Download SWRETAC Trauma Triage Destination Guidelines

PROTOCOL
SECTION
NUMBER
NUMBER
OF PAGES
DATE
SECTION 100: Assessment
100
1
REVISED 02/2007
Initial Assessment
101
2
REVISED 02/2007
Neurological Assessment
102
2
REVISED 02/2007
Ongoing Assessment
103
1
REVISED 02/2007
Patient Assessment Algorithm
104
2
REVISED 02/2007
Pediatric Assessment
105
1
REVISED 02/2007
Rapid Assessment
106
2
REVISED 02/2007
Page 1 of 2
Section 101
INITIAL ASSESSMENT
ASSESSMENT
• Form a general impression of the patient (sick/not sick; hurt/not hurt)
• Determine the chief complaint/apparent life threats
• Assess mental status (AVPU)
o A-Alert
o V-Responsive to verbal stimulus
o P-Responsive to painful stimulus
o U-Unresponsive
• Briefly note body position and extremity movement.
• Airway:
o Observe the mouth and upper airway for air movement.
o Open airway if needed: use head tilt-chin lift in medical patients; chin lift (without head tilt)
or jaw thrust in trauma victims.
o Protect cervical spine from movement in appropriate trauma victims. Use assistant to provide
continuous manual stabilization.
o Look for evidence of upper airway problems, such as vomitus, bleeding, facial trauma.
o Clear upper airway of mechanical obstruction with finger sweep or suction, as needed.
• Breathing:
o Expose chest and observe chest wall movement.
o Note respiratory rate (qualitative), noise, and effort.
o Auscultate for breath sounds.
o Treat respiratory arrest with:
 Pocket mask or bag-valve-mask for initial ventilatory control.
 Check pulse and begin CPR if no pulse.
 Intubate after initial ventilation if necessary.
o
Assess for partial or complete obstruction. (Procedures: Airway Obstruction)
o If respiratory rate < 12/min or breathing appears inadequate:
 Assist respirations with pocket mask or BVM; administer supplemental O2.
 Consider tracheal intubation to secure airway if necessary.
 Transport rapidly
o Observe skin color, mentation for signs of hypoxia.
o Administer O2 if signs of hypoxia
o Look for life-threatening respiratory problems and briefly stabilize (See TreatmentTrauma:Chest Trauma):
 Open or sucking chest wound: seal.
 Large flail segment: stabilize.
 Tension pneumothorax: transport rapidly and decompress chest. (See Procedures: Needle
Decompression of Pneumothorax)
• Circulation:
o Pulse
 Palpate for pulse: radial pulse presence implies BP>80 systolic; carotid or femoral pulse
presence implies BP>60-70. If the patient is pulseless and apneic, begin CPR
 Note pulse quality (strong, weak) and general rate (slow, fast, moderate).
 Check capillary refill time in fingertips which should be less than two seconds.
o Major Bleeding
 Control hemorrhage by direct pressure with clean dressing to wound. (If needed, use
elevation, pressure points; use tourniquet ONLY in extreme situation)
o If evidence of medical shock or severe hypovolemia, obtain baseline vital signs immediately
and begin treatment and transport.
Assessment: Initial Assessment
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Section 101
INITIAL ASSESSMENT
SPECIAL NOTES
• Initial assessment may take 30 seconds or less in a medical patient or victim of minor trauma. In
the severely traumatized patient, however, assessment and treatment of life-threatening injuries
evaluated in the initial assessment may require rapid intervention, with treatment and further
assessment en route to the hospital.
• In the conscious patient, the initial assessment may be completed by your initial greeting to the
patient. This may make it clear that the ABCs are stable and emergency intervention is not
required before completing assessment.
• Neck should be immobilized and secured during airway assessment or immediately following
initial assessment if indicated.
• Vital signs should be obtained during the focused and detailed assessment. If immediate
intervention for profound shock or hypoventilation is required, this may need to be initiated
before numerical vital signs are taken.
• Pediatric assessment (See Assessment: Pediatric)
Assessment: Initial Assessment
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Section 102
NEUROLOGIC ASSESSMENT
ASSESSMENT
• Management of patients with head injury or neurologic illness depends on careful assessment of
neurologic function.
• Changes are particularly important. The first observations of neurologic status in the field provide
the basis for monitoring sequential changes. Therefore, it is important that the first responder
accurately observes and records neurologic assessment, using measures which will be followed
throughout the patient's hospital course.
• Vital Signs: observe particularly for adequacy of ventilations; depth, frequency, and regularity of
respirations.
• Level of consciousness:
• Glasgow Coma Score: Score = Sum of scores in 3 categories: (15 points possible)
o Eye opening:
 1 -None
 2- To pain
 3- To speech
 4- Spontaneously
o Best verbal response:
 1-None
 2-Garbled sounds
 3-Inappropriate words
 4-Disoriented sentences
 5 -Oriented
o Best motor response:
 1- None
 2- Abnormal extension
 3 -Abnormal flexion
 4 -Withdrawal to pain
 5 -Localizes pain
 6 -Obeys commands
• Eyes:
o Direction of gaze, extraocular movement.
o Size and reactivity of pupils.
• Movement: observe whether all four extremities move equally well.
• Sensation (if patient awake): observe for absent, abnormal, or normal sensation at different levels
if cord injury is suspected.
SPECIAL NOTES
• The Glasgow Coma Scale (GCS) used above has gained acceptance as one method of scoring and
monitoring patients with head injury. It is readily learned, has little observer-to-observer
variability, and accurately reflects cerebral function. Always record specific responses rather than
just the score (sum of observations). Be sure to note any changes as the GSC is more useful when
deficits arise. Note also that the other parameters listed must be observed to assess fully the
neurologically impaired patient.
• Use your written report to follow and document changes in neurologic findings.
• At a minimum, gross motor function must be documented before and after moving a patient with
suspected spinal injury.
• Sensory deficit levels should be marked gently on the patient's skin with a pen to help identify
any changes.
Assessment: Neurological Assessment
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Section 102
NEUROLOGIC ASSESSMENT
•
•
•
•
•
Note what stimulus is being used when recording responses. Applied noxious stimuli must be
adequate to the task but not excessive. Initial mild stimuli can include light pinch, dull pinprick,
or light sternal rub. If these are unsuccessful at eliciting a pain response, pressure with a dull
object to base of nailbed, stronger pinch (particularly in axilla), or sternal rub will be necessary to
demonstrate the patient's best motor response.
When responses are not symmetrical, use motor response of the best side for scoring GCS and
note asymmetry as part of neurologic evaluation.
Use of restraints or intubation of patient will make some observations less accurate. Be sure to
note on chart if circumstances do not permit full verbal or motor evaluation.
Remember that a patient who is totally without response will have a score of 3, not 0.
In small children, the GCS may be difficult or impossible to evaluate. Use an age-appropriate
neurological assessment for small children. Children who are alert and appropriate should focus
their eyes and follow your actions, respond to parents or caregivers, and use language and
behavior appropriate to their age level. In addition, they should have normal muscle tone and a
normal cry. Several observers should attempt to elicit a "best verbal response," to avoid over or
underestimation of level of consciousness.
Assessment: Neurological Assessment
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Section 103
ONGOING ASSESSMENT
ASSESSMENT
 Repeat initial assessment for a stable patient, repeat and record every 15 minutes. For an unstable
patient, repeat and record at a minimum every 5 minutes.
o Reassess mental status.
o Maintain an open airway.
o Monitor breathing for rate and quality.
o Reassess pulse for rate and quality.
o Monitor skin color and temperature.
o Reassess and record vital signs.

Repeat focused assessment regarding patient complaint or injuries.
o Be attentive to any changes that occur during transport: increasing pain, increased respiratory
distress, declining mental status. Any change in the patient’s status warrants a repeat
assessment.
o Treat any changes as indicated.

Check interventions:
o Assure adequacy of oxygen delivery/artificial ventilation.
o Assure management of bleeding.
o Assure adequacy of other interventions.
Assessment: Ongoing Assessment
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Section 104
PATIENT ASSESSMENT ALGORITHM
Assessment: Patient Assessment Algorithm
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Section 104
PATIENT ASSESSMENT ALGORITHM
SPECIAL NOTES
 Do not let the gathering of information distract from management of life-threatening problems.
 Appropriate questioning can provide valuable information while establishing authority,
competence, and rapport with patient. Questions should be objective and should not “lead” the
patient.
 Two types of information are used to assess medical or trauma conditions. Subjective information
is related by the patient in taking a history, and describes symptoms. The physical exam provides
signs or objective information that may or may not correlate with the patient’s symptoms.
 In medical situations, history is commonly obtained before or during physical assessment. In
trauma cases, it may be simultaneous or following the detailed assessment. An assistant is often
used for gathering information from family or bystanders.
 In trauma cases, carefully examine all areas where the patient complains of pain, but realize that
the patient’s capacity to feel pain is usually limited to one or two areas- even if more areas are
injured! That is why a systematic survey is important even in an awake patient.
 Use bystanders to confirm information obtained from the patient and to provide facts when the
patient cannot.
 History from the scene is invaluable.
 Over-the-counter medications including aspirin, homeopathic remedies, and herbal supplements
are frequently overlooked by patient and rescuer, but may be important to emergency problems.
Birth control pills are also frequently overlooked so be sure to ask.
 Confidentiality is mandatory. Patients are in need and vulnerable, they deserve respect, kindness
and discretion.
 Complete legible documentation is critical to convey the information above.
 Be systematic. If you jump from one obvious injury to another, the subtle injury that is most
dangerous to the patient is easily missed.
 If the patient has any significant airway or circulatory deterioration, these problems must be
addressed immediately. Otherwise, complete the assessment before you begin to address the
problems that have been identified.
 Obtain and record two or more sets of vital signs and neurologic observations. A patient cannot
be called “stable" without at least two sets of vital signs giving similar normal readings. Serial
vital signs are an important parameter of the patient’s physiologic status. Vital signs should be
repeated frequently, at least every 15 minutes in stable patients and at least every 5 minutes in
unstable patients.
Assessment: Patient Assessment Algorithm
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Section 105
PEDIATRIC ASSESSMENT
ASSESSMENT
• General:
o Level of alertness, eye contact, attention to surroundings
o Muscle tone: normal, increased, or weak and flaccid
o Responsiveness to parents, caregivers; is the patient playful or irritable?
•
Head:
o Signs of trauma
o Fontanelle, if open: abnormal depression or bulging
•
Face:
o Eyes: Pupils- size, symmetry, reaction to light; conjugate gaze.
o Hydration: brightness of eyes; is child making tears? Is the mouth moist?
•
Neck: note stiffness or lack of movement.
•
Chest:
o Note presence of stridor, retractions (depressions between ribs on inspiration) or increased
respiratory effort.
o Ascultate the chest:
 Breath sounds: symmetrical, rales, wheezing?
 Heart: rate, rhythm, murmurs
•
Abdomen: distention, rigidity, bruising, tenderness
•
Extremities:
o Brachial pulse, femoral pulse; capillary refill
o Signs of trauma
o Muscle tone, symmetry of movement
o Skin temperature and color, capillary refill
o Areas of tenderness, guarding or limited movement
•
Neurologic exam: See Neurologic Assessment keeping in mind that any examination that requires
a verbal response only applies as far as the verbal ability of the patient. Most importantly, it is
essential to use those who know the patient to determine if the behavior, verbal ability, and motor
function are at baseline or a departure from normal. Use these measures rather than a pediatric
Glasgow Coma Score in your assessment, documentation, and reports to the hospital.
SPECIAL NOTES
• See Pediatric- General Guidelines for further guidelines in pediatric assessment.
• Children can be examined easily from head to toe, but lack of understanding by the patient, poor
cooperation, and fright often limit the ability to assess completely in the field. Children often
cannot verbalize what is bothering them, so it is important to do a systematic survey which covers
areas that the patient may not be able to tell you about. Any observations about spontaneous
movements of the patient and areas that the child protects are very important. In the patient with a
medical problem, the more limited set of observations listed below should pick up potentially
serious problems.
Treatment Protocol: Pediatric Assessment
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Section 106
RAPID ASSESSMENT
ASSESSMENT
Medical: Unresponsive
• Assess ABCs and treat as indicated.
• Perform a rapid assessment of the specific area of complaint
• Position the patient to protect the airway
• Examine the head, neck, chest, abdomen, pelvis, back, and extremities.
• Obtain baseline vital signs: blood pressure, pulse, respirations, skin temperature and color
• Obtain SAMPLE Information from others who are with the patient.
o S-Signs and Symptoms, chief complaint
o A-Allergies
o M-Medications
o P-Pertinent medical history
o L-Last oral intake, Last menstrual period
o E-Events leading to illness
• Based on the exam findings, initiate proper interventions
• Transport immediately.
• Perform detailed and ongoing assessment
Trauma:
• Perform a rapid trauma assessment on patients with significant mechanism of injury (MOI) to
determine life threatening injuries. The rapid trauma assessment should be performed on
responsive and unresponsive patients alike.
• An integral part of this assessment is evaluation using the simple mnemonic "DCAP-BTLS" (see
below) for each area of the body. In the responsive patient, symptoms should be sought before
and during the trauma assessment.
• Assess ABCs and treat as indicated.
• Continue spinal immobilization.
• Initiate transport.
• Assess mental status:
o A-Alert
o V-Verbal
o P-Painful
o U-Unresponsive
• As you inspect and palpate, look and feel for the following examples of injuries or signs of injury:
o D-Deformity
o C-Contusions/Crepitation
o A-Abrasions
o P-Punctures/Penetrations/Paradoxical Movement
o B-Burns
o T-Tenderness
o L-Lacerations
o S-Swelling
• Examine the entire patient by inspecting and palpating each area. Do not neglect to roll patient
with spinal precautions and examine the posterior body
• Assess baseline vital signs: Blood pressure, Pulse, Respirations, Skin Temperature, and Color
Assessment: Rapid Assessment
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Section 106
RAPID ASSESSMENT
•
•
•
Assess SAMPLE history briefly- this may be done after transport has been initiated.
o S-Signs and Symptoms, chief complaint
o A-Allergies
o M-Medications
o P-Pertinent Medical History
o L-Last oral intake, LMP
o E-Events leading to illness
Based on the exam findings, initiate proper intervention
Perform detailed and ongoing assessment
Assessment: Rapid Assessment
Revised 2/2007
2
PROTOCOL
SECTION
NUMBER
NUMBER
OF PAGES
DATE
SECTION 200: Treatment - Pediatric
200
1
REVISED 09/2014
Infant Found Down – SIDS
201
1
REVISED 09/2014
Neonatal Resuscitation
202
2
REVISED 09/2014
Pediatric Dehydration
203
1
REVISED 04/2015
Pediatric General Guidelines
204
2
REVISED 09/2014
Pediatric Respiratory Distress
205
2
REVISED 09/2014
Pediatric Resuscitation
206
2
REVISED 04/2015
Pediatric Seizures
207
1
REVISED 09/2014
Page 1 of 1
Section 201
INFANT FOUND DOWN /
SUDDEN INFANT DEATH SYNDROME (SIDS)
INFORMATION NEEDED
• History: position in which the child was found, condition of the bed, last time the child was seen
well, seizure activity, trauma, possibility of ingestion
• Associated symptoms: history of fever, respiratory symptoms, infection, vomiting, diarrhea, other
signs of infections
• Past medical history: prematurity, chronic illness
SPECIFIC OBJECTIVE FINDINGS
• ABCs
• Neurologic: level of consciousness, responsiveness, muscle activity and tone
• Skin: signs of trauma
• Check for presence of froth or blood-tinged sputum at mouth or nose. (consistent with SIDS)
• Dependent lividity or early rigor mortis. Body temperature.
TREATMENT
• Initiate or continue resuscitation based on field pronouncement protocol.
• Airway: manage as indicated.
• Breathing: ventilate with 100% oxygen; suction as needed.
• Circulatory: support cardiac output as indicated by:
o External chest compressions
o Establish venous access or intraosseus access.
o Pediatric ALS as indicated
o Monitor cardiac rhythm
• Contact medical control for field pronouncement if appropriate.
• Support the parents and siblings.
• Activate appropriate support for the family if the patient is pronounced dead in the field. Police,
County Social Services, and the SIDS support line should be contacted.
SPECIAL PRECAUTIONS
• Rarely are "SIDS" cases homicides.
• SIDS cause is unknown. Cases occur between one month and one year of age. All cases are
mandatory coroner cases.
• Consider possible NAT (non-accidental trauma, child abuse) and pass on any concerns to
receiving facility personnel. It is best to avoid mentioning this to the family.
• For family support and community education, family members may welcome the following
contact information:
The Colorado SIDS Program, Inc.,
6825 East Tennessee Avenue, Suite 300, Denver, Colorado 80224
Local#: 303-320-7771 or toll-free# at 1-888-285-7437
Website access is http://www.coloradosids.org
Treatment-Pediatric: Infant Found Down / SIDS
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Section 202
NEONATAL RESUSCITATION
INDICATIONS
• Infants with scores of 7-10 usually require supportive care only
• A score 4 – 6 indicates moderate depression
• Infants with score of 3 or less require aggressive resuscitation
TREATMENT
NOTE: This protocol is to be used in conjunction with OB-GYN Active Labor protocol.
• Suction neonate's mouth and nose with bulb syringe as soon as head is delivered. Deep tracheal
suctioning is only done when meconium-stained amniotic fluid is seen or was reported in broken
waters and the neonate is not vigorous. If there is meconium staining but the neonate is vigorous,
do not perform tracheal suctioning. Suction again after delivery.
• Dry infant, wrap in clean dry blanket, keep warm.
• Use tactile stimulation if needed to initiate respirations.
• Observe neonate, check vital signs and APGAR score
APGAR 7-10
• Clamp cord in two places 8-10 inches from infant. Cut cord between clamps.
• Give infant to mother to nurse.
APGAR Scale:
0 Points
1 Point
2 Points
Apearance (Color)
Blue, pale
Body pink, Extremities blue
Fully Pink
Pulse (Heart Rate)
Absent
<100
>100
Grimace (Irritability)
No response
Some
Vigorous
Activity (Muscle Tone)
Flaccid
Some flexion
Active motion
Respiratory Effort
Absent
Slow, irregular
Strong cry
APGAR <7
• Initiate PALS algorithm below
•
•
•
•
If no pulse or pulse < 60 despite assisting ventilations, start chest compressions. The best way is
too grasp the neonate in both hands, fingers around back and thumbs on chest, and then compress
chest with both thumbs at a rate of 100 compressions per minute.
Endotracheal intubation should be considered early.
If neonate has signs of poor perfusion, establish venous access via the intraosseous route or the
cut umbilical cord, using the umbilical vein. (See sections 500 for pediatric infusion dosages).
See section 700 for procedure on umbilical vein catheterization.
Treat any arrhythmia per protocol.
Treatment-Pediatric: Neonatal Resuscitation
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Section 202
NEONATAL RESUSCITATION
Meconium Present
• Attempts should be made to keep the neonate from aspirating meconium. Suction mouth
repeatedly to remove. A vigorous neonate will not need deep suction and will assist in protecting
his/her own airway.
• A listless neonate with meconium staining needs to have the airway visualized and deep
suctioning done with pediatric-sized suction.
• The neonate can also be orally intubated with an endotracheal tube and then that tube can be used
as a suction catheter. (Use a 0 to 1 size straight blade laryngoscope and 2.5 to 3.5 size ET tube
depending on the gestational age of the newborn.)
• You may need to intubate multiple times until airway is clear, using a clean tube each time. If
you are to ventilate via the endotracheal tube it should be clear of meconium.
SPECIAL PRECAUTIONS
• Epinephrine should be administered preferably via the intravenous route
• Consider Naloxone if poor respiratory effort. Be aware that this may induce seizures in neonates
whose mother has a history of narcotic dependency
Treatment-Pediatric: Neonatal Resuscitation
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Section 203
PEDIATRIC DEHYDRATION
INFORMATION NEEDED
• History: onset and progression of symptoms, frequency of vomiting and diarrhea, urine output
(wet diapers), oral intake, recent trauma, possible drug ingestion
• Past medical history including immunization history.
• Social situation including sick contacts, home environment, travel.
SPECIFIC OBJECTIVE FINDINGS
• General appearance: LOC, muscle tone, color
• ABCs and vital signs
• Skin: warmth of distal extremities, color, skin turgor, capillary fill time (should be less than 2
seconds), pulses
• Mucous membranes moist, presence of tears
• Musculoskeletal: evaluate for trauma
• The signs of dehydration are:
o EARLY - tachycardia and tachypnea for age, decreased LOC, capillary filling time longer
than two seconds, cool skin, mucous membranes dry, sunken eyes and fontanelle;
o LATE - loss of skin turgor, diminished pulses, and shock
TREATMENT
• Airway: manage as indicated, administer O2
• Breathing: ventilation as indicated
• Circulation:
o Establish peripheral venous access.
o Consider fluid bolus of crystalloid fluids: 20cc/kg.
o Do not delay transport for IV attempts.
o Consider insertion of intraosseous catheter (See Intraosseus Infusion Protocol)
SPECIAL PRECAUTIONS
• Assessment of dehydration is primarily by physical exam. Vital signs may be abnormal, but they
are nonspecific.
• Monitor carefully for signs of decreased tissue perfusion (shock). Early shock is present if
capillary fill time is greater than 2 seconds, and there are poor pulses, muscle tone and color, or
decreased mental status. Decompensated shock is present if systolic BP is <normal for age.
• Determination of tachycardia or hypotension is based on age. (See Pediatric Assessment protocol)
Treatment-Pediatric: Pediatric Dehydration
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Section 204
PEDIATRICS GENERAL GUIDELINES
Pediatric patients, for the purpose of the protocols, defined as age < 12 years, have unique anatomy,
physiology, and developmental needs that affect prehospital care as well as hospital care. Because
children make up a small percentage of total calls and few pediatric calls involve critically ill or injured
patients, it is important to be cognizant of these differences. Therefore, utilize medical control early for
guidance when treating pediatric patients with significant findings. Pediatric emergencies are usually not
preceded by chronic disease. If recognition of compromise occurs early, and intervention is swift and
effective, the child will often be restored to full health.
The following should be kept in mind during the care of children in the prehospital setting:
• Airways are smaller, softer, and easier to obstruct or collapse.
• Respiratory reserves are small. A minor insult like improper position, vomiting, or airway
narrowing can result in major deficits in ventilation and oxygenation.
• Unless the child has an abnormality within the cardiovascular anatomy or physiology, children
often respond quickly to airway positioning and supplemental oxygen. Airway and respiration is
even more of a priority in children since any circulatory compromise often stems from inadequate
oxygenation or ventilation.
• Circulatory reserves are also small. The loss of as little as one unit of blood can produce severe
shock in an infant. Conversely, children respond to fluid resuscitation. It is much easier to
determine the response to fluid resuscitation in children than in adults.
• Assessment of the pediatric patient can be accurately done using your knowledge of the anatomy
and physiology specific to infants and children.
• Listen to the parents' assessment of the patient's problem. They often can detect small changes in
their child's condition. This is particularly true if the patient has chronic disease.
• The proper equipment is very important when dealing with the pediatric patient. A complete
selection of pediatric airway management equipment, IV catheters, cervical collars, and drugs has
been mandated by the state. This equipment should be stored separately to minimize confusion.
• Blood pressure readings may be deferred only in the following
o Children who are fully awake and interactive without any signs of shock.
o Children without respiratory distress.
o Children without a history of or any signs of dehydration
o Children without a history of kidney disease.
• If there is any question at all, obtain a blood pressure
• When following these protocols, the age groups used are:
o INFANTS: birth to one year
o TODDLERS: one through five years
o SCHOOL AGE: six through fourteen years
Treatment-Pediatrics: General Pediatric Guidelines
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Section 204
PEDIATRICS GENERAL GUIDELINES
Treatment-Pediatrics: General Pediatric Guidelines
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Section 205
PEDIATRIC RESPIRATORY DISTRESS
INFORMATION NEEDED
• History: sudden or gradual onset of symptoms, cough, fever, wheezing, hoarseness, stridor
• History of potential foreign body aspiration or trauma
• Past medical history
• Current medication use
SPECIFIC OBJECTIVE FINDINGS
• Airway: look for respiratory distress during inspiration, listen for abnormal breathing sounds such
as stridor, cough, and wheezing, feel for air movement, crepitation, and tracheal deviation
• Breathing: respiratory rate and effort, chest wall movement/adequacy of tidal volume, color, use
of accessory muscles, retractions, nasal flaring, head bobbing, or grunting
• Respiratory sounds by auscultation of chest: wheezing, rales, decreased (unilateral?), prolonged
inspiratory or expiratory phases.
• Mental status: AVPU
• General appearance: leaning forward or drooling (suggests upper airway obstruction), skin color
and temperature, muscle tone.
TREATMENT
• Administer high-flow oxygen by blow-by or non-rebreather mask.
• As long as the child is adequately ventilating and has adequate mentation, avoid agitating the
patient. Keep the patient in his position of comfort. Use parent to hold child if needed.
• If the child is not ventilating adequately, assist with a BVM.
• In the rare case that the child cannot be ventilated with a BVM device:
o Reposition airway. Consider oral airway if patient unconscious.
o If still unable to ventilate, visualize the airway with a laryngoscope. Remove any foreign
object with Magill forceps.
o If nothing is seen, orally intubate the patient.
• Consider intubation only if unable to provide ventilatory support with a BVM and oral airway or
if air transport delayed or not available.
• Assess and consider treatment for the following problems if respiratory distress is severe and the
patient does not respond to proper positioning and administration of high flow Oxygen.
o Croup or epiglottitis:
 Allow patient to remain in position of comfort if alert.
 Consider administering epinephrine via nebulizer if croup is likely and there is
respiratory distress.
o Asthma:
 Administer albuterol. Consider adding ipratropium for age >2y/o
 Use continuous nebulization of albuterol sulfate for respiratory distress.
 Consider epinephrine, SQ.
• If diagnosis is unclear, transport patient with 100% O2, reassess frequently and be prepared to
manage the patient's airway.
SPECIAL PRECAUTIONS
• Children with asthma, croup, epiglottitis, or laryngeal edema usually have respiratory arrest due
to exhaustion. Most children can still be ventilated with a BVM.
• Children with severe asthma may not exhibit wheezing. The patients will have prolonged
expiratory phases, or simply a frequent cough and may appear listless, agitated, or unresponsive.
• Respiratory distress is a critical situation that can be made worse with prolonged scene times.
Treatment-Pediatric: Pediatric Respiratory Distress
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Section 205
PEDIATRIC RESPIRATORY DISTRESS
•
•
•
•
•
Intubation of the infant is most easily accomplished with an infant-sized straight laryngoscope
blade.
Do not intubate unless you can visualize the ETT going through the cords. If you are unable to
intubate the trachea quickly, withdraw, re-oxygenate with BVM, and try again. No harm will
result to the child if you keep the patient well oxygenated and don't traumatize the airway with
multiple intubation attempts. Transporting while using BVM only is acceptable and may be
preferable in many circumstances.
Any child with a witnessed or suspected apneic episode should be transported.
Cyanosis is a late sign in pediatric hypoxia. Provide 100% oxygen for any child in distress.
Consider the differential assessment for each finding:
o Stridor: foreign body, croup, epiglottitis or other bacterial upper airway infection, laryngeal
trauma, et
o Wheezing: foreign body, asthma, bronchiolitis, hydrocarbon exposure.
o Respiratory distress: pneumothorax, foreign body, pneumonia, shock, CHF.
Treatment-Pediatric: Pediatric Respiratory Distress
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Page 1 of 2
Section 206
PEDIATRIC RESUSCITATION
INFORMATION NEEDED - DO NOT delay rapid intervention to collect information.
• Time since the child was last in good health
• History of any recent illness or injury
• Past medical history
SPECIFIC OBJECTIVE FINDINGS
• General appearance: LOC, interactions, muscle tone, color
• Airway: obstruction, stridor, drooling, cough
• Breathing: respiratory rate, skin color (cyanosis late sign), chest wall symmetry and depth of
movement, work of breathing (grunting, nasal flaring, retractions), wheezing
• Circulation: heart rate, peripheral pulses, capillary filling time, skin color, extremity skin
temperature
• Level of consciousness, pupil size and reaction to light
• Physical assessment
TREATMENT
• Airway/Breathing:
o Manage airway. Effective airway management is by far the most critical aspect of treatment.
Bag-mask ventilation using proper technique may be as good if not superior to endotracheal
intubation for EMS treatment.
o Administer oxygen via blow-by, non-rebreather mask, bag-mask ventilation or via
endotracheal tube.
o If apneic, ventilate with a BVM, intubate as indicated, ventilation rate 20/min. Ensure
adequate chest rise and fall (tidal volumes).
• Circulation:
o Initiate CPR if indicated.
o Monitor cardiac rhythm.
o Establish peripheral venous access.
o If unable to establish a peripheral IV after 2 attempts or 90 seconds, establish an intraosseous
infusion. If unable to see good peripheral vein, go straight to IO infusion.
o If any signs of poor perfusion, infuse a 20 mL/kg crystalloid fluid bolus. Contact medical
control if you feel perfusion is compromised on reassessment.
• Medications:
o Stabilizing the airway and supporting respiration are the mainstays of treatment. Specific
treatment should be focused on the etiology of the arrest.
o Arrhythmias are treated as noted in Arrhythmia Algorithms. See medication protocols for
pediatric doses.
o Hypoglycemia is common in younger children. If the child has altered mental status, check
the glucose level and administer dextrose IV if indicated.
SPECIAL PRECAUTIONS
• The most successful pediatric resuscitations occur before a full cardiopulmonary arrest. Assess
pediatric patients carefully and assist with airway, breathing, and circulatory problems before the
arrest occurs, to improve the outcome in pediatric patients.
• Pediatric arrests are most likely to be primary respiratory events. The rescuer's primary attention
must be directed to securing the airway and providing good ventilation before specific treatment
of cardiac rhythm. Any cardiac rhythm can spontaneously convert to sinus rhythm in a wellventilated child.
Pediatric-Treatment: Infant and Child Resuscitation
Revised 4/20115
1
Page 2 of 2
Section 206
PEDIATRIC RESUSCITATION
•
•
•
•
•
Oxygen and fluids are the mainstays of pediatric resuscitations.
Cardiopulmonary arrest from trauma is treated with airway management, rapid transport, CPR
and fluid administration en route. (Treatment -Traumatic arrest protocol)
Recommendations for obstructed airway are abdominal thrusts over the age of one year. Infants
less than one year old should be treated with back blows and chest thrusts. Early laryngoscopy
should be used in an attempt to visualize and remove upper airway obstructions (Procedures Obstructed Airway)
If a child 1 year or older is in arrest, AEDs can be used.
Use of a length-based emergency tape such as the Broselow tape which is highly accurate and
allows for rapid drug and fluid doses along with correct equipment size and use. Its use should be
routine for any pediatric emergency.
Pediatric-Treatment: Infant and Child Resuscitation
Revised 4/20115
2
Page 1 of 1
Section 207
PEDIATRIC SEIZURES
INFORMATION NEEDED
• History: preceding activity level, onset and duration of seizure, description of seizure activity,
fever, color change, recent illness, head trauma, possibility of ingestion, cardiac symptoms.
• Past history: previous seizures, current medications, chronic illness
SPECIFIC OBJECTIVE FINDINGS
• Airway: look for respiratory distress, listen for abnormal breathing sounds, feel for air movement,
crepitation, tracheal deviation.
• Breathing: respiratory rate and effort, chest wall movement (adequacy of tidal volume), use of
accessory muscles, retractions
• Circulation: heart rate, pulse, capillary filling time, skin color, blood pressure
• Neurologic: mental status, muscle tone, focal findings, post-ictal period, incontinence. Note
improvement or deterioration in mental status with time.
• Note ocular movements and especially if persistent deviation to one side.
• Musculoskeletal: note any associated injuries.
TREATMENT
• Airway: Maintain patent airway by BLS maneuvers. Suction as needed. Administer 100% O2.
• Breathing: Assist ventilation as needed. (rarely necessary)
• If child is in status seizure:
o Administer Midazolam (Versed) IN.
o Establish peripheral venous access. Administer Ativan (Lorazepam) IV, or diazepam
(Valium) IV or Midazolam IV
o If unable to start peripheral IV: administer Midazolam IM and repeat once if still in status.
Lorazepam IM may be used secondary to Midazolam IM.
o Determine blood glucose level and draw appropriate blood tubes if possible.
o If hypoglycemic, give IV dextrose.
o If seizures continue, contact medical control.
• If the child has stopped seizing and is post-ictal, transport while continuing to monitor vital signs
and neurologic condition. Establish IV and be prepared to administer diazepam or midazolam.
• If child is febrile initiate mild cooling measurers.
• See sections 500 (medications) for appropriate dosing
SPECIAL PRECAUTIONS
• Be ready to protect the child’s airway, especially after giving Midazolam. BVM is sufficient in
most cases.
• Some seizures occur without tonic or clonic movements. Be sure to observe ocular movements.
If there is persistent deviation to one side, treat for status epilepticus.
• Febrile seizures occur in normal children between 5 months and 5 years. Such seizures are
usually short, lasting less than 5 minutes, not recurrent, and usually do not require anti-seizure
drug therapy.
• Do not force anything between the teeth.
• Consider hypoglycemia as a cause for non-traumatic seizure.
• Breath-holding spells in toddlers can result in seizures.
Treatment-Pediatric: Pediatric Seizures
Revised 9/2014
1
PROTOCOL
SECTION
NUMBER
NUMBER
OF PAGES
DATE
SECTION 300: Treatment - Medical
300
1
REVISED 07/2014
Abdominal Pain - Medical
301
1
REVISED 07/2014
Allergy Anaphalaxis
302
2
REVISED 04/2015
Altered Mental Status
303
2
REVISED 04/2015
Arrhythmias
304
4
REVISED 07/2014
Blood Component Administration
305
2
REVISED 04/2015
Behavioral Disorders
306
1
REVISED 04/2015
Cardiac Arrest
307
2
REVISED 07/2014
Chest Pain
308
2
REVISED 04/2015
CVA-Stroke
309
2
REVISED 04/2015
Diabetic Emergencies
310
1
REVISED 04/2015
Hypertensive Emergencies
311
2
REVISED 04/2015
OB-GYN
312
4
REVISED 04/2015
Respiratory Emergencies
313
3
REVISED 07/2014
Seizures
314
2
REVISED 04/2015
Shock
315
3
REVISED 04/2015
Syncope
316
2
REVISED 04/2015
Toxins and Overdose
317
4
REVISED 04/2015
Vomiting
318
1
REVISED 04/2015
Page 1 of 2
Section 301
ABDOMINAL PAIN
INFORMATION NEEDED
• Pain:
o nature (cramping, sharp, dull), severity, duration, location; radiation to back, groin, chest,
shoulder.
• Associated Symptoms:
o Nausea. Vomiting (blood or coffee ground). black or tarry stools, urinary difficulties,
menstrual history, fever. Last BM, last meal.
• Past History:
o Previous trauma, abnormal ingestions, medications, known diseases, surgeries, OB/Gyn
history.
SPECIFIC OBJECTIVE FINDINGS
• Vital signs:.
• General appearance:
o restless, quiet, sweaty, pale.
• Abdomen:
o tenderness, guarding, distention, rigidity, pulsatile mass, response to movement.
• Patient position:
o keeping still or moving (writhing)
• Input/Output:
o Emesis, stool, or urine; describe, amount.
• Equality of pulses:
o Check for equality of pulses- especially in lower extremities
TREATMENT
• Position of comfort.
• NPO (Nothing By Mouth).
• Administer O2.
• Signs of shock: establish venous access. Administer normal Saline standard volume 500cc fluid
bolus; contact Medical Control if no improvement.
• Monitor vital signs during transport- 12 lead EKG strongly suggested for patients with upper
abdominal pain.
• Pain control- administer a small dose of morphine or fentanyl for severe pain only if the patient is
hemodynamically stable. Do not withhold pain medicine for fear of altering the exam. See
medication protocols for dosing.
SPECIAL PRECAUTIONS
• The most important diagnoses to consider are those associated with catastrophic internal
bleeding: ruptured aneurysm, bleeding ulcer, ectopic pregnancy, etc. Since the bleeding is not
apparent, you must think of the volume depletion and monitor patient closely to recognize shock.
If a patient presents in shock (see Shock: Medical), contact Medical Control and consider air
transport to the nearest hospital with surgical consultation available.
• Elderly patients may have significant hypovolemic shock with systolic blood pressures above 90
mm Hg. With signs of hypovolemia (see Shock: Medical) contact base and treat with fluids.
• Upper abdomen and lower chest pain may reflect thoracic pathology such as myocardial
infarction, etc. Massive fluid resuscitation may be contraindicated. If in doubt, consult medical
control and monitor closely.
Treatment-Medical: Abdominal Pain
Revised 7/2014
1
Page 1 of 2
Section 302
ALLERGY / ANAPHYLAXIS
INFORMATION NEEDED
• History:
o Current sequence of events, exposure to allergens (bee stings, drugs, nuts, seafood most
common), prior allergic reactions.
• Current symptoms:
o Itching, wheezing, nausea, weakness, rash, anxiety, SOB, airway swelling or irritation.
• Medications:
o Past medical history.
o Current medications including newly prescribed, over-the-counter or alternative medications
SPECIFIC OBJECTIVE FINDINGS
• Vital signs:
o Heart Rate – Tachycardia?
o Blood Pressure – Hypotension?
o Breath Sounds – Wheezes? Stridor? Diminished?
• Level of consciousness.
• Airway:
o Swelling including tongue and face, stridor (upper airway noise)
• Skin:
o Hives, swelling, flushing.
TREATMENT
Allergic Reactions
• Assure and maintain a patent airway
• Administer oxygen 100% via NRB
• Remove cause of anaphylaxis- stinger or other allergen
• Establish Large Bore I.V. Administer bolus crystalloid fluids.
• Monitor Cardiac Rhythm
• Benadryl
•
Anaphylactic reactions
• All of the above plus the following
• Consider early intubation to preserve an airway
• Epinephrine IM if airway swelling or compromise (may be given via EPI-PEN see epinephrine or
epinephrine auto injector protocol)
• Aggressive fluid resuscitation
• Methylprednisolone (Solu-Medrol)
ALLERGY / ANAPHYLAXIS
Treatment–Medical: Allergy/Anaphylaxis
Revised 4/2015
1
Page 2 of 2
Section 302
SPECIAL PRECAUTIONS
•
•
•
•
•
•
•
•
The difference between a mild allergic reaction and anaphylaxis is often subtle. The symptoms
may rapidly progress en route. Consulting medical control is advised.
Anxiety, tremor, palpitations, tachycardia, and headache may occur with administration of
epinephrine. These may be particularly severe with IV administration. In children, epinephrine
may induce vomiting.
Epinephrine may exacerbate preexisting coronary artery disease and cause angina, MIs or
arrhythmias. Judicious and careful use is advised and should be discussed with medical control
especially in the elderly or patients with cardiac disease.
Two forms of epinephrine are carried as part of paramedic equipment. The standard ampules of
aqueous epinephrine contain a 1:1000 dilution appropriate for IM injection. IV epinephrine
should be given in a 1:10,000 dilution. Use the 1:10,000 prefilled syringe for IV dosing to avoid
mistakes. Be sure you are giving the proper dilution to your patient, and give slowly.
If IV epinephrine is ineffective or the effects transitory, infuse epinephrine at 1mcg/min.
(see protocol)
Examine the airway carefully as the edema may be localized to the mouth, tongue or uvula. If
there is evidence of progressive swelling, early intubation is advised. See endotracheal intubation
protocol and be prepared to use an adjunct airway if swelling is significant.
Before treating anaphylaxis, verify that the patient has subjective and objective signs of true
anaphylaxis rather than a mild and limited allergic reaction. Epinephrine will only aggravate
those who are hyperventilating and increase their anxiety.
If airway swelling is due to an ACE inhibitor reaction consider early intubation and/or prompt
transport to a facility with FFP. These reactions can occur with a patient on newly prescribed
ACE inhibitors or one that has been on the therapy for many years.
Treatment–Medical: Allergy/Anaphylaxis
Revised 4/2015
2
Page 1 of 2
Section 303
ALTERED MENTAL STATUS
INFORMATION NEEDED
• Present history:
o Time of onset of change noted by patient or caregiver, progression of present illness or
symptoms ; preceding symptoms such as headaches, seizures, confusion, trauma, etc. Ask
about changes in speech, numbness, focal weakness, facial droop, visual changes, gait/
balance.
• Past history:
o Previous medical or psychiatric problems, including diabetes, previous stroke, trauma, high
blood pressure, heart disease or arrhythmias, seizure disorder, bleeding disorders.
o Determine baseline mental status and progression of changes
• Medications:
o use, misuse, or abuse (including illicit drug use)
• Surroundings:
o check for pill bottles, syringes, etc., and bring with patient. Note odor in house.
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Level of consciousness and neurological status
• Any signs of head trauma or other trauma
• Neurological exam:
o motor strength- weakness limited to one side
o sensory- loss of sensation on one side
o facial weakness- noticeable droop per your exam or per caregiver
o gait/ balance- ambulation (with assist if patient unstable)
o GCS
o speech- slurring; difficulty articulating or finding words
• Needle tracks
• Medical alert tag
• Past pertinent medical history:
o Stroke / CVA.
o Cardiac history.
o Diabetes.
o Seizures.
o Head injury.
o Psychiatric or mental illness
TREATMENT
• Assure and maintain a patent airway. Suction if needed.
• Recovery position unless spinal precautions indicated.
• Oxygen
• Monitor Vital Signs - including ECG
• Establish IV.
• Obtain Blood Glucose Level
• Administer Dextrose per protocol if Blood Sugar less than 60 mg / dL or with symptoms of
hypoglycemia.
• Consider Narcan 1-2mg IVP or IM
• Frequently reassess airway reflexes and GCS
Treatment–Medical: Altered Mental Status
Revised 4/2015
1
Page 2 of 2
Section 303
ALTERED MENTAL STATUS
SPECIAL PRECAUTIONS
• Safety to rescuer: check for gases or other toxins.
• Be particularly attentive to airway. Difficulty with secretions, vomiting, and inadequate tidal
volume are common.
• Hypoglycemia may present as focal neurologic deficit or coma.
• Coma in the diabetic may be due to hypoglycemia or to hyperglycemia (diabetic ketoacidosis). IV
dextrose should be given to all unconscious diabetics, as well as patients with coma of unknown
origin unless a blood glucose reading in the high range is obtained. Do not give oral sugar to an
unconscious patient
• Stroke patients may be alert but unable to respond (aphasic); therefore, communicate with the
patient and explain what you are doing. Be sensitive to the patient with expressive aphasia who
can understand you but cannot express words. These patients may become agitated and require
sedation if verbal de-escalation fails.
• Naloxone is useful in any potential narcotic overdose, but be sure the patient is controlled before
giving naloxone to a patient in whom there is a suspicion or history of narcotic dependency. The
acute withdrawal precipitated in an addict may result in violent combativeness. Give slowly to
avoid adverse effects (see medication protocol)
• Use caution with administration of dextrose in a suspected hemorrhagic stroke as it is toxic
outside of the vasculature and can cause destruction of brain tissue. Do not withhold dextrose if
the patient is hypoglycemic.
• If the patient requires air transport to the nearest appropriate hospital, be sure to relay pertinent
history to the flight crew as well as the physician at the hospital as this information is crucial for
proper patient care.
• Medication interaction, unintentional or intentional overdose is a common cause of altered mental
status, especially in the elderly. Obtaining an accurate medication list or brining the medications
to the hospital is essential.
Treatment–Medical: Altered Mental Status
Revised 4/2015
2
Page 1 of 4
Section 304
ARRHYTHMIAS: GENERAL
INFORMATION NEEDED
• Present symptoms:
o Sudden or gradual onset, palpitations
• Associated symptoms:
o Chest pain, dizziness or fainting, trouble breathing, abdominal pain, fever
• Prior history:
o Arrhythmias, cardiac disease, exercise level, pacemaker
• Current medications or ingestions:
o Particularly cardiac
o Toxic substances or overdoses
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Signs of poor cardiac output:
o Altered level of consciousness, mental status changes
o Appearance of shock: cool/clammy skin, pallor
o Blood pressure < 90 systolic
o Chest pain consistent with angina
• Signs of cardiac failure:
o Neck vein distention
o Lung congestion, rales
o Peripheral edema
• Signs of hypoxia:
o Marked respiratory distress
o Cyanosis
o Tachycardia
TREATMENT
• ABCs- apply oxygen and assist ventilations.
o Oxygenation and good CPR is crucial.
o Manage airway aggressively as appropriate for the patient.
o Intubate if indicated without delaying appropriate CPR and defibrilation
• Establish venous or intraosseous access.
• Evaluate the patient. Is the patient perfusing adequately or are there signs of inadequate perfusion?
• Apply cardiac monitor and evaluate arrhythmia.
o Is there a pulse corresponding to monitor rhythm?
o Rate: tachycardia, bradycardia, normal?
o Are the ventricular complexes wide or narrow?
o What is the relation between atrial activity (P waves) and ventricular activity (QRS complexes)?
o Is the arrhythmia potentially dangerous to the patient? (see below)
• Document the arrhythmia by rhythm strip and 12 lead EKG if available.
• Treat if needed according to pulse rate (see algorithms) or as directed by medical control.
• Document results of treatment by checking pulse and recording change on paper tape.
• Transport once patient has stabilized. Monitor condition enroute. If patient is not stable, discuss
destination and need for air ambulance with medical control. Consider utilizing local physicians and
clinic if available.
Treatment–Medical: Arrhythmias
Revised 2/2007
1
Page 2 of 4
Section 304
ARRHYTHMIAS: GENERAL
Asystole / PEA
• Chest compressions 30:2, assist ventilations: 5 cycles, then check pulses
• Attempt transcutaneous pacing only if witnessed asystole
• Epinephrine
• Atropine
• Consider termination of efforts after repeating the above 3 times and continued asystole- contact
medical control--see Determination of Death in Field protocol
• For pulseless electrical activity, remember the causes of PEA and treat accordingly:
o Hypovolemia - -IV fluid bolus
o Tension pneumothorax - -Chest decompression per protocol
o Hypoxia - -Check tube placement and patency
o Acidosis - -Oygen,ventilation, fluid resuscitation, sodium bicarbonate
o Cardiac tamponade -IV fluid bolus
o Hypothermia –rewarming- see Hypothermia protocol
o Hypoglycemia- administer D50 or glucagon
o Pulmonary embolism- oxygen and ventilatory support
o Myocardial infarction- see chest pain protocol
o Drug overdose- see toxins and overdoses protocol
o Hyperkalemia –peaked T waves, wide QRS on ECG; consider sodium bicarbonate
• Patients who convert from a viable rhythm into asystole should have transcutaneous pacing
instituted immediately. However, pacing should be withheld from those patients who present
in asystole.
• When asystole is diagnosed, check the integrity of the leads and electrode patches and
confirm this interpretation in at least two leads.
• Avoid interruptions in chest compressions. Once an advanced airway is established, continue
to give 8-10 breaths per minute and check pulses and rhythm every 2 minutes.
Ventricular Fibrilation / Pulseless Ventricular Tachycardia
• Chest compressions 30:2, assist ventilations: 5 cycles, then check pulses
• Defibrillate
• Immediately continue compressions 5 cycles
• Check pulse/rhythm- if VF/ pulseless Vtach, Defibrillate
• Epinephrine
• Continue compressions 5 cycles
• Check pulse/rhythm- if VF/ pulseless Vtach, Defibrillate
• Epinephrine
• Amiodarone
• Continue compressions – 5 cyles
• Check pulse/rhythm- if VF/ pulseless Vtach, Defibrillate and repeat steps above; contact medical
control
• Consider Magnesium Sulfate for torsades de pointes
• Consider Sodium Bicarbonate per protocol
Treatment–Medical: Arrhythmias
Revised 2/2007
2
Page 3 of 4
Section 304
ARRHYTHMIAS: GENERAL
Tachycardia with pulse - Unstable patient
• Cardiovert see cardioversion protocol
Tachycardia with pulse – Stable patient
• Evaluate 12 lead ECG for prolonged (> 0.12s) QRS, and regularity of rhythm
• Narrow QRS – Regular
o Vagal maneuvers
o Adenosine per protocol
o If rhythm does not convert, continue monitoring
o Contact medical control.if signs of shock
• Narrow QRS – Irregular
o Continuous monitoring
o Contact medical control if signs of shock
• Wide complex – Regular
o Amiodarone 150 mg over 10 min
o Consult medical control and consider cardioversion
• Wide complex – Irregular
o Continous monitoring
o Contact medical control and consider cardioversion
o Magnesium Sulfate if polymorphic (torsades de pointes)
Bradycardia – Stable
• Observe on monitor
• If patient is symptomatic
o Treat with fluid bolus and position patient supine
Bradycardia – Unstable
• Atropine per protocol
• For 2nd degree type II and 3rd degree consider transcutaneous pacing as initial treatment
• Transcutanous pacing if refractory to atropine
• Consider Dopamine or Epinephrine drip
• Consult medical control if hypotension / hypoperfusion persists
Premature Ventricular Contractions
• The treatment of PVCs is rarely, if ever, indicated in the prehospital setting. PVCs are most often a
sign of inadequate coronary perfusion or hypoxia, thus treat the cause.
• Patients with PVCs and active chest pain should have their pain treated aggressively with oxygen,
aspirin, nitrates, and pain medications (see chest pain protocol).
• Prophylactic use of anti-arrhythmicx is contraindicated.
Treatment–Medical: Arrhythmias
Revised 2/2007
3
Page 4 of 4
Section 304
ARRHYTHMIAS: GENERAL
SPECIAL PRECAUTIONS
• Treat the patient, not the arrhythmia! If the patient is perfusing adequately, there is no need for
emergency treatment. This is true of bradyarrhythmias as well as tachyarrhythmias. What is normal
for one person may be fatal to another.
• Documentation of and recording arrhythmias is extremely important. Field treatment of an arrhythmia
may be life saving, but long-term treatment requires knowing what the problem was.
• Correct arrhythmia diagnosis based only on monitor strip recordings is difficult and often not possible.
Treatment must be based on observable parameters: rate, patient condition and distance from the
hospital.
• Dangerous rhythms are those which do not necessarily cause poor perfusion, but are likely to
deteriorate. They require recognition and treatment to prevent degeneration to mechanically
significant arrhythmias. Some of these potentially dangerous rhythms include ventricular tachycardia
and high degree AV block: Mobitz II 2nd degree block or 3rd degree block.
• Cardiac arrest and life-threatening arrhythmias can be treated in the field, and show the benefits of
"stabilization before transfer" in prehospital care. The patient is better off when the duration of arrest
or poor perfusion is minimized.
• ALS providers should use the monitor and defibrillate as indicated. For BLS providers
•
•
•
using an AED, follow the above protocol and override the promptings of the AED, giving
only 1 shock and quickly resuming compressions and ventilations for five cycles. Call
for ALS immediately.
If ongoing efforts result in no change in patient condition, reassess the airway, CPR, and IVs. Then
consult with medical control for field pronouncement.
EMT-Intermediates must contact medical control in order to administer the medications listed below.
This may be done once the patient is stable and should not delay treatment of the patient.
Drug dosages vary in the pediatric and elderly populations. See drug protocols for details.
Treatment–Medical: Arrhythmias
Revised 2/2007
4
Page 1 of 1
Section 305
BEHAVIORAL DISORDERS
INFORMATION NEEDED
• Obtain history of current event, inquire about recent crisis, toxic exposure, drugs, alcohol, emotional
trauma, suicidal or homicidal thoughts, attempts or plans.
• Obtain past history; inquire about previous psychiatric and medical problems, medications.
SPECIFIC OBJECTIVE FINDINGS
• Evaluate vital signs.
• Thoughts of suicide - bizarre or abrupt behavior changes.
• Significant past medical history.
• Determine ability to relate to reality.
• Is the patient a threat to self or others?
• Hallucinations / Delusions.
• Is there a medical problem - Medic Alert Tag?
• Drug or Alcohol abuse.
• Signs of trauma.
TREATMENT
• Assure and maintain a patent airway
• Administer Oxygen
• Monitor Vital Signs
• Establish I.V.
• Cardiac Monitor
• Obtain Blood Glucose Level
PROCEDURE
FR
EMT B
Dextrose IVP if blood sugar < than 60
mg / dL or with assoc. symptoms.
Narcan- with caution
EMT B IV
EMT I
EMT P
VO/P
SO
SO
VO/P
SO
Consider Chemical Restraint. (Acute
psychotic episodes or ETOH related
overdoses)
• Haldol or Versed
VO/P
SO
SO
• Ativan
SPECIAL PRECAUTIONS
• Psychiatric patients often have an organic basis for mental disturbances. Beware of hypoglycemia,
hypoxia, head injury, intoxication, or toxic ingestion.
• If the patient does not require immediate treatment, take the time to attempt to develop a rapport with
the patient. Other measures may be avoided if this can be accomplished
• If emergency treatment is necessary, do as little as possible to adequately treat the patients physical
condition while being especially respectful of their personal space.
• If the situation appears threatening, involve police before attempting to restrain. DO NOT put
yourself at risk. Remember, a violent or threatening patient means the scene is unsafe and needs to be
secured prior to establishing patient contact or care.
• Beware of weapons. These patients can become very violent.
• All levels of EMTs may initiate a mental health hold only with the permission and online contact with
medical control. (Mental Health Hold protocol)
Treatement–Medical: Behavioral Disorders
Revised 4/2015
1
Page 1 of 1
Section 306
CARDIAC ARREST: MEDICAL
INFORMATION NEEDED
• History of arrest:
o Onset, preceding symptoms, bystander CPR, other treatment, duration of arrest
• Past history:
o Diseases, medications
• Surroundings:
o Evidence of drug ingestion, toxic exposures, trauma, other unusual presentations
SPECIFIC OBJECTIVE FINDINGS
• Level of Consciousness
• Pulseless.
• Apneic.
• Air Temperature; Skin Temperature
• Signs of Trauma, blood loss
• Patient History and Medications.
TREATMENT
• Initiate CPR for min of 2 min (unless patient fits criteria for field pronouncement in Operational
protocols: death in field)
• Access and maintain a patent airway. Ventilate with 100% Oxygen
• ECG monitor; quik-combo pads
• Defibrillate if indicated
• Establish IV or IO access
• Follow specific arrhythmia protocols for drug administration
• If possible, change providers performing CPR every cycle
• Assess ETCO2 frequently to insure adequate compressions and to see if ROSC has occurred
SPECIAL PRECAUTIONS
• Cardiac arrest in a trauma situation is not treated according to this protocol (see Traumatic
Arrest protocol).
• Survival from cardiac arrest is related to the time to BOTH BLS and ALS treatment. Don't
forget CPR and make sure it is constant with minimal interruptions while you prepare the
advanced equipment. If needed, a call for back-up should be initiated promptly
• See Neonatal and Pediatric Resuscitation protocols for special pediatric details.
• Large peripheral veins (antecubital or external jugular) are preferred IV sites in an arrest.
• Be sure to recheck for pulselessness and unresponsiveness upon arrival, even if CPR is in
progress. This will avoid needless treatment of "collapsed" patients who are inaccurately
diagnosed initially, or who have spontaneous return of cardiac function after an arrhythmia or
syncopal episode.
• If ROSC achieved follow Therapeutic Hypothermia protocol
Treatment–Medical: Cardiac Arrest
Revised 7/2014
1
Page 1 of 2
Section 307
CHEST PAIN: MEDICAL
INFORMATION NEEDED
o Pain: character, onset, duration, location, radiation, aggravation, alleviation, relationship to
exertion and respirations. Similarity to previous episodes- especially prior to previous MI.
o Associated symptoms: Nausea, vomiting, diaphoresis, respiratory difficulty,
lightheadedness, cough, fever.
o Past history: Previous cardiac or pulmonary problems, medications (including those for
erectile dysfunction), drug allergies, past or current drug use (amphetamine, cocaine,
ephedra).
SPECIFIC OBJECTIVE FINDINGS
•
•
•
Vital signs.
General appearance: Color, apprehension, sweating.
Signs of heart failure: Neck vein distention, peripheral edema, respiratory distress.
Breath Sounds: Rales, wheezes or decreased sounds.
Chest wall tenderness
Abdominal tenderness
Peripheral pulses.
TREATMENT
• Assure and maintain a patent airway. Reassure patient. Place in position of comfort
• Cardiac Monitor, 12 lead ECG (to be completed within 5 minutes of patient contact)
o Repeat after treatment to record any changes in 12 lead ECG
• Administer Oxygen, check breath sounds regularly
• Monitor Vital Signs
• Establish I.V.
o If STEMI is suspected, establish a 2nd I.V (i.e. Buff Cap)
o Left Antecubital is the preferred site for the cardiac catheter lab.
• Fluid challenge if hypotensive (contact medical control)
• Emergent transport for patients with arrhythmias refractory to treatment.
• Consider obtaining an iSTAT troponin
**STEMI ALERT- Patients who are diagnosed with a myocardial infarction should be
transported immediately to Mercy Medical Center for intervention in the cath lab. Notify MMC
ER attending as soon as possible of a STEMI alert.
STEMI (S-T elevation MI) Alert Criteria:
1.) Findings consistent with Acute Coronary Syndrome
2.) 1mm ST elevation in 2 contiguous leads
NOTES
• Findings which are more consistent with a acute coronary syndrome:
o Discomfort or pressure over the chest which, if intermittent, lasts minutes, not seconds.
o Worse with exertion.
o The patient has a history of coronary artery disease, including a history of coronary stents / or
bypass grafting
o Associated symptoms include shortness of breath, nausea, lightheadedness, numbness or
tingling in upper extremities, sweating, or even a recent history of increased fatigue.
o A history of diabetes, hypertension, stimulant abuse, hypercholesterolemia, or obesity all
increase the risk of coronary artery disease.
o S-T depression, T wave inversions, new bundle branch blocks on 12-lead EKG
Treatment–Medical: Chest Pain
Revised 4/2015
Page 2 of 2
Section 307
CHEST PAIN: MEDICAL
PROCEDURE
•
FR
EMT B
EMT B IV
EMT I
EMT P
SO
SO
SO
SO
SO
SO
SO
SO
12 Lead EKG, repeat as needed
Administer Aspirin - 325 mg PO
If acute MI suspected: notify medical control immediately and send copy of EKG if possible. Confirm
appropriate destination. The patient may need to go the nearest hospital for thrombolytics if
catheterization not available at MRMC or if transport to MRMC is delayed.
Nitroglycerin Tablet (SL) – NTG paste
may be administered in lieu of multiple
doses of tablet NTG
If pain persists- give Fentanyl 1-2
mcg/kg IV
VO/P
VO/P
SO
SO
VO/P
SO
SPECIAL PRECAUTIONS
• Suspicion of an acute MI is based on history. Do not be reassured by a "normal" EKG or monitor
reading. Conversely, "abnormal" strips (particularly ST and T changes) can be due to technical
factors or non acute cardiac diseases. ST elevation that changes after nitroglycerin administration
can be significant and should be documented.
• Pain control with NTG is preferred and should come before narcotic pain management. Utilize a
low dose narcotic such as Fentanyl for pain management. Contact Medical Control to consider
further NTG doses.
• Administer prescribed nitroglycerin or SL spray if BP > 90 systolic and patient not taking
medications such as Viagra. Repeat until pain relieved: every 5 min up to 3 doses, or systolic BP
< 90 (includes patient administered nitroglycerin within last 15 minutes).
• Constant monitoring is essential. As many as 50% of patients with acute MI who develop
ventricular fibrillation may have no warning arrhythmias.
• Establish IV prior to giving NTG as patient may need fluids if hypotension develops.
• Remember there are many causes for chest pain. Consider pulmonary embolus, pneumonia,
aneurysm, pneumothorax, pericarditis. Withhold further NTG if initial doses are ineffective.
• Beware of IV fluid overload in the potential cardiac patient. If SBP >100, a minimal rate of fluid
is all that is needed. If pressures drop below this after NTG, give small bolus of fluid.
• If patient's pain is relieved spontaneously or after administration of aspirin or oxygen, consult
medical control concerning NTG administration.
• NTG may still be indicated even if patient is taking medications for erectile dysfunction. Contact
medical control if the patient's history is consistent with angina, but is taking a medication such as
Viagra.
Treatment–Medical: Chest Pain
Revised 4/2015
Page 1 of 2
Section 308
CEREBROVASCULAR ACCIDENT: CVA / STROKE
INFORMATION NEEDED
• Seizure activity- recent or past history
• Baseline mental and motor function of patient.
o Use a bystander that can attest to the baseline status of the patient and whether your findings
are an acute change
SPECIFIC OBJECTIVE FINDINGS
• Use Prehospital Stroke Screen (follows protocol) for all suspected stroke patients.
• Establish onset of symptoms as precisely as possible.
• Assess the patient:
o Facial smile/grimace.
o Grips and arm strength.
o Inability to hold out extended arm without drifting down (pronator drift)
o Focal motor weakness limited to one side- in particular check for :
o Speech changes:
 Dysarthria: difficulty articulating- slurred speech
 Aphasia: difficulty understanding when spoken to or difficulty finding words- frequent
pauses
o Alteration in mental status from baseline.
o History of, or signs of trauma to head or neck
o Pupil size and bilateral reactivity.
o GCS
o Blood glucose- treat if hypoglycemic
o EKG(12 lead)- evaluate for arrhythmia or STEMI
• If the patient’s mental status is altered, find out the baseline mental and motor status from those
who know the patient.
TREATMENT
• Assure and maintain a patent airway.
o Consider Intubation if airway reflexes are compromised.
o Assist ventilations with BVM if needed.
• Elevate head 6 to 12 in. Recovery Position.
• Establish I.V.
• Dextrose IVP if blood sugar is less than 60 mg/dL or symptoms consistent with hypoglycemia.
• Monitor Cardiac Rhythm
• CVA Patients should be transported to PSMC for neurological tele-medicine evaluation. Notify
ER of “Stroke Alert” if criteria met (see below)
SPECIAL PRECAUTIONS
• Dextrose (D50) indicated only in patients with a documented blood sugar < than 60 mg / dL.
• In patients with suspected head injury, refer to Head Injury protocol.
• Use caution with any agent that lowers blood pressure. Marked decreases in blood pressure, even
if patient is still hypertensive, will worsen the ischemic effects.
• Do not give aspirin.
Treatment-Medical: CVA
Revised 4/2015
1
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Section 308
CEREBROVASCULAR ACCIDENT: CVA / STROKE
Prehospital Stroke Screen
1. Patient
Name___________________________________________________________________
Last
First
2. Information/History from:
Patient
Family
Name___________________________Phone_________________
Other
3. Last known time patient was at baseline or deficit free and awake:
Military time_________________
Date________________________
Screening Criteria
Yes Unknown
No
______________________________________________________________________________________
4. Witnessed seizure at onset- ABSENT
5. Symptoms – onset less than 7 hours ago and not improving
6. At baseline – patient was not wheelchair bound or bedridden
7. Blood glucose between 60 and 400
_______________________________________________________
8. Exam: Look for obvious asymmetry_______________________
Normal
Right
Left
Facial Smile/
Droop
Droop
Grimace
Grip
Weak Grip
Weak Grip
No Grip
No Grip
Arm Strength
Drifts Down
Drifts Down
Falls Rapidly
Falls Rapidly
Based on exam, patient has only unilateral
(one-sided) weakness
_
Items 4-8 are all YES or unknown – Screening Criteria Met


If criteria for stroke are met and patient is not in shock or not requiring advanced airway
managment, notify PSMC immediately of stroke alert and transport without delay.
If not, return to appropriate treatment protocol. Patient may still be experiencing a stroke
even if criteria are not met.
Treatment-Medical: CVA
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Section 309
DIABETIC EMERGENCIES
INFORMATION NEEDED
• History of event:
o Onset (rapid or gradual).
o Fever.
o Recent physical or emotional stress.
o Illness. Headache. Inability to concentrate.
o Confusion.
o Trembling.
o Seizures.
• Last oral intake.
• Recent history of polydipsia or polyuria
• Medications (Insulin and other diabetic medications).
• Past medical history
SPECIFIC OBJECTIVE FINDINGS
• Medical Alert Tag.
• Mental status, level of consciousness
• Nausea. Vomiting. Diarrhea.
• Skin color. Temperature. Hydration.
• Hypoglycemia may present with rapid onset, pale and moist skin, altered mental status including
seizures. Often rapid recovery with administration of glucose.
• Hyperglycemia may present with gradual onset, warm and dry skin, rapid respirations and pulse,
nausea and vomiting.
o If prolonged or severe, may be coinciding with ketoacidosis which can lead to dehydration,
hypovolemia, or shock.
o Not all patients with this presentation have been diagnosed with diabetes. Have a high index of
suspicion in any patient with the above presentation which may coincide with an infection.
TREATMENT
ADULT
• Obtain Blood Glucose Level
• Establish I.V.
• Hyperglycemia (glucose > 200 mg/dL)
o If glucose>200, administer bolus of crystalloid fluids.
o Treat nausea and vomiting with Phenergan as needed.
• Hypoglycemia (glucose <60 mg/dL) or shows symptoms of hypoglycemia
o patient alert & able to protect airway- administer oral glucose or orange juice
o Establish IV. Administer Dextrose IVP
o If unable to establish IV, administer Glucagon IM
• Monitor Cardiac Rhythm.
• Obtain Blood Glucose Level 20 minutes later
Treatment–Medical: Diabetic Emergencies
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Section 309
DIABETIC EMERGENCIES
PEDIATRIC
• Obtain Blood Glucose Level
• Establish I.V.
• Hyperglycemia (glucose > 200 mg/dL)
o Administer crystalloid fluids IV/IO: 20mL/kg over one hour and continue to monitor
• Hypoglycemia (glucose <60 mg/dL) or shows symptoms of hypoglycemia
o Patient alert & able to protect airway- administer oral glucose or orange juice
o For ages 1-8 years
 Administer Dextrose 25% (D25) IVP
o For infants (age < 1 year)
 Administer Dextrose 10% (D10) IVP
o If unable to establish IV, administer Glucagon IM – see medications: glucagon
• Obtain Blood Glucose Level 20 minutes later
SPECIAL PRECAUTIONS
• Treat the patient if symptomatic even if the glucometer findings are within the normal range.
• Patients with an insulin pump or who are taking oral hypoglycemics are at risk of continuing
hypoglycemia. Recheck blood glucose.
• Patients can become combative and violent, use precaution.
• Hypoglycemia can mimic CVA.
• Diet drinks do not contain sugar and will not have the desired effect.
• Medications can alter signs, symptoms and response to glucose administration
• Any diabetic who becomes hypoglycemic should be transported regardless of your ability to
successfully reverse the hypoglycemia.
Treatment–Medical: Diabetic Emergencies
Revised 4/2015
2
Page 1 of 2
Section 310
HYPERTENSIVE EMERGENCIES
INFORMATION NEEDED
• History of hypertension and current medications
• Previous pertinent medical history:
o High blood pressure
o Heart attack or heart failure
o Stroke
o Kidney failure w/ dialysis
o Diabetes.
o New symptoms:, dizziness, nausea, visual impairment, or headache.
• Associated symptoms:
o Pulmonary edema
o Nuchal rigidity
o Unequal pulses.
• Current medications:
o Including over the counter (OTC): Cold, Allergy, and Herbal medications.
o Prescription medications.
• Illicit drug use:
o Amphetamines, cocaine, crystal methamphetamine, or other stimulants.
SPECIFIC OBJECTIVE FINDINGS
• Blood pressure: high suspicion of hypertension causing symptoms if SBP>200, DBP>120
• Symptoms of encephalopathy: confusion, seizures, vomiting, coma
• Evaluate for:
o pulmonary edema
o neck stiffness
o paresthesias
o focal weakness
TREATMENT
• Assure and maintain a patent airway
• Keep the patient in a sitting position.
• Oxygen
• Check Breath Sounds
• Monitor Vital Signs
• ECG and cardiac monitoring
• Establish I.V.
PROCEDURE
EMT I
EMT P
Consider NTG Administration
• 1 spray SL up to 3 sprays
VO/P
SO
Consider: Morphine with associated
pulmonary edema
• Morphine: 2 mg IVP.
VO/P
SO
Treatment-Medical:Hypertensive Emergencies
Revised 4/2015
FR
EMT B
1
EMT B IV
Page 2 of 2
Section 310
HYPERTENSIVE EMERGENCIES
SPECIAL PRECAUTIONS
• Secondary hypertension (high BP in response to stress or pain) is commonly seen in the field. It
does not require field treatment, and may not even mean the patient has chronic hypertension
requiring ongoing treatment.
• Hypertensive encephalopathy is rare and is manifest by altered mental status, blurred vision, and
improves with lowering the blood pressure. It can be treated with nitroglycerin or morphine.
• Hypertension is more common in association with other problems (pulmonary edema, seizures,
chest pain, coma, or altered mental states). It should be managed by treating the primary problem.
• Diastolic pressures and mean arterial pressures are much more important in determining danger
of severe hypertension than is systolic pressure. These are poorly measured in the field. The
diagnosis of "malignant" hypertension is not based on numerical levels, but rather on microscopic
changes in blood vessels and damage to organs, which place this disease beyond the scope of
prehospital care.
• Don't forget that false elevation of BP can result from a cuff that is too small for the patient. The
cuff should cover 1/3 to 1/2 of the upper arm, and the bladder should completely encircle the arm.
• Hypertension is seen in severe head injury and intracranial bleeding, and is thought to be a
protective response that increases perfusion to the brain. Treatment should be directed toward the
intracranial pressure. Do not treat hypertension in these cases.
• In all other cases, consult medical control to discuss lowering blood pressure and avoid lowering
it more than 20-30%.. Consider nitroglyercin infusion in your consultation with them.
Treatment-Medical:Hypertensive Emergencies
Revised 4/2015
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Section 311
OB/GYN
INFORMATION NEEDED
• Symptoms: pain, cramping, passage of clots or tissue, dizziness, weakness; if pregnant, inquire
about urge to push, contractions (regularity and timing), ruptured membranes.
• Obtain menstrual history: last normal menstrual period, duration of period, amount of flow, birth
control method.
• If pregnant; inquire about due date/gestational age, prenatal care, previous cesarean section, any
complications with this or any previous pregnancy. Find out who is the mother’s obstetrician.
• Past and present history of hypertension (preeclampsia/eclampsia) including symptoms such as
headache, seizures, swelling in face or extremities.
• Past history: bleeding problems, pregnancies, medications, allergies.
SPECIFIC OBJECTIVE FINDINGS
• Vital signs including fetal heart sounds if present.
• Evidence of blood loss, clots or tissue fragments (bring tissue to ED).
• Signs of hypovolemic shock; altered mental status, hypotension, tachycardia, sweating, or pallor.
• Fever.
• Abdominal pain; steady or tearing
• Active labor; observe for frequency of contractions and relaxation of uterus. Where privacy is
possible, visualize and examine EXTERNAL vaginal orifice. This exam is to be by observation
only and does not allow for a digital exam unless specifically directed by medical control.
o Vaginal bleeding or fluid (note color).
o Crowning (check during contraction).
o Abnormal presentation (i.e. foot, arm, cord).
• Difficulty breathing, shortness of breath
Pre-Eclampsia
• Hypertension: BP > 140/90
• Headache
• Edema
Eclampsia
• Hypertension
• Seizures
• Altered mental status
Prolapsed Cord
• Umbilical cord presents before infant
Nuchal Cord
• Cord is visible around infant’s neck
Breech Presentation
• Any body part other than head presenting first
Placenta Abruptio
• Abdominal pain
• May or may not have vaginal bleeding or bloody show
• Can be related to trauma
Treatment–Medical: OB/GYN
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Section 311
OB/GYN
Placenta Previa
• Painless, painful, or crampy pain
• May or may not have vaginal bleeding or bloody show
TREATMENT
• Assure and maintain a patent airway
• Administer Oxygen
Pre-Eclampsia
o Elevate patient’s head 6-12 inches
o Consider Magnesium Sulfate
Eclampsia
o Elevate patient’s head 6-12 inches
o Magnesium Sulfate 4 grams IV.
o Consider Diazepam or Midazolam if refractory to above treatments
Delivery is Not Imminent
• Monitor Vital Signs
• Establish I.V.
• Cardiac Monitor
• Analgesia: per protocol.
Delivery is Imminent
• Support the head as it emerges. Gentle pressure to prevent explosive delivery
• Suction mouth, then nose with bulb syringe. Do not use mechanical suction
• When infant delivered, clamp cord in 2 places 8 to 10 inches from the infant. Cut cord in
between clamps
• Dry infant and keep warm
• If infant doesn't breathe spontaneously, begin resuscitation efforts immediately. (see Treatment –
Pediatric: Neonatal Resusitation protocol)
• Placenta normally delivers w/in 30 min. Don't delay transport or force delivery. Place placenta in
bag and bring with patient.
• If excessive maternal bleeding occurs, initiate fundal massage of the uterus and treat for shock.
Potential Complications with Delivery
• Nuchal Cord
o Cord can usually be slipped over head as it presents. If wrapped too tightly, clamp in two
places, cut and unwrap.
• Prolapsed Cord
o Dire emergency for the infant.
o Place mother in knee-chest position.
o Palpate cord for pulses
o If pulses are absent; use two fingers to push presenting part off of the cord and create a space
for circulation. This is essential for infant survival. Do not attempt to replace cord.
o Keep cord moist.
o Notify hospital early to prepare for emergency c-section. Emergent transport.
OB/GYN
Treatment–Medical: OB/GYN
Revised 4/2015
2
Page 3 of 3
Section 311
•
Breech Presentation
o Place mother in knee-chest position and transport.
o Urge mother not to push with contractions.
o Breech (buttocks) presentation may deliver. If arms and legs follow, head may lodge in birth
canal. If this occurs, you may be able to ease head out gently or push vaginal wall away from
face to create airway.
o Arm or single foot presentation will require a c-section.
•
Continued Bleeding After Delivery
o If the patient is having heavy vaginal bleeding and the placenta has not been delivered,
consult medical control and consider delivery of the placenta which is performed by using
one hand to apply downward pressure to the uterus and the other gently applying downward
traction on the cord.
o Massage uterus (Fundal Massage) and encourage mother to attempt breast-feeding her
newborn to help get the uterus to contract and reduce post-partum bleeding.
 Fundal massage is performed by finding the superior boarder of the uterus on palpation of
the abdomen and massaging it. The mother will find this uncomfortable if it is done
correctly, causing uterine contractions and slowing blood loss
o Other causes for bleeding may include vaginal lacerations. Direct pressure should be applied
with sterile gauze.
o Consult medical control for postpartum bleeding that is not controlled by the above
techniques and continue rapid transport, treating shock if present.
•
Uterine Rupture
o Treat for hemorrhagic shock
o Place patient on left lateral recumbent position
o establish a 2nd large bore IV +crystalloid fluid bolus
•
Placenta Abruptio
o Treat for hemorrhagic shock
o establish a 2nd large bore IV + crystalloid fluid bolus
•
Placenta Previa
o Treat for hemorrhagic shock
o establish a 2nd large bore IV + crystalloid fluid bolus
•
Preterm labor, premature rupture of membranes
o Defined as labor or amniotic rupture prior to 37 weeks gestation
o True contractions are often difficult to determine by history or exam, but if the patient is
experiencing forceful contractions up to every 5 minutes or greater or has had a substantial
loss of fluid per vagina, consider the patient to be experiencing preterm labor.
o Administer IV crystalloid fluids
o Give bolus and placing the patient on her left lateral recumbent position.
o Consult medical control as to destination and medication orders including Magnesium
Sulfate 2-4 grams IV.
o Avoid Magnesium Sulfate if the patient is having heavy bleeding associated with the
contractions.
OB/GYN
Treatment–Medical: OB/GYN
Revised 4/2015
3
Page 4 of 3
Section 311
SPECIAL PRECAUTIONS
• Do not place any objects including gauze, instruments, or fingers in the vaginal canal. The digital
exam of the cervix needs to take place either at a local clinic or at the hospital. If the patient is
experiencing contractions less than every five minutes or you find other indications that delivery
is imminent; consider local medical facilities to avoid a delivery in the ambulance.
• Amount of vaginal bleeding is difficult to estimate. Try to get an estimate of number of saturated
pads in previous 6 hours.
• A patient in shock from vaginal bleeding should be treated like any other patient with
hypovolemic shock.
• If patient is pregnant, bring in any tissue which was passed. Laboratory analysis may be
important in determining status of pregnancy.
• Always consider pregnancy as a cause of vaginal bleeding. The history may contain inaccuracies,
denial, or wishful thinking.
• If the patient is pregnant, ask if she feels as though she is delivering. Particularly with a history
of prior deliveries, most mothers will know.
DESTINATION
• If the contractions are 5 minutes apart or less or if there are any other signs that delivery is
imminent, consider transport to PSMC to help determine how soon the delivery may occur.
Consult medical control as well as the patient’s obstetrician.
• For any of the other scenarios listed above, rapid transport to the hospital is key. Air transport
should be considered if ground transport would be greater than one hour.
Treatment–Medical: OB/GYN
Revised 4/2015
4
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Section 312
RESPIRATORY EMERGENCIES
INFORMATION NEEDED
• History
o acute change or injury, slow deterioration
• Past history
o Chronic lung or heart problems or known diagnosis, medications, home oxygen, past allergic
reactions, recent surgery, tobacco abuse
• Associated symptoms
o Chest pain, cough, fever, hand or mouth paresthesia
• Has this patient been intubated for this condition in the past.
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Oxygenation/ perfusion
o Level of consciousness, cyanosis
• Respiratory effort
o Accessory muscle use, forward position, pursed lips
• Neurologic signs
o Slurred speech, impaired consciousness, evidence of drug/alcohol ingestion
• Signs of upper airway obstruction
o Hoarseness, drooling, exaggerated chest wall movements, stridor
• Signs of congestive failure
o Neck vein distention in upright position, rales, peripheral edema
• Breath sounds
o Clear, decreased, rales, wheezing, or rhonchi
• Skin signs
o Hives, upper airway edema
• Evidence of trauma
o Crepitation of neck or chest, bruising, steering wheel damage, penetrating wounds
TREATMENT
• Assure and maintain patent airway
• Assist patient with ventilations if rate or depth is inadequate.
• Monitor Vital Signs
• Check Breath Sounds
• Oxygen
• SEE CHART BELOW FOR INDIVIDUAL TREATMENTS
Treatment-Medical: Respiratory Emergencies
Revised 9/2014
1
Page 2 of 3
Section 312
RESPIRATORY EMERGENCIES
SPECIFIC EMERGENCIES
Emergency
Signs & Symptoms
Medications
Asthma
•
•
•
•
Dyspnea.
Coughing.
Wheezing.
Diminished Breath Sounds.
•
•
•
•
Nebulized Albuterol:
Nebulized Atrovent:
SoluMedrol
Consider Epinephrine,
Magnesium Sulfate
Congestive Heart Failure:
•
•
•
•
•
•
•
Dyspnea.
Orthopnea.
Tachycardia.
JVD.
Hypertension.
Peripheral Edema.
Wheezing or Rhonchi
•
•
•
Nitroglycerin:
Morphine Sulfate
Sitting position
Croup:
•
•
•
•
Seal-like bark.
Stridor.
History of fever or cold.
Shortness of breath.
Drooling
•
•
Nebulized, cool water
Nebulized Epinephrine if
severe
Epiglottitis:
•
•
•
High grade fever.
Drooling.
Tripod Positioning.
Keep patient calm and avoid
any procedures that cause
irritation or distress.
•
Oxygen Therapy.
◊ Preferred over
intubation.
◊ Ventilate- Bag Valve
Mask if needed.
Contact medical control if
you suspect this condition
Sudden onset- not always
associated with trauma
Localized pain.
Cough.
Dyspnea.
Hypotension
Diminished breath sounds.
Guarding.
•
•
Pneumothorax:
•
•
•
•
•
•
•
Treatment-Medical: Respiratory Emergencies
Revised 9/2014
2
•
Oxygen Therapy.
Watch for signs of Tension
Pneumothorax and treat per
protocol
Page 3 of 3
Section 312
RESPIRATORY EMERGENCIES
Emergency
Pneumonia:
Signs & Symptoms
•
•
•
•
•
Fever.
Dyspnea.
Productive cough.
Rales
Medications
•
•
Oxygen Therapy
Nebulized Albuterol
Nebulized Atrovent if
respiratory distress
SPECIAL PRECAUTIONS
• Don't overdiagnose "psychogenic" in the field. Your patient could have a pulmonary embolus or other
serious problem; give him or her the benefit of the doubt. Treatment with oxygen will not harm the
“hyperventilator”, and it will keep you from underestimating the problem.
• Wheezing in older persons may be due to pulmonary edema ("cardiac asthma").
• Act early and do not wait for the patient to be in full respiratory arrest to begin assisting ventilations
and securing an advanced airway, especially in cases of anaphylaxis or other forms of airway edema
that is progressing. Use other resources such as the air ambulance or clinic early.
Treatment-Medical: Respiratory Emergencies
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Section 313
SEIZURES
INFORMATION NEEDED
• History of event from witnesses- loss of consciousness, type of movements, trauma
• Medical history:
o Diabetes. Fever. Overdose, Alcohol abuse / withdrawal. Epilepsy. Hypoxia. Pregnancy,
head trauma, headaches, compliance with anticonvulsants
• Medications including OTC or street drugs
• Others in home who may be receiving treatment for tuberculosis.. Overdose of isoniazide may
cause seizures for which there is a specific antidote. Report this to the receiving hospital.
SPECIFIC OBJECTIVE FINDINGS
• Consider patients to be in status epilepticus (uncontrolled seizures) if they are actively seizing
upon arrival.
• Altered mental status, post-ictal state
• Incontinence: urine or feces.
• Signs of trauma including shoulder dislocation
• Trauma to tongue is unlikely to cause serious problems, however, trauma to teeth may. Attempts to
force an airway into the patient's mouth can completely obstruct airway. Do not use bite sticks or jaw
screws.
• Neuro exam including pupils, extra-occular movments, motor, sensory, speech, and if possible, gait.
• Environmental clues:
o Pills, Alcohol, or Chemical bottles / containers- bring pill bottles to hospital if possible.
TREATMENT
• Assure and maintain a patent airway and appropriate oxygenation.
• Monitor Vital Signs
• Check Breath Sounds
• Obtain Blood Glucose Level
• Establish I.V.
• Monitor Cardiac Rhythm
• Consider intubation if signs of respiratory depression
• If seizure persists despite the measures listed below, rapidly transport to hospital
• Monitor carefully for continued seizure activity and treat accordingly
SEIZURES
IF STATUS EPILEPTICUS - Seizure Activity Persists
PROCEDURE
Treatment–Medical: Seizures
Revised 4/2015
FR
EMT B
1
EMT B IV
EMT I
EMT P
Page 2 of 2
Section 313
ADULT:
Initial treatment:
Versed: 5 mg IM. (Repeat once prn)
• Establish IV
Recurrent seizure- Valium 5mg IV
VO/P
VO/P
PEDIATRIC:
Versed 0.2mg/kg (max 5mg) IN
Versed 0.1 mg/kg slow IVP
VO/P
If later in pregnancy or post-partum:
Magnesium Sulfate 2gm IVP
SO
SO
SO
SO
SPECIAL PRECAUTIONS
• Move hazardous materials away from patient. Restrain the patient only if needed to prevent injury.
Protect patient's head.
• Be aware of associated trauma as either the cause of the seizure or as a result from falling. Obtain this
part of the history from witnesses, if present. Spinal precautions and immobilization should be
initiated unless a reliable history or exam reveals no evidence of associated trauma.
• Be careful not to over-treat any patient who is conscious and having seizure-like activity. If this
activity is not subsiding with the above treatment, insure your safety as well as the patients’, and begin
transport.
• Seizure can be due to lack of glucose or oxygen to the brain, as well as to the irritable focus we
associate with epilepsy. Hypoxia from transient arrhythmia or cardiac arrest (particularly in younger
patients) may cause seizure and should be treated promptly. Always check for pulse once a seizure
terminates.
• Hypoxic seizures can also result when the tongue obstructs the airway in the supine position, or when
overly helpful bystanders prop the patient up or improperly elevate the head.
• Alcohol-related seizures are common, but cannot be differentiated from other causes of seizure in the
field. Assessment in the intoxicated patient should still include consideration of hypoglycemia and all
other potential causes. Field management is as for any seizure.
• Seizures may be due to arrhythmias or stroke. It is important to look for and recognize arrhythmias in
the field since they may be the cause of the seizure.
• Medical personnel are often called to assist epileptics who seize in public. If a patient clears
completely, is taking medications prescribed his/her own physician, and is experiencing the usual
frequency of seizures, transport may be unnecessary. Consult medical control.
• Midazolam and diazepam have a tendency to decrease respiratory effort, therefore be prepared to
assist ventilations.
• Complications form seizures include rhabdomyolysis, trauma, paralysis, aspiration, and renal failure.
Treatment–Medical: Seizures
Revised 4/2015
2
Page 1 of 3
Section 314
SHOCK
INFORMATION NEEDED
• Medications.
• Mechanism of injury.
SPECIFIC OBJECTIVE FINDINGS
• Vital signs in Compensated Shock
o Tachycardia.
o Tachypnea
o Normal blood pressure.
• Vital signs in Decompensated Shock
o Tachycardia.
o Hypotension.
o Level of consciousness
 Confusion.
 Anxiety.
 Restlessness.
 Apathy.
 Combativeness.
 Stupor.
 Coma.
o Skin
 Pale.
 Dusky.
 Ashen.
 Cyanotic.
 Diaphoretic.
TREATMENT
• Assure and maintain patent airway
• Administer Oxygen
• Monitor Vital Signs
• Check Breath Sounds
• Shock Position
• Establish 2 Large Bore IV's of crystalloid fluids.
• EZ-IO if unable to obtain IV access and patient is symptomatic
ADULT
• Fluid bolus
• Consider Dopamine
• Cardiac Monitor
PEDIATRIC
• Fluid bolus
• Consider Dopamine
Treatment–Medical: Shock
Revised 4/2015
1
Page 2 of 3
Section 314
SHOCK
SPECIFIC EMERGENCIES
Emergency
Allergies / Anaphylatic Shock
•
•
Severe allergic reaction
causes edema to the airway.
Changes in vascular
permeability cause
hypotension
Cardiogenic Shock
•
A weakened heart is unable
to pump the blood to meet
the body's needs.
o
o
Acute AMI.
Chest Trauma.
Hypovolemic / Hemorrhagic.
Dehydration: Blood Loss:
•
•
•
•
Blunt or penetrating trauma
to chest, abdomen, pelvis, or
major vessels.
G.I. Bleed.
Nausea. Vomiting.
Diarrhea.
Ruptured ectopic pregnancy.
Neuorgenic:
•
Loss of vascular sympathetic
tone resulting in vasodilation
below the site of the spinal
cord injury.
Signs & Symptoms
•
•
•
•
•
•
•
Hives.
Uticaria.
Edema to lips and face.
Dyspnea.
Wheezes.
Diminished breath sounds.
Hypotension
•
•
•
Benadryl.
Epinephrine
SoluMedrol
•
•
•
•
•
•
Tachycardia / Bradycardia.
JVD.
Dyspnea.
Rales.
Peripheral Edema.
Consider Tension
Pneumothorax.
•
Sit upright. Position of
comfort.
Fluid challenge.
Consider Dopamine if
unresponsive to fluidsdiscuss with medical control
Evaluate and treat
dysrhythmia per protocol.
•
•
•
•
•
•
Weakness.
Confusion.
Tachypnea.
Tachycardia.
Orthostatic changes.
Peripheral vasoconstriction.
•
•
•
Warm, dry, and pink skin
below the level of the spinal
cord injury.
Bradycardia.
Labored breathing with use
of accessory muscles.
Muscular paralysis
corresponding to level of
injury. Priapism.
•
•
•
•
•
•
Treatment–Medical: Shock
Revised 4/2015
Treatment
2
•
•
•
•
•
Control obvious bleeding.
Fluid bolus to blood pressure
equal to or greater than 90
mm/Hg systolic.
Rapid Transport.
Full Spinal Immobilization.
Consider fluid bolus.
Consider Dopamine if
unresponsive to fluids.
Treat Hypothermia.
Page 3 of 3
Section 314
SHOCK
Emergency
Sepsis
•
•
•
Systemic bacterial infection
causes vasodilation and
vessel wall instability.
Usually seen in the very
young and the elderly.
Spinal cord patients with
urinary tract infections.
Signs & Symptoms
•
•
Early:
o Vasodilation.
o Warm, flushed skin.
o Tachycardia/tachypnea
o Blood Pressure is normal
to slightly decreased.
Late:
o Cool, pale, and cyanotic
skin.
o Tachypnea with
pulmonary edema.
o Tachycardia.
o Hypotension.
Treatment
•
•
Fluid challenge if
hypotensive.
Consider Dopamine if
unresponsive to fluids.
SPECIAL PRECAUTIONS
• Patients on cardiac and blood pressure medications such as Beta-Blockers may not be able to
show signs of shock.
• Orthostatic changes in vital signs indicate hypovolemia.
• Hypotension is usually not observed in pediatrics unless the child has lost approximately 25% of
the circulating blood volume.
Treatment–Medical: Shock
Revised 4/2015
3
Page 1 of 2
Section 315
SYNCOPE
INFORMATION NEEDED
• History of event
o Onset.
o Events prior to syncopal episode
o Complete loss of consciousness, how long
o Altered mental status.
• Seizure activity.
• Precipitating factors
o Was the patient sitting, standing, lying down
o Is the patient pregnant
• Past History
o Medications.
o Diseases- most notably cardiac history including CHF.
• Trauma
o Recent or past.
SPECIFIC OBJECTIVE FINDINGS
• Associated Symptoms
o Vertigo.
o Nausea.
o Chest or abdominal pain.
o Vomiting blood.
o Vaginal or rectal bleeding.
o Diarrhea.
o Fever.
o Heat exposure.
TREATMENT
• Assure and maintain patent airway
• Oxygen
• Monitor Vital Signs (Orthostatic)
o Check Breath Sounds
• Establish IV.
o Consider fluid bolus
• Administer Dextrose 50% (D50) if blood sugar is less than 60 mg/dL or with associated
symptoms
• Monitor Cardiac Rhythm
• If over the age of 40 or prior history of cardiac disease - 12 Lead ECG
• Consider Narcan.
SPECIAL PRECAUTIONS
• Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the
patient is still unconscious or has an altered mental status, treat the underlying condition.
• Most syncope is vasovagal, with dizziness progressing to syncope over several minutes. Recumbent
position should be sufficient to restore vital signs and level of consciousness to normal. This is not a
diagnosis that can be made in the field. Most patients with this scenario will still need evaluation in
the emergency department.
Treatment–Medical: Syncope
Revised 4/2015
1
Page 2 of 2
Section 315
SYNCOPE
•
•
•
•
•
•
•
Place patient on continuous cardiac monitoring while transporting.
Syncope which occurs without warning or while in a recumbent position is potentially serious, and may
be caused by an arrhythmia.
Any patient over the age of 40, a sycopal episode should raise a high suspicion for a cardiac cause.
These patients should have a 12 lead ECG performed. Record the cardiac rhythm if the patient
experiences any symptoms or if an arrhythmia is present.
Near-syncope is defined as an event in which the patient feels close to fainting, but does not lose
consciousness. These events should be treated as syncopal episodes in elderly patients, those with
palpitations, or those with a cardiac history.
Any elderly patient with syncope and back pain should be considered to have an aortic aneurysm
until proven otherwise.
In children 1-4 years of age, seizures or congenital cardiac abnormalities are the most life-threatening
causes. Consult medical control if there is any question.
Myoclonic jerking--short duration (seconds) clonic-tonic activity--may follow the syncopal event.
These are often confused with seizure activity.
Treatment–Medical: Syncope
Revised 4/2015
2
Page 1 of 4
Section 316
TOXINS and OVERDOSES
INFORMATION NEEDED
• Method of exposure:
o Ingestion.
o Inhalation.
o Injection.
o Absorption.
• What substance: milligrams of each tablet, number of tablets, total amount in bottle.
• How long ago.
• How long was the exposure, was patient in confined space.
• Estimated weight of the patient (obtain from family or friends if patient unable to respond).
SPECIFIC FINDINGS
*CM= cardiac monitoring during transport
Type of Drug
Alcohols:
•
•
•
Overdose
Chronic Abuse
Ethylene glycol,
methanol
(antifreeze,
windshield fluid)
Alcohol:
•
•
Occurs 12 – 24
hours after last
ingestion
•
•
•
•
Tremors.
Seizures.
Hallucinations.
Coma.
•
•
•
•
OTC
Analgesic.
Anti-inflammatory.
Anti-coagulant.
•
•
•
•
•
•
•
•
Tinnitus.
Lethargy.
Nausea.
Dyspnea.
Tachypnea.
Seizures.
Pulmonary Edema
Diaphoresis
Withdrawal
Aspirin
Acetaminophen:
•
•
•
•
•
•
Tylenol.
Sominex.
Nyquil.
*Pox=continuous pulse oximetry during transport
Special Considerations
Effects
Signs & Symptoms
Treatment
*Pox
CNS Depression.
• Slurred Speech.
• Risk of vomiting /
aspiration.
GI Bleed.
• Ataxia.
• Protect Airway.
Liver Failure.
• Altered LOC.
• Suspect Trauma.
• Respiratory
• Use caution with
Depression
administration of
• Malnutrition
medications.
•
•
•
•
•
OTC Analgesic.
Sleep / Cold
medications.
Treatment–Medical: Toxins and Overdoses
Revised 4/2015
1
Nausea & vomiting.
abdominal pain
Symptoms may be
delayed 12 – 24
hours.
*Pox
• Patients taking
Antabuse with
alcohol ingestion /
exposure (cough
syrup, cologne,
deodorant…)
• Valium.
*CM*Pox
• Suspect metabolic
acidosis. Treat with
Sodium Bicarbonate
• Assure proper
oxygenation.
• GI Bleed.
*CM*Pox
• Liver failure within
72 to 96 hours.
• Common in suicidal
overdoses
• chronic toxicity
Page 2 of 4
Section 316
TOXINS and OVERDOSES
Type of Drug
Effects
Signs & Symptoms
•
•
•
CNS depressant.
Sedative.
Anti-convulsant
•
•
Slurred speech.
Respiratory
depression
•
•
CNS depressant.
Tranquilizer
•
•
•
•
•
Sedation.
Slurred speech.
Altered LOC.
Dilated pupils.
Respiratory
Depression.
Carbon Monoxide
•
•
Combustion from
fires and engines.
•
CO binds to the
hemoglobin.
Causes cellular
asphyxia
•
•
•
•
•
•
Headache.
Syncope.
Dyspnea.
Nausea & vomiting.
Seizures & Coma.
Cardiac ischemia
Caustic Substances:
•
•
•
Acid & Alkaline.
Petroleum Products.
Anti-freeze.
•
•
•
•
•
Tissue burns.
Dyspnea.
Pulmonary edema.
Vomiting.
GI Bleed.
•
Causes auditory and
visual disturbances.
•
•
•
•
Headaches.
Psychosis.
Dilated pupils.
May have increased
temperature (PCP).
•
•
Narcotic analgesics.
CNS depressants.
•
•
•
Sedation.
Pin-point pupils.
Respiratory
depression.
Bradycardia.
Pulmonary edema.
Hypothermia.
Barbiturates:
• Phenobarbital.
• Quaaludes.
Benzodiazepines:
•
•
•
•
•
•
•
•
Valium.
Ativan.
Clonopin.
Xanax
Drano.
Detergent.
Gasoline.
Ethylene glycol.
Hallucinogens:
•
•
•
•
LSD.
Peyote.
Mescaline.
PCP
Narcotics / Opiates:
•
•
•
•
•
Heroin.
Morphine.
Darvon.
Demerol.
Dilaudid
Treatment–Medical: Toxins and Overdoses
Revised 4/2015
•
•
•
2
Special Considerations
Treatment
*Pox
• Alcohol will
exaggerate the
sedative effects
• Supportive care
*Pox
• Supportive care
• Alcohol will
exaggerate the
sedative effects.
• Withdrawal may
occur- seizures
*CM*Pox
• High flow oxygen is
indicated via NRB
mask
• Monitor
*CM*Pox
• Airway
management is a
priority.
• Do not induce
vomiting or use
charcoal
• Brush powders from
skin.
• Flush with copious
amounts of water
•
•
Protect self.
Patient may be
violent.
• Check for
secondary trauma.
• Haldol or Versed
*Pox
• Reverse with
Narcan.
• Patient may become
violent with rapid or
excessive
administration.
Page 3 of 4
Section 316
TOXINS and OVERDOSES
Type of Drug
Organophosphates:
•
•
•
•
Signs & Symptoms
•
•
•
Systemic
cholinergic.
Paraquat.
Insecticides.
Fertilizers.
Stimulants:
•
•
•
•
•
Effects
•
•
•
•
Cocaine.
Amphetamines.
Crack & Crank.
Designer drugs.
Diet herbal
supplements.
•
Tricyclic
Antidepressants:
•
•
•
•
•
•
•
Elavil.
Amitriptyline.
Pamelor.
Sinequan.
Imipramine.
•
•
•
CNS Stimulants.
Appetite
Suppressant.
•
•
Prescription
antidepressant
causing sedation.
Flushed skin.
•
•
•
•
•
SLUDGE syndrome
Pulmonary edema.
Cardiovascular
effects.
Seizures.
Coma.
Tachyarrhythmias.
Dyspnea.
Increased body
temperature.
Dehydration.
Sedation.
Anticholinergic
response.
Tachycardia.
Hypotension.
Cardiac
dysrhythmias.
Seizures.
Metabolic acidosis.
Special Considerations
*CM*Pox
• Personal Protective
Equipment is
critical for safety of
crews.
• Large doses of
Atropine- alert
hospital. Emergent
transport
*CM*Pox
• Supportive
measures.
• Versed or Valium
• Caution w/ Haldol
*CM*Pox
• Protect airway.
• Widening QRS >
0.12 or tachycardia
may indicate need
for Sodium
Bicarbonate.
• Contact medical
control for orders.
TREATMENT
• Remove patient from environment if it is safe, providers are trained, and correct level of PPE is
available. Remove contaminated clothing.
• Brush/flush w/ sterile water, as indicated
• Assure and maintain a patent airway
• Suction airway if necessary. Prepare for vomiting.
• Oxygen
• Monitor Vital Signs
o Check Breath Sounds
• Activated charcoal especially if ingestion within past hour. Consider medical control contact.
Contraindicated if patient not protecting airway
• Establish I.V.
o Crystalloid fluids. Consider fluid bolus and second I.V
• Obtain Blood Glucose level
• Administer Dextrose if blood glucose level less than 60 mg/dL or patient shows signs of
hypoglycemia.
• Continuous cardiac and pulse oximetry monitoring is the rule with the exception in cases where
the patient is not cooperating. Patients often take other substances which they do not disclose.
Treatment–Medical: Toxins and Overdoses
Revised 4/2015
3
Page 4 of 4
Section 316
TOXINS and OVERDOSES
SPECIAL PRECAUTIONS
• Medical conditions or associated trauma may complicate patient’s presentation.
• Assess mental status and vital signs frequently.
• Attempt to establish patient’s intent (i.e.: accidental, abuse, suicidal).
• Secure mental health hold through physician contact or law enforcement if indicated.
• Restraints may be indicated. Document carefully and check distal pulses at regular intervals.
• Bring all containers, pill bottles. Get as much information as possible.
• Contact Emergency Department as soon as possible. Decontamination in the field may be
required. DO NOT contaminate providers or ambulance.
• Pepper Mace (OC/pepper spray) is best treated by blotting with clean dry towels. Use of water
will activate the product rather than flush it out, aggravating symptoms.
Resource Contact Information
• Rocky Mountain Poison Center #: 303-739-1123 (local) or 1-800-332-3073 (statewide)
• Nationwide Poison Control Access#: 1-800-222-1222
• Poison Control Phone for Hearing Impaired: 303-739-1127
• CHEMTREC: 1-800-424-9300
Treatment–Medical: Toxins and Overdoses
Revised 4/2015
4
Page 1 of 1
Section 317
VOMITING
INFORMATION NEEDED
• Frequency, duration of vomiting
• Presence of blood or bile in vomitus
• Orthostatic symptoms.
• Associated symptoms: abdominal pain, weakness, confusion
• Medication ingestion
• Past medical history: diabetes, cardiac disease, abdominal problems
• Frequency of alcohol / or cannabis use
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Signs of shock and poor perfusion
• Color of vomitus: presence of blood
• Abdomen: tenderness, guarding, rigidity, distention
• Signs of dehydration: poor skin turgor, dry mucous membranes, confusion
TREATMENT
• Position patient: left lateral recumbent if vomiting; otherwise, supine. NPO (with the exception
of Zofran ODT)
• Oxygen as needed
• Establish IV; administer crystalloid fluid bolus 20cc/kg mL
• Consider Odansetron (Zofran) or Haldol / Droperidol per protocol.
• Monitor vitals during transport
• Treat for shock if present per protocol.
SPECIAL PRECAUTIONS
• Vomiting may be a symptom of a more serious problem. The most serious causes are GI bleed,
head injury, or other surgical emergency. A rare cardiac patient may also present with vomiting
as the predominant symptom.
• Consider drug overdose; a patient who does not call the ambulance for medication ingestion may
call later when GI symptoms become severe. Look for pill fragments in the vomitus.
• Dehydration may be particularly severe in children with simple vomiting. IVs may be very
difficult to start, particularly with infants. If a child appears dehydrated, has signs of shock, and
an IV cannot be established after two attempts, establish an intraosseous line per protocol.
Treatment–Medical: Vomiting
Revised 4/2015
1
PROTOCOL
SECTION
NUMBER
NUMBER
OF PAGES
DATE
SECTION 400: Treatment - Trauma
400
1
REVISED 04/2015
Abdominal Trauma
401
1
REVISED 04/2015
Amputations
402
1
REVISED 04/2015
Burns
403
1
REVISED 04/2015
Chest Trauma
404
2
REVISED 04/2015
Extremity Trauma
405
1
REVISED 09/2014
Face & Neck Trauma
406
2
REVISED 04/2015
Head Trauma
407
2
REVISED 09/2014
Spinal Trauma
408
1
REVISED 04/2015
Traumatic Arrest
409
1
REVISED 09/2014
Trauma Destination & Activation
410
2
REVISED 09/2014
Trauma General Guidelines
411
2
REVISED 04/2015
Page 1 of 1
Section 401
ABDOMINAL TRAUMA
INFORMATION NEEDED
• Location, onset, and mechanism are key elements.
• For penetrating trauma: weapon, trajectory
• For auto: condition of steering wheel, dash, vehicle; speed, patient trajectory; seatbelts in use,
including lap-belt only, airbag deployment
• Past history: medical problems, prior abdominal surgeries medications, drugs, alcohol.
• Pregnancy or possibility of pregnancy.
SPECIFIC OBJECTIVE FINDINGS
• Observe: distention, bruising, entrance/exit wounds
• Palpate: areas of tenderness, guarding; pelvis stability to lateral and suprapubic compression.
TREATMENT
• Stabilize life-threatening airway and circulatory problems first.
• Administer Oxygen
• Spinal immobilization if indicated (rarely indicated in a penetrating trauma).
• Establish venous access.
• Observe carefully for signs of blood loss.
• If signs of shock:
o Rapid transport
o Second IV, large bore
o Administer fluid bolus, crystalloid fluids to a MAP of 65mmHg with signs of good perfusion.
o Contact medical control. additional fluid bolus as directed
• For penetrating injuries: cover wounds and eviscerations with moist saline gauze to prevent
further contamination and drying. Do not attempt to replace or reduce.
• Monitor vital signs during transport.
SPECIAL PRECAUTIONS
• The extent of abdominal injury is difficult to assess in the field. With significant blunt trauma
injuries to multiple organs are the rule.
• Patients with spinal cord injury, altered sensorium due to drugs or alcohol, head injury or
significant distracting injuries (i.e. long bone fractures) may not complain of tenderness and may
lack guarding in the face of significant intra-abdominal injury.
• Seatbelts, steering wheels, handlebars and other blunt objects may cause occult intra-abdominal
injury that is not apparent until several hours after the trauma. You must consider forces involved
to properly assess and treat a trauma victim.
• In children, significant intra-abdominal injury, which may lead to shock, may be present without
any external signs of injury, such as abrasions or hematomas.
• The pregnant patient deserves special attention during transport. Transport the patient on her left
side or angle backboard to prevent hypotension due to uterine compression of the inferior vena
cava.
Treatment-Trauma: Abdominal Trauma
Revised 4/2015
1
Page 1 of 1
Section 402
AMPUTATIONS
INFORMATION NEEDED
• History: time and mechanism of amputation; care for severed part prior to rescuer arrival
• Past history: medications, bleeding disorders, medical problems
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Other injuries
• Blood loss at scene
• Structural attachments in partial amputations if identifiable
TREATMENT
• Resuscitate and treat other more urgent injuries that are easily overlooked in cases of
amputation.
• Control hemorrhage with direct pressure, elevation.
• If hypotension or signs of shock:
o Establish venous access.
o Fluid bolus: crystalloid fluids titrated to MAP of 65mmHg
o Administer high-flow O2.
o Pain control- morphine sulfate or fentanyl if vitals stable.
o Keep patient NPO.
• Patient: gently cover stump with sterile dressing. Saturate with sterile saline. Cover with
dry dressing. Elevate.
• Severed part: wrap in sterile gauze, preserving all amputated material. Moisten with sterile
saline. Place in watertight container (specimen cup, plastic bag, etc) to avoid soaking the
severed part. Place container in cooler with ice (do not freeze).
• Apply tourniquet if bleeding uncontrolled with direct pressure (see extremity trauma
protocol)
SPECIAL PRECAUTIONS
• Partial amputations should be dressed and splinted in alignment with extremity to ensure
optimum blood flow.
• Avoid torsion in handling and splinting.
• Do not use dry ice to preserve severed part.
• Control all bleeding by direct pressure only to preserve tissues. The most profuse bleeding
may occur in partial amputations, where cut vessel ends cannot retract to stop bleeding.
Avoid tourniquet if at all possible. Never clamp bleeding vessels.
• Many factors enter into the decision to attempt reimplantation (age, location, condition of
tissues, other options). A decision regarding treatment cannot be made until the patient and
part have been examined by a physician and may not be made at the initial destination. Try
to help the family and patient understand this, and don't falsely elevate hopes.
Treatment-Trauma: Amputation
Revised 4/2015
1
Page 1 of 3
Section 403
BURNS
INFORMATION NEEDED
• History of injury
o Time elapsed since burn
o Was the patient in a closed space with steam or smoke?
o Was there electrical contact?
o Loss of consciousness?
o Accompanying explosion, toxic fumes, or possible trauma?
• Patient’s past history
o Cardiac or pulmonary disease?
o Medications?
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Extent of the burn in terms of percentage with a description or diagram of areas involved.
Use rule of nines or estimate percent with patients palm equal to 1% area.
• Is there evidence of CO poisoning or other toxic inhalation?
o Altered mental status, headache, vomiting, seizure, coma
• Is there evidence of inhalation burns?
o Respiratory distress, cough, hoarseness, singed nasal or facial hair, soot on face,
erythema of mouth, carbonaceous sputum
• Note entrance and exit wounds for electrical burns
• Associated trauma
TREATMENT
Thermal burns
• Remove smoldering or non-adherent clothing
• O2 if indicated from history or with evidence of respiratory burns, toxic inhalation,
significant flame, or smoke exposure
• Assess for associated trauma from blast or fall. Consider cervical spine precautions.
• Remove rings, bracelets, and other constricting items.
• If burn is moderate to severe, greater than 15% body surface area (BSA), cover wounds
with dry clean or sterile dressings to avoid hypothermia. Increase heat in ambulance to
prevent hypothermia during transport.
• Initiate Parkland Formula: 4mL/kg x % TBSA burned. This is the total fluid to be
administered in the 1st 24hrs with the 1st half in the 1st 8 hrs.
• Use dressings wet with saline on smaller, <15% BSA, burns for patient comfort.
• Establish IV access in unburned arm if possible.
• Consider Fentanyl or Morphine Sulfate for pain management.
• Monitor for airway distress and prepare to intubate if needed.
Inhalation Injury
• Administer 100% O2 during transport.
• Be prepared to intubate or assist ventilation if respirations are inadequate.
• Monitor cardiac rhythm
• Monitor SpCO
Chemical Burns
• Identify chemical, consult the emergency resource guide (ERG).
Treatment-Trauma: Burns
Revised 4/2015
1
•
Page 2 of 3
Section 403
DO NOT contaminate yourself; wear PPE appropriate for the chemical involved or
contact HAZMAT team. EMS personnel should not participate in the decontamination
process unless they are trained and equipped to do so.
BURNS cont.
•
•
•
•
•
•
•
•
Remove all clothing and any solid chemical that may provide continued contamination by
brushing or wiping off.
Notify hospital immediately if decontamination will be required at the hospital.
Assess and treat injuries.
Rinse stable patients for 15 min with plain water if appropriate for the chemical involved.
Check eyes and flush with saline if available for a minimum of 15 minutes if needed.
Be alert for toxidromes associated with the chemical. Contact medical control, poison
control, or the chemical manufacturer for expected symptoms.
Remove bracelets, rings, or constricting bands.
Wrap burned area in clean dry cloths for transport. Watch for hypothermia post
decontamination.
Electrical Injury
• Stay clear of live or possibly live electrical wires. Contact Fire department or electrical
company to confirm ‘dead’ wires.
• Separate victim from electrical source once it is safe to do so.
• Initiate CPR, monitor cardiac rhythm, and treat per protocol.
• Prolonged respiratory support may be needed.
• Consider C-spine precautions and treat other injuries as needed.
Destination Criteria
• Patients who meet the following criteria require immediate transport to the closest trauma
center.
o Any burn > 10% BSA
o Full thickness burns > 5% BSA
o Burns to face, anterior neck, or airway
o Evidence of inhalation injury
o Significant electrical or chemical injury
• If the above criteria are not met, consult medical control for destination. Those patients
with isolated burns to the hands, feet, genitalia, perineum, or major joints may require
transfer to a burn center.
SPECIAL PRECAUTIONS
• Leave blisters intact when possible.
• Suspect airway burns with any facial burn or burn received in an enclosed space. Edema
may become severe, but may not be immediately apparent. Avoid unnecessary trauma to
the airway. Use humidified O2 if available.
• Assume Carbon Monoxide poisoning in all closed space burns. Continue treatment with
100% O2 for several hours.
• Other toxic products of combustion are more commonly encountered than one would think.
Contact Medical Control for specific direction if other toxic inhalation is suspected.
• Consider child abuse in pediatric burns, especially “pattern” burns.
Treatment-Trauma: Burns
Revised 4/2015
2
•
•
•
Page 3 of 3
Section 403
Lightning strikes can cause ventricular asystole and prolonged respiratory arrest. Prompt,
continuous respiratory assistance, sometimes for hours or days, can result in a complete
recovery.
Field decontamination of chemical exposures has been shown to significantly reduce the
extent of the burn. Gross decontamination should occur prior to placing the patient in the
ambulance.
In patients with severe burns, their ability to prevent heat loss is significantly compromised.
The duration of the ambulance transport may be long enough to cause significant
hypothermia. Keep ambulance as warm as needed during transport despite discomfort to
EMS personnel.
Treatment-Trauma: Burns
Revised 4/2015
3
Page 1 of 2
Section 404
CHEST TRAUMA
INFORMATION NEEDED
• Location of injury. Associated symptoms and complaints of respiratory distress, neck pain,
• other areas of injury
• Mechanism: amount of force involved (particularly deceleration), speed of impact, seatbelt
use/type, airbag.
• Penetrating trauma: size of object, caliber of bullet, trajectory, distance from patient.
• Past medical history: medications, prior medical problems
SPECIFIC OBJECTIVE FINDINGS
• Observe: wounds, sucking or bubbling from open wounds, chest wall movement, neck veins
• Palpate: tenderness, crepitation, tracheal position, tenderness on sternal compression, pulse
pressure
• Auscultate: breath sounds, heart sounds (quality)
• Surroundings: vehicle, steering wheel condition, dashboard.
TREATMENT
• Clear and open airway. Immobilize spine, if indicated.
• Manage airway/ventilations as indicated.
• Administer O2.
• If penetrating injury present, transport rapidly with further stabilization en route.
• For open chest wound with air flow noted; use Ascherman chest seal, or occlusive dressing
taped on three sides.
• Observe chest for paradoxical movements.
• Control hemorrhage with direct pressure.
• Obtain baseline vital signs, neurologic assessment.
• If neck veins flat and patient in shock, transport rapidly and treat hypovolemia en route:
o Establish venous access- 2 large bore.
o Rapid flluid bolus: crystalloid fluids
o Monitor cardiac rhythm.
o Contact medical control
• Suspected Tension Pneumothorax : (patient in shock with neck veins distended, if respiratory
status markedly deteriorating with clinical findings of pneumothorax)
o Release occlusive dressings on open chest wounds, consider needle decompression;
• Suspected Pericardial tamponade, (distant heart sounds, narrow pulse pressure, distended neck
veins):
o Establish venous access- 2 large bore
o Rapid fluid bolus: crystalloid fluids
• Suspected Cardiac contusion (typical ischemic chest pain or severe chest wall contusion)
o Monitor cardiac rhythm.
o Establish venous access.
o Treat arrhythmias per protocols.
• If patient stable without signs or symptoms of shock:
o Complete focused assessment.
o If significant injury suspected:
 Establish venous access.
 Monitor cardiac rhythm en route.
• Immobilize impaled objects in place with dressings to prevent movement. Large objects may
require manual stabilization during transport.
• Monitor and record vital signs, and level of consciousness every five minutes with significant
injury.
Treatment-Trauma: Chest Trauma
Revised 4/2015
1
Page 2 of 2
Section 404
CHEST TRAUMA
SPECIAL PRECAUTIONS
• Chest trauma is treated with difficulty in the field and prolonged treatment before transport is
not indicated if significant injury is suspected. If patient is critical, transport rapidly or transfer
to helicopter crew immediately. Do not spend time treating non-emergent problems at the
scene. Penetrating injury in particular should receive immediate transport with minimal
intervention on scene.
• Consider medical causes of respiratory distress such as asthma, pulmonary edema, MI, or COPD
when obtaining the patient history. These may have either caused the trauma or been
aggravated by it.
• Chest injuries sufficient to cause respiratory distress are commonly associated with significant
blood loss. Treat hypovolemia with IV Normal Saline bolus for goal MAP of 65mmHg..
• Myocardial contusion can occur, particularly with sudden deceleration injury, as from a steering
wheel. Pain is similar to myocardial infarct pain. Monitor the patient and treat arrhythmias as in
a medical patient, but think first of hypoxia and hypovolemia as potential causes of arrhythmias.
• Check the back for injuries, especially the patient in shock, where a cause is not evident (check
the back, axillary region and base of neck).
• Significant intrathoracic injuries can exist without external signs of injury or with minimal signs
of injury such as in stab wounds.
• Consider use of CPAP in stabilization of flail chest with severe respiratory distress: this patient
must be monitored closely for pneumothorax, have intubation equipment ready.
Cardiac Arrest in the Trauma Patient
• Patients with significant chest trauma who are found to be pulseless at the time of arrival have
miminal chance of surviving. Fully assess the patient and check rhythm on the monitor. see
Field Pronouncement of Death protocol
• Patients with significant chest trauma who experience cardiac arrest during initial evaluation
and transport also have minimal chance of surviving unless arrival at the hospital is within 10
minutes. In this case, begin CPR and establish an airway and continue to the hospital. Notify the
hospital of the cardiac arrest. If arrival to the hospital is longer than 10 minutes, discuss
termination of efforts with medical control.
Treatment-Trauma: Chest Trauma
Revised 4/2015
2
Page 1 of 1
Section 405
EXTREMITY TRAUMA
INFORMATION NEEDED
• Mechanism of injury; direction of forces involved
• Be sure to completely assess patient even if there is a distracting open fracture or the arm or leg.
• Location of pain, range of motion.
• Deformity; numbness
• Previous fractures, injuries or surgery to affected areas
• Other medical history: medications, smoking history, attempts to treat current injury
SPECIFIC OBJECTIVE FINDINGS
• Position of involved extremity
• Vital signs
• Quality of distal pulses, capillary refill
• Sensation to light touch or sharp object
• Range of motion if able- assess crepitation
• Skin- is there a laceration or open wound? Proximity to joint? Open fracture?
• Blood loss- estimate
• If lower extremities or hip, assess if patient is willing or able to weight-bear- do not force patient.
TREATMENT
• Transport in position of comfort
• Spinal immobilization if indicated (see spinal immobilization protocol).
• Remove shoes, watches, bracelets or other constricting items if present
• Continue assessment of vitals, distal pulses and capillary refill
• If patient is experiencing severe pain after being in position of comfort, establish IV: Administer
morphine sulfate or fentanyl IV and monitor vitals. (see Morphine and Fentanyl protocols for
maximum dosing)
• Apply dressings to wounds – recheck distal pulses
• Splint affected extremity if deformity exists without greatly delaying transport time. Use gentle
and constant axial traction to reduce angulation, especially if there is a loss of distal pulses. Be
sure to pad splint appropriately. Use Sager splint as directed for suspected isolated mid-shaft
femur fractures.
• Remove splint if pain is exacerbated or any loss of distal pulses once applied.
• Use of tourniquet if unable to control hemorrhage. Use according to manufacturer
specifications.
-Ensure that the tourniquet is visible by cutting away clothing.
-Apply the tourniquet proximal to the wound. Do not apply tourniquets over
joints.
-Tighten tourniquet until bleeding stops.
-Mark the date and time the tourniquet was applied. Tourniquet should only
be removed by receiving hospital personnel.
Treatment-Trauma: Extremity Trauma
Revised 9/2014
1
Page 1 of 2
Section 406
FACE AND NECK TRAUMA
INFORMATION NEEDED
• Mechanism of injury: impact to steering wheel, windshield, or other objects; clothesline-type
injury to face or neck; blunt object to head, face, or neck
• Management before arrival by bystanders, first responders
• Patient complaints: areas of pain; visual blurring or double vision, difficulty hearing, drainage
from ear; neck pain; dental occlusion, tooth loss; shortness of breath; stridor
• Past medical history: medications, medical illnesses
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Airway: jaw or tongue instability, loose teeth, vomitus or blood in airway, other evidence of
impairment or obstruction
• Neck: tenderness, crepitation, hoarseness, bruising, swelling, stridor
• Blood or drainage from ears, nose
• Level of consciousness, evidence of head trauma
• Injury to eye: lid laceration, conjunctival injection, blood anterior to pupil, abnormal pupil shape,
unequal pupil size, abnormal globe position
TREATMENT
• Control airway and apply C-spine immobilization if indicated (high suspicion for all facial
trauma).
ο Open airway using jaw thrust, keeping neck in alignment with in-line cervical
immobilization.
ο Suction blood and other debris.
ο Stabilize tongue and mandible with chin lift. Manual traction of the tongue may be necessary
to keep posterior pharynx open as needed.
ο Note evidence of laryngeal injury and transport immediately by air if signs present.
ο Intubate if bleeding severe or airway cannot be maintained. When midface fractures are
suspected,
• Administer O2 .
• control hemmorhage
• Monitor vitals frequently.
• Establish venous access.
ο Fluid bolus, crystalloid fluids.
• Assess neurologic status.
• Complete detailed assessment/focused assessment if no life-threatening injuries present.
• Cover injured eyes with protective shield or cup - avoid pressure or direct contact to eye.
• Do not attempt to stop free drainage from ears, nose. Cover lightly with dressing to avoid
contamination.
• Bring avulsed teeth with you. Keep moist in saline-soaked gauze.
• Monitor airway closely during transport for development of obstruction or respiratory distress.
Suction and treat as needed.
• Airway obstruction is the primary cause of death in persons sustaining head and face trauma.
Meticulous attention to suctioning and basic airway maneuvers may be the most important
treatment rendered.
• Remember that the apex of the lung extends into the lower neck and may be injured in
penetrating injuries of the lower neck, resulting in pneumothorax or hemothorax.
• Do not be concerned with contact lens removal in the field.
Treatment-Trauma: Face and Neck Trauma
Revised 4/2015
1
Page 2 of 2
Section 406
FACE AND NECK TRAUMA
SPECIAL PRECAUTIONS
• Fracture of the larynx should be suspected in patients with respiratory distress, abnormal voice,
and history of direct blow to neck from steering wheel, rope, fence wire, etc. Intubation may be
unsuccessful in the patient with a fractured larynx, and attempts may result in increased injury.
The patient needs immediate and rapid transport if you suspect this potentially lethal injury. Do
not attempt intubation unless the patient is in severe respiratory distress. Bag-valve-mask
ventilation is preferred.
• If a penetrating injury creates a complete disruption of the trachea and an opening is visualized,
insert endotracheal tube and ventilate.
Treatment-Trauma: Face and Neck Trauma
Revised 4/2015
2
Page 1 of 2
Section 407
HEAD TRAUMA
INFORMATION NEEDED
 History: mechanism of injury, estimate of force involved; helmet use.
 History since injury: loss of consciousness (duration), change in level of consciousness, memory
loss for events before and after trauma, movement (spontaneous or moved by bystanders), seizure
activity, vomiting
 Past history: medications (esp. insulin), medical problems, seizure history, alcohol or drug use
SPECIFIC OBJECTIVE FINDINGS
 Vital signs (note respiratory pattern and rate)
 Neurologic assessment: Glasgow Coma Score
 External evidence of trauma: contusions, abrasions, lacerations, drainage from nose, ears
TREATMENT
• Assess airway and breathing; treat life-threatening conditions
• Use assistant to provide in-line cervical immobilization when indicated.
• Manage airway and assist ventilations
• Oxygen
• Intubate if indicated
o Ventilate at a rate to keep ET CO2 between 35-40 mmHg
• Establish IV
• Fluid bolus if signs of shock
• Control hemorrhage. Stop scalp bleeding with direct pressure. Continued pressure may be
needed.
• Immobilize spine
• If patient is combative, consider sedation (See Medication Protocols). The airway and - spine can
be more appropriately managed with a relaxed patient.
• TRANSPORT RAPIDLY if patient has multiple injuries, or unstable neurologic, respiratory or
circulatory status.
• Contact medical control to assist with destination as patient may need to be transported to
nearest neurosurgeon for neurosurgical stabilization
• Intubation is indicated if the patient is unable to protect the airway. While there is no absolute
GCS that indicates need for intubation, a GCS < 10 warrants aggressive airway management.
• An elevated BP along with bradycardia is a common finding in head injury.
• Monitor and record airway, vital signs, and level of consciousness repeatedly at scene and during
transport. Status changes are important.
SPECIAL PRECAUTIONS
 When head injury patients deteriorate, check first for airway, oxygenation and blood pressure.
These are the most common causes of "neurologic" deterioration. If the patient has tachycardia or
hypotension, evaluate for hypovolemia from associated injuries.
 Secondary brain injury and adverse outcomes can occur in brain-injured patients who exhibit
hypotension and/or hypoxia. Early aggressive treatment of hypotension and administration of
high flow oxygen may prevent further injury.
 The most important information you provide for medical control is the level of consciousness and
its changes. Is the patient stable, deteriorating or improving?
 Restlessness can be a sign of hypoxia. Cerebral anoxia is the most frequent cause of death in head
injury.
Treatment-Trauma: Head Trauma
Revised 9/2014
1
Page 2 of 2
Section 407
HEAD TRAUMA


Scalp lacerations can cause profuse bleeding, and are difficult to define and control in the field. If
direct local pressure is insufficient to control the bleeding, evacuate any large clots from flaps and
large lacerations with sterile gauze, and use direct hand pressure to provide hemostasis. If the
underlying skull is unstable, pressure should be applied to the periphery of the laceration over
intact bone.
Routine prophylactic hyperventilation should be avoided. It has been shown to be detrimental to
cerebral blood flow and patient outcome. Hyperventilation (ET CO2 between 30-35) in the field
for head trauma is indicated only when signs of cerebral herniation such as extensor/flexor
posturing or asymmetric, nonreactive pupils are present after correcting hypotension and/or
hypoxemia.
Treatment-Trauma: Head Trauma
Revised 9/2014
2
Page 1 of 1
Section 408
SPINAL TRAUMA
INFORMATION NEEDED
• Mechanism of injury and forces involved: be suspicious with falls, decelerations, diving accidents
and motor vehicle accidents.
• Numbness, tingling, focal weakness.
• Past medical problems and medications
SPECIFIC OBJECTIVE FINDINGS
• Vital signs, including neurologic assessment
• Level of sensory and motor deficit; presence of any evidence of neurologic function below level
of injury
• Physical exam, with careful attention to organs or limbs which may not have sensation. Also
assess for other distracting injuries.
• Palpation of spine- tenderness, step-offs, deformities.
TREATMENT
• Assess airway and breathing; treat life-threatening difficulties. Use controlled ventilation for high
cervical cord injury associated with abdominal breathing. Use assistant to provide in-line cervical
immobilization while managing ABCs
• Administer O2.
• Control hemorrhage.
• Immobilize cervical, thoracic and lumbosacral spine as indicated.
• Obtain and record vital signs and neurologic assessment before and after immobilization.
• Establish venous access. If signs of hypovolemia: fluid bolus,crystalloid fluids, contact medical
control.
• Monitor airway, vitals, and neurologic status frequently at scene and during transport.
SPECIAL PRECAUTIONS
• Be prepared to turn entire board on side if patient vomits (patient must be secured to
immobilizing splint).
• Neurogenic shock is likely with significant spinal cord injury. If present, elevate legs 10-12
inches. Ensure adequate respirations.
• If hypotension is unresponsive to simple measures, it is likely due to other injuries. Neurologic
deficits make other injuries hard to evaluate. Cord injury above the level of T-8 makes the
abdominal examination unreliable.
• Spinal immobilization in patients with penetrating trauma should be accomplished only when
neurologic deficit or impaled foreign body is present.
• It is important from a clinical and medical legal perspective to record neurologic assessment
before and after spinal immobilization.
Treatment-Trauma: Spinal Trauma
Revised 4/2015
1
Page 1 of 1
Section 409
TRAUMATIC ARREST
INFORMATION NEEDED
• Time of arrest
• Mechanism: blunt vs. penetrating
• Signs of irreversible death (decapitation, dependent lividity, etc.)
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Evidence of significant blood loss
• Evidence of blunt head, thorax or abdominal trauma
TREATMENT
Blunt Trauma Arrest
• Initiate basic life support, administer O2
• Manage airway and respirations
o Consider ETT and Chest Decompression
• If patient is still in cardiac arrest after above treatments, consider field pronouncement.
• If pulse returns with above treatment, start IV, administer IV fluids rapidly, control any bleeding
found on exam; Contact medical control to report patient status.
Penetrating Trauma Arrest
• Initiate basic life support, administer O2
• Manage airway and respirations
o Consider ETT and Chest Decompression
• If cardiac activity returns with above treatment, treat arrhythmias per protocols.
o Contact medical control to report patient status
o Rapid Transport
• Consider field pronouncement if the following:
o Signs of irreversible death
o ALS has been unavailable for at least 20 minutes from the time EMS personnel initiate onscene assessment and there is no return of vital signs or signs of life
o no return of pulses despite above measures and patient is more than 10 minutes from arrival
to trauma center.
SPECIAL PRECAUTIONS
• Victims of blunt trauma who are still in cardiac arrest after initiation of ACLS have a mortality
rate of 100%.
• Trauma arrests secondary to penetrating truncal injuries can be resuscitated and saved. There is a
higher rate of survival in victims of low velocity penetrating injuries than victims of high velocity
injuries.
Treatment-Trauma: Traumatic Arrest
Revised 9/2014
1
Page 1 of 2
Section 410
TRAUMA DESTINATION AND TRAUMA TEAM ACTIVATION
INFORMATION NEEDED
SWRETAC / MRMC Trauma Team Activation Guidelines:
• Contact medical control if a patient meets any of the criteria below.
SPECIFIC OBJECTIVE FINDINGS
Respiratory
 Unable to adequately ventilate
Physiology
• Intubation
• Respiratory rate and level of distress
• Capillary Refill >2 sec or BP
• GCS
Anatomy
• Penetrating injuries
• Chest injury
• Paralysis or evidence of spinal cord injury.
• Amputation proximal to wrist or ankles
• Unreactive or non-symmetric pupil
• Fractures
Mechanism of Injury
• Assessment of the energy transfer the patient experienced
TREATMENT
• If patients do not meet these criteria but have a significant mechanism, prolonged extrication,
death at scene of other occupant, suspected non-accidental trauma --- contact medical control and
they will make the decision as to trauma team activation.
• The nearest appropriate trauma center for patients served by the Upper San Juan Ambulance
Service is Pagosa Springs Medical Center unless the incident occurs west of Yellow Jacket Pass,
in which case MRMC is the nearest appropriate trauma center.
• Helicopter activation may be appropriate when initial information from dispatch relates potential
serious injury (see Medical Helicopter Activation protocol) and transport times exceed air
transport times. Once the patient is transferred to the air ambulance crew, their protocols and
medical control dictate destination.
• Rarely is trauma isolated to the head. Suspected CHI should be transported to the nearest trauma
center to rule out other internal injuries and for stabilization.
• During a multiple casualty event, the algorithm below may be modified.
• This algorithm applies to both air and ground scene transports
• DISCRETION OF PRE-HOSPITAL PERSONNEL BASED ON FACTORS BELOW
MAY DETERMINE TRANSPORT DESTINATION
Treatment-Trauma: Trauma Destination and Trauma Team Activation
Revised 9/2014
1
Page 2 of 2
Section 410
SWRETAC Trauma Triage Destination Guidelines
Step 1 – Respiratory
1. Unable to adequately ventilate
YES

NO ↓
Transport to closest
facility or ALS intercept
Step 2 – Physiology
Children (AGE 0-12)
Or < 5 FT IN HEIGHT
•
•
•
•
Intubation
Respiratory Distress
Capillary Refill > 2 sec or BP
abnormal for age (<70+2x age)
Glasgow Motor Score < 14
NO ↓
Step 3 – Anatomy
•
•
•
•
•
•
•
•
•
•
Transport to closest
appropriate trauma center
Adult
•
•
•
•
Intubation
Systolic BP < 90
Respiratory rate < 10 or > 29
with distress
Glasgow Motor Score < 14
YES

(any one of the below)
Penetrating injuries to head, neck , torso, pelvis, or extremities proximal to knee or
elbow
Flail chest
Two or more proximal long bone fractures
Crushed, degloved, or mangled extremity
Amputation proximal to wrist or ankle
Unstable pelvis or suspected significant pelvic fracture
Open or depressed skull fracture
Paralysis or evidence of spinal cord injury
Significant burns
Unreactive or unequal pupils.
Transport to closest
appropriate trauma center
YES

NO ↓
Step 4 – Mechanism
•
•
•
•
(any one of the below)
Falls
o Adult > 20 feet
o Child >2 times height of child
High-Risk Auto Crash
o Intrusion > 12 in - occupant side or > 18 in - any area
o Partial or complete ejection from vehicle
o High energy dissipation
o Death in the same passenger compartment
Auto vs Pedestrian / Bicyclist thrown, run over, or with > 20 MPH impact
Motorcycle crash > 20 MPH
YES

Transport to closest
appropriate trauma
center
NO ↓
Step 5 – Co-morbidity Considerations (any one of the below)
•
•
•
•
•
•
•
AGE > 55 years of age
Anticoagulation and bleeding disorders
Significant Burns
Time sensitive extremity injury
End stage renal disease requiring dialysis
Pregnancy > 20 weeks
EMS Provider Judgment
NO ↓
Transport to closest appropriate hospital
Treatment-Trauma: Trauma Destination and Trauma Team Activation
Revised 9/2014
2
YES

Consider transport to
closest appropriate
trauma center
Transport to any acute
care facility.
Page 1 of 2
Section 411
TRAUMA - GENERAL
INFORMATION NEEDED
Mechanism of injury
• Cause, precipitating factors, weapons used
• Trajectories and forces involved
• For vehicular trauma:
o Specific description of mechanism such as auto vs. pole, rollover, broadside, high speed
o Condition of vehicle including windshield, steering wheel, compartment intrusion, condition
of dashboard/firewall/pedals, type and use of seatbelts, supplemental restraint system (e.g.
airbag) deployment
• Helmet use; motorcycle, bicycle, skiing, snowboarding, skateboarding, rollerblading
• Patient complaints.
• Initial position and level of consciousness of patient.
• Patient movement, treatment since injury
• Other factors such as drugs, alcohol, medications, diseases, pregnancy
Scene evaluation
• Note potential hazard to rescuers and patient.
• Identify number of patients; organize triage operations if appropriate
• Observe position of patient, surroundings, probable mechanism, and vehicle condition
SPECIFIC OBJECTIVE FINDINGS
Trauma Team Activation Criteria for MRMC
• Notify medical control immediately if any criteria are met
Respiratory
• Unable to adequately ventilate
Physiology
• Children (younger than 12 years) or <5 feet tall
o Intubation or
o Respiratory Distress or
o Capillary Refill >2 sec or SBP abnormal for age (<70 + 2X age) or
o GCS < 5
• Adult
• Intubation or
• Systolic BP<90 or
• Respiratory Rate < 10 or > 29 with distress or
• GC <5
Anatomy
• Penetrating injuries- head neck, torso, pelvis
• Flail chest
• Bilateral femur fractures
• Unstable pelvis or suspected significant pelvic fracture
• Paralysis or evidence of spinal cord injury.
• Amputation above the wrist or ankles
• Significant burns
• Unreactive or non-symmetric pupil
Treatment-Trauma: Trauma Overview
Revised 4/2015
1
Page 2 of 2
Section 411
TRAUMA - GENERAL
TREATMENT
Initial assessment in multiple trauma is performed at the same time as treatment.
•
•
•
•
•
•
•
•
Airway with C-spine immobilization. Use suction, oral or nasal airway initially
Breathing: apply O2, assist with ventilations as needed.
Circulation, with control of major bleeding, establish IVs and give crystalloid fluid bolus
Transport decision (See Operations: Transport Destination)
If patient unstable, call for helicopter immediately or discuss with medical control if helicopter
not readily available. Stabilize as much as possible while in transport as outlined above.
If patient stable, reassess for potentially life-threatening injuries and treat accordingly.
Monitor vital signs, neurological status and cardiac rhythm enroute
Serial vital signs and observations of respiratory, circulatory and neurologic status prior to arrival
are critical.
SPECIAL PRECAUTIONS
• There are patients who cannot tolerate a full assessment before life-saving intervention is needed.
Likewise, splinting, bandaging, and, often, the focused history and physical examination are
procedures that may need to be bypassed in the critical patient. Time and the treatment available
in a trauma center are critical elements in resuscitation.
• Critical injuries involve:
o Difficulty with respiration
o Difficulty with circulation (hypoperfusion - shock)
o Decreased level of consciousness
• Any trauma patient with one or more of these above conditions needs to be transported to the
nearest appropriate trauma center. Treatment may occur en route or while awaiting the
helicopter, but should never delay the patient in reaching the destination. See criteria below for a
list of criteria that warrants trauma team activation at MRMC. If these criteria are met, notify
MRMC that the patient meets trauma team activation criteria.
• The trauma patient is the greatest risk to the rescuer for exposure to "bodily fluids." Use BSI.
Treatment-Trauma: Trauma Overview
Revised 4/2015
2
PROTOCOL
SECTION
NUMBER
NUMBER OF
PAGES
DATE
SECTION 500 - Medications
500
2
REVISED 1/2014
Aspirin
501
1
Revised 01/2014
Activated Charcoal
502
1
Revised 01/2014
Adenosine
503
2
Revised 01/2014
Albuterol
504
2
Revised 01/2014
Alteplace
505
2
Created 01/2014
Amiodarone
506
2
Revised 01/2014
Antimicrobial
507
2
Revised 01/2014
Atropine
508
2
Revised 01/2014
Blood Products
509
1
Revised 04/2015
Calcium Gluconate
510
1
Revised 01/2014
Dextrose
511
2
Revised 01/2014
Diazapam
512
2
Revised 01/2014
Diltiazem
513
2
Revised 01/2014
Diphenhydramine
514
2
Revised 01/2014
Dopamine
515
2
Revised 01/2014
Droperidol
516
2
Created 01/2014
Epinephrine
517A
3
Revised 01/2014
Epinephrine Auto Injector
517B
2
Revised 01/2014
Etomidate
518
1
Revised 01/2014
Fentanyl
519A
2
Revised 02/2015
Fentanyl Drip
519B
2
Revised 02/2015
Glucagon
520
1
Revised 01/2014
Haldol
521
2
Revised 01/2014
Heparin
522
1
Revised 01/2014
Insulin
523
2
Revised 01/2014
Ipatropium
524
1
Revised 01/2014
IV Solutions
525
2
Revised 04/2015
Levaphed
526
1
Created 01/2014
Lidocaine
527
1
Revised 01/2014
Lorazapam
528
2
Revised 01/2014
Magnesium Sulfate
529
2
Revised 01/2014
Methylprednisone
530
1
Revised 01/2014
Midazolam
531A
2
Revised 02/2015
Midazolam Drip
531B
2
Created 2/2015
Morphine Sulfate
532
2
Revised 01/2014
Naloxone
533
1
Revised 01/2014
Nitroglycerine
534A
2
Revised 01/2014
Nitroglycerine Infusion
534B
2
Revised 01/2014
Nitroglycerine Paste
534C
2
Revised 01/2014
Ondansetron
535
1
Revised 01/2014
Oxygen
536
1
Revised 01/2014
Phenylephrine
537
1
Revised 01/2024
Potassium Chloride
538
1
Revised 02/2014
Protonix
539
1
Created 02/2014
Rocuronium
540
1
Revised 01/2024
Sodium Bicarbonate
541A
2
Revised 01/2024
Sodium Bicaroinate
541B
2
Revised 01/2014
Succinylcholine
542
2
Revised 01/2014
Tetracaine
543
1
Revised 01/2014
Page 1 of 1
Section 501
ACETYLSALICYLIC ACID (ASPIRIN / ASA)
PHARMACOLOGY
• ASA inhibits blood clotting. It inhibits the formation of thromboxane A2, a platelet
aggregating, vasoconstricting prostaglandin.
• Platelet aggregation has been implicated in the pathogenesis of atherosclerosis contributing to
the acute episodes of TIAs, unstable angina, and acute myocardial infarction.
• Unstable angina is precipitated by a sudden fall in coronary blood flow. One possible
mechanism is platelet aggregation surrounding a thrombosing plaque.
• ASA has been shown to be beneficial in decreasing sudden cardiac death and myocardial
infarction in patients with unstable angina.
• ASA has been shown to be of added benefit in maintaining vessel patency after percutaneous
coronary intervention (PCI) or after administration of a thrombolytic agent therapy.
INDICATIONS
• Patients with chest pain or other symptoms, which may be of cardiac origin.
• ASA is not to be used for analgesia (i.e. headache).
• Aspirin is one of the few interventions that has been shown to decrease mortality with a cardiac
event and therefore should be considered early in the care of the patient.
CONTRAINDICATIONS
• Known hypersensitivity or allergy to the drug.
PRECAUTIONS / SIDE EFFECTS
• Patients taking Coumadin and/or Plavix may receive aspirin.
• Since aspirin is a relatively safe medication, it should be administered to all patients complaining
of non-traumatic chest pain unless contraindicated.
• Use in caution with known asthma patients.
• Patients with active GI bleeding.
ADMINISTRATION
ADULT
PROCEDURE
•
FR
324 mg ASA in the form of 4
Children's chewable aspirin. (81 mg
each tablet)
PREGNANCY CLASSIFICATION:
• D, during last trimester
SUPPLIED AS:
• Chewable tablets. 81 mg each. (1¼ grain)
Medications: Aspirin
Revised 1/2014
1
EMT B
EMT B IV
EMTP
PCC
VO
VO
SO
SO
Page 1 of 1
Section 502
ACTIVATED CHARCOAL
PHARMACOLOGY
• Activated charcoal is pharmacologically inert and it is not absorbed in the gastrointestinal tract. It
is produced by pyrolysis of organic material and an activation process which cleanses and
fragments the charcoal, which increases surface area by creation of external and internal pores.
These pores act as reservoirs for absorbing specific toxins in the stomach. Sorbitol provides an
osmotic cathartic effect to promote gastrointestinal tract evacuation and to prevent constipation
and compaction of charcoal.
INDICATIONS
• Ingestion of toxins within the last 2 hrs.
CONTRAINDICATIONS
• Inability to swallow or to protect their airway
• This may be a relative contraindication after placement of an NG tube.
• Acid / Base ingestion
• Hydrocarbon ingestion (gasoline)
PRECAUTIONS / SIDE EFFECTS
• A larger dose may be required for a person who has ingested a large meal prior to administration
ADMINISTRATION
• Shake container thoroughly prior to administration
• Get patient to swallow the charcoal without looking at it if possible
• May be administered orally or though NG tube.
ADULT
PROCEDURE
•
FR
50 g
EMT B
EMT B IV
EMTP
PCC
VO
VO
SO
SO
EMT B
EMT B IV
EMTP
PCC
VO
VO
SO
SO
PEDIATRIC (0-12 yrs)
PROCEDURE
•
FR
1 g/kg max 25 g
PREGNANCY CLASSIFICATION
SUPPLIED AS
•
25 g in a premixed bottle
Medication: Acitvated Charcoal
Revised 1/2014
1
Page 1 of 2
Section 503
ADENOSINE ( ADENOCARD)
PHARMACOLOGY
• Adenosine is an endogenous nucleoside with antiarrhythmic activity.
• Slows AV nodal conduction and / or sinus nodal conduction secondary to re-entry.
• Because of its short plasma half-life (less than 10 seconds with IV doses), the clinical effects
of adenosine occur rapidly and are very brief.
• Transient effects can include heart block, asystole, arrhythmias, flushing, dyspnea, chest pain, or
anxiety.
INDICATIONS
• For termination of episodes of acute supra-ventricular tachycardia in stable patients without signs
of shock and poor perfusion.
• Stable wide complex regular tachycardia of unknown origin
CONTRAINDICATIONS
• Atrial fibrillation: adenosine is not safe in patients with an irregular, wide QRS, tachycardia. This
may be atrial fibrillation with aberrant conduction and may become worse if the AV node is
slowed or blocked.
PRECAUTIONS / SIDE EFFECTS
• Transient effects can include heart blocks, asystole, or arrhythmias.
• Flushing, dyspnea, or chest pain may occur.
• Theophylline and caffeine are antagonists. Larger doses may be required if patients have ingested
either.
• Use of Digitalis may extend asystole.
• Whenever possible establish the IV at the antecubital.
• Patients with signs of shock require immediate cardioversion.
• Stable, asymptomatic patients, with history of PSVT, may not need to be treated.
• Patients who take Methylxanthine compounds such as caffeine or theophylline will require higher
doses to achieve cardioversion.
ADMINISTRATION
• Any patient receiving Adenosine must be on a monitor and a 12-lead EKG should be performed
and documented. Obtain a continuous EKG strip during drug administration.
• Third dose requires medical control contact. Provider should be looking toward other causes and
treatments if the 2nd dose is ineffective.
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
•
6 mg dose followed by a 10 cc bolus.
SO
SO
•
Repeat dose of 12 mg may be
administered if SVT persist.
SO
SO
Repeat dose of 12 mg may be
administered if SVT persist.
Medication: Adenosine
Revised 1/2014
SO
SO
•
1
Page 2 of 2
Section 503
(requires med control)
ADENOSINE ( ADENOCARD)
PEDIATRIC
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
•
0.1 mg / kg dose followed by a 5cc
fluid bolus.
Maximum 1st dose:
6 mg
SO
SO
•
0.2 mg / kg for second dose.
Maximum 2nd dose:
12 mg
SO
SO
•
0.2 mg / kg for third dose. Requires
Med Control Contact
Maximum 3rd dose:
12 mg
SO
SO
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
•
3mg/ml in a prefilled syringe ( 6 and 12 mg)
Medication: Adenosine
Revised 1/2014
2
Page 1 of 2
Section 504
ALBUTEROL SULFATE
PHARMACOLOGY
• Has selective beta-adrenergic stimulating properties resulting in potent bronchodilation.
• Rapid onset of action (under 5 minutes), and duration of action between 2-6 hours
• Stimulates the release of insulin as well as the Na/K+ causing potassium to be shifted into
the cell.
INDICATIONS
• For relief of bronchospasm in the following:
o Asthma.
o Emphysema
o Acute allergic reactions.
o COPD.
o May have benefit in other respiratory illnesses such as bronchitis or any form of
reactive airway disease.
• Patients with suspected Hyperkalemia
CONTRINDICATIONS
• Asthma as a result of myocardial infarction.
PRECAUTIONS / SIDE EFFECTS
• Albuterol has sympathomimetic effects. Use with caution in patients with known coronary
disease. Monitor pulse, blood pressure, cardiac monitor and 12-lead EKG (if available) in
patients with a history of heart disease.
• When inhaled, albuterol sulfate can result in paradoxical bronchospasm, which can be life
threatening. If this occurs, the preparation should be discontinued immediately.
• Medications such as MAO inhibitors and tricyclics may potentiate tachycardia and
hypertension.
• The heart rate will rise, but if it rises beyond 150 bpm in adults, discontinue and look for
other causes.
ADMINISTRATION
• Monitor blood pressure and heart rate closely and contact medical control if any concerns
arise.
• Document effect of each treatment in terms of air movement and lung sounds.
• Endotracheally intubated patients may be given albuterol sulfate by attaching the nebulizer
in-line.
ADULT
PROCEDURE
•
2.5 mg in a 3 ml saline premixed
solution. Oxygen flow at 6 to 8L
•
For more severe cases and
hyperkalemia, administer continuous
nebulizer treatment.
Medications: Albuterol Sulfate
Revised 1/2014
FR
1
EMT B
EMT B IV
EMP
PCC
VO
VO
SO
SO
SO
SO
Page 2 of 2
Section 504
ALBUTEROL SULFATE
PEDIATRIC
PROCEDURE
•
2.5 mg in 3ml O2 at 6L
May dilute in 3ml NS
•
For more severe cases and
hyperkalemia, administer continuous
nebulizer treatment.
FR
EMT B
EMT B IV
EMT I
EMT P
VO
VO
SO
SO
VO
SO
MDI=EMT-B may assist patients in taking his or her prescribed metered-dose inhalers
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• 2.5 mg in 3ml saline.
Medications: Albuterol Sulfate
Revised 1/2014
2
Page 1 of 2
Section 505
ALTEPLASE- INTERFACILITY
PHARMACOLOGY
• Alteplase (recombinant) is a tissue plasminogen activator (TPA). It enhances the
conversion of plasminogen to plasmin by binding to fibrin, initiating fibrinolysis with
limited systemic proteolysis.
INDICATIONS
• Acute myocardial infarction- for those cases in which the time to percutaneous coronary
intervention (PCI) is expected to be prolonged or when PCI is unavailable
• Cerebrovascular accident- ischemic, acute as determined by the Emergency Department
physician in consultation with the neurologist.
• Pulmonary embolism- large embolus causing hemodynamic compromise
CONTRAINDICATIONS
- (these will have been reviewed by the sending physician prior to administration)
• bleeding disorder including INR > 1.7
• head trauma, serious, recent (within 3 months)
• hypertension, uncontrolled (eg, greater than 185 mmHg systolic or greater than 110 mmHg
diastolic) at time of treatment
• internal bleeding, active
• intracranial hemorrhage, history or evidence of on pretreatment evaluation
• intracranial neoplasm, arteriovenous malformation, or aneurysm
• intracranial surgery, intraspinal surgery recent (within 3 months)
• previous stroke, recent (within 3 months)
• (ischemic stroke) seizure at onset of stroke
• (ischemic stroke) subarachnoid hemorrhage, suspected, on pretreatment evaluation
• (myocardial infarction or pulmonary embolism) history of cerebrovascular accident
• (myocardial infarction or pulmonary embolism) hypertension, severe uncontrolled (eg,
greater than 185 mmHg systolic or greater than 110 mmHg diastolic) and/or severe, at time
of treatment
ADMINISTRATION
- for interfacility use only. The sending facility will initiate the medication. EMS will monitor
the infusion while transporting the patient to the closest appropriate facility who has agreed to
accept the patient. Confirm infusion rates with the sending physician and nurse.
• Acute myocardial infarction: Activase(R), Accelerated infusion: patients over 67 kg- total
dose 100 mg IV, patient will have been given 15 mg IV bolus, 50 mg over 30 minutes, then
35 mg over 60 minutes
• Acute myocardial infarction: Activase(R), Accelerated infusion: patients 67 kg or less,
patient will have been given 15 mg IV bolus, then 0.75 mg/kg over 30 minutes, then 0.50
mg/kg over 60 minutes; total dose not to exceed 100 mg
• Cerebrovascular accident, acute, Ischemic: Activase(R), 0.9 mg/kg IV (not to exceed 90
mg total dose), infused over 60 minutes with 10% of the total dose given as an initial bolus
by sending facility over 1 minute; the remainder over the next hour
• Pulmonary embolism: Activase(R), 100 mg IV infused over 2 hours
Medications: Alteplase
1/2014
1
Page 2 of 2
Section 505
ALTEPLASE- INTERFACILITY
PRECAUTIONS / MONITORING
• Bleeding is the most common side effect. If bleeding occurs from any skin lesions or IV
site, use direct pressure
• Serious bleeding may manifest as shock including altered mental status, hypotension, or
GI bleeding. If this occurs, stop the infusion immediately and manage for shock.
ADULT
PROCEDURE
•
FR
EMT B
Atleplase-Confirm infusion rate
prior to leaving facility
Medications: Alteplase
1/2014
EMT B IV
EMT I
EMT P
VO
2
Page 1 of 2
Section 506
AMIODARONE (CORDARONE)
PHARMACOLOGY
• Amiodarone has multiple effects showing Class I, II, III and IV antiarrhythmic actions.
• The dominant effect is prolongation of the action potential duration and the refractory
period of myocardial automaticity.
• Onset is within minutes.
INDICATIONS
• Cardiac arrest from Ventricular Tachycardia or Ventricular Fibrillation.
• Following successful defibrillation.
• Sustained wide complex tachycardia with a pulse (except wide complex irregular
rhythms)
• Unstable wide complex tachycardia following unsuccessful cardioversion.
• May also be administered as a continuous infusion but only for interfacility transport where the
sending hospital sets up the infusion and instructs on infusion rate.
CONTRAINDICATIONS
• Second degree and third degree AV Blocks.
• Hypersenitivity to Amiodarone (Cordarone).
• Cardiogenic Shock and Pulmonary Congestion.
• Do not treat ventricular escape beats or accelerated idioventricular rhythm with
amiodarone.
PRECAUTIONS / SIDE EFFECTS
• WPW is a relative contraindication.
• Use caution in wide complex irregular tachycardia.
• May cause severe hypotension and profound bradycardia.
• Use with caution in sympathomimetic toxidromes (i.e. cocaine or amphetamine overdose)
ADMINISTRATION
• Although the maximum dose is very high, medical control contact is required to exceed the dosing
below.
• Mix w/ D5W
Medication Protocol – Amiodarone
Revised 1/2014
1
Page 2 of 2
Section 506
AMIODARONE (CORDARONE)
ADULT
PROCEDURE
FR
EMT B
EMT B IV
Cardiac Arrest
•
•
•
SO
SO
SO
SO
SO
SO
SO
VO
SO
EMTP
EMT P
SO
SO
150 mg placed in a 250 cc bag over 10
minutes.
Unstable wide complex tachycardia
after unsuccessful cardioversion
•
SO
150 mg placed in a 250 cc bag over 10
minutes.
Wide complex tachycardia (Stable)
•
PCC
300 mg IV push.
May repeat once in 3-5 min with
150mg IV push.
Maximum cumulative dose is 2 G IV /
24 hrs
Successfully defibrillated cardiac arrest
from VF/VT – adult
•
EMTP
150 mg placed in a 250 cc bag over 10
minutes.
Continuous infusion- interfacility only
•
900mg diluted in 500 mL D5W at rate
of 0.5-15mg/min.
PEDIATRIC
PROCEDURE
FR
EMT B
Cardiac Arrest
•
5 mg / kg bolus given IV or IO.
PREGANANCY CLASSIFICATION
• D
SUPPLIED AS
• 50 mg/ml in 3ml prefilled syringe
Medication Protocol – Amiodarone
Revised 1/2014
2
EMT B IV
Page 1 of 2
Section 507
ANTIMICROBIAL ADMINSTRATION- INTRAVENOUS
PHARMACOLOGY
• Varies depending on medication
INDICATIONS
•
•
•
Microbial infections including bacterial, viral, fungal, parasitic infections.
Common antibiotics used:
o Ceftriaxone (Rocephin)- effective against Strep pneumoniae and multiple other
organisms. Usual dose 1-2 gram IV over 30-60 minutes. May be given IM.
o Levofloxacin (Levaquin)- effective against gram-negative bacteria. Usual dose 500750 mg IV over 60-90 minutes. May cause hypotension.
o Azithromycin (Zithromax)- effective against multiple bacteria. Usually given orally,
but may be given as 500mg IV over 1-3 hours.
o Gentamicin- effective against gram-negative bacteria.. Usual dose 1-1.7mg/kg over
30min-1hour. Not to be given concurrently with Penicillin-class agents.
o Cefazolin (Ancef)- effective against gram-positive bacteria. Usual dose 1-2 g over
10-60 minutes.
o Clinidamycin (Cleocin)- effective against anaerobic bacteria. Usual dose 300-900mg
IV not to exceed 30mg/min or PO. Contraindicated for those with colitis
o Vancomycin- effective against MRSA. Usual dose 0.5-1 gram over 1-2 hours.
Rapid infusion may cause hypotension and profuse flushing (red-man syndrome).
Very necrotic to tissue if infiltration occurs.
o Pipercillin/Tazobactam (Zosyn)- broad coverage antibiotic for serious bacterial
infections. Usual dose 3.375 g IV over 30 minutes.
o Ampicillin/Sublactam (Unasyn)- broad coverage antibiotic for serious bacterial
infections. Usual dose 1.5-3g IV over 15-30 minutes.
o Ampicillin- effective against certain gram-positive bacteria. Indicated in meningitis
for infants and elderly. Usual IV dose 1-2g (adults) 50-100mg/kg (peds) over 15-30
minutes.
Others
o Metronidazole (Flagyl)- effective against parasites and anaerobic bacteria. Usual
dose 500mg PO/IV over 30-60 min. May cause nausea, vomiting.
o Acyclovir- antiviral. Indicated for viral encephalitis Usual dose 5-10mg/kg over 1
hour.
CONTRAINDICATIONS
•
Hypersensitivity to the antimicrobial agent.
PRECAUTIONS
•
•
Hypersensitivity, anaphylaxis. Stop infusion and treat per anaphylaxis protocol (Section
302 Allergy Anaphylaxis).
Infiltration of IV can be damaging to soft tissue- stop infusion and establish new IV site.
ADMINISTRATION
•
Only to be started by sending facility. Monitored during interfacility transport
Appendix: Interfacility Medications
Revised 1/2014
1
Page 2 of 2
Section 507
ADULT
PROCEDURE
FR
EMT B
EMT B
IV
EMTP
PCC
VO
SO
Anitmicrobial Infusion
•
dosing varies
PREGNANCY CLASSIFICATION
• Varies
Appendix: Interfacility Medications
Revised 1/2014
2
Page 1 of 2
Section 508
ATROPINE SULFATE
PHARMACOLOGY
• Parasympathetic / Cholinergic/Muscarinic blocking agent that:
o Increases heart rate.
o Increases conduction through the AV node.
o Decreases motility and tone to the GI tract.
o Decreases action and tone of urinary bladder.
o Dilates pupils.
• Note: This drug blocks cholinergic (vagal) influences already present. If there is little cholinergic
stimulation present, effects will be minimal.
INDICATIONS
• Increases heart rate in unstable bradycardia patients.
• To increase conduction in 2nd and 3rd degree blocks and pacemaker failures.
• As an antidote for organophosphate poisonings that exhibit cholinergic reactions which may
present with one or more of the following findings of the acronym:
o SLUDGE BBB
o Salivation.
o Lacrimation.
o Urination.
o Defecation.
o GI Motility.
o Emesis.
o Bronchorhea
o Bradycardia
o Bronchospasm
CONTRAINDICATIONS
• Atrial Fibrillation.
• Atrial Flutter.
• Tachycardias.
PRECAUTIONS / SIDE EFFECTS
• Bradycardias in the setting of an acute MI are common and may be beneficial. Do not treat them
unless there are signs of poor perfusion and/or hypotension. If in doubt, consult medical control.
• Pediatric bradycardias are most commonly secondary to hypoxia. Correct the ventilation first, and
only treat the rate directly if that fails. Epinephrine is almost always the first-line drug for
bradycardia in pediatric patients.
• Remember that atropine will dilate the pupils and that this is not a sign of anoxic brain injury.
• For patients with suspected cardiac chest pain who have a high degree AV block (Mobitz II 2nd
degree block or 3rd degree block), atropine is relatively contraindicated, consult medical control in
these situations if a slow ventricular rate is present.
Medications: Atropine Sulfate
Revised 1/2014
1
Page 2 of 2
Section 508
ATROPINE SULFATE
ADMINISTRATION
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
EMTP
PCC
SO
SO
•
Bradycardia
•
0.5 mg to 1.0 mg IVP
Organophosphate Poisoning
•
1 to 2 mg increments to alleviate life
threatening symptoms. No Max Dose
Contact med control for repeat
dosing
PEDIATRIC
• Pediatric Bradycardias are primarily caused by hypoxia!
PROCEDURE
Primary AV block
• 0.02mg/kg (min dose 0.1mg)
FR
EMT B
PREGANANCY CLASSIFICATION
• C
SUPPLIED AS
•
1 mg / 10cc in a 10 cc pre-filled syringe.
Medications: Atropine Sulfate
Revised 1/2014
2
EMT B IV
Page 1 of 1
Section 509
MONITORING BLOOD PRODUCT ADMINISTRATION
BACKGROUND
• Select patients undergoing elective surgery at PSMC will have blood components ordered for
them to be available the day of surgery.
• In the event that the patient requires blood products, nurses at PMSC will follow a strict protocol
prior to administering the products.
• The patient may require transfer to MRMC. EMT-Ps are allowed to monitor and continue the
administration of blood products during transport.
PRIOR TO TRANSPORT
• Obtain vital signs including temperature.
• Confirm and clarify orders from the sending physician for the blood products.
• Obtain a copy of the consent for blood products signed by the patient or designee.
• If another unit of product is to be started on the patient, verify with the nurse that the IDs on the
patient and the product match.
TRANSFUSION REACTION
• Definition: an incompatibility between the donor and recipient blood which causes an adverse
event. This includes immunologic and non-immunologic reactions.
• A reaction may occur after as little as 10mL of incompatible blood has been infused. Any
unexpected or unfavorable symptom or sign that occurs during transfusion should be considered
to have been caused by the blood product. These include:
o Fevers, chills
o Hives, itching, flushing
o Nausea, vomiting
o Chest pain
o Difficulty breathing including coughing, wheezing, congestion, cyanosis, hypoxia
o Distended neck veins,
o Hypotension
o Tachycardia
o Abdominal or back pain.
TREATMENT
• If any of these signs or symptoms present after the initiation of the blood product, stop the
transfusion immediately.
• Infuse normal saline (NOT LACTATED RINGERS) in new tubing unless the patients shows signs
volume overload (hypertension, distended neck veins, short of breath, rales
• Recheck vital signs including temperature.
• Oxygenate to keep saturations > 92%
• If signs of anaphylaxis are present (hives, fever, itching, laryngeal edema), give epinephrine
SC,monitor airway patency and control airway if necessary via endotracheal intubation. Continue
IV fluids and administer Methylprednisolone and Diphenhydramine.
o For minor allergic reactions (itching, hives, without hypotension, wheezing, or larygenal
edema), administer Diphenhydramine
• Consult medical control at MRMC for further directions and notify them of the patient and the
adverse reaction.
PROCEDURE
•
FR
Monitoring of medical facility
initiated blood products
Treatment–Medical: Blood Product Administration
Created 4/2015
1
EMT B
EMT B IV
EMTP
PCC
VO
SO
Page 1 of 1
Section 510
CALCIUM GLUCONATE
PHARMACOLOGY
• Moderates nerve and muscle function and facilitates normal cardiac function. It is required for
muscle contraction
• Increases myocardial automaticity.
• May reduce cardiac toxicity or failure caused by hyperkalemia.
INDICATIONS
• Calcium channel blocker overdose / toxicity. (Cardizem, Verapamil)
• Life threatening hyperkalemia. (Hypotension with wide QRS)
• Consider in renal failure, dialysis and / or endocrine dysfunction patients.
• Magnesium sulfate toxicity. Occurs in setting of Magnesium infusion given for patients with
severe preeclampsia or eclampsia. (see Magnesium sulfate protocol)
• Cardiac arrest for any of the following suspected causes: renal failure, dialysis with suspected
hyperkalemia, or calcium channel blocker overdose.
CONTRAINDICATIONS
• Ventricular fibrillation.
• Digitalis toxicity.
• Hypercalcemia.
PRECAUTIONS / SIDE EFFECTS
• Base physician contact is strongly recommended to discuss course of treatment.
• Rapid infusion may cause hypotension, bradycardia, or asystole.
• Use with caution for patients taking digitalis. May precipitate digitalis toxicity.
• Assure vessel patency. Infiltration will cause severe pain and tissue necrosis.
ADMINISTRATION
• Flush the IV line between the administration of calcium gluconate and sodium bicarbonate.
Medications: Calcium Gluconate
Revised 1/2014
1
Page 2 of 1
Section 510
CALCIUM GLUCONATE
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
EMT P
•
Cardiac arrest: 3 gram slow IVP
over 5 to 10 minutes. May repeat
once in 10 min
SO
SO
•
Calcium channel blocker
overdose: 3 gram slow IVP over 5
to 10 minutes. May repeat once in
10 min
SO
SO
•
Hyperkalemia: 3 gram slow IVP
over 5 to 10 minutes. May repeat
once in 10 min
Magnesium Toxicity: 3 gram slow
IVP over 5 to 10 minutes. May
repeat once in 10 min
SO
SO
•
PEDIATRIC
PROCEDURE
FR
EMT B
EMT B IV
EMTP
EMT P
•
Cardiac arrest: 60 mg/kg slow IVP
over 5 to 10 minutes. No faster than
100 mg a minute. max 1g
SO
SO
•
Calcium channel blocker
overdose: 60 mg/kg gram slow IVP
over 5 to 10 minutes. No faster than
100 mg a minute. max 1g
SO
SO
•
Hyperkalemia: 60 mg/kg gram
slow IVP over 5 to 10 minutes. No
faster than 100 mg a minute. max
1g
SO
SO
PREGANANCY CLASSIFICATION
• C
SUPPLIED AS
•
100 mg/ml in a 10 ml Vial. 10% Solution.
Medications: Calcium Gluconate
Revised 1/2014
2
Page 1 of 2
Section 511
DEXTROSE
PHARMACOLOGY
• Glucose is the body's basic source of energy and is required for cellular metabolism. A sudden
drop in blood sugar level will result in disturbances of normal metabolism, manifested clinically
as a decrease in mental status, sweating and tachycardia. Further decreases in blood sugar may
result in coma, seizures, and cardiac arrhythmias. Serum glucose is regulated by insulin, which
stimulates storage of excess glucose from the blood stream, and by glucagon, which mobilizes
stored glucose into the blood stream.
INDICATIONS
• Hypoglycemia. (i.e. Insulin shock in the diabetic patient).
• The unconscious patient with an unknown history. Any patient with a neurologic deficit or altered
state of consciousness, which may be due to hypoglycemia.
• Non-traumatic seizure patients who show no improvement in postictal state.
• Patients in status epilepticus not responsive to benzodiazepines (valium or versed).
• Blood glucose test < 80 if clinically indicated.
• Poisons and Overdoses protocol.
• In children with alcohol exposure, suspected sepsis, hypoperfusion or altered mental status.
PRECAUTIONS / SIDE EFFECTS
• In patients with clinical findings suggestive of a CVA, caution should be used when considering
dextrose unless the patient has a measurable hypoglycemia.
• Extravasation of glucose can cause tissue necrosis. Ensure IV patency before and during dextrose
infusion.
• Even though correction of glucose may be accomplished at the scene, this does not mean that
other problems requiring prompt treatment can be overlooked. In the elderly patient,
hypoglycemia often accompanies other serious illnesses. Many oral medications have a long
duration of action and can further decrease serum glucose even after correction with dextrose.
Recheck the glucose 30 to 40 minutes after administration of dextrose.
• One bolus should raise the blood sugar 50-100 mg/ml and, therefore, will be adequate for
most patients.
• Effect may be delayed in the elderly patients with poor circulation.
• Do not administer dextrose to a patient who is seizing due to trauma.
• Do not withhold dextrose in a patient suspected of being hypoglycemic.
Medication: Dextrose
Revised 1/2014
1
Page 2 of 2
Section 511
DEXTROSE
ADMINISTRATION
• Draw appropriate blood tubes for blood sugar determination prior to administering dextrose.
• Standing order for initial dose only. Physician order for subsequent doses.
• Dilute D50, 1:1 in NS for D25 (Add 25 ml of D50 and 25 ml NS to a burette drip set)
• Dilute D50, 1:5 in NS for D10 (Add 10 ml of D50 and 40 ml NS to a burette drip set)
ADULT (8 years or older)
PROCEDURE
•
FR
EMT B
25 Grams (50 ml) of D50 IVP.
Consider a 2nd dose for patients with
a slow response.
EMT B IV
EMTP
PCC
SO
SO
SO
EMT B IV
EMTP
PCC
SO
SO
SO
EMT B IV
EMTP
PCC
SO
SO
SO
PEDIATRIC (1 to 8 Years)
PROCEDURE
•
FR
EMT B
2 to 4 ml/kg (0.5 to 1 g/kg) of D25
IVP or IO.
PEDIATRIC (< 1 Year of age)
PROCEDURE
•
FR
EMT B
2 to 4 ml/kg (0.2 to 0.4) g/kg of D10
IVP or IO.
PREGANANCY CLASSIFICATION
• C
SUPPLIED AS
• 25 grams in 50 ml (0.5 g/ml).
Medication: Dextrose
Revised 1/2014
2
Page 1 of 2
Section 512
DIAZEPAM (VALIUM)
PHARMACOLOGY
• Tranquilizer.
• Anticonvulsant.
• Skeletal muscle relaxant.
INDICATIONS
• Status epilepticus. Seizures lasting longer than 3 minutes or concurrent seizures without
regaining consciousness refractory to Versed. If the patient is seizing on your arrival, status
seizure can be assumed.
• For the treatment of drug-induced hyperadrenergic states manifested by tachycardia and
hypertension (i.e., cocaine, amphetamine overdose).
• For patients who are combative from head injury.
• Combative (out-of-control) patients from suspected stimulant abuse (i.e.: cocaine, PCP,
ecstasy, amphetamines).
• Severe musculoskeletal spasms.
• Alcohol withdrawal: anxiety, agitation, tremors, hypertension, tachycardia.
PRECAUTIONS / SIDE EFFECTS
• Since diazepam can cause respiratory depression and/or hypotension, the patient should be
monitored closely. Very rarely, cardiac arrest can occur.
• Do not give unless the patient is actively seizing.
• Diazepam should be used with caution in any patient under the influence of alcohol.
Haloperidol is often safer and should be considered instead of diazepam.
• Common side effects include drowsiness, dizziness, fatigue, and ataxia. Paradoxical
excitement or stimulation can occur.
• Valium is in an oil based solution and therefore should not be mixed with other agents or
diluted with intravenous solutions
• When used to treat drug-induced hyperadrenergic states, larger doses of diazepam may be
required.
ADMINISTRATION
• If given in combination with a benzodiazepine, the patient must be continuously monitored with
capnography and q10 min vital signs recorded.
• Rectal administration in children should be through a TB/1 cc syringe with the needle
removed. Lubrication may be required before insertion of the syringe. The syringe barrel
should be completely inserted prior to administration.
• Patients receiving diazepam should be placed on oxygen, cardiac monitor, and pulse
oximeter.
ADULT
PROCEDURE
•
•
FR
EMT B
1 to 10 mg slow IVP. Each 5 mg
dose given over 1 minute.
Maximum dose of 10 mg.
Medication: Diazepam
Revised 1/2014
1
EMT B IV
EMTP
PCC
SO
SO
Page 2 of 2
Section 512
DIAZEPAM (VALIUM)
PEDIATRIC
PROCEDURE
•
FR
EMT B
0.3 mg / kg slow IVP or 0.5 mg/kg
rectally up to a maximum of 10 mg.
EMT B IV
EMTP
PCC
SO
SO
PREGANANCY CLASSIFICATION
• D – In Humans: An increased risk of congenital malformations associated with the use of minor
tranquilizers (chlordiazepoxide, diazepam, and meprobamate) during the first trimester of
pregnancy has been suggested in several studies.
SUPPLIED AS
• 5 mg/ml in a 2 ml carpuject
Medication: Diazepam
Revised 1/2014
2
1 of 2
Section 513
DILTIAZEM
PHARMACOLOGY
• Diltiazem Hydrochloride for Injection is a calcium ion influx inhibitor (slow channel blocker or
calcium channel antagonist).
• Diltiazem inhibits the influx of calcium (Ca2+) ions during membrane depolarization of cardiac
and vascular smooth muscle. The therapeutic benefits of diltiazem in supraventricular
tachycardias are related to its ability to slow AV nodal conduction time and prolong AV nodal
refractoriness.
• Diltiazem slows the ventricular rate in patients with a rapid ventricular response during atrial
fibrillation or atrial flutter. Diltiazem converts paroxysmal supraventricular tachycardia (PSVT)
to normal sinus rhythm by interrupting the reentry circuit in AV nodal reentrant tachycardias and
reciprocating tachycardias, e.g., Wolff-Parkinson-White syndrome (WPW)
INDICATIONS
• Continued reduction of heart rate and control of rapid ventricular rate in atrial fibrillation or atrial
flutter.
• Conversion and management of paroxysmal supraventricular tachycardias (PSVT) to sinus
rhythm. This includes AV nodal reentrant tachycardias and reciprocating tachycardias associated
with an extranodal accessory pathway such as the WPW syndrome or short PR syndrome.
CONTRAINDICATIONS
• Patients with sick sinus syndrome except in the presence of a functioning ventricular pacemaker.
• Patients with second- or third-degree AV block except in the presence of a functioning ventricular
pacemaker.
• Patients with severe hypotension or cardiogenic shock.
• Patients with ventricular tachycardia
• Patients who have demonstrated hypersensitivity to the drug.
• Intravenous diltiazem and intravenous beta-blockers should not be administered together or in
close proximity (within a few hours).
• It should not be used in patients with atrial fibrillation or atrial flutter associated with an
accessory bypass tract such as in Wolff- Parkinson-White (WPW) syndrome or short PR
syndrome.
• Hypotension
PRECAUTIONS / SIDE EFFECTS
• Hypotension - generally short-lived, but may last from 1 to 3 hours typically managed with use of
intravenous fluids or the Trendelenburg position
• Diltiazem Hydrochloride is extensively metabolized by the liver and excreted by the kidneys and
in bile. The drug should be used with caution in patients with impaired renal or hepatic function
• If possible, it is recommended that diltiazem hydrochloride not be co-infused in the same
intravenous line with any other drug. Physical incompatibilities (precipitate formation or
cloudiness) were observed when diltiazem hydrochloride was infused in the same intravenous
line with the following drugs: acetazolamide, acyclovir, aminophylline, ampicillin, cefamandole,
cefoperazone, diazepam, furosemide, heparin, hydrocortisone sodium succinate, insulin, (regular:
100 units/mL), methylprednisolone sodium succinate, mezlocillin, nafcillin, phenytoin, rifampin,
and sodium bicarbonate
• In rare instances, worsening of congestive heart failure has been reported in patients with
preexisting impaired ventricular function.
Page 2 of 2
Section 513
•
Safety and effectiveness in pediatric patients have not been established.
ADMINISTRATION
• Inappropriate for field initiation.
• The recommended initial infusion rate of diltiazem hydrochloride injection is 10 mg/h. Some
patients may maintain response to an initial rate of 5 mg/h. The infusion rate may be increased in
5 mg/h increments up to 15 mg/h as needed, if further reduction in heart rate is required.
• Ensure receipt of detailed dosing instructions.
• Active blood pressure monitoring every 15 minutes
• Discontinue infusion if BP drops below 90
ADULT
PROCEDURE
Diltiazem
• Check infusion rate and establish
baseline BP prior to departure
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• Varies
Medication: Diltiazem
Revised 1/2014
FR
EMT B
EMT B IV
EMTP
PCC
VO
SO
Page 1 of 1
Section 514
DIPHENHYDRAMINE (BENADRYL)
PHARMACOLOGY
• An antihistamine that blocks action of histamine released from cells during an allergic reaction
• Direct CNS effects, which may be stimulant or, more commonly, depressant, depending on
individual variation.
• Anticholinergic, antiparkinsonian effect, which is used to treat acute dystonic reactions to
antipsychotic drugs (Haldol, Thorazine, Compazine, etc.) These reactions include oculogyric
crisis, acute torticollis, facial grimacing, as well as generalized anxiety with twitching
(akesthesias).
INDICATIONS
• Allergic reactions
• Anaphylaxis
• To prevent or counteract acute dystonic reactions to anti-psychotic medications such as Haldol.
CONTRAINDICATIONS
• Patients taking monoamine oxidase inhibitors. (MAO inhibitors)
PRECAUTIONS / SIDE EFFECTS
• May have additive depressant effect with alcohol and other CNS depressants.
• Use w/ caution for patients w/ asthma, glaucoma, cardiovascular disease, and HTN due to
atropine like effect.
• May see CNS stimulation in children.
• Side effects include dry mouth, dilated pupils, flushing, and drowsiness.
• Extrapyramidal reactions may be noted with the administration of haloperidol (Haldol). Be
prepared to administer diphenhydramine to help counteract these side effects. An IM dose of
haloperidol may be followed by diphenhydramine via either slow IV or IM administration.
ADMINISTRATION
• The IV route is preferred over the IM route.
ADULT
PROCEDURE
•
FR
EMT B
EMT B IV
25 to 50 mg slow IVP or deep IM
injection.
EMTP
PCC
SO
SO
EMTP
PCC
SO
SO
PEDIATRIC (Children up to 8)
PROCEDURE
•
1 to 2 mg/kg slow IVP. Not to
exceed 25 mg total.
PREGANANCY CLASSIFICATION
• B
SUPPLIED AS
• 50 mg/ml in a 1 ml vial
Medications: Diphenhydramine
Revised 1/2014
FR
EMT B
EMT B IV
Page 1 of 2
Section 515
DOPAMINE (INTROPIN)
PHARMACOLOGY
• Dopamine is a chemical precursor of epinephrine. It occurs naturally in humans.
• Vasopressor that increases cardiac output.
• Dosage dependant effects:
1 to 4 mcg/kg/min
Dilates renal and mesenteric vessels
4 to 10 mcg/kg/min
β effects on the heart. Increasing cardiac output
10 to 20 mcg/kg/min
α effects on the heart. Peripheral vasoconstriction. Increased
blood pressure
20 to 40 mcg/kg/min
α effects. Reverses dilation of renal and mesenteric vessels.
INDICATIONS
• Symptomatic hypotension from causes other than hypovolemia such as cardiogenic shock,
neurogenic shock, septic shock and anaphylactic shock
• Symptomatic bradycardia refractory to Atropine and pacing.
CONTRAINDICATIONS
• Hypovolemia Dopamine is contraindicated in hypovolemic shock
• Tachydysrhythmias.
• Hypertension.
• Reduce dose for patients on MAO inhibitors.
PRECAUTIONS / SIDE EFFECTS
• Pressor agents worsen tissue hypoxia in the presence of hypovolemia. Invasive monitoring
is often the only way to differentiate forms of shock in the elderly, and treatment with
dopamine is therefore indicated in the field only in severely unstable patients with evidence
of increased venous pressure.
• Dopamine is best administered by an infusion pump to accurately regulate rate. This is
another reason it is hazardous for field use. Monitor closely.
• Tissue extravasation at the IV site can cause skin sloughing due to vasoconstriction. Be sure
to make Emergency Department personnel aware if there has been any extravasation of
dopamine-containing solutions, so that proper treatment can be instituted.
• Dopamine may induce tachydysrhythmias. If the heart rate exceeds 140, the infusion should
be stopped.
• At low doses, decreased blood pressure may occur due to peripheral vasodilatation.
Increasing infusion rate will correct this.
• Can cause hypertensive crisis in susceptible individuals
Medications: Dopamine
Revised 1/2014
1
Page 2 of 2
Section 515
DOPAMINE (INTROPIN)
ADMINISTRATION
• Should not be added to sodium bicarbonate or other alkaline solutions, since dopamine will
be inactivated at higher pH.
• 400 mg in 250 ml D5W. Yields a concentration of 1600 mcg/ml
ADULT
PROCEDURE
•
FR
EMT B
EMT B IV
start at 4mcg/kg/min, max 20
mcg/kg/min
EMTP
PCC
SO
SO
EMTP
EMT P
SO
SO
PEDIATRIC
PROCEDURE
•
FR
EMT B
EMT B IV
start at 4mcg/kg/min, max 10
mcg/kg/min
DRIP RATE CHART APPLIES TO 1600 mcg/ml ONLY!
Patient Weight
in kg
mcg /kg
20 kg
30 kg
40 kg
50 kg
60 kg
/ min
1.5
2
3
4
5
2 mcg
70 kg
80 kg
90 kg
100 kg
5
6
7
8
5 mcg
4
6
8
9
11
13
15
17
19
10 mcg
8
11
15
19
23
26
30
34
38
15 mcg
11
17
23
28
34
39
45
51
56
20 mcg
15
23
30
38
45
53
60
68
75
Drops
per min
with 60
drop set
PREGANANCY CLASSIFICATION
• C
SUPPLIED AS
• 40 mg/ml in a 10 ml vial.
Medications: Dopamine
Revised 1/2014
2
Page 1 of 2
Section 516
DROPERIDOL (INAPSINE)
PHARMACOLOGY
• An anti-psychotic that produces a dopaminergic, alpha-adrenergic blockade which causes
peripheral vasodilation. Its major actions are sedation and tranquilization. It also has anti-emetic
properties.
• Onset of action is 3-10 minutes after IM/IV administration with peak effect in 30 minutes.
Duration of the sedative effect is 2 - 4 hours but may be prolonged in certain individuals.
INDICATIONS
• Chemical restraint in patients that require transport and are behaving in a manner that poses a
threat to their own well-being or others.
• Nausea and vomiting refractory to Ondasetron (Zofran)—may be used if the patient does not
respond to Ondansetron (Zofran).
CONTRAINDICATIONS
• Do not administer to any patient:
o With a suspected acute myocardial infarction
o With known QT prolongation. Those who appear malnourished such as chronic alcoholics
are at risk of having this.
o With a systolic blood pressure under 100 mm Hg, or the absence of a radial pulse
o Exhibiting signs of sedation, respiratory depression, or CNS depression
o With known Parkinson's Disease
o With a known pregnancy or currently breast-feeding
o With severe liver or cardiac disease
o Age less than 6 years.
• The action of droperidol adds to the effect of sedative/tranquilizer type medications and
should be used with caution in the presence of these types of medications. In this setting,
be prepared for respiratory depression, apnea, muscular rigidity, and hypotension.
PRECAUTIONS / SIDE EFFECTS
• Droperidol may cause hypotension, tachycardia, and prolongation of the QT interval, which may
in turn cause arrhythmias, namely Torsade de Pointes.
• When administering this medication, the patient must be placed on a cardiac monitor. If initial
dose is given IM, place the IV and monitor once the patient is cooperative.
• Due to the vasodilatory effect, Droperidol can cause a transient hypotension that is usually selflimiting and can be treated effectively with position and fluids.
• Should profound hypotension occur that is unresponsive to positioning and fluid therapy and
vasopressors are required, epinephrine should not be used since Droperidol may block its
vasopressor activity and paradoxically further lower the blood pressure. Droperidol may also
decrease the effectiveness of dopamine.
• Some patients may experience unpleasant sensations manifested as restlessness, hyperactivity, or
anxiety following droperidol administration. Extra-pyramidal reactions have been noted
•
hours to days after treatment, usually presenting as spasm of the muscles of the tongue,
face, neck, and back. This may be treated with diphenhydramine.(see diphenhydramine
protocol)
Rare instances of neuroleptic malignant syndrome (high fever, muscular rigidity, hypoor hypertension) have been known to occur after the use of Droperidol. The severely
dehydrated patient is at greater risk of this complication. If suspected, contact medical
control, consider administration of Diazepam and cool the patient.
Medications: Droperidol
1/2014
1
Page 2 of 2
Section 516
.
DROPERIDOL(INAPSINE)
ADMINISTRATION ADMINISTRATION
PROCEDURE
FR
EMT B
EMT B IV
EMPT
PCC
SO
SO
SO
SO
SO
SO
AGITATION, PSYCHOSIS
•
•
Adult Dose: 2.5 to 5 mg IM/IV.
Pediatric Dose 0.05mg/kg IM/IV
Not to exceed 0.1mg/kg
•
After 10 minutes, if desired effect
has not been achieved, contact
medical control to consider a
second dose.
NAUSEA / VOMITING
•
•
Adult dose: 1.25 IM/IV
Pediatric Dose 0.05mg/kg IM/IV
Not to exceed 0.1mg/kg
PREGNANCY CLASSIFICATION
• D – Reports of fetal limb malformation with use during 1st trimester, not for use w/ breast
feeding.
SUPPLIED AS
• 5mg/ml in a 2 ml vial
Medications: Droperidol
1/2014
2
Page 1 of 3
Section 517A
EPINEPHRINE
PHARMACOLOGY
• Catecholamine with α and β effects.
o Positive inotropic, chronotropic, and dromotropic effects.
o Increases peripheral vascular resistance.
o Increases arterial blood pressure.
o Increases myocardial oxygen consumption.
o Potent bronchodilator.
INDICATIONS
• Medical Cardiac Arrest, including:
o Ventricular fibrillation
o Asystole
o PEA
• Bradycardia:
o If refractory to atropine and pacing, adults with BP < 90 with signs of poor perfusion
o Pediatric patients with signs of poor perfusion
• Moderate to severe allergic reactions.
• Anaphylaxis or severe angioedema.
• Life-threatening airway obstruction suspected secondary to croup or epiglottitis
• Asthma
• Bradycardia refractory to Atropine in adults.
• First line medication in Pediatric bradycardia.
• Hypotension with stable rhythm after volume resuscitation
• Beta Blocker or Ca blocker overdose
PRECAUTIONS / SIDE EFFECTS
• Do not add to solutions containing bicarbonate.
• Increase in myocardial oxygen consumption can precipitate angina or MI in patients with
coronary artery disease.
• Use with caution in patients with hypertension, hyperthyroidism, peripheral vascular disease, or
cerebrovascular disease or any patient over the age of 50.
• Asthma is not the only cause of wheezing. Epinephrine is contraindicated in pulmonary edema.
• Anaphylaxis is a systemic allergic reaction with cardiovascular collapse. Angioedema involves
swelling of mucous membranes; potential exists for airway compromise. Mild or moderate
allergic reactions with urticaria or wheezing may progress to anaphylaxis or severe angioedema.
Monitor patient carefully and treat according to patient status.
• Anxiety, tremor, palpitations, vomiting, and headache are common side effects.
• For nebulized administration:
o In the less-than-critical patient, saline alone via nebulizer may bring symptomatic relief from
croup.
o Tachycardia and agitation are the most common side effects. Since these are also the
hallmarks of hypoxia, watch the patient very closely! Other side effects of parenteral
epinephrine may also be seen.
o Nebulizer treatment may cause blanching of the skin in the mask area due to local
epinephrine absorption. Reassure parents.
Medication Protocols - Epinepherine
Revised 1/2014
1
Page 2 of 3
Section 517A
EPINEPHRINE
ADMINISTRATION
ADULT
PROCEDURE
FR
EMT B
EMTP
EMT P
Cardiac Arrest (1:10,000) IVP
• 1.0 mg every 5 minutes
SO
SO
Bradycardia / Hypotension
• Establish an Epi drip at 2 mcg/ min.
• Titrate to BP of >90 systolic
SO
SO
Allergic Reactions
Asthma/Bronchospasm
• 0.3 mg (1:1,000) SQ or IM.
SO
SO
Severe Asthma / Anaphylaxis
• 0.1 mg (1:10,000) Slow IVP.
• Followed by Epi drip at 2 mcg / min
SO
SO
To Mix Drip
• Add 1 mg in 250 cc D5W for a 4 mcg/ml concentration.
• Run at 30 drops/min in a 60 drop set for a 2 mcg/min drip
Medication Protocols - Epinepherine
Revised 1/2014
2
EMT B IV
Page 3 of 3
Section 517A
EPINEPHRINE
PEDIATRIC
PROCEDURE
FR
EMT B
Cardiac Arrest
• 0.01 mg/kg IVP/IO of 1:10,000
Bradycardia / Hypotension
• 0.01 mg/kg (1:10,000) IV
• Establish epi drip 0.1-1 mcg/kg/min
Allergic Reactions
Asthma/Bronchospasm
• 0.01 mg/kg (of 1:1,000) SQ or IM.
(max 0.3 mg)
Anaphylaxis
• 0.01 mg/kg (1:10,000) IV
• Establish epi drip 0.1-1 mcg/kg/min
Life-threatening airway obstruction
secondary to croup or epiglottitis
• 5 mg (5.0 ml of 1:1000 solution of
epinephrine, undiluted, nebulized). In
smaller infants, weighing <10 kg, the
recommended dose is
0.5 ml/kg of 1:1000epinephrine.
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
•
•
•
1:10,000 - 0.1 mg/ml in 10 ml prefilled syringe
1:1,000 - 1 mg / ml in 1 ml vial
1:1,000 - 1 mg/ml in 30 ml multi-dose vial.
Medication Protocols - Epinepherine
Revised 1/2014
3
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
SO
SO
SO
SO
SO
SO
SO
SO
SO
Page 1 of 2
Section 517B
EPINEPHRINE AUTO INJECTOR (EPI PEN)
PHARMACOLOGY
• Catecholamine with α and β effects.
o Positive inotropic, chronotropic, and dromotropic effects.
o Increases peripheral vascular resistance.
o Increases arterial blood pressure.
o Increases myocardial oxygen consumption.
o Potent bronchodilator.
INDICATIONS
• Signs and symptoms of a moderate to severe allergic reaction.
CONTRAINDICATIONS
• Avoid using epinephrine (non cardiac arrest patients) in the following situations.
o Hypertension.
o Hyperthyroidism.
o Ischemic heart disease.
o Cerebrovascular insufficiency.
o Patients in labor.
o Hypovolemic shock.
PRECAUTIONS / SIDE EFFECTS
• Other medications can use the auto injection system. Read labels carefully.
ADMINISTRATION
ADULT OR PEDIATRIC
PROCEDURE
•
FR
Administer patients prescribed Epi
Pen.
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SPECIAL INFORMATION NEEDED
• Patient Assessment.
• Assure type of medication is correct.
• Treatment prior to arrival.
PREGANANCY CLASSIFICATION
• C
SUPPLIED AS
• EPI PEN 0.3 mg 1:1000 (Adult and Pediatric versions)
Medications: Epinephrine Auto Injector
Revised 1/2014
1
Page 1 of 1
Section 518
ETOMIDATE
PHARMACOLOGY
• Ultra short-acting, non-barbiturate hypnotic with no analgesic effects.
• It is used to facilitate intubation as an induction agent. It produces a rapid induction of deep
sedation with minimal cardiovascular or respiratory effects.
• It is rapidly distributed following IV injection and is rapidly metabolized and excreted.
INDICATIONS
• For use in those patients requiring Rapid Sequence Intubation (see RSI protocol)
• May also be used alone to assist in intubation in cases where paralysis may not be indicated.
CONTRAINDICATIONS
• Known hypersensitivity
• Non-invasive airway management provides adequate ventilation and oxygenation for the duration
of transport.
PRECAUTIONS / SIDE EFFECTS
• Involuntary muscle contraction (myoclonus).
• Nausea / vomiting.
• Transient adrenocortical suppression.
ADMINISTRATION
ADULT
PROCEDURE
•
FR
EMT B
0.3mg/kg IV/IO
•
•
EMT B IV
EMTP
PCC
SO
SO
Dosing: 0.3mg/kg IV for all ages. If induction inadequate, repeat with higher dose: 0.6mg/kg.
Consider analgesic such as Fentanyl if pain is present.
PREGNANCY CLASSIFICATION: C
Medication: Etomidate
Created 1/2014
1
Page 1 of 2
Section 519A
FENTANYL (SUBLIMAZE)
PHARMACOLOGY
• Synthetic opioid agonist
• Binds to opioid receptors in CNS, reduces stimuli from sensory nerve endings, alters pain
reception, increases pain threshold
• Short duration of action and minimal histamine release
INDICATIONS
• Acute pain management (preferable in elderly patients)
• Breakthrough pain management in patients on chronic opioids
• Adjunct to induction and maintained sedation (see RSI protocol section 17XX)
• Dyspnea (comfort measures of the DNR/cancer patient)
CONTRAINDICATIONS
• Respiratory depression or insufficiency (unless using as adjunct in RSI)
PRECAUTIONS / SIDE EFFECTS
• Use with caution in patients with signs of hypoperfusion
• Use with caution in patients with significant bradycardia
• Use with caution with multi-systems/head/chest/abdominal injury
• Be prepared for management of respiratory depression
• Side effects include: hypotension, skeletal/thoracic muscle rigidity (with high doses, especially in
the elderly/children when administered too rapidly), bradycardia (can be treated with atropine in
severe bradycardia), drowsiness, nausea, headache, confusion, dizziness
ADMINISTRATION
•
•
•
•
•
•
After pain control has been achieved through bolus doses, consider fentanyl drip (see 519B).
Vital signs should be assessed, especially BP and respirations prior to and during administration
Any administration that combines together fentanyl and benzodiazepine/dopamine antagonist
requires close monitoring including capnography/cardiac monitor (EKG) to avoid respiratory
depression/aspiration
May be administered IV, IN, IM, nebulized (shown to be effective in treating pain and dyspnea)
IV infusion, using medication infusion pump, provides reliable management of pain/sedation for
extended periods of transport
IV incompatibilities: azithromycin (zithromax), pantoprazole (protonix), phenytoin (dilantin),
lidocaine (same syringe)
PROCEDURE
Pain management:
• 0.5-3 mcg/kg slow IVP/IM.
• 50 mcg increments IN or
nebulized
• Any administration >400mcg
will trigger an automatic
physician review of trip.
FR
EMT B
PEDIATRIC
Medications: Fentanyl
Updated 4/2014
1
EMT B IV
EMT P
PCC
SO
SO
Page 2 of 2
Section 519A
PROCEDURE
FR
EMT B
EMT B IV
Pain management:
• 0.5-2 mcg/kg slow
IVP/IN/nebulized, up to 50mcg
• Any cumulative dose >2mcg/kg
will trigger an automatic
physician review of trip.
PREGNANCY CLASSIFICATION
•
C (D if used for prolonged periods or at high dosages at term)
Medications: Fentanyl
Updated 4/2014
2
EMT P
PCC
SO
SO
Page 1 of 2
Section 519B
FENTANYL (SUBLIMAZE) DRIP
PHARMACOLOGY
• Synthetic opioid agonist.
• Analgesic with short duration of action.
• Binds to opioid receptors in CNS, reduces stimuli from sensory nerve endings, alters pain
reception, increases pain threshold
• Minimal histamine release.
• Less hemodynamic compromise than other agents
INDICATIONS
• Pain control and sedation in intubated patients .
• Maintenance of pain control in patients with extreme pain where pain management has already
been achieved though bolus dose pain management.
CONTRAINDICATIONS.
• Uncorrected hypotension.
• Known allergy.
PRECAUTIONS / SIDE EFFECTS
• Fentanyl may cause hypotension. Monitor vitals q 5 minutes and treat appropriately if
hypotension occurs.
ADMINISTRATION
• Use boluses/loading doses as per fentanyl protocol to control pain/initiate intubation and then
initiate continuous infusion on a pump. Mix 1000mcg in 100ml D5W or NS for a concentration
of 10mcg/ml. Alternately 500mcg may be placed in 50ml D5W or NS for same concentration.
Begin infusion with dosing as noted below, titrate to achieve appropriate pain control.
• If mixing a concentration other than those above, contact with medical control to ensure correct
infusion.
• Consider benzodiazapine bolus if further sedation is required.
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
•
1-5mcg/kg/hr
SO
SO
•
If pt requires >5mcg/kg/hr, contact
medical control
VO
VO
Medications: Fentanyl
Revised 02/2015
1
Page 2 of 2
Section 519B
FENTANYL (SUBLIMAZE)
PEDIATRIC
PROCEDURE
FR
EMT B
EMT B IV
EMPT
PCC
•
0.5-2.0mcg/kg/hr
SO
SO
•
Contact medical control for dosing >
2.0mcg/kg/hr.
VO
VO
PREGANANCY CLASSIFICATION
• C, this drug is excreted in breast milk.
SUPPLIED AS
• varied
Medications: Fentanyl
Revised 02/2015
2
Page 1 of 2
Section 520
GLUCAGON
PHARMACOLOGY
• Causes glucose mobilization in the body by release of liver stores of glycogen and conversion to
glucose.
• Can be helpful with patients that have an overdose of β blocking agents, raising BP & HR.
INDICATIONS
• Insulin shock w/ unconscious patient when D50 is not available or an IV line can't be established.
• Cardiac arrest patients taking β blocking agents.
CONTRAINDICATIONS
• None if indications are met.
PRECAUTIONS / SIDE EFFFECTS
• IV glucose is the treatment of choice for insulin shock.
• Patients without liver glycogen stores may not be able to respond to Glucagon administration.
• Nausea or vomiting may occur.
ADMINISTRATION
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
Hypoglycemia
• 1.0 mg IM for adults.
• Or 2mg IN for adults
SO
SO
Beta Blocker Overdose
• 3.0 mg or 0.03 mg / kg IVP over
30 secs.
SO
SO
EMTP
PCC
Hypoglycemia
• 0.1 mg/kg IM/IN up to 1 mg.
SO
SO
Beta Blocker Overdose
• 0.1 mg/kg IVP, IO, IM, or SQ up
to 1 mg.
SO
SO
PEDIATRIC
PROCEDURE
FR
EMT B
PREGNANCY CLASSIFICATION
• B
SUPPLIED AS
Medications: Glucagon
Revised 1/2014
1
EMT B IV
•
Page 2 of 2
Section 520
1 Unit (1.0 mg) vials of powder in a kit, must be reconstituted.
Medications: Glucagon
Revised 1/2014
2
Page 1 of 2
Section 521
HALOPERIDOL (HALDOL)
PHARMACOLOGY
• Haloperidol is in the class of antipsychotic medications. Haloperidol produces a dopaminergic
blockade, a mild alpha-adrenergic blockade, and causes peripheral vasodilation. Its major actions
are sedation and tranquilization. It also has anti-emetic properties.
• Onset of action is 10 minutes after IM administration with peak effect in 30 minutes. Duration of
the sedative effect is 2 - 4 hours but may be prolonged in certain individuals.
INDICATIONS
• Chemical restraint in patients that require transport and are behaving in a manner that poses a
threat to their own well-being or others.
• Nausea and vomiting refractory to Ondansetron (Zofran).—may be used if the patient does not
respond to Zofran or Zofran is unavailable.
CONTRAINDICATIONS
• Do not administer to any patient:
o With a suspected acute myocardial infarction
o With a systolic blood pressure under 100 mm Hg, or the absence of a radial pulse
o Exhibiting signs of sedation, respiratory depression, or CNS depression
o With known Parkinson's Disease
o With a known pregnancy
o With severe liver or cardiac disease
o Age less than 6 years.
• The action of haloperidol adds to the effect of sedative/tranquilizer type medications and
should be used with caution in the presence of these types of medications. In this setting,
be prepared for respiratory depression, apnea, muscular rigidity, and hypotension.
PRECAUTIONS / SIDE EFFECTS
• Haldol may cause hypotension, tachycardia, and prolongation of the QT interval, which may in
turn cause arrhythmias, namely Torsades de Pointes.
• When administering this medication intravenously, the patient must be placed on a cardiac
monitor. If initial dose is given IM, place the IV and monitor once the patient is cooperative.
• Due to the vasodilatory effect, haloperidol can cause a transient hypotension that is usually selflimiting and can be treated effectively with position and fluids.
• Should profound hypotension occur that is unresponsive to positioning and fluid therapy and
vasopressors are required, epinephrine should not be used since haloperidol may block its
vasopressor activity and paradoxically further lower the blood pressure. Haldol may also decrease
the effectiveness of dopamine.
• Some patients may experience unpleasant sensations manifested as restlessness, hyperactivity, or
anxiety following haloperidol administration. Extra-pyramidal reactions have been noted
•
hours to days after treatment, usually presenting as spasm of the muscles of the tongue,
face, neck, and back. This may be treated with diphenhydramine.(see diphenhydramine
protocol)
Rare instances of neuroleptic malignant syndrome (high fever, muscular rigidity, hypoor hypertension) have been known to occur after the use of haloperidol. The severely
dehydrated patient is at greater risk of this complication. If suspected, contact medical
control, consider administration of Diazepam and cool the patient.
.
Medications: Haloperidol
Revised 1/2014
1
Page 2 of 2
Section 521
HALOPERIDOL (HALDOL)
ADMINISTRATION
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
SO
AGITATION, PSYCHOSIS
•
•
Adult Dose: 5 to 10 mg IM.
Followed by 2.5-5mg IV
•
After 10 minutes, if desired effect
has not been achieved, contact
medical control to consider a
second dose.
NAUSEA / VOMITING
•
•
Adult dose: 1.25-2.5mg IV
Age6-12: 1.25mg IV
PREGNANCY CLASSIFICATION
• D – Reports of fetal limb malformation with use during 1st trimester, not for use w/ breast
feeding.
SUPPLIED AS
• 5mg/ml in a 1 ml vial
Medications: Haloperidol
Revised 1/2014
2
1 of 1
Section 522
HEPARIN INFUSION
PHARMACOLOGY
•
Prevents further coagulation by its activation of antithrombin III. Antithrombin III, the body's
primary anticoagulant, inactivates thrombin and inhibits the activity of activated factor X in the
coagulation process.
INDICATIONS
• Treatment of pulmonary embolism and deep venous thrombosis.
• Treatment of acute myocardial infarction
• Treatment of acute coronary syndrome.
• Treatment of arterial thromboembolism.
CONTRAINDICATIONS
• Severe or uncontrolled bleeding.
• Thrombocytopenia (low platlets)
• Hypersensitivity to heparin.
PRECAUTIONS / SIDE EFFECTS
• Bleeding which may manifest as bleeding from IV site, wounds, gastrointestinal tract, mucous
membranes, gingiva. If possible apply direct pressure.
• Intracranial bleeding may occur which may not have any clinical manifestations at first. Watch
for any changes in mental status or speech, seizures, or development of focal neurological
deficits.
• Stop infusion immediately if any signs of intracranial or any other severe bleeding.
ADMINISTRATION
• Must be started by sending facility. Usual bolus is 60-80 international units (IU)/kg. This is
followed by an infusion rate of 12-18 IU/kg/hr.
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
VO
VO
Heparin Infusion
•
12-18 IU/kg/hr
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• Varies
Medication: Heparin
Revised 1/2014
1 of 2
Section 523
INSULIN INFUSIONS
PHARMACOLOGY
• A modification of human insulin which is a combination of amino acids that mimic physiologic
insulin secretion and thus achieves better glycemic control in patients with diabetes.
• A number of analogs are available with varying rates of absorption, peak and duration of action.
INDICATIONS
• Obtain and maintain target blood glucose levels, ideally between 80 and 110 mg/d, through nurse
or physician-implemented insulin infusion.
• Mainstay of treatment to correct diabetic ketoacidosis
CONTRAINDICATIONS
• The most significant adverse effect of insulin is hypoglycemia.
• Insulin administrations with BG levels below 80 are contraindicated.
PRECAUTIONS / SIDE EFFECTS
• Hypoglycemia which may or may not be symptomatic. The hypoglycemia can occur well after
the infusion has been stopped
• Hypokalemia is common in patients with ketoacidosis.
• When the insulin infusion is halted in patients with ketoacidosis, blood glucose levels often
rapidly rebound to hyperglycemic levels.
• Because the kidneys are involved in the degradation of insulin, renal dysfunction will reduce the
clearance of insulin and prolong its effect.
• True allergic reactions and cutaneous reactions are rare.
ADMINISTRATION
• Inappropriate for field initiation.
• Overall, the median insulin infusion rate required to maintain normoglycemia is 0.1 units/kg/h.
• Insure receipt of detailed insulin dosing instructions. Commonly a dextrose solution (D5NS)
should be started when the patient’s BGL drops below 300.
• Inquire as to whether potassium will be needed during transport and have sending facility initiate
this if needed. ( see Potassium infusion)
• Contact Medical Control for any questions regarding termination or resumption of the insulin
infusion.
• Bedside capillary glucose monitoring every 30 minutes
• Discontinue infusion if BG level drops below 80
ADULT AND PEDIATRIC
PROCEDURE
FR
EMT B
EMT B
IV
EMTP
PCC
VO
VO
Insulin
•
Check infusion rate and establish
baseline BG prior to departure
PREGNANCY CLASSIFICATION
• B
SUPPLIED AS
Varies
Medication Insulin
Revised 1/2014
Page 1 of 1
Section 524
IPRATOPRIUM BROMIDE (ATROVENT)
PHARMACOLOGY
• Anticholinergic agent that relaxes bronchial smooth muscle and dries respiratory tract secretions.
• Increased pulmonary function through bronchodilation.
• Acetylcholine antagonist. Inhibits vagal influence.
INDICATIONS
• Bronchospasm related to:
o Asthma
o Chronic Bronchitis
o Emphysema.
CONTRAINDICATIONS
• Patients with a known hypersensitivity to Ipratropium Bromide.
PRECAUTIONS
• Should not be used as the primary agent for treatment of bronchospasm: to be used in conjunction
with albuterol.
• Use with caution in patients with coronary artery disease.
• Pulse, blood pressure, and EKG must be monitored.
• Palpitations, dizziness, anxiety, tremors, headache, nervousness, and dry mouth.
• Can cause paradoxical bronchospasm. If this occurs discontinue treatment.
ADMINISTRATION
• Should always be mixed with Albuterol.
ADULT
PROCEDURE
FR
EMT B
EMT B IV
Mild/Moderate Bronchospasm
• 500 mcg mixed with 2.5mg albuterol
via oxygen driven nebulizer if initial
albuterol is ineffective.
Severe Bronhospasm
• 500 mcg mixed with first dose of
2.5mg albuterol via oxygen driven
nebulizer.
EMTP
PCC
VO/P
SO
VO/P
SO
EMTP
PCC
VO/P
SO
PEDIATRIC
PROCEDURE
•
FR
EMT B
500 mcg in 2ml mixed with 2.5mg
albuterol at 6L O2
May dilute with 3 ml NS
PREGNANCY CLASSIFICATION
• B
SUPPLIED AS
• 0.5 mg in 2 ml bullet
Medications: Ipratropium Bromide
Revised 1/2014
1
EMT B IV
Page 1 of 2
Section 525
IV SOLUTIONS
PHARMACOLOGY
• Initiation of all IVs in the field in these protocols utilizes crystalloid fluids. The standard IV drip
rate will be TKO unless a fluid bolus or fluid challenge is required.
TKO Fluid Rate
INDICATIONS
• Anticipated need for IV
• Drug administration
PRECAUTIONS / SIDE EFFECTS
• Volume overload is a constant danger, particularly in cardiac and renal patients. Keep a close eye
on your IV rate during transport.
Fluid Challenge
INDICATIONS
• Hypotension felt to be secondary to cardiac cause (i.e. acute MI, pericardial tamponade,
cardiogenic shock)
PRECAUTIONS / SIDE EFFECTS
• Volume overload is a constant danger, particularly in cardiac patients. Keep a close eye on your
IV rate during transport.
Fluid Bolus
INDICATIONS
• Hemorrhagic shock, volume depletion, (dehydration, burns, severe vomiting, sepsis)
• Shock caused by increased vascular space (neurogenic shock)
PRECAUTIONS / SIDE EFFECTS
• In hemorrhagic shock, volume expansion with blood is the treatment of choice. Crystalloid fluids
will temporarily expand intravascular volume and "buy time," but does decrease oxygen-carrying
capacity, and is insufficient in severe shock. Because of this, rapid transport is still necessary to
treat severely hypovolemic patients who need blood and possibly surgical intervention.
Administer the minimum amount of fluids to maintain a MAP of 60mmHg in the hemorrhagic
patient.
• Volume overload is a constant danger, particularly in cardiac patients. Keep a close eye on your
IV rate during transport. For this reason, a fluid challenge (see below) is more appropriate in
cardiac patients.
• Flow rate through a 14g cannula is twice the rate through an 18g cannula, and volume
administration in trauma patients can be accomplished more rapidly. If the patient has poor veins,
a smaller bore is better than no IV at all.
• IVs in an unstable trauma patient should be placed enroute, and may be left to the hospital setting
for short transports. Do not delay transport in critical patients for IV attempts.
Medications: IV Solutions
Revised 4/2015
1
Page 2 of 2
Section 525
IV SOLUTIONS
ADMINISTRATION
ADULT
PROCEDURE
FR
EMT B
TKO Rate
• 5 to 10 drops/minute
Fluid Bolus
• 20ml/kg (30ml/kg for septic shock)
through large bore cannula, as
rapidly as possible.
• Repeat if patient is still hypotensive
x3, then consider pressor.
Fluid Challenge
• 250 mL-500mL over 20 minutes,
recheck BP.
• If not improved, consider
vasopressor such as Dopamine
EMT-P only
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
SO
SO
SO
SO
EMT B IV
EMPT
PCC
SO
SO
SO
SO
SO
SO
PEDIATRIC (under 1 year of age)
PROCEDURE
FR
EMT B
TKO Rate
• 5 to 10 drops/minute or a Buff cap
Fluid Bolus
• 10 ml/kg NS through large bore
cannula, as rapidly as possible.
• Repeat x3 if still hypotensive then
consider pressor.
PREGNANCY CLASSIFICATION
SUPPLIED AS
• 1L crystalloid fluid bag
• 250 ml D5W fluid bag
Medications: IV Solutions
Revised 4/2015
2
Page 1 of 1
Section 526
NOREPINEPHRINE (LEVOPHED)
PHARMACOLOGY
• Infusion is primarily an alpha 1 agonist with some beta 1 agonist properties. Levophed is a potent
vasoconstrictor with mild increases in heart rate through Beta 1 and coronary artery dilation.
INDICATIONS
• Levophed is given to patients in shock that is refractory to fluid replacement therapy
CONTRAINDICATIONS
• Volume-depleted patients
• Any patient with peripheral or mesenteric thrombosis
PRECAUTIONS / SIDE EFFECTS
• Levophed may cause tachycardia, palpitation, dysrhythmias, hypertension, potent systemic and
peripheral vasoconstriction, decreased renal perfusion
• Levophed may cause headache, anxiety, dizziness and weakness
• Infusions needs continuous monitored. Extravastion of the infusion can cause necrosis of the
tissue. D/C infusion should extravasation occurs. Restart large IV in large vein and continue
infusion. Notify receiving facility should extravasation occur
• Even though BP values may improve without appropriate fluid therapy the patient system
circulation and perfusion will be poor.
ADMINISTRATION
• Inappropriate for field initiation.
• Levophed is best infused through Central Venous Catheter. If central line unavailable infuse only
in large vein through as large as possible angio catheter.
• Medication should not be piggybacked or infused with other medication into same IV site.
• The recommended initial infusion range of Levophed (Norepinephrine) injection is 2-20mcg/min.
Ensure receipt of detailed dosing instructions.
• Active blood pressure monitoring every 5 minutes
• Titrate by 2 mcg/min every 2-5min to target mean-arterial pressure (MAP) as determined by
sending physician.
ADULT
PROCEDURE
•
FR
EMT B
Levophed- Check infusion rate
and establish baseline BP prior to
departure
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• 8mg/250 D5W
Medications: Levophed
1/2014
1
EMT B IV
EMTP
CCP
VO
SO
Page 1 of 2
Section 527
LIDOCAINE
PHARMACOLOGY
• Anti-dysrhythmic action (Ib) by suppressing automaticity in the His-Purkinje system and by
elevating electrical stimulation threshold of the ventricle during diastole.
• Inhibits Na+ ion channels, stabilizing neuronal cell membranes and inhibiting nerve impulse
initiation and conduction (amide local anesthetic).
INDICATIONS
• Pain relief with IO infusion.
• Second-line treatment of ventricular arrhythmias
• Treatment for tricyclic antidepressant overdose
CONTRAINDICATIONS
• Presence of Bundle Branch Blocks.
• Bradycardias with the presence of AV Blocks.
• Periods of Sinus Arrest.
• Patients with Atrial Fibrillation / Atrial Flutter may experience tachycardia.
• Hypotension. (Systolic less than 80 mm/Hg)
PRECAUTIONS / SIDE EFFECTS
• Can cause:
o CNS Disturbances.
o Sleepiness.
o Dizziness.
o Tinnitus.
o Parasthesia.
o Disorientation.
o Confusion.
o Seizures.
ADMINISTRATION
• Patients over the age of 60 should have their initial doses decreased, usually by one half.
• Liver dysfunction will prolong duration of Lidocaine effects. Consider half the standard dose.
• The extension set of the EZ IO holds 0.9ml. 0.9ml of a 2% lidocaine solution is 18mg.
ADULT
PROCEDURE
FR
EMT B
IO infusion
• 18mg SIVP May repeat as needed
(max 3 mg / kg)
Unstable Vtach / Vfib
• 1.5 mg/kg bolus
TCA Overdose
• 1.5 mg/kg bolus
Medications: Lidocaine
Revised 1/2014
1
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
SO
Page 2 of 2
Section 527
PEDIATRIC
PROCEDURE
IO infusion
•
0.5mg/kg
SIVP, not to
exceed adult
dose. May
repeat once.
FR
EMT B
EMT B IV
Unstable Vtach
/ Vfib
·
1.5 mg/kg
bolus
TCA Overdose
·
1.5 mg/kg
bolus
PREGNANCY CLASSIFICATION
• B
SUPPLIED AS
• 20 mg/ml in a 5ml prefilled syringe
Medications: Lidocaine
Revised 1/2014
2
EMTP
PCC
SO
SO
SO
SO
SO
SO
Page 1 of 2
Section 528
LORAZEPAM (ATIVAN)
PHARMACOLOGY
• Lorazepam is a benzodiazepine that potentiates the effects of gamma-aminobutyric acid, an
inhibitory neurotransmitter and depresses the CNS at the Limbic and Subcortical levels of
the brain. It is longer acting than diazepam, and is better absorbed with IM use.
INDICATIONS
• First line treatment for seizures when an IV is in place. Intranasal or IM Versed will be first
line for patients w/o an IV
• Treatment of anxiety or agitation that is compromising the patient’s care or putting the
caregivers at risk.
• Alcohol withdrawal
• Sympathomemetic overdose
CONTRAINDICATIONS
• Patients with a history of hypersensitivity to benzodiazepines
• Narrow angle glaucoma
PRECAUTIONS / SIDE EFFECTS
• Respiratory depression – monitor respiratory quality and the patients’ ability to protect
their airway. Utilize capnography if the sedative effects are significant.
• Hypotension and bradycardia – usually mild and uncommon.
• In cases of respiratory distress assure that the respiratory illness has been addressed and is
not the cause of the anxiety prior to administration of lorazepam.
• Use caution in patients with hepatic or renal disease since the metabolism and clearance of
the drug will be delayed.
• Rate of injection should be slow, not greater than 2 mg/min.
• Use caution in patients under 12 years old.
• Use caution with poly-pharmacological overdose due to synergistic effects with alcohol and
narcotics
• Contact medical control for use in combination with other benzodiazepines or narcotics.
ADMINISTRATION
ADULT
PROCEDURE
FR
EMT B
Agitation / Sympathomemetic OD
• 0.5 - 1 mg slow IV or IM
Status Epilepticus
• 1 - 2 mg slow IV or IM
Alcohol withdrawal
• 1 - 2 mg slow IV or IM
Medications: Lorazepam
Revised 1/2014
1
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
SO
Page 2 of 2
Section 528
LORAZEPAM (ATIVAN) cont.
PEDIATRIC
PROCEDURE
FR
EMT B
Agitation / Sympathomimetic OD
• 0.05 mg/kg slow IV or IM
Status Epilepticus
• 0.05 – 0.15 mg/kg slow IV or IM
EMT B IV
EMTP
PCC
SO
SO
SO
SO
PREGNANCY CLASSIFICATION
• D – In Humans: An increased risk of congenital malformations associated with the use of minor
tranquilizers (chlordiazepoxide, diazepam, and meprobamate) during the first trimester of
pregnancy has been suggested in several studies. In animals: reduction of tarsals, tibia,
metatarsals, malrotated limbs, gastroschisis, malformed skull, and microphthalmia
SUPPLIED AS
• 2 mg Carpojects
Medications: Lorazepam
Revised 1/2014
2
Page 1 of 2
Section 529
MAGNESIUM SULFATE
PHARMACOLOGY
• Cardiac - Stabilizes potassium pump, correcting repolarization. Shortens the Q-T interval in
the presence of ventricular arrhythmias due to drug toxicity or electrolyte imbalance.
• Respiratory - May act as a bronchodilator in acute bronchospasm due to asthma or other
bronchospastic diseases. For best results, it should be used after normal field nebulizer
therapy has been attempted.
• Obstetrics - Controls seizures by blocking neuromuscular transmission. Also lowers blood
pressure and decreases cerebral vasospasm.
INDICATIONS
• Cardiac
o Refractory VF and pulseless VT (after amiodarone)
o Cardiac arrest from suspected torsade de pointes
o Wide complex tachycardia with pulse in absence of shock and refractory to Amiodarone
• Respiratory
o Acute bronchospasm unresponsive to continuous inhaled beta-agonists, ipratropium,
and epinephrine.
• Obstetrics
o Pregnancy > 20 weeks with signs and symptoms of pre-eclampsia or eclampsia, defined
as:
 Blood pressure > 140/90 with altered mental status
 Seizures = eclampsia
o Contraindicated if the patient presents with heavy vaginal bleeding.
PRECAUTIONS / SIDE EFFECTS
• AV block
• Decrease in respiratory or cardiac function
• Use with caution in patients taking digitalis
• Monitor deep tendon reflexes (patellar) for early signs of toxicity.
• Later sign of toxicity is respiratory depression. Ventilatory assistance may be needed.
• Administer Calcium Gluconate 3gm IVP to reverse effects of magnesium in case of toxicity.
• Not for pediatric use
ADMINISTRATION
• May be initiated only as an IV bolus
• Continuous infusion only for interfacility transport.
Medications: Magnesium Sulfate
Revised 1/2014
1
Page 2 of 2
Section 529
MAGNESIUM SULFATE
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
SO
SO
VO
SO
SO
SO
SO
VO
SO
Cardiac Arrest (Refractory VF and
Pulseless VT or Torsades)
•
2.0 grams IVP.
Wide Complex Tachycardia with
pulse and without poor perfusion
refractory to Amiodarone
•
2.0 grams IV over 2 minutes
Respiratory (Acute Bronchospasm)
•
2.0 grams slow IVP over 2
minutes
Pre-eclampsia patients
•
•
2-4 grams IVP over 2 minutes
2 grams/hr infusion
(interfacility)
Eclampsia patients
•
•
4 grams slow IVP over 2
minutes
2 grams/hr infusion
(interfacility)
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• 0.5 g/ml in 10 ml prefilled syringe
Medications: Magnesium Sulfate
Revised 1/2014
2
Page 1 of 1
Section 530
METHYLPREDNISOLONE (SOLU-MEDROL)
PHARMACOLOGY
• Anti-inflammatory
• Suppresses immune / allergic responses
INDICATIONS
• Anaphylaxis
• Severe asthma / COPD
CONTRAINDICATIONS
• Hypersensitivity to this drug
PRECAUTIONS / SIDE EFFECTS
• Must be reconstituted and used promptly
• GI Bleeding
• Be aware that the effect of methylprednisolone is generally delayed for several hours. Although
it is worthwhile to administer methylprednisolone early in the treatment of a patient with
severe respiratory distress or anaphylaxis you may not see any effect from the drug for several
hours. Do not expect to see any immediate response.
• Methylprednisolone is not considered a first line drug. Be sure to attend to the patient’s primary
treatment priorities (i.e. airway, ventilation, beta-agonist nebulization) first. Do not delay
transport to administer this drug.
ADMINISTRATION
• Drug is supplied in a dual chambered vial. To mix the chambers, push the ends together and
slowly tip vial to mix.
ADULT
PROCEDURE
FR
EMT B
EMT B IV
Anaphylaxis, Severe Asthma/COPD
•
EMTP
PCC
S
SO
EMTP
PCC
SO
SO
125 mg IV
PEDIATRIC
PROCEDURE
FR
EMT B
Anaphylaxis, Severe Asthma
•
2 mg/kg IV
PREGNANCY CLASSIFICATION
SUPPLIED AS
• 125 mg dry drug, final 2 ml solution
Medications: Methylprednisolone
Revised 1/2014
1
EMT B IV
Page 1 of 2
Section 531A
MIDAZOLAM (VERSED)
PHARMACOLOGY
• Benzodiazapine that is a GABA receptor agonist in the CNS.
• CNS depressant leading to sedation and amnesia.
• Anticonvulsant
• No effect on pain and has less muscle relaxant properties than diazepam.
INDICATIONS
• Sedation prior to cardioversion or pacing.
• Status epilepticus: via the intranasal (pediatric) or intramuscular (adults) route while establishing
an IV for further dosing.
• RSI (see RSI protocol) and post-intubation sedation.
• Agitated patient who is a threat to crew safety.
CONTRAINDICATIONS
• Patients with a history of hypersensitivity to benzodiazepines
• Narrow angle glaucoma
PRECAUTIONS / SIDE EFFECTS
• Can cause significant respiratory depression, apnea, and hypotension especially when
used in combination with other sedatives such as alcohol or narcotics. Continuous pulse
oximetry and cardiac monitoring are mandatory. Emergency resuscitative equipment must be
immediately available.
• Consider lower doses for elderly patients; significant respiratory depression, apnea, and
hypotension are more frequently encountered.
• Side Effects include hypotension, respiratory depression, and amnesia.
• If a patient is in respiratory distress but still awake and agitated, Versed may only be used to aid
in assisting ventilation via a BVM if the patient is combative. It should not be used for deep
sedation and should be used very cautiously when a patient is in respiratory distress. Etomidate is
the preferred induction agent for patients who are needing intubation and are hemodynamically
compromised
ADMINISTRATION
• Appropriate for IVP, IM, IN, IO, and Rectal routes.
ADULT
PROCEDURE
FR
EMT B
Airway/Cardioversion/Pacing
• 1 to 5.0 mg slow IVP or IM given
over at least 2 minutes.
o On a normal-sized 70 kg patient
who has does not have narcotics
or alcohol in their system, start
with 3mg IV/IM and add 1-2 mg
after 10 minutes if adequate
sedation not achieved.
Medication: Versed
Revised 1/2014
1
EMT B IV
EMTP
PCC
SO
SO
Page 2 of 2
Section 531A
MIDAZOLAM (VERSED) cont.
ADULT cont.
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
RSI - induction
• 0.3 mg/kg slow IVP or IO
SO
SO
RSI - maintenance
• 0.1 mg/kg slow IVP or IO
SO
SO
SO
SO
EMTP
PCC
SO
SO
SO
SO
Status Epilepticus
• 5mg IM or IN (establish IV)
Agitation
• 3 mg slow IVP
• 5 mg IN or IM
PEDIATRIC
PROCEDURE
FR
EMT B
Status Epilepticus
• 0.05 mg / kg slow IVP. Given
over at least 2 minutes.
OR
• 0.2 mg/kg intranasal. Establish
IV access and repeat if necessary:
0.1 mg/kg IV (maximum dose 5
mg).
PREGNANCY CLASSIFICATION
• D
SUPPLIED AS
• 1 mg/ml in a 5 ml vial
Medication: Versed
Revised 1/2014
2
EMT B IV
Page 1 of 2
Section 531B
MIDAZOLAM (VERSED) DRIP
PHARMACOLOGY
• Benzodiazapine that is a GABA receptor agonist in the CNS.
• CNS depressant leading to sedation and amnesia.
• Anticonvulsant
• No effect on pain and has less muscle relaxant properties than diazepam.
INDICATIONS
• Post intubation sedation: to be used as an adjunct to analgesic drip when patient comfort is not
achieved solely through analgesia.
CONTRAINDICATIONS
• Patients with a history of hypersensitivity to benzodiazepines
• Narrow angle glaucoma
PRECAUTIONS / SIDE EFFECTS
• Can cause significant respiratory depression, apnea, and hypotension especially when
used in combination with other sedatives such as alcohol or narcotics. Continuous pulse
oximetry, capnography and cardiac monitoring as well as BP’s q 5 minutes are mandatory.
Ensure ventilator is set to administer proper tidal and minute volumes.
• If hypotension occurs, attempt to correct with fluids or pressors. Proper sedation is a gold
standard of post intubation.
ADMINISTRATION
• Via infusion pump only. Place 20mg in 50ml D5W for a concentration of 0.4mg/ml.
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
EMTP
PCC
DO
DO
DO
DO
Post Intubation Sedation
• 1 to 3 mg/hr
MIDAZOLAM (VERSED) cont.
PEDIATRIC
PROCEDURE
FR
EMT B
Post Intubation Sedation
• 0.025-0.1mg /kg/hr is the typical
dose. Consult with medical
control.
PREGNANCY CLASSIFICATION
• D
Medication: Versed
Created 02/2015
1
EMT B IV
Page 2 of 2
Section 531B
SUPPLIED AS
• 10 mg/ml in a 2 ml vial
Medication: Versed
Created 02/2015
2
Page 1 of 2
Section 532
MORPHINE SULFATE
PHARMACOLOGY
• Narcotic analgesic.
• Decreases respiratory rate and volume.
• Peripheral vasodilation.
• Constricts pupils.
• Reflex cardiac effect (from vasodilatation):
o Decreased myocardial oxygen consumption
o Decreased left ventricular end-diastolic pressure
o Decreased cardiac work
• Effect: maximum within 7 minutes IV
INDICATIONS
• Presumed cardiac chest pain associated with suspected AMI or unstable angina.
• Pain management
• Cardiogenic pulmonary edema
• Isolated extremity injuries
CONTRAINDICATIONS
• Severe respiratory depression.
• Hypotension or Hypovolemia.
• Patients taking an MAO inhibitor within 14 days.
PRECAUTIONS / SIDE EFFECTS
• May cause dizziness, itching, convulsions, nausea, or vomiting.
• Use with caution in head injuries, altered mental status, or multisystem trauma.
• Relay to patient not to expect complete pain relief.
• Patients receiving morphine should have vital signs and oxygen saturation monitored.
• The major side effects and complications from morphine result from vasodilatation. This
causes no problems if the patient is supine and not volume depleted. It may cause problems
if the patient is upright, hypovolemic, or has decreased cardiac output (after MI).
• Morphine can cause respiratory depression. Be prepared to assist ventilation if the patient
stops breathing.
• If given in combination with a benzodiazepine, the patient must be continuously monitored
with capnography and q10 min vital signs recorded.
• Naloxone reverses the effects of narcotics, particularly respiratory depression and should
be readily available.
Medications: Morphine
Revised 1/2014
1
Page 2 of 2
Section 532
MORPHINE SULFATE
ADMINISTRATION
ADULT
PROCEDURE
•
FR
EMT B
EMT B IV
2.0 to 10 mg IVP. Titrated to effect.
EMTP
PCC
SO
SO
EMTP
PCC
SO
SO
PEDIATRIC
PROCEDURE
•
FR
EMT B
0.1 to 0.2 mg / kg IVP
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• 10 mg/ml in a 1 ml carpoject
Medications: Morphine
Revised 1/2014
2
EMT B IV
Page 1 of 1
Section 533
NARCAN (NALOXONE)
PHARMACOLOGY
• Narcotic antagonist.
• Can be used via intra-nasal route.
INDICATIONS
• Reverse respiratory depression from suspected narcotic overdose.
• May be effective in Clonidine overdoses.
• Seizure of unknown etiology, to rule out narcotic overdose (particularly propoxyphene)
• This drug is remarkably safe and free from side effects. Do not hesitate to use it if indicated.
PRECAUTIONS / SIDE EFFECTS
• In patients physically dependent on narcotics, frank and occasionally violent withdrawal
symptoms may be precipitated. Be prepared to restrain the patient.
• May need large doses (8-12 mg) to reverse propoxyphene (Darvon/Darvocet) overdose.
• The duration of some narcotics is longer than naloxone and the patient must be monitored
closely. Repeated doses of naloxone may be required. Patients who have received this drug
must be transported to the hospital because coma may reoccur when naloxone wears off.
• With an endotracheal tube in place and assisted ventilation, narcotic overdose patients may
be safely managed without naloxone.
 Administration of Narcan can precipitate flash pulmonary edema.
ADMINISTRATION
• Titrate the dose (1-2 mg at a time) to reverse circulatory and respiratory depression, but to keep
the patient groggy.
ADULT
PROCEDURE
•
FR
2.0 mg IVP, IM, or IN.
Dose may be repeated once after 5
minutes if necessary
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
EMT B
EMT B IV
EMT I
EMT P
SO
SO
SO
SO
PEDIATRIC (Children under 5 years of age)
PROCEDURE
•
FR
0.1 mg/kg IVP, IM, or IN up to 1 mg
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS:
• 1 mg/ml in a 2ml prefilled syringe
Medications: Naloxone
Revised 1/2014
1
Page 1 of 2
Section 534A
NITROGLYCERIN
PHARMACOLOGY
• Cardiovascular effects include:
o Reduced venous tone; causes blood-pooling in peripheral veins, decreasing venous return to
the heart.
o Decreased peripheral resistance.
o Dilation of coronary arteries (if not already at maximum) and relief of coronary artery spasm.
• Generalized smooth muscle relaxation.
INDICATIONS
• Angina. Chest, arm, or neck pain or any symptom thought to be cardiac in origin.
• Control of hypertension in angina, acute MI, aortic dissection or hypertensive emergencies.
• Cardiogenic pulmonary edema: to increase venous pooling, lowering cardiac preload and
afterload.
• NTG paste is indicated in the conditions listed above when a continuous dosing would benefit the
patient. See NTG paste protocol.
CONTRAINDICATIONS
• Blood pressure < 90 systolic
• Patient must have working IV in place prior to administration of nitroglycerin. Contact medical
control if unable to establish IV.
PRECAUTIONS / SIDE EFFECTS
• Common side effects include throbbing headache, flushing, dizziness, and burning under the
tongue. These side effects may be used to check potency.
• Less common: orthostatic hypotension, sometimes marked
• Generalized vasodilatation may cause profound hypotension and reflex tachycardia especially in
patients with a right-sided or inferior MI. Patient should be placed in supine position and given
IV fluids if this complication arises.
• Use with caution in patients taking medications for erectile dysfunction such as Sildenafil
(Viagra).
• Therapeutic effect is enhanced, but adverse effects are increased when patient is upright.
• Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective in
relieving chest pain caused by esophageal spasm.
• May be effective even in patients using paste, discs, or oral-acting nitrate preparations.
Medications: Nitroglycerin
Revised 1/2014
1
Page 2 of 2
Section 534A
NITROGLYCERIN
ADULT ADMINISTRATION
PROCEDURE
•
0.4 mg SL. May initiate NTG paste
after 1st tablet.
•
0.4 mg SL continued dosing beyond
3rd.
FR
EMT B
EMT B IV
EMTP
PCC
VO/P/
assist
VO/P/
assist
SO
SO
SO
SO
assist = EMT-B may assist a patient in taking his or her prescribed nitroglycerin.
Note: 1 Nitroglycerine SL tablet is = to 1 Nitroglycerine SL spray
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS:
• Metered spray 0.4 mg / tablet
Medications: Nitroglycerin
Revised 1/2014
2
Page 1 of 2
Section 534B
NITROGLYCERIN INFUSION
PHARMACOLOGY
• Cardiovascular effects include:
o Reduced venous tone; causes blood-pooling in peripheral veins, decreasing venous return to
the heart.
o Decreased peripheral resistance.
o Dilation of coronary arteries (if not already at maximum) and relief of coronary artery spasm.
• Generalized smooth muscle relaxation.
INDICATIONS
• control of angina, vasodilator of coronary arteries in acute coronary syndrome or acute MI
• management of hypertension, aortic dissection or hypertensive emergencies
CONTRAINDICATIONS
• Hypersensitivity to nitrates
• Hypotension (SBP <90)
• severe anemia
• closed angle glaucoma
• cerebral hemorrhage and head trauma, increased ICP
• constrictive pericarditis/ pericardial tamponade
PRECAUTIONS / SIDE EFFECTS
• patients with right-sided heart failure from MI or other causes will become dangerously
hypotensive with NTG, thus the need for frequent monitoring
• If patient has been taking medications for erectile dysfunction (eg Viagra) during the past 48
hours, NTG may cause irreversible hypotension
• Analgesics for side effects such as headache may be indicated
• Tolerance may develop if administered over 12 hours.
• Cautious use in patients with hepatic or renal disease.
ADMINISTRATION
• 5mcg/min initially, titrated upwards by 5mcg/min increments for control of angina or BP.
Titration should be done only with careful, frequent monitoring of hemodynamic response.
Check vitals every 10 min while infusing.
ONLY GOOD FOR 200mcg/ml CONCENTRATION
mcg/min
cc/hr
mcg/min
cc/hr
10
3
110
33
20
6
120
36
Medications: Nitroglycerin infusion
Revised 1/2014
30
9
130
39
40
12
140
42
1
50
15
150
45
60
18
160
48
70
21
170
51
80
24
180
54
90
27
190
57
100
30
200
60
Page 2 of 2
Section 534B
NITROGLYCERIN INFUSION
ADULT
PROCEDURE
•
Initiation of NTG infusion
(must be started at a facility)
•
Monitor, titration of NTG infusion
FR
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• 50 mg in 250 ml D5W
Medications: Nitroglycerin infusion
Revised 1/2014
2
EMT B
EMT B IV
EMT P
PCC
VO
SO
Page 1 of 2
Section 534C
NITROGLYCERIN PASTE (NITRO-BID)
PHARMACOLOGY
• Cardiovascular effects include:
o Reduced venous tone; causes blood-pooling in peripheral veins, decreasing venous return to
the heart.
o Decreased peripheral resistance.
o Dilation of coronary arteries (if not already at maximum) and relief of coronary artery spasm.
• Generalized smooth muscle relaxation.
INDICATIONS
• Secondary to Nitro SL, used to maintain therapeutic levels for longer transports
o Control of angina, vasodilator of coronary arteries in acute coronary syndrome or acute MI
o Management of hypertension, aortic dissection or hypertensive emergencies
CONTRAINDICATIONS
• Hypersensitivity to nitrates
• Hypotension (SBP <100)
• Severe anemia
• Cerebral hemorrhage and head trauma, increased ICP, Narrow angle glaucoma
• Constrictive pericarditis/ pericardial tamponade
PRECAUTIONS / SIDE EFFECTS
• Nitro-Bid may cause burns if placed near a defibrillation or pacing pad or paddle
• Wear gloves – any paste on your skin will go into your bloodstream!
• Patients with right-sided heart failure from MI or other causes may become dangerously
hypotensive with NTG, thus the need for frequent monitoring
• If patient has been taking medications for erectile dysfunction (eg Viagra) during the past 48
hours, NTG may cause irreversible hypotension. Consult w/ Medical Control.
• Tolerance may develop if administered over greater than a 12 hour period.
• Cautious use in patients with hepatic or renal disease.
ADMINISTRATION
• Expose upper left shoulder
• Lay out a measuring paper, printed side down
• Apply paste along the measured rule on the paper
• Place paper ointment down on the pt’s skin
• Tape down the edges of the paper
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
•
1” paste applied to upper L shoulder,
may repeat up to 4” as tolerated
SO
SO
•
½” paste is to be used if a fluid bolus
is required after SL Nitro
SO
SO
Medications: Nitroglycerin Paste
Revised 1/2014
1
Page 2 of 2
Section 534C
NITROGLYCERIN PASTE (NITRO-BID)
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• 30 gram tube, 2%
Medications: Nitroglycerin Paste
Revised 1/2014
2
Page 1 of 1
Section 535
ONDANSETRON (ZOFRAN)
PHARMACOLOGY
• Antiemetic
• Blocks Serotonin 5-HT3
o Peripherally on vagus nerve terminals
o Centrally on area of postrema (medullary structure in the brain that controls vomiting)
INDICATIONS
• Prevention or control of nausea and vomiting.
• Oral dissolving tablet effective and preferred for pediatric patients with mild dehydration without
evidence of shock
CONTRAINDICATIONS
• Do not use in children < than 1 year of age.
PRECAUTIONS / SIDE EFFECTS
• Headache, malaise, constipation, diarrhea, and dizziness
ADMINISTRATION
ADULT
PROCEDURE
•
•
4 mg IVP or IM. May repeat once in
15 to 20 minutes.
8 mg ODT PO
PEDIATRIC
PROCEDURE
•
•
0.2 mg/kg (max of 4 mg) SIVP or
IM. May repeat once in 15 to 20 min
4mg ODT PO
EMT
EMT-IV
EMTP
PCC
SO
SO
SO
VO
VO
SO
SO
SO
EMT
EMT-IV
AEMT
EMTP
PCC
SO
SO
SO
SO
VO
VO
PREGNANCY CLASSIFICATION
• B
SUPPLIED AS
• 2 mg / ml in a 2 ml vial
• 4mg oral dissolving tablet
Medications: Ondansetron
Revised 1/2014
AEMT
1
SO
Page 1 of 1
Section 536
OXYGEN
PHARMACOLOGY
• Essential for tissue metabolism.
INDICATIONS
• Hypoperfusion
• Hypoxemia (Restlessness may be an important sign of hypoxia.)
• Toxic Inhalation Injury
• Cardiac CP/Angina
• CVA
• DO NOT withhold oxygen therapy, even those patients with chronic lung disease.
PRECAUTIONS / SIDE EFFECTS
• Use the most efficient delivery system of oxygen your patient will tolerate.
• Safety is paramount. Be sure that gauges and regulators are free from residue, especially
hydrocarbons and regular maintenance checks have been performed.
• Avoid standing the bottle up. DO NOT withhold oxygen therapy, even those patients with chronic
lung disease.
ADMINISTRATION
• The amount and method of administration must be based on clinical judgment and the field
impression of the illness.
OXYGEN FLOW RATES
DEVICE
OXYGEN CONCENTRATIONS
•
Bag Valve Mask
80% to 100% with supplemental oxygen. At least
15 Liters / Minute
•
Nasal Cannula
24% to 40% at 5 to 6 Liters / Minute.
•
Non Rebreather Mask
Up to 90% at 15 Liters / Minute.
PROCEDURE
•
Oxygen: NC, NRB, or BVM
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
PREGNANCY CLASSIFICATION
SUPPLIED AS:
• D, L, or M cylinders up to 2100 psi
Medications: Oxygen
Revised 1/2014
1
Page 1 of 1
Section 537
PHENYLEPHRINE (NEO-SYNEPHRINE)
PHARMACOLOGY
• When used for topical nasal administration, phenylephrine primarily exhibits alphaadrenergic stimulation. This stimulation can produce moderate to marked vasoconstriction
and subsequent nasal decongestion.
INDICATIONS
• Prior to nasotracheal intubation or insertion of a nasopharangeal airway to induce
vasoconstriction of the nasal mucosa.
CONTRAINDICATIONS
• None if indications are met.
PRECAUTIONS / SIDE EFFECTS
• Avoid administration into the eyes, as it will cause dilation of the pupils.
ADMINISTRATION
ADULT or PEDIATRIC
PROCEDURE
•
FR
EMT B
Two sprays of 1% solution in the
nostril prior to attempting
nasotracheal intubation or
insertion of NPA
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• 0.5% in spray applicator
Medication: Phenylephrine
Revised 1/2014
1
EMT B IV
EMTP
PCC
SO
SO
1 of 1
Section 538
POTASSIUM CHLORIDE
PHARMACOLOGY
• Potassium is the chief cation of body cells (160 mEq/liter of intracellular water) and is concerned
with the maintenance of body fluid composition and electrolyte balance. Potassium participates in
carbohydrate utilization and protein synthesis, and is critical in the regulation of nerve conduction
and muscle contraction, particularly in the heart.
• Normally about 80 to 90% of the potassium intake is excreted in the urine, the remainder in the
stools and to a small extent, in the perspiration. The kidney does not conserve potassium well so
that during fasting, or in patients on a potassium-free diet, potassium loss from the body
continues resulting in potassium depletion. A deficiency of either potassium or chloride will lead
to a deficit of the other.
INDICATIONS
• Replacement of potassium for patients with severe hypokalemia.
• Oral replacement is not feasible due to intractable vomiting
• Diabetic ketoacidosis accompanied by initial low to normal potassium levels where insulin
infusion drives potassium out of the intravascular space into the cells.
CONTRAINDICATIONS
• Patients with hyperkalemia which is often seen in renal failure.
• Direct undiluted IV bolus of potassium chloride is fatal.
PRECAUTIONS / SIDE EFFECTS
• Continuous cardiac monitoring required due to risk of hyperkalemia. Watch for EKG changes
consistent with hyperkalemia (widening QRS, peaked T waves, sine wave). If signs of
hyperkalemia present, stop infusion and administer Calcium Chloride.
• To be administered only by infusion as described below.
• K+ will cause irritation to veins and discomfort. Insure that IV is in place and not infiltrating.
Administer analgesics as needed.
ADMINISTRATION
• Inappropriate for field initiation.
• Confirm that the sending facility has diluted the mixture (usually 20-40 meq/L)
• Maximum infusion rate = 10meq/ hour.
ADULT
PROCEDURE
Potassium Chloride
• Infusion only
• Maximum rate 10meq/hr
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
• Varies
Medication: Potassium Chloride
Revised 1/2014
FR
EMT B
EMT B IV
EMTP
PCC
VO
VO
Page 1 of 1
Section 539
PROTONIX (PANTOPRAZOLE)
PHARMACOLOGY
• Protonix (Pantoprazole) for injection is a proton pump inhibitor which increases gastric pH.
• Onset of action 15-30 minutes. Duration 24 hours.
INDICATIONS
• Patients with upper GI bleeding from gastric or duodenal ulcers or variceal bleeding from portal
hypertension
• It is also used for dyspepsia, reflux disease, esophagitis
CONTRAINDICATIONS
• Known hypersensitivity to Prontonix.
ADMINISTRATION
• Only for interfacility monitoring.
• Prior to continuous infusion a bolus may be given at the ER prior to transport
• The recommended initial infusion rate of Protonix (Pantoprazole) is 8ml/hr over 8 hours.
• Midazolam (Versed) and other sedatives are incompatible with Protonix. Do no infuse together
ADULT
PROCEDURE
•
FR
EMT B
Protonix-Check infusion rate
prior to leaving facility
EMTP
PCC
VO
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
1mg/1ml (80mg/80cc NS or D5W)
Medications: Protonix
1/2014
EMT B IV
1
Page 1 of 1
Section 540
ROCURONIUM
PHARMACOLOGY
• Rocuronium is a short acting, non-depolarizing, neuromuscular blocking agent. Muscle paralysis
is produced by competing with acetylcholine for cholinergic receptor sites at the neuromuscular
junction. The muscle paralysis proceeds from eyes, face, neck, limbs, chest, abdomen, and lastly
the diaphragm.
INDICATIONS
• Patients requiring Rapid Sequence Intubation (see RSI protocol) for airway management in whom
Succinylcholine is contraindicated.
• Maintenance of paralysis on an intubated patient once initial neuromuscular blockade is wearing
off.
• Sedation and pain management must be repeated prior to administration of Rocuronium.
Appropriate post-RSI care should focus on proper sedation and pain management. If proper
sedation is achieved, repeat paralyzation is rarely needed.
• Not to be used to control seizure activity.
CONTRAINDICATIONS
• Known hypersensitivity to rocuronium.
PRECAUTIONS / SIDE EFFECTS
• Apnea- lasts 30-60 minutes. Avoid use of rocuronium if ventilation not possible after failed
intubation attempt.
• Avoid maintaining paralysis if destination within 10 minutes. Alert the hospital that the paralytic
is wearing off so that they can administer more after the patient’s arrival.
• The onset of action is between 1-2 minutes. This may be delayed in patients with liver and
cardiac disease. The duration of action may be prolonged in patients with a history of liver
disease.
ADMINISTRATION
ADULT / PEDIATRIC
PROCEDURE
•
•
FR
EMT B
EMT B IV
0.6 mg/kg IV or IO for maintenance.
1mg/kg for induction
•
Onset for above dose: 1-4 minutes; Duration: approximately 45 min.
PREGNANCY CLASSIFICATION
• B
SUPPLIED AS
•
50mg / 5mL vial
Medication: Rocuronium
Revised 1/2014
1
EMTP
PCC
SO
SO
Page 1 of 2
Section 541A
SODIUM BICARBONATE
PHARMACOLOGY
• Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. Acids
are increased when body tissues become hypoxic due to cardiac or respiratory arrest.
INDICATIONS
• Supected hyperkalemia as evidenced by wide QRS or sine wave on ECG. Often seen in
patients with a history of renal disease.
• Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures
• Renal protection for patients who require intravenous contrast for imaging studies
(interfacility only).
CONTRAINDICATIONS
• DO NOT administer in mixtures with Epi, Dopamine, Calcium, or Dilantin.
• Metabolic or Respiratory alkalosis.
• Severe pulmonary edema.
• Abdominal pain of unknown origin.
• Hypocalcemia. Hypokalemia. Hypernatremia.
PRECAUTIONS / SIDE EFFECTS
• May increase cerebral acidosis, especially with patients suffering from DKA.
• Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a
paradoxical intracellular acidosis.
• Each ampule of sodium bicarbonate contains 44-50 mEq of sodium. This increases
intravascular volume, which increases the workload of the heart.
• Hyperosmolality of the blood can occur, resulting in cerebral impairment.
• Sodium bicarbonate's lack of proven efficacy and its numerous adverse effects have lead to
the reconsideration of its role in cardiac resuscitation. Effective ventilation and circulation
of blood during CPR are the most effective treatments for acidemia associated with cardiac
arrest.
• Administration of sodium bicarbonate has not been proven to facilitate ventricular
defibrillation or to increase survival in cardiac arrest. Metabolic acidosis lowers the
threshold for the induction of ventricular fibrillation, but has no effect on defibrillation
threshold.
• The inhibition effect of metabolic acidosis on the actions of catecholamines has not been
demonstrated at the pH levels encountered during cardiac arrest.
• Metabolic acidosis from medical causes (e.g. diabetes) develops slowly, and field treatment
is rarely indicated.
• Sodium bicarbonate may be considered for the dialysis patient in cardiac arrest due to
suspected hyperkalemia.
Medications: Sodium Bicarbonate
Revised 8/2014
1
Page 2 of 2
Section 541A
SODIUM BICARBONATE
ADMINISTRATION
ADULT
PROCEDURE
FR
EMT B
EMT B IV
Cardiac Arrest or Hyperkalemia
•
PCC
SO
SO
SO
SO
VO
VO
EMTP
PCC
SO
SO
1.0 mEq / kg IVP
Tricyclic Antidepressant Overdoses
•
EMTP
1-2mEq/kg, repeat q 5 minutes until
QRS duration is <100ms
Renal protection from IV contrast
•
1-3 mL/kg/hour infusion
(150 mEq diluted in 1L D5W)
PEDIATRIC (1 to 8 years of age)
PROCEDURE
FR
EMT B
EMT B IV
Cardiac Arrest or Hyperkalemia
•
1.0 mEq / kg IVP
Tricyclic Antidepressant Overdoses
•
SO
1-2mEq/kg, repeat q 5 minutes until
QRS duration is <100ms.
PREGNANCY CLASSIFICATION
•
SUPPLIED AS
• Adult/Pediatric: 8.4% (1 mEq/ml) in a 50 ml prefilled syringe
Medications: Sodium Bicarbonate
Revised 8/2014
2
Page 1 of 2
Section 541B
SODIUM BICARBONATE
PHARMACOLOGY
• Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. Acids
are increased when body tissues become hypoxic due to cardiac or respiratory arrest.
INDICATIONS
• Supected hyperkalemia as evidenced by wide QRS or sine wave on ECG. Often seen in
patients with a history of renal disease.
• Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures
• Cardiac arrest patients with return of pulse.
• Renal protection for patients who require intravenous contrast for imaging studies
(interfacility only).
CONTRAINDICATIONS
• DO NOT administer in mixtures with Epi, Dopamine, Calcium, or Dilantin.
• Metabolic or Respiratory alkalosis.
• Severe pulmonary edema.
• Abdominal pain of unknown origin.
• Hypocalcemia. Hypokalemia. Hypernatremia.
PRECAUTIONS / SIDE EFFECTS
• May increase cerebral acidosis, especially with patients suffering from DKA.
• Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a
paradoxical intracellular acidosis.
• Each ampule of sodium bicarbonate contains 44-50 mEq of sodium. This increases
intravascular volume, which increases the workload of the heart.
• Hyperosmolality of the blood can occur, resulting in cerebral impairment.
• Sodium bicarbonate's lack of proven efficacy and its numerous adverse effects have lead to
the reconsideration of its role in cardiac resuscitation. Effective ventilation and circulation
of blood during CPR are the most effective treatments for acidemia associated with cardiac
arrest.
• Administration of sodium bicarbonate has not been proven to facilitate ventricular
defibrillation or to increase survival in cardiac arrest. Metabolic acidosis lowers the
threshold for the induction of ventricular fibrillation, but has no effect on defibrillation
threshold.
• The inhibition effect of metabolic acidosis on the actions of catecholamines has not been
demonstrated at the pH levels encountered during cardiac arrest.
• Metabolic acidosis from medical causes (e.g. diabetes) develops slowly, and field treatment
is rarely indicated.
• Sodium bicarbonate may be considered for the dialysis patient in cardiac arrest due to
suspected hyperkalemia.
Medications: Sodium Bicarbonate
Revised 1/2014
1
Page 2 of 2
Section 541B
SODIUM BICARBONATE
ADMINISTRATION
ADULT
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
VO
VO
Renal protection from IV contrast
•
1-3 mL/kg/hour infusion
(150 mEq diluted in 1L D5W)
PREGNANCY CLASSIFICATION
•
SUPPLIED AS
• Adult/Pediatric: 8.4% (1 mEq/ml) in a 50 ml prefilled syringe
Medications: Sodium Bicarbonate
Revised 1/2014
2
Page 1 of 2
Section 542
SUCCINYLCHOLINE
PHARMACOLOGY
• Short- acting depolarizing neuromuscular blocking agent with high affinity for acetylcholine
receptor sites.
• Onset of paralysis is less then one minute following IV administration.
• The effects, including apnea, last approximately 4-6 minutes with IV use. There is no effect on
level of consciousness.
INDICATIONS
• Patients requiring Rapid Sequence Intubation (see RSI protocol) for airway management.
CONTRAINDICATIONS
• Known hypersensitivity to succinylcholine.
• Patient who are at risk of having or developing high potassium levels:
o Renal-failure patients – look for evidence of an antecubital or abdominal dialysis port,
urinary catheter bag on the leg.
o History of muscular dystrophy or history of prior neuromuscular injury causing
denervated muscle.
o Burn or crush injury > 8 hours old.
• Penetrating eye injury
• Narrow angle glaucoma.
• Malignant hypertension.
• Cholinesterase inhibitor toxicity (insecticides).
• Inadequate sedation prior to or after administration of succinylcholine.
• Not to be used to control seizure activity.
PRECAUTIONS / SIDE EFFECTS
• Apnea- lasts 4-6 minutes. Avoid use of succinylcholine if ventilation not possible after failed
intubation attempt.
• Malignant hyperthermia
• Dysrhythmias,
• cardiac arrest
• hyperkalemia,
• increased intraocular pressure.
ADMINISTRATION
• 1.5mg/kg IV or IO given after onset of sedation via inducting agent.
• 4mg/kg IM if unable to establish IV or IO access.
• Watch for fasciculations. This indicates depolarization has occurred and intubation can be
attempted once they have stopped.
• Succinylcholine has no effect on consciousness and pain threshold. Conscious patients will need
adequate sedation before and after the use of a paralytic.
• Absorption: Onset: 0.5 to 1 minute IV; Duration: 4-6 minutes IV.
Medication: Succinylcholine
Revised 1/2014
1
Page 2 of 2
Section 542
SUCCINYLCHOLINE
ADULT
PROCEDURE
•
•
FR
EMT B
1.5 mg/kg IV or IO
4mg/kg IM
PREGNANCY CLASSIFICATION
• C
SUPPLIED AS
•
200 mg in a 10 ml vial
Medication: Succinylcholine
Revised 1/2014
2
EMT B IV
EMTP
PCC
SO
SO
SO
SO
Page 1 of 1
Section 543
TETRACAINE OPTHALMIC SOLUTION
PHARMACOLOGY
• Local anesthetic that blocks nerve conduction.
• Onset=15 seconds; duration= approximately 15 minutes
INDICATIONS
• Severe eye irritation or pain from foreign body sensation, abrasions, inflammation, trauma.
• Post irrigation of eye after chemical or other substance exposure.
CONTRAINDICATIONS
• Hypersensitivity.
PRECAUTIONS / SIDE EFFECTS
• The most common adverse effect is further damage to the eye after anesthesia has taken place.
Patients should not touch, rub, or place anything in the eye, including contact lenses.
• Apply anesthetic drops only after you have initiated transport. This avoids patient refusal when
they erroneously assume that the problem has resolved after the anesthetic has been given.
ADMINISTRATION
• 2 drops to the affected eye. You may need to hold the eyelid open and have the patient look
toward their nose while inserting the drops in lateral portion of the eye.
ADULT
PROCEDURE
•
FR
EMT B
Tetracaine 2 drops to eye
PREGANANCY CLASSIFICATION
• Not applicable- does not affect fetus if applied topically
SUPPLIED AS
• 2 ml dropper of 0.5% solution
Medications: Tetracaine Opthalmic
Revised 1/2014
1
EMT B IV
EMTP
PCC
SO
SO
PROTOCOL
SECTION
NUMBER
NUMBER
OF PAGES
DATE
SECTION 600: Treatment - Environmental
600
1
REVISED 06/2014
Avalanche
601
1
REVISED 06/2014
Bites and Stings
602
1
REVISED 06/2014
Drowning
603
1
REVISED 06/2014
High Altitude Illness
604
1
REVISED 06/2014
Hyperthermia
605
1
REVISED 04/2015
Hypothermia / Frostbite
606
2
REVISED 06/2014
Snakebites
607
1
REVISED 06/2014
Page 1 of 1
Section 601
AVALANCHE BURIAL VICTIM
INFORMATION NEEDED
• Length of time the victim was buried.
• Mechanism for trauma: cliffs, trees.
SPECIFIC OBJECTIVE FINDINGS
• Vital signs, including temperature
• Signs of trauma
• Respiratory distress, cyanosis, altered mental status.
TREATMENT
• Clear airway and keep patent with OPA or NPA if needed.
• Keep warm and avoid further exposure. Victims of avalanche burial experience a rapid drop in
core temperature after extrication from snow.
• Administer oxygen.
• Assist ventilations if needed.
• Endotracheal intubation if not maintaining airway or signs of respiratory distress.
• Establish IV and give warmed fluids, if available.
• Rapid extrication.
SPECIAL PRECAUTIONS
• SCENE SAFETY - Do not enter avalanche terrain with a potential for more avalanche. If
you are not sure what is avalanche terrain, ask someone who is trained to evaluate the risk
potential. Trained personnel will bring the patient to the ambulance crew.
• Immobilize spine if indicated (see protocol for spinal immobilization).
• The two leading causes of death in avalanche burial are hypoxia and trauma.
• Treat for hypothermia and prevent heat loss.
Environmental: Avalanche
Revised 06/2014
1
Page 1 of 1
Section 602
BITES AND STINGS
INFORMATION NEEDED
• Type of animal or insect; time of exposure.
• Symptoms:
o Local: pain, stinging
o Generalized: dizziness, weakness, itching, trouble breathing, airway swelling, muscle cramps.
• History of previous exposures, allergic reactions.
SPECIFIC OBJECTIVE FINDINGS
• Identification of animal if possible.
• Local signs: redness, swelling, heat in area of bite.
• Systemic signs: hives, wheezing, respiratory distress, abnormal vital signs.
TREATMENT
Snakes (See Snake Bite Protocol).
Spiders
• Ice for comfort.
• Bring in spider, if captured and contained or if dead, for accurate identification, if possible.
• Transport for observation if systemic signs and symptoms present.
Bees and Wasps
• Remove sting mechanism. Do not squeeze venom sac if this remains on stinger, rather, scrape
with straight edge.
• Observe patient for signs of systemic allergic reaction. Transport rapidly if signs or symptoms of
anaphylaxis and treat per protocol (Allergy Anaphylaxis protocol.)
• Transport all patients with systemic symptoms or history of systemic symptoms from prior bites.
SPECIFIC PRECAUTIONS
• Many skin infections present as a small red lesion that is often attributed to an insect bite. If the
redness or swelling is rapidly progressing, you palpate the skin and feel subcutaneous air, or the
patient appears ill; immediate transport is indicated.
• For all types of bites and stings, the goal of prehospital care is to prevent further inoculation and
to treat allergic reactions.
• Allergy kits consist of injectable epinephrine and oral antihistamine, and are prescribed for
persons with known systemic allergic reactions. Prehospital care personnel may assist w/ EPIPEN per protocol.
• About 60% of patients who have experienced a generalized reaction to a bite or sting in the past
will have a similar or more severe reaction upon reinoculation. Although it is not inevitable, this
group of patients must be considered at high risk for anaphylaxis. In addition, a small group of
patients will have anaphylaxis as a "first" reaction.
• Time since envenomation is important. Anaphylaxis rarely develops more than 60 minutes after
inoculation.
Environmental: Bites and Stings
Revised 06/2014
1
Page 1 of 1
Section 603
DROWNING
This protocol includes Drowning, Near Drowning, and Submersion
INFORMATION NEEDED
• How long patient was submerged?
• Degree of contamination, water temperature?
• Diving accident? Water depth?
SPECIFIC OBJECTIVE FINDINGS
• Vital signs
• Neurologic status: monitor on a continuing basis.
• Signs of trauma
• Lung exam: rales or signs of pulmonary edema, respiratory distress
TREATMENT
• Clear upper airway of vomitus or large debris.
• Start CPR if needed.
• Stabilize neck prior to removing patient from water if any suggestion of neck injury.
• Suction as needed.
• Administer O2.
• If patient not awake and alert:
o Assist ventilation using pocket mask or BVM.
o Intubate if indicated and apply positive pressure ventilation.
o Establish venous access.
o Monitor cardiac rhythm during transport; treat arrhythmias per protocol.
• Transport patient, even if initial assessment is normal.
SPECIAL PRECAUTIONS
• Be prepared for vomiting. Immobilize the spine when indicated for log-rolling to protect the neck
and manage the airway.
• All near-drownings should be transported. Even if patients initially appear fine, they can
deteriorate. Monitor closely. Pulmonary edema often occurs due to aspiration, hypoxia, and other
factors. It may not be evident for several hours after submersion.
• Beware of neck injuries - they often go unrecognized. Collar and backboard should be applied in
the water.
• If patient is hypothermic, defibrillation and pharmacologic therapy may be unsuccessful until the
patient is rewarmed. Prolonged CPR may be needed. (See Hypothermia protocol)
• Heimlich maneuver is not indicated
Environmental: Drowning
Revised 06/2014
1
Page 1 of 1
Section 604
HIGH ALTITUDE ILLNESS
INFORMATION NEEDED
• Current and highest altitude, time at this altitude, duration of ascent.
• Medical problems, medications, home elevation, previous experience at altitude.
SPECIFIC OBJECTIVE FINDINGS
• Presenting symptoms generally fall into two categories:
o Acute mountain sickness (AMS) - headache, sleeplessness, anorexia, nausea, fatigue which
may progress to HACE.
o High-altitude Pulmonary Edema (HAPE) - breathlessness, cough, headache, trouble
breathing, confusion, fatigue, nausea.
o High-altitude Cerebral Edema (HACE) - ataxia, headache, confusion, stroke-like picture with
focal deficits, seizure and coma.
• Vital signs
• Mental status: confusion, lack of coordination, coma
• Lungs: respiratory rate, distress, rales, sputum (bloody or frothy)
TREATMENT
• Put patient at rest, position of comfort.
• Administer Oxygen.
• Suction as needed. Assist ventilation if patient has cyanosis, confusion, and poor respiratory
effort.
• Establish venous access, if conditions permit.
• Monitor vitals during transport
• Consider Nitroglycerin for respiratory distress- contact Medical Control
.
SPECIAL PRECAUTIONS
• Recognition of the problem is the most critical part of treating high altitude illness. While in the
mountains, recognize symptoms which are out of proportion to those being experienced by the
rest of the party: fatigue, or trouble breathing (particularly at rest and while lying down).
• The mainstay of treatment is oxygen. Descent is helpful and essential if oxygen is not readily
available, but increasing the concentration of oxygen inspired has the most immediate benefit.
• Acute mountain sickness, the mild form of illness during altitude adaptation, consists of fatigue,
headache, and poor sleeping, without severe CNS or respiratory symptoms. Treatment is rest and
prescribed medications. This increases the body's time to acclimatize.
• In addition to the more common condition of pulmonary edema, cerebral edema may occur, with
confusion and a stroke-like picture with focal deficits. Treatment is the similar in that oxygen
should be initiated and the patient transported to the hospital.
Environmental: High Altitude Sickness
Revised 06/2014
1
Page 1 of 1
Section 605
HYPERTHERMIA
INFORMATION NEEDED
• Patient age, activity level
• Medications: depressants, tranquilizers, alcohol, etc.
• Associated symptoms: cramps, headache, orthostatic symptoms, syncope, nausea, weakness
SPECIFIC OBJECTIVE FINDINGS
• Vital signs including temperature
• Mental status: confusion, coma, seizures, psychosis
• Skin flushed and warm to hot: with or without sweating
• Air temperature and humidity; patient dress
• Heat Exhaustion
o vomiting
o normal mentation
o cramps
• Heat Stroke
o altered level of consciousness
o Sweating may still be present, especially in exercise-induced heat stroke
TREATMENT
• Ensure that airway is patent.
• Remove clothing.
• Administer Oxygen.
• Cool by spraying tepid water using a fan or use water-soaked sheets.
• Establish venous access and give bolus of crystalloid fluids.
• Administer Diazepam if patient has shaking chills during cooling. Do not give if hypotensive.
• Monitor cardiac rhythm.
• Monitor vitals during transport.
SPECIAL PRECAUTIONS
• Heat stroke is a medical emergency.
• The elderly and persons on medications which impair the body's ability to regulate heat are at
particular risk for heat stroke.
• Be aware that heat exhaustion can progress to heat stroke.
• Consider this as a cause of loss of consciousness (heat syncope) or altered mental status,
especially in the elderly.
• Do not let cooling in the field delay your transport. Cool patient as possible while en route.
• Do not use ice water or cold water to cool patients, as these may induce vasoconstriction.
Environmental: Hyperthermia
Revised 4/2015
1
Page 1 of 2
Section 606
HYPOTHERMIA AND FROSTBITE
INFORMATION NEEDED
• Length of exposure
• Air temperature, water temperature, wind, wet clothing
• History and timing of changes in mental status
• Drugs: alcohol, sedatives, anticonvulsants, others
• Medical problems: diabetes, epilepsy, alcoholism, etc.
• With localized injury
o History of thawing/refreezing?
SPECIFIC OBJECTIVE FINDINGS
• Vital signs, mental status, shivering. Prolonged observation for 1-2 min. may be necessary to
detect pulse, respirations.
• Skin temperature (estimated); a close approximation of core temperature can be made via the
rectal thermometer; also note current temperature of environment.
• Evidence of local injury: blanching, blistering, erythema of extremities, ears, nose.
• Cardiac rhythm - may not be able to obtain except with needle electrodes or until warming has
been initiated- do not delay transport.
TREATMENT
Hypothermia
• If no pulse or respirations
o Keep patient warm/in a warm environment as much as possible
o CPR
o Administer 200J - 1 shock if indicated.
o Resume CPR
o Establish airway
o Repeat defibrillation for recurrent VF/VT
o Only 1 round of ACLS IV medications until core temperature rises above 30°C (86°F)
 See VT/VF protocols for medications
o Administer warmed IV fluids.
• If pulse and respirations present
o Keep patient warm/in a warm environment as much as possible
o Administer O2. Assist with bag-valve-mask as needed. Use warmed-humidified oxygen if
available.
o Avoid unnecessary rough movement—handle the patient carefully.
o Remove wet or constrictive clothes from patient. Wrap in blankets and protect from wind
exposure.
o Increase ambient temperature in ambulance.
o Establish venous access. Administer warmed IV fluids.
o Monitor vitals during transport.
HYPOTHERMIA AND FROSTBITE
Environmental: Hypothermia and Frostbite
Revised 06/2014
1
Page 2 of 2
Section 606
Frostbite
• Remove wet or constricting clothing. Keep skin dry and protected from wind.
• Do not allow the limb to thaw if there is a chance that limb may refreeze before evacuation is
complete, or if patient must walk to transportation.
• Rewarm minor "frostnip" areas by placing in axilla or against a warm object. Avoid hot objects
as patient will be unable to sense burning.
• Dress injured areas lightly in clean cloth to protect from pressure, trauma or friction. Do not rub.
Do not break blisters.
• Maintain core temperature by keeping patient warm with blankets, warm fluids, etc.
• Transport with frostbitten areas supported and elevated if feasible.
• If patient is able to swallow, administer Aspirin 324mg p.o.
SPECIAL PRECAUTIONS
Hypothermia:
• Shivering does not occur below 90 degrees F. Below this the patient may not even feel cold, and
occasionally will even undress and appear vasodilated.
• The heart is most likely to fibrillate below 85-88 degrees F. Prolonged CPR may be necessary
until the temperature is above this level.
• ALS drugs are used sparingly as peripheral vasoconstriction may prevent entry into central
circulation until temperature is restored. At that time, a large bolus of medications may be infused
into the heart.
• Bradycardias are normal and should not be treated.
• Patients who appear dead after prolonged exposure to cold air or water should not be pronounced
"dead" until they have been rewarmed. Full recovery from hypothermia with undetectable vital
signs, severe bradycardia, and even periods of cardiac arrest has been reported.
• Rewarming should be accomplished with careful monitoring in a hospital setting, whenever
possible.
• Consider other reasons for altered mental status.
Frostbite:
• Thawing is extremely painful and should be done under controlled conditions, preferably in the
hospital. Careful monitoring, pain medication, prolonged rewarming, and sterile handling are
required.
• It is clear that partial rewarming, or rewarming followed by refreezing, is far more injurious to
tissues than delay in rewarming or walking on a frozen extremity to reach help. Do not rewarm
prematurely. Indications for field rewarming are almost nonexistent.
• Warming with heaters or stoves, rubbing with snow, and other methods of stimulating the
circulation are dangerous and should not be used.
Environmental: Hypothermia and Frostbite
Revised 06/2014
2
Page 1 of 1
Section 607
SNAKE BITES
INFORMATION NEEDED
• Appearance of snake (e.g. rattle, color, banding)
o DO NOT handle or attempt to catch a snake, even a “dead” one. Let animal control catch it if
they are available.
• Time of bite
• Prior first-aid by patient or friends
• Symptoms: local pain and swelling, peculiar or metallic taste sensations. Severe envenomations
may result in hypotension, paralysis, coma, or bleeding.
SPECIFIC OBJECTIVE FINDINGS
• Bite wound: location, configuration (1, 2, or 3 fang marks; entire jaw imprint, none)
• Snake identification: look for elliptical pupils, thermal pit and rattle
• Signs of envenomation: spreading numbness and tingling from the site, local edema and pain,
ecchymosis, bleeding, hypotension. Mark time and extent of erythema and edema with pen.
TREATMENT
• Remove patient and rescuers from area of snake to avoid further injury.
• Remove rings or other bands which may constrict with local swelling.
• Immobilize bitten part at heart level.
• Minimize venom absorption by keeping bite area still and patient quiet.
• Transport promptly for definitive observation and treatment.
• Apply loose dressing above bite if located on an extremity. This is only to impede lymphatic
flow. Check pulses and capillary refill regularly to insure that the tourniquet is not impeding
blood flow.
• Do not use ice or refrigerants. Do not try and suction venom or remove with incision.
• Establish venous access.
• Oxygen
• Monitor vital signs.
• Provide supportive care as needed.
• Consider pain management.
• Alert receiving facility ASAP as croafab reconstitution is a lengthy processes.
SPECIAL PRECAUTIONS
• The only two endemic venomous snakes in Colorado are the Western Rattlesnake and the
massasauga. If animal control is able to safely package the snake, bring it in for examination. Do
not jeopardize fellow rescuers by attempting to "round it up."
• At least 25% of poisonous snake strikes do not result in envenomation. Conversely, the initial
appearance of the bite may not reflect the severity of envenomation.
• Fang marks are characteristic of pit viper bites, such as from the rattlesnake, water moccasin, or
copperhead, which are native to North America. Jaw prints (without fangs) are more
characteristic of nonvenomous species.
• Exotic poisonous snakes, such as those found in zoos, have different signs and symptoms than
those of pit vipers
Environmental: Snake Bites
Revised 06/2014
1
PROTOCOL
SECTION
NUMBER
NUMBER
OF PAGES
DATE
SECTION 700: Procedures
700
1
REVISED 02/2014
Airway Management
701
2
REVISED 02/2014
Airway Obstruction
702
1
REVISED 02/2014
Airway Suctioning
703
2
REVISED 02/2014
Bandaging
704
1
REVISED 02/2014
Blood Draw
705
1
REVISED 02/2014
Bag Valve Mask Ventilation
706
2
REVISED 02/2014
Cardioversion
707
2
REVISED 02/2014
Constant Positive Airway Pressure (CPAP)
708
1
REVISED 02/2014
Defibrillation
709
2
REVISED 02/2014
EnVe Ventilator
710
3
REVISED 02/2014
Indwelling Catheters
711
2
REVISED 02/2014
Intraosseous Access
712
2
REVISED 02/2014
iSTAT
713
1
REVISED 02/2014
Gastric Tube Insertion
714
1
REVISED 02/2014
Medication Administration
715
3
REVISED 02/2014
Nasal Entotracheal Intubation
716
1
REVISED 02/2014
Needle Decompression of Pneumothorax
717
2
REVISED 02/2014
Oral Endotracheal Intubation
718
2
REVISED 02/2014
Oxygen Powered Ventilator
719
1
REVISED 02/2014
Rapid Sequence Intubation
720
3
REVISED 02/2014
Rescue Airway
721
3
REVISED 02/2014
Restraints
722
2
REVISED 02/2014
Spinal Immobilization
723
1
REVISED 02/2014
Splinting-Extremity
724
1
REVISED 02/2014
Splinting-Traction
725
1
REVISED 02/2014
Surgical Cricothyrotomy
726
2
REVISED 02/2014
Therapeutic Hypothermia
727
1
REVISED 02/2014
Transcutaneous Cardiac Pacing
728
1
REVISED 02/2014
Umbilical Vein Catheterization
729
1
REVISED 02/2014
12 lead EKG
730
3
REVISED 02/2014
Vascular Access
731
2
REVISED 02/2014
Page 1 of 2
Section 701
AIRWAY MANAGEMENT
INDICATIONS
• The patient is unable to adequately ventilate themselves.
• Inadequate air exchange in the lungs due to jaw or facial fracture, causing narrowing of air
passage.
• Lax jaw or tongue muscles causing airway narrowing in the unconscious patient
• Noisy breathing or excessive respiratory effort that could be due to partial obstruction
PRECAUTIONS / COMPLICATIONS
• The following protocols are recommended as a guide for approaching difficult medical and
trauma airway problems. They assume that the responder is skilled in the various procedures, and
will need to be modified according to training level.
• Advanced procedures should only be attempted if simpler ones fail and if the technician is
qualified. Individual cases may require modification of these protocols, in this case consult
medical control.
• Neck extension may be difficult in elderly persons with extensive arthritis and little neck
motion. Do not use force; jaw thrust or chin-lift without head tilt will be more successful.
• Children's airways have less supporting cartilage; overextension can kink the airway and
increase the obstruction. Watch chest rise to determine the best head angle.
• Cervical spinal cord injury from neck hyperextension in trauma victim with cervical fracture
• Death due to inadequate ventilation or hypoxia
• Nasal or posterior pharyngeal bleeding due to trauma from airway adjuncts.
• Increased airway obstruction from tongue following improper oropharyngeal airway
placement
• Aspiration of blood or vomitus from inadequate suctioning and continued contamination of
lungs from upper airway
TECHNIQUE
Medical Respiratory Arrest
• Open airway using head tilt-chin lift or head tilt-neck lift.
• Ventilate with BVM and supplemental oxygen .
• Insert nasopharyngeal airway or oropharyngeal airway if patency is difficult to maintain.
• Suction as needed.
• Perform orotracheal intubation prior to transport if arrest continues.
Medical Respiratory Insufficiency
• Open the airway using most efficient method.
• Insert nasopharyngeal airway if patency compromised.
• Suction as needed.
• Apply supplemental O2 by nasal cannula or mask as needed.
• Assist respirations by BVM as needed.
• Perform nasotracheal or orotracheal intubation if patient is unable to adequately protect airway
nor able to adequately oxygenate and ventilate.
Procedure Protocol: Airway Management
Reviewed 02/2014
1
Page 2 of 2
Section 701
AIRWAY MANAGEMENT
Traumatic Respiratory Arrest
• Open airway using jaw thrust maneuver, protecting neck.
• Ventilate with BVM and supplemental oxygen.
• Visualize airway and remove visible obstruction with magil forceps; suction as needed.
• Have assistant provide continuous stabilization of head and neck.
• Draw tongue and mandible forward if needed in patients with facial injuries.
• Perform orotracheal intubation while maintaining in-line immobilization of neck.
Traumatic Respiratory Insufficiency
• Open airway using jaw thrust maneuver, protecting neck.
• Administer high flow O2; support with BVM ventilations
• Visualize airway and remove visible obstruction with magil forceps; suction as needed.
• Have assistant provide continuous stabilization of head and neck.
• Use hand to draw tongue and mandible forward if needed with facial injuries.
• Perform orotracheal intubation as indicated, while maintaining in-line stablilization of neck.
Procedure Protocol: Airway Management
Reviewed 02/2014
1
Page 1 of 1
Section 702
AIRWAY OBSTRUCTION
INDICATIONS
• Complete or partial obstruction of the airway due to a foreign body
• Complete or partial obstruction due to airway swelling from anaphylaxis, croup, or epiglottitis
• Patient with unknown illness or injury who cannot be ventilated after procedures of previous
protocol: Opening the Airway.
PRECAUTIONS / COMPLICATIONS
• Perform chest thrusts only in visibly pregnant patients, obese patients, and in infants.
• Patients with partial airway obstruction can be very uncomfortable and vociferous. Abdominal or
chest thrusts will not be effective and may be injurious to the patient who is still ventilating.
Resist the temptation to attempt relief of obstruction if it is not complete, but be ready to
intervene promptly if arrest occurs.
• Hypoxia from airway obstruction can cause seizures. Chest or abdominal thrusts may not be
effective until the patient becomes relaxed after the seizure is over.
• Hypoxic brain damage and death from unrecognized or unrelieved obstruction
• Trauma to ribs, lung, liver and spleen from chest or abdominal thrusts (particularly when forces
are not evenly distributed)
• Vomiting and aspiration after relief of obstruction
• Creation of complete obstruction after blind incorrect finger probing
• Tonsillar or pharyngeal laceration from over-vigorous finger sweep
TECHNIQUE
Complete Airway Obstruction
• Open airway using head tilt-chin lift or jaw thrust.
• Attempt to ventilate using mouth-to-mask or BVM ventilations.
• If unable to ventilate, reposition airway and reattempt ventilations.
• If airway remains obstructed, visualize with laryngoscope and remove any obvious foreign body
using Magill forceps.
• Reposition the airway and attempt to ventilate.
• If unable to ventilate, administer 5 subdiaphragmatic abdominal thrusts.
• Reposition the airway and reattempt to ventilate.
• When obstruction relieved:
o Keep patient on side, remove debris if it can be visualized.
o Apply O2, high flow; reservoir mask.
o Assess adequacy of ventilation, and support as needed.
o Suction aggressively.
o Restrain if combative.
Partial Airway Obstruction
• Have patient assume most comfortable position.
• Apply O2, high flow by non-rebreather mask.
• Attempt suctioning of upper airway.
• If patient unable to move air, confused, or otherwise deteriorating, visualize airway, remove
foreign body or perform abdominal thrusts as noted above.
Procedures: Airway Obstruction
Reviewed 02/2014
1
Page 1 of 2
Section 703
AIRWAY SUCTIONING
INDICATIONS
• To remove foreign material that can be removed by a suction device
• To remove excess secretions or pulmonary edema fluid in upper airway or lungs (with
endotracheal tube in place)
• To remove meconium or amniotic fluid in mouth, nose and oropharynx of newborn
PRECAUTIONS / COMPLICATIONS
• Hypoxia due to excessive suctioning time without adequate ventilation between attempts
• Persistent obstruction due to inadequate tubing size for removal of debris
• Lung injury from aspiration of stomach contents due to inadequate suctioning
• Asphyxia due to recurrent obstruction if airway is not monitored after initial suctioning
• Conversion of partial to complete obstruction by attempts at airway clearance
• Trauma to the posterior pharynx from forced use of equipment
• Vomiting and aspiration from stimulation of gag reflex
• Induction of cardiorespiratory arrest from vagal stimulation
• Complications may be caused both by inadequate and overly vigorous suctioning. Technique
and choice of equipment are very important. Choose equipment with enough power to suction
large amounts rapidly to allow time for ventilation.
• Proper airway clearance can make the difference between a patient who survives and one
who dies. Airway obstruction is one of the most common treatable causes of prehospital
death.
TECHNIQUE
Suction of the adult/child:
• Turn patient on side if possible, to facilitate clearance.
• Open airway and inspect for visible foreign material.
• Remove large or obvious foreign matter with magil forceps or a gloved hand. Use padded tongue
blade or oropharyngeal airway (do not pry) to keep airway open. Sweep finger across posterior
pharynx and clear material out of mouth.
• Attach tonsil tip (or use open end for large amounts of debris).
• Ventilate and oxygenate the patient as needed prior to the procedure.
• Insert tip into oropharynx under direct vision, with sweeping motion.
• Continue intermittent suction interspersed with active oxygenation by mask or cannula. Use
positive pressure ventilation if needed (BVM)
• If suction becomes clogged, dilute by suctioning water from a glass to clean tubing. If suction
clogs repeatedly, use connecting tubing alone, or manually remove large debris.
Suction of the newborn:
• Use a bulb syringe or soft suction catheter with the lowest suction setting that is effective.
• As soon as infant's head has delivered, insert suction tip into the mouth and back to oropharynx.
• Apply suction while slowly withdrawing catheter from the mouth.
• Insert catheter tip into each nostril and back to posterior pharynx.
• Apply suction while slowly withdrawing catheter from each nostril.
• As soon as infant has delivered, repeat process.
• If there is evidence of meconium aspiration, suction trachea using a soft suction catheter or an
appropriate size ET tube under direct vision with laryngoscope.
Procedure: Airway Suctioning
Revised 02/2014
1
Page 2 of 2
Section 703
AIRWAY SUCTIONING
Suction of endotracheal tube:
• Attach suction catheter to tubing of suction device (leaving suction end in sterile container).
• Put on sterile gloves.
• Preoxygenate patient.
• Detach bag from endotracheal tube and insert sterile tip of suction catheter without suction.
• When catheter tip has been gently advanced as far as possible, apply suction and withdraw
catheter slowly.
• Rinse catheter tip in sterile water or saline.
• Repeat as needed. Reoxygenate patient prior to suctioning again.
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
Suction of adult/child
SO
SO
SO
SO
SO
Suction of newborn
SO
SO
SO
SO
SO
SO
SO
Suction of endotracheal tube
Procedure: Airway Suctioning
Revised 02/2014
2
Page 1 of 1
Section 704
BANDAGING
INDICATIONS
• To stop external bleeding by application of direct and continuous pressure to wound site
• To protect patient from contamination to lacerations, abrasions, burns
PRECAUTIONS / COMPLICATIONS
• Although external skin wounds may be dramatic, they are rarely a high management priority in
the trauma victim.
• Loss of distal circulation from bandage applied too tightly around extremity; for this reason, do
not use elastic bandages or apply bandages too tightly.
• Restriction of breathing from circumferential chest wound splinting
• Continued bleeding no longer visible under dressings. (This is particularly common with scalp
wounds that continue to lose large amounts of unnoticed blood.)
• Inadequate hemostasis: some wounds require continuous direct manual pressure to stop
bleeding.
TECHNIQUE
• Use BSI.
• Control hemorrhage with direct pressure, using sterile dressing.
• Assess patient fully and treat all injuries by priority once assessment is complete.
• Remove gross dirt and contamination from wound: clothing (if easily removable), dirt, gasoline,
acids, or alkalis.
• Use copious irrigating saline or tap water for chemical contamination.
• Evaluate wound for depth, presence of fracture in wound, foreign body, or evidence of injury to
deep structures.
• Note distal motor, sensory, and circulatory function prior to applying dressings.
• Apply sterile dressing to wound surface. Touch outer side of dressing only.
• Wrap dressing with clean gauze or cloth bandages applied just tightly enough to hold dressing
securely (if no splint applied).
• Assess wound for evidence of continued bleeding.
• Check distal pulses, color, capillary refill, and sensation after bandage applied.
• Continue to apply direct hand pressure over dressing, or use air splint if bleeding not controlled
with bandage alone.
• For deep or gaping muscle wounds in which bleeding cannot be controlled with direct pressure,
pack the wound with sterile gauze than reapply a sterile dressing with pressure.
PROCEDURE
Bandaging of adult/child
Procedure: Bandaging
Revised 1102/2014
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
1
Page 1 of 1
Section 705
BLOOD DRAW
INDICATIONS
• Patients receiving an IV in the field.
• Patients that may have been exposed to carbon monoxide
PRECAUTIONS / COMPLICATIONS
• Improper technique in obtaining the specimen will result in inaccurate or invalid test results. This
wastes critical time and defeats the purpose of drawing specimens in the field.
TECHNIQUE
Field Draw
• Identify the patient
• After initiating an IV and removing the needle, attach the Vaccutainer holder to the hub of the IV
catheter.
• Fill tubes in the following order; blue, red, green, purple. It is essential to fill the tubes in the
correct order otherwise specimen results can be inaccurate.
• Tubes should be inverted gently back and forth several times to ensure adequate mixing of blood
with the substance in the tube. Do not shake the tube as this could cause hemolysis, which could
interfere with test results.
• Tubes should be labeled with the patient’s name, date of birth, time of draw, and initials of the
phlebotomist.
• The tubes should be placed in a small biohazard bag. Tubes may then be taped to the IV bag or
placed in the blood tube tray under the proper room number at MRMC.
PROCEDURE
FR
EMT B
Blood Draw
Procedures: Blood Draw
Revised 02/2014
1
EMT B IV
EMTP
PCC
SO
SO
SO
Page 1 of 2
Section 706
BAG VALVE MASK VENTILATION
INDICATIONS
• Provide positive pressure mechanical ventilation for patients who are not breathing adequately
due to respiratory depression, failure, or arrest.
PRECAUTIONS / COMPLICATIONS
• It is easy to force air into the stomach and cause vomiting.
• Aspiration from vomiting will have a negative effect on the patients recovery.
• To avoid aspiration
o Ventilate at the proper rate and tidal volume for the age of your patient
• If a pneumothorax is present, assisted ventilation can make it worse or convert to a tension
pneumothorax. Be observant and prepared. Do not withhold ventilation.
• Prepare for advanced airway procedures and/or chest decompression if needed.
• Early intubation may be of benefit for patients who continue to bleed or vomit or for those
patients in whom the mask is not effective (poor seal or persistent obstruction)
TECHNIQUE
• Select proper size mask and bag for the age of the patient
• Properly sealing the mask against the face is critical to effective positive pressure ventilation.
• Perform head tilt chin lift or jaw thrust as indicated for the patient.
• Look, Listen, and Feel for air movement.
• Suction prior to ventilation if blood, emesis or other debris present in upper airway. Remove any
foreign body if present.
• Assess effectiveness of ventilations: chest rise, breath sounds, patient’s color; also assess with
continuous pulse oximetry.
• If ventilation is not satisfactory, reposition and resuction airway. If still unsuccessful, see
obstructed airway protocol.
• Feel for air leak or resistance to air passage. Adjust mask fit as needed.
• If patient resumes spontaneous respirations, continue to administer supplemental oxygen.
o Intermittent assistance with ventilation may still be needed.
• Insert oral or nasal airway to assist airway patency if the patient will tolerate it.
• Ventilate gently and slowly (time allowed for exhalation should be 2-3 times the duration of
inhalation or bag squeeze) to reduce the risk of gastric distention and possible creation of a
pneumothorax.
PROCEDURE
Bag Valve Mask ventilation of
adult/child
Procedure: BVM Ventilation
Revised 02/2014
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
1
Page 2 of 2
Section 706
BAG VALVE MASK VENTILATION
•
•
The chart below is a general guide only. Use the mask that fits and only ventilate until the chest
begins to rise.
Rule of thumb is 6-10 ml/kg for computation of tidal volume. More volume will be needed with
a mask due to air leakage and dead space in the mask.
AGE
0 to 1 year
VENTILATION
RATE (per min)
40 - 60
TIDAL
VOLUME (ml)
30 – 100
1-8 years
20
100 - 250
8-14 years
12
250 - 500
>14 years
10
500 - 800
Procedure: BVM Ventilation
Revised 02/2014
2
MASK SIZE
BAG SIZE
Neonate /
Infant
Infant /
Toddler /
Small Adult
Small Adult /
Med Adult
Small Adult /
Med Adult /
Large Adult
Pediatric
Pediatric
Pediatric /
Adult
Adult
Page 1 of 3
Section 707
CARDIOVERSION
INDICATIONS
• Symptomatic Tachycardia
o Altered level of consciousness
o pale, cool skin
o hypotension
o poor capillary refill / low pulse oximetry
PRECAUTIONS
• Precautions for defibrillation apply. Protect rescuers!
• If the defibrillator does not discharge on "sync" with tachycardia, adjust the lead amplitude and
attempt to cardiovert again.
• If sinus rhythm is achieved, even transiently, with cardioversion, subsequent cardioversion should
be attempted.. Leave the setting the same; consider correction of hypoxia, acidosis, etc. to hold
the conversion.
• If the patient is pulseless, begin CPR and treat as cardiac arrest, even if the electrical rhythm
appears organized.
• People with chronic atrial fibrillation are very difficult to convert, and their atrial fibrillation is
not usually the cause of their decompensation. If you get a history of "irregular heartbeat," look
elsewhere for the problem.
• Sinus tachycardia rarely exceeds 150 beats/min. in adults (220 beats/min. in children < 8 years
old), and does not require cardioversion. Treat the underlying cause.
• Do not be overly concerned about the dysrhythmias that normally occur in the few minutes
following successful cardioversion. These usually respond to time and adequate oxygenation, and
should only be treated if they persist.
Prodecure: Cardioversion
Revised 11/2013
1
Page 2 of 3
Section 707
CARDIOVERSION
TECHNIQUE
Tachycardia
With serious signs and symptoms related to the tachycardia
(signs of poor perfusion)
↓
If ventricular rate is > 150 beats/min., prepare for and deliver
IMMEDIATE CARDIOVERSION
Immediate cardioversion is generally not needed for rates < 150 beats/min.
↓
While preparing for cardioversion
• Ensure adequate oxygenation, ventilation
• establish IV
• Prepare for intubation, including suction
Consider premedication with Midazolam (see Midazolam protocol) only if patient is awake and alert
↓
Engage the synchronization mode by pressing the “sync” buttonReset this for each cardioversion
↓
Verify that monitor is marking each R wave, indicating sync mode
(adjust monitor if necessary)
↓
Apply pads or paddles with gel: sternum-apex
↓
Synchronized Cardioversion
ADULT
PRODEDURE
Narrow regular tachycardia
•
EMTP
PCC
SO
FR
EMT B
EMT B IV
EMTP
SO
PCC
SO
200J
FR
EMT B
EMT B IV
EMTP
SO
PCC
SO
100J
PRODEDURE
Wide irregular tachycardia
•
EMT B IV
SO
PRODEDURE
Wide regular tachycardia
•
EMT B
50-100J
PRODEDURE
Narrow irregular tachycardia
•
FR
FR
EMT B
EMT B IV
EMTP
SO
Defibrillate 200J
Prodecure: Cardioversion
Revised 11/2013
1
PCC
SO
Page 3 of 3
Section 707
PEDIATRIC
PRODEDURE
Ventricular tachycardia, Paroxysmal
Surpaventricular Tachycardia, Atrial
fibrillation, Atrial flutter
•
FR
EMT B
EMTP
PCC
SO
0.5-1 J/Kg If not effective,
increase to 2J/kg
Prodecure: Cardioversion
Revised 11/2013
EMT B IV
1
Page 1 of 1
Section 708
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
INDICATIONS
• Congestive heart failure exacerbation including pulmonary edema
• Severe bronchospasm from reactive airway (asthma) or obstructive airway disease (COPD)
• Pneumonia
PRECAUTIONS / COMPLICATIONS
• Patient must exhibit severe signs and symptoms of dyspnea and hypoxia
• Patient must be awake and alert
• Patient must have ability to maintain an open airway
• Cardiogenic shock: high intrathoracic pressures my exacerbate depressed myocardial function
CONTRAINDICATIONS
• Pneumothorax
• Respiratory arrest
• Agonal respirations
• Children under 12 years of age
• Unconscious or obtunded
• Penetrating chest trauma
• Persistent nausea/vomiting
• Facial abnormalities/facial trauma
• Active upper GI bleeding or history of recent gastric surgery
TECHNIQUE
• Patient should be in a sitting position
• Attach cardiac monitor and pulse oximeter.
• Explain the procedure to the patient.
• Attach CPAP device start at a pressure of 5 cm H2O and titrate to a maximum of 10 cm H2O
• Check for air leaks.
• Treatment should be given continuously throughout transport to ED
• If respiratory status or level of consciousness deteriorates, remove device and consider BVM
ventilation or endotracheal intubation.
ADULT
PRODEDURE
Continuous Positive Airway Pressure
(CPAP)
• 5-10 cm H2O
FR
EMT B
EMT B IV
EMTP
PCC
SO
SO
SPECIAL CONSIDERATIONS
• Do not remove CPAP until hospital personnel prepared to switch patient to their equipment.
• Monitor patient for gastric distention, which may lead to vomiting.
• For suspected cardiogenic pulmonary edema, administer sublingual NTG prior to attaching CPAP
mask. Consider Nitroglycerin paste.
Procedure: CPAP
Revised 02/2014
1
Page 1 of 2
Section 709
DEFIBRILLATION
INDICATIONS
• Ventricular fibrillation
• Wide complex tachycardia in pulseless patient
PRECAUTIONS / COMPLICATIONS
• Dry the chest wall if wet. Saline or electo gel may result in bridging, which conducts the current
through the skin rather than through the heart.
• Nitroglycerin paste, which is commonly used by cardiac patients, is flammable, and may ignite if
not wiped from the chest prior to paddle contact. Other transdermal patches should be removed.
• Defibrillation should be accompanied by visible muscle contraction by patient. If this does not
occur, recheck equipment.
• Unsuccessful defibrillation is often due to hypoxia or acidosis. Careful attention to airway
management and proper CPR is important.
• Protect rescuers - "Clear" the patient
• Inadequate contact between quick combo pads and skin may cause skin burns.
• Defibrillation may not be successful in ventricular fibrillation due to hypothermia until the core
temperature is above 88 degrees F. Prolonged CPR during rewarming may be necessary before
conversion is possible.
• Artifact can simulate ventricular fibrillation. A fully awake and well-pefusing patient is unlikely
to be experience ventricular fibrillation.
TECHNIQUE
• Place quik-combo pads in appropriate position to determine rhythm.
o Place one patch just to the right of the upper sternum and below the clavicle, and the other
just to the left of the apex, or just to the left of the left nipple in the anterior axillary line.
• Record rhythm
• Check that synchronizer switch is "off."
• Charge defibrillator with patches placed on chest.
• Recheck rhythm. "Clear" the area.
ADULT
PRODEDURE
Pulseless Ventricular tachycardia or
ventricular fibrillation (AED disabled)
• 200J
Pulseless Ventricular tachycardia or
ventricular fibrillation (AED enabled)
Procedure: Defibrillation
Revised 02/2014
FR
EMT B
SO
SO
1
EMT B IV
SO
EMTP
PCC
SO
SO
Page 2 of 2
Section 709
DEFIBRILLATION
PEDIATRIC
• Use pediatric pads or pediatric adapters for paddles
PRODEDURE
Pulseless Ventricular tachycardia or
ventricular fibrillation (AED disabled)
• 2 J/Kg 1st
• 4 J/Kg after 1st
Pulseless Ventricular tachycardia or
ventricular fibrillation (AED enabled)
Procedure: Defibrillation
Revised 02/2014
FR
EMT B
SO
SO
2
EMT B IV
SO
EMTP
PCC
SO
SO
Page 1 of 3
Section 710
EnVe VENTILATOR
INDICATIONS:
Mechanical ventilation of intubated patients.
Non-invasive ventilation of patient’s in ventilatory insufficiency or failure.
PRECAUTIONS / COMPLICATIONS
Pneumothorax/barotraumas.
Increased interthoracic pressure leading to decreased cardiac output.
Ventilator associated pneumonia
 Ideally all intubated patients should have an OG/NG tube placed.
 Any parameters outside of FiO2, PEEP, RR or Vt may only be changed by an RT and that RT must
accompany the patient for the transport if changes are required.
TECHNIQUE
A) Ventilator Mode
1. Select ventilator settings according to patient’s needs, taking into consideration the
nature and extent of disease, trauma, medical history, and hemodynamic and
respiratory status.
2. Standard ventilation parameters:
a. FiO2 based on need/device.
1) Initially 100% acceptable for most patients.
2) Ideally, should try to use lowest FiO2 necessary to maintain patient’s
oxygenation status.
b. Tidal Volume (Vt) = 4 - 8 mL/Kg. based on ideal body weight
c. Respiratory rate determined by age and ventilation requirements.
d. PEEP.
e. Mode:
SIMV/AC.
g. Once patient is connected to the ventilator, assess:
1) Breath sounds.
2) Chest rise.
3) Pain level/anxiety.
4) SpO2.
5) ET CO2.
6) Monitor PIP and Pplat levels keeping <30
3. Employ strategies to prevent ventilator-associated pneumonia (VAP).
B. CPAP
1) Failure of oxygenation/ventilation.
2) Cardiogenic or non-cardiogenic pulmonary edema (e.g. HAPE).
3) Bronchospasm
4) Pneumonia
5) Atelectesis
6) Flail chest stabilization
2. Contraindications:
a. Loss of airway reflexes
b. Respiratory inadequacy
Procedure: EnVe Ventilator
Revised 2/2014
1
Page 2 of 3
Section 710
c. Head trauma with suspected increased ICP.
d. Facial trauma.
e. Tracheostomy.
3. Procedure:
a. Explain the procedure and use of the mask to the patient.
b. Select mask for proper fit.
c. Insure continuous SpO2 monitoring.
d. Attach circuit to vent and turn vent on.
1) Select Non-Invasive Ventilation.
2) Set FiO2 at 100%.
3) Set PEEP at 5 cm H20, titrate up as needed to 15cm H20
e. Place mask on the patient’s face. Often times it helps to have the patient hold the mask
and acclimate to it prior to attaching head straps. Adjust the head straps to obtain
an adequate seal (Avoid being too tight).
g. Connect vent circuit to mask.
h. Monitor vital signs and assess work of breathing.
i. If necessary, consider pain control or anxiolytics, but only to extent required to
provide comfort and cooperation with ventilation.
j. If necessary, increase pressures by 2-3 cm H2O until desired effect is achieved.
k. If no improvement shown, be prepared for endotracheal intubation and mechanical
ventilation (See Impaired Airway).
C. Ventilator Associated Pneumonia (VAP) Prevention.
 Utilize non-invasive ventilation preferentially, when appropriate.
 Avoid nasotracheal intubation.
 Maintain backrest elevation 30° - 45°, if possible.
 Keep pharynx clear of oral secretions, blood, and emesis.
 Monitor ET tube cuff pressures and maintain between 20 – 30 cm H2O pressure.
PROCEDURE
•
FR
EMT B
EMTP
PCC
SO
Enve ventilator
Procedure: EnVe Ventilator
Revised 2/2014
EMT B IV
2
Page 3 of 3
Section 710
Procedure: EnVe Ventilator
Revised 2/2014
3
Page 1 of 2
Section 711
INDWELLING CATHETERS
INDICATIONS
• To obtain rapid venous access for the critical patient when peripheral access cannot be obtained.
• For use after failed IV or IO access; unless patient or patient's family insist on the direct usage of
Vascular Access Device (VAD)
PRECAUTIONS / COMPLICATIONS:
• Obtain information and assistance from family members or home health professionals who are
familiar with the device.
• Assure placement and patency of the VAD prior to infusing any fluids or medications.
• Flush the catheter completely with sterile normal saline.
• Use aseptic technique.
• Patients with VADs are very susceptible to site infection or sepsis. Use sterile techniques at all
times.
• Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is suspected, do not utilize
the lumen.
• Rarely, a catheter will migrate. If a catheter migration is suspected, do not use the VAD and treat
the patient according to symptoms. The symptoms may include the following:
o Burning with infusion
o Site bleeding
o Shortness of breath
o Chest pain
o Tachycardia and/or
o Hypotension
• Catheters are durable but may leak or be torn. Extravasation of fluids or medications occurs and
may cause burning and tissue damage. Clamp the catheter and do not use.
• Air embolism may occur if the VAD is not clamped in between infusions. Avoid this by properly
clamping the catheter and preventing air from entering the system.
TECHNIQUE
Special Information Needed:
• Obtain pertinent medical history if possible.
• Obtain any information possible regarding the type of VAD, number of lumens, purpose of the
VAD, etc.
• Contact medical control for advice on any infusion pumps or drip medications.
Central Venous Catheters or PICC Lines:
• Identify the location and type of VAD (i.e. central venous catheter, peripheral inserted central
catheter).
• Utilize knowledgeable family members, significant others or home nurse if available.
• Clamp the VAD closed to prevent air embolus.
• If multiple lumen, identify the lumen to be used.
• Utilize aseptic technique.
• Briskly wipe the injection cap with an alcohol and/or povidone-iodine pad.
• Attach syringe, needle may be required, to hub of lumen to be used. Aspirate slowly for a positive
blood return. Obtain blood samples if necessary. Then flush the line with saline.
• Attach syringe or drip set, needle may be required, to hub of lumen to be used and infuse
medications or fluids.
Procedures: Indwelling Catheters
Revised 2/2014
1
Page 2 of 2
Section 711
INDEWLLING CATHETERS
•
•
•
Secure the IV tubing.
Reassess the infusion site.
Reassess patient condition.
Implanted Ports:
•
•
•
•
•
•
•
•
•
•
•
Identify the location and type of VAD (e.g. implanted port).
Utilize knowledgeable family members, significant others or home nurse if available.
Carefully palpate the location of the implanted port.
If multiple ports, identify the port to be used.
Using sterile technique, prep the site with alcohol and/or povidone-iodine pad. Wipe from the
center outward three times in a circular motion.
Using a sterile gloved hand, press the skin firmly around the edges of the port.
Using a syringe filled with solution, insert the needle perpendicular to the skin.
Aspirate slowly for blood return, then flush the port prior to infusion. When aspirating blood from
a VAD, use a syringe that is 10cc or less to avoid complications.
Secure the IV tubing (attached to the needle left in the port). .
Reassess the infusion site.
Reassess the patient.
PROCEDURE
EMTP
PCC
PICC line access
SO
SO
Implanted Ports
VO
VO
Procedures: Indwelling Catheters
Revised 2/2014
FR
EMT B
2
EMT B IV
Page 1 of 1
Section 712
INTRAOSSEOUS ACCESS
EZ-IO NEEDLE AND DRIVER
INDICATIONS
• Peripheral IV cannot be established in 2 attempts or within 90 seconds and the patient exhibits
one or more of the following:
o Respiratory compromise
o Signs of shock - poor perfusion.
o Cardiac arrest (medical or trauma)
CONTRAINDICATIONS
• Known history of ostogenesis imperfecta or osteoporosis is a relative contraindication.
PRECAUTIONS / COMPLICATIONS
• Consider alternate site if any of the following exist:
o Fracture of the bone selected for IO infusion.
o Skin or soft tissue infection or burn at insertion site.
o Excessive tissue at insertion site with the absence of anatomical landmarks.
o Previous significant orthopedic procedures to include IO insertion within 24 hours
o Prosthesis.
• If a rapid syringe bolus or Blood Pump flush of saline is not performed prior to infusion the IO
will not likely flow.
• Insertion of the EZ-IO in conscious patients does not require local anesthesia. IO infusion in
conscious patients has been noted to cause severe discomfort. Use lidocaine (see below)
TECHNIQUE
• Locate appropriate insertion site
o Proximal tibia – two finger widths breadth below the tuberosity on the anteromedial surface
o The greater tubercle of a non-traumatized humeral head can also be used when either tibias
cannot be used. Large adult (45mm) needle is recommended.
o Distal tibia – 1-2 finger widths above the medial malleolus depending on age.
• Prepare insertion site using aseptic technique
• Stabilize site
• Attach appropriate needle set to driver and insert until needle enters marrow.
• Confirm placement
• Syringe bolus or Blood Pump flush the EZ-IO catheter with normal saline.
• Pressure must be maintained via pressure infuser or IV pump for continuous infusion.
• Lidocaine may be used as analgesia in the conscious patient (refer to Lidocaine protocol).
• Examine site and dependant portion of the extremity for signs of infiltration.
• Secure IO needle and apply wristband to patient.
• If the initial IO attempt is unsuccessful, attempt again at another site. Do not use the same
extremity more than once.
ADULT OR PEDIATRIC
PRODEDURE
Respiratory compromise, Signs of
shock - poor perfusion, Cardiac
arrest (medical or trauma)
• Use appropriate needle for age:
pediatric or adult
Procedure: Intraosseous Access
Revised 02/2014
FR
EMT B
EMT B IV
EMTP
SO
1
PCC
SO
Page 1 of 2
Section 713
iSTAT Blood Monitor
INDICATIONS
• Critically ill patients in both the scene and interfacility settings.
• Any patient suspected of MI, sepsis, electrolyte derangements, etc.
• Any critically injured patient with a trauma activation.
PRECAUTIONS / COMPLICATIONS
• Blood sample obtained must be used within 2 minutes if collected in a syringe, 10 if collected in
a green top to be accurate for chem8, CG4 and troponin. Blood sample for PT/INR must be used
immediately.
• The least amount of movement of the Istat machine, the more accurate the results.
• Troponin I level may also be elevated with the following conditions:
o Recent cardiac contusion
o Recent heart surgery
o Myocarditis
o Pulmonary embolism
o Prolonged tachyarrhythmia
•
•
•
•
•
•
•
AVOID:
Drawing blood from an arm with an IV line in place as this will dilute the sample and may
interfere with test results.
Venous stasis as with prolonged tourniquet application may alter lab results
Avoid extra muscle activity, such as clenching and unclenching the fist, as this may increase
potassium results.
Hemolysis (alcohol left over puncture site, or a traumatic draw)
Icing before filling cartridge
Time delays before filling cartridge esp. lactate and PT/INR
Exposing sample to air when measuring pH, PCO2, PO2 and TCO2
TECHNIQUE
1. Cartridge must stand at room temp, in its pouch, for 5 minutes.
2. Use BSI
3. Obtain blood to be tested
1. Draw blood into syringe, roll syringe between palms at least 5 time in 2 different directions,
expel air (blood must be tested within 2 minutes of drawing into the syringe)
2. Alternatively, blood drawn from a green top may be used for all but the PT/INR cartridges.
3. For PT/INR sample, use a lancet to puncture skin and cartridge can be filled directly from
finger.
4. Remove cartridge from package handling the cartridge from the sides and not putting
pressure over calibrant packet.
5. Place cartridge on flat surface avoiding any unnecessary movements.
6. Fill desired cartridge to appropriate level as indicated by the blue fill arrow
7. Close cover over sample well
8. Turn analyzer on and enter appropriate information (operator ID, patient ID and cartridge
information)
9. Insert cartridge into analyzer at the keypad end when the “insert cartridge” message
appears. Do not remove cartridge while “cartridge locked” message appears in information
window.
iSTAT protocol
Revised 10/2014
1
Page 2 of 2
Section 713
10. Document lab result in patient care record under interventions as iSTAT so tracking can be
accomplished. Non-CCT endorsed paramedics should consult medical direction with abnormal
results for direction with patient care. Print lab result and leave a copy with the receiving medical
facility.
PROCEDURE
FR
EMT B
Draw and report blood results
EMT B IV
EMTP
PCC
SO
SO
SO
Draw and interpret blood results
SO
Definitions:
*MI = Myocardial Infarction
*PT = prothrombin time
*INR = International Normalized Ratio
*pH = Power of Hydrogen
*PCO2 = partial pressure of carbon dioxide
*PO2 = partial pressure of oxygen
*TCO2 = total carbon dioxide
*BSI = body substance isolation
*FR = first responder
*EMT B = Emergency Medical Technician Basic
*EMT B IV = EMT B with IV certification
*EMTP = Paramedic
*PCC = Paramedic with critical care endorsement from the state of Colorado.
iSTAT protocol
Revised 10/2014
2
Page 1 of 1
Section 714
GASTRIC TUBE INSERTION
INDICATIONS
• Distended abdomen with severe abdominal pain
• Prevention or treatment of abdominal distention in the patient in whom an endotracheal tube or
supraglottic airway has been placed.
• To administer activated charcoal
CONTRAINDICATIONS
• Nasogastric tubes are contraindicated in those with craniofacial trauma, recent nasal surgery, or
bleeding problems
PRECAUTIONS / COMPLICATIONS
• Do not force NG tube. Severe bleeding can result especially in patients taking anti-clotting
medications
• Consider Neo-synephrine
• Use caution with head injury. Stop insertion if any resistance is met.
• May stimulate vomiting and cause aspiration in the patient that is unable to protect their airway.
TECHNIQUE
• Measure tube from tip of nose, around ear, to epigastrum and mark measurement on tube.
• For those patients with an endotracheal tube, orogastric tubes are preferred. Insert tube alongside
endotracheal tube.
• For those with supraglottic airways with a gastric port, simply insert the gastric tube in the
designated gastric port
• For the awake patient, explain the procedure to the patient..
• Select tube based upon naris size
• ‘Work’ tube to add a curve and flexibility to tube.
• Lubricate the end of the tube
• Have patient place their chin toward their chest if patient does not have c-spine trauma
• Insert NG tube in the larger naris (usually R)
• Insert tube, when patient feels the urge to gag, urge them to swallow and advance tube.
o If a cup of water and straw are available have patient suck through straw while inserting tube.
• Stop at mark and attach a large syringe or bulb syringe to tube.
• Squeeze while listening over epigastrum.
• NOTE If breath sounds are noted from the tube or patient becomes short of breath,
remove tube promptly.
• May also be placed orally if ETT is already in place
PROCEDURE
EMTP
PCC
Nasogastric tube insertion
SO
SO
Orogastric tube insertion
SO
SO
Procedure: Gastric Tube Insertion
Revised 02/2014
FR
EMT B
1
EMT B IV
Page 1 of 3
Section 715
MEDICATION ADMINISTRATION
INDICATIONS
• Medication administration will benefit the patient.
PRECAUTIONS / COMPLICATIONS
• Local extravasation during IV medication injection, particularly with dopamine or dextrose, may
cause tissue necrosis. Watch carefully and be ready to stop injection immediately.
• Certain medications can be administered via one route only, others via several. If you are
uncertain about the drug you are giving; contact medical control
• Allergic and anaphylactic reactions occur more rapidly with IV injections, but may occur with
medication administered by any route.
• Too rapid IV injection can cause untoward side effects (except for adenosine); for example,
diazepam can cause apnea, and epinephrine can cause asystole or severe hypertension.
• IM and SQ routes are unpredictable:
o Medications are absorbed erratically via these routes and may not be absorbed at all if the
patient is seriously ill and severely vasoconstricted.
o Later treatment may be affected because of slow release and late effects of medication given
hours before.
• Multi dose vials are only sterile if each person uses sterile technique. Vials should be considered
multi dose, but single patient use.
TECHNIQUE
Medication selection
• Five Rights
o right patient
o right medication
o right dose
o right route
o right time
• check drug for clarity and expiration date
Drawing Medication From Container
• Use syringe just large enough to hold appropriate quantity of medication
• Attach appropriate needle to syringe.
• Ampule
o Break ampule away from you using a gauze pad to protect fingers.
o Filter needle is required for ampules
o Invert ampule, insert filter needle
o Draw out medication
o Push air out of syringe
• Multi or single dose vial
o Break cap off of vial
o Wipe with an alcohol pad
o Invert vial and insert needle into rubber stopper
o Draw medication
o Push air out of syringe
• Pre-filled syringe
o Push air out of syringe
o Needle may need to be attached to administer medication
Procedures: Medication Administration
Revised 02/2014
1
Page 2 of 3
Section 715
MEDICATION ADMINISTRATION
Intravenous / Intraosseous
• Use needle appropriate for viscosity of fluid injected. Glucose requires larger gauge needle; for
most other medications, smaller is appropriate.
• Wipe IV tubing luer lock port with alcohol.
• Attach syringe to leur lock port
• Pinch IV tubing closed between bag and needle
o May not be necessary or desirable if you wish to dilute or give drug slowly.
• Inject at a rate appropriate for medication.
• Detach syringe from port.
• Record medication given, dose, amount, and time.
• Give small saline fluid flush to get the drug from the tubing to the patient.
o IO may require flush with a syringe or a pressure infuser on the IV bag.
Intramuscular Technique (for ages 8 or greater ONLY)
• Prep area of skin with alcohol or Betadine wipe.
• Without touching site, apply slight traction to the skin. This allows the skin to slide back over the
needle hole and keeps the medication from seeping out.
• Inject 21 g 1½" needle into desired muscular site (deltoid, gluteus, or vastus lateralis)
perpendicular to the skin.
• Aspirate to ensure needle is not in blood vessel.
• Inject medication slowly into muscular site.
• Withdraw needle and observe for any bleeding or swelling. Apply sterile dressing to injection
site.
• Record medication given, dose, amount, and time.
Subcutaneous
• Use 25 g needle, 5/8" length for most subcutaneous injections.
• Locate injection site between clavical and pectoralis muscle
• Cleanse site with alcohol or Betadine wipe.
• Eject air from syringe.
• Pinch skin. Insert needle at 45 degree angle.
• Aspirate, and if there is no blood return, inject medication.
• Remove needle and put pressure over injection site with sterile swab.
• Record medication given, dose, amount, and time.
Oxygen Powered Nebulizer
• Assemble nebulizer.
• Use hand-held nebulizer with mouthpiece or remove T piece and insert into a NRB.
• Unscrew chamber from the bottom of the nebulizer
• Tear top off of plastic ampule and squeeze medication into chamber
• Attach to O2 tubing and set at 6-8 L/min (sufficient to produce good vaporization).
• Administer until solution is gone from chamber.
• Record medication given, dose, amount, and time.
Procedures: Medication Administration
Revised 02/2014
2
Page 3 of 3
Section 715
MEDICATION ADMINISTRATION
Intranasal
• Fill atomizer syringe with the indicated dose.
• Attach atomizer
• Assure that patient’s nare is clear
• Place atomizer in a patent nare
• Quickly inject while holding atomizer in nare
• Volumes greater than 0.5mL will often drain into the oropharynx. If possible, use both nares and
divide the dose if the volume exceeds 0.5mL
Rectal
• Use a tuberculin syringe (without needle) lubricated with a water-soluble, lubricating jelly.
• Insert needleless syringe into rectum completely to end of syringe (4-5cm).
• Inject the medication and withdraw the syringe. No flushing is necessary.
Procedures: Medication Administration
Revised 02/2014
3
Page 1 of 1
Section 716
NASOTRACHEAL INTUBATION
INDICATIONS
• Same function as orotracheal intubation in patients greater than 12 years of age.
• Used in the breathing patient requiring intubation.
• Asthma or pulmonary edema with respiratory failure, where intubation may need to be achieved
in a sitting position
CONTRAINDICATIONS
• Should not be attempted in children less than 12 years of age.
• Shouldn't be attempted in patients with liver failure due to coagulation problems & epistaxis.
• The use of nasotracheal intubation is contraindicated in patients with significant nasal or
craniofacial trauma.
• Apnea
PRECAUTIONS / COMPLICATIONS
• Blind nasotracheal intubation is a very gentle technique. In the field, the secret of blind intubation
is perfect positioning and patience.
• All the potential complications of orotracheal intubation plus:
o Nasal bleeding caused by tube trauma
o Vomiting and aspiration in the patient with intact gag reflex.
TECHNIQUE
• Head must be exactly in midline for successful intubation.
• Have suction ready. Vomiting can occur, as with any stimulation of the airway.
• Often nares are asymmetrical and one side is much easier to intubate. Avoid inducing bilateral
nasal hemorrhage by forcing a nasotracheal tube on multiple attempts.
• Intubation
o Hyper oxygenate patient
o Administer Neo-Synephrine followed by 2% Lidocaine Jelly into each nare.
o Lubricate tube cuff w/ 2% Lidocaine Jelly.
o Advance ET tube with a slight side to side twisting motion to ease passage through the
turbinates. If significant resistance is encountered, attempt intubation in other nostril.
o Listen for airflow through tube or BAM cap in order to move tube toward trachea.
o Inflate cuff and secure tube.
o Listen for epigastric and bilat B/S.
o Attach Capnography / ET CO2 detector
o Apply C - Collar to stabilize ET tube.
PROCEDURE
FR
EMT B
Nasotracheal Intubation
Procedures: Nasotracheal Intubation
Revised 02/2014
1
EMT B IV
EMTP
PCC
SO
SO
Page 1 of 2
Section 717
NEEDLE DECOMPRESSION OF PNEUMOTHORAX
INDICATIONS
• Tension pneumothorax is rare, but when present may rapidly lead to death and must be treated
promptly.
• The following signs are significant. Not all may be present and may progress over time.
Intervene quickly as some signs are late findings
o Respiratory distress- severe
o Hypoxia
o Chest pain
o Decreased or absent breath sounds on affected side to auscultation of chest
o Subcutaneous crepitation (air in the form of bubbles under the skin)
o Tympanitic percussion note on affected side
o Hyperexpanded chest on affected side
o Tracheal shift away from affected side (late finding)
o Distended neck veins
o Shock - low BP
o If patient is intubated, increasing difficulty in bagging
• Because of the variability and the progression of findings, the items in bold are the main findings
to look for. If all of these are present, proceed with the decompression.
• If the patient is in cardiac arrest after a traumatic injury to the chest, needle decompression is
indicated on one or both sides.
PRECAUTIONS / COMPLICATIONS
• Nontension pneumothorax is relatively common, is not immediately life threatening, and should
not be treated in the field.
• Treatment of tension pneumothorax is not difficult, although complications of the procedure can
be severe, but diagnosis must be accurate and is not always easy.
• Accurate diagnosis is paramount. Note that simple pneumothorax can easily progress to a tension
pneumothroax. Not all of the above signs may be present.
• Tension pneumothorax is a rare condition, but can occur both with trauma and more rarely
spontaneously. It can also occur as a complication of CPR.
• Non-traumatic sudden onset of chest pain and shortness of breath in a normal individual may also
be caused by a spontaneous pneumothorax (particularly in patients with COPD or asthma). These
can also progress to a "tension" state.
• Tension pneumothorax can be precipitated by occlusion of an open chest wound with a dressing.
If, after dressing an open chest wound, the patient deteriorates, remove the dressing
• Creation of pneumothorax if none existed previously
• Laceration of blood vessels; intercostal vessels run in grove under each rib
• Severe pain: if you're doing this in the field, patient should be sick enough not to require
anesthesia.
• Infection: clean rapidly but vigorously. Use sterile gloves, if possible.
Procedure: Needle Chest Decompression
Revised 02/2014
1
Page 2 of 2
Section 717
NEEDLE DECOMPRESSION OF PNEUMOTHORAX
TECHNIQUE
• Decompress using one of the needle technique
o Expose entire chest. Clean chest vigorously with alcohol, Betadine, or soap.
o Insert an angiocath (14g or larger in adult; 18g in children) with syringe attached, the 2nd
intercostal space, midclavicular line.
o Avoid the inferior aspect of the rib.
o Rarely and only if unable to use the 2nd intercostals space, the angiocath may be inserted
between the 5th space, midaxillary line. Hit the rib, then slide above it.
o If air is under tension, barrel will pull easily and "pop" out the back. Remove syringe,
advance catheter and remove needle.
o Apply chest seal over catheter to create a one-way valve. Be sure the adhesive is applied to
cleaned skin.
• Repeat procedure if initial needle becomes clogged or if signs of tension pneumotharox progress
despite initial decompression.
• Contact medical control if there is a question of whether a simple pneumothorax is progressing to
a tension pneumothorax. This is only when the patient’s respiratory status is under control or if
there is any question as to the presence of a tension pneumothorax.
PROCEDURE
FR
EMT B
Needle Chest Decompression
Procedure: Needle Chest Decompression
Revised 02/2014
2
EMT B IV
EMT I
EMT P
SO
SO
Page 1 of 2
Section 718
ORAL ENDOTRACHEAL INTUBATION
INDICATIONS
• Definitive control of airway for patients and prevents aspiration.
• It also provides the patient with a more efficient delivery of oxygen via positive pressure.
• Certain medications can be delivered through the ET tube for resuscitation.
PRECAUTIONS / COMPLICATIONS
• Oral intubation of patients with suspected C-Spine injury requires in line stabilization.
• Take care to limit attempts for intubation to 30 seconds. Ventilate between each attempt.
• Premedicate with Fentanyl IV prior to intubation for pain control, consider higher dose in the
head injured patient.
• Esophageal intubation: particularly common when tube not visualized as it passes through cords. The
greatest danger is in not recognizing the error. Capnography is the gold-standard for insuring adequate
placement. Other methods of verifying adequate placement include auscultation over stomach during
trial ventilations that should reveal air gurgling through gastric contents with esophageal placement.
Also make sure patient's color improves as it should when ventilating.
• Intubation of right mainstem bronchus: be sure to listen to chest bilaterally.
• Upper airway trauma due to excess force with laryngoscope or to traumatic tube placement
• Vomiting and aspiration during traumatic intubation or intubation of patient with intact gag reflex
• Hypoxia due to prolonged intubation attempt
• Cervical spine fracture in patients with arthritis and poor cervical mobility
• Cervical cord damage in trauma victims with unrecognized spine injury
• Ventricular arrhythmias or fibrillation in hypothermia patients from stimulation of airway
• Induction of pneumothorax, either from traumatic insertion, forceful bagging, or aggravation of
underlying pneumothorax.
TECHNIQUE
• Assess airway and anatomy
o Intercisor space- 3 finger widths
o Hyoid to chin distance- 3 finger widths
o Thyroid to floor of mouth- 2 finger widths
o Oral cavity (Mallampatti score)
o Obstruction
o Neck mobility
• If any of the above present difficulties, have adjunct airway ready
• Pre-oxygenate patient with high flow oxygen and effective BVM ventilations.
• Prepare equipment
o Correct ET tube size with ½ size smaller available. Pediatric sizes= (age in yrs/4) + 4.
o Stylet
o Correct size laryngoscope
o Suction- have ready and use as needed
o ET CO2 detector / capnography
• Have assistant help manipulate trachea- use your free hand to position the assistant’s hand
• Inflate cuff and secure tube.
• Attach Capnography or ET CO2 detector.
• Listen for epigastric sounds and bilat breath sounds
o The provider that performs intubation is responsible for verifying tube placement.
• Consider applying C - Collar to stabilize ET tube.
Procedure: Oral Endotracheal Inubation
Revised 02/2014
1
Page 2 of 2
Section 718
ORAL ENDOTRACHEAL INTUBATION
PROCEDURE
FR
EMT B
Insert endotracheal tube
•
•
•
•
•
•
EMT B IV
EMTP
PCC
SO
SO
Re-auscultate over stomach and both sides of chest whenever the patient is moved. Continue to
monitor ETCO2.
If ETCO2 rises, SpO2 declines, or bagging becomes difficult, consider the following causes and
treat these conditions as they are found.
o Dislodged or displaced ET tube.
o Tube obstruction such as by clot or edema fluid.
o Tension pneumothorax.
o Worsening lung conditions such as wheezes or rales.
Limit orotracheal intubation attempts to three, after which BVM or an adjunct airway device
should be used. This will minimize the amount of airway trauma that could make hospital
intubation attempts very difficult. (See Rescue Airway)
When it is difficult to see the vocal cords despite your best set up, consider either switching to an
adjunct airway or threading the endotracheal tube under the epiglottis where the glottic opening
should be. If esophageal intubation occurs, remove tube and prepare to use adjunct airway while
assisting ventilations with the bag valve mask.
Once care of the patient has been transferred to a physician, have the physician complete the
intubation form and return to you to submit to the medical director.
If attempts to perform endotracheal intubation or other adjunct airway devices are unsuccessful,
use the assistance of the physicians at the hospital or others such as the flight-crew who have
additional airway capabilities. In the interim, continue to provide ventilation via the bag-valve
mask
Procedure: Oral Endotracheal Inubation
Revised 02/2014
2
Page 1 of 1
Section 719
OXYGEN POWERED VENTILATOR
INDICATIONS
• Respiratory failure
• Intubated patients once tube placement has been confirmed by ET CO2 and breath sounds
PRECAUTIONS / COMPLICATIONS
• Respiratory status may deteriorate
• Patient may have spontaneous respirations that conflict with the ventilator
• Barotrauma from the ventilator pressures which in turn may cause a pneumothorax
• Decreased cardiac output due to increased thoracic pressures.
TECHNIQUE
Initial Setup
• Switch power to ON
• Set FiO2 to 100%
• Start maximum peak inspiratory pressure at 30 cm H20
• Estimate lean body mass in kilograms, use Broselow tape for pediatric estimates
• Set Tidal Volume to 6-8 cc/kg of ideal body weight ( 1300 cc maximum)
• Start PEEP at 5 and titrate according to instructions below
• Set rate according to age:
AGE
RATE per minute
Adult / Child > 12 yrs
10-14
Child 1-12 yrs
14-20
Infant <1yr
26-30
PROCEDURE
•
FR
Oxygen powered ventilator
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
NOTE: The individual provider must have medical director approval regardless of provider level.
Ongoing Management
• Frequent reassessment is crucial. Follow ET CO2, O2 saturations, vital signs, level of
consciousness, perfusion.
• Keep FiO2 at 100%
• If O2 saturation falling below 95% despite above settings, increase respiratory rate by 4-6
ventilations per minute. If ETCO2 falls below 30 mmHg, decrease rate and add PEEP 2-3 cm
H20.
• Target ETC02 between 35-40 mmHg, but it is acceptable to drop down to 30 mmHg for patients
who appear toxic or have a head injury.
• If BP and O2 saturation is trending down check for pneumothorax. Treat according to protocol
(see Needle Decompression Pneumothroax) and turn PEEP to 0 cmH20.
• Other causes for decreasing O2 saturation: obstruction in ventilator tubing, dislodgement of ET
tube, or obstruction of ET tube.
• Consult medical control to help in your ventilator settings or if there are other questions regarding
management of the patient.
Procedure: Oxygen Powered Ventilator
Revised 011/2013
1
Page 1 of 3
Section 720
RAPID SEQUENCE INTUBATION
INDICATIONS
• Patients requiring endotracheal intubation and definitive airway control.
• Patients in respiratory arrest or distress who fail non-invasive airway management (BVM, CPAP)
• Patients in respiratory arrest or distress whose airway reflexes are still present.
• Age=13 or older.
PRECAUTIONS/CONTRAINDICATIONS
• Contraindicated when non-invasive airway management is able to provide adequate oxygenation,
ventilation, and patient is able to protect airway from aspiration for the duration of transport.
• Contraindicated if inability to orotracheally intubate patient such as severe
•
•
maxillofacial/neck trauma, angioedema or severe anatomic abnormalities
Neuromuscular blockade ceases the patient’s respiratory effort. Use extreme caution with RSI on
patients with a difficult airway in whom BVM is not effective or airway adjuncts would not be an
option.
Contraindication to RSI medications (see Etomidate, Midazolam, Succinylcholine, Rocuronium
protocols).
TECHNIQUE
Initial Setup
• Assess for difficult airway (LEMON score). Have needle cricothyrotomy equipment ready.
• High-flow oxygen via bag-valve mask.
• Position patient to assure optimal visualization.
• Prepare equipment to include: suction, continuous ECG w/ ETCO2 and SpO2, laryngoscope,
properly sized ET tube, and rescue airways
• Assure a patent IV, preferably 2 IV’s.
• Verify medications and doses.
Procedure
• Preoxygenate with BVM to reach highest O2 saturation possible on pulse-oximetry . Continue
high-flow oxygen via NC during intubation.
• Pre-treatment with Fentanyl especially for patients with possible head injury or multi system
trauma. Allow 1 minute to circulate.
• Induction: Etomidate. May use Midazolam if the patient is hemodynamically stable.
• Neuromuscular blockade: Succinylcholine unless contraindicated (see medication protocols).
o If contraindicated: Rocuronium.
• Relaxation should take place within 30-60 seconds for Succinylcholine and 60-90 seconds for
Rocuronium.
• Use apneic oxygenation techniques. BVM ventilation may be indicated in certain patients.
• Have assistant ready to help manipulate laryngeal positioning
• Perform endotracheal intubation per protocol- use suction as needed.
• Confirm ET tube placement:
o ETCO2 capnography is the primary confirmation measure.
o Breath sounds
o Chest rise
o Patient response including color, pulse-oximetry
• Secure and note position of tube. Monitor with continuous capnography.
Procedures: RSI
Revised 02/2014
1
Page 2 of 3
Section 720
•
•
•
•
•
RAPID SEQUENCE INTUBATION
Repeat sedation and analgesia. Continue sedation via Midazolam if hemodynamically stable.
Repeat Etomidate for sedation only if hemodynamically compromised. Continue Fentanyl for
pain control.
Monitor patient for adequate sedation, which is difficult when a patient is paralyzed. Signs of
inadequate sedation:
o Rise in blood pressure or heart rate
o Increased respiratory rate- overbreathing assisted ventilations.
o Patient agitation
Succinylcholine’s effects last 6-10 minutes. Continue paralysis, if needed, using Rocuronium
whose effects last 30-60 minutes.
Assist ventilation with BVM between attempts. If ventilation via BVM fails, attempt to place an
airway adjunct or perform cricothyrotomy if necessary.
Use airway form to document and turn into supervisor. Have the accepting physician verify tube
placement or follow up if the patient was taken by air ambulance.
DRUG DOSING QUICK REFERENCE
Age ≥ 13
Fentanyl
0.5-3mcg/kg
Etomidate
0.3 mg/kg, repeat with 0.6mg/kg
if initial dose is ineffective.
Midazolam
0.3 mg/kg for induction,
0.1mg/kg for maintenance
Succinylcholine
1.5 mg/kg
Rocuronium
1.0 mg/kg for induction,
0.6mg/kg for reparalyzation
Procedures: RSI
Revised 02/2014
2
Page 3 of 3
Section 720
RAPID SEQUENCE INTUBATION
Preparation
Baseline GCS and neuro exam
Assess for difficult airway (LEMON score)
Restrain if needed
Preoxygenate
Assure patent IV or establish IO
Verify Medications and Doses
Pre-Medication
Patient awake, in severe pain, or suspect
increased ICP?
Yes
Consider Fentanyl
Yes
Consider Atropine
0.01 mg/kg SIVP
No
Bradycardic?
No
Induction with Etomidate
0.3mg/kg IVP
Paralysis
Succinylcholine 1.5 mg/kg IVP
or Rocuronium 1.0mg/kg IVP
Able to Intubate?
No
Yes
Refer to Rescue Airway Protocol
Document
Procedures: RSI
Revised 02/2014
3
Page 1 of 3
Section 721
RESCUE AIRWAY PROTOCOL
INDICATIONS
• To provide adequate ventilation to an apneic patient.
Unable to Intubate
Unsuccessful
(1) Attempt
Intubation
Successful
3 Attempts
Only
Ventilate w/
BVM
Troubleshoot
Reposition
ELM
Change Blade
Change Provider
Change ET size
S i
After 3rd Attempt
Insert
King tube
Successful
Unsuccessful
Ventilate w/
BVM
Ventilate to
SpO2 >90 and
ETCO2 35-40
Troubleshoot
Reposition
Change Provider
Suction
Or Insert King LT
Successful
Surgical or Needle
Cricothyrotomy
Procedure: Rescue Airway
Revised 02/2014
Troubleshoot
Reposition
NPA/OPA
Laryngeal manipulation
Suction
Obstructed Airway?
1
After 2nd Attempt
Ventilate w/
BVM
Unsuccessful
Page 2 of 3
Section 721
RESCUE AIRWAY PROTOCOL
PRECAUTIONS
• If attempts to perform endotracheal intubation are unsuccessful, use of these airway adjuncts
should be considered. All providers have a standing order to proceed with the use of these
devices, within their scope of practice (see below), when initial attempts to perform endotracheal
intubation are unsuccessful or they may be used initially if the patient’s airway appears to be
difficult due to anatomy or airway trauma.
• With each attempt of endotracheal intubation, edema and potential trauma and bleeding will make
the next attempt more difficult. If another medic (ALS) is present that has experience with
airway management, have him or her attempt if you have attempted with no success. It may be
wise to use one of these adjunct airway devices initially if indicated (see above). Bag-valve mask
is just as viable an option in those in whom an adequate seal can be made and in whom
obstruction is not present. The decision of using an adjunct airway vs. using the bag-valve mask
must be made in light of transport time.
King LTS and LTS-D Laryngeal Tube
•
•
•
•
•
•
•
•
•
•
•
•
•
Choose the correct size of tube according to the patient’s height:
o 35-45 inches: size 2 (green)
o 41-51 inches: size 2.5 (orange)
o 4-5 feet: size 3 (yellow)
o 5-6 feet: size 4 (red)
o over 6 feet: size 5 (purple)
Inspect tube and inflate cuffs.
Lubricate the posterior side of the tube as well as the beveled, distal end with water-soluble jelly.
While applying chin-lift, insert the tube into the corner of the mouth.
Advance the tube until the base of the connector is aligned with the teeth or gums. While
advancing, direct the tube to the midline.
Inflate the cuffs according the following:
o Green tube: 25-35 ml
o Orange tube: 30-40 ml
o Yellow tube: 45-60 ml
o Red tube: 60-80 ml
o Purple tube: 70-90 ml
Assess position using breath sounds and ETCO2.
If ventilation is inadequate, retract tube by 1 cm and reassess until ventilation adequate.
If the patient is breathing spontaneously, the distal ventilatory opening may become obstructed by
the epiglottis. If this is suspected, deflate the cuffs and advance the tube by 1-2 cm.
For the LTS-D tubes (yellow, red, purple), provide gastric decompression via an 18 Fr gastric
tube inserted through the airway and connected to suction.
A laryngoscope may be used to assist with the insertion of the laryngeal tube.
The King tube does not prevent aspiration of gastric contents. The King LT-D (used only for
pediatric sizes 2 and 2.5) does not have a gastric lumen and may cause esophageal injury in the
event that the patient vomits after inflation of the balloon. For these reasons it is important to
transport the patient emergently to the nearest facility so that a definitive airway can be
established.
Contraindicated in awake patients with an intact gag reflex, cases of caustic ingestions, and those
with known proximal esophageal disease.
Procedure: Rescue Airway
Revised 02/2014
2
Page 3 of 3
Section 721
RESCUE AIRWAY PROTOCOL
Surgical or Needle Cricothyrotomy
• Reserved as a last resort in patients for whom bag valve mask is unsuccessful.
• Contraindicated for patients with direct trauma to the cricoid cartilage or larynx including
retraction of the trachea after transection.
• Surgical technique only for age>8
• Refer to Cricothyrotomy protocol for specific instructions for each
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
King LTS-D (sizes 3,4,5)
SO
SO
SO
SO
King LT-D (sizes 2, 2.5)
SO
SO
SO
SO
SO
SO
SO
Intubation
• Oral
• Nasal
Surgical Cricothyrotomy
SO
Needle Cricothyrotomy
SO
Procedure: Rescue Airway
Revised 02/2014
3
Page 1 of 2
Section 722
RESTRAINTS
INDICATIONS
• Use of physical restraint on patients is permissible if the patient poses a danger to himself or to
others. Only reasonable force is allowable, i.e., the minimum amount of force necessary to
control the patient and prevent harm to the patient or others.
• Contact medical control for physician direction if there is uncertainty as to whether or not the use
of restraints is warranted to transport the unwilling or uncooperative patient.
• Restraints are to be applied to patients only in limited circumstances:
o A patient whose medical or mental condition warrants immediate ambulance transport and
who is exhibiting behavior that the prehospital provider feels may or will endanger the patient
or others.
o The prehospital provider reasonably believes the patient's life or health is in danger and that
delay in treatment and transport would further endanger the patient's life or health, and there
is no reasonable opportunity to obtain the necessary consent to provide treatment or obtain
informed refusal.
o The patient is being transported under the direction of a mental health hold, security hold, or
police custody.
PRECAUTIONS / COMPLICATIONS
• Restraints shall be used only when necessary to prevent a patient from seriously injuring
themselves or others (including the ambulance crew), and only if safe transportation and
treatment of the patient cannot be done without restraints. They may not be used as punishment,
or for the convenience of the crew.
• Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts
to restrain a patient should only be done with adequate assistance present.
• Be sure to evaluate the patient adequately to determine the medical condition, mental status and
decisional capacity of the patient. The hostile, angry, unwilling patient with decision-making
capacity may refuse treatment.
• Be sure that restraints are in good condition (will not break and will not injure the patient).
• Do not use "hobble" restraints and do not restrain patient in the prone position.
• Ensure that patient has been searched for weapons.
• Aspiration can occur, particularly if the patient is supine. It is the responsibility of the attendant to
continually monitor the patient's airway.
• Nerve injury can result from hard restraints.
• Do not overlook the medical causes for combativeness, such as hypoxia, hypoglycemia, stroke,
hyperthermia, hypothermia, or drug ingestion.
• Contraindications, precautions, and special considerations regarding the use of chemical
restraints are found in the medications section.
TECHNIQUE
• Determine that the patient's medical or mental condition warrants ambulance transport to the
hospital and that the patient lacks decision-making capacity, or there is basis for police custody or
a mental health hold to be instituted.
• Treat the patient with respect. Attempts to verbally calm the patient should be done prior to the
use of restraints. To the extent possible, explain what is being done and why.
• Have all equipment and personnel ready (restraints, suction, a means to promptly remove
restraints, and adequate number of personnel).
• Use assistance such that, if possible, one rescuer handles each limb and one manages the head or
supervises the application of restraints.
Procedures: Restraints
Revised 02/2014
1
Page 2 of 2
Section 722
RESTRAINTS
•
•
•
•
•
•
•
•
•
Consider the patient's strength and range of motion in the need for and method of applying
restraints.
Apply restraints to the extent necessary to subdue the patient.
After application of restraints, check all limbs for circulation. During the time that a patient is in
restraints, an assessment of the patient's condition including assessment of the patient’s airway,
circulation and vital signs shall be made at least every fifteen minutes, but more frequently if
conditions warrant.
During transport and pending the arrival at the hospital, the patient shall be kept under constant
supervision.
The patient care report shall include: attempts at verbal persuasion to calm patient; description of
the facts justifying use of restraints; the type of restraints; a description of the steps taken to
assure that the patient's needs, comfort and safety were properly cared for; the condition of the
patient during restraint, including reevaluations during transport; and the condition of the patient
on arrival at the hospital.
Removal of restraints should be done with sufficient manpower and caution for protection of the
patient and healthcare providers.
Utilize police assistance if necessary and if possible.
Handcuffs or other "hard restraints" are not to be applied by prehospital providers. If police apply
handcuffs, the officer should be requested to stay with the patient and ride in the ambulance
during transport.
The use of chemical restraints is limited to the use of Haloperidol (see Haloperidol protocol)
o If used, cardiac monitoring and intravenous access should be performed as soon as
possible.
PRODEDURE
•
Physical Restraints
•
Chemical Restraints
FR
EMT B
EMT B IV
SO
SO
EMTP
SO
PCC
SO
SO
Procedures: Restraints
Revised 02/2014
2
Page 1 of 1
Section 723
SPINAL IMMOBILIZATION
INDICATIONS
• Significant mechanism of injury including:
o Falls from height
o Motor vehicle accidents
o Diving accidents
o Deceleration injuries
• Complaints of neck pain, numbness, tingling, or focal weakness
• Spinal tenderness on palpation
• Patients with altered mental status in which a traumatic mechanism of injury is suspected-- this
includes intoxicated patients
• Painful distracting injury including long-bone fractures
• Neurological deficit on exam
• If all of the above are negative and the patient is unable to rotate head 45 degrees in both
directions due to pain, cervical spinal immobilization is indicated.
• Patients with significant facial or head trauma are at higher risk of cervical spine injury.
PRECAUTIONS / COMPLICATIONS
• Immobilize the patient entirely on the splint; immobilizing only the head on the splint has
potential for causing additional injury.
• Use of a Vacumattress rather than a long-spine board is preferable especially in elderly or
pregnant patients, and those with potential pelvic fractures. If high suspicion of spinal cord
injury- use a rigid splint underneath Vacumattress when transferring the patient.
• An ambulatory patient may still have a spinal injury and should be immobilized if indication
criteria met. Applying only cervical collar is acceptable if tenderness limited to cervical spine in
patients ambulatory at the scene.
• If the patient complains of nausea or is obtunded, be prepared to rotate the patient in the event
that vomiting occurs. Start anti-emetics immediately on such patients.
• If the patient is combative despite chemical restraints or the cervical collar does not fit
adequately, other methods of immobilizing the spine are acceptable.
• Refer to Trauma Protocol: Spinal Trauma for treatment of suspected spinal cord injury.
TECHNIQUE
• Ensure that patient remains immobile while preparing immobilization. One rescuer should take
responsibility of immobilizing C-spine and maintain manual stabilization of the head throughout
procedure.
• Patient should be moved to the splint in manner that does not twist or push the spine side to side.
o utilize a log roll or slide in a direction parallel to the spine
• Form the vacumatress in a shape that provides adequate stabilization. Place sheet between the
patient and the mattress to facilitate removal at the destination.
• Secure straps starting from torso and proceed to feet.
• Immobilize C spine in a neutral position with a collar. If the collar does not fit or is not tolerated,
use the vacumatress and other resourses to insure neutral positioning.
• Keep helmet in place if it keeps the C spine in neutral position. Remove it if airway
compromised and access necessary.
Procedures: Spinal Immobilization
Revised 02/2014
1
Page 1 of 1
Section 724
SPLINTING: EXTREMITY
INDICATIONS
• Pain, tenderness, swelling, or deformity in extremity which may be due to fracture or dislocation
• In an unstable extremity injury: to reduce pain; limit bleeding at the site of injury; and prevent
further injury to soft tissues, blood vessels or nerves
PRECAUTIONS / COMPLICATIONS
• Critically injured trauma victims should not be delayed in transport by lengthy evaluation of
possible non-critical extremity injuries. Prevention of further damage may be accomplished by
securing the patient to a spine board when other injuries demand prompt hospital treatment.
• The patient with altered level of consciousness from head injury or drug/alcohol influences
should be carefully examined and conservatively treated, because his ability to recognize pain and
injury is impaired.
• Make sure the obvious injury is also the only one. It is particularly easy to miss fractures
proximal to the most visible one.
TECHNIQUE
• In a stable patient where no environmental hazard exists, splinting should be done prior to
moving the patient.
• Check pulse, capillary refill, and sensation distally prior to movement or splinting.
• IF DISTAL PULSES ARE ABSENT; Reduce angulated fractures, including open fractures, with
gentle axial traction as needed to immobilize properly.
• Remove bracelets, watches, or other constricting bands prior to splint application.
• Identify and dress open wounds. Note wounds that contain exposed bone or are near fracture sites
and may communicate with a fracture.
• To minimize pain and soft tissue damage, avoid sudden or unnecessary movement of fracture site.
• Choose splint to immobilize the joint above and below injury. Pad rigid splints to prevent
pressure injury to extremity.
• Apply gentle continuous traction to extremity and support to fracture site during splinting
operation.
• Check distal pulses, capillary refill, and sensation after reduction splinting. Realign gently if
adequate circulation or sensation is lost.
PRODEDURE
Extremity Splint
FR
SO
Reducing a Fracture
• Attempt once if pulses are absent
• Contact medical control if
unsuccessful
Procedures: Splinting-Extremity
Revised 02/2014
1
EMT B
EMT B IV
EMTP
PCC
SO
SO
SO
SO
SO
SO
SO
SO
Page 1 of 1
Section 725
SPLINTING – TRACTION
INDICATIONS
• A fracture of the midshaft or upper third of femur.
CONTRAINDICATIONS
• Fractures in the distal third of the femur
o May cause injury to the popliteal vessels superior to the knee
• Supracondylar fractures of the distal end of the femur are contraindicated because traction can
cause anterior rotation of the distal bone fragment; forcing the sharp fractured bone end down
into the popliteal artery and nerve.
• Suspected open fractures (relative contraindication)
• Suspected pelvic fractures
PRECAUTIONS / COMPLICATIONS
• Tissue damage from bone ends if the traction is interrupted.
• Hypoperfusion of the foot from the constriction of the ankle strap
• Splint will be too large for most pediatrics
• The sling should be tightened as much as possible so that the splint does not stick out beyond the
patient any farther than necessary.
TECHNIQUE
• Examine the pelvis, leg, ankle, and foot for other fractures.
• Assess distal circulation.
• Apply manual traction to the ankle until relief is felt.
• Prepare straps and traction splint.
• Apply ankle sling to ankle on the injured leg
• Position the upper end of the splint.
o Sager on pubic bone with up arrow up
o Hare under leg on ischial tuberocity
• Attach sling to splint
• Apply traction until relief is felt or 10% of body weight is reached.
• Secure splint with elastic wraps provided.
• Judicious use of analgesics such as Fentanyl or Morphine in addition to Diazepam may be
beneficial to the patient. See specific medication protocols in regards to monitoring required.
ADULT
PRODEDURE
Traction Splint
Procedure: Splinting-Traction
Revised 02/2014
FR
EMT B
EMT B IV
SO
SO
EMTP
PCC
SO
SO
1
Page 1 of 1
Section 726
CRICOTHYROTOMY
SURGICAL CRICOTHYROTOMY
INDICATIONS
• Performed in patients which providers are unable to intubate and unable to ventilate ONLY.
• Age greater than 8 years of age.
• Severe facial trauma
• Airway obstruction that the provider is unable to make patent with BLS interventions
CONTRAINDICATIONS
• Should not be attempted in patients where airway is managed with BMV and adjuncts
• Should not be performed on patient with anterior neck trauma.
• Should not be performed on patient where airway is managed with advanced airways
• Not to be performed on patients where anatomical landmarks cannot be distinguished
PRECAUTIONS / COMPLICATIONS
• Surgical cricothyrotomy is an advanced life saving airway skill that should be only used on
patients who will die without airway management.
• Aspiration
• Hemorrhage
• Posterior tracheal wall perforation
• Thyroid gland perforation
• Esophageal laceration
• Vocal cord injury
TECHNIQUE
• Prepare all equipment needed for procedure
• Locate cricothyroid membrane
• Cleanse site with Betadine solution
• Stabilize the trachea with non-dominate hand and hold in midline position
• Using a scalpel in dominate hand, make a vertical incision through the skin overlying the
cricothyroid membrane.
• Locate the cricothyroid membrane and insert the scalpel horizontally through it.
• Place the hook into the opening and keep it in place- use an assistant if available
• Invert the scalpel so that the handle is in the incision and turn the scalpel to enlarge the opening.
• You may also use finger to enlarge the opening
• Place the gum elastic bougie into the opening and verify location into the trachea.
• Insert endotracheal tube over the gum elastic bougie into the opening and advance
caudally down into the trachea.
• Inflate cuff and check cuff pressure.
• Ventilate with BVM and 100% oxygen.
• Determine proper placement via observation of chest rise, auscultation of breath sounds, moisture
in tube, ETCO2 confirmation, lack of epigastric sounds, SPO2 improvement
• Secure tube with umbilical tape
Procedures:724 Surgical Cricothyrotomy
02/2014
1
Page 2 of 1
Section 726
NEEDLE CRICOTHYROTOMY
•
•
•
•
•
•
•
Indicated for patients ages 8 or younger in whom intubation and ventilation attempts have failed
Prepare O2 tubing by using IV tubing and making a small 0.5 cm hole in one side of the tubing.
Attach a 5mL syringe to a 10, 12 or 14 gauge angiocath. Insert angiocath 45º toward feet into
cricothyroid membrane while stabilizing the larynx and applying negative pressure to the syringe.
When air appears in the syringe, advance the catheter and remove the needle. Secure the catheter
in place.
Attach tubing from O2 source. Open valve to 15L/min. Place finger over hole until pressure
builds and release. Repeat this at a rate of 20 times per minute.
This is a temporizing measure while emergently transporting the patient to the nearest hospital.
Complications include bleeding, subcutaneous emphysema, obstruction, and aspiration.
PROCEDURE
FR
EMT B
EMT B IV
EMTP
PCC
Surgical Cricothyrotomy
SO
Needle Cricothyrotomy
SO
Procedures:724 Surgical Cricothyrotomy
02/2014
2
Page 1 of 1
Section 727
THERAPEUTIC HYPOTHERMIA
INDICATIONS (all must be met)
• Non-traumatic cardiac arrest including those from hanging or drowning
• Return of spontaneous circulation after ACLS measures
• Stable rhythm
• Age at least 12 or older with adult body habitus
• Advanced airway (ET tube, King tube) in place with no purposeful response to pain
o Contact medical control if unable to establish advanced airway
• Temperature > 34°C (93°F)
PROCEDURE
• If not already established, ventilate patient via advanced airway
o Keep ETCO2 >30 mmHg
o Keep O2 saturations between 94-96%
• Establish 2nd IV
• Expose patient and apply ice packs to groin and bilateral axillae.
• Cold saline (4°C) bolus of 30 mL/kg with a max of 2L
• Insert esophageal temperature probe.
• Administer Dopamine per protocol with a goal of MAP > 70
• Reassess temperature every 10 minutes
o If temperature < 33°C (91°F), discontinue cooling and continue resuscitation
COMPLICATIONS
• Shivering is common during the induction of cooling
o Treat with Etomidate 20mg IV / IO
o If shivering continues despite above measure, treat with Rocuronium 50mg IV/IO
• Metabolic acidosis may be caused from hyperventilation- monitor ET CO2 closely
• Coagulopathy- direct pressure to any bleeding
• Bradycardia- treat with Dopamine if MAP < 70
SPECIAL PRECAUTIONS
• Do not delay transport to cool except to obtain ice packs or cold saline
• Continue to monitor ECG
• Notify MRMC Emergency Department of patient and that cooling measures have been
instituted
• Consider air transport if transport by ground to MRMC Emergency Department would be
considerably longer (difference > 30 minutes)
• Treat seizure activity per Seizure protocol
PROCEDURE
EMTP
PCC
Initiation of Therpeutic Hypothermia
SO
SO
Insertion of Esophageal Temperature
Probe
SO
SO
Procedure- Therapeutic Hypothermia
Revised 02/2014
FR
EMT B
1
EMT B IV
Page 1 of 1
Section 728
TRANSCUTANEOUS CARDIAC PACING
INDICATIONS
• To maintain adequate perfusion when there is insufficient cardiac rate that has not improved with
adequate oxygenation, ventilation, and medications such as atropine.
• For symptomatic bradyarrhythmias: first line treatment for high-degree AV block (type II 2nd
degree or 3rd degree AV nodal block)
PRECAUTIONS / COMPLICATIONS
• Capture can be difficult in some patients
• Patient may experience discomfort; consider midazolam. (See Protocol for Midazolam)
• Use the same precautions as with defibrillation
• Patients in atrial fibrillation may require higher energy settings for capture than others.
• V-fib and V-tach are rare complications, but follow appropriate protocols if either occur
• Pacing is rarely indicated in patients under the age of 12 years
• Muscle tremors may complicate evaluation of pulses
• Pacing may cause diaphragmatic stimulation
• CPR is safe during pacing. A mild shock may be felt if direct active electrode contact is made
TECHNIQUE
•
•
•
•
•
•
•
•
•
•
•
Apply electrodes as per manufacturer specifications: (-) right anterior, (+) left lateral.
Turn Lifepak 15 on
Apply 4 lead electrodes and cables
Press pacer to turn pacer function on
Confirm that the Lifepak 15 is sensing the patient’s spontaneous QRS complexes. This can be
confirmed by a triangle marker above each QRS complex. If not, pacer may discharge on an
existing complex
Select pacing rate at 80 beats per minute (BPB)
Set initial current to 40 mAmps.
Increase current 10 mAmps every 10-15 seconds until electrical capture or 200 mAmps (usually
captures around 100 mAmps)
If there is electrical capture, check for pulses (mechanical capture)
If there are no pulses with electrical capture, continue increasing amperage until mechanical
capture is obtained. After mechanical capture is obtained, increase amperage by 10mAmps.
If no capture occurs with maximum output, discontinue pacing and resume ACLS.
PROCEDURE
FR
EMT B
Transcutaneous Pacing
Procedure: Transcutaneous Cardiac Pacing
Revised 02/2014
1
EMT B IV
EMTP
PCC
SO
SO
Page 1 of 3
Section 730
12 LEAD ELECTROCARDIOGRAM
INDICATIONS
• Patients complaining of chest pain or other symptoms that may be cardiac-related. See chest pain
protocol.
TECHNIQUE
• Expose skin, remove restrictive clothing, being attentive to the patient’s privacy.
• Cleanse areas (see diagram) with alcohol or mild soap.
• Dry skin completely
• Place electrodes according to the diagram below and recheck.
• Have the patient lie completely still, preferably in the semi-fowlers position..
• Check screen to verify adequate tracing.
• Print tracing
• If there is artifact, correct by placing limb leads more proximally and make sure the patient is
completely still.
• Review tracing and transport immediately. ALS providers should review the tracing for signs of
myocardial injury (see below).
• If possible, transmit the tracing if evidence of ST-elevation MI is present as long as this does not
delay transport. Medical control may advise on additional interventions as well as the appropriate
destination and advise the receiving facility as soon as possible (STEMI ALERT). If the patient
is experiencing a myocardial infarction, the destination hospital will be able to prepare for any
further necessary interventions such as percutaneous coronary intervention or thrombolysis.
ADULT
PRODEDURE
•
Place leads and acquire 12 lead
•
Interpret 12 lead
FR
Placement of EKG leads
Procedures: 12 Lead Electrocardiogram
Revised 02/2014
1
EMT B
EMT B IV
SO
SO
EMT I
EMT P
SO
SO
SO
SO
Page 2 of 3
Section 730
12 LEAD ELECTROCARDIOGRAM
EKG Tracings
Myocardial infarction examples:
Anterior wall MI:
____________________________________________________________
Inferior wall MI
Procedures: 12 Lead Electrocardiogram
Revised 02/2014
2
Page 3 of 3
Section 730
12 LEAD ELECTROCARDIOGRAM
Left bundle branch blocks: should be considered as a myocardial infarction until previous EKGs are
obtained.
Procedures: 12 Lead Electrocardiogram
Revised 02/2014
3
Page 1 of 1
Section 729
UMBILICAL VEIN CATHETERIZATION
INDICATIONS
• Administration of medications and fluids for resuscitation and stabilization of the newly born
infant.
PRECAUTIONS / COMPLICATIONS
• The umbilical vein may not be patent after one week
• Keep the neonate warm while performing the catheterization
• Universal precautions. Sterile technique is ideal, but in the critically ill neonate, this may not be
practical.
• Hemorrhage, infection, perforation are potential complications
CONTRAINDICATIONS
• Congenital abnormalities of abdomen or signs of severe abdominal infection.
TECHNIQUE
• Prepare equipment in advance: this includes angiocath or catheter, 3-way stop-cock, saline,
umbilical tie, hemostats, light source, IV fluids
• Clean / prepare stump
• Tie a loose knot at the base of the cord
• Cut cord 1 cm above the abdomen
• Identify umbilical vein- it is has the larger lumen with the thinner wall. The two, smaller and
thicker-walled arteries will be present.
• Insert catheter or angiocath (2.0 inch 16g/14g) without needle, 1-2cm beyond the point of blood
return.
• Infuse saline/ or medications if indicated
• Secure the catheter by tightening the knot at the base of the umbilicus and tape the IV tubing to
the Abdomen
• When removing, tighten the string at the base and occlude the vein to prevent air from being
sucked into the vein.
PRODEDURE
•
FR
EMT B
EMTP
SO
Umbilical Vein Catheterization
Procedures: Umbilical Vein Catheterization
Created 02/2014
EMT B IV
1
PCC
SO
Page 1 of 2
Section 731
VASCULAR ACCESS
PERIPHERAL
INDICATIONS
• Administer fluids for volume expansion
• Administer drugs
PRECAUTIONS / COMPLICATIONS
• Due to the uncontrolled environment in which prehospital IVs are started, take extra care to use
sterile technique.
• Due to the high complication rate associated with prehospital IV therapy, use good judgment
when deciding which patients should receive an IV.
• Pyrogenic reactions due to contaminated fluids become evident in about 30 min after starting the
IV. Patient will develop fever, chills, nausea, vomiting, headache, backache, or general malaise.
If observed, stop and remove IV immediately. Save the solution so it may be cultured.
• Local: hematoma formation, infection, thrombosis, phlebitis. Note: the incidence of phlebitis is
particularly high in the leg. Avoid use of lower extremity if possible.
• Systemic: sepsis, pulmonary embolus, catheter fragment embolus, fiber embolus from solution in
IV
• Sites that are over a bone and away from a joint are more stable allow full range of motion of the
limb
• For patients with a history of renal failure, do not use the antecubital veins nor the veins on the
radial side of the forearm- anterior or posterior. Use the veins on the ulnar side distal to the
antecubital fossa
• The point between the junction of two veins is more stable and often easier to use.
• Start distally, and if successive attempts are necessary, you will be able to make more proximal
attempts on the same vein without extravasation of IV fluid.
• Venipuncture has little morbidity; however, the excess fluids inadvertently run in when nobody is
watching can harm to the patient
• The most difficult problem with IV insertion is knowing when to try and when to stop trying.
Valuable time is often wasted attempting IVs when a critical patient requires blood. IV solutions
may "buy time," but they frequently lose time instead. In critical patients do not delay transport
while attempting IV insertion at the scene. Establish IO access if the patient is critical.
CONTRAINDICATIONS
• Do not start IVs distal to a fracture site or through skin damage with more than erythema or
superficial abrasion.
TECHNIQUE
• Inspect fluid bag for clarity, leakage, and expiration date.
• Connect tubing to IV solution bag.
• Fill drip chamber one-half full by squeezing.
• Prepare supplies
o Veniguard
o Alcohol swab
o Select catheter size, or sizes
o tourniquet
• Gloves are mandatory, consider eyewear and mask
• Cleanse insertion site with alcohol or iodine pads.
• If necessary to palpate after cleanse, cleanse tip of gloved finger first.
Procedures: Vascular Access
Revised 02/2014
1
Page 2 of 2
Section 731
VASCULAR ACCESS
•
•
•
•
•
•
•
Perform venipuncture
After the catheter is in place, remove the needle or stylette
Attach tubing or saline lock
Open full to check flow and placement, then adjust to indicated rate (see IV solution protocol)
Secure with Veniguard
Recheck to be sure IV rate is as desired.
If you are unable to start an IV after 2 attempts consider Intraosseous Access ( see
Intraosseous protocol)
SALINE LOCK (BUFF CAP)
• May be preferred over saline and tubing for a peripheral IV if fluid administration is not indicated
• Lock must be flushed w/ saline after it is attached to the catheter
o It is much easier to attach the flush to the buff cap before attaching the buff cap to the
catheter.
EXTERNAL JUGULAR VEIN
INDICATIONS
• Inability to secure extremity IV access
• Stable vital signs without evidence of shock
TECHNIQUE
• Position the patient: supine, head down (this may not be necessary or desirable if congestive heart
failure or respiratory distress present). Turn patient's head opposite side of procedure.
• Align the cannula in the direction of the vein, with the point aimed toward the ipsilateral shoulder
(on the same side).
• "Tourniquet" the vein lightly with one finger above the clavicle and apply traction to the skin
above the angle of the jaw.
• Make puncture midway between the angle of the jaw and the midclavicular line
• Puncture the skin with the bevel of the needle upward; enter the vein either from the side or from
above.
• Note blood return and advance the catheter over the needle and remove tourniquet.
ADULT
PRODEDURE
•
FR
EMT B
EMT B IV
SO
External Jugular Vein
ADULT and PEDIATRIC
PRODEDURE
EMT I
FR
EMT B
EMT B IV
EMT I
EMT P
SO
EMT P
•
Peripheral IV
SO
SO
SO
•
Saline Lock
SO
SO
SO
Procedures: Vascular Access
Revised 02/2014
2
Page 1 of 2
Section 801
DNR / ADVANCE MEDICAL DIRECTIVES
GENERAL PRINCIPALS
• There are several types of advance medical directives (documents in which a patient identified the
treatment to be withheld in the event the patient is unable to communicate or participate in
medical treatment decisions).
o Do not resuscitate (DNR) orders are generally intended to be written by a physician for a
patient whose medical condition is such that commencement of resuscitation efforts would be
futile.
o Colorado Medical Orders for Scope of Treatment (MOST) form has been in effect since
2010. This form clearly outlines what treatment the patient has identified as their wishes
regarding medical care. All health care providers must follow the directives on this form
o The Colorado CPR Directive is a specific situation under Colorado law that provides for CPR
to be withheld or withdrawn. (See section below - CPR Directive).
• Only those CPR directives executed originally by a guardian, agent, or proxy decision maker may
be revoked by that same guardian, agent, or proxy decision maker. The individual may revoke his
or her own CPR directive at any time.
Advance Diretives including DNR, MOST, Living Will or DURABLE POWER OF ATTORNEY
• Resuscitation may be withheld from or terminated for a patient who has a valid, written do not
resuscitate order or other advanced medical directive only if:
o Documentation is present or the patient is wearing an official bracelet, necklace or other
identification that clearly states DO NOT RESUSCITATE. This may include a photocopy or
faxed copy of the directive.
o The documentation is clear to the prehospital provider that CPR, intubation and defibrillation
are refused by the patient or by the patient's attending physician who has signed the
document, and there is no apparent indication of suicidal gesture or intent by the patient.
o Prehospital providers presented with advance directives that are unclear should proceed with
resuscitation and establish medical control contact for guidance on treatment and transport.
 If the directive document is long and detailed, then it is probably more reasonable for
resuscitation to be initiated and the patient to be transported so that the base physician
can review the document and possibly contact the patient's attending physician.
 The duration of the resuscitation should be guided by the same factors of any medical
cardiac arrest (Treatment-Medical: Cardiac Arrest).
• Refusal of CPR does not mean refusal of care and/or transportation. A patient with a CPR
directive is to be evaluated by EMS personnel and be provided appropriate and available
palliative (comfort care) treatment and measures as directed by local protocol or on-line medical
control.
• There may be times in which the prehospital provider feels compelled to perform or continue
resuscitation, such as hostile scene environment, family members adamant that "everything be
done", or other highly emotional or volatile situations. In such circumstances, the prehospital
provider should attempt to confer with medical control for direction and if this is not possible, the
prehospital provider must use his or her best judgment in deciding what is reasonable and
appropriate, including transport, based on the clinical and environmental conditions, and
established base contact as soon as possible. Documentation of these events must be explicit.
• Under Colorado Law, refraining from performing CPR, when there is a CPR Directive, does not
constitute assisting a suicide, and caregivers who honor a CPR Directive by withholding CPR are
protected from legal liability.
Operations: DNR Orders, CPR Only, and Advanced Medical Directives
Revised 9/2014
1
Page 2 of 2
Section 801
ADVANCE MEDICAL DIRECTIVES
Procedure
Upon finding a patient with a CPR Directive (form, bracelet, or necklace):
• Perform initial patient assessment.
• Verify that the information on the form or, if present, on the back of necklace or bracelet, appears
to be appropriate for the patient (look at race, sex, date of birth, eye and hair color). If possible,
try to verify identity of patient by an additional source (e.g., family member, driver's license or
other readily available sources).
• Upon verification of the CPR Directive, withhold CPR. If CPR has been started, it should be
stopped.
• If there is any question of the validity of the document or the identity of the patient, initiate full
resuscitation measures and contact the base for guidance. Be sure to inform the medical control of
the CPR Directive form, bracelet, or necklace, and the condition and history of the patient.
• Complete documentation, including attaching a copy of monitor strips. In addition to the
standard documentation, the following information should be documented when possible by the
prehospital provider on the run report:
o Patient's status (e.g. condition found, medical history obtained)
o Type of "CPR Directive" found (document, bracelet or necklace)
o CPR Directive number, if available
o Name of attending physician, if known
o Special circumstances which justify initiating resuscitation if this was done despite the
presence of the CPR Directive
o Monitor strips in at least two leads.
• Provide appropriate emotional support to family if possible.
• If the death occurs outside of a health care facility or if tissue donation has been declared, then
the coroner is to be immediately contacted. If the declarant has indicated on the CPR Directives
form a desire to donate any tissues, appropriate authorities should be notified.
• The following resuscitation measures are to be withdrawn or withheld from a person who has a
valid CPR Directive:
o CPR and chest compressions
o Endotracheal intubation or other advanced airway management
o Artificial ventilation
o Defibrillation
o Cardiac resuscitation measures and medications.
• The following interventions may be administered or provided:
o Assist in maintenance of airway (non-advanced airway management, such as positioning)
o Suctioning
o Oxygen
o Pain medication
o Control bleeding
Operations: DNR Orders, CPR Only, and Advanced Medical Directives
Revised 9/2014
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Section 802
CONTACTING MEDCIAL CONTROL
The purpose of online medical control is for immediate consultation with a physician regarding patient
care. The designated medical control for the Upper San Juan Hospital District Ambulance Agency is the
emergency physicians at Pagosa Springs Medical Cen ter. Other physicians or health care providers may
advise and assist with patient care as long as their assistance conforms with the designated protocols.
Refer to the protocol for On-Scene Medical Provider
Medical control should be contacted whenever consultation or direction is deemed necessary. It is
appropriate when there is a question regarding a treatment, a procedure, or the destination of transport.
Other instances in which contact with medical control is necessary:
 Interventions within the EMS provider’s scope of practice where contact with medical control is
required by protocol.
o As a general guideline medical control contact is required on any call in which the patient
is refusing transport but the medic, after a careful assessment, believes that the patient
should be transported and/or has any of the following symptoms or conditions
o Conditions listed in Determining ALS Transport protocol
o Indication of mind-altering substance use
o Loss of consciousness- including syncope
o Trauma beyond an isolated extremity injury or any trauma with a significant mechanism
o Neurological complaint including focal weakness or numbness
o Neck pain related to trauma
o Patients < 18 years of age when a parent or legal guardian is not present or cannot be
contacted.
o Pregnant patients
o Abnormal vital signs
 Those cases in which the condition is clearly non-emergent without any of the symptoms or
situations listed above and given that the patient is competent, is able to understand the risks of
non-transport, and can be released to a competent caregiver, the EMS provider may release the
patient without contacting medical control.
 For any patient who has received an intervention and subsequently refuses transport, medical
control must be contacted prior to releasing the patient.
 In any case of non-transport, careful documentation of a patient’s mental status and competence
in decision making is required. The EMS provider should also insure and document that the
patient understands the nature of the condition. A refusal of treatment form should be signed by
the patient and a witness—preferably someone besides the provider.
 For patients who have Do Not Resuscitate orders at the scene and who refuse transport, contact
with medical control is still necessary.
 For patients who request transport to a local clinic, remember, the doctors at the clinic are not
medical control and ambulances are required to transport to an emergency if the call for service is
generated through the dispatch center
Operations: Contacting Medical Control
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Section 803
DETERMINING ALS TRANSPORT
GENERAL PRINCIPALS
• Certain patients who are transported by the Upper San Juan Ambulance Agency require transport
by medics with advanced life support (ALS) training. This protocol is to act as a guideline for
determining when an ALS team is needed to transport the patient to the nearest appropriate
destination. These protocols are designed with the acknowledgement that an ALS team is not
available at all times and that in rare cases, extenuating circumstances may exist which preclude
this guideline. This protocol is to be used in conjunction with the protocol on determining
Helicopter Activation and Transport.
Findings or symptoms that necessitates ALS transport:
• Apnea or difficulty breathing which may include:
o Abnormal respiratory rate or pulse oximetry reading
o Increased work of breathing not relieved with oxygen
o Airway obstruction or impending obstruction
o History of cardiac or pulmonary disease
• Chest pain-which may include:
o Palpitations or previously undiagnosed arrhythmia
o History of cardiac disease or arrhythmia
• Abnormal vital signs
• Loss of consciousness for any reason
• Altered mental status or unresponsive
• Seizure
• Focal neurological complaints or findings including weakness.
• Trauma with significant mechanism, trauma patients requiring transport to trauma destination
(see SWRETAC Trauma Triage Guidelines), this includes motor vehicle crashes with death of
another occupant.
• Bleeding beyond a minor wound (i.e. hemetemesis, hemoptysis, vaginal or rectal bleeding, or
secondary to major trauma)
• Significant environmental exposure (heat, cold, burns, electric, near drowning)
• Overdose
• Patients requiring sedation or pain control during transport.
• Toxic or hazardous exposure
• Active labor
This list is not all-inclusive as there may be calls that do not fit specifically with theses criteria. Good
judgment by all providers is needed when making the decision regarding the level of care required. When
in doubt, consult with medical control. It will ultimately benefit the patient to wait a few minutes for
ALS availability rather than begin transport via BLS where ALS interventions may be required. If the
patient has advance directives, such as DNR orders, available at the scene and transport is requested, the
patient may be transported by BLS as long any foreseeable ALS interventions are against the patient’s
wishes in the directives. For such cases, contact medical control.
Procedures: ALS Transport
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Section 803
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Section 804
FIELD PRONOUNCEMENT OF DEATH
PURPOSE
• To determine when resuscitation efforts may be withheld or ceased
GENERAL PRINCIPALS
CPR will not be initiated or may be terminated under the following circumstances:
Unwitnessed Arrest
• Pulseless, apneic, and asystolic, including other signs listed below.
• Exceptions
o Patients less than sixteen years of age
o Drowning with submersion time of < 60 minutes
o Hypothermia
o Barbiturate ingestion
o Lightning strike
Witnessed Arrest
• Confirmed pulseless and apneic for ten or more minutes and is asystolic on arrival of advanced
life support. Must be confirmed by a qualified (CPR certified) witness who has observed the
patient carefully.
A Pulseless, Apneic Patient Who Has Multiple Signs of Prolonged Lifelessness
• Recognized signs are:
o Rigor Mortis: Muscular stiffness following death, progressing from the upper to lower body,
first detectable in the short muscles. Determination of rigor mortis should include immobility
of the jaw muscles and upper extremities.
o Lividity: Visible pooling of blood in dependent extremities or dependent areas of the body.
o Pupils: Fixed and dilated.
o Body Temperature: Loss of body warmth in a warm environment.
o Obvious Death:
 Decapitation
 Incineration
 Destruction or separation of major organs (brain, liver, heart)
o Pulseless, apneic patient with injury not compatible with life
Blunt trauma arrest
• Any patient who has suffered a blunt trauma event and is apneic and pulseless after appropriate
interventions such as ensuring airway patency or needle decompression of the chest.
o Make sure that the patient is in cardiac arrest from the trauma and not from a medical
condition prior to the trauma.
o Contact medical control prior to terminating treatment.
Declared Mass Casualty Incident
• Pulseless, apneic or agonal patient where triage principles and available resources preclude
initiation of resuscitation.
Penetrating Trauma
• Penetrating traumatic arrest where arrival to the appropriate facility will be greater than thirty
minutes from the time of confirmation of lack of pulse and apnea by first responders. Consult
medical control.
Procedures: Field Pronouncement of Death
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Section 804
FIELD PRONOUNCEMENT OF DEATH
Advanced Directives
• See Advanced Directives Protocol
IF THERE IS ANY DOUBT WHETHER TO START OR WITHHOLD CPR, START CPR AND
RESUSCITATE WHILE AWAITING FURTHER DIRECTION FROM ADVANCED DIRECTIVES
OR THE PATIENT’S POWER OF ATTORNEY.
BLS providers:
o May withhold resuscitation efforts in consultation with medical control in situations
described above that do not require ALS interventions.
Documentation
• ALS Providers:
o Will evaluate patient and situation. A sixty second strip documenting asystole in at least two
leads is required (60 seconds minimum) or lack of ROSC after 3 rounds of ACLS.
o Contact medical control.
o Notify the appropriate law enforcement agency and the coroner.
o Ensure scene security until relieved by a law enforcement representative.
o If CPR has been initiated by bystanders, continue CPR and other necessary interventions. If
the assessment at that time is consistent with death as defined above, contact medical control
and cease efforts if medical control is in agreement. If able, include the bystander who
performed CPR in a short debriefing at the scene.
o In event contact with medical control is not possible: document the findings as described
above as well as the time that a field determination of death as made. Once in contact with
medical control, relay this information to them.
o If possible, await the arrival of the coroner at the scene as long as this does not keep your
ambulance out of service for more than 30 minutes.
• In addition to standard PCR documentation, the following should be included:
o Condition, position found at time of arrival
o Any DNR orders, if present, along with DNR order number
o Name of primary care physician, if known
o Any circumstances justifying or explaining why CPR was initiated
o Monitor strips in at least two leads, if applicable. This includes patients for whom
resuscitation efforts were performed by EMS.
Procedures: Field Pronouncement of Death
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Section 805
HANDCUFFED PATIENT
PURPOSE
• The patient is being transported under police custody and has already been placed in handcuffs by
a police officer.
PRECAUTIONS / COMPLICATIONS
• Any attempt to restrain a patient involves risks to the patient and the prehospital provider. Efforts
to restrain a patient should only be done with adequate assistance present.
• At no time should the patient be placed in a prone position for a prolonged time at the scene or
during transport to the hospital.
• Ensure that patient has been searched for weapons.
GENERAL PRINCIPALS
For the patient who does not require spinal immobilization
• Maintain restraint via the handcuffs.
• Secure the patient to the gurney in a position of comfort, utilize seat belts.
• Treatment and transport should be done with the patient remaining in the handcuffs.
• Request that the officer stay with the patient and ride in the ambulance during transport. If an
officer is unable to ride during transport, obtain handcuff key from officer in the event the
handcuffs need to be removed for patient care/intervention. This should only be done in extreme
situations (i.e. patient arrest, or extremis). Ultimately, EMS is not responsible for the hold on this
patient. The first priority is the safety of the EMS crew. If the patient cannot be controlled or
there is a risk of harm to providers during transport; do not transport until adequate assistance
from law enforcement is present.
For the patient who requires transport with spinal immobilization
• Consider chemical restraint early to avoid further injury to the patient.
• Ensure that you have adequate assistance available to maintain restraint of the patient.
• Secure the patient's cervical spine with a cervical collar if indicated.
• Assign one individual to support the patient's head.
• Bring the stretcher, with backboard or scoop if indicated, to the patient.
• Secure each arm and both legs with Kerlix prior to having the officer remove the handcuffs.
• Roll the patient onto a backboard or scoop.
• Place the stretcher next to the patient and lift the patient onto the stretcher.
• Secure one arm of the patient to the scoop or backboard with handcuffs. If further restraint is
required, use Kerlix or Velcro cuffs to restrain other extremities.
Operations: Handcuffed Patient
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Section 806
MEDICAL HELICOPTER ACTIVATION
PURPOSE
• To provide a standard for the activation of medical helicopter resources providing emergency
medical care in the prehospital setting within the Upper San Juan Health Service District.
GENERAL PRINCIPLES
• Consider use of medical helicopter scene response when:
o Patient(s) with life-threatening trauma and prolonged extrication and/or transport time (i.e.
using Medical helicopter will reduce “scene to hospital” time). Refer to trauma triage
algorithm guideline.
o Major burns, significant hypothermia, near drowning victims.
o Critical cardiac patients: myocardial infarction (STEMI), cardiogenic shock, dysrhythmias
with hemodynamic compromise, tamponade.
o Prehospital cardiac or respiratory arrest.
o Risk of potential airway compromise: angioedema, epiglottitis.
o GI hemorrhage with hemodynamic compromise.
o Neurological: severe head trauma, status epilepticus, CNS hemorrhage.
o Surgical emergencies: aortic dissection or aneurysm, fasciitis, extremity ischemia.
o Obstetric: 3rd trimester bleeding, active premature labor <34 weeks.
o Multiple casualty incidents and inability of ground transport units to manage and transport all
patients in a timely manner.
o Ground transport would leave the district uncovered by ALS crews for an extended period of
time.
• The highest level EMS provider on-scene or the Incident Commander should make the decision
to mobilize a medical helicopter.
• Decision may be made to launch medical helicopter prior to arrival on scene. Reliable
information from bystanders or first responders indicating the possible need for helicopter
resources may be deemed sufficient for activation without delay.
• Patients requiring critical interventions should be provided those interventions in the most
expeditious manner possible.
• Patients who are stable should be transported in a manner that best addresses the needs of the
patient and the system.
• Patients with critical injuries or illnesses resulting in unstable vital signs require transport by the
fastest available modality, with a transport team that has the appropriate level of care capabilities.
PROCEDURE
Dispatch of Air Ambulance
• The closest available Air Ambulance will be coordinated via dispatch determined by shortest time
of arrival.
• EMS providers may assist in coordinating transport, but are not to bypass dispatch nor delay care
of critical patients while trying to coordinate transport
Cancellation of Air Ambulance
• Only the on-scene Incident Commander, in collaboration with the on-scene medical authority,
may cancel a medical helicopter en route. Even if the helicopter is en route or has landed, this
does not mean the patient should go by air. If they do not meet the above criteria, they should be
transported by ground so as to make the helicopter available for more emergent needs.
• Medical Control may be used as a resource to assist with cancellation decisions.
• Medical helicopter services retain final authority to cancel the mission for any reason, such as
weather or other safety concerns.
Operations: Medical Helicopter Activation
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Section 806
MEDICAL HELICOPTER ACTIVATION
Destination Hospital
• Consultation with medical control prior to transfer of care may help determine most appropriate
facility.
• Once care is transferred, medical helicopter crews function under separate operational protocols
and retain all decisional authority for patient destinations.
• When possible, after the patient has left via helicopter, notify the receiving hospital to give report
since the flight crews may not be able to communicate with the hospital.
Quality Assessment
• All agencies providing prehospital emergency medical services activating medical helicopters
may request quality assessment information from the helicopter services for the purpose of
reviewing system procedures, performance and assuring timely, high quality services. Agencies
providing such medical helicopter services are to maintain and provide this information as
requested.
Operations: Medical Helicopter Activation
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Section 807
MENTAL HEALTH HOLD (MHH)
PURPOSE
• To insure the safety of the patient and of the medical provider.
GENERAL PRINCIPALS
Indications
• Any person who appears to be mentally ill and an imminent danger to others or to him/herself
• Any person who appears to be mentally ill and gravely disabled
Who may initiate
• The paramedic may initiate mental health hold only with the permission and online contact with the
receiving physician. If medical control and law enforcement are unavailable, the patient can only be
transported if there is voluntary consent and there is no threat to the provider’s safety.
• The law allows only physicians, trained nurses, and peace officers to place mental health holds.
PROCEDURE
• Restrain if necessary (Prodecures: Restraints), use assistance of law enforcement if the patient is
combative, do not put yourself at risk.
• Call medical control for the physician to place the patient on a mental health hold
• Transport to nearest Emergency Department.
• Provide appropriate documentation of events so 72-hour hold can be filled out by the physician at the
receiving facility
PROCEDURE
EMT B
EMT B IV
EMT P
PCC
Placement of a patient on a mental health
hold as indicated
VO
VO
VO
VO
Operations: Mental Health Hold
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MULTIPLE CASUALTY INCIDENTS
PURPOSE
• To provide a guide for responders to a multiple casualty incident.
• To provide a consistent standardized approach to an MCI incident.
GENERAL PRICIPALS
• MCI: An incident where the combination of numbers and types of injuries that go beyond the
capability of an entity's normal response.
• Refer to SWRETAC Field Operational Guide (FOG) for detailed instructions.
PROCEDURE
• Scene Safety
• Scene Size Up (type of incident, approx. # of patients, severity level of injuries, potential scene
problems)
• Initiate Incident Command if first on scene, or contact command personnel and proceed to
assignment.
o If initiating IC, designate channel 15, AC TAC 1, as primary frequency for all agencies.
• Set up a level 4 MCI to be expanded upon as needed. (FOG pg. 28-31)
o Designate Medical Branch Director (FOG pg. 11)
o Triage Group: (FOG pg, 14)
 Initiate START/JumpSTART, DO NOT PROVIDE EXTENSIVE TREATMENT.
(FOG pg. 7-8) Identify a “pediatric” patient based on appearance: if the patient appears
to be less than 8 years old, treat them as a pediatric patient.
 Attach triage tags to the patient, not the clothing
 Assign an individual to secure GREENS (walking wounded) to a designated area.
 Begin transfer of remaining patients to Treatment Group in the following order: REDS,
YELLOWS, BLACKS
o Treatment Group: (FOG pg. 16)
 Organize treatment area such that RED and YELLOW areas are near each other and are
separated from GREEN and BLACK areas.
 Re-triage patients upon arrival at treatment area, keeping in mind that YELLOW can
decompensate to RED rapidly.
 Treat patients as necessary and provide ongoing assessment as time allows.
 Track all patients with triage tag # and acuity.
o Transport Group: (FOG pg. 17)
 Ensure communications link is established with designated Trauma Center ED.
 Establish ambulance staging areas and landing zones.
 Transport patients in order of priority to appropriate receiving facilities. (Try to keep
families together if possible.)
 Track all patients with triage tag #, acuity, and location.
SPECIAL NOTES
• Don appropriate identification vests.
• Activate EMS Call Tree; consider early on.
• Request MCI Trailer; consider early on.
• Trailer code: 3766
Section 808-MCI
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MULTIPLE CASUALTY INCIDENTS
Section 808-MCI
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Section 808-MCI
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Section 808-MCI
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Section 809
ON SCENE MEDICAL PROVIDER
PURPOSE
To provide guidelines for prehospital personnel who encounter a physician or other medical provider at
the scene of an emergency
GENERAL PRINCIPLES
• The prehospital provider has a duty to respond to an emergency, initiate treatment, and conduct
an assessment of the patient to the extent possible.
• A physician or other provider who voluntarily offers or renders medical assistance at an
emergency scene is generally considered a "Good Samaritan." However, once a physician
initiates treatment, he/she may feel a physician-patient relationship has been established.
• Good patient care should be the focus of any interaction between prehospital care providers and
the provider offering assistance.
PROCEDURE
• See algorithm below.
SPECIAL NOTES
• Every situation may be different, based on the medical provider, the scene, and the condition of
the patient.
• Other providers apart from a licensed physician may assist in care, but are not authorized to
depart from established protocols.
• Contact medical control when any question(s) arise.
Operations: On Scene Intervention By Medical Provider
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Section 809
ON SCENE MEDICAL PROVIDER
Operations: On Scene Intervention By Medical Provider
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Section 809
EMT arrives on scene and initiates
patient care
Other medical provider initiates care
prior to EMS arrival or arrives after EMS
and wishes to provide care.
EMT and other medical provider will
identify themselves and their level of
Physician on scene
Other medically-trained provider
may assist in patient care
all within the established protocols
Continue with patient care and
provide Instructions for Providers if
the need arises.
Physician involved in patient care
and will not relinquish patient
care.
Physician wishes to provide
assistance with EMTs in charge of
patient care and within their scope of
OR
Physician requests or performs
care inconsistent with protocols
Continue with patient care and
provide Instructions for Providers if
the need arises.
Provide physician with Instructions for
Providers. Advise physician of your
responsibility to the patient.
Physician does not relinquish
patient and continues care
inconsistent with protocols.
Contact Medical Control
Physician complies
Continue with patient care and
provide Instructions for Providers if
the need arises.
Follow medical control’s
directions. Document patient care
provided and any difficulties or
problems on the patient care report
Operations: On Scene Intervention By Medical Provider
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Section 809
ON SCENE BY MEDICAL PROVIDER
INSTUCTIONS FOR PROVIDERS
NOTE TO PHYSICIANS AND OTHER MEDICAL PROVIDERS ON INVOLVEMENT WITH EMTs
THANK YOU FOR OFFERING YOUR ASSISTANCE.
The prehospital personnel at the scene of this emergency operate under standard policies, procedures, and
protocols developed by their physician advisor. The drugs carried and procedures allowed are restricted
by law and written protocols.
If you are not a physician or are not licensed in the State of Colorado, you may offer your assistance only
under the direction of the EMTs who abide by established protocols and who are under the direction of
medical control physicians.
If you are a physician and after identifying yourself by name as a physician licensed in the State of
Colorado and providing identification, you may be asked to assist in one of the following manners:
1. Offer your assistance or suggestions, but the prehospital care providers will remain under the
direction of their established medical control physician.
2. With the assistance of the prehospital care providers, talk directly to the medical control physician
and offer to direct patient care and accompany the patient to the receiving hospital. Prehospital care
providers are required to obtain an order directly from their medical control physician for this to
occur.
Upper San Juan Health District Ambulance Service
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Section 810
REFUSAL AGAINST MEDICAL ADVICE /
NON TRANSPORT OF PATIENT
GENERAL PRINCIPLES
• When mentally competent patients refuse or revoke consent, they are exercising their right to
terminate the medical relationship with prehospital providers. Patients, who are thinking clearly,
acting rationally, have minimal illness or injury, and in whom there is no indication of substance
use, must be allowed to refuse all or part of the care offered and/or transport. Complete
documentation and contact with medical control are critical once a medical relationship has been
established and the patient elects to refuse or revoke consent.
• Because an oriented patient may not necessarily possess the ability to process information
effectively, patient assessment must also include the patient’s comprehension abilities if refusing
transport. The patient should be able to demonstrate a capability to understand
o The nature of the condition
o The risks and benefits of the proposed treatment
o The risks and benefits of refusing care
TERMINATION OF THE MEDICAL RELATIONSHIP
• Non-licensed medical providers (such as emergency medical technicians of all levels working in
the prehospital setting under a physician license) do not have the authority to terminate the
medical relationship once established. Contacting medical control is required when terminating
the medical relationship except for specific circumstances. (See Operations: Contacting Medical
Control)
• Termination of care for any patient is acceptable in the following:
o Patient is transported to an emergency department, hospital bed, or clinic where a brief report
is given to the accepting providers.
o Patient is a threat to the medics’ safety and must be transported by law enforcement for
medical clearance.
o Patient meets criteria for refusal of care.
REFUSAL WHEN TREATMENT/TRANSPORT IS PRUDENT
Incompetent to Refuse
• A patient is incompetent to refuse if they have an altered mental status so that they:
o Cannot understand the risk of refusal.
o Cannot remember questions asked or answers already given.
• Patients on mental health hold cannot refuse treatment and transport. If patient exhibits signs of
being a danger to himself or others, the care provider is to notify law enforcement and stay with
the patient until their arrival UNLESS there is any danger to the care provider. In this situation
the care providers will move to a safe area and wait for law enforcement there.
• If a reasonable person would consent to transport given similar circumstances, the patient should
be transported if at all possible. With mentally incompetent patients, use law enforcement
assistance when necessary. Both EMS providers and law enforcement are protected by the "good
faith" rule in the state of Colorado.
• A paramedic may institute a 72 hr M1 mental health hold on the behalf of the medical control
physician in order to transport a patient who is a threat to himself, manifest or declare suicidal
intentions, or are incompetent to refuse care.
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Section 810
REFUSAL AGAINST MEDICAL ADVICE
NON TRANSPORT OF PATIENT
Competent to Refuse
Mentally competent patients who have significant illness or injury who adamantly refuse treatment and
transport are more troubling. Prehospital personnel must make every reasonable effort to inform the
patient of their suspected condition and the implications of their decision. This may include timeconsuming deliberation, if necessary. Medics should:
•
•
•
•
•
Allow the provider who has established the best possible rapport with the patient to communicate
with the patient.
Explain the nature of the emergency and the risks and benefits of both treatment and refusal; then
ask patient to use their own words to explain what they have been told to determine if they
understand all three elements.
Enlist the help of family members or friends to convince the patient, or recognize when such
intervention is not helpful and manage that aspect.
Utilize medical control as a resource to help the patient understand the gravity of the illness and
need for emergent evaluation
Mentally competent adults who refuse consent for treatment/transport have the right to make their
own medical treatment decisions even if such refusal might result in severe deterioration or death.
In this event, the following are required:
o Repeated attempts to convince the patient in front of witnesses.
o Consultation with medical control. Have, or attempt to have patient or surrogate speak
directly with the base station physician.
o A reasonable attempt to have the patient sign the refusal of care document after it has been
explained to them in front of at least one witness. This must also be signed by a witness,
preferably not another medical provider.
o When the patient refuses to sign the document, the refusal form should be filled out and
"refused to sign" written on it, then again witnessed.
o Make a reasonable attempt to have a family member or friend take responsibility for the
patient.
o Patients in the custody of law enforcement can refuse treatment and transport providing the
law enforcement official agrees to sign the AGAINST MEDICAL MEDICAL ADVICE
form..
Refusal Documentation
• Documentation in the prehospital care report must include:
o Patient name, address, date of birth and SSN.
o Specific information regarding the nature of the incident, assessment of the patient,
explanation of the risks of refusal.
o Documentation that the patient was able to comprehend the nature of the emergency as well
as the benefit of transport vs. risks of non-transport.
o Documentation of base contact and the advice given by the physician.
o Attached “AMA / Refusal of Care” signed by patient, if possible.
o Attached “Consent for Treatment” form when treatment has been rendered, signed by patient,
if possible.
o Patient refusals to sign documents must be noted on the form and in the PCR narrative.
Operations: Refusal AMA Non-Transport
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Section 810
REFUSAL AGAINST MEDICAL ADVICE
NON TRANSPORT OF PATIENT
Patient consents to transport but refuses specific treatments:
Mentally competent adults who refuse consent for treatments (i.e. IV access, medications, spinal
precautions, etc) but agree to transport usually present less of an issue to EMS providers because at
the very least they are being transported to the hospital. In this event the following are recommended:
 Explain the treatment or procedure and its benefits thoroughly.
 Explain the risks associated with refusing the treatment or procedure.
 Use tactics to convince the patient, such as enlisting family or friends and base station
consultation, if necessary.
 Communicate the treatment refusal during the initial patient report from the field and
during the bedside report.
 Thoroughly document all of the above in the patient report.
Minors
• EMS calls for minor injuries or illnesses with children also create challenges related to consent.
Patients under the age of 18 years--unless emancipated--must have a legally responsible
representative make the decisions regarding termination of their medical care, such as:
o A parent
o A grandparent
o A sibling 18 years or older
o A legal guardian
o A legal proxy, such as an adult leader or counselor, preferably with a "consent for medical
treatment" form signed by a parent, if possible
• With minor injuries/illnesses requiring no medical care, a parent may be contacted by phone for
consent to terminate the medical relationship. Minors requiring medical care should be
transported when no parent or representative is available.
• All refusal of care issues with minors, just as with adults, must be communicated to medical
control prior to terminating the medical relationship.
EMS Generated Refusals
• In the absence of a medic safety issue, EMS personnel are expressly NOT allowed to refuse to
transport a patient who is requesting to go to the hospital.
• EMS personnel may assist in the decision making process with a patient, but must be clear that
transport is always an option.
• EMS personnel may refuse to treat and transport patients for reasons of personal safety. Any
unsecured scene, such as, hazardous materials or potentially violent patient may result in the
acceptable delay of medical care until which point EMS personnel are no longer at risk of
personal injury.
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Section 811
TRANSPORT DESTINATION
ONCE EMS IS ACTIVATED
• All patients will be transported to the closest appropriate hospital. For most calls, this will be the
Pagosa Springs Medical Center (PSMC). See EXCEPTIONS below.
• Patients refusing transport to the most appropriate hospital must meet specific criteria in order to
legally refuse (See Operations: Refusal AMA non-transport).
• Any request for “medical clearance” by law enforcement or other agencies requires transport to
the nearest appropriate hospital. EMS does not perform a medical screening exam.
EXCEPTIONS
Trauma patients
• Specific criteria are outlined by the SWRETAC as to the appropriate destination for trauma
patients. (See Trauma: Trauma Destination and Activation). Any patient who meets these
criteria must be transported to the nearest appropriate trauma center, which in most cases is
PSMC, but should be verified with medical control.
Chest Pain
• All patients with EKG evidence of an acute myocardial infarction (STEMI) need to go directly to
Mercy Regional Medical Center. The decision whether to transport by ground versus air depends
on the location of the patient. As a general rule, any patient in town and west of there should go
by ground ambulance. Contact Mercy Regional Medical Center (MRMC) for STEMI activation
and to make sure interventional cardiology is available.
• If interventional cardiology is not available or if transport to MRMC within 1 hour is not
possible, discuss destination with medical control.
• All other patients whose chest pain fits the description of an acute coronary syndrome (see
Medical: Chest Pain protocol) may benefit from transport directly to MRMC for definitive care.
If possible, obtain a troponin and consult medical control to determine which facility would be
the most appropriate.
Patient requests to go to a clinic.
• Inform the patient that EMS is required to transport to the nearest appropriate emergency room.
Patient refuses to be transported to nearest appropriate hospital.
• Any competent patient has the right to be transported to a specific hospital if they are alert and
competent to make their own decisions. USJHD’s ambulance service has a duty to transport
patients to the closest appropriate hospital. If the system status allows, the patient’s request can
be honored if they are informed that the transport will likely not be covered by insurance. If
USJHD ambulance crew is unable to accommodate a transport to a facility that is not PSMC
because of system status or patient acuity, the patient may sign and AMA refusal and transport
themselves elsewhere.
Operations: Transport Destination
Revised 9/2014
1
Page 1 of 2
STANDBY/ FIRE SCENE REHABILITATION
PURPOSE
• To provide evaluation and care to firefighters involved in a strenuous incident or training.
GENERAL PRICIPALS
• Rehabilitation and medical evaluation will be provided when a med unit is requested by the IC.
• EMTs will be responsible for the evaluation based upon this protocol and Pagosa Fire Protection
SOPs.
PROCEDURE
• Response will be non-emergent unless requested by command or victims are reported to be
trapped in the structure.
• Park vehicle in safe location that will provide easy egress if a patient needs transport. It is
imperative not to get blocked in by responding fire apparatus. The location should be close to the
rehydration portion of rehab and ideally near the air bottle exchange station.
• Contact the Incident Commander, face to face if possible, and determine if contact will be IC
directly or the Rehab Officer.
• EMS personnel are to maintain a 50’ distance from any structure fire or hazardous environment.
• Firefighters will be evaluated after (2) 30 min air bottles have been depleted or 40 min of
strenuous activity.
• Any Firefighter who is in obvious distress or is sent by command for an evaluation will have a
detailed medical evaluation and a PCR will be completed for this patient.
• Rehab Procedure
o They will be evaluated for pulse, BP, and oral temp. This information will be recorded on the
PFPD rehabilitation report (sample below).
o Firefighters will remain in rehab a minimum of 15 min. unless they meet the criteria for
release upon entry to rehab.
o Any firefighter that has a complaint upon entry into rehab will receive a full evaluation and a
PCR will be completed for this patient.
o Any firefighter that does not meet the criteria for release after two consecutive 15 min periods
shall be reported to the IC or Rehab Officer and should consider transport to the ED.
o IC or Rehab Officer shall be informed of any personnel whose condition may pose a threat to
themselves or their fellow firefighters.
• EMS unit will remain on scene until released by IC or Rehab Officer. If the Unit must leave to
cover a 911 call, the IC of Rehab officer shall be informed of the departure
Section 812-Standby-Fire Rehab
Revised 9/2014
1
Page 2 of 2
STANDBY/ FIRE SCENE REHABILITATION
CRITERA FOR RELEASE FROM REHAB
Pulse
BP
< 120/min
90/60<X<160/100
REHABILATION REPORT
Name
Times
B/P
Respirations
<24/min
Pulse
Resp
In
Out
In
Out
Section 812-Standby-Fire Rehab
Revised 9/2014
2
Temp
Temperature
<100.6
Eval by
complaints
Page 1 of 3
Section 901
ABBREVIATIONS FOR FIELD USE
a before
change
AAA abdominal aortic aneurysm
COPD chronic obstructive pulmonary disease
AAO x awake, alert, and oriented times
C-spine cervical spine
abd abdomen
C-section cesarean section
AB abortion
CP chest pain
ABC airway, breathing, circulation
CPR cardiopulmonary resuscitation
ACLS Advanced Cardiac Life Support
CRT capillary refill time
adm admission
CTA/CTL clear to auscultation
ALS Advanced Life Support
CTLS cervical, thoracic, lumbar spine
am morning
CSF cerebrospinal fluid
AMA against medical advice
CVA cerebral vascular accident
AMS altered mental status
CVP central venous pressure
amp(s) ampule(s)
d/c discharge/discontinue
ant anterior
D&C dilatation and curettage
asa aspirin
detox detoxification
ATF at time found
D5W dextrose 5% in water
D50W dextrose 50% in water
ATLS Advanced Trauma Life Support
DOA dead on arrival
AAO X alert awake oriented X
DOB date of birth
A&O X alert and oriented X
DOE dyspnea on exertion
A&P anterior and posterior
DOS dead on-scene
a&p auscultation and percussion
Dr. doctor
≈ approximately
drsg/dsg dressing
@ at
DT delirium tremens, dispatched to
BBB Bundle Branch Block
Dx diagnosis
BCLS Basic Cardiac Life Support
↓ decrease
BLS Basic Life Support
bil bilateral
ea each
BIBA
ED emergency department
BM bowel movement
ECG/EKG electrocardiogram
BP blood pressure
EENT eye, ear, nose, throat
BS breath sounds
EMS emergency medical services
BVM bag, valve, mask
EMT Emergency Medical Responder
c with
EMTB EMT-Basic
C Centigrade
EMT B IV EMT-Basic w/IV certification
Ca cancer
EMTP Paramedic
Ca++ calcium
ENT ear, nose, throat
CABG coronary artery bypass graft(s)
EOA esophageal obturator airway
CAD coronary artery disease
EOM extraocular movement
cath catheter, catheterization
et and
CBC complete blood count
ET endotracheal
cc cubic centimeter
ETT endotracheal tube
ETA estimated time of arrival
CC chief complaint
etc and so forth
CCU coronary care unit
ETOH alcohol (ethyl)
CHF congestive heart failure
exam examination
CHI closed head injury
= equal
circ circulation
F Fahrenheit
cm centimeter
f female
CMS circulation, movement, sensation
FB foreign body
CNS central nervous system
FD fire department
CO carbon monoxide
FR First Responder
c/o complaining of/complaint of
fl fluid
CO2 carbon dioxide
Appendix: Abbreviations for Field Use
Revised 2/2007
3
Page 2 of 3
Section 901
ABBREVIATIONS FOR FIELD USE
lb pound
Fx fracture
lg large
female
LLL left lower lobe
1o first degree/primary
LLQ left lower quadrant
GB gallbladder
LMP last menstrual period
GC gonorrhea or gonococcus
LOC loss of consciousness, level of
GCS Glasgow coma scale
consciousness
GI gastrointestinal
L-spine lumbar spine
g gram
GPA gravida, para, abort
gr grain
GSW gunshot wound
gtt(s) drop(s)
GU genitourinary
GYN gynecology
→ going to/leading to
> greater than
h/hr hour
HA headache
HACE high-altitude cerebral edema
HAPE high-altitude pulmonary edema
HAZMAT hazardous materials (incident)
HB heart block
HBV hepatitis B virus
Hct hematocrit
HEENT head, eyes, ears, nose, throat
Hg mercury
Hgb hemoglobin
HIV human immunodeficiency virus
HPI history of present illness
H & P history and physical
HR heart rate
ht height
Hx history
hypo- low
H2O water
ICU intensive care unit
I & D incision and drainage
IM intramuscular
inf inferior
int internal
IV intravenous
↑ increase
J Joule(s)
JVD jugular venous distention
K+ potassium
KVO/ TKO keep vein open / to keep open
L/l liter
L left
lac laceration
lat lateral
LBBB left bundle branch block
LSB long spine board
LUL left upper lobe
LUQ left upper quadrant
< less than
m male
MAST medical antishock trousers, military
antishock trousers
mcg microgram
MCL midclavicular line,
med(s) medication(s)
mEq milliequivalent
Mg magnesium
mg/mgm milligram
MI myocardial infarction
min minute
misc miscellaneous
ml milliliter
mm millimeter
MOE x movement of extremities times
MOI mechanism of injury
MS/MSO4 morphine sulfate
MVA motor vehicle accident
male
N/A not applicable
NaCl/NS normal saline
NaHCO3 sodium bicarbonate
NC nasal cannula
neg negative
NKDA no known drug allergies
noc/noct night
NPO nothing by mouth
NSR normal sinus rhythm
NT non-tender
NTG nitroglycerin
N/V/D nausea and vomiting and diarrhea
∅ none
O2 oxygen
OB obstetrics
occ occasional
OD overdose
OJ orange juice
ophth ophthalmology
OR operating room
Appendix: Abbreviations for Field Use
Revised 2/2007
3
Page 3 of 3
Section 901
ABBREVIATIONS FOR FIELD USE
Ortho orthopedics
sec second
oz ounce
SL sublingual
p after
SOB shortness of breath
palp palpation
S/NT/ND soft non-tender, non-distended
PASG pneumatic antishock garment
sol solution
PAT paroxysmal atrial tachycardia
sm small
path pathology
stat at once
PCC Paramedic with Critical Care
sup superior
Endorsement
Sx sign/symptom
PD police department
surg surgery
PE physical examination/pulmonary
SVT supraventricular tachycardia
edema/pulmonary embolus
synch synchronous
peds pediatrics
2o second degree/secondary
TB tuberculosis
per by or through
tbsp tablespoon
PERRL pupils equal, round and react to light
temp temperature
PERLA pupils equal and react to light and
TIA transient ischemic attack
accommodation
tid three times a day
PID pelvic inflammatory disease
TKO to keep open
PMH past medical history
TM tympanic membranes
PND paroxysmal nocturnal dyspnea
tol tolerated
po by mouth
tsp teaspoon
pos/�/+ positive
Tx treatment
post posterior
POV privately owned vehicle
∴ therefore
PSVT paroxysmal supraventricular
3o third degree, tertiary
tachycardia
U/A upon arrival
psych psychiatric
uncons unconscious
pt patient
unk unknown
PTA prior to arrival
URI upper respiratory infection
PVC premature ventricular contractions
uro urology
Ψ psychiatric
UTI urinary tract infection
q every
≠ not equal/unequal
quad quadrant
vag vaginal
® right
VF ventricular fibrillation
RBBB right bundle branch block
via by way of
RBC red blood cell
vol volume
resp respirations
V/S vital signs
RLQ right lower quadrant
VT ventricular tachycardia
RS regular sinus
WBC white blood cell
R/O rule out
wc wheelchair
ROM range of motion
WNL within normal limits
ROS review of systems
WPW Wolff-Parkinson-White Syndrome
RUQ right upper quadrant
wt weight
Rx take, treatment
x times
s without
y/o year(s) old
SAB spontaneous abortion
yr year(s)
SC/sub q subcutaneous
Appendix: Abbreviations for Field Use
Revised 2/2007
3
Page 1 of 1
Section 902
PREGANANCY CLASSIFICATION
United States FDA Pharmaceutical Pregnancy Categories
Adequate and well-controlled studies have failed to demonstrate a risk to the fetus
Pregnancy
in the first trimester of pregnancy (and there is no evidence of risk in later
Category A
trimesters).
Animal reproduction studies have failed to demonstrate a risk to the fetus and
there are no adequate and well-controlled studies in pregnant women OR Animal
Pregnancy
studies which have shown an adverse effect, but adequate and well-controlled
Category B
studies in pregnant women have failed to demonstrate a risk to the fetus in any
trimester.
Animal reproduction studies have shown an adverse effect on the fetus and there
Pregnancy
are no adequate and well-controlled studies in humans, but potential benefits may
Category C
warrant use of the drug in pregnant women despite potential risks.
There is positive evidence of human fetal risk based on adverse reaction data
Pregnancy
from investigational or marketing experience or studies in humans, but potential
Category D
benefits may warrant use of the drug in pregnant women despite potential risks.
Studies in animals or humans have demonstrated fetal abnormalities and/or there
Pregnancy is positive evidence of human fetal risk based on adverse reaction data from
Category X investigational or marketing experience, and the risks involved in use of the drug
in pregnant women clearly outweigh potential benefits.
Appendix: Pregnancy Classification
Revised 8/2007
1
Page 1 of 2
Section 903
Quick Reference Algorithm for Oxygen-Powered Ventilator
INITIAL SETTINGS
FiO2 = 100%
Tidal Volume Vt = 6-8ml/kg
PEEP 5cm H2O
PIP limit 30 cm H2O
AGE
RATE per minute
Adult / Child > 12 yrs
10-14
Child 1-12 yrs
14-20
Infant <1yr
26-30
GOALS
1) SpO2 > 95%
2) ETCO2 35-45 mmHg (30-35 for head injury / sepsis)
3) PIP < 30 cm H2O
Appendix: Ventilator Quick Reference
Revised 01/2010
1
Page 2 of 2
Section 903
SpO2 > 95% ?
No
Yes
PIP >30 cm H20 ?
Yes
No
Verify Vent circuit & ET tube;
DOPE; Vt by 200-400 cc
PIP <30 cmH2O ?
Rate by 4/ min;
SpO2 > 95% ?
Yes
No
No
Yes
PEEP 2-3 cm H2O
PIP <30 cmH2O ?
No
Vt by 200 cc
SpO2 > 95% ?
SpO2 >
95% ?
Yes
Yes
No
No
Systolic BP
or PIP ?
PEEP by 2-3 cc
H2O; max 10
SpO2 > 95% ?
No
Yes
Yes
Yes
Evaluate for Tension
Pneumothorax
Consult Medical
Control
Appendix: Ventilator Quick Reference
Revised 01/2010
2
Manage ETCO2 by adjusting
respiratory rate. If ETCO2 <10 evaluate
DOPE, consider esophageal tube
placement. Elevated ETCO2 may be
seen in pts with Hx of pulmonary
disease.
PROTOCOL
SECTION
NUMBER
NUMBER
OF PAGES
DATE
SECTION 1000: CCTEMTP
1000
2
Created 09/2014
Ketamine
1001
1
Created 09/2014
Page 1 of 2
Section 1001
KETAMINE (KETALAR)
PHARMACOLOGY
• Rapid-acting general anesthetic that selectively blocks afferent impulses and interacts with CNS
transmitter system
• Produces anesthetic state and profound analgesia
• Does not affect normal pharyngeal-laryngeal reflexes
INDICATIONS
• Induction/maintenance of RSI
• DSA/DSI
CONTRAINDICATIONS
• Patients with a condition in which an increase in blood pressure would be hazardous (e.g.,
aneurysms, angina, CHF, elevated ICP, hypertension, elevated intraocular pressures, psychotic
disorders, thyrotoxicosis)
• Patients with an hypersensitivity to the drug
PRECAUTIONS / SIDE EFFECTS
• Use with caution in patients with GERD, hepatic impairment, cardiovascular disease
• Side effects: increased B/P, increased heart rate, arrhythmia, increased ICP, nausea,
nystagmus. Emergence Reactions: vivid dreams, hallucinations, delirium, confusion,
excitement, and/or irrational behavior
• Use caution in patient’s using thyroxine replacement therapy
• Use extreme caution with patient’s in decompensated heart failure
ADMINISTRATION
• Patient’s being administered ketamine should be on cardiac monitor and VS every 3-5 min
• For IV maintenance infusion: dilute 500mg in 250ml D5W to provide 2 mg/ml concentration
• Induction dose: 1-2 mg/kg over 60 seconds IV, 3-7 mg/kg IM
• Maintenance dose: 1-2 mg/kg/hr
• IV incompatibilities: Doxapram (Dopram)
PROCEDURE
RSI induction:
FR
1-2 mg/kg IV
EMT B
EMT B IV
EMT P
P CC
SO
RSI maintenance:
SO
1-2 mg/kg/hr via medication pump
PREGNANCY CLASSIFICATION
• D (not recommended in use of pregnant patients)
Section 1001: Critical Care/Specialty Care Medications
Created: 9/2014
1