indicated (Certified EMT-I only)
EMT-Paramedic: 16. Reassess patient (monitor airway & respiratory status closely)
17. Consider epinephrine (1:10,000) 0.5 mg IV push for
significant hypotension/shock (if SBP < 90)
18. Apply cardiac monitor and treat per ACLS protocol
19. Solu-Medrol 125 mg IV
20. Intubate as indicated
21. Dopamine 5 mcg/kg/min titrated up to 20 mcg/kg/min in
symptomatic patient with SBP < 90 mmHg
BURNS
EMT-Basic: 1. Confirm ALS en route, as indicated.
2. Ensure scene safety
3. Remove patient from heat, flame, electrical, and chemical
exposure (protective wear/Hazmat Services with chemical or
radiation contamination)
4. Secure airway and consider cervical spine injury
5. Administer 100% oxygen by NRB mask (assist ventilation
with BVM with oral or nasal airway if indicated)
6. Assess for inhalation burns (Suspect if patient is found in a
closed, smoky environment and/or has burns to the face, neck,
singed nasal hairs, cough and/or stridor, or soot in the sputum)
7. Apply pulse oximeter (if available)
8. Obtain relevant history (Circumstances, Past Medical
History, Injury, and Medications)
9. Determine type, extent, and seriousness of burn (see below)
10. Stop burning process, remove clothing, and cool skin
(flush, stop cooling process if shivering)
11. Decontaminate chemical burns with irrigation
12. Look for entrance and exit wounds with electrical burns
and consider other traumatic injuries
13. Cover wounds with dry sterile dressing
14. Perform complete assessment
EMT-Intermed: 15. Reassess patient
16. Obtain IV access (do not delay transport for IV access)
17. 250-500 cc bolus IV normal saline (may repeat bolus x 2 as
needed for hypotension)
18. Intubate as indicated (Certified EMT-I only. Early
intubation warranted with signs of inhalation injury)
EMT-Paramedic: 19. Reassess patient (manage airway)
20. Intubate as indicated (early intubation warranted with signs
of inhalation injury)
21. Apply cardiac monitor and treat per ACLS protocol
(monitor for dysrhythmia, particularly with electrical burn)
22. Consider Pain Management (See Pain Management
Protocol)
- Morphine sulfate 2-5 mg IV for pain, may repeat once
(Do not administer if SBP < 100 mmHg)
- Toradol 30 mg IV for pain (Use ONLY in atraumatic
burn patients. See precautions)
EXTENT AND SERIOUSNESS OF BURN INJURIES
a) Rule of Nines
b) 1% body surface area is equal to the surface of the palm of the patient's hand.
c) Seriousness of Burns
MINOR MODERATE CRITICAL
1st degree < 70% 1st degree > 70% 2nd degree > 30%
2nd degree < 10% *2nd degree 10-30% 3rd degree > 2%
*3rd degree < 2% Any burns with trauma
Any burns with head,
Face, feet, genitalia
* Only if hands, face, feet, or genitalia are not involved
CARDIAC EMERGENCIES: ANGINA/CHEST PAIN
EMT-Basic: 1. Confirm ALS en route.
2. Assess ABCs, vital signs, and responsiveness
3. Administer oxygen 2 liters nasal cannula or higher
concentrations as indicated with shock or respiratory
distress
4. Apply pulse oximeter
5. Obtain relevant history (Onset, Radiation, Associated
Symptoms, Past Medical History, Allergies, and Medications)
6. May assist patient in taking their own nitroglycerin as
prescribed if indicated (Hold if SBP < 100)
7. Transport immediately with ALS intercept
8. Thrombolytic screening
9. Complete assessment
10. May give two (2) 81-mg baby ASA (only orange flavor) or
one (1) adult ASA to patient suspected of having cardiac-
related chest pain
EMT-Intermed: 11. Reassess patient (ABCs)
12. Obtain IV access x 2 – normal saline at TKO (Do not delay
transport)
13. Nitroglycerin sublingual 0.4 mg, 1 every 5 minutes to a
maximum dose of 3 (hold if SBP < 100)
14. Normal saline 250-500 cc IV bolus for hypotension. May
repeat bolus x 2 as needed.
15. May apply cardiac monitor and run a rhythm strip if ALS
unit en route (may NOT interpret rhythm)
EMT-Paramedic: 16. Reassess patient
17. Apply cardiac monitor and treat per ACLS protocol
18. Morphine sulfate 2-5 mg IV for significant chest pain
(Hold if SBP < 100)
19. Dopamine 5 mcg/kg/min and titrate to 20 mg/kg/min for
symptomatic hypotension to maintain SBP > 90
CARDIAC EMERGENCIES: ARREST
EMT-Basic: 1. Confirm ALS en route.
2. Assess ABCs and responsiveness (confirmed arrest)
3. Apply automated external defibrillator (AED) and follow
prompts as per AED protocol
4. Administer oxygen 100% bag valve mask with oral or
nasopharyngeal airway (auscultate for bilateral breath
sounds with ventilations)
5. Initiate CPR
6. Gather history as available from family/bystanders
EMT-Intermed: 7. Reassess patient (ABCs and continue CPR)
8. Obtain IV access – normal saline at TKO
9. Intubate for definitive airway as indicated (Certified EMT-I
only)
10.May apply cardiac monitor if ALS en route (may not
interpret rhythm)
EMT-Paramedic: 11. Reassess patient
12. Quick look with defibrillator pads and treat rhythm per
ACLS protocol (see Arrest Rhythm Protocols below)
13. Intubate for definitive airway as indicated
(SEE SPECIFIC ARREST PROTOCOLS ON THE FOLLOWING PAGES)
ARREST RHYTHM PROTOCOLS
ASYSTOLE:
1. Quick look-asystole
2. Continue CPR
3. Consider immediate transcutaneous pacing (set heart rate at 100 bpm,
start at 200 MA (may titrate down after capture), and check for mechanical
capture (feel for pulse))
4. Epinephrine (1:10,000) 1 mg IV push or double dose via ET tube. May
repeat dose every 3-5 minutes
5. Atropine 1 mg IV push or double dose via ET tube (max 0.04 mg/kg).
Repeat dose every 3-5 minutes (limit 3 doses)
6. Consider Sodium bicarbonate 1 mEq/kg IV
7. Re-evaluate
8. If no response, consider Termination of Resuscitation Protocol and
contact Medical Control
PEA:
1. Quick look-PEA, continue CPR
2. Attempt to identify treatable underlying causes:
Condition Treatment
Hypovolemia Give fluid bolus (1 liter NS open)
Hypoxia Adequate airway management
Hydrogen Ions (acidosis) Consider sodium bicarb
Hyperkalemia Consider sodium bicarb
Hypothermia Aggressively warm patient
Tension Pneumothorax Chest decompression
Tricyclic Overdose Consider sodium bicarb
3. Epinephrine (1:10,000) 1 mg IV push or 2 mg via ET tube. Repeat every
3-5 minutes
4. Atropine 1 mg IV push or double dose via ET tube (if PEA rate is slow).
Repeat every 3-5 minutes (limit 3 doses)
5. Normal saline 1 liter open
6. Consider sodium bicarbonate 1 mEq/kg IV
7. Re-evaluate
8. If no response, consider Termination of Resuscitation Protocol and
contact Medical Control
V-FIB/PULSELESS V-TACH:
1. Quick look-V-fib/pulseless V-Tach
2. Immediate defibrillation 200 J, 300 J, 360 J
3. Initiate CPR
4. Intubate as indicated
5. Epinephrine (1:10,000) 1 mg IV push or 2 mg via ET tube every 3-5 min
6. Defibrillate 360 J after each dose
7. Antiarrhythmic therapy (administer only 1 antiarrhythmic agent)
- Amiodarone 300 mg IV push over 3 minutes, may repeat 150-mg
IV push dose in 10 minutes OR
- Lidocaine 1 mg/kg IV push or via ET tube, may repeat once in 5
minutes (if rhythm converts, hang drip at 2-4 mg/min) OR
- Procainamide 20 mg/min IV infusion (Caution: Hold if hypotension
or QRS widening > 50%. Max total dose 17 mg/kg.)
8. Defibrillate 360 J after each dose
9. Consider sodium bicarbonate 1 mEq/kg IV
10. Re-evaluate
11. If no response, consider Termination of Resuscitation Protocol and
contact Medical Control
CARDIAC EMERGENCIES: ARRHYTHMIAS
EMT-Basic: 1. Confirm ALS en route.
2. Assess ABCs and responsiveness (Confirmed pulse and
spontaneous respirations)
3. Administer oxygen 100% NRB mask or assist with bag
valve mask with oral or nasopharyngeal airway as
indicated (auscultate for bilateral breath sounds with
ventilations)
4. Apply pulse oximeter
5. Assess patient (General appearance, responsiveness, ABCs)
6. Obtain relevant history (Onset, Circumstances, Past Medical
History, and Medications)
7. Transport immediately unless ALS within 5 minutes
EMT-Intermed: 8. Reassess patient (ABCs)
9. Obtain IV access – normal saline at TKO
10. Transport immediately unless ALS within 5 minutes
11. Intubate for definitive airway as indicated (Certified EMT-I
only)
12. May apply cardiac monitor and run a rhythm strip (may
NOT interpret rhythm)
EMT-Paramedic: 13. Reassess patient
14. Apply cardiac monitor and treat per ACLS protocol (see
Arrhythmia Protocols below)
15. Intubate for definitive airway as indicated
(SEE SPECIFIC ARRHYTHMIA PROTOCOLS ON FOLLOWING PAGE)
ARRHYTHMIA PROTOCOLS
BRADYCARDIA:
1. Asymptomatic patient:
- Continue cardiac monitoring and oxygen
- Transport with frequent reevaluation
2. Symptomatic patient: (with chest pain, dyspnea, decreased LOC, SBP < 80,
and/or pulmonary congestion):
- Continue cardiac monitoring and oxygen
- Atropine 1 mg IV push, may repeat q 3-5 min up to 3 doses (Caution: With
2nd degree type 2 and 3rd degree heart blocks, prepare for external pacing)
- Consider external pacing (May sedate patient with Versed 2 mg IV prior to
pacing if SBP >100 (see Conscious Sedation protocol). Set heart rate at 70
bpm, start at 20 MA, increase MA by 20 until mechanical capture)
- Dopamine 5 mcg/kg/min titrate to 20 mcg/kg/min prn to maintain SBP > 90
- Transport with frequent re-evaluations
NARROW COMPLEX TACHYCARDIA (SVT heart rate > 150):
1. Unstable patient: (altered LOC, poor perfusion, hypotension, shortness
of breath, chest pain, shock)
- Continue cardiac monitoring and oxygen
- May attempt Adenosine 6 mg IV push with immediate 10-20 cc NS
flush prior to cardioversion (ONLY if IV access readily available)
- Immediate synchronized cardioversion 50 J, 100 J, 200 J, 300 J, 360 J
2. Stable patient: (alert, oriented, good perfusion):
- Continue cardiac monitoring and oxygen
- Vagal maneuvers (avoid carotid massage in elderly)
- Adenosine 6 mg rapid IV push with immediate 10-20 cc NS flush.
- If no change, adenosine 12-mg rapid IV push with flush. Repeat if
no response in 1-2 minutes.
- If patient remains stable, observe and transport.
- If patient becomes unstable, immediate synchronized cardioversion
WIDE COMPLEX TACHYCARDIA (with a pulse):
1. Unstable patient: (altered LOC, poor perfusion, hypotension, shortness
of breath, chest pain, shock)
- Continue cardiac monitoring and oxygen
- Immediate synchronized cardioversion 100 J, 200 J, 300 J, 360 J
- Antiarrhythmic therapy (administer only 1 antiarrhythmic agent)
- Amiodarone 150 mg IV push over 3 min. May repeat in 10 min if
unchanged. OR
- Lidocaine 1 mg/kg IV push. May repeat 0.75 mg/kg IV push q 5 min
(max 3 mg/kg. If rhythm converts, hang drip at 2-4 mg/min)
2. Stable patient: (alert, oriented, good perfusion):
- Continue cardiac monitoring and oxygen
- Antiarrhythmic therapy (administer only 1 antiarrhythmic agent)
- Amiodarone 150 mg IV push over 3 minutes. May repeat in 10 min if
unchanged OR
- Lidocaine 1 mg/kg IV push. May repeat 0.75 mg/kg IV push q 5 min
(max 3 mg/kg. If rhythm converts, hang drip at 2-4 mg/min)
- If patient remains stable, monitor and transport.
- If patient becomes unstable, immediate synchronized cardioversion
CHILDBIRTH
EMT-Basic: 1. Confirm ALS en route.
2. Administer oxygen 100% NRB mask
3. Complete assessment
4. Obtain history (Last menstrual period, due date,
complications, prenatal care, onset/frequency of contractions,
number of pregnancies/live children, medical history)
5. Visual inspection of the perineal area should only be done
when contractions are less than 5 minutes apart and/or
there is bleeding or fluid discharge
- If no crowning, transport patient in the left
lateral position with frequent reassessment
- If crowning present, prepare to assist and facilitate
delivery (See possible complications below)
6. EMT should NOT place a gloved hand inside the vagina
except in the case of breach delivery with entrapped head
or prolapsed umbilical cord
7. During delivery, apply gentle pressure with a flat hand on
the baby's head to prevent explosive delivery
8. Upon delivery, suction baby's mouth and then nose with
bulb syringe, clamp and cut umbilical cord, and warm and
dry baby. (See Neonatal Resuscitation below if problems)
9. Assess mother and child. Note APGAR scores at 1 and 5
minutes. (See chart below for APGAR scoring)
10.Transport mother and child (car seat if available)
EMT-Intermed: 11. Reassess patient, assist with delivery if needed
12. Obtain IV access – normal saline at TKO
13. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
EMT-Paramedic: 14. Reassess patient, assist with delivery if needed
POTENTIAL COMPLICATIONS OF CHILDBIRTH
▪ Excessive Bleeding:
1. Pre-delivery transport on left side
2. Post-delivery transport emergent in shock position
3. If placenta delivered, may perform uterine massage in attempt to slow bleeding
4. Obtain IV access x 2
5. NS 500 cc bolus IV for hypotension, repeat as indicated (See Shock Protocol)
▪ Cord Around Neck:
1. Loosen cord and remove from neck
2. If unable to loosen cord, clamp in 2 places and cut
3. Complete delivery sequence
▪ Prolapsed Cord:
1. Transport immediately with hips elevated and knees to chest.
2. Insert fingers in birth canal to relieve pressure on the cord
3. DO NOT attempt to push the cord back
▪ Breech Presentation:
1. If body delivered and head remaining in canal, support child's body and insert two fingers into the canal to create an air passage at the nasal area of the child's face by pushing the vaginal canal away from the child's face until delivery complete
APGAR SCORE
| | Sign |0 Points |1 Point |2 Points |
|A |Activity (Muscle Tone) |Absent |Arms and Legs Flexed |Active Movement |
|P |Pulse |Absent |Below 100 bpm |Above 100 bpm |
|G |Grimace (Reflex Irritability) |No Response |Grimace |Sneeze, cough, pulls away |
|A |Appearance (Skin Color) |Blue-gray, pale all over |Normal, except for extremities |Normal over entire body |
|R |Respiration |Absent |Slow, irregular |Good, crying |
NEONATAL RESUSCITATION
CONSIDER:
1. Hypovolemia. Give fluid bolus 10 cc/kg NS
2. Hypoglycemia (blood sugar < 40 mg/dL).
Give D10, 1 cc/kg IV/IO bolus (make D10 by
diluting D50 4:1 with NS)
3. Suspected narcotic dependence:
Give Narcan 0.1 mg/kg IV/IO every 3 minutes
DIABETIC EMERGENCIES
EMT-Basic: 1. Confirm ALS en route, as indicated.
2. Administer oxygen 2 liters nasal cannula or higher
concentrations as indicated with shock or respiratory
distress
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Provokes, Quality, Radiation,
Severity, Time, Interventions, Associated Symptoms,
Allergies, Medications, Past Med/Surg History, Last Meal)
5. Perform complete assessment
6. Check blood glucose (If < 80 mg/dl and patient alert, give 1
tube oral glucose)
7. Repeat blood glucose after therapy
EMT-Intermed: 8. Reassess patient
9. Obtain IV access – normal saline at TKO
10. If blood sugar < 80 or altered LOC, give D50 1 amp IV
push or Glucagon 1 mg IM (if no IV access available)
11. If blood sugar > 400, give normal saline 250-500 cc IV
bolus (Use caution with history of renal failure or CHF)
EMT-Paramedic: 12. Reassess patient
13. Apply cardiac monitor and treat per ACLS protocol
14. If blood sugar normalized and altered LOC persists, see
Altered Level of Consciousness Protocol
EYE INJURIES
EMT-Basic: 1. Keep patient calm
2. Remove contact lenses if possible (have patient remove if
alert)
3. Obtain history (when, where, how)
4. Treat traumatic eye injuries:
- Penetrating
- Do not remove object
- Secure in place
- Cover other eye as well (if patient can tolerate)
- Non-Penetrating
- For dust/dirt, flush with water
- For blunt trauma, avoid pressure to eye, apply
sterile wet dressing, and transport sitting upright
(unless other traumatic injury)
5. For chemical eye injuries/burns, flush with water for a
minimum of 20 minutes (determine type of chemical)
6. Treat nontraumatic eye injuries:
- Obtain relevant history (history of strokes, glaucoma,
other eye problems)
- For acute unilateral vision loss, transport patient flat
HEAT EXPOSURE
EMT-Basic: 1. Confirm ALS en route, as indicated.
2. Administer oxygen 2 liters nasal cannula or higher
concentrations as indicated with shock or respiratory
distress
3. Apply pulse oximeter (if available)
4. Move patient to cool environment and remove any tight
clothing
5. Obtain relevant history (Onset, Provokes, Quality, Radiation,
Severity, Time, Interventions, Associated Symptoms,
Allergies, Medications, Past Med/Surg History, Last Meal)
6. Perform complete assessment (reassess vital signs and mental
status every 10 minutes)
7. Determine type of exposure:
- Heat stroke (Most serious. Temperature often 105+. Skin
usually hot and dry. Often altered LOC and/or seizure.)
- Heat exhaustion (Associated with dehydration with
overexertion. Core temperature usually below 105.
Possible syncope with orthostatic hypotension. Skin pale
and moist)
- Heat cramps (Due to dehydration, overexertion, and
electrolyte abnormalities. Skin moist with muscle cramps)
8. Administer oral fluids if patient alert and without nausea
9. Cool with mist or cool wet sheets or air conditioning.
10. For heat stroke/exhaustion, apply cold packs to axilla,
groin, and neck (cease if shivering)
EMT-Intermed: 11. Reassess patient
12.Obtain IV access
13. 250-500 cc bolus IV normal saline (may
repeat bolus x 2 as needed for hypotension)
14. Intubate as indicated (Certified EMT-I only)
EMT-Paramedic: 15. Reassess patient
16. Apply cardiac monitor and treat per ACLS protocol
17. Intubate as indicated
18. Treat seizures as per Seizure Protocol
HYPERTENSION MANAGEMENT
(Paramedics Only)
“High Blood Pressure” is rarely a chief complaint, but instead more commonly a physical finding.
WHEN NOT TO TREAT:
▪ Transient HTN: May be seen at times of stress, with pain and anxiety in these situations treatment of the underlying cause of the HTN is most appropriate (respiratory distress: aerosol, anxiety: assurance, pain: pain management) and NOT antihypertensive therapy.
▪ Chronic HTN: Many patients have long standing uncontrolled HTN without symptoms, rapid reduction of BP in these cases may due more harm then benefit and thus should NOT be initiated.
▪ Stroke: HTN is a normal physiologic response in stroke patients and is the bodies attempt to improve blood flow to the stroked area. BP should NOT be treated in these patients.(exception: DBP>120)
WHEN TO TREAT:
▪ Symptomatic patients with 2 consecutively elevated DBP > 110 measured 3-5minutes apart. (symptoms of HTN: chest pain, shortness of breath, headache, blurry vision, fatigue, nausea)
▪ Stroke patients with a DBP >120
▪ Aortic Dissection: (severe tearing back or chest pain) if suspected, BP control should be more aggressive to prevent worsening of the dissection. Treat for DBP > 90
TREATMENT:
Nitroglycerin SL 0.4mg q5 minutes up to 3 doses
GOAL OF TREATMENT (not normalization of BP):
To lower DBP:
▪ < 110mmHg in symptomatic patients
▪ 90
15. Intubate as indicated (Certified EMT-I only)
16. Contact Medical Control for permission to administer
morphine for pain control if indicated.
EMT-Paramedic: 17. Reassess patient
18. Apply cardiac monitor and treat per ACLS protocol
19. Intubate as indicated
20. Treat any life threats as appropriate
21. Pain management (See Pain Management Protocol)
- Morphine sulfate 2-5 mg IV (drug of choice in trauma
patients) for severe pain (HOLD if SBP < 100). May
repeat dose if indicated.
- Consider Toradol with focal extremity injuries ONLY
(see Pain Management Protocol)
[pic]
ADULT GLASGOW COMA SCORE
|Eye Opening |Verbal Response |Motor Response |
|4-Spontaneous |5-Oriented & converses |6-Obeys verbal commands |
|3-To verbal Commands |4-Disoriented & converses |5-Localizes pain |
|2-To pain |3-Inappropriate words |4-Withdraws from pain |
|1-No response |2-Inconprehensible sounds |3-Decorticate to pain |
| |1-No response |2-Decerebate to pain |
| | |1-No response |
INFANT GLASGOW COMA SCORE
|Eye Opening |Verbal Response |Motor Response |
|4-Spontaneous |5-Coos, babbles |6-Spontaneous |
|3-To speech |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 |
| |1-No response |2-Extension |
| | |1-No response |
▪ A Score between 13 and 15 may indicate a mild head injury
▪ A score between 9 and 12 may indicate a moderate head injury
▪ A score of 8 or less indicate a severe head injury (Endotracheal intubation is indicated)
REVISED TRAUMA SCORE
|Glasgow Coma Score (GCS) |Systolic Blood Pressure |Respiratory Rate |
|4=(13-15) |4=(>89) |4=(10-29) |
|3=(9-12) |3=(76-89) |3=(>29) |
|2=(6-8) |2=(50-75) |2=(6-9) |
|1=(4-5) |1=(1-49) |1=(1-5) |
|0=(3) |0=(0) |0=(0) |
II. PEDIATRIC PROTOCOLS
NORMAL PEDIATRIC VITAL SIGNS
|Age |Pulse |Resp |SBP* (70 + 2 x Age) |
|Newborn |126-160 |30-60 |60-70 |
|Up to 1 yo |100-140 |30-60 |70-80 |
|1 to 3 yo |100-140 |20-40 |76-90 |
|4 to 6 yo |80-120 |20-30 |80-100 |
|7 to 9 yo |80-120 |16-24 |84-110 |
|10 to 12 yo |60-100 |16-20 |90-120 |
* Blood pressure is a late and unreliable indicator of shock in children
INFANT GLASGOW COMA SCORE
|Eye Opening |Verbal Response |Motor Response |
|4-Spontaneous |5-Coos, babbles |6-Spontaneous |
|3-To speech |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 |
| |1-No response |2-Extension |
| | |1-No response |
▪ A Score between 13 and 15 may indicate a mild head injury
▪ A score between 9 and 12 may indicate a moderate head injury
▪ A score of 8 or less indicate a severe head injury (Endotracheal intubation is indicated)
QUICK-REFERENCE FOR COMMON PEDIATRIC MEDICATIONS AND DOSAGES
(See Complete Medication Protocols for Indications, Contraindications, Side Effects/Warnings, Administration, and Dosages)
|Medication |Dose |Route |Remarks |
|Acetaminophen (Tylenol) |10 mg/kg |PO |Useful for musculoskeletal pain and fever control |
|Activated charcoal |1 gm/kg |PO |Do not give to child with altered level of consciousness |
|Adenosine |0.1 mg/kg |IV, IO |Indicated for SVT. First dose 6 mg, second dose 6 mg. Max dose 12 mg |
|Albuterol |2.5 mg |Aerosol |Indicated for wheezing as per protocol |
|Amiodarone |5 mg/kg |IV, IO |Over 20-60 minutes, max 15 mg/kg per day. For shock-refractory pulseless VT/VF: 5 mg/kg rapid |
| | | |IV/IO |
|Atropine |0.02 mg/kg |IV, IO, ET |Minimum dose 0.1 mg; max dose for child 0.5 mg; max dose for adolescent 1.0 mg; may repeat x1; |
| | | |also useful before intubating children < 5 years old, blocks bradycardia due to vagal nerve |
| | | |stimulation |
|Dextrose 25% |2 mL/kg |IV, IO |Try to obtain bedside glucose level before administering – administer if blood glucose < 80; |
| | | |dilute 50% 1:1 with sterile water; consult Medical Control if infant < 1 month as solution may |
| | | |need to be further diluted. |
|Diazepam (Valium) |0.2-0.3 mg/kg |IV |Indicated for uncontrolled seizure activity; anticipate respiratory depression. Max dose 10 mg|
|Diazepam (Valium) |0.5 mg/kg |Rectal |Indicated for uncontrolled seizure activity; anticipate respiratory depression. Max dose 10 mg|
|Diphenhydramine (Benadryl) |1 mg/kg |IV |Useful in allergic reactions and anaphylaxis. Max dose 50 mg |
|Epinephrine (1:10,000) |0.1 mL/kg (0.01 |IV, IO |Commonly used in cardiac arrest rhythms as first dose. Increase second dose 10 X (may use |
| |mg/kg) | |1:1,000 solution) |
|Epinephrine (1:1,000) |0.1 mL/kg (0.1 |ET, IV, IO |Commonly used in cardiac arrest rhythms. Use for all ET doses, and second and subsequent IV/IO|
| |mg/kg) | |doses. The ET route has limited absorption, use IV/IO route whenever possible |
|Epinephrine (1:1,000) |0.01 mL/kg |SubQ |Used for anaphylaxis. Max dose is 0.3 mL |
|Lidocaine |1 mg/kg |IV, IO, ET |Can repeat once. If successful, start continuous infusion at 20-50 mg/kg/min. Also useful |
| | | |before intubating for cerebral protection and decreases airway reactivity |
|Morphine |0.1 mg/kg |IV/IM |Useful for moderate pain. May cause respiratory depression. Hypotension and reflex |
| | | |bradycardia may develop from histamine release |
|Midazolam (Versed) |0.1 mg/kg |IV/IO/IM |Indicated for uncontrolled seizure activity; anticipate respiratory depression. Useful to |
| | | |facilitate advanced airway management in combative patients |
|Naloxone (Narcan) |0.1 mg/kg |IV,IO,ET |Useful for unknown unconscious, known narcotic overdoses |
|Procainamide |15 mg/kg |IV |Over 30-60 minutes. Alternative treatment for recurrent or refractory VT, SVT |
IV = Intravenous ET = Endotracheal IO = Intraosseous IM = Intramuscular
Refer to Broselow Pediatric Emergency tape for length-based drug treatment when unsure of weight, age, or drug dosage
PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS
EMT-Basic: 1. Confirm ALS en route
2. Secure airway and consider cervical spine injury
3. Administer 100% oxygen by NRB mask (assist ventilation
with BVM if indicated at 20 bpm)
4. Apply pulse oximeter (if available)
5. Obtain relevant history (Onset, Circumstances, Past Medical
History-DM, Seizure, Drug Abuse, Head Injury, Medications,
Recent Illness, Associated Symptoms, and Allergies) 6. Perform complete assessment
7. Document Glasgow Coma Scale
8. Check blood glucose (If < 70 and patient alert, give oral
glucose 1 tube – must have gag reflex)
9. Place patient in position of comfort
10. Transport immediately unless ALS < 5 minutes
EMT-Intermed: 11. Reassess patient (manage airway)
12. Obtain IV access – normal saline at TKO (do not delay
transport)
13. D25 2 mL/kg IV bolus if blood sugar < 70 or not obtainable
(or Glucagon 0.5 mg IM ONLY for children > 20 kg)
14. 20 cc/kg bolus IV normal saline for any of the following:
Unresponsive, appears dry, tachycardic, hypotensive, poor
capillary refill, or blood sugar > 400 mg/dL (may repeat
bolus once as indicated)
15. Intubate patient as indicated (Certified EMT-I only)
EMT-Paramedic: 16. Reassess patient (manage airway)
17. Apply cardiac monitor and treat per ACLS protocol
18. Consider Narcan 0.1 mg/kg IV/IO/ET (Max dose 2 mg. for
patients with normal blood sugar, impaired respirations, and
no response to fluid bolus, or if any suspicion of narcotic
overdose. Also consider patient restraint.)
19. Intubate patient if indicated for airway protection/
ventilation (if no response to Narcan and/or D25)
PEDIATRIC ARRHYTHMIAS
Arrhythmia in children is more frequently a result of airway compromise/poor oxygenation than of cardiac origin. Initial therapy should always consist of proper ventilation and oxygenation.
Arrhythmias in children should be treated ONLY if the arrhythmia compromises cardiac output or has potential for degenerating into a rhythm that compromises cardiac output.
EMT-Basic: 1. Confirm ALS en route
2. Open and manage airway 100% O2 by NRB mask (Assist
ventilations with BVM if respiratory rate is slow, fast, or there
are any signs of hypoxia)
3. Apply pulse oximeter
4. Assess circulation. Start CPR if signs of decreased cardiac
output and heart rate < 60 that is not improving with
oxygenation. Signs of decreased cardiac output include:
- Poor perfusion
- Hypotension
- Decreased LOC
- Respiratory difficulty
- Pulmonary congestion
5. Assess patient (General appearance, responsiveness, vital
signs, perfusion, and lung sounds)
6. Obtain relevant history (Onset, circumstances, past medical
history, and medications)
7. Transport immediately unless ALS < 5 minutes
EMT-Intermed: 8. Reassess patient (manage airway)
9. Intubate as indicated (Certified EMT-I only)
10. Obtain IV/IO access – normal saline at TKO (do not delay
transport)
11. May apply cardiac monitor and run a rhythm strip (may
NOT interpret rhythm)
12. Transport immediately unless ALS unit < 5 minutes
EMT-Paramedic: 13. Reassess patient
14. Apply cardiac monitor and treat per PALS protocol (see
specific Arrhythmia Protocols below)
15. Intubate for definitive airway as indicated
(SEE SPECIFIC ARRHYTHMIA PROTOCOLS ON FOLLOWING PAGES)
PEDIATRIC ARRHYTHMIA PROTOCOLS
BRADYCARDIA:
- Asymptomatic patient (Alert, good pulse, good perfusion, no distress):
1. Continue cardiac monitoring and oxygenation
2. Transport with frequent reevaluation
- Symptomatic patient (Heart rate < 60 and poor perfusion, respiratory
difficulty, decreased LOC, and/or pulmonary congestion):
1. Assure adequate oxygenation prior to further treatment
2. Begin CPR if no improvement with oxygenation (heart rate < 60,
poor perfusion, unstable)
3. Epinephrine (1:10,000) 0.01 mg/kg (0.1 mL/kg) IV/IO or
epinephrine (1:1,000) 0.1 mg/kg (0.1 mL/kg) diluted in 3-5 cc
normal saline via ET tube. Repeat every 3-5 minutes as needed
4. Atropine 0.02 mg/kg (minimum dose 0.1 mg) IV/IO or atropine 0.04
mg/kg via ET tube. May repeat once in 3-5 minutes
5. Transport and contact Medical Control for possible pediatric
pacing
NARROW COMPLEX TACHYCARDIA:
Note: Consider normal pulse for age, possible hypovolemia, and any history of Wolff-Parkinson-White (transport immediately if history of WPW)
- Unstable patient: (Altered LOC, poor perfusion, hypotension, difficulty
breathing, shock)
1. Prepare for immediate synchronized cardioversion
2. May attempt adenosine 0.1 mg/kg (max 6 mg) rapid IV/IO bolus
with immediate 5-10 cc NS flush (if IV access readily available).
May repeat adenosine 0.2-mg/kg dose (max 12 mg) in 1-2 minutes
3. Consider sedation with Versed 0.1 mg/kg slow IV/IO
(max 2 mg) prior to cardioversion if time permits (see
Conscious Sedation Protocol)
4. Synchronized cardioversion 1J/kg, 2J/kg, 2J/kg
- Stable patient: (alert, oriented, good perfusion):
1. Transport immediately with continued monitoring
2. Consider vagal maneuvers (ice pack to face, blowing through straw)
3. If at any time patient becomes unstable, immediate synchronized
cardioversion
WIDE COMPLEX TACHYCARDIA (with a pulse):
- Unstable patient: (altered LOC, poor perfusion, hypotension, difficulty
breathing, CHF)
1. Prepare for immediate synchronized cardioversion
2. Consider sedation with Versed 0.1 mg/kg slow IV/IO (max 2 mg) if
time permits. (See Conscious Sedation Protocol)
3. Synchronized cardioversion 1J/kg, 2J/kg, 2J/kg
4. Administer antiarrhythmic (administer only 1 antiarrhythmic
agent)
- Amiodarone 5 mg/kg IV/IO over 20-60 minutes OR
- Lidocaine 1.0 mg/kg IV push (no response in 5 minutes, repeat
at 0.5 mg/kg. Max 3 mg/kg) If rhythm converts, continue
lidocaine 0.5 mg/kg IV every 20 minutes OR
- Procainamide 15 mg/kg IV/IO over 30-60 minutes
5. Repeat synchronized cardioversion at 2J/kg
- Stable patient: (alert, oriented, good perfusion):
1. Administer antiarrhythmic (administer only 1 antiarrhythmic
agent)
- Amiodarone 5 mg/kg IV/IO over 20-60 minutes OR
- Lidocaine 1.0 mg/kg IV push (no response in 5 minutes, repeat
at 0.5 mg/kg. Max 3 mg/kg) If rhythm converts, continue
lidocaine 0.5 mg/kg IV every 20 minutes OR
- Procainamide 15 mg/kg IV/IO over 30-60 minutes
2. If patient remains stable, monitor and transport.
3. If at any time patient becomes unstable, immediate synchronized
cardioversion
PEDIATRIC CARDIAC ARREST
Cardiac arrest in children is primarily a result of airway compromise/poor oxygenation. Initial therapy should always consist of proper ventilation and oxygenation.
Transport immediately if excessive hemorrhage or hypothermia associated with the arrest.
EMT-Basic: 1. Confirm ALS en route
2. Open airway 100% O2 BVM ventilation
3. Assess circulation (confirmed arrest)
4. Initiate CPR
5. Apply automated external defibrillator (AED) if available
and follow prompts (For children ( 8 years old only. See
AED Protocol)
6. Transport immediately unless ALS < 5 minutes
EMT-Intermed: 7. Reassess patient and manage airway
8. Intubate patient as indicated (Certified EMT-I only)
9. Obtain IV/IO access – normal saline at TKO (do not delay
transport)
10.May apply cardiac monitor if ALS en route (May not
interpret rhythm)
EMT-Paramedic: 11. Reassess patient and manage airway
12. Intubate as indicated
13. Apply cardiac monitor and treat per PALS protocol
(SEE SPECIFIC ARREST PROTOCOLS ON FOLLOWING PAGES)
PEDIATRIC ARREST PROTOCOLS
ASYSTOLE/PEA:
1. Confirm asystole in 2 different leads and continue CPR
2. Consider treatable causes:
Condition Treatment
Hypovolemia Give 20 cc/kg NS bolus
Hypoxia Adequate airway management
Hydrogen Ions (acidosis) Consider sodium bicarb 1 mEq/kg
Hyperkalemia Consider sodium bicarb 1 mEq/kg
Hypothermia Aggressively warm patient
Tension Pneumothorax Chest decompression
Tricyclic Overdose Consider sodium bicarb 1 mEq/kg
Hypoglycemia Give D25, 2 mL/kg bolus
3. Epinephrine (1:10,000) 0.01 mg/kg (0.1 mL/kg) IV/IO every 3-5 minutes
or epinephrine (1:1,000) 0.1 mg/kg (0.1 mL/kg) in 3-5 cc NS via ET tube
4. Normal saline 20 cc/kg IV/IO bolus
5. Check blood sugar. If < 70, give D25, 2 mL/kg IV/IO
6. Sodium bicarbonate 1 mEq/kg IV/IO
7. Continue CPR and transport
V-FIB/PULSELESS V-TACH:
1. Immediate defibrillation 2J/kg, 4J/kg, 4J/kg
2. If no response, resume CPR
3. Epinephrine (1:10,000) 0.01 mg/kg (0.1 mL/kg) IV/IO every 3-5 minutes
or epinephrine (1:1,000) 0.1 mg/kg (0.1 mL/kg) in 3-5 cc NS via ET tube
4. Defibrillate at 4J/kg approximately 1 minute after each dose
5. Consider antiarrhythmic (administer only 1 antiarrhythmic agent)
- Amiodarone 5 mg/kg IV/IO over 2-3 minutes. May repeat 2.5-mg/kg
dose in 10 minutes OR
- Lidocaine 1 mg/kg bolus IV/IO. May repeat 0.5-mg/kg dose every 5
minutes up to 3-mg/kg total
6. Defibrillate at 4J/kg approximately 1 minute after each dose
7. Continue CPR and transport
CHILD ABUSE / NEGLECT
GENERAL CONSIDERATIONS: Child abuse/neglect are widespread enough that nearly all EMTs and Paramedics will see these problems at some time. The first step in recognizing abuse or neglect is to accept that they exist and to learn the signs and symptoms.
PROCEDURES:
1. Initiate treatment as necessary for situation using established protocols.
2. If possible, remove child from scene, transporting to hospital even if there is no medical reason for transport.
3. If parents refuse permission to transport, notify law enforcement for appropriate disposition. Do not jeopardize your safety. If patient is in immediate danger, let law enforcement handle scene.
4. Advise parents to go to hospital. Avoid accusation as this may delay transport. The adult with child may not be the abuser.
5. Carefully document findings and report to physicians at the hospital. An EMT must also report or assure that actual or suspected child abuse/neglect is reported to the local law enforcement agency or the Children's Services Board.
PEDIATRIC FLUID AND DRUG ADMINISTRATION
EMT-Intermed:
▪ Peripheral venous access lines will be the first route for fluid and drug administration for any life or limb threatening emergency situation.
▪ Normal saline will be the fluid of choice for all resuscitative measures.
▪ Unless there are compelling factors, no more than two attempts at peripheral access should be made in a pediatric patient.
▪ In a life threatening situation where venous access appears futile and the child's condition is unstable, intraosseous access should be established immediately following airway stabilization.
▪ Contraindications to intraosseous access include recently fractured bone, known bone disorder, and unsuccessful prior attempt. Relative contraindications include cellulitis or infected burn at site (see IO procedure)
EMT-Paramedic:
When peripheral IV or IO access is not available for administering medications:
▪ Endotracheal tube route may be used for lidocaine, atropine, Narcan, and epinephrine.
▪ Intramuscular (IM) route may be used for Versed, morphine, and Toradol.
▪ Rectal route may be used for Valium (diazepam).
PEDIATRIC RESPIRATORY DISTRESS:
UPPER AIRWAY OBSTRUCTION
TOTAL OBSTRUCTION/FOREIGN BODY:
EMT-Basic: 1. ALS en route
2. Manual clearing ONLY if foreign body is visible (no blind
finger sweep)
3. Back blows and chest thrusts if < 1 year old
4. Abdominal or chest thrusts if > 1 year old
5. If airway cannot be cleared in < 60 seconds, transport
immediately (do not take history, do not perform further
physical assessment)
EMT-Intermed: 6. Continue attempts to clear airway
EMT-Paramedic: 7. Continue attempts to clear airway
8. May attempt laryngoscopy and McGill forceps if complete
obstruction with history of foreign body in an unconscious
patient
9. Cricothyrotomy as indicated (see procedure protocol)
PARTIAL OBSTRUCTION:
EMT-Basic: 1. ALS en route
2. Do NOT agitate child. Do NOT examine throat.
3. 100% oxygen by NRB or blow-by as tolerated
4. Obtain brief history (allergies, medications, past medical
history, events surrounding incident)
5. Assess general appearance
6. Allow child to assume position of comfort, allow parent to
be with/hold child
7. Transport immediately with ALS intercept
EMT-Intermed: 8. Reassess
9. Do NOT start IV unless child in arrest (do not agitate)
10. Do NOT attempt invasive airway unless child in arrest
11. Transport immediately
PEDIATRIC RESPIRATORY DISTRESS:
WHEEZING
EMT-Basic: 1. ALS en route
2. Rapid assessment (general appearance, ABCs)
3. 100% oxygen NRB (BVM assist with ventilation as indicated)
4. Allow position of comfort
5. Obtain relevant history as possible (history of asthma,
allergic reaction, illness)
6. May assist with prescribed EPI-pen if allergic reaction is
suspected
7. May assist with albuterol MDI if prescribed
8. Transport immediately with ALS intercept
EMT-Intermed: 9. Reassess (attention ABCs)
10. Do not start IV/agitate child (unless unresponsive)
11. Epinephrine 0.01 mg/kg (1:1000) subcutaneous (max dose
0.3 mg) for severe wheezing/distress ONLY
12. Albuterol aerosol 1.25-2.5 mg with oxygen prn (May repeat
twice as needed)
13. Benadryl 1 mg/kg IM/IV/IO for suspected allergic
reactions
14. Consider intubation (ONLY if child unresponsive)
15. Transport with ALS intercept
EMT-Paramedic: 16. Reassess (airway management)
17. Consider intubation (ONLY if child unresponsive)
18. Apply cardiac monitor and treat per PALS
19. Consider Solu-Medrol 2 mg/kg IV/IM/IO
20. Transport immediately
PEDIATRIC SEIZURES
EMT-Basic: 1. Confirm ALS en route
2. Seizure precautions (protect patient from self-injury)
3. Consider C-spine precautions
4. Administer oxygen 100% NRB mask
5. Suction airway as needed
6. Apply pulse oximeter (if available)
7. Obtain relevant history as possible (Onset, history/frequency
of seizures, drug abuse, medications/medication changes,
duration of seizure activity, postictal state, head injury)
8. Perform complete assessment
9. Check blood glucose (If < 60 or > 300, refer to Diabetic
Emergency Protocol)
10. Transport with ALS intercept
EMT-Intermed: 11. Reassess patient
12. Obtain IV access – normal saline at TKO (do not delay
transport)
13. D25 2 ml/kg IV bolus if blood sugar 20 kg)
14. Valium 0.2 mg/kg slow IV over 3 minutes (max 5 mg) for
status epilepticus. May repeat dose if seizure does not
subside.
15. Normal saline 10 cc/kg bolus for hypotension or if blood
sugar > 300
16. Intubate as indicated (Certified EMT-I only)
EMT-Paramedic: 17. Reassess patient
18. Valium 0.2 mg/kg slow IV over 3 minutes (max 5 mg) or 0.5
mg/kg rectal (max 10 mg) for status epilepticus. May repeat
dose if seizure does not subside.
19. Apply cardiac monitor and treat per PALS protocol
20. Intubate as indicated
PEDIATRIC SHOCK
EMT-Basic: 1. Confirm ALS en route
2. Administer oxygen 100% NRB mask (prepare to assist
ventilation)
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Possible Exposures/New
Medications, Allergies, Associated Symptoms, Interventions,
Past Medical History)
5. Perform rapid assessment (pulse and respirations)
TACHYCARDIA IS OFTEN THE FIRST SIGN OF SHOCK
IN CHILDREN. DO NOT DEPEND ON BLOOD PRESSURE
6. Place patient in position of comfort
7. Transport immediately with ALS intercept
EMT-Intermed: 8. Reassess patient (attention ABCs)
9. Obtain IV access (do not delay transport)
10. Normal saline 20 cc/kg IV bolus if signs of hypoperfusion
or dehydration are present (may repeat bolus twice as
indicated)
11. Epinephrine 0.01 mg/kg SQ (1:1000) (max 0.3 mg) for
allergic/anaphylactic shock ONLY (bee sting, insect bite)
12. Intubate as indicated (Certified EMT-I only)
13. Transport immediately with ALS intercept
EMT-Paramedic: 14. Reassess patient (monitor ABCs closely)
15. Identify type of shock and treat accordingly:
– Anaphylactic Shock
1. Epinephrine 0.01 mg/kg SQ (1:1000) (max 0.3
mg)
2. Benadryl 1 mg/kg IM/IV (max 25 mg)
3. Albuterol aerosol 1.25-2.5 mg with O2 prn
– Hypovolemic, Septic, or Neurogenic Shock
1. Normal saline 20 cc/kg bolus. May repeat x 2
2. Check blood sugar. If < 60 mg/dl, give:
- D25 2 ml/kg IV/IO bolus OR
- Glucagon 0.5 mg IM ONLY for children
> 20 kg)
16. Apply cardiac monitor and treat per PALS protocol
17. Intubate as indicated
III. MEDICAL PROCEDURES
AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
The automatic external defibrillator should be used on any patient meeting the following criteria: unconscious, pulseless, and breathless regardless of the cause. Current information available on medical policies and practices does not differentiate between ventricular fibrillation as a result of a medical condition or resulting from a traumatic injury. The instrument is programmed to determine a shockable rhythm. If questions arise, follow written protocol and contact Medical Control ASAP.
A) Patient Assessment
1. Check patient responsiveness
2. Primary exam (ABCs)
B) Request ACLS Back-up (Basic and Intermediate Squads)
C) Initiation of B.L.S.
D) Use of A.E.D.
1. Patient Criteria. Patient must be 8 years old or older and:
a) Pulseless
b) Breathless
c) Unconscious
2. Begin Basic Life Support Procedures
a) Open and maintain clear airway
b) Support ventilation with appropriate equipment
c) Begin CPR
d) Set up A.E.D.
1) Properly place defibrillator pads on patient
2) Connect pads to A.E.D. unit if not already done
3) Turn A.E.D. unit on
4) Follow audio/visual prompts (directions) given by A.E.D. unit
e) If second rescuer is available, have him/her secure airway, support ventilation
with appropriate equipment and begin CPR (chest compressions).
E) Transportation
1. If ACLS unit more than 10 minutes away or delayed, consider transportation of patient if:
a) Nine (9) electrical shocks have been delivered to the patient
b) Three (3) consecutive messages that no shock is indicated have been delivered
2. Meet ACLS unit rather than waiting extended amount of time for ACLS unit to arrive:
a) Continue Basic Life/Advanced Life Support measures
b) If patient requires defibrillation during transport, stop the transporting unit for the
A.E.D. to properly analyze and deliver electrical shock to patient
AIRWAY AND BREATHING
1. SECURE AIRWAY
2. ADMINISTER OXYGEN THERAPY
a) All patients should be evaluated for the administration of high-flow oxygen (NRB at 12-15 lpm). If the patient does not tolerate the NRB, give low-flow oxygen via nasal cannula at 1-6 lpm.
b) Special consideration should be given to the COPD patient when administering oxygen:
1. If exhibiting mild respiratory distress, should receive low-flow oxygen via nasal cannula
2. If exhibiting moderate to severe respiratory distress and shows signs of hypoxia,
administer high-flow oxygen via NRB
c) Any patient unresponsive to low-flow oxygen administration should receive high-flow oxygen.
3. CONTINUOUS PULSE OXIMETRY
NEVER BASE ANY TREATMENT OR OXYGEN THERAPY SOLELY ON THE READING FROM THE PULSE OXIMETER
a) Place the monitor near the patient where it can be readily seen.
b) Place with sensor against fingernail. If evidence of nail polish is present, remove it or reposition the sensor until the display changes and confirms that proper sensing has been established.
c) Make sure that the sensor has been connected to both the monitor and the patient and turn the switch to the "on" position.
d) Treat hypoxia appropriately with the proper delivering device and liter flow.
e) Considerations in overall patient condition:
1. Temperature of extremities
2. Anemic conditions
3. Carbon monoxide exposure
4. RAPID ASSESSMENT
5. TREAT IDENTIFIED CAUSE
ENDOTRACHEAL INTUBATION
Indications: Victim with respiratory arrest and/or insufficiency to achieve complete control over their airway (loss of gag reflex, hypoventilation, persistent airway compromise despite basic maneuvers) should be intubated. Oral-tracheal intubation is the preferred technique for placement of an endotracheal tube in all patients.
Benefits: It protects the airway from aspiration of foreign material, allows for intermittent positive pressure ventilation to be achieved with 100% oxygen, makes the trachea and the respiratory tract available for suctioning, and also eliminates the problem of gastric distention.
Risks/Complications: Esophageal intubation, tracheal rupture, right mainstem bronchus intubation, broken teeth, laryngospasms, trauma to the oral-pharynx, and trauma or puncture of trachea due to misplacement of stylet
Procedure for performing a endotracheal intubation is as follows:
a) Preoxygenate with 100% O2 BVM
b) Prepare and check equipment
c) Put victim's head in sniffing position (C-spine precautions as indicated)
d) Suction the mouth and the pharynx as needed
e) Visualize the epiglottis and vocal cords
f) Select the proper size tube and insert with the right hand, starting at the corner of the
mouth down into the trachea, past the vocal cords approximately 2 inches (Intubation attempt should not take longer than 30 seconds. If delays, reoxygenate with 100% O2 BVM prior to each re-attempt. Children < 8 years old should have an uncuffed tube)
GUIDE FOR TUBE SIZING
Neonate.......... 3mm (id) 18-24 months..... 5-6mm (id)
3-12 months..... 4-5mm (id) 2-4 years........... 6mm (id)
12-18 months....5mm (id) 4-7 years........... 6-7mm (id)
Most adults....... 8mm (id) 7-10 years......... 7mm (id)
g) Remove laryngoscope and stylet (if used), holding the tube securely. Ventilate and
confirm placement.
- Check for breath sounds with 5-point auscultation bilateral anterior and lateral
chest and epigastrium
- Mist/condensation in tube
- CO2 detector change (if available)
- Increasing pulse oximeter
IF ANY CONCERN OR QUESTION OF PROPER TUBE PLACEMENT, TUBE SHOULD BE REMOVED AND BVM VENTILATION CONTINUED.
h) If breath sounds heard, inflate tube's cuff with 4-6cc of air and secure the tube.
i) Verify lung sounds/tube placement each time patient moved or every 10 minutes.
j) Document the intubation by noting the following:
1. Number of attempts
2. Person(s) making attempts
3. Size of tube used
4. Lung sounds before and after intubation, and time of each check
5. Measurement on tube at lips of patient when lung sounds are present
6. Any complications
COMBI-TUBE PROTOCOL
(MAY ONLY BE PERFORMED BY PARAMEDICS & EMT-INTERMEDIATES WITH INTUBATION CERTIFICATION)
Indications: The patient is unconscious and unable to protect own airway; no apparent gag reflex. Cardiorespiratory/respiratory (pulse present) arrest.
Contraindications:
1. Patients under 70 pounds and under 5 feet tall
2. Responsive patients with an intact gag reflex
3. Patients with known esophageal disease
4. Patients who have ingested caustic substances
5. Known or suspected foreign body obstruction of the larynx or trachea
6. Presence of tracheostomy
Procedure for using Combi-tube in the pre-hospital setting is as follows:
a) The first priority is to defibrillate the patient in cases of ventricular fibrillation. The AED
should be applied first, using conventional airway management, following the AED
protocol
b) The Combi-tube should be placed during the one minute of CPR between sets of AED
analyses (this may somewhat delay subsequent AED analyses)
c) Hyperventilate the patient prior to Combi-tube insertion for 10-15 seconds using either a
BVM or mouth-to-mask device with supplemental oxygen
d) Insertion – done quickly between ventilation:
1. Except in cases of suspected cervical spine injury, hyper-extend the head and
neck
2. In cases of suspected cervical spine injury, C-spine precautions will be taken at all
times
3. Patent airway and ventilation should already have been established by other basic
methods
4. In the supine patient, insert the thumb of a gloved hand into the patient's mouth,
grasping the tongue and lower jaw between the thumb and index finger, and lift
upward
CAUTION: WHEN FACIAL TRAUMA HAS RESULTED IN SHARP, BROKEN TEETH OR DENTURES, REMOVE DENTURES AND EXERCISE EXTREME CAUTION WHEN PASSING THE COMBI-TUBE INTO THE MOUTH TO PREVENT THE CUFF FROM TEARING
5. With the other hand, hold the Combi-tube with the curve in the same direction as
the curve of the pharynx. Insert the tip into the mouth and advance carefully
until the printed ring is aligned with the teeth
CAUTION: DO NOT FORCE. IF THE TUBE DOES NOT ADVANCE EASILY, REDIRECT IT OR WITHDRAW AND REINSERT. HAVE SUCTION AVAILABLE AND READY WHENEVER WITHDRAWING TUBE.
6. If the Combi-tube is not successfully placed within 30 seconds, remove the device
and hyperventilate the patient for 30 seconds using basic methods, as described in
c) above, before re-attempting insertion
e) Inflation of Combi-tube:
1. Inflate line 1, blue pilot balloon leading the pharyngeal cuff, with 100 ml of air
using the 140-ml(cc) syringe (This may cause the Combi-tube to move slightly
from the patient's mouth)
2. Inflate line 2, white pilot balloon leading the distal cuff, with approximately 15
ml of air using the 20-ml(cc) syringe
f) Ventilation:
1. Begin ventilation through the longer blue (distal) tube. Watch for chest rise. If
auscultation of breath sounds is positive, and auscultation of gastric air sounds is
negative, continue ventilation
2. If no chest rise, negative lung sounds, and/or positive gastric air sounds with
ventilation through the distal tube, begin ventilation through the shorter clear
(proximal) tube. Confirm ventilation with chest rise, presence of auscultated lung
sounds, and absence of gastric air sounds
3. If there is no chest rise or positive lung sounds through either tube, remove the
device, hyperventilate the patient 20-30 seconds as described in c) above, and
repeat the insertion/inflation/ventilation procedures
4. Continue to ventilate the patient through the tube which resulted in lung sounds
using a BVM or a manually-triggered oxygen delivery value
5. REASSESS TUBE PLACEMENT FOLLOWING EVERY PATIENT
MOVEMENT.
g) If two consecutive attempts at intermediate airway placement fail to result in a proper
placement and ventilation, do not attempt placement again. Ventilate the patient using
basic methods and equipment.
h) Removal of Combi-tube (at direction of Medical Control, or when attempting re-
insertion, or if the patient awakens) Remove Combi-tube as follows:
1. Have suction ready
2. Deflate blue tube
3. Deflate white tube
4. Remove Combi-tube
5. Be prepared for vomiting
NOTE ON SUCTIONING THROUGH THE COMBI-TUBE: When suctioning the patient through the Combi-tube, always introduce the suction catheter through tube #2 (white). Because the Combi-tube will always be in the esophagus, most through-the-tube suctioning will be gastric suctioning and will result in decreased gastric distention. In the event that the Combi-tube is in the trachea, suctioning of the patient's airway will result.
CONTINUE CPR AND VENTILATION AS APPROPRIATE DURING TRANSPORT, AND CONTACT MEDICAL CONTROL FOR DIRECTION
NOTE: PARAMEDICS ATTEMPTING NEEDLE DECOMPRESSION OR CRICOTHYROTOMY MUST BE CURRENTLY CERTIFIED IN PRE-HOSPITAL TRAUMA LIFE SUPPORT (PTLS) OR BASIC TRAUMA LIFE SUPPORT (BTLS), OTHERWISE CONTACT MEDICAL CONTROL
NEEDLE DECOMPRESSION
(Paramedics Only)
Chest decompression should be performed via needle thoracentesis immediately following the identification of a tension pneumothorax.
The procedure should be performed as follows:
1. Prep site if time permits.
2. Insert large gauge angiocath (16G or 14G) attached to a syringe with the plunger pushed fully in.
3. Locate the second intercostal space in the mid-clavicular line on the affected side.
4. Insert the needle and catheter OVER the rib and into the thorax.
5. Pull back on the syringe plunger to confirm the presence of air in the pleural space
6. Remove the syringe and advance the catheter.
7. Continuously re-assess the patient's respiratory status.
CRICOTHYROTOMY
(Paramedics Only)
Indications: Unable to provide adequate oxygenation and unable to intubate by another route. This may be seen with cervical spine injuries, maxillofacial trauma, laryngeal trauma, and oropharyngeal obstruction (infectious swelling, allergic reaction, inhalation burns, foreign body, and mass lesions).
Risks/Complications: Bleeding, infection, voice change, persistent stoma, obstructive problems, misplacement of the airway.
NEEDLE CRICOTHYROTOMY PROCEDURE:
1. Identify cricothyroid membrane (small depression immediately inferior to the thyroid cartilage and superior to the cricoid cartilage).
2. Prep the area with antiseptic solution.
3. Insert 14G angiocath connected to a syringe at a 45-degree angle caudally (aim towards the feet) through the cricothyroid membrane while pulling back on the syringe plunger. Entrance of air into the syringe indicates the needle is in the trachea.
4. Advance the catheter over the needle into the trachea.
5. Begin ventilating with a positive pressure device. Watch for chest rise, release pressure, and allow passive exhalation.
SURGICAL CRICOTHYROTOMY PROCEDURE:
1. Identify cricothyroid membrane (small depression immediately inferior to the thyroid cartilage and superior to the cricoid cartilage).
2. Prep the area with antiseptic solution.
3. Make a 2-3 cm vertical skin incision over the cricothyroid membrane. Once the membrane is exposed, make a 1.5-cm horizontal incision through the membrane into the trachea (maintain a slight caudal direction with the blade to avoid vocal cord damage).
4. Use forceps to spread open the membrane (may use the blunt end of the scalpel and twist to open the membrane if time does not allow for proper equipment).
5. Insert appropriate sized ET tube (6mm), advance caudally 3-4 cm, and inflate cuff.
6. Confirm tube placement (auscultate breath sounds, monitor pulse oximetry, and CO2 detector (if available)).
7. Secure tube in place.
ALTERNATIVE MEDICATION ROUTES
Endotracheal route of administration is not considered to be the preferred route for drugs, but can be considered when intravenous or interosseous access cannot be established.
The following drugs are permitted to be administered via the endotracheal tube:
▪ Narcan
▪ Atropine
▪ Epinephrine
▪ Lidocaine
No drug, other than those listed on this page, can be administered via the endotracheal tube route. If in question, contact Medical Control
A previously established surgical tracheal opening may also be used in place of the endotracheal tube.
Medications should be administered at two (2) times the IV dosage and diluted with 10 ml of saline or sterile water before administration.
PROCEDURE:
1. Remove needle from syringe
2. Hyperventilate patient and make sure ET tube and airway are clear of mucous
3. Disconnect ventilation device from tube and squirt medication rapidly into tube
4. Reconnect ventilation device and rapidly ventilate patient to assure passage of
medication down tube and airway
SPECIAL NOTE: DO NOT TAKE LONGER THAN 15 SECONDS TO ADMINISTER MEDICATION IN ORDER TO PREVENT HYPOXIA OF THE PATIENT
ASSISTING WITH MEDICATION ADMINISTRATION
First responders and Basic EMTs may assist patients in taking their medications under certain conditions. These conditions are as follows:
▪ The medication must be prescribed for the patient currently being treated. The medication container must bear the name of the patient being treated
▪ The medication must not be expired
▪ Medications in unmarked containers (pill boxes, etc.), containers that do not bear the patient's name, or containers where the patient's name is altered should not be administered
First responders may ONLY assist a patient in taking medication that has been prescribed for the patient being treated.
An EMT-Basic may additionally administer:
▪ Four (4) 81-mg chewable baby aspirin (total of 324 mg)
DUE TO COMMON ALLERGIES, USE ONLY ORANGE FLAVORED
CHEWABLE BABY ASPIRIN
▪ One (1) adult aspirin (325 mg) to patient suspected of having cardiac-related chest pain or discomfort.
CERVICAL SPINE (C-SPINE) IMMOBILIZATION
IMPORTANT
A complete assessment of the patient's C-spine MUST be done. Lack of verbal complaint of neck and/or back pain is not sufficient reason for eliminating cervical spine and spinal immobilization:
Full C-Spine immobilization MUST include:
– C-Collar (appropriate size for patient)
– Backboard with straps at shoulders, hips, lower legs
– Head immobilization blocks or other CIM device
GUIDELINES:
Apply cervical collar/immobilize if:
1. Any complaint of neck pain, back pain, or pain on palpation of same areas with a history of
recent trauma (watch patient's face for grimace)
2. Knowledge or suspicion of ethanol/drugs on board
3. History of loss of consciousness or altered level of consciousness related to injury
4. Any co-existing distracting injury or pain (for example, head, chest, abdomen, long bone
fracture)
5. Any patient with a mechanism of injury worrisome for cervical spine injury, including:
– Falls
– Blow to the head
– Ejection from motor vehicle
– Severe deformity of motor vehicle or extrication required
– Struck by motor vehicle with speed greater than 20 mph
– Near-drowning patient
– Death of another person in same vehicle
CONSCIOUS SEDATION
(Paramedics Only)
Monitoring of Patients During Conscious Sedation:
1. Place the patient on a cardiac monitor
– If the patient becomes hypotensive, administer a fluid bolus per protocol
2. Closely monitor patient's respiratory effort and effectiveness
– If the patient's respiratory effort or effectiveness decreases significantly, or if the patient becomes apneic, immediately begin ventilatory assistance
– Consider intubating the patient
3. Monitor patient's O2 saturation via pulse oximetry
Conscious Sedation for Patients to be Cardioverted:
1. Secure and protect patient's airway
2. Administer oxygen as is appropriate for the patient's condition
3. Establish IV 0.9% NaCl (normal saline) and run at TKO
4. Administer 2 mg of Versed IV push as an initial dose to induce amnesia
(Do NOT give if SBP < 100) May repeat dose once in 5 minutes as needed.
Pediatric Versed 0.1 mg/kg slow IV/IO (max 2 mg IV/IO)
5. Contact Medical Control for any additional dosages
Adjunct to Intubation for Conscious Patients:
1. Secure and protect patient's airway
2. Administer oxygen as is appropriate for the patient's condition
3. Establish IV 0.9% NaCl (normal saline) and run at TKO
4. Administer 2 mg of Versed IV push as an initial dose
(Do NOT give if SBP < 100) May repeat dose once in 5 minutes as needed.
Pediatric Versed 0.1 mg/kg slow IV/IO.
5. Contact Medical Control for any additional dosages
EXTERNAL PACEMAKER
DO NOT DELAY OTHER THERAPIES SUCH AS AIRWAY CONTROL, MEDICATION, OR CPR TO INSTITUTE EXTERNAL PACING
INDICATIONS:
▪ An external pacemaker may be used to treat patients with bradycardia (or other conditions at the discretion of the on-line Medical Control physician
▪ External pacemakers are indicated as the first line of therapy associated with second degree heart block Mobitz II and third degree heart block when a pulse is present
▪ External pacing may also be indicated for the treatment of sinus bradycardia or ventricular rhythms < 60 bpm unresponsive to atropine if the patient is symptomatic with chest pain, shortness of breath, or hypotension when a pulse is present
APPLICATION:
▪ For conscious patients with bradycardia, set the rate at 70 bpm and current at 20 mA initially. Increase the amperage by 20 mA every 10 seconds until capture is obtained
▪ For unconscious patients with bradycardia, set the rate at 100 bpm and 200 mA (after capture, may titrate down to maintain the lowest voltage maintaining capture)
▪ Once electrical capture is obtained, check for mechanical capture (a pulse)
▪ On-line Medical Control consultation is indicated for all pediatric patients prior to using an external pacemaker
▪ Remove nitroglycerin patches prior to using an external pacemaker
HEIMLICH MANEUVER
CONSCIOUS, NON-OBESE, ACCESSIBLE ADULT VICTIM. A choking victim can't speak or breathe and needs your help immediately. Never slap the victim's back, as this may make matters worse. Follow these steps to help an adult choking victim:
1. From behind, wrap your arms around the victim's waist.
2. Make a fist and place the thumb side of your fist against the victim's upper abdomen,
below the ribcage and above the navel.
3. Grasp your fist with your other hand and press into their upper abdomen with a quick
upward thrust. Do not squeeze the ribcage; confine the force of the thrust to your hands.
4. Repeat until object is expelled.
5. Transport for evaluation immediately after rescue.
UNCONSCIOUS ADULT VICTIM OR WHEN RESCUER CANNOT REACH AROUND VICTIM.
1. Place the victim on his/her back and, facing the victim, kneel astride their hips.
2. With one of your hands on top of the other, place the heel of your bottom hand on the
upper abdomen below the rib cage and above the navel.
3. Use your body weight to press into the victim's upper abdomen with a quick upward
thrust. Repeat until the object is expelled.
4. If the victim has not recovered, proceed with CPR.
5. Transport for evaluation immediately after rescue.
INFANT VICTIM. Never slap the victim's back, as this may make matters worse. Follow these steps to help a choking infant:
1. Lay the child down, face up, on a firm surface and kneel or stand at the
victim's feet, or hold infant on your lap facing away from you.
2. Place the middle and index fingers of both of your hands below the
victim's rib cage and above their navel.
3. Press into the victim's upper abdomen with a quick upward thrust; do not
squeeze the rib cage. Be very gentle.
4. Repeat until object is expelled.
5. Transport for evaluation immediately after rescue.
INTEROSSEOUS INFUSION
INDICATIONS:
▪ To establish parenteral means to administer fluids, blood products and parenteral medications, and to draw blood (except for CBCs)
▪ May be used in any instance that an IV route would be appropriate
▪ Its use should be considered after two IV attempts have failed or if no peripheral IV sites are found
▪ This procedure is indicated primarily in children
CONTRAINDICATIONS:
▪ Osteomyelitis or cellulitis over the proposed site
▪ Fracture at or above the proposed site
▪ Previous IO attempt at the proposed site
RISKS:
▪ Subcutaneous infiltration
▪ Osteomyelitis
▪ Subcutaneous infections
▪ Growth plate damage
PROCEDURE:
1. Prepare as for a surgical procedure, using sterile technique
2. Attempt to have feet in flexed position against board or sandbag
3. The preferred site is the proximal anteromedial tibia, 1-3 cm below the tibial tuberosity.
Secondary site is the distal femur, midline, 3 cm above condyle
4. With a steady push and/or rotary motion, push needle through subcutaneous tissue and bone until
a drop or pop is felt
5. Once the needle has reached the bone marrow, saline should be injected via syringe to clear
needle and then aspiration should be attempted. The infusion should flow freely without
evidence of subcutaneous infiltration
6. The needle should feel firm in position and stand upright without support
7. Infusion via this route is the same as venous access without limit to rate of administration, drugs
pushed, or fluid type infused
8. After removing needle (for successful or unsuccessful attempt), apply pressure to area for five
minutes and apply dressing to area
INTRAVENOUS THERAPY
GUIDELINES:
▪ Intravenous cannulation is restricted to the following sites:
– Dorsum of the hands, wrists, forearm, and antecubital fossa
– Long saphenous vein at the medial malleolus
(antecubital vein is the site of first choice during cardiac arrests and trauma)
▪ Trauma fluid resuscitation: Bolus of 20 ml/kg NS infused using a macrodrip set via a large-bore angiocatheter (14-18G) Rapid infusion, reassessment, repeat bolus as indicated (should be initiated while en route to the medical facility, excluding cases of entrapment or difficult extrication)
▪ A TKO or KVO infusion rate for non-resuscitation situations is set at 10 ml/hr (1 drop every 6 seconds when using a macrodrip administration set)
▪ Utilize the saline-lock for intravenous cannulation when appropriate (refer to protocols)
GENERAL CONSIDERATIONS:
▪ IVs will be started by the EMT-Intermediate and/or the Paramedic ONLY
▪ IV placement must NOT delay transport of any critical patient
▪ Generally, no more than two (2) attempts or more than five (5) minutes should be spent attempting an IV. If unable to initiate an IV line, transport patient and notify hospital that IV was not able to be started
▪ Blood draws for hospital laboratory testing will not be required under this protocol
IV SOLUTION:
0.9% sodium chloride will be the only fluid used in the pre-hospital setting under this protocol.
MECHANICS FOR STARTING A PERIPHERAL IV:
1. Prepare equipment
2. The initial attempt should be the dorsum of the hand. Further attempts should proceed to the
forearm (antecubital fossa for cardiac arrests/trauma/critical patients)
3. Apply tourniquet
4. Cleanse site with alcohol
5. First attempt at insertion on an adult patient should be:
a) 16G IV catheter for trauma patients
b) 18G IV catheter for medical patients
6. Puncture the skin with the bevel of the needle upward. Note blood return and advance catheter
into the vein
7. Attach IV tubing
8. Secure IV using appropriate measures to insure stability of the line
9. Check for signs of infiltration
10. Adjust flow rate
|Document All IV Attempts |Document all IV Medications Administered |
|1. Time IV was started/attempted |1. Name of medication |
|2. Size of catheter or needle used |2. Dosage given |
|3. Location of IV site |3. Time given |
|4. Type and amount of solution infused |4. Initial of EMT who administered medication |
|5. Initial of EMT who attempted/started IV | |
PAIN MANAGEMENT
(Paramedics Only)
Pain management in the pre-hospital setting should be limited to patients with moderate to severe pain. Paramedic must always consider the type of pain, the patient's overall condition, allergies, co-existing medical conditions, and drug contraindications when deciding if pain management is appropriate and which pain medication should be administered.
Guidelines as to which medication is most appropriate for specific situations are outlined below. (refer to pharmacologic protocol for complete drug information)
Morphine 2-5mg IV, may repeat dose once as needed (HOLD if SBP 90 mm/Hg (maximum 1.2 mg or 3 doses)
OXYGEN (O2)
THERAPEUTIC EFFECTS:
Reverses the deleterious effects of hypoxemia on the brain, heart, and other vital organs.
INDICATIONS:
Any condition in which global or local hypoxemia may be present:
▪ Cardiac or respiratory arrest (given with artificial ventilation)
▪ Dyspnea or respiratory distress from any cause
▪ Chest pain
▪ Shock
▪ Coma from any cause
▪ Chest trauma
▪ Near-drowning
▪ Pulmonary edema
▪ Toxic inhalations (smoke, chemicals, carbon monoxide)
▪ Acute asthmatic attack
▪ Acute decompensation of COPD
▪ Stroke
▪ Head injury
▪ Repeated seizures
▪ Any patient in critical condition
CONTRAINDICATIONS:
None
WARNINGS / PRECAUTIONS:
May depress respirations in rare patients with chronic obstructive pulmonary disease. This is NOT a contraindication to its use, but simply means that such patients must be watched closely and assisted to breathe if the respiratory rate declines.
SIDE EFFECTS:
None when given for short periods to adults (less than 24 hours)
HOW SUPPLIED AND ADMINISTERED:
As a compressed gas in cylinders of varying sizes. Administered by inhalation from a dosage mask, nasal cannula, endotracheal tube, etc. A patent airway and adequate ventilation must be ensured.
ADULT DOSAGE:
Depends on the condition being treated. For cardiac arrest and other critical conditions, 100% oxygen should be given as soon as possible.
PROCAINAMIDE (PRONESTYL)
THERAPEUTIC EFFECTS:
Procainamide reduces the automaticity of various pacemaker sites in the heart and slows intraventricular conduction, which makes it effective in suppressing ventricular ectopy.
INDICATIONS:
PVCs, ventricular tachycardia, and ventricular fibrillation that are refractory to lidocaine
CONTRAINDICATIONS:
Patients with severe conduction system disturbances, especially second- and third-degree heart blocks
WARNINGS / PRECAUTIONS:
▪ Patients with PVCs in conjunction with bradycardia should first be treated with atropine or pacing to correct bradycardia prior to administration of procainamide.
▪ Constantly monitor blood pressure and QRS width during administration
SIDE EFFECTS:
Central Nervous System: Drowsiness, seizures, confusion
Cardiovascular: Hypotension, bradycardia, heart blocks, cardiac arrest
Gastrointestinal: Nausea, vomiting
Respiratory: Respiratory arrest
ADULT DOSAGE:
Mix 1000 mg in 100 ml of D5W and, using a macrodrip (10 gtts/ml) set, run at 20-30 gtts/min to administer 20-30 mg/min until one of the following criteria is met:
1. Dysrhythmia is suppressed
2. Systolic BP drops 10 mmHg or more
3. QRS widens by 50% of its original width
4. A total of 17 mg/kg (or 1.2 g) has been administered
If dysrhythmia is suppressed by procainamide, start maintenance infusion at 1-4 mg/min (15-60 gtt/min)
SODIUM BICARBONATE
THERAPEUTIC EFFECTS:
Neutralizes excess acids (usually lactic acid) to form a weak, volatile acid that is broken down into CO2 and H2O, which helps return the blood towards a physiologic pH, in which normal metabolic processes and sympathomimetic agents (such as epinephrine) work more effectively. Sodium bicarbonate is effective only when administered with adequate ventilation and oxygenation. Alkalizing agent used to buffer acids present in the body during and after severe hypoxia.
INDICATIONS:
▪ To treat metabolic acidosis due to:
– Salicylate (aspirin) overdose - Barbiturate overdose
– Cardiac arrest - Tricyclic antidepressant overdose
– Hyperkalemia - Severe ketoacidosis
– Shock - Physostigmine toxicity
– Methanol toxicity - Ethylene glycol toxicity
▪ To treat hyperkalemia
▪ To promote the excretion of some types of drugs taken in overdose
CONTRAINDICATIONS:
Congestive heart failure; alkalotic states
WARNINGS / PRECAUTIONS:
▪ Excessive bicarbonate therapy inhibits the release of oxygen
▪ Bicarbonate does not improve the ability to defibrillate
▪ May inactivate simultaneously administered catecholamines
▪ Will precipitate if mixed with calcium chloride
▪ Patients in borderline heart failure cannot tolerate salt loads of this magnitude
▪ Sodium bicarbonate administration transiently raises the arterial carbon dioxide level, and thus its administration must be accompanied by adequate ventilation
▪ Do not give bicarbonate in the same syringe with epinephrine or calcium.
SIDE EFFECTS:
▪ Metabolic alkalosis
▪ Hypernatremia
▪ Cerebral acidosis
▪ Sodium and H2O retention, which can cause CHF (Increases the vascular volume because sodium bicarbonate has the same effect as other salt-containing infusions. Three 50-ml syringes of sodium bicarbonate (1 mEq/ml) contain approximately the same amount of salt as 1 liter of normal saline. Patients in borderline heart failure cannot tolerate these salt loads)
▪ Lowers serum potassium (this may be desirable at times, as in hyperkalemia, but in cardiac patients, if the potassium falls too low, dysrhythmias may occur. This is especially likely in patients taking diuretics)
▪ Raises arterial carbon dioxide level (thus must be accompanied by adequate ventilation)
HOW SUPPLIED AND ADMINISTERED:
Vials and prefilled syringes of 50 ml, containing 1 mEq/ml. Given by IV bolus injection. Administration should be guided by arterial blood gasses and pH, when available. Do not give bicarbonate in the same syringe with epinephrine or calcium.
ADULT DOSAGE:
Cardiac Arrest: 1 mEq/kg IV (8.4%) after the first minutes of CPR. Repeat with 0.5 mEq/kg every
10 minutes. Acidosis should be prevented with adequate ventilation.. Do not give
bicarbonate in the same syringe with epinephrine or calcium. For other conditions,
as ordered by physician.
PEDIATRIC DOSAGE:
Cardiac Arrest: 1 mEq/kg IV (8.4%) diluted with NS, Repeat with 0.5 mEq/kg every 10 minutes
Infants: 0.5 mEq/kg IV (4.2% diluted with NS) slowly. May repeat in 10 minutes. For
other conditions, as ordered by physician.
SOLU-MEDROL
THERAPEUTIC EFFECTS:
Solu-Medrol is a potent, synthetic anti-inflammatory steroid that decreases inflammatory response and reduces edema in many tissues
INDICATIONS:
▪ Severe anaphylactic and hypersensitivity/allergic reactions
▪ Acute asthma attacks
▪ Bronchospasm associated with COPD exacerbation that does not respond to other treatments
▪ Acute spinal cord injury
CONTRAINDICATIONS:
▪ Known hypersensitivity
▪ Patients with systemic fungal infections
▪ Premature infants/neonates
▪ Spinal cord injuries more than eight (8) hours old
WARNINGS / PRECAUTIONS:
▪ Steroids have been shown to have little effect on cerebral edema associated with head trauma and are not recommended in the prehospital setting for this reason.
▪ Corticosteroids should be avoided in burn or smoke inhalation patients with wheezing because studies have shown an increased risk of infection and mortality
SIDE EFFECTS:
Side effects are commonly seen with prolonged administration, but rarely seen with single doses:
Central Nervous System: Seizures, vertigo, headache
Cardiovascular: Fluid retention, hypertension, hypotension, dysrhythmias, CHF,
electrolyte imbalance
Gastrointestinal: Nausea, vomiting, GI bleeding, abdominal distention
Multisystemic: Anaphylactic reaction
Skin: Urticaria
HOW SUPPLIED AND ADMINISTERED:
125-mg vials
ADULT DOSAGE:
For asthma/associated bronchospasm , COPD, or severe allergic reactions: 125 mg IV
PEDIATRIC DOSAGE:
For asthma/associated bronchospasm or severe allergic reaction: 2 mg/kg IV (maximum 125 mg)
THIAMINE HCL (VITAMIN B-1/BIAMINE)
THERAPEUTIC EFFECTS:
Thiamine is a water-soluble vitamin and member of the B-complex group that functions as an essential co-enzyme in carbohydrate metabolism. Thiamine provides the appropriate thiamine levels to allow glucose to be utilized in sufficient amounts, thus reversing cellular hypoglycemia secondary to thiamine deficiency
INDICATIONS:
▪ Given along with administration of Dextrose 50% to prevent Wernicke and/or Korsakoff Syndrome as seen in acute alcohol intoxication.
▪ Coma or seizure of unknown etiology, especially if alcohol use suspected
▪ Suspected alcohol intoxication
▪ Suspected poor nutrition
▪ Delirium Tremens
CONTRAINDICATIONS:
Contraindicated in patients with a history of sensitivity to thiamine
SIDE EFFECTS:
Central Nervous System: Weakness, restlessness, sweating, feelings of warmth, tightness of throat
Cardiovascular: Angioneurotic edema, cardiovascular collapse, slight fall in blood
pressure following rapid IV administration,
Gastrointestinal: Nausea
Multisystemic: Anaphylaxis
Respiratory: Pulmonary edema
Skin: Cyanosis, urticaria, pruritus (itching)
HOW SUPPLIED AND ADMINISTERED:
100 mg/cc ampule
ADULT DOSAGE:
100 mg IV or IM
PEDIATRIC DOSAGE:
10-25 mg (rarely used) IV/IO
TORADOL (KETOROLAC)
THERAPEUTIC EFFECTS:
Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) that also exhibits peripherally acting, non-narcotic analgesic activity by inhibiting prostaglandin synthesis. Onset is within 10 minutes and lasts 2-6 hours.
INDICATIONS:
▪ Short-term management of moderate to severe pain
CONTRAINDICATIONS:
▪ Hypersensitivity to the drug
▪ Contraindicated in pregnancy labor and delivery because may adversely affect fetal circulation and inhibit uterine contractions, thus increasing the risk of uterine hemorrhage
▪ Patients with history of asthma
▪ Patients with allergies to aspirin or other non-steroidal anti-inflammatory drugs
▪ Bleeding disorders
▪ Renal failure
▪ Hypotension
▪ Patient on Coumadin/anticoagulant therapy (increased bleeding time)
WARNINGS / PRECAUTIONS:
Use with caution and reduced doses when administering to elderly patients
SIDE EFFECTS:
Central Nervous System: Headache, sedation
Cardiovascular: Hypertension, hypotension,
Gastrointestinal: Nausea
Hematologic: Bleeding disorders
Multisystemic: Anaphylaxis from hypersensitivity, edema
Skin: Rash
HOW SUPPLIED AND ADMINISTERED:
15 mg or 30 mg in 1 ml
60 mg in 2 ml
ADULT DOSAGE:
30-60 mg IM or 30 mg IV over 1 minute
Over 65 or Renal Impaired: 15 mg IV over 1 minute
PEDIATRIC DOSAGE:
Not recommended
VERSED (MIDAZOLAM)
THERAPEUTIC EFFECTS:
Midazolam is a short-acting benzodiazepine central nervous system depressant that produces sedation and lack of recall.
INDICATIONS:
▪ Conscious sedation as an adjunct to cardioversion and intubation
▪ Severe agitation or anxiety states
▪ Premedication prior to external transthoracic pacing
CONTRAINDICATIONS:
▪ Known hypersensitivity to the drug
▪ History of glaucoma
▪ Signs or symptoms of shock
▪ Renal failure
▪ Ethanol intoxication
▪ Coma
▪ Pregnancy
WARNINGS / PRECAUTIONS:
Midazolam does not protect against increase in intracranial pressure and bradycardia associated with intubation attempts. Emergency resuscitative equipment should be readily available, as respiratory depression is more common with Midazolam than with any other benzodiazepines
SIDE EFFECTS:
Central Nervous System: Retrograde amnesia, euphoria, altered mental status, dizziness, prolonged
emergence from anesthesia, drowsiness, confusion
Cardiovascular: PVCs, bradycardia, tachycardia, nodal rhythms, hypotension
Gastrointestinal: Nausea, vomiting, hiccups, coughing
Local: Pain, burning, swelling, redness at injection site
Respiratory: Respiratory depression or arrest, laryngospasm, bronchospasm, dyspnea
HOW SUPPLIED AND ADMINISTERED:
Tubex containing 5 mg/2 mL prefilled syringe
ADULT DOSAGE:
2 mg slow IVP
PEDIATRIC DOSAGE:
0.1 mg/kg slow IV push to a maximum dose of 2 mg
V. ADMINISTRATIVE PROTOCOLS
AEROMEDICAL TRANSPORT
▪ Rotor wing air medical services may be requested directly to the scene by:
a) An on-scene EMS organization
b) hospitals and healthcare facilities
▪ A request for rotor wing air medical service response may be initiated when one or more of the following conditions exist:
(a) The patient's airway, breathing, or hemorrhage/circulation can not be controlled by conventional means and the estimated arrival time of the air medical service is less than the time required for ground transport to the nearest hospital.
OR
(b) Air transport to a medical facility/the most appropriate trauma center will occur in a shorter time than ground transport to a medical facility/the most appropriate trauma center.
(i) Time estimation should be made from the time the patient is ready for transport to arrival at the medical facility/the most appropriate trauma center. This should include aircraft response to the scene.
Destinations:
(a) An appropriate medical facility/the most appropriate trauma center based upon, but not limited to the following factors...
(i) Time to definitive care
(ii) Capabilities of receiving hospitals
(iii) Patient wishes and family continuity
(iv) Maximizing utilization of resources
COMMUNICATIONS / WHEN TO CALL MEDICAL CONTROL
A member of the prehospital care team must contact Medical Control at the earliest time conducive to good patient care. This may be a brief early notification or "heads up." It may mean that the hospital is contacted from the scene if assistance is needed in the patient's immediate care or permission is required for part of the patient care deemed necessary by the paramedic or EMT in charge.
When possible, the member of the team most knowledgeable about the patient should be the one calling in the report. Although all EMTs and paramedics have been trained to give a full, complete report, this is often not necessary and may interfere with the physician's duties in the Emergency Department. Reports should be as complete but concise as possible to allow the physician to understand the patient's condition. It is not an insult for the physician to ask questions after the report is given. This is often more efficient than giving a thorough report consisting mostly of irrelevant information.
If multiple victims are present on the scene, it is advisable to contact Medical Control with a preliminary report. This should be an overview of the scene, including the number of victims, seriousness of the injuries, estimated on-scene and transport times to the control hospital or possible other nearby facilities. This allows preparation for receiving the victims and facilitates good patient care.
When calling in a report, it should begin by identification of the squad calling, and the level of care which is able to be provided to the patient (i.e., basic, advanced or medic), and the nature of the call (who you need to talk with, physician or nurse) as follows:
CODE THREE PATIENTS TYPES OF CODE THREE PATIENTS
MOST SERIOUSLY ILL OR INJURED: ACCORDING TO TRIAGE PRIORITY:
1. Type of squad: Basic, intermediate, paramedic. - Airway and/or breathing difficulty
2. Age and sex of patient. - Cardiac Arrest
3. Type of situation: Injury and/or illness - Circulation difficulty (bleeding/shock)
4. Specific complaint: Short and to-the-point - Open chest and abdominal injury
(i.e., chest pain, skull fracture) - Complicated childbirth
5. Mechanism: MVA / MCA / fall - Chest pain
6. Vital signs: B/P / Pulse / Resp. / LOC / EKG - Unconsciousness
7. Patient care: Airway management, - Severe head injury
circulatory support, drug therapy - Severe burns
8. General impression: Stable / unstable - Severe poisoning
9. ETA to medical facility - Status epilepticus
- Altered LOC
- Multiple fractures
CODE TWO PATIENTS TYPES OF CODE TWO PATIENTS
SIGNIFICANTLY ILL OR INJURED, BUT STABLE: ACCORDING TO TRIAGE PRIORITY:
1. Type of squad: Basic, intermediate, paramedic - C-spine injury
2. Age and sex of patient - Acute ABD pain
3. Type of situation: Injury and/or illness - Moderate burns
4. Specific complaint: Short and to-the-point - Normal childbirth
(i.e., 10% 2nd degree burn to leg) - Violent and/or combative patient
5. Mechanism: MVA / MCA / fall - Psychiatric
6. Vital signs: B/P / Pulse / Resp. / LOC / EKG
7. ETA to medical facility
CODE ONE PATIENTS TYPES OF CODE ONE PATIENTS
MINOR ILLNESSES OR INJURIES: ACCORDING TO TRIAGE PRIORITY:
1. Type of squad: Basic, intermediate, paramedic - Minor injuries
2. Age and sex of patient - Minor illness
3. Type of situation: Injury and/or illness
4. Specific complaint: Short and to-the-point
(i.e., ABD pain for the last two weeks)
CORONER DEATH NOTIFICATION
As required by law, all unexplained or unnatural deaths must be reported to the Coroner's office.
An unnatural death is any death that is not the direct result of a natural, medically-recognized disease process. Any death where an outside intervening influence, either directly or indirectly, is contributory to the individual's demise, or accelerates and exacerbates an underlying disease process to such a degree as to cause death, would fall into the category of unnatural death.
A cause of death is etiologically specific. Any injury or disease process, however brief or prolonged, which initiates a dependent and related sequence of events ultimately responsible for the individual's demise, is the cause of death.
There are five manners of death: Natural, Homicide, Suicide, Accident and Undetermined. The manner of death, simply put, is the circumstances in which the cause of death took place. Autopsy alone cannot determine the manner of death. The manner of death is based upon all available knowledge of a particular case, including the terminal events, scene investigation, police report, and social and medical background information.
A mechanism of death is not etiologically specific, but any pathophysiological derangement that is incompatible with life and should not be confused with a cause of death. Ventricular fibrillation or hypoxia are mechanisms of death; however they can occur in advanced arteriosclerotic coronary artery disease, low voltage electrocution, or homicidal strangulation.
The Trumbull County Coroner's Office is staffed 24 hours a day, 365 days a year. To report a death, call (330) 675-2516 promptly after a death. A Forensic Investigator will request the following information. Even if you do not have all the information, that should not inhibit you from making notification. On the basis of this information, the decision will be made whether or not the death falls under the jurisdiction of the Coroner and you will be advised accordingly.
1. Name, age, race, and sex of the decedent.
2. Address and location of the decedent.
3. Telephone number and location of the next of kin.
4. The time of death and who made the pronouncement.
5. If the individual was transported, who made the transport?
6. A brief narrative of the circumstances surrounding the death.
7. Where the decedent was found and by whom, if known.
8. When the decedent was last seen alive and by whom, if known.
9. Any past medical history.
10. Current medications, if known.
11. The name and telephone number of the attending physician, if known.
DEAD ON ARRIVAL (DOA)
When a DOA is encountered, the squad members should avoid disturbing the scene or the body as much as possible, unless it is necessary to do so in order to care for and assist other victims. Once it is determined that the victim is in fact dead, the squad members should move as rapidly as possible to transfer responsibility or management of the scene to the Police Department and/or Coroner's Office. It is the squad member's responsibility to notify the Coroner's Office directly at (330) 675-2516 or to ensure that the Coroner's Office has been notified by a police officer on the scene.
A determination that the victim is dead rests with the squad members. Any of the following may be used as guidelines to support the determination that a victim is deceased:
1. There is an injury which is incompatible with life (i.e., decapitated, burned beyond recognition)
2. The victim shows signs of decomposition, rigor mortis, or extremely dependent lividity.
3. If the patient is an adult with an unwitnessed cardiac arrest, has a history of an absence of vital signs for greater than 20 minutes, and is found in asystole, not secondary to hypothermia or cold water drowning.
4. If there are valid DNR orders, see Do Not Resuscitate Protocol.
5. If the patient has a history of terminal disease, the family refuses resuscitation, and permission to pronounce the patient dead is given by Medical Control.
CAUTION: IF ANY DOUBT EXISTS THAT THE VICTIM IS DEAD AT THE TIME OF ARRIVAL OF THE SQUAD, RESUSCITATIVE MEASURE SHOULD BE INSTITUTED IMMEDIATELY.
WHENEVER RESUSCITATIVE MEASURES ARE INSTITUTED, THEY MUST BE CONTINUED UNTIL ARRIVAL AT A HOSPITAL, UNTIL A PHYSICIAN HAS PRONOUNCED THE VICTIM DEAD, OR A VALID DNR IS PRONOUNCED.
DO NOT RESUSCITATE (DNR) GUIDELINES & FORMS
Pre-hospital (out of hospital) providers are frequently called to care for patients who are known to have incurable or terminal illnesses. These guidelines are designed to help EMS providers and Medical Control physicians determine how, when, and to what level of resuscitation a patient desires or requires. Many patients and/or their families have consciously altered their consent for treatment, made out a Living Will, or entered into Hospice Care agreements.
NOTE: LIVING WILL OR DURABLE POWER OF ATTORNEY DOES NOT MEAN DNR
DNR orders are defined to withhold CPR and Advanced Life Support from patients suffering from terminal illness, but a DNR order may be written with specific guidelines, such as Comfort Care only or Full Medical Management with "checklist" treatment modalities (e.g., medications, blood products, tube feedings.) implemented only if noted. Prehospital providers and Medical Control physicians must be sensitive to, and involved with, the administration of palliative and supportive care interventions, such as to make the patient comfortable, relieve pain, and allay the patient's/family's fear and apprehension.
NOTE: DNR ORDERS DO NOT MEAN "DO NOT TREAT"
A DNR/Comfort Care patient may revoke their status at any time by either direct communication with the prehospital provider or by a private physician directed verbally or in writing by the patient, guardian, or family when the patient cannot communicate with the EMS provider.
The DNRCC must be properly completed by a physician or nurse, legible with all appropriate signatures included, witnessed, and dated within two (2) years. If written by a nurse and not countersigned by a physician, the order must include the patient's name, state that it is a verbal or telephone order, the order must be less than two (2) weeks old, and the patient must be a nursing home or Hospice patient.
If there is no written order, but a physician requests the patient be made DNR, the physician should directly contact Medical Control.
1. DNR Comfort Care – The protocol is activated immediately when a valid "DNR Comfort Care" order is issued and/or upon identification of the person as a "DNR Comfort Care" patient. (See following state Comfort Care protocol)
2. DNR Comfort Care Arrest – The protocol is implemented in the event of cardiac or respiratory arrest. Prior to cardiac or respiratory arrest, a DNR Comfort Care Arrest patient may receive all necessary care and treatment appropriate to the patient's needs (See following state Comfort Care protocol)
3. DNR Identification – The following items are approved as DNRCC Identification
▪ A valid DNR/Support Care document is present or the order is documented on the "DNRCC Identification Form" (See following form)
▪ A Living Will authorizes the withholding or withdrawal of CPR
▪ The patient, guardian, or family refuses care
▪ The patient is wearing a DNR/Comfort Care bracelet/ID or a transparent hospital bracelet with an insert bearing the statewide Comfort Code logo, or their wallet contains a card bearing the statewide Comfort Care logo
NOTE: IT IS IMPERATIVE THAT THE ORIGINAL DNR/COMFORT CARE ORDER (OR A COPY) ACCOMPANY THE PATIENT WHEREVER THE PATIENT GOES
4. Interaction with the Patient, Family, and Bystanders – The patient always may request resuscitation, even if he or she is a DNRCC patient and the protocol has been activated. The request for resuscitation amounts to a revocation of DNRCC status
If family or bystanders request or demand resuscitation for a person for whom the DNRCC Protocol has been activated, do not proceed with resuscitation. Provide comfort measures as outlined on the form
5. A DNRCC Order for a Patient Shall be Considered Current: – UNLESS discontinued by the patient's attending physician/CNP/CNS, or revoked by the patient. EMS personnel are not required to research whether a DNRCC order that appears to be current has been discontinued
6. EMS Personnel who Receive a Verbal DNR Order from a Physician, CNP, or CNS, Must Verify the Identify of the Person Issuing the Order:
▪ Personal knowledge of the physician, CNP, or CNS
▪ List of practitioners with other identifying information
▪ A return telephone call to verify information provided
▪ Contact Medical Control
7. Relationship of DNRCC with Living Wills and Durable Powers of Attorney for Healthcare
▪ A Living Will Supersedes a Durable Power of Attorney (DPOA) for healthcare
▪ A Living Will with a DNRCC identification that is added supersedes the DPOA for healthcare
▪ A Living Will supersedes a DNRCC order that is inconsistent with the Living Will
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❏ DNRCC
(If this box is checked the DNR Comfort Care Protocol is activated immediately.)
❏ DNRCC—Arrest
(If this box is checked, the DNR Comfort Care Protocol is implemented in the event of a cardiac arrest or a respiratory arrest.)
Patient Name:_________________________________________________________________________
Address:______________________________________________________________________________
City________________________________________ State_______________ Zip___________________
Birthdate____________________________ Gender ❏ M ❏ F
Signature_____________________________________________________ (optional)
Certification of DNR Comfort Care Status (to be completed by the physician)*
(Check only one box)
❏ Do-Not-Resuscitate Order—My signature below constitutes and confirms a formal order to emergency medical services and other health care personnel that the person identified above is to be treated under the State of Ohio DNR Protocol. I affirm that this order is not contrary to reasonable medical standards or, to the best of my knowledge, contrary to the wishes of the person or of another person who is lawfully authorized to make informed medical decisions on the person’s behalf. I also affirm that I have documented the grounds for this order in the person's medical record.
❏ Living Will (Declaration) and Qualifying Condition—The person identified above has a valid Ohio Living will (declaration) and has been certified by two physicians in accordance with Ohio law as being terminal or in a permanent unconscious state, or both.
Printed name of physician*:_____________________________________________________________
Signature____________________________________ Date___________________________________
Address:_____________________________________________ Phone__________________________
City/State______________________________________________ Zip___________________________
* A DNR order may be issued by a certified nurse practitioner or clinical nurse specialist when authorized by section 2133.211 of the Ohio Revised Code
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After the State of Ohio DNR Protocol has been activated for a specific DNR Comfort Care patient, the Protocol specifies that emergency medical services and other health care workers are to do the following:
WILL:
▪ Suction the airway
▪ Administer oxygen
▪ Position for comfort
▪ Splint or immobilize
▪ Control bleeding
▪ Provide pain medication
▪ Provide emotional support
▪ Contact other appropriate health care providers such as Hospice, home health, attending physician/CNS/CNP
WILL NOT:
▪ Administer chest compressions
▪ Insert artificial airway
▪ Administer resuscitative drugs
▪ Defibrillate or cardiovert
▪ Provide respiratory assistance (other than that listed above)
▪ Initiative resuscitative IV
▪ Initiate cardiac monitoring
If you have responded to an emergency situation by initiating any of the WILL NOT actions prior to confirming that the DNR Comfort Care Protocol should be activated, discontinue them when you activate the Protocol. You may continue respiratory assistance, IV medications, etc., that have been part of the patient’s ongoing course of treatment for an underlying disease.
DRUG BOX EXCHANGE GUIDELINES
To insure the effective efficient management of the Drug Box Exchange Program, there is a common agreement between St. Joseph Health Center and Trumbull Memorial Hospital that they will follow these guidelines as closely as possible without compromising patient care standards.
I. RESERVE SUPPLY Each hospital shall keep on hand in the Emergency Department a sufficient number of loaded Exchange Boxes for Paramedic Squads to reduce turnaround time for EMS units. Each hospital shall maintain an accurate log that includes the date, squad name, M Box number coming in, M Box number going out, lock number going out, and signatures of both pre-hospital and E.D. personnel.
NOTE: DRUG BOXES SHOULD ONLY BE SIGNED OUT BY PARAMEDICS
(since all boxes contain medications and narcotics)
II. EXCHANGING WITH PARTICIPATING SQUADS This program is designed to encourage all EMS squads who function under both St. Joseph Health Center protocols and Trumbull County protocols to participate in this program.
III. EXCHANGING WITH NON-PARTICIPATING SQUADS Squads choosing not to participate in the Box Exchange Program will still be allowed to exchange with individual hospitals items of medication only, but must go to the hospital pharmacy to do so. Squads wishing to participate in the program should contact the EMS Coordinator or such designee at each institution.
NO EXCHANGE BOXES SHOULD BE OPENED IN THE EMERGENCY DEPARTMENT TO RE-SUPPLY SQUADS
IV. BASE HOSPITAL Each squad participating in the Box Exchange Program will be assigned a "Base Hospital" which will serve as their support unit. The squads shall be divided into groups based on their geographic location (departments and/or private companies with multiple locations will use their main station as the criteria for base hospital selection). Squads will make the final choice in cases where a question may arise concerning a Base Hospital (i.e., department and/or private provider is located on a geographic boundary that allows either hospital to service the squad). The purpose of the Base Hospital is to be the resource unit for a particular squad where they will return if any questions arise, not as the sole medical command.
V. SQUAD RESPONSIBILITY Should abuse of the equipment take place, the responsible squad will be required to pay for replacement equipment. Each EMS squad participating in the program will be required to do the following:
1. Deposit a non-refundable $25.00 fee and sign for each exchange box received
2. Use the boxes with care and respect so as not to subject them to abuse
3. Report any defects in material or workmanship of the exchange boxes to the
Base Hospital so proper documentation and adjustment can be made
4. If any department requests withdrawal from the Drug Box Exchange Program,
the drug box in their possession shall be returned at the time of receipt of their
letter of forfeiture, and the box will be inventoried
OBTAINING INDIVIDUAL PROTOCOL
Provide medical command with appropriate documentation of
qualifications:
- Letter of recommendation from employer
- Copy of state of Ohio EMT card
- Copy of current BLS certification
- Copy of current ACLS certification (EMT-P ONLY)
- Copy of current PALS certification (EMT-P ONLY)
- Copy of current PHTLS/BTLS certification (EMT-P ONLY)
It is understood that PALS and BTLS certifications have not previously been mandated in Trumbull county. Thus, a 6-month grace period for obtaining these certifications will be granted to actively practicing paramedics transitioning to the medical direction of St. Joseph Health Center. Following this grace period, it is expected for paramedics to have obtained, and to continue to maintain, their certifications in order to practice under St. Joseph Health Center protocol.
Successful Completion of Protocol Testing:
– Written Protocol Test: A passing score will be 85% or higher
– Procedural skills lab/testing: All personnel must attend and demonstrate understanding and indications for procedures
Candidates who do not successfully pass either the written or procedural testing, will be permitted to re-test not sooner than 21 days after the initial attempt. Candidates will be given no greater than 2 re-testing opportunities per year.
Demonstrate Clinical Ability Through Successful Supervised Participation in the Field as a "Third Person":
– Candidates must submit documentation of each run, as well as written approval from the supervising preceptor:
▪ EMT-Basics – must complete a minimum of 5 supervised runs and assessments
▪ EMT-Intermediates – must complete a minimum of 10 supervised runs and assessments; and a minimum of 5 successful IVs in the field
▪ EMT-Paramedics – must complete a minimum of 10 ALS supervised runs and assessments; and must complete a minimum of 5 successful IVs in the field
The supervising preceptor will be an EMT of greater or equal certification to the candidate. Preceptors must be actively practicing Medics with a minimum of 2 years of current experience in good standing. All preceptors must be approved by the Medical Director.
Receiving Final Protocol:
Protocol will be issued on a probationary status to Medics fully completing and submitting the documentation listed above. The probationary period will last for a minimum of one (1) month, or the time necessary for the completion of a minimum of 10 runs. During this probationary period, all runs will be reviewed. At the completion of this probationary period, a decision will be made by the Medical Director to either approve full protocol, extend probation, hold protocol pending counsel/further education, or deny protocol.
Maintaining Individual Protocol:
1. Maintaining Certifications: All Medics will be expected to keep their state certifications (BLS, ACLS, PALS, PTLS/BTLS) for their practicing level, as well as their license, up to date.
2. Continuing Medical Education (CME): Emergency medicine is a dynamic field, and it is important for all of us to keep up-to-date on the current information and to refresh our understanding of complex medical issues. For this reason, it will be mandated that all EMTs provide documentation annually to medical command demonstrating their active involvement in continuing education. (CME may be obtained from any certified source):
a. EMT-Basics must submit……………….4 hours CME annually
b. EMT-Intermediates must submit………..8 hours CME annually
c. EMT-Paramedics must submit………….16 hours CME annually
3. Special Labs. Individual may be required to attend specific educational or procedural labs if significant deficiencies in their performance are identified
Revoking/Suspending Individual Protocol:
Any individual's protocol may be revoked or suspended at any time at the discretion of the Medical Director. Reinstatement of revoked/suspended protocol may be offered, requirements for which will be determined on an individual basis. Automatic suspension of protocol will occur if any Medic fails to comply with the criteria set forth for maintaining protocol, including current certifications and annual CME.
Reinstatement of Protocol:
EMS personnel who previously held protocol under the direction of St. Joseph Health Center and have left in “Good Standing” may reinstate as instructed below:
- Return 6 months but 24 months: Will be required to complete the entire “Obtaining
Protocol” process.
Obtaining and Maintaining Departmental Protocol:
- Departmental Protocol will be issued and renewed annually once all criteria are
met.
- Monthly run reports must be submitted to the St. Joseph Health Center Medical
Directory for quality assurance purposes
- Annual documentation is to be sent to the St. Joseph Health Center EMS office:
a) Current drug license
b) Current roster
c) Drug box maintenance fees paid up to date.
Departments not in compliance with the above criteria, will have their protocol suspended, and will not be able to practice under the medical authority of the Medical Director.
Obtaining/Maintaining EMT-Intermediate Intubation Certification:
EMT-Intermediate providers wishing to obtain intubation privileges must fully demonstrate their competence to provide successful endotracheal intubation, both in the hospital and in the field. (Obtain form from St. Joseph Health Center EMS office):
Step I : Candidates must first complete a minimum of 5 in-hospital intubations under the supervision of a physician. Signed approval must be obtained from the supervising physician prior to proceeding to Step II.
Step II: Candidates must complete 3 field intubations under the direct supervision of an approved paramedic supervisor. (May NOT attempt any field intubations until hospital approval Step I has been successfully completed). EMT-Intermediates should submit the signed approval form documenting intubations to the Medical Director for final approval and official intubation certification/privileges. An updated protocol card will be issued.
Step III (Maintaining Certification): Certification is to be renewed annually:
– Two (2) documented in-field/ER intubations performed throughout the year – automatically renewed
– Less than two (2) intubations performed during the year – repeat supervised hospital intubations for renewal
– If intubation certification has lapsed by > 1 year – repeat entire certification process
LINEN REPLACEMENT
Linens soiled and used in the pre-hospital setting may present a significant public health issue. Therefore, all participating EMS squads, both public and private, will:
1. Remove all soiled and used linens from their respective transport vehicles after each patient transport is completed. Each receiving hospital will designate an appropriate container as a receptacle for the deposit of soiled linen used by participating EMS squads in the pre-hospital setting during transport to the receiving hospital; and
2. Obtain from the receiving hospital such linen replacement consistent with that used during the patient transport, but not more than:
A. Two (2) bed sheets
B. One (1) pillow case
C. One (1) bath blanket
D. One (1) towel
E. One (1) washcloth
IF ANY OF THE LINENS ARE NOT USED, THE SQUAD WILL NOT SEEK AND WILL NOT RECEIVE A REPLACEMENT FOR THE UNUSED ITEM
Hospitals in the Region 10 area of Ashtabula, Columbiana, Mahoning, and Trumbull counties have collectively pledged to continue the practice of replacing linen supplies used by pre-hospital units because there are no facilities in the entire four-county area equipped to deal with biohazard linen except the receiving hospitals. Abandonment of this practice would leave EMS squads without a proper means to handle linen needs.
THIS PROCESS WILL BE IDENTICAL AT ALL RECEIVING HOSPITALS FOR ALL PARTICIPATING EMS SQUADS. NO MEMBER SQUAD OR RECEIVING HOSPITAL WILL BE GRANTED ANY EXCEPTIONS, VARIANCES, OR OTHER WAIVERS
PATIENT REFUSAL OR WITHDRAWAL OF CONSENT
GENERAL STATEMENT: Competent adult patients have the right to give consent for, or refuse, any or all treatments. EMS should attempt to obtain vital signs on all patients. Competent adult patients also have the right to give consent for, or refuse, ambulance transport.
When waiting to obtain lawful consent from the person authorized to make such consent would present a serious risk of death, serious impairment of health, or would prolong severe pain or suffering of the patient, treatment may be undertaken to avoid those risks without consent.
IN NO EVENT SHOULD LEGAL CONSENT PROCEDURES BE ALLOWED TO DELAY IMMEDIATELY REQUIRED TREATMENT
I. ADULTS
1. Refusal. If a patient wishes to refuse either treatment, examination, or transportation, the EMT will complete a Patient Refusal Checklist (see following pages). The patient:
a) Must be advised of benefits of treatment & transport, as well as specific risks
of refusal.
b) Must be able to relate to EMT in his or her own words what these risks and
benefits are.
c) Will be provided with a Refusal Information Sheet (see following pages). A
copy of this
Refusal Information Sheet or the refusal section of the checklist will be signed
by the patient, dated, and both will be kept with the patient's file.
2. Withdrawal. A competent patient may withdraw consent for treatment at any time. Prior to discontinuing or withdrawing treatment, the EMT shall determine if the patient is competent:
a) Mental Competence – Decision Making Ability. A person is mentally
competent if he:
1. Is capable of understanding the nature & consequences of the proposed
treatment.
2. Has sufficient emotional control, judgment, discretion to manage his
own affairs.
Ascertaining that the patient is oriented, has an understanding of what happened, and may possibly happen if treated or not treated, and a plan of action -- such as whom he will call for transportation home – should be adequate for these determinations.
b) Impairment. Patients may be considered incompetent to refuse care and/or
transportation when they appear impaired. Patients who appear impaired
include:
- Suicidal patients - Patients impaired by
illicit drugs
- Patients impaired by alcohol - Patients impaired by
prescription or
- Patients impaired by medical conditions nonprescription drugs
II. PEDIATRIC
1. A critically ill or injured child should be treated and transported immediately.
2. In non-emergency cases involving minors, consent should be obtained from the parent
or legal guardian prior to undertaking any treatment. All children must be evaluated
for acuity of illness, regardless of obtaining parental consent.
EMS PATIENT REFUSAL CHECKLIST
1. ASSESSMENT OF PATIENT (CIRCLE APPROPRIATE RESPONSE)
ALCOHOL / DRUGS INGESTION PER HISTORY OR EXAM YES NO
ALTERED LEVEL OF CONSCIOUSNES YES NO
HEAD INJURY YES NO
ORIENTED TO: PERSON PLACE TIME SITUATION
2. MEDICAL CONTROL
CONTACTED VIA: PHONE RADIO TIME ___________
UNABLE TO CONTACT ( MEDICAL CONTROL PHYSICIAN: ___________________
If Medical Control not able to be contacted, explain in comments section of checklist
ORDERS:
( INDICATED TREATMENT / TRANSPORT MAY BE REFUSED BY PATIENT
( USE REASONABLE FORCE / RESTRAINT TO PROVIDE TREATMENT
( USE REASONABLE FORCE AND / OR RESTRAINT TO TRANSPORT
OTHER: ___________________________________________________________________________
3. PATIENT ADVISED (CIRCLE APPROPRIATE RESPONSE)
▪ MEDICAL TREATMENT / EVALUATION NEEDED YES NO
▪ AMBULANCE TRANSPORT NEEDED YES NO
▪ FURTHER HARM MAY RESULT WITHOUT MEDICAL YES NO
TREATMENT OR EVALUATION
▪ TRANSPORT BY MEANS OTHER THAN AMBULANCE COULD YES NO
BE HAZARDOUS IN LIGHT OF THE PATIENT'S PRESENT ILLNESS
OR INJURY
4. DISPOSITION
( REFUSED ALL EMS SERVICES
( REFUSED TRANSPORT, ACCEPTED FIELD TREATMENT
( REFUSED FIELD TREATMENT, ACCEPTED TRANSPORT
( RELEASED IN CARE OR CUSTODY OF SELF
( RELEASED IN CUSTODY OF LAW ENFORCEMENT AGENCY
AGENCY: ________________________________
OFFICER: ________________________________
( RELEASED IN CARE OR CUSTODY OF RELATIVE OR FRIEND
NAME: ___________________________________
RELATION: _______________________________
5. COMMENTS: _______________________________________________________________
_______________________________________________________________________________
EMT SIGNATURE __________________________ DATE: _____________ TIME: _________
PHYSICIAN AT THE SCENE
GOOD SAMARITAN PHYSICIAN:
This is a physician with no previous relationship to the patient who is not the patient's private physician, but is offering assistance in caring for the patient. The following criteria must be met for the physician to assume any responsibility for the care of the patient:
1. Medical Control must be informed and give approval
2. The physician must have proof they are a physician. They should be able to show you
their medical license. Notation of physician name, address, and certification numbers
must be documented on the run report
3. The physician must be willing to assume responsibility for the patient until relieved by
another physician, usually at the emergency department
4. The physician must not require the EMT to perform any procedures or institute any
treatment that would vary from protocol and/or procedure
If the physician is not willing or able to comply with all of the above requirements, his assistance must be courteously declined
PHYSICIAN IN HIS/HER OFFICE OR URGENT CARE CENTER:
1. EMS should perform its duties as usual under the supervision of Medical Control or by
protocol
2. The physician may elect to treat the patient in his office
3. The EMT should not provide any treatment under the physician's direction that varies
from protocol. If asked, the EMT should decline until contact is made with Medical
Control
4. Once the patient has been transferred into the squad, the patient's care comes under
Medical Control
RESTRAINT POLICY
GENERAL GUIDELINES:
1. Soft restraints are to be used only when necessary in situations where the patient is potentially violent and may be of danger to themselves or others. EMS providers must remember that aggressive violent behavior may be a symptom of medical conditions such as, but not limited to:
a) Head trauma
b) Alcohol/drug related problems
c) Metabolic disorders (i.e., hypoglycemia, hypoxia, etc.)
d) Psychiatric/stress related disorders
2. Patient health care management remains the responsibility of the EMS provider. The method of restraint shall not restrict the adequate monitoring of vital signs, ability to protect the patient's airway, compromise peripheral neurovascular status or otherwise prevent appropriate and necessary therapeutic measures. It is recognized that evaluation of many patient parameters requires patient cooperation and thus may be difficult or impossible.
3. All restraints should have the ability to be quickly released, if necessary.
4. Restraints applied by law enforcement (i.e., handcuffs) require a law enforcement officer to remain available to adjust restraints as necessary for the patient's safety. This policy is not intended to negate the need for law enforcement personnel to use appropriate restrain equipment to establish scene control.
5. Patient shall not be transported in a face down prone position to ensure adequate respiratory and circulatory monitoring and management.
6. Restrained extremities should be monitored for color, nerve and motor function, pulse quality, and capillary refill at the time of application and every 15 minutes hereafter.
7. After addressing and/or treating metabolic causes of aggressive or violent behavior, administration of a benzodiazepine and/or Haldol as a chemical restraint should be considered.
8. Restraint documentation on the EMS report shall include:
a) Reason for restraint
b) Agency responsible for restraint application (i.e., EMS, police)
c) Documentation of cardio-respiratory status and peripheral neurovascular status
TERMINATION OF RESUSCITATION EFFORTS (IN NON-TRAUMATIC CARDIAC ARREST)
Resuscitation may be discontinued in the prehospital setting when the patient is nonresuscitable after an adequate trial of ACLS (see below) when the patient's survivability is questionable.
1. Adequate Trial of ACLS
An adequate trial of ACLS according to the Journal of American Medical Association's guidelines occurs when:
a) Adequate BCLS has been provided for a reasonable amount of time;
b) Endotracheal intubation has been successfully accomplished;
c) Intravenous access has been achieved and rhythm-appropriate medications and
countershocks for V-Fib have been administered according to protocol; and
c) Persistent asystole or agonal electrocardiographic patterns are present and no reversible
causes are identified
2. Immediate Transporation to the Emergency Department
The patient WILL BE be transported to the emergency department when:
a) The patient is an adult that exhibits signs or symptoms of hypothermia or drug overdose
b) The patient is a child
c) ACLS cannot be provided in a timely manner
d) Endotracheal intubation
e) Cardiac defibrillation
f) Cardiac medication administration, or
g) Intravenous catheterization, when there is copious pulmonary edema or aspirated
material emanating from the endotracheal tube
h) The BLS service can enter the emergency department faster than prehospital ACLS can
be initiated
3. Transporation to the Emergency Department After On-Scene ACLS
a) There is a stable pulse
b) Persistent ventricular tachycardia or coarse ventricular fibrillation (> 1 cm amplitude)
4. Termination of Resuscitation Efforts
Paramedics WILL CONTACT Medical Control to terminate resuscitation efforts in the field when:
a) There is no return of circulation (spontaneous pulse > 60 bpm) after 20 minutes of ACLS
b) Presenting rhythm is asystole and persists unaffected by 2-3 doses of epinephrine and
atropine accompanied by ACLS
c) Adult cardiopulmonary arrest (not associated with trauma, body temperature aberration,
respiratory etiology, or drug overdose)
d) Absence of persistent, recurring, or refractory V-Fib/tachycardia or any continuous
neurological activity (e.g., spontaneous respirations, eye opening, or motor response)
Upon termination of life support efforts, the body is to be transported to the Medical Control facility with all IVs and ETT in place for pronouncement. Documentation should be completed and forwarded to Medical Control within 48 hours of the run.
TERMINATION OF RESUSCITATION EFFORTS (IN TRAUMA PATIENT CARDIAC ARREST)
Resuscitation may be discontinued in the prehospital setting when the patient is nonresuscitable after an adequate trial of ACLS (previous page) when the patient's survivability is questionable.
1. No Signs of Life
a) Trauma patient has no vital signs and no signs of life when there is no cardiac,
respiratory, or neurologic function:
1. No palpable pulse
2. No blood pressure
3. No respiratory effort
4. No swallowing, eye, or extremity movement
5. No pupillary activity
b) Trauma patients with no signs of life at the scene or in transport have virtually no chance
of survival, even when no signs of life are restricted to no pulse, respirations, or pupil
reactivity.
c) Trauma patient survival is negligible when there is cardiac arrest and asystole or
idioventricular rhythm
d) Trauma patients with prehospital cardiac arrest for more than 5-10 minutes rarely survive
2. Protocol Guidelines
a) The 10-minute time period begins as soon as a BLS/ALS provider recognizes that the
patient has no signs of life
b) Patients with no signs of life upon BLS/ALS arrival
1. When possible, immediately check the cardiac rhythm
2. If asystole is present, terminate all support; handled by Coroner at this
point
3. If asystole is absent or the rhythm is unknown:
I. Initiate BLS/ALS as soon as possible; promptly establish the most
appropriate airway & transport to nearest emergency department
II. If there is no return of any signs of life within 10 minutes of
BLS/ALS, obtain Medical Control and recommend the termination
of resuscitation efforts; transport body to emergency department
III.When the patient access prevents the administration of BLS/ALS,
all support is terminated if there is no sign of life witnessed for 10
minutes; handled by Coroner
IV. If there is return of any signs of life, immediately transport the
patient to the nearest emergency department
c) Patients deteriorating to conditions as set forth in 1a above after BLS/ALS arrival:
1. If the patient can be delivered to the emergency department within 10
minutes, initiate BLS/ALS and immediately transport the patient
2. If the patient cannot be delivered to the emergency department within 10
minutes, follow items under 2b3 above
CONTACT MEDICAL CONTROL FOR PERMISSION
TO TERMINATE RESUSCITATION EFFORTS
Upon termination of life support efforts, the body is to be transported to the Medical Control facility with all IVs and ETT in place for pronouncement. Documentation should be completed and forwarded to Medical Control within 48 hours of the run.
-----------------------
CONSIDER SOLU-MEDROL
125 mg IV
TRANSPORT
NORMAL SALINE 500 cc BOLUS IF HYPOTENSIVE
ALBUTEROL AEROSOL 2.5 mg
and
BENADRYL 25-50 mg IM/IV
and
SOLU-MEDROL 125 mg IV
TENSION PNEUMOTHORAX
PLEURAL DECOMPRESSION
CONSIDER EPINEPHRINE
(1:1000) 0.3mg SQ
OR GLUCAGON
MORPHINE
2-5 mg IV
LASIX 40-80 mg
SLOW IVP
DETERMINE AND TREAT CAUSE
NITROGLYCERIN 0.4 mg q5 min SL
KEEP SBP >100
PROVENTIL AEROSOL 2.5 mg (3cc) O2 at 8L/min
ASTHMA / COPD
ASSIST WITH INHALER
EPINEPHRINE (1:1000) 0.3mg SQ
(CAUTION)
ANAPHYLAXIS
ASSIST WITH AUTO-INJECTOR EPINEPHRINE
ASSYMMETRICAL
RALES
PULMONARY EDEMA
DECREASED SOUNDS WITH WHEEZES
ABNORMAL LUNG SOUNDS
IV NS, TKO, MONITOR EKG
ASSESS PATIENT PULSE OXIMETER LUNG SOUNDS
CLEAR LUNG SOUNDS
TREAT UNDERLYING CAUSE (MI, PE, etc.) TRANSPORT
CONTACT MEDICAL CONTROL
OBTAIN HISTORY
& MEDICATIONS
OPEN AIRWAY PROVIDE O2 NRB/BVM
EMT-P
EMT-I
EMT-B
RESPIRATORY DISTRESS
SPONTANEOUS BREATHING
PAIN CONTROL
(PER PROTOCOL)
AMPUTATION
(CONTROL BLEEDING)
(TRANSPORT PART COOL & DRY)
SPLINTING
(EVALUATE CIRCULATION & NEURO BEFORE, DURING, & AFTER)
HYPER- OXYGENATE
(IF SUSPECTED HERNIATION)
ELEVATE HEAD WITH C-SPINE PROTECTION
EVALUATE NEURO (GLASGOW COMA SCORE)
PENETRATING INJURY
(SECURE OBJECT: DO NOT REMOVE)
BLUNT INJURY
(TREAT HYPOVOLEMIA)
EVISCERATION
(SURROUND ORGANS WITH MOIST DRESSING AND ELEVATE KNEES)
OPEN CHEST WOUND
(NON-POROUS 3-SIDED DRESSING)
FLAIL CHEST
(STABILIZE)
PNEUMO/HEMO THORAX
(POSITION ON INJURED SIDE AND ELEVATE HEAD)
EVALUATE BREATH SOUNDS
EXTREMITY
HEAD
ABDOMINAL
CHEST
* FOCUSED ASSESSMENT/ MANAGEMENT OF INJURED AREAS (DCAP-BTLS)
* TRANSPORT AND CONTACT MEDICAL CONTROL
NON-URGENT PATIENTS
SCENE SIZE-UP -- SAFETY, MECHANISM OF INJURY, NUMBER OF PATIENTS, IDENTIFY THE NEED FOR AND SUMMON ADDITIONAL RESOURCES.
INITIAL ASSESSMENT -- DETERMINE LIFE-THREATS, PRIORITIZE PATIENTS FOR TRANSPORT, ASSESS AND MANAGE AIRWAY, CIRCULATION, BLEEDING, AND CONTROL C-SPINE
INTUBATE PATIENT WITH C-SPINE CONTROL
DECOMPRESS TENSION PNEUMOTHORAX/SURGICAL CRICOTHYROTOMY
EMT-P
EMT-I
EMT-B
* RAPID TRAUMA ASSESSMENT (DCAP-BTLS)
* TRANSPORT IMMEDIATELY (CONTACT MEDICAL CONTROL)
* DURING TRANSPORT, DETAILED ASSESSMENT/MANAGEMENT OF SPECIFIC INJURIES
* IV ACCESS X2 WITH NS TO MAINTAIN SBP > 90
URGENT PATIENTS
TRAUMA EMERGENCIES
Contact medical direction and consider transport to trauma center
Consider trauma team alert
YES
NO
Reevaluate with medical direction
Step Four
* Age < 5 or > 55
* Cardiac disease, respiratory disease
* Insulin-dependent diabetes, cirrhosis, or morbid obesity
* Patient with bleeding disorder or patient on anticoagulants
Contact medical direction and consider transport to a trauma center
Consider trauma team alert
YES
NO
* Auto-pedestrian/auto-bicycle injury with significant (>5 mph) impact
* Pedestrian thrown or run over
* Motorcycle crash > 20 mph or with separation of rider from bicycle
Initial speed > 40 mph
Major auto deformity > 20 inches
Intrusion into passenger compartment > 12 inches
* High-speed auto crash
* Falls > 20 feet
* Rollover
* Ejection from automobile
* Death in same passenger compartment
* Extrication time > 20 minutes
Evaluate for evidence of mechanism of injury and high-energy impact
Take to trauma center; alert trauma team.
Steps 1 and 2 triage attempts identify the most seriously injured patients in the field. In a trauma system, these patients would preferentially be transported to the highest level of care within the system.
YES
*
NO
Step Three
Assess anatomy of injury
Step Two
Step One
Take to trauma center; alert trauma team.
Steps 1 and 2 triage attempts identify the most seriously injured patients in the field. In a trauma system, these patients would preferentially be transported to the highest level of care within the system.
NO
YES
FIELD TRIAGE DECISIONS SCHEME
Measure vital signs and level of consciousness
Glasgow Coma Scale (see following page).......................................... < 14 or
Systolic blood pressure......................................................................... < 90 or
Respiratory rate..................................................................................... < 10 or > 29
Revised Trauma Score (see following page)........................................ < 11
▪ Pelvic fractures
▪ Open and depressed skull fracture
▪ Paralysis
▪ Amputation proximal to wrist and ankle
▪ Major burns
▪ All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee
▪ Flail chest
▪ Combination trauma with burns
▪ Two or more proximal long-bone fractures
|IKLcd
* Pregnancy
* Immunosuppressed patients
Intubate
Epinephrine (1:10,000)
0.01-0.03 mg/kg
IV/IO/ET
q 3-5 min
ALS available & HR ................
................
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