Download ROUTT COUNTY EMS PROTOCOLS NWRETAC

ROUTT COUNTY
EMS PROTOCOLS
NWRETAC
Revised July 26, 2016
NWRETAC Regional Protocols
changes
1. Title page updated along with headers and footers
2. 2020 / 2030 - Remove “with poor perfusion” from arrhythmia protocols title
3. 7000 Lidocaine – standardize for IO administration 40 mg (2 cc) for adults, 20
mg (1cc) for kids, 10 mg (0.5 cc) < 2 yo
4. There was some question about IM fentanyl but it was present in last revision
so no changes there.
Routt EMS Changes
1. Drug table is list of allowed drugs, routes and dosages for Routt County EMS
Providers.
NWRETAC COMBINED MEDICAL
PROTOCOLS
Version 16.1
Approved: January 1, 2016
Next Revision: June 2016
Approved by the Medical Directors of the NWRETAC including:
Bill Hall, MD
Timothy Hsu, MD
James Jex, MD
Sam Kevan, MD
Greg Minion, MD
Brad Neese, MD
Ben Peery, MD
Laila Powers, MD
Matt Skwiot, MD
Mike Stahl, MD
Jeffrey Womble, MD
The above medical directors would like to express their thanks to the
Denver Metro EMS Medical Directors who pioneered in Colorado the
algorithm format used in these protocols and from whom much of this
material was obtained.
Table of Contents
NWRETAC COMBINED MEDICAL PROTOCOLS ........................................................................ 3
0010 GENERAL GUIDELINES: INTRODUCTION ............................................................................. 9
0020 GENERAL GUIDELINES: BENCHMARKS .............................................................................. 10
0030 GENERAL GUIDELINES: PATIENT DETERMINATION: “PATIENT OR NO PATIENT”11
0040 GENERAL GUIDELINES: CONSENT ........................................................................................ 12
0050 GENERAL GUIDELINES: CONFIDENTIALITY ..................................................................... 14
0060 GENERAL GUIDELINES: PATIENT NON-TRANSPORT OR REFUSAL .......................... 15
0070 GENERAL GUIDELINES: PHYSICIAN AT THE SCENE/MEDICAL DIRECTION .......... 16
1000 ADULT (AGE > 12 YEARS) UNIVERSAL RESPIRATORY DISTRESS ALGORITHM .. 18
1010 OBSTRUCTED AIRWAY ............................................................................................................ 19
1020 PROCEDURE PROTOCOL: CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP). 20
1030 ADULT (AGE > 12 YEARS) ASTHMA .................................................................................... 21
1040 COPD .............................................................................................................................................. 22
1050 CHF / PULMONARY EDEMA.................................................................................................... 23
1060 PROCEDURE PROTOCOL: OROTRACHEAL INTUBATION ............................................. 24
1070 PROCEDURE PROTOCOL: NASOTRACHEAL INTUBATION.......................................... 25
1080 PROCEDURE PROTOCOL: KING AIRWAY ........................................................................... 27
1100 PROCEDURE PROTOCOL: PERCUTANEOUS CRICOTHYROTOMY .............................. 29
1110 PROCEDURE PROTOCOL: SURGICAL CRICOTHYROTOMY........................................... 30
2000 ADULT CHEST PAIN .................................................................................................................. 31
2010 CARDIAC ALERT PROTOCOL.................................................................................................. 33
2020 ADULT (AGE > 12 YEARS) BRADYARRHYTHMIA ........................................................... 34
2030 ADULT (> 12 YEARS) TACHYARRHYTHMIA ..................................................................... 35
2040 ADULT (AGE ≥ 12 years) CARDIAC ARREST GENERAL PRINCIPLES ........................ 36
2050 GENERAL GUIDELINES: ADVANCED MEDICAL DIRECTIVES ....................................... 38
2060 ADULT (AGE > 12 YEARS) UNIVERSAL PULSELESS ARREST ALGORITHM........... 40
2070 GENERAL GUIDELINES: TERMINATION OF RESUSCITATION AND FIELD
PRONOUNCEMENT GUIDELINES ...................................................................................................... 41
2080 PROCEDURE PROTOCOL: INTRAOSSEOUS CATHETER PLACEMENT....................... 43
2090 PROCEDURE PROTOCOL: SYNCHRONIZED CARDIOVERSION .................................... 45
2100 PROCEDURE PROTOCOL: TRANSCUTANEOUS CARDIAC PACING ............................. 46
3000 UNIVERSAL ALTERED MENTAL STATUS ........................................................................... 47
3010 HYPOGLYCEMIA ......................................................................................................................... 48
3020 SEIZURE - ADULT (> 12 YEARS)............................................................................................ 49
3030 STROKE ......................................................................................................................................... 50
3040 ALCOHOL INTOXICATION ....................................................................................................... 51
3050 ABDOMINAL PAIN/VOMITING .............................................................................................. 52
3060 ALLERGY AND ANAPHYLAXIS ............................................................................................... 53
3070 AGITATED/COMBATIVE PATIENT PROTOCOL ............................................................... 54
3070 AGITATED/COMBATIVE PATIENT GUIDELINE ............................................................... 55
3080 PROCEDURE PROTOCOL: RESTRAINT PROTOCOL ........................................................ 56
3085 TRANSPORT OF THE HANDCUFFED PATIENT ................................................................ 58
3090 HYPERTENSION .......................................................................................................................... 59
3100 MEDICAL HYPOTENSION / SHOCK PROTOCOL ............................................................... 60
3110 OVERDOSE AND ACUTE POISONING ................................................................................... 61
4000 GENERAL TRAUMA CARE ........................................................................................................ 62
4010 PROCEDURE PROTOCOL: TOURNIQUET PROTOCOL .................................................... 63
4020 TRAUMATIC SHOCK PROTOCOL - ADULT (AGE > 12 YEARS) .................................... 64
4030 TRAUMATIC PULSELESS ARREST - ADULT (AGE > 12 YEARS) .................................. 65
4040 ABDOMINAL TRAUMA ............................................................................................................. 66
4050 AMPUTATIONS ........................................................................................................................... 67
4060 BURNS ............................................................................................................................................ 68
4070 CHEST TRAUMA ......................................................................................................................... 69
4075 TENSION PNEUMOTHORAX DECOMPRESSION ............................................................... 70
4080 FACE AND NECK TRAUMA....................................................................................................... 71
4090 HEAD TRAUMA PROTOCOL .................................................................................................... 72
4100 SPINAL TRAUMA - ADULT ...................................................................................................... 73
4105 SPINAL IMMOBILIZATION PROTOCOL............................................................................... 74
4110 SPECIAL TRAUMA SCENARIOS PROTOCOL ....................................................................... 75
4120 TRAUMA IN PREGNANCY ........................................................................................................ 76
5000 HIGH ALTITUDE ILLNESS ........................................................................................................ 77
5010 ENVIRONMENTAL HYPERTHERMIA ................................................................................... 78
5020 ENVIRONMENTAL HYPOTHERMIA ...................................................................................... 79
5030 INSECT/ARACHNID STINGS AND BITES PROTOCOL ..................................................... 80
5040 NEAR DROWNING ...................................................................................................................... 81
5050 SNAKE BITE PROTOCOL .......................................................................................................... 82
6000 CHILDBIRTH PROTOCOL ........................................................................................................ 83
6010 OBSTETRICAL COMPLICATIONS .......................................................................................... 84
6020 NEONATAL CONSIDERATIONS .............................................................................................. 85
6030 PEDIATRIC NEONATAL RESUSCITATION .......................................................................... 86
6040 GENERAL GUIDELINES FOR PEDIATRIC PATIENTS ....................................................... 87
6050 PEDIATRIC UNIVERSAL RESPIRATORY DISTRESS ALGORITHM (AGE < 13 YEARS)
..................................................................................................................................................................... 88
6060 PEDIATRIC BRADYCARDIA WITH POOR PERFUSION ................................................... 89
6070 PEDIATRIC (AGE < 13 YEARS) TACHYCARDIA WITH POOR PERFUSION .............. 90
6080 PEDIATRIC (AGE < 13 YEARS) CARDIAC ARREST-GENERAL PRINCIPLES ............. 91
6090 PEDIATRIC (AGE ............. < 13 YEARS) PULSELESS ARREST BLS/AED ALGORITHM
94
6100 PEDIATRIC PULSELESS ARREST ALS ALGORITHM ........................................................ 95
6110 PEDIATRIC MEDICAL HYPOTENSION / SHOCK GUIDELINE ........................................ 96
6120 PEDIATRIC APPARENT LIFE-THREATENING EVENT (ALTE) ..................................... 97
6130 PEDIATRIC SEIZURE (< 13 YEARS) ...................................................................................... 98
6140 CARE OF THE CHILD WITH SPECIAL NEEDS..................................................................... 99
6150 PEDIATRIC TRAUMA CONSIDERATIONS (AGE < 13 YEARS) ................................... 100
7000 MEDICATIONS .......................................................................................................................... 101
ADENOSINE (ADENOCARD) ................................................................................................................ 101
ALBUTEROL SULFATE (PROVENTIL, VENTOLIN) ............................................................................. 103
AMIODARONE (CORDARONE) ............................................................................................................. 105
ASPIRIN (ASA) ....................................................................................................................................... 106
ATROPINE SULFATE............................................................................................................................. 107
DEXTROSE 10% .................................................................................................................................... 108
DIPHENHYDRAMINE (BENADRYL) ...................................................................................................... 109
DOPAMINE (INTROPIN) ........................................................................................................................ 110
DROPERIDOL (INAPSINE) .................................................................................................................... 112
EPINEPHRINE (ADRENALIN) ................................................................................................................ 113
IPRATROPIUM BROMIDE (ATROVENT) .............................................................................................. 115
LIDOCAINE 2% SOLUTION ................................................................................................................... 116
MAGNESIUM SULFATE ......................................................................................................................... 117
MIDAZOLAM (Versed) ............................................................................................................................ 118
NALOXONE (NARCAN).......................................................................................................................... 120
NITROGLYCERINE (NITROSTAT, NITROQUICK, etc)......................................................................... 121
ONDANSETRON (ZOFRAN) .................................................................................................................. 122
OPIOIDS (FENTANYL, MORPHINE) ..................................................................................................... 123
ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE) ............................................................................... 125
OXYGEN ................................................................................................................................................. 126
SODIUM BICARBONATE ....................................................................................................................... 128
8000 PROCEDURE PROTOCOL: THERAPEUTIC INDUCED HYPOTHERMIA AFTER
CARDIAC ARREST ............................................................................................................................... 129
ROUTT COUNTY SPECIFIC EMS PROTOCOLS ...................................................................... 130
Drug Table with Provider Levels and Allowed Drugs .......................................................... 134
Routt EMS Protocol Changes to the NWRETAC Protocols ................................................... 136
Operational .......................................................................................................................................... 137
BLOODBORNE / AIRBORNE PATHOGENS EXPOSURE CONTROL PLAN ....................................... 137
CISD STRESS MANAGEMENT ............................................................................................................. 142
CONTROLLED SUBSTANCES INVENTORY ........................................................................................ 143
DISCIPLINARY PROCEDURES: AGENCIES ........................................................................................ 144
DISCIPLINARY PROCEDURES: PROVIDERS...................................................................................... 145
PROTOCOL DEVIATION LEVELS: PROVIDERS .................................................................................. 147
HAZARDOUS MATERIALS PROTOCOL ............................................................................................... 148
INTERAGENCY ASSISTANCE .............................................................................................................. 149
INTER-FACILITY PATIENT TRANSFER................................................................................................ 150
MEDICAL HELICOPTER EVACUATION / RENDEZVOUS ................................................................... 151
MEDICAL QUALITY CONTROL PROGRAM ......................................................................................... 152
NURSES FUNCTIONING IN THE PREHOSPITAL ENVIRONMENT .................................................... 152
TRIAGE COLOR GUIDELINES .............................................................................................................. 154
YAMPA VALLEY MEDICAL CENTER EMERGENCY PHYSICIAN SCENE RESPONSE .................... 155
Drug Protocol ...................................................................................................................................... 156
DIPHENHYDRAMINE (BENADRYL) ...................................................................................................... 156
HYDROMORPHONE (DILAUDID) .......................................................................................................... 157
ETOMIDATE (AMIDATE) ........................................................................................................................ 159
FENTANYL ............................................................................................................................................. 160
HALOPERIDOL (HALDOL) ..................................................................................................................... 161
LIDOCAINE 2% SOLUTION ................................................................................................................... 163
LORAZEPAM (ATIVAN).......................................................................................................................... 164
METHYLPREDNISOLONE (SOLU-MEDROL) ................................................................................... 165
MIDAZOLAM (Versed) ............................................................................................................................ 166
SUCCINYLCHOLINE (ANECTINE) ........................................................................................................ 167
VECURONIUM (NORCURON) ............................................................................................................... 168
Procedure Protocol ........................................................................................................................... 169
AIRWAY MANAGEMENT: LARYNGEAL MASK AIRWAY/i-Gel ............................................................ 169
ADVANCED AIRWAY MANAGEMENT: NEEDLE CRICOTHYROTOMY.............................................. 171
RAPID SEQUENCE INTUBATION (R.S.I.) ADULT ................................................................................ 173
SPLINTING: EXTREMITY...................................................................................................................... 176
0010 GENERAL GUIDELINES: INTRODUCTION
INTRODUCTION
The following protocols have been developed and approved by the NWRETAC Medical Directors group.
These protocols define the standard of care for EMS providers in the NWRETAC area, and delineate the
expected practice, actions, and procedures to be followed.
No protocol can account for every clinical scenario encountered, and the NWRETAC Medical Directors
recognize that in rare circumstances deviation from these protocols may be necessary and in a patient’s
best interest. Variance from protocol should always be done with the patient’s best interest in mind and
backed by documented clinical reasoning and judgment. Whenever possible, prior approval by direct
verbal order from base station physician is preferred. Additionally, all variance from protocol should be
documented and submitted for review by agency Medical Director in a timely fashion.
The protocols have a new look and are presented in an algorithm format. An algorithm is intended to
reflect real-life decision points visually. An algorithm has certain limitations, and not every clinical
scenario can be represented. Although the algorithm implies a specific sequence of actions, it may
often be necessary to provide care out of sequence from that described in the algorithm if dictated by
clinical needs. An algorithm provides decision-making support, but need not be rigidly adhered to and
is no substitute for sound clinical judgment.
In order to keep protocols as uncluttered as possible, and to limit inconsistencies, individual drug
dosing has not been included in the algorithms. It is expected the providers will be familiar with
standard drug doses. Drug dosages are included with the medications section of the protocols as a
reference.
If viewing protocol in an electronic version, it will be possible to link directly to a referenced protocol by
clicking on the hyperlink, which is underlined.
PROTOCOL KEY
Boxes without any color fill describe actions applicable to all levels of EMT. Boxes with orange fill are
for actions for EMT-IV level or higher, yellow boxes for Advanced EMT and higher, green boxes for EMTIntermediate and higher, and blue-filled boxes are for Paramedics only. When applicable, actions
requiring base contact are identified in the protocol. All medication administrations by EMTs per
Chapter 2 reference.
EMT
EMT-IV
AEMT
EMT-I
Paramedic
Teaching points deemed sufficiently important to be included in the protocol are separated into greyfilled boxes with a double line border:
PEDIATRIC PROTOCOLS
For the purposes of these clinical care protocols, pediatric patients are those < 13 years of age and are
still within the length based tape sizing, except where identified in a specific protocol.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
9
0020 GENERAL GUIDELINES: BENCHMARKS
“Benchmarking” is the process of comparing an organization’s performance to national or industry
“benchmarks”, or “best practices”. This process allows an organization to develop plans on how to
make improvements, or adapt certain best practices, with the aim of increasing system-wide
performance.
“Benchmarking” is an integral part of the Continuous Quality Improvement (CQI) plan in place in the
NWRETAC. We will be continuously comparing our performance to EMS “best practices”, and targeting
education, protocol development and discipline to help us improve our performance where needed. The
spirit of Benchmarking and CQI are this: most problems are found in processes, not people. CQI does
not seek to blame, but rather to improve. The intent is to look at our system as a whole, and gather
objective data to analyze and thus improve processes.
A simple example: for EMS patients with AMS, a “best practice benchmark” might be that 100% have
their blood glucose measured in the field. If our system data shows that it is only occurring 80% of the
time in an agency or region, then we have a system-wide problem. Is it a charting issue (not using
checkbox)?; a training issue (EMT-B’s are not being taught how to use glucometer)?; an education
issue (providers do not know they need to check BG in AMS)?; or is it a protocol issue (protocols are
not clear)? If individual providers are persistently deficient, then they will also be counseled/disciplined
as needed. However, the issue uncovered is undoubtedly a system problem, not an individual provider
problem.
The NWRETAC medical directors will be tracking these items for use in comparison between systems in
our region as well as other regions within the State of Colorado and the State as a whole.
A “Benchmark Notation”, designated “BMK”, has been added within each individual protocol for which
benchmarks will be tracked, in order to remind providers of the “best practices” we are shooting for as
a System for that protocol.
The following protocols have the “BMK” designation and this is what will be tracked:
1. Airway
a. Intubation success rate
i. Per patient
ii. Per attempt
b. Complications
i. Misplaced tube
ii. Unintended extubation
2. Cardiac arrest
a. ROSC/Transport rate
b. Survival to discharge rate (VF/VT, other)
3. Chest Pain
a. ECG done in pts > 34 with non-traumatic CP
b. ASA administration rates
4. Universal Altered Mental Status – BG check (precursor to hypoglycemia, seizure, stroke, alcohol
intoxication). Also BG Check in:
a. Agitated / Combative Patient
b. Heat/Cold
c. Head Trauma
d. Near Drowning with AMS
e. SZ in Pregnancy
f. Pediatric seizures
5. Pediatrics – use of length based tape
Your agency medical director may have other items which will be tracked in your agency or
system. These will be identified in the “Local Protocols” sections of the protocols.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
10
0030 GENERAL GUIDELINES: PATIENT DETERMINATION: “PATIENT OR NO PATIENT”
Person is a
minor
(Age < 18 yrs)
Yes
General Guidelines
This protocol is intended to refer to individual patient
contacts. In the event of a multiple party incident, such
as a multi-vehicle collision, it is expected that a
reasonable effort will be made to identify those parties
with acute illness or injuries. Adult patients indicating
that they do not wish assistance for themselves or
dependent minors in such a multiple party incident do
not necessarily require documentation as patients.
No
Person lacks
decision-making
capacity
(See adjacent)
Yes
No protocol can anticipate every scenario and
providers must use best judgment. When in doubt
as to whether individual is a “patient”, err on the
side of caution and perform a full assessment and
documentation
No
Acute illness or
injury suspected
based on
appearance,
MOI, etc
Yes
Decision-Making Capacity
(Must meet all criteria)
No
Person has a
complaint
resulting in a call
for help
Yes
•
•
•
•
Understands nature of illness or injury
Understands consequences of refusal of care
Not intoxicated with drugs or alcohol
No criteria for a Mental Health Hold:
o Not homicidal or suicidal
o Not gravely disabled or psychotic
o Not a danger to self or others
No
rd
3 party caller
indicates
individual is ill,
injured or
gravely disabled
Yes
Individual meets
definition of a
Patient
(PCR Required)
No
Person does not meet
definition of a patient,
and does not require
PCR or refusal of care
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
11
0040 GENERAL GUIDELINES: CONSENT
CONSENT
General Principles: Adults
A. An adult in the State of Colorado is 18 years of age or older.
B. Every adult is presumed capable of making medical treatment decisions. This includes the right
to make "bad" decisions that the prehospital provider believes are not in the best interests of the
patient.
C. A person is deemed to have decision-making capacity if he/she has the ability to provide
informed consent, i.e., the patient:
1. Understands the nature of the illness/injury or risk of injury/illness
2. Understands the possible consequences of delaying treatment and/or refusing transport
3. Given the risks and options, the patient voluntarily refuses or accepts treatment and/or
transport.
D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse
medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the
need for therapies, offer again, and treat to the extent possible.
E. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing
treatment.
F. Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening
injuries/illnesses.
G. Involuntary Consent: a person other than the patient in rare circumstances may authorize
Consent. This may include a court order (guardianship), authorization by a law enforcement
officer for prisoners in custody or detention, or for persons under a mental health hold or
commitment who are a danger to themselves or others or are gravely disabled.
Procedure: Adults
A. Consent may be inferred by the patient's actions or by express statements. If you are not sure
that you have consent, clarify with the patient or CONTACT BASE. This may include consent for
treatment decisions or transport/destination decisions.
B. Determining whether or not a patient has decision-making capacity to consent or refuse medical
treatment in the prehospital setting can be very difficult. Every effort should be made to
determine if the patient has decision-making capacity, as defined above.
C. For patients who do not have decision-making capacity, CONTACT BASE.
D. If the patient lacks decision-making capacity and the patient's life or health is in danger, and
there is no reasonable ability to obtain the patient's consent, proceed with transport and
treatment of life-threatening injuries/illnesses. If you are not sure how to proceed, CONTACT
BASE.
E. For patients who refuse medical treatment, if you are unsure whether or not a situation of
involuntary consent applies, CONTACT BASE.
General Principles: Minors
A. A parent, including a parent who is a minor, may consent to medical or emergency treatment of
his/her child. There are exceptions:
1. Neither the child nor the parent may refuse medical treatment on religious grounds if the
child is in imminent danger as a result of not receiving medical treatment, or when the
child is in a life-threatening situation, or when the condition will result in serious
handicap or disability.
2. The consent of a parent is not necessary to authorize hospital or emergency health care
when an EMT in good faith relies on a minor's consent, if the minor is at least 15 years of
age and emancipated or married.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
12
3. Minors may seek treatment for abortion, drug addiction, and venereal disease without
consent of parents. Minors > 15 years may seek treatment for mental health.
B. When in doubt, your actions should be guided by what is in the minor's best interests and base
contact.
Procedure: Minors
A. A parent or legal guardian may provide consent to or refuse treatment in a non- life-threatening
situation.
B. When the parent is not present to consent or refuse:
1. If a minor has an injury or illness, but not a life-threatening medical emergency, you
should attempt to contact the parent(s) or legal guardian. If this cannot be done
promptly, transport.
2. If the child does not need transport, they can be left at the scene in the custody of a
responsible adult (e.g., teacher, social worker, grandparent). It should only be in very
rare circumstances that a child of any age is left at the scene if the parent is not also
present.
3. If the minor has a life-threatening injury or illness, transport and treat per protocols. If
the parent objects to treatment, CONTACT BASE immediately and treat to the extent
allowable, and notify police to respond and assist.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
13
0050 GENERAL GUIDELINES: CONFIDENTIALITY
CONFIDENTIALITY
A. The patient-physician relationship, the patient-registered nurse relationship, and the patientprehospital provider relationship are recognized as privileged. This means that the physician,
nurse, or prehospital provider may not testify as to confidential communications unless:
1. The patient consents
2. The disclosure is allowable by law (such as Medical Board or Nursing Board
proceedings, or criminal or civil litigation in which the patient's medical condition is in
issue)
B. The prehospital provider must keep the patient's medical information confidential. The patient
likely has an expectation of privacy, and trusts that personal, medical information will not be
disclosed by medical personnel to any person not directly involved in the patient's medical
treatment. Exceptions include:
a. The patient is not entitled to confidentiality of information that does not pertain to the
medical treatment, medical condition, or is unnecessary for diagnosis or treatment.
b. The patient is not entitled to confidentiality for disclosures made publicly.
c. The patient is not entitled to confidentiality with regard to evidence of a crime.
C. Additional Considerations:
1. Any disclosure of medical information should not be made unless necessary for the
treatment, evaluation or diagnosis of the patient.
2. Any disclosures made by any person, medical personnel, the patient, or law enforcement
should be treated as limited disclosures and not authorizing further disclosures to any
other person.
3. Any discussions of prehospital care by and between the receiving hospital, the
crewmembers in attendance, or at in-services or audits are done strictly for educational
or performance improvement purposes. Further disclosures are not authorized.
4. Radio communications should not include disclosure of patient names.
5. This procedure does not preclude or supersede your agency’s HIPAA policy and
procedures.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
14
0060 GENERAL GUIDELINES: PATIENT NON-TRANSPORT OR REFUSAL
EMS
Dispatch
A person who has decision-making capacity
may refuse examination, treatment and
transport
A person has decision making capacity sufficient to
refuse treatment and transport if he or she:
Cancelled
PTA
Arrived on
scene
Not a patient
(see Patient
Determination)
Standing
order refusal
•
•
•
•
•
Confirm decision-making capacity
EMS assistance offered and declined
Risks of refusal explained to patient
Patient understands risks of refusal
Name of Base Station physician authorizing
refusal of care unless standing order refusal
• Signed refusal of care against medical advise
document, if possible
Base contact for
refusal
Standing Order Refusal
No Base Contact required if ALL
criteria met:
≥18 or parent/guardian on scene
Decision-making capacity
No drug/alcohol involvement
Complaint or injury is minor, i.e.:
isolated extremity injury or minor
soft tissue injury
• Additional agency-specific criteria
may exist
•
•
•
•
Documentation Requirements for Refusal
Patient
No
transport
Transport
• Understands nature of illness or injury; and
• Understands the risks of refusing treatment or
transport; and
• Given the risks and options, voluntarily refuses
treatment or transport
Base Contact
Refusal
All calls not meeting
criteria for Standing
Order Refusal
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
15
0070 GENERAL GUIDELINES: PHYSICIAN AT THE SCENE/MEDICAL DIRECTION
PHYSICIAN AT THE SCENE/MEDICAL DIRECTION
Purpose
A. To provide guidelines for prehospital personnel who encounter a physician at the scene of an
emergency
General Principles
A. The prehospital provider has a duty to respond to an emergency, initiate treatment, and conduct
an assessment of the patient to the extent possible.
B. A physician 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.
C. Good patient care should be the focus of any interaction between prehospital care providers and
the physician.
Procedure
A. See algorithm below.
Special notes
A. Every situation may be different, based on the physician, the scene, and the condition of the
patient.
B. CONTACT BASE when any question(s) arise.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
16
PHYSICIAN AT THE SCENE/MEDICAL DIRECTION ALGORITHM
EMS arrives on
scene
EMS provider attempts
patient care
Physician reports on patient
and relinquishes patient care
Physician wants to help or is involved in
or will not relinquish patient care
Provide care per protocol
Prehospital provider indentifies self and
level of training
Physician willing to just
help out
Provide general
instructions and utilize
physician assistance
Physician does not
relinquish patient care
and continues with care
inconsistent with
protocols
Physician requests or
performs care inappropriate
or inconsistent with protocols
Advise physician of your
responsibility to the patient
and request they ride in with
patient if they will not
relinquish care
Physician
relinquishes care
Provide care per
protocol
Contact Base for
Medical Consult
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
17
1000 ADULT (AGE > 12 YEARS) UNIVERSAL RESPIRATORY DISTRESS ALGORITHM
Respiratory Distress
EMT
EMT-I
For all patients:
While assessing ABCs: give supplemental
O2 titrated to 90-94%, monitor vital signs,
cardiac rhythm, SpO2 and ETCO2
Consider pulmonary and
non-pulmonary causes of
respiratory distress:
EMT IV
AEMT
Paramedic
No
Obstructed Airway Protocol
Patent airway?
•
•
•
•
•
•
Pulmonary embolism
Pneumonia
Heart attack
Pneumothorax
Sepsis
Metabolic acidosis (e.g.:
DKA)
• Anxiety
Yes
No
Are ventilations adequate for
physiologic state?
Assist ventilations with BVM
and airway adjuncts as
needed. BLS should call for
ALS assist or rendezvous.
Yes
No
Is SpO2 > 90 % with
supplemental O2?
Assess for CPAP or need for
advanced airway
No
Yes
Is anaphylaxis likely?
Mixed picture may exist
• Goal is maximization of
oxygenation and ventilation
in all cases
• CPAP may be particularly
useful in mixed picture with
hypoxia and/or
hypoventilation
• Avoid albuterol in suspected
pulmonary edema
?
Allergic Rxn Protocol
No
Yes
Is asthma or COPD likely?
?
Asthma or COPD protocols
No
Is CHF/pulmonary edema
likely?
Yes
CHF/Pulmonary Edema
protocol
• Transport
• Provide supportive care
• Maximize oxygenation and
ventilation
• Contact base if needed for
consult
• Consider 12 lead ECG
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
18
1010 OBSTRUCTED AIRWAY
EMT
EMT-I
If patient can speak,
obstruction is incomplete
Does patient show universal sign of
choking?
Yes
Assess severity of obstruction
Severe or Complete Obstruction
(mute, silent cough, severe stridor)
• Open airway w. head tilt-chin lift
or jaw thrust if craniofacial
trauma
• Attempt ventilation with BVM
Unconscious Patient
Begin chest thrusts
Each time airway is opened look in
mouth for FB and if found, remove it
• Do not interfere with a
spontaneously breathing or
coughing patient
• Position of comfort
• Give high flow oxygen
• Suction if needed
Yes
Once obstruction relieved:
• Perform laryngoscopy
• Use McGill forceps to remove
object if possible
Yes
• Position of comfort or left lateral
recumbent position
• O2 via NRB 15 Lpm
• Monitor ABCs, SpO2, vital signs
• Suction PRN and be prepared
for vomiting, which commonly
occurs after obstruction relieved
No
• For visibly pregnant or obese
patients perform chest thrusts
instead
• Consider chest thrusts in any
patient if abdominal thrust
ineffective
• For infants < 1 yr old, 5 chest
thrusts, then 5 back blows
Mild or Partial Obstruction
Yes
No
Perform abdominal thrusts until
obstruction relieved then reattempt
ventilations w. BVM
Paramedic
• Perform Heimlich maneuver
• For visibly pregnant or
obese patients perform
chest thrusts only
• For infants, 5 chest thrusts,
then 5 back slaps
No
Able to ventilate or
obstruction cleared?
AEMT
Attempt to determine cause of
obstruction
If obstruction is
complete, patient will be
mute.
Able to ventilate or
obstruction cleared?
EMT IV
If still obstructed and unable to
ventilate:
Alternative: oral intubation &
attempt to push object into
mainstem bronchus with ETT
Is obstruction
cleared?
No
• Supportive care and rapid
transport
• If patient deteriorating or
develops worsening distress
proceed as for complete
obstruction
Cricothyrotomy is a difficult and
hazardous procedure that is to be
used only in extraordinary
circumstances. The reason for
performing this procedure must be
documented and submitted for
review to the EMS Medical Director
within 24 hours
• Consider cricothyrotomy in
adult patient if suspected
supraglottic obstruction and
unable to ventilate with BVM.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
19
1020 PROCEDURE PROTOCOL: CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Indications:
• Symptomatic patients with moderate-to-severe respiratory
distress as evidenced by at least two (2) of the following:
o Rales (crackles)
o Dyspnea with hypoxia (SpO2 < 90% despite O2)
o Dyspnea with verbal impairment – i.e. cannot speak in full
sentences
o Accessory muscle use
o Respiratory rate > 24/minute despite O2
o Diminished tidal volume
EMT
EMT IV
EMT-I
AEMT
Paramedic
Contraindications:
• Respiratory or cardiac arrest
• Systolic BP < 100 mmHg
• Lack of airway protective reflexes (gag)
• Significant altered level of consciousness such that unable to follow verbal instructions or
signal distress
• Vomiting or active upper GI bleed
• Suspected pneumothorax
• Trauma
• Patient size or anatomy prevents adequate mask seal
Technique:
1. Place patient in a seated position and explain the procedure to him or her
2. Assess vital signs (BP, HR, RR, SpO2, and ETCO2)
3. Operate CPAP device according to manufacturer specifications
4. PEEP should be set at 5 cm of water initially, may be increased to maximum 10 cm of water as
needed.
5. Apply the CPAP mask and secure with provided straps, progressively tightening as tolerated to
minimize air leak
6. Patients should be considered “critical” with vital signs recorded every 5 minutes
7. Assess patient for improvement as evidenced by the following:
a. Increased SpO2
b. Appropriate ETCO2 values and waveforms
c.
Increased tidal volume
8. Observe for signs of deterioration or failure of response to CPAP:
a. Decrease in level of consciousness
b. Sustained or increased heart rate, respiratory rate or decreased blood pressure
c. Sustained low or decreasing SpO2 readings
d. Rising ETCO2 levels or other ETCO2 evidence of ventilatory failure
e. Diminished or no improvement in tidal volume
9. EMT-I/Paramedic - may consider midazolam (single dose) if patient too anxious to tolerate mask
Precautions:
• Should patient deteriorate on CPAP:
o Troubleshoot equipment
o Assess need for possible chest decompression due to pneumothorax
o Assess for possibility of hypotension due to significantly reduced preload from positive
pressure ventilation
• In-line nebulized medications may be given during CPAP as indicated and in accordance with
manufacturer guidelines
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
20
1030 ADULT (AGE > 12 YEARS) ASTHMA
Presentation suggests asthma:
wheezing, prolonged expiratory phase,
decreased breath sounds, accessory
muscle use, known hx of asthma
Universal Respiratory Distress
Protocol and prepare for
immediate transport
EMT
EMT IV
EMT-I
AEMT
Paramedic
Titrate oxygen 90-94%, check SpO2, &
consider IV for severe respiratory
Therapeutic Goals:
• Maximize oxygenation
• Decrease work of breathing
• Identify cardiac ischemia
(Obtain 12 lead EKG)
• Identify complications, e.g.
pneumothorax
EMT may administer either mdi or
nebulized albuterol with base contact
for verbal order
Give nebulized albuterol + ipratropium
May give continuous neb for severe
respiratory distress
Yes
Is response to treatment adequate?
No
•
Severe exacerbation:
Consider IM epinephrine.
Indicated only if no response to
neb and severe distress
IM epinephrine is only
indicated for most severe
attacks deemed lifethreatening and not
responding to inhaled
bronchodilators. Use extreme
caution when administering.
Cardiopulmonary monitoring
is mandatory
Yes
Is response to treatment adequate?
No
• Consider CPAP
• If CPAP contraindicated, ventilate
with BVM, and call for ALS for
possible advanced airway
• Consider IM epinephrine (if not
already given)
• Reassess for pneumothorax
• Obtain ECG: rule out unstable
rhythm, ACS
Consider pulmonary and
non-pulmonary causes of
respiratory distress:
Examples: pulmonary
embolism, pneumonia,
pulmonary edema,
anaphylaxis, heart attack,
pneumothorax, sepsis,
metabolic acidosis (e.g.:
DKA), Anxiety
• Continue monitoring and assessment en route
• Be prepared to assist ventilations as needed
• Contact base for medical consult as needed
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
21
1040 COPD
Presentation suggests COPD:
Hx of COPD w. wheezing, prolonged
expiratory phase, decreased breath
sounds, accessory muscle use
Universal Respiratory Distress
Protocol and prepare for
immediate transport
EMT
EMT IV
EMT-I
AEMT
Paramedic
Titrate oxygen 90-94%, check SpO2,
start IV and place on monitor
Therapeutic Goals:
• Maximize oxygenation
• Decrease work of breathing
• Identify cardiac ischemia
(Obtain 12 lead EKG)
• Identify complications, e.g.
pneumothorax
EMT may administer either mdi or
nebulized albuterol with base contact
for verbal order
Give nebulized albuterol + ipratropium
May give continuous neb for severe
respiratory distress
Yes
Is response to treatment adequate?
No
• Reassess for pneumothorax
• Consider alternative diagnoses,
including cardiac disease
• Consider CPAP if severe distress
• Assist ventilations with BVM as
needed
• Consider advanced airway if CPAP
contraindicated or not available
CPAP may be very helpful in
severe COPD exacerbation,
however these patients are at
increased risk of
complications of CPAP such
as hypotension and
pneumothorax.
Cardiopulmonary monitoring
is mandatory
Obtain ECG: rule out unstable rhythm,
ACS
•
•
•
Continue continuous cardiac monitoring, SpO2 and
capnography, if available
Be prepared to assist ventilations as needed
Contact base for medical consult as needed
Special Notes:
•
Correct hypoxia: do not withhold maximum oxygen for fear of CO2 retention
•
Consider pulmonary and non-pulmonary causes of respiratory distress: Examples: pulmonary embolism,
pneumonia, pulmonary edema, anaphylaxis, heart attack, pneumothorax, sepsis, metabolic acidosis (e.g.: DKA), Anxiety
•
Patients with COPD are older and have comorbidities, including heart disease.
•
Wheezing may be a presentation of pulmonary edema, “cardiac asthma”
•
Common triggers for COPD exacerbations include: Infection, dysrhythmia (e.g.: atrial fibrillation), myocardial ischemia
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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1050 CHF / PULMONARY EDEMA
Universal Respiratory Distress
Protocol
EMT
EMT IV
EMT-I
AEMT
Paramedic
CHF/Pulmonary edema
SpO2, EtCO2
Obtain venous access
Give nitroglycerin (NTG)
Yes
Is oxygenation and ventilation
adequate?
No
Start CPAP protocol
•
•
Obtain 12 lead ECG: rule out
unstable rhythm, ACS
Consider midazolam for
control of anxiety
Therapeutic Goals:
• Maximize oxygenation
• Decrease work of breathing
• Identify cardiac ischemia
(Obtain 12 lead ECG)
Special Notes:
• In general diuretics have no
role in initial treatment of
acute pulmonary edema.
Yes
Is response to treatment adequate?
No
If failing above therapy:
• Remove CPAP and ventilate
with BVM
• Consider pneumothorax
• Consider alternative
diagnoses/complications
• Consider advanced airway
• Continue monitoring and
assessment
• Transport
• Contact base for medical consult
as needed
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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1060 PROCEDURE PROTOCOL: OROTRACHEAL INTUBATION
Indications:
EMT-I
•
•
•
•
Paramedic
Respiratory failure
Absence of protective airway reflexes
Present or impending complete airway obstruction
Anticipated prolonged need for positive pressure ventilation
Contraindications:
• There are no absolute contraindications. However, in general the primary goals of airway
management are adequate oxygenation and ventilation, and these should be achieved in the least
invasive manner possible
o Orotracheal intubation is associated with worse outcomes among pediatric patients and
head injured patients when compared to BLS airway maneuvers. Therefore, it is relatively
contraindicated in these populations
o Intubation is associated with interruptions in chest compressions during CPR, which is
associated with worse patient outcomes. Additionally, intubation itself has not been
shown to improve outcomes in cardiac arrest
Technique:
1. Initiate BLS airway sequence
2. Suction airway and pre-oxygenate with BVM ventilations, if possible
3. Check equipment and position patient:
a. If trauma: have assistant hold in-line spinal immobilization in neutral position
b. If no trauma, sniffing position or slight cervical hyperextension is preferred
4. Perform laryngoscopy
5. Bougie if needed
6. Place ETT. Confirm tracheal location and appropriate depth and secure tube
7. Confirm and document tracheal location by:
a. Direct visualization of ETT passing cords
b. EtCO2
c. Presence and symmetry of breath sounds
d. Rising SpO2
e. Other means as needed
8. Ventilate with BVM. Assess adequacy of ventilations
9. During transport, continually reassess ventilation, oxygenation and tube position with
continuous EtCO2 and SpO2
Precautions:
• Ventilate at age-appropriate rates. Do not hyperventilate
• If the intubated patient deteriorates, think “DOPE”
o Dislodgement, Obstruction, Pneumothorax, Equipment failure (no oxygen)
• Reconfirm and document correct tube position after moving patient and before disconnecting
from monitor in ED
• Unsuccessful intubation does not equal failed airway management. Many patients cannot be
intubated without paralytics. Use King Airway or BVM ventilations if 3 attempts at intubation
unsuccessful.
Documentation: (BMK)
• Number of attempts at intubation (attempt = insertion of laryngoscope into mouth with intent to
intubate)
• Reasons why intubation attempt was unsuccessful
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
24
•
Any complications during procedure including misplaced tubes, or unintended extubation.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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1070 PROCEDURE PROTOCOL: NASOTRACHEAL INTUBATION
Indications:
•
•
•
Paramedic
Age ≥ 9 years spontaneously breathing patient with indication for intubation who cannot tolerate
either supine position or laryngoscopy
Present or impending airway obstruction
Anticipated prolonged need for positive pressure ventilation
Contraindications:
•
•
•
Apnea
Severe mid-face trauma
Patient can be safely ventilated with non-invasive means such as CPAP or BVM
Technique:
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Initiate BLS airway sequence
Suction airway and pre-oxygenate with BVM ventilations, if possible
Check equipment and position patient appropriately
Administer phenylephrine nasal drops in each nostril
Lubricate ETT with Lidocaine jelly or other water-soluble lubricant
Insert tube in largest nare and advance during inspiration until tube in trachea. Continue
advancing tube until air is definitely exchanging through tube, then advance 2 cm more and
inflate cuff
Note tube depth and tape securely
Confirm and document endotracheal location by:
a. ETCO2
b. Presence and symmetry of breath sounds
c. Rising SpO2
d. Other means as needed
Ventilate with BVM. Assess adequacy of ventilations
During transport, continually reassess ventilation, oxygenation and tube position with
continuous ETCO2 and SpO2
Reconfirm and document correct tube position after moving patient and before disconnecting
from monitor in ED
Precautions:
•
•
•
Ventilate at age-appropriate rates. Do not hyperventilate
If the intubated patient deteriorates, think “DOPE”
o Dislodgement
o Obstruction
o Pneumothorax
o Equipment failure (no oxygen)
Blind nasotracheal intubation is a very gentle technique. The secret to success is perfect
positioning and patience.
Documentation: (BMK)
• Number of attempts at intubation (attempt = insertion of endotracheal tube with intent to pass
into trachea)
• Reasons why intubation attempt was unsuccessful
• Any complications during procedure including misplaced tubes, or unintended extubation.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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1080 PROCEDURE PROTOCOL: KING AIRWAY
Indications:
• Rescue airway if unable to intubate a patient in need of
airway protection
• Primary airway if intubation anticipated to be difficult and
rapid airway control is necessary
• Primary airway in pulseless arrest, when attempts at
intubation are likely to interrupt CPR
• Designated advanced airway for EMTs
EMT
EMT IV
EMT-I
AEMT
Paramedic
Contraindications:
• Intact gag reflex
• Caustic ingestion
• < 48inches tall
Technique
1. Initiate BLS airway sequence
2. Select proper size King airway based on patient height, assemble and test equipment, lubricate
posterior aspect distal tip with water-soluble lubricant (included)
3. Suction airway and pre-oxygenate with BVM ventilations, if possible
4. If trauma: have assistant hold in-line spinal immobilization in neutral position
5. If no trauma, sniffing position or slight cervical hyperextension is preferred
6. Insert and place King Tube as previously instructed.
7. Using supplied syringe, inflate cuff balloon with correct volume of air (marked on King tube).
8. Attach bag to King and begin ventilating patient. While bagging, slowly and slightly withdraw
King until ventilations are easy and chest rise is adequate
9. Confirm tube placement by auscultation, chest movement, and ETCO2
10. Monitor patient for vomiting and aspiration
11. Continuously monitor and record ETCO2, SpO2, vital signs
Precautions:
1. Use with caution in patients with broken teeth, which may lacerate balloon
2. Use with caution in patients with known esophageal disease
3. Do not remove a properly functioning King tube in order to attempt intubation
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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1090 PROCEDURE PROTOCOL: CAPNOGRAPHY
EMT
Indications:
• MANDATORY: to rule out esophageal intubation and
confirm endotracheal tube position in all intubated
patients.
• To identify late endotracheal tube dislodgement
• To monitor ventilation and perfusion in any ill or injured patient
EMT IV
EMT-I
AEMT
Paramedic
Contraindications:
• None
Technique:
1. In patient with ETT or advanced airway: place EtCO2 detector in-line between airway adaptor and
BVM after airway positioned and secured
2. Patients without ETT or advanced airway in place: place EtCO2 cannula on patient. May be
placed under CPAP or NRB facemask
3. Assess and document both capnography waveform and EtCO2 value
Precautions:
1. To understand and interpret capnography, remember the 3 determinants of EtCO2:
a. Alveolar ventilation
b. Pulmonary perfusion
c. Metabolism
2. Sudden loss of waveform EtCO2:
a. Tube dislodged
b. Circuit disconnected
c. Cardiac arrest
3. High EtCO2 (> 45)
a. Hypoventilation/CO2 retention
4. Low EtCO2 (< 25)
a. Hyperventilation
b. Low perfusion: shock, PE, sepsis
5. Cardiac Arrest:
a. In low-pulmonary blood flow states, such as cardiac arrest, the primary determinant of
EtCO2 is blood flow, so EtCO2 is a good indicator of quality of CPR
b. If ETCO2 is dropping, change out person doing chest compressions
c. In cardiac arrest, if ETCO2 not > 10 mmHg after 20 minutes of good CPR, this likely
reflects very low CO2 production (dead body) and is a 100% predictor of mortality
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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1100 PROCEDURE PROTOCOL: PERCUTANEOUS CRICOTHYROTOMY
Paramedic
Introduction:
•
Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be used only in
extraordinary circumstances as defined below. The reason for performing this procedure must be
documented and submitted for review to the EMS Medical Director as soon as possible but no later
than 24 hours after the call.
Indications:
•
A life-threatening condition exists AND advanced airway management is indicated, AND adequate
oxygenation and ventilation cannot be accomplished by other less invasive means.
Contraindications:
•
•
Anterior neck hematoma is a relative contraindication
Age < 12 is a relative contraindication
Technique:
1. Prepare skin using aseptic solution
2. Position the patient in a supine position, with in-line spinal immobilization if indicated. If cervical
spine injury not suspected, neck extension will improve anatomic view
3. Perform cricothyrotomy according to manufacturer’s instructions for selected device
4. Confirm and document tube placement by:
a. ETCO2
b. Breath sounds
c. Rising pulse oximetry
d. Other means as needed
5. Ventilate with BVM assessing adequacy of ventilation
6. Observe for subcutaneous air, which may indicate tracheal injury or extra- tracheal tube position
7. Secure tube with tube ties or device
8. Continually reassess ventilation, oxygenation, tube placement and waveform EtCO2.
Precautions:
•
•
Success of procedure is dependent on correct identification of cricothyroid membrane
Bleeding will occur, even with correct technique. Straying from the midline is dangerous and likely
to cause hemorrhage
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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1110 PROCEDURE PROTOCOL: SURGICAL CRICOTHYROTOMY
Paramedic
Introduction:
•
Surgical cricothyrotomy is a difficult and hazardous procedure that is to be used only in
extraordinary circumstances as defined below. The reason for performing this procedure must be
documented and submitted for review to the EMS Medical Director as soon as possible but no later
than 24 hours after the call.
Indications:
•
A life-threatening condition exists AND advanced airway management is indicated, AND adequate
oxygenation and ventilation cannot be accomplished by other less invasive means.
Contraindications:
•
•
Age < 8 is an absolute contraindication
Anterior neck hematoma is a relative contraindication
Technique:
1. Assemble and check equipment as soon as this procedure becomes a possibility.
2. Prepare skin using aseptic solution
3. Position the patient in a supine position, with in-line spinal immobilization if indicated. If cervical
spine injury not suspected, neck extension will improve anatomic view
4. Perform surgical cricothyrotomy
a. Once hole in membrane is created, something should remain in orifice until ETT placed.
b. Bougie assisted
c. 6.0 ETT in most adults
5. Confirm and document tube placement by:
a. ETCO2
b. Breath sounds
c. Rising pulse oximetry
d. Other means as needed
e. Goal is to create an airway so any patent airway is a success
6. Ventilate with BVM assessing adequacy of ventilation
7. Observe for subcutaneous air, which may indicate tracheal injury or extra- tracheal tube position
8. Secure tube with tube ties
9. Continually reassess ventilation, oxygenation, tube placement and waveform EtCO2.
Precautions:
•
•
Success of procedure is dependent on correct identification of cricothyroid membrane
Bleeding will occur, even with correct technique. Straying from the midline is dangerous and likely
to cause hemorrhage
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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2000 ADULT CHEST PAIN
General:
EMT
EMT-IV
AEMT
A. Consider life-threatening causes of chest pain first
in all patients:
1. Acute coronary syndromes (ACS)
EMT-I
Paramedic
2. Pulmonary embolism (PE)
3. Thoracic aortic dissection (TAD)
4. Tension pneumothorax (PTX)
B. Do not delay obtaining 12 lead ECG, if available, and notify receiving facility immediately if
Cardiac Alert criteria met.
Document specific findings:
A. Complete set of vital signs
B. General appearance: skin color, diaphoresis
C. Cardiovascular exam: presence of irregular heart sounds, JVD, murmur, pulse asymmetry,
dependent edema
D. Pulmonary exam: crackles/rales and/or wheezes/rhonchi
E. Chest wall and abdominal tenderness
Treatment:
A.
B.
C.
D.
E.
F.
ABCs
Reassure patient and place in position of comfort
Place patient on cardiac monitor
Administer oxygen – titrate to SaO2 90-94%. DO NOT GIVE OXYBEN IF NORMOXIC
Start IV
If patient > 34 years old (BMK), or strong concern for cardiac cause if < 35 years old:
1. Administer 4 chewable 81mg aspirin
2. EMT-Basics - Contact base for verbal order for patient-assisted and supplied
nitroglycerine, if applicable. Obtain 12 lead ECG for transmission or subsequent ALS
evaluation if available.
3. AEMTs - Administer nitroglycerine 0.4mg SL or spray if SBP > 100. Repeat dose every 5
minutes, up to a maximum of 3 doses, holding if SBP < 100. Consider nitroglycerine
paste if patient responds to sublingual NTG.
G. EMT-Intermediates and paramedics - Obtain 12-lead ECG. (BMK)
1. If patient has at least 1 mm ST segment elevation (STE) in at least 2 anatomically
contiguous leads, notify receiving hospital and request CARDIAC ALERT (see Cardiac
Alert Protocol).
2. Administer opioids IV for persistent pain that is not relieved by 3 doses SL
nitroglycerine, unless contraindicated. It is acceptable to administer morphine before 3
doses of nitro if nitro deemed ineffective for pain control.
3. Consider base station contact for additional medication orders if pain persists.
Precautions:
A. If inferior MI diagnosed (ST elevation in II, III, aVF), consider possibility of right ventricular
infarct. Do not delay transport or receiving hospital contact; however, obtain right-sided ECG
leads en route if time and conditions allow in order to identify right ventricular infarct.
B. If RV infarct pattern present (ST elevation in right-sided precordial leads, typically RV4), give
nitroglycerine with extreme caution as hypotension common.
C. If hypotension develops following nitroglycerine administration in any patient, treat with 250cc
NS boluses.
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D. Nitroglycerine is contraindicated in patients taking medication for erectile dysfunction
(phosphodiesterase inhibitors, e.g.: Viagra, Cialis) if taken in the previous 36 hours.
E. Suspicion of an acute MI is based on history. Do not be reassured by a “normal” monitor strip.
Conversely, “abnormal” strips (particularly ST and T wave changes) can be due to technical
factors or nonacute cardiac diseases. ST elevation that changes after nitroglycerin
administration can be significant and should be documented.
F. Constant monitoring is essential. As many as 50% of patients with acute MI who develop
ventricular fibrillation may have no warning arrhythmias.
G. Beware of IV fluid overload in the potential cardiac patient.
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2010 CARDIAC ALERT PROTOCOL
EMT-I
Paramedic
Goal:
• To identify patients with ST-segment elevation myocardial infarction (STEMI) in the prehospital
setting and provide advanced receiving hospital notification in order to minimize door-to-balloon
times for percutaneous coronary intervention (PCI)
Inclusion Criteria:
• Symptoms compatible with ACS (chest pain, diaphoresis, dyspnea, etc)
• 12-lead ECG showing ST-segment elevation (STE) at least 1 mm in two or more anatomically
contiguous leads
• Age 35-85 years old (If STEMI patient outside age criteria, contact receiving hospital for consult)
Exclusion Criteria:
• Wide complex QRS (paced rhythm, BBB, other)
• Symptoms NOT suggestive of ACS (e.g.: asymptomatic patient)
• If unsure if patient is appropriate for Cardiac Alert, discuss with receiving hospital MD
Actions:
• Treat according to chest pain protocol en route (cardiac monitor, oxygen, aspirin, nitroglycerine and
opioids)
• Notify receiving hospital ASAP with ETA and request CARDIAC ALERT. Do not delay hospital
notification. If possible, notify ED before leaving scene
• Start 2 large bore peripheral IVs
• Rapid transport
• If patient does not meet inclusion criteria, or has exclusion criteria, yet clinical scenario and ECG
suggests true STEMI, request medical consult with receiving hospital emergency physician
Additional Documentation Requirements:
• Time of first patient contact
• Time of first ECG
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2020 ADULT (AGE > 12 YEARS) BRADYARRHYTHMIA
EMT
Bradycardia with a pulse
Heart rate < 60 and
inadequate for clinical
condition
•
•
•
•
Support ABCs
Give Oxygen
Start IV
Initiate transport
EMT IV
EMT-I
AEMT
Paramedic
• Cardiac monitor
• Identify rhythm
• 12-lead ECG
Are there signs or symptoms of poor
perfusion present?
(Altered mental status, chest pain,
hypotension, signs of shock)
Adequate perfusion
Monitor and transport
Poor perfusion
• Give atropine
• Prepare for transcutaneous pacing
• Consider dopamine early if pacing
Reminders:
• If pulseless arrest develops, go to pulseless
arrest algorithm
• Search for possible contributing factors: “5 Hs
and 5 Ts”
• Symptomatic severe bradycardia is usually
related to one of the following:
o
Ischemia (MI)
o
Drugs (beta blocker, Calcium
channel blocker)
o
Electrolytes (hyperkalemia)
• Consider epinephrine if pacing
ineffective
Monitor and transport
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2030 ADULT (> 12 YEARS) TACHYARRHYTHMIA
Tachyarrhythmia With Poor Perfusion
EMT
• Support ABCs
• IV access
• Give Oxygen
1
Stable
• 12 lead ECG
• Identify rhythm
• Measure QRS width
EMT-I
2
Is patient stable?
Unstable signs include altered mental status, chest pain,
hypotension, signs of shock-rate-related symptoms
uncommon if HR < 150
Narrow QRS
(< 0.12 msec)
Wide QRS
(> 0.12 msec)
Is rhythm
regular?
Is rhythm
regular?
3
Regular
• Try valsalva maneuver
• Give adenosine IV If
suspected AV nodal
reentrant tachycardia
(AVNRT)*
Irregular
• Atrial fibrillation, flutter
or MAT
• Do not give adenosine
• Monitor and transport
• If becomes unstable,
go to box 2
EMT IV
Regular
• V Tach (> 80%) or
SVT w. aberrancy
• Consider call in for
direct order for
amiodarone
AEMT
Paramedic
Unstable
Immediate synchronized
cardioversion
• 12 lead ECG
• Identify rhythm
• Contact Base
Irregular
• See box 3
• Contact base for
consult
• Do NOT give
adenosine
• EMT-I requires direct
order for adenosine
Does rhythm
convert?
Converts
*AVNRT was
historically referred
to as “PSVT”
Doesn’t Convert
• Monitor in transport
• If recurrent dysrhythmia,
go to box 1
• Contact base for consult
• Monitor in transport
• If unstable, go to box 2
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2040 ADULT (AGE ≥ 12 years) CARDIAC ARREST GENERAL PRINCIPLES
Specific Information Needed For Patient Care Report
•
•
•
•
Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime before CPR
and duration of CPR
Past History: medications, medical history, suspicion of ingestion, trauma, environmental
factors (hypothermia, inhalation, asphyxiation)
Lack of DNR orders if elderly or infirm.
Initial rhythm on placement of cardiac monitor (BMK)
Document Specific Objective Findings
•
•
•
•
•
Unconscious, unresponsive
Agonal, or absent respirations
Absent pulses
Any signs of trauma, blood loss
Skin temperature
General Guidelines: Chest Compressions
•
•
•
•
Push hard (2” compressions is adults) and push fast (100-120/minute)
Ensure full chest recoil
Rotate compressors every 2 minutes with rhythm checks (CPR Cycle)
During CPR, any interruption in chest compressions deprives heart and brain of necessary
blood flow and lessens chance of successful defibrillation
o Continue CPR while defibrillator is charging, and resume CPR immediately after all
shocks. Do not check pulses except at end of CPR cycle and if rhythm is organized at
rhythm check
o Try to coordinate to make analyze/rhythm checks and defibrillation pauses < 10 sec.
General Guidelines: Defibrillation
•
•
•
In unwitnessed cardiac arrest, give first 2 minutes of CPR without interruptions for ventilation.
During this time period passive oxygenation is preferred with OPA and NRB facemask.
If arrest is witnessed by EMS, immediate defibrillation is first priority, CPR should be performed
while attaching defibrillator.
All shocks should be given as single maximum energy shocks
o Manual biphasic: follow device-specific recommendations for defibrillation. If uncertain,
give maximum energy (e.g. 200J)
o Manual monophasic: 360J
o AED: device specific
General Guidelines: Ventilation during CPR
•
•
•
If suspected cardiac etiology of arrest, during first approximately 5-6 minutes of VT/VF arrest,
passive oxygenation with OPA and NRB facemask is preferred to positive pressure ventilation
with BVM or advanced airway
EMS personnel must use good judgment in assessing likely cause of pulseless arrest. In
patients suspected of having a primary respiratory cause of cardiopulmonary arrest, (e.g.: COPD
or status asthmaticus), adequate ventilation and oxygenation are a priority
In general, patients with cardiac arrest initially have adequately oxygenated blood, but are in
circulatory arrest. Therefore, chest compressions are initially more important than ventilation to
provide perfusion to coronary arteries
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36
•
Do not interrupt chest compressions and do not hyperventilate. Hyperventilation decreases
effectiveness of CPR and worsens outcome.
General Guidelines: Timing Of Placement Of Advanced Airway
•
•
•
Advanced airway (e.g. King, LMA, ETT) may be placed at any time after initial 3 rounds of chest
compressions and rhythm analysis, provided placement does not interrupt chest compressions
Once an advanced airway is in place, compressions are given continuously and breaths given
asynchronously at 8-10 per minute
Always confirm advanced airway placement with ETCO2
o Use continuous waveform capnography if available. In low flow states such as cardiac
arrest, colorimetric CO2 detector may be inaccurate and not sense very low CO2 level
General Guidelines: Pacing
•
•
Pacing is not indicated for asystole and PEA. Instead start chest compressions according to
Universal Pulseless Arrest Algorithm.
Pacing should not be undertaken if it follows unsuccessful defibrillation of VT/VF as it will only
interfere with CPR and is not effective
General Guidelines: ICD/Pacemaker patients
If cardiac arrest patient has an implantable cardioverter defibrillator (ICD) or pacemaker: place
pacer/defib pads at least 1 inch from device. Biaxillary or anterior posterior pad placement may be used
Transport of Cardiac Arrest Patients
•
•
•
•
The best chance of survival for out of hospital cardiac arrest is by providing high quality,
uninterrupted CPR and early defibrillation
It is virtually impossible to perform adequate CPR in a moving ambulance
Patients should generally have resuscitation attempts performed on scene and patients not
transported without return of spontaneous circulation (ROSC) unless scene safety or other
extreme circumstances dictate otherwise.
Patients who do not have ROSC should be considered for termination of resuscitation (TOR)
efforts according to TOR Policy.
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2050 GENERAL GUIDELINES: ADVANCED MEDICAL DIRECTIVES
Advance Medical Directives
A. These guidelines apply to both adult and pediatric patients.
B. There are several types of advance medical directives (documents in which a patient identifies
the treatment to be withheld in the event the patient is unable to communicate or participate in
medical treatment decisions).
C. Some patients may have specific physician orders on a Colorado Medical Orders for Scope of
Treatment (MOST) form. A MOST form order to withhold CPR or resuscitation should be honored
by EMS.
D. Suspected suicide does not necessarily negate an otherwise valid CPR Directive, DNR order or
other advanced medical directive. CONTACT BASE
E. DO NOT RESUSCITATE (DNR) ORDERS AND MEDICAL ORDERS FOR SCOPE OF TREATMENT
(MOST)
1. EMS providers frequently encounter patients who have valid DNR paperwork and wish
no resuscitative efforts to be initiated. The decision to honor, or not honor, a DNR must
be made quickly and accurately. This order does mean the patient refuses medical care.
Other treatment may be provided prior to cardiac or respiratory arrest. More extensive
limitations of treatment are accomplished through advanced directives where specific
treatments or procedures can be refused. Patients with a terminal illness are unique and
require thoughtful consideration at critical times. Healthcare providers should always
remember: “To cure sometimes, relieve occasionally, comfort always.”
2. The person who executes the DNR or MOST order may request to have any of the
following procedures withheld, with documentation of each procedure present at the top
of the DNR or MOST order:
a. Cardiopulmonary resuscitation;
b. Advanced airway management;
c. Artificial ventilation;
d. Transcutaneous cardiac pacing
3. The DNR form is not to be honored and full resuscitative efforts, including BLS and
ACLS, are to be initiated if the patient or the executioner of the order (guardian) does any
of the following:
a. Destroys the form and removes the identification device; or
b. Directs someone in their presence to destroy the form and remove the
identification device; or
c. Verbally communicates to the responding health care professional(s) or
attending physician that it is his/her intent to revoke the order.
F. Overview of State Rule 6 CCR 1015-2
1. Colorado regulations regarding CPR directives and the withholding of CPR by EMS
personnel were revised in the State effective as of April 30, 2010.
a. Please see www.coems.info for complete information
b. See the “Information sheet for EMS providers” at this site
2. DNR orders are one type of “advanced directive” regarding medical care. Others include
MOST, CPR directives, medical durable power of attorneys and living wills. All are
allowed by Colorado law to document end of life wishes.
3. THE OFFICIAL COLORADO DNR ORDER IS NO LONGER THE ONLY EMS PERSONNEL
ENFORCEABLE DNR ORDER IN COLORADO.
a. By State Rule Section 3.1.3 – “Any CPR directive which is apparent and
immediately available and which directs that resuscitation not be attempted
constitutes lawful authority to withhold or discontinue CPR”.
b. By State Rule Section 4.2.4 – “EMS personnel shall comply with an individuals
CPR Directive when it is apparent and immediately available”.
c. By State Rule Section 3.1.2 – “A CPR Directive may be made by any other
manner”. This means that no particular form or format must be used for a
DNR/CPR directive to be valid.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
38
G.
H.
I.
J.
K.
d. By State Rule Section 5.1 – “Any EMS personnel who in good faith complies with
a CPR directive shall not be subject to civil or criminal liability or regulatory
sanction for such compliance..”.
4. Per State Rule Section 3.1.1 – An advanced directive ideally contains: Patient name, date
of birth, directive concerning CPR or other treatments, signature, date signed,
PCP/hospice contact, and any other pertinent information.
a. But, as per Rule 3.1.2 – no particular form or format is required.
b. If it is apparent, immediately available, and appears valid you must honor it. That
is the spirit of the rule.
5. State Rule Section 3.1.2.a states – “A CPR directive bracelet or necklace may be
considered as valid”. The rule does not state that the patient must be wearing the device
to be valid.
6. State Rule Section 4.2.5 states – “In the absence of a CPR Directive, consent to CPR is
presumed”.
7. State Rule Section 4.2.1.a states – “This may include directives (sic) from other States”
8. State Rule Section 4.2.4.b states – “ a valid CPR Directive which has been scanned,
photocopied, faxed or otherwise reproduced shall be honored”.
A Living Will ("Declaration as to Medical or Surgical Treatment") requires a patient to have a
terminal condition, as certified in the patient's hospital chart by two physicians.
Other types of advance directives may be a "Durable Medical Power of Attorney," or "Health
Care Proxy". Each of these documents can be very complex and require careful review and
verification of validity and application to the patient's existing circumstances. Therefore, the
consensus is that resuscitation should be initiated until a physician can review he document or
field personnel can discuss the patient’s situation with the base physican. If there is
disagreement at the scene about what should be done, CONACT BASE for guidance.
Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family or an
attending physician directs resuscitation be ceased, the prehospital provider should
immediately CONTACT BASE. The prehospital provider should accept verbal orders to cease
resuscitation only from the Base physician.
There may be times in which the prehospital provider feels compelled to perform or continue
resuscitation, such as a 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 the base 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
establish base contact as soon as possible.
Additional Considerations:
a. Patients with valid DNR orders or advanced medical directives should receive supportive
or comfort care, e.g. medication by any route, positioning and other measures to relieve
pain and suffering. Also the use of oxygen, suction and manual treatment of an airway
obstruction as needed for comfort.
b. Mass casualty incidents are not covered in detail by these guidelines. (See Colorado
State Unified Disaster Tag and Triage System: A Guide to MCI).
c. If the situation appears to be a potential crime scene, EMS providers should disturb the
scene as little as possible and communicate with law enforcement regarding any items
that are moved or removed from the scene.
d. Mechanisms for disposition of bodies by means other than EMS providers and vehicles
should be prospectively established in each county or locale.
e. In all cases of unattended deaths occurring outside of a medical facility, the coroner
should be contacted immediately.
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2060 ADULT (AGE > 12 YEARS) UNIVERSAL PULSELESS ARREST ALGORITHM
BLS Sequence
ALS Sequence
Adult Pulseless Arrest
Start CPR
Attach Defibrillator
Give O2
Call for ALS if not already
initiated
Start CPR
Get AED
EMT
EMT-I
•
•
•
•
Check rhythm
& shock if
indicated.
Repeat every 2
min
BLS
If witnessed arrest or bystander
CPR in progress, apply AED
immediately and shock if advised.
If unwitnessed, unknown down time
without CPR, then perform CPR for
two minutes (200 compressions)
prior to AED analyzing/defibrillation
Ventilate patient no more than 6-8
times per minute. DO NOT STOP
COMPRESSIONS FOR
VENTILATIONS.
If ALS not available in 5 minutes
after arrival, consider rendezvous
and immediate transport. If ALS not
available within 30 minutes of
arrest and CPR has been on-going
for 30 minutes without return of
pulses, consider termination of
resuscitation.
Airway
• Consider king –LTS placement
after AED analysis for ventilation
assistance and airway control.
ALS
• Intubate patient (or use King-LTS)
but do not stop compressions for
first 3 minutes to do so.
• If possible, obtain 12 lead ECG
after spontaneous return of
circulation.
• If not return of circulation after 20
minutes of ALS care, consider
termination of resuscitation.
AEMT
Paramedic
Shockable
Rhythm?
Yes
If elderly or
infirm ask about
CPR directives
– Do Not Delay
Treatment
EMT IV
No
VT/VF
B
Asystole/PEA
Shock
• CC 2 min
• IV/IO
• Epinephrine
• CC 2 min
• IV/IO
• Epinephrine
No
Shockable
Rhythm?
No
Yes
Shockable
Rhythm?
Yes
A
Shock
• CC 2 min
• Epinephrine
every 3-5 min
• If asystole, go
to box B
• If organized
rhythm, check
pulse. If no
pulse, go to
box B
• If ROSC, begin
post-cardiac
arrest care
Go to
Box A
Shockable
Rhythm?
Yes
Shock
• CC 2 min
• Epinephrine
every 3-5 min
• Amiodarone
• Treat reversible
causes
•
•
•
•
•
•
•
•
•
Reversible Causes:
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary,
coronary
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2070 GENERAL GUIDELINES: TERMINATION OF RESUSCITATION AND FIELD PRONOUNCEMENT
GUIDELINES
Purpose
To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the
prehospital setting.
General Principles
A. Agency policy determines base contact requirements for patients for whom resuscitative efforts
are being withheld.
B. Attempt resuscitation for all patients found pulseless and apneic, unless any of the following are
present:
1. Physician orders as specified on the Colorado Medical Orders for Scope of Treatment
(MOST) form: “No CPR. Do Not Resuscitate/DNR/Allow Natural Death”, present with the
patient
2. A valid CPR directive present with the patient
3. Dependent lividity or rigor mortis
4. Decomposition
5. Decapitation
6. Evidence of massive blunt head, chest, or abdominal trauma with obvious mortal
wounds (with obvious signs of vital organ destruction such as brain, thoracic contents,
etc.).
7. Third degree burns over more than 90% of the total body surface area
C. The following guidelines for termination of resuscitation do not apply for any of the following
cases as prolonged resuscitation may be warranted. Contact base for further directions after 30
minutes of resuscitation:
1. Hypothermia
2. Drowning with hypothermia and submersion < 60 minutes.
3. Pregnant patient with estimated gestational age ≥ 20 weeks
D. In general, a patient’s best chances at survival are from good CPR and rapid defibrillation.
Patients without return of spontaneous circulation should not be transported from scene without
extenuating circumstances.
E. If ANY patient meets the criteria described above as a non-resuscitation candidate, access to the
scene should be limited as much as possible with due care to disturb the scene as little as
possible. As in all cases of out-of-hospital deaths, every effort should be made to console
family, friends, survivors, and witnesses without interfering with ongoing investigations. Victim
Assistance Program (VAP) services should be notified when appropriate.
F. After pronouncement, do not alter condition in any way or remove equipment (lines, tubes, etc.),
as the patient is now a potential coroner’s case.
Termination of Resuscitation (TOR)
A. All cases described below require contact with a base physician to approve termination of
resuscitation (TOR).
1. Blunt Trauma Arrest: a. Contact Base for TOR if patient found apneic and pulseless and no response to
BLS airway care.
b. Consider needle thoracostomy if ALS available 2. Penetrating Trauma Arrest:
a. Resuscitate and transport to a trauma facility if less than 10 minutes to trauma
center.
b. Consider needle thoracostomy if ALS available.
c. If time of arrest suspected to be > 10 minutes, and no signs of life or response to
BLS care (as above), consider base contact for TOR.
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41
3. Medical Pulseless Arrest:
a. Resuscitate according to Universal Pulseless Arrest Algorithm on scene (unless
unsafe) until one of the following end-points met:
i. Return of spontaneous circulation (ROSC).
ii. Patent airway with EtCO2 <10 during high quality CPR
iii. No ROSC despite 20 minutes of provision of ALS care or BLS
care with
an AED. If shockable rhythm still present, continue resuscitation and
contact base for consideration of transport.
iv. Contact base for TOR at any point if continuous asystole for at
least 20
minutes in any patient despite adequate CPR with ventilation and no
reversible causes have been identified.
b. For BLS-only providers, contact Base for TOR when all of the following criteria
met:
i. No AED shock advised
ii. No ROSC
iii. 20 minutes of quality CPR with patent airway or:
1. Arrest unwitnessed by either EMS or bystanders
2. No bystander CPR before EMS arrival
B. Field Pronouncement Orders
1. EMT shall contact base on recorded line (or per agency specific protocols) and speak
directly to physician.
2. Report shall include the following:
a. A request for field pronouncement.
b. Patient age and sex.
c. Apparent cause of death and approximate downtime.
d. Reasons CPR should not be initiated (see #1 above).
e. Any other pertinent information.
3. Documentation shall include:
a. Physician name.
b. Time of death (pronouncement).
c. Documentations shall also include consideration of the following, if available, in
addition to normal written report information:
i. Body position and location when discovered, including differences from
when last seen alive.
ii. Patient condition when last seen alive.
iii. Clothing and condition of clothing.
iv. Conditions of residence/business.
v. Statements made on the scene by significant individuals.
vi. Any unusual circumstances.
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2080 PROCEDURE PROTOCOL: INTRAOSSEOUS CATHETER PLACEMENT
Indications (must meet all criteria):
AEMT
EMT-I
Paramedic
1. There is confirmed existence of shock, cardiac arrest, or
unresponsive with unstable/unacceptable vital signs.
2. Three peripheral IV attempts have been unsuccessful or 90 seconds have passed.
3. Intraosseous shall not be used for prophylactic access, pain control medications or for simple
dehydration.
Technique:
1. Determine the correct catheter to use
a. Pediatric – Pink color, for patients 3-39 Kg
b. Adult – Blue color, for patients ≥40 kg
2. Locate insertion site (only one attempt at each insertion site, 3 attempts total)
a. Avoid using in patients with osteogenesis imperfect, or bones with obvious fractures,
prior IO insertions, osteomyelitis, or skin infection at insertion site.
b. Adult
i. Proximal tibia - one finger width medial to the tibial tuberosity.
ii. Humeral Head – palpate intertubercular groove. Move 1 finger laterally to insert in
greater tubercle.
iii. Distal tibia – just above medial malleolus
c. Pediatric
i. Proximal tibia if tibial tuberosity is not palpable - Two finger widths below the
bottom of the patella, then medial along the flat aspect of the tibia
ii. Proximal tibia with palpable tibial tuberosity – One finger width distal to the tibial
tuberosity along the flat aspect of the medial tibia
3. Clean skin with iodine, if available
4. Prior to powering the driver, insert the needle set (perpendicular to insertion site) through the
skin to the bone; verify the 5 mm mark can be seen
a. If the 5 mm mark is visible continue with the insertion
b. If the 5 mm mark is not visible switch to another site or try a longer needle
5. Power the driver and complete insertion
a. Do Not Push Down with excessive force on the Driver and Needle Set during insertion
b. Use moderate pressure and allow the Driver and the Needle Set to do the work
6. Stop when the IO space is reached. You know the IO space has been reached when:
a. There is a sudden lack of resistance (“stop when you feel the pop”)
b. In select adult cases, when the flange gently touches the skin
7. Attach the primed EZ-Connect extension to the catheter Luer-lock
8. If patient is awake and responsive, administer 2% Lidocaine as a local anesthetic. Prime the EZConnect extension with it before connection to the hub.
a. Adults: 0.2 ml increments for 1 cc (20 mg); allow 15-30 seconds. Then start second 1 cc
(20mg) dose and titrate to effect; max 3 mg/kg per 24 hours (70 kg = 210 mg/24 hours).
b. Pediatrics: 0.5 mg/kg IO slowly over 90-120 seconds. Maximum dose in pediatric patients
is 20 mg.
9. Rapidly syringe flush it with 10 ml of fluid
a. Amount of syringe flush is the same for pediatric and adult
b. Some patients may require multiple syringe flushes
10. Confirm catheter placement by:
a. Noting blood on the tip of the stylet
b. The catheter is firmly seated in the bone
c. Noting blood filling the catheter hub
d. After flushing the IO noting fluids and medications flow without difficulty and there are
no signs of extravasation
11. Secure the EZ-IO and protect the sterile connection point on the catheter hub
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43
12.
13.
14.
15.
16.
An infusion pressure bag or syringe may be needed to improve fluid flow
Place the supplied wrist band on the patient’s arm
Once EZ-IO is placed remember:
Routinely reconfirm the catheter is secure and in position
Maintain appropriate protection at the insertion site to prevent accidental bumping or
dislodgement
17. Frequently monitor the EZ-IO, fluids, and extremity
18. Remove the EZ-IO within 24 hours
Immediate Complications:
1. Compartment syndrome with improper placement.
2. Subperiosteal infusion with improper placement.
3. Slow infusion secondary to clotting of marrow in the needle.
4. Bone Fracture.
Delayed Complications:
1. Sepsis.
2. Fat embolism.
3. Osteomyelitis occurs in septic patients, use of I/O lines beyond 24 hours, and infusion of
hypertonic solutions
4. Growth plate and marrow damage from I/O infusions are possible, but largely unstudied.
Contraindications:
1. Fracture of target bone
2. Cellulitis (skin infection overlying insertion site)
3. Osteogenesis imperfecta (rare condition predisposing to fractures with minimal trauma)
4. Total knee replacement (hardware will prevent placement)
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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2090 PROCEDURE PROTOCOL: SYNCHRONIZED CARDIOVERSION
Unstable tachyarrhythmia with a
pulse
•
•
•
•
Check:
O2 via NRB facemask
Functioning IV line
Suction
Advanced airway equipment ready
Anxiolyse with midazolam
whenever possible
Perform Synchronized
Cardioversion
• Use 200 Joules biphasic in adults
and 1-2 Joules/kg in children < 12
years old
Paramedic
This procedure protocol applies
to conscious, alert patients with
signs of poor perfusion due to
tachyarrhythmia in whom
synchronized cardioversion is
indicated according to
Tachyarrhythmia with Pulse
protocol
Place pads anterior posterior if
possible and away from any
noted pacer, otherwise use right
upper chest/left lateral chest
position. If using paddles they
should be applied with 25 lbs of
pressure.
Continue treatment according to
Tachycardia with a Pulse protocol
Precautions:
• If rhythm is AV nodal reentrant tachycardia (AVNRT, historically referred to as “PSVT”) it is
preferred to attempt a trial of adenosine prior to electrical cardioversion, even if signs of
poor perfusion are present, due to rapid action of adenosine
• If defibrillator does not discharge in “synch” mode, then deactivate “synch” and reattempt
• If sinus rhythm achieved, however briefly, then dysrhythmia resumes immediately,
repeated attempts at cardioversion at higher energies are unlikely to be helpful. First
correct hypoxia, hypovolemia, etc. prior to further attempts at cardioversion
• If pulseless, treat according to Universal Pulseless Arrest Algorithm
• Chronic atrial fibrillation is rarely a cause of hemodynamic instability, especially if rate is <
150 bpm. First correct hypoxia, hypovolemia, before considering cardioversion of chronic
atrial fibrillation, which may be difficult, or impossible and poses risk of stroke
• Sinus tachycardia rarely exceeds 150 bpm in adults or 220 bpm in children < 8 years and
does not require or respond to cardioversion. Treat underlying causes.
• Transient dysrhythmias or ectopy are common immediately following cardioversion and
rarely require specific treatment other than supportive care
• Caution should be used if patient thought to be digitalis toxic as they may be most likely to
convert to ventricular fibrillation.
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2100 PROCEDURE PROTOCOL: TRANSCUTANEOUS CARDIAC PACING
Indications
1. Symptomatic bradyarrhythmias (includes A-V block) not responsive to
medical therapy.
EMT-I
Paramedic
Precautions
1. Conscious patient will experience discomfort; consider relief with opioids 50 mcg IV or
midazolam 3 mg IV if blood pressure allows.
Technique
1. Apply electrodes as per manufacturer specifications: (-) left anterior, (+) left posterior.
2. Turn pacer unit on.
3. Set initial current to 40 mAmps .
4. Select pacing rate at 60 beats per minute (BPM)
5. Start pacing unit.
6. Confirm that pacer senses intrinsic cardiac activity by adjusting ECG size.
7. Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps (usually captures
around 100 mAmps).
8. If there is electrical capture, check for pulses and increase amps by 2 mAmps..
9. If no capture occurs with maximum output, discontinue pacing and resume Bradycardia
Protocol.
10. If there are no pulses with capture, consider a fluid challenge or dopamine at 10 mcg/kg/min,
titrate to SBP>100.
Precautions:
1. Ventricular fibrillation and ventricular tachycardia are rare complications, most often seen in
digitalis toxicity. Follow appropriate protocols if either occur.
2. Pacing is rarely indicated in patients under the age of 12 years.
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3000 UNIVERSAL ALTERED MENTAL STATUS
Altered Mental Status (∆MS)
EMT
EMT-IV
EMT-I
Assess ABCs
Go to pulseless arrest, respiratory distress or
obstructed airway algorithms as appropriate
No
Persistent ∆MS?
Yes
AEMT
Paramedic
• Determine character of event
• Consider seizure, syncope and
TIA
• Monitor and transport with
supportive care
Check BGL (BMK) and consider
trial of Naloxone if respirations < 10
Yes
Hypoglycemia protocol
BGL < 60 mg/dL or clinical
condition suggests hypoglycemia?
No
Yes
Seizure protocol
Seizure activity present?
No
Perform rapid neurologic
assessment including LOC and
Cincinnati Prehospital Stroke Score
(CPSS)
Focal neuro deficit or
positive CPSS?
Yes
Stroke protocol
Determine time last seen normal
Consider Stroke Alert criteria and
contact destination hospital
No
Consider other causes of ∆MS:
Head trauma, overdose, hypoxia,
hypercapnea, heat/cold emergency,
sepsis, & metabolic
EtOH intoxication?
Yes
Intoxication/EtOH protocol
• During transport: give
supplemental oxygen, monitor
vital signs, airway, breathing,
and cardiac rhythm.
• Give fluid bolus if volume
depletion or sepsis suspected
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3010 HYPOGLYCEMIA
EMT
EMT-IV
EMT-I
Check blood glucose level in ANY patient with signs
or symptoms consistent with hypoglycemia (BMK)
AEMT
Paramedic
Examples:
Altered MS, agitation, focal neurologic deficit, seizure,
weakness, diaphoresis, decreased motor tone, pallor
Regarding refusals after a
hypoglycemic episode:
Base contact is required, especially if
on oral meds.
If hypoglycemia still
most likely despite
normal reading on
glucometer,
administer sugar
regardless, while
considering other
causes of altered
mental status
No
Transport is always indicated for the
following patients:
• All pts with unexplained
hypoglycemia
• Pts taking oral hypoglycemic meds
• Pts not taking food by mouth
• Pts who do not have competent adult
to monitor
Is BGL < 70?
Yes
Can the patient safely tolerate
oral glucose?
intact gag reflex, follows verbal
commands
Yes
Administer oral glucose.
Reassess patient
No
• Alternative: If
severe symptoms
(coma), consider
base contact for
IO and
administer
dextrose IO
No
Call for ALS assistance.
Are you able to establish IV
access?
Yes
Still symptomatic?
No
Yes
Administer D10
a. BG 40-60 = 50ml
b. BG < 40 = 100ml
c. Patient 1ml/kg or above dosing,
whichever is less
Symptoms resolved?
No
Recheck BGL and
consider other
causes of altered
mental status
Yes
Monitor and transport or
contact base for refusal if
indicated
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
48
3020 SEIZURE - ADULT (> 12 YEARS)
EMT
• Support ABCs:
• Titrate O2 to SaO2 90-94%
• Check blood glucose if available and treat
per Diabetic Emergencies (BMK)
• Universal seizure precautions (see below)
• Consider the cause (see below)
EMT-IV
EMT-I
AEMT
Paramedic
Actively Seizing?
Yes
No
• Seizure lasting > 5 min or recurrent seizures?
No
• Check pulse and reassess ABC
• Give supplemental oxygen
Yes
• Transport and monitor ABCs, vital signs,
and neurological condition
• Cardiac monitoring if recurrent seizures
and/or meds given
• Complete head to toe assessment
Give Midazolam
Actively seizing after 5 minutes?
No
Universal Seizure Precautions:
• Ensure airway patency, but do not force
anything between teeth. NPA may be
useful
• Give oxygen
• Suction as needed
• Protect patient from injury
• Check pulse immediately after seizure
stops
• Keep patient on side
Yes
• Establish IV access if not
already in place
• Repeat midazolam
Actively seizing after 5 minutes?
Document:
No
Yes
Contact Base
Consider the Cause of Seizure
•
•
•
•
•
•
•
•
•
Epilepsy
EtOH withdrawal or intoxication
Hypoglycemia
Stimulant use
Trauma
Intracranial hemorrhage
Overdose (TCA)
Eclampsia
Infection: Meningitis, sepsis
• Document: Seizure history: onset, time
interval, previous seizures, type of
seizure
• Obtain medical history: head trauma,
diabetes, substance abuse, medications,
compliance with anticonvulsants,
pregnancy
Pregnancy and Seizure:
• If 3 trimester pregnancy or post-partum:
administer magnesium sulfate
rd
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
49
3030 STROKE
POSSIBLE STROKE
Any acute onset neurological deficit
due to
EMT
EMT-IV
AEMT
EMT-I
Paramedic
likely
Cincinnati Prehospital Stroke
Assess and Stabilize ABC’s titrate oxygen
90-94%
Think “FAST” (face, arm, speech,
Assess Facial
Assess Cincinnati Prehospital Stroke
(Presence of single sign
Say: “Smile for me”, or “Show me your
Assess Arm Pronator
Check BG (BMK) and treat
hypoglycemia if
Consider naloxone if respirations <
Demonstrate, and say: “Put your arms up for me like
and hold them while I count to
Assess
Say: “Repeat after me: you can’t teach on old dog
tricks”, or “No ifs, ands, or
Determine when last KNOWN to be
normal and document specific time
“At 2:15 PM”, not “1 hour ago”
•
•
•
CPSS does not identify all strokes. See
Obtain medical history
Document medications
Identify family or friend who may assist with history
and decision-making, get contact info and strongly
encourage to come to ED as they may be needed for
consent for treatments
Stroke Mimics
Hypoglycemia (BMK)
Post-ictal paralysis
Complex migraine
Overdose
Trauma
Bell’s palsy
Consider common stroke mimics/syndromes
•
•
•
Start IV and draw blood
Document cardiac rhythm
Ensure full monitoring in place: cardiac, SpO2
Fully monitor patient and continually reassess:
Improvement or worsening of deficit
Adequacy of ventilation and oxygenation
Cardiovascular stability
•
•
•
•
•
•
•
•
Notify receiving hospital of suspected stroke and
time of onset of symptoms in order to provide
hospital the opportunity for Stroke Alert
It is more important that you know timeline of
your patient’s symptoms than an individual
hospital’s Stroke Alert criteria, which may
vary
The Cincinnati Prehospital Stroke Score
(CPSS) is designed to be very reproducible and
identify those strokes most likely to benefit from
reperfusion therapy, but does not identify all
strokes.
The CPSS has a high positive predictive value, but
a low negative predictive value. Meaning if you
have a positive CPSS, you are almost certainly
having a stroke, but if you do not have a positive
CPSS, you still may be having a stroke
Stroke signs may be very subtle, therefore it is
important to know other signs of stroke, which
include:
•
Impaired balance or coordination
•
Vision loss
•
Headache
•
Confusion or altered mental status
•
Seizure
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
50
3040 ALCOHOL INTOXICATION
EMT
EMT-IV
AEMT
Clinical alcohol
intoxication
EMT-I
Determine LOC and assess ABCs
•
•
•
•
Always consider
alternative diagnoses:
see universal altered
mental status protocol
Obtain vital signs
Perform head-to-toe exam
Determine medical history, medications
Check BGL unless mild symptoms and if
considering release (BMK)
BGL < 60 mg/dL or clinical condition suggests
hypoglycemia?
Paramedic
Yes
Hypoglycemia protocol
No
Does patient have evidence of incapacitating
intoxication?
Yes
No
Transport to ED
Does patient have signs of acute illness or
injury?
Yes
No
Transport to ED
DEFINITIONS:
Intoxicated patient with any of the
following must be transported to ED:
Incapacitating Intoxication
•
Inability to maintain airway
•
Inability to stand from seated
position and walk with minimal
assistance
•
At immediate risk of environmental
exposure or trauma due to unsafe
location
Acute Illness or Injury
•
Abnormal vital signs
•
Physical complaints that might
indicate an underlying medical
emergency, e.g.: chest pain
•
Seizure or hypoglycemia
•
Signs of trauma or history of acute
trauma
•
Signs of head injury, e.g.: bruising,
lacerations, abrasions
Contact base if considering release to other
party, e.g.: police, family
(IMPORTANT: individual agency policy may
apply)
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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3050 ABDOMINAL PAIN/VOMITING
EMT
Abdominal pain
and/or vomiting
Abdominal exam:
• Gently palpate 4
quadrants, noting areas of
tenderness, guarding,
rigidity or distension
• Note any pulsatile mass
• Note surgical scars
• Onset, location, duration,
radiation of pain
• Associated sx: vomiting,
GU sx, hematemesis,
coffee ground emesis,
melena, rectal bleeding,
vag bleeding, known or
suspected pregnancy,
recent trauma
EMT-I
AEMT
Paramedic
• Assess ABCs
• Titrate oxygen 90-94%
• Identify signs of shock and
hypovolemia
• Consider cardiac etiology
• Identify GI bleeding
• Transport in position of comfort
• Head-to-toe assessment
• Start IV
• If GI bleed, consider 2nd IV
• Vital signs, head-to-toe exam
History:
EMT-IV
• Cardiac monitor and 12 lead
ECG if diabetic, age > 50 and
upper abdominal pain or
unstable vital signs
Elderly Patients:
• Much more likely to have
life-threatening cause of
symptoms
• Always consider vascular
emergencies: AAA, MI
• Shock may be occult, with
absent tachycardia in
setting of severe
hypovolemia
• Consider odansetron if N/V
Yes
Signs of hypotension, poor
perfusion or shock?
•
•
•
•
No
Consider opioid for
severe pain
2 large bore IVs
20 cc/kg NS bolus
Elevate legs
Reassess response to
treatment
• See Hypotension/shock
protocol
• Monitor and transport
• Frequent reassessment for
deterioration and response to
treatment
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
52
3060 ALLERGY AND ANAPHYLAXIS
Allergic reaction, anaphylaxis or angioedema
EMT
•
•
•
•
Assess ABCs, titrate oxygen 90-94%
If possible, determine likely trigger
Determine PMH, medications, allergies
Classify based on symptom severity and
systems involved
• Other specific protocols may apply: e.g.:
obstructed airway, bites & envenomations
EMT-I
Generalized or Systemic Reaction
Multisystem involvement: skin, lungs, airway, etc
Does patient have any of the
following signs or symptoms?
•
•
•
•
Hypotension
Signs of poor perfusion
Bronchospasm, stridor
Altered mental status
No
Consider
diphenhydramine if
significant discomfort
EMT-IV
AEMT
Paramedic
Localized Reaction
Including isolated tongue, airway
No
Airway involvement?
Tongue or uvula swelling, stridor
Yes
Transport and reassess
for signs of deterioration
Impending airway obstruction?
Yes
No
• Give epinephrine IM, then:
• Start IV and give IV fluid
bolus 20cc/kg NS
• Give diphenhydramine
• Consider addition of
albuterol if wheezing
• Monitor ABCs, SpO2,
cardiac rhythm
• Reassess for signs of
deterioration
If persistent signs of severe
shock with hypotension not
responsive to IM epinephrine
and fluid bolus:
• Contact base
• Consider IV epinephrine
• Consider IV epinephrine drip
EMT may use EpiPen
auto injector if available
whenever epinephrine
IM indicated. Requires
base contact for verbal
order
Yes
Give immediate IM
epinephrine & manage
airway per Obstructed
Airway Protocol
• Start IV
• Give diphenhydramine
Definitions:
• Anaphylaxis: severe allergic reaction that is rapid in onset and potentially
life-threatening. Multisystem signs and symptoms are present including skin
and mucus membranes
o
Mainstay of treatment is epinephrine
• Angioedema: deep mucosal edema causing swelling of mucus membranes
of upper airway. May accompany hives
o
Epinephrine indicated for any impending airway
obstruction.
Document:
• History of allergen exposure, prior allergic reaction and severity, medications
or treatments administered prior to EMS assessment
• Specific symptoms and signs presented: itching, wheezing, respiratory
distress, nausea, weakness, rash, anxiety, swelling of face, lips, tongue,
throat, chest tightness, etc.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
53
3070 AGITATED/COMBATIVE PATIENT PROTOCOL
EMT
Patient is agitated and a danger
to self or others
• Attempt to reasonably address
patient concerns
• Assemble personnel
EMT-IV
EMT-I
AEMT
Paramedic
General Guideline:
Emphasis should be placed on scene
safety, appropriate use of restraints and
aggressive treatment of the patient’s
agitation.
Assume the patient has a medical
cause of agitation and treat
reversible causes. Check BG
(BMK), assess for trauma.
Excited Delirium Syndrome
Yes
Does patient have signs of the
Excited Delirium Syndrome?
No
Paranoia, disorientation, hyperaggression, hallucination,
tachycardia, increased strength,
hyperthermia
Patient does not respond to verbal
de-escalation techniques
Restraint Protocol
Obtain IV access as soon
as may be safely
accomplished
Restraints
No transport in hobble or
prone position. Do not inhibit
patient breathing, ventilations
Still significantly
agitated?
Sedate
• Consider cause of
agitation
• Options: midazolam or
droperidol
Still significantly
agitated?
• Repeat sedation dose
• If still significantly
agitated 5 minutes
after 2nd dose
sedative, Contact
Base
These patients are truly out of
control and have a life-threatening
medical emergency they will have
some or all of the following sx:
• Give midazolam
• Up to a total of 3 doses may be
given as a standing order. Goal
is rapid tranquilization in order to
minimize time struggling
• Complete Restraint Protocol
Consider Cause of Agitation:
Both benzodiazepines and
butyrophenones (e.g. droperidol)
are acceptable options for agitated
patients. In certain clinical
scenarios individual medications
may be preferred
•
•
•
•
EtOH (butyrophenone)
Sympathomimetic (benzo)
Psych (butyrophenone)
Head injury (butyrophenone)
• Reassess ABCs post sedation
• High flow O2
• Start 2 large bore IVs as soon
as may be safely accomplished
• Administer 2 liters NS bolus
Start external cooling measures
Full cardiac, SpO2, EtCO2 (if
available) monitoring and rapid
transport
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
54
3070 AGITATED/COMBATIVE PATIENT GUIDELINE
EMS Take Downs / Law Enforcement Assistance
Purpose
Agitated and combative patients are a great concern for EMS provider safety.
Most EMS providers are ill prepared and trained to engage in physical take downs of combative patients.
EMS has a main goal of patient care and protection, and they also have medications which can assist in
the tranquilization of the patient AFTER they have been physically subdued.
Law enforcement has much more training and tools to be available to be able to handle the combative
patient.
Procedure
Law enforcement shall be contacted immediately if they are not already on scene whenever a patient is
exhibiting potentially violent behavior.
Law enforcement shall be lead on any calls where the patient needs to be controlled by physical force on
scene. Obviously this does not apply if this occurs during transport.
Once physical control of patient has been accomplished by law enforcement, EMS shall THEN follow the
medication and restraint portions of the above guideline.
If the patient is VERY agitated, make sure Excited Delirium is considered.
CONTACT ON-LINE MEDICAL CONTROL FOR:
If law enforcement is unavailable, EMS shall not put themselves in a position to perform acts they are not
qualified to perform.
If law enforcement is on scene but is unwilling to assist in gaining physical control of the patient
If law enforcement needs orders from a physician to place an M-1 and take patient into custody.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
55
3080 PROCEDURE PROTOCOL: RESTRAINT PROTOCOL
Indications:
EMT
EMT-IV
AEMT
A. Physical restraint of patients is permissible and encouraged
EMT-I
Paramedic
if the patient poses a danger to him or herself 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. Try
alternative methods first (e.g., verbal de-escalation should be used first if the situation allows).
B. Paramedic/EMT-I: Consider pharmacological treatment (tranquilization) of agitation in patients
that require transport and are behaving in a manner that poses a threat to themselves or others,
and any patient who requires physical restraints. See Agitated/Combative Patient Protocol: The
term “chemical restraint” is no longer preferred.
C. Restraints may be indicated for patients who meet the following criteria:
1. A patient who is significantly impaired (e.g. intoxication, medical illness, injury,
psychiatric condition, etc) and lacks decision-making capacity regarding his or her own
care and insight into their current behavior.
2. A patient who exhibits violent, combative or uncooperative behavior who does not
respond to verbal de-escalation and such behavior poses a danger to themselves or
others either directly or by interfering with emergency treatment.
3. A patient who is suicidal, homicidal, or on a mental health hold and considered to be a
risk for behavior dangerous to his or herself or to healthcare providers.
Precautions:
A. When appropriate, involve law enforcement, especially if there is potential for a “takedown”.
This should be performed preferentially by law enforcement officers trained in such procedures.
B. Restraints shall be used only when necessary to prevent a patient from seriously injuring him or
herself or others (including the ambulance crew), and only if safe transportation and treatment
of the patient cannot be accomplished without restraints. They may not be used as punishment,
or for the convenience of the crew.
C. 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.
D. Be sure to evaluate the patient adequately to determine his or her medical condition, mental
status and decision-making capacity.
E. Do not use hobble restraints and do not restrain the patient in the prone position or any position
that is impairing the airway or breathing.
F. Search the patient for weapons.
G. Handcuffs are not appropriate medical restraints and should only be placed by law enforcement
personnel. See Handcuff Protocol.
Technique:
A. Treat the patient with respect. Attempts to verbally reassure or calm the patient should be done
prior to the use of restraints. To the extent possible, explain what is being done and why.
B. Have all equipment and personnel ready (restraints, suction, a means to promptly remove
restraints).
C. Use assistance such that, if possible, 1 rescuer handles each limb and 1 manages the head or
supervises the application of restraints.
D. Apply restraints to the extent necessary to allow treatment of, and prevent injury to, the patient.
Under-restraint may place patient and provider at greater risk.
E. After application of restraints, check all limbs for circulation. During the time that a patient is in
restraints, continuous attention to the patient’s airway, circulation and vital signs in mandatory.
A restrained patient may never be left unattended.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
56
Documentation :
Document the following in all cases of restraint:
A. Description of the facts justifying restraint
B. Efforts to de-escalate prior to restraint
C. Type of restraints used
D. Condition of the patient while restrained, including reevaluations during transport
E. Condition of the patient at the time of transfer of care to emergency department staff
F. Any injury to patient or to EMS personnel
Complications:
A. Aspiration: continually monitor patient’s airway
B. Nerve injury: assess neurovascular status of patient’s limbs during transport
C. Complications of medical conditions associated with need for restraint
1. Patients may have underlying trauma, hypoxia, hypoglycemia, hyperthermia,
hypothermia, drug ingestion, intoxication or other medical conditions
D. Excited Delirium Syndrome. This is a life-threatening medical emergency. These patients are
truly out of control. They will have some or all of the following symptoms: paranoia,
disorientation, hyper-aggression, hallucination, tachycardia, increased strength, and
hyperthermia. See Agitated/Combative Patient Protocol.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
57
3085 TRANSPORT OF THE HANDCUFFED PATIENT
General: EMS personnel have no legal authority to enforce restraint and custody on behalf of law
enforcement. The use of handcuffs in the back of an ambulance may hinder the provider’s ability to give
appropriate medical care if there is not the availability to remove them immediately. EMS providers may
legally restrain someone if the patient’s sensorium is altered to the point where the patient presents an
acute danger to themselves or the EMS providers. However, EMS personnel should never use handcuffs
for this purpose. While we want to be helpful and assist law enforcement in their duties, it should not
come by putting ourselves at medical and legal risk.
Purpose:
1. Guideline for transport of patients in handcuffs placed by law enforcement who do not otherwise
have a medical reason for use of restraints.
Guideline:
1. Handcuffs are only to be placed by law enforcement. EMS personnel are not permitted to use
handcuffs for restraint purposes.
2. Every effort should be made to arrange for a member of law enforcement to accompany the incustody patient in the back of the ambulance at all times when transporting a patient in
handcuffs.
3. If the officer is not available to ride in the ambulance, alternate arrangements should be
considered such as law enforcement transport of patient or keys held by EMS personnel.
4. EMS personnel are not responsible for the law enforcement hold on these patients. If patient
becomes threatening EMS should stop and let patient go. This assumes that the patient has
capacity to refuse care if not for being in custody (i.e. no ExDS, AMS or severe intoxication).
Concurrent law enforcement notification should be done.
5. Accompanied handcuffed patients shall never be placed in the prone position.
6. Handcuffs may be used with spinal immobilization but are not recommended. Medical priorities
should take priority in the positioning of the handcuffs.
7. It is encouraged that each agency should discuss these issues with their local law enforcement
agencies and come to agreements PRIOR to having this discussion on a scene.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
58
3090 HYPERTENSION
EMT
EMT-IV
EMT-I
AEMT
Paramedic
General Considerations: There are many causes for hypertension, most of which do not require
immediate treatment. Acute problems are rarely due to hypertension itself. Make sure you are treating
the underlying condition and not just the hypertension. This protocol is intended for isolated
hypertension.
IF PREGNANT TREAT PER OB/GYN PROTOCOL
Monitor Airway
Administer O2
-titrate to SaO2 > 92%
Establish IV access
-Monitor cardiac rhythm, consider 12 lead ECG
-If diastolic remains >130 and patient has symptoms of
encephalopathy, chest pain, pulmonary edema, CONTACT
BASE to consider nitroglycerine 0.4mg SL and/or
nitroglycerine paste
Acute stroke victims will frequently have elevated blood
pressures which should not be treated in the field
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
59
3100 MEDICAL HYPOTENSION / SHOCK PROTOCOL
Adult with SBP < 90 mmHg
AND/OR signs of poor perfusion
Shock is a state of decreased
tissue oxygenation. Significant
vital organ hypoperfusion may
be present without hypotension.
Home medications and/or
comorbidities may also limit
development of tachycardia
**
Goal is to maximize oxygen
delivery with supplemental
oxygen and assisted
ventilations (if needed), and to
maximize perfusion with IV
fluids
•
•
•
•
•
•
EMT
EMT-IV
EMT-I
AEMT
Paramedic
ABCs
Complete set of vital signs
Full monitoring
O2 via NRB facemask @ 15L/min
IV access
ALS transport
Signs of poor perfusion?
Altered mental status
Tachycardia
Cool, clammy skin
Venous lactate > 4 (see below)
No
Recheck and monitor
If patient remains
asymptomatic and clinically
stable, treatment may not be
necessary
Yes
Treat according to appropriate
protocol
Septic Shock
Defined by:
Yes
1.
Presence of Systemic
Inflammatory Response
Syndrome (SIRS)
Life-threatening brady or
tachydysrhythmia?
AND
No
2.
Suspected infection
AND
3.
Signs of hypoperfusion
(hypotension or elevated
venous lactate)
SIRS criteria:
• HR > 110
• RR > 24
• Temp > 100.4° or < 96.8° F
The initial treatment of septic
shock involves maximizing
perfusion with IVF boluses, not
vasopressors
• Consider etiology of shock state
• Give 500cc NS bolus IV/IO and
reassess
Repeat 500cc boluses, reassessing for
pulmonary edema, up to 2 liters total or
until goal of SBP > 90 mmHg and signs
adequate perfusion
Consider the etiology of your
patient’s shock state, which
may have specific treatments,
e.g.:
•
•
•
•
•
Sepsis
Hemorrhage
Anaphylaxis
Overdose
Cyanide or carbon
monoxide poisoning
• Other: PE, MI, tension
pneumothorax
For ongoing hypotension, poor perfusion or
pulmonary edema, contact base for
dopamine drip
If patient at risk for adrenal insufficiency,
see Adrenal Insufficiency protocol
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
60
3110 OVERDOSE AND ACUTE POISONING
PPE and decontaminate when appropriate
EMT
•
•
•
•
•
Obtain specific information:
Type of ingestion(s)
What, when and how much ingested?
Bring the poison, container, all medication and other
questionable substances to the ED
Note actions taken by bystanders or patient (e.g.: induced
emesis, “antidotes”, etc)
Supportive Care is key to overdose management
EMT-IV
EMT-I
AEMT
Paramedic
ABCs
IV, oxygen, monitor
• Naloxone
• Airway adjuncts and
BVM ventilations as
needed
Need for airway
management?
IV fluid bolus per
hypotension/shock protocol
Hypotension?
Altered mental
status?
See airway management
protocols
Yes
Universal Altered
Mental Status
Protocol
Consider dopamine if no
response to 20cc/kg NS bolus
• Check BGL (BMK)
• Consider specific
ingestions
No
Specific
ingestion?
Stimulant
Tachycardia,
HTN, agitation,
sweating,
psychosis
Midazolam for
severe
symptoms
See Agitated/
Combative
Patient protocol
Tricyclic
antidepressant
or cyclobenzaprine
or carbamazepine
Wide complex
tachycardia, seizure
Organophosphate
or nerve agent
Calcium Channel
Blocker
DUMBELS
syndrome
Bradycardia, heart
block, hypotension
Sodium bicarb for
QRS > 100 msec
If intubated, consider
hyperventilation to
ETCO2 25-30
Nerve Agent
Antidote Kit
20 cc/kg NS bolus
20 cc/kg NS bolus
Dopamine for
hypotension
Dopamine
See Seizure protocol
ß-Blocker
Bradycardia, heart
block, hypotension
Atropine
(EMT-I requires
verbal order)
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
61
4000 GENERAL TRAUMA CARE
•
•
•
•
BSI
Scene safety
Consider mechanism
Consider need for additional
resources
•
•
•
•
•
General impression
ABCs and LOC
Rapid Trauma Assessment
Prepare for immediate transport
SAMPLE history
EMT
EMT-IV
EMT-I
AEMT
Paramedic
• Titrate oxygen to 90-94% SaO2
• Assist ventilations and manage airway as
indicated
• Spinal immobilization if indicated
Control exsanguinating hemorrhage:
• Direct pressure
• Tourniquet protocol if indicated
• Pelvic stabilization if indicated
Assess disability and limitation:
• Brief neuro assessment
• Extremity splinting if indicated
• Rapid transport to appropriate Trauma Center
nd
• Large bore IV, 2 if unstable
• Consider IV fluid bolus 20cc/kg if unstable or
suspected significant injuries. See Traumatic
Shock Protocol
• Monitor vital signs, ABCs, neuro status, GCS
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
62
4010 PROCEDURE PROTOCOL: TOURNIQUET PROTOCOL
Indications
EMT
A. A tourniquet may be used to control potentially fatal
hemorrhage only after other means of hemorrhage control
have failed.
EMT-IV
EMT-I
AEMT
Paramedic
Precautions
A. A tourniquet applied incorrectly can increase blood loss.
B. Applying a tourniquet can cause nerve and tissue damage whether applied correctly or not. Proper
patient selection is of utmost importance.
C. Injury due to tourniquet is unlikely if the tourniquet is removed within 1 hour. In cases of lifethreatening bleeding benefit outweighs theoretical risk.
D. A commercially made tourniquet is the preferred tourniquet. If none is available, a blood pressure
cuff inflated to a pressure sufficient to stop bleeding is an acceptable alternative. Other improvised
tourniquets are not allowed.
Technique
A. First attempt to control hemorrhage by using direct pressure over bleeding area.
B. If a discrete bleeding vessel can be identified, point pressure over bleeding vessel is more effective
than a large bandage and diffuse pressure.
C. If unable to control hemorrhage using direct pressure, apply tourniquet according to manufacturer
specifications and using the steps below:
1. Cut away any clothing so that the tourniquet will be clearly visible. NEVER obscure a tourniquet
with clothing or bandages.
2. Apply tourniquet proximal to the wound and not across any joints.
3. Tighten tourniquet until bleeding stops. Applying tourniquet too loosely will only increase blood
loss by inhibiting venous return.
4. Mark the time and date of application on the patient’s skin next to the tourniquet.
5. Keep tourniquet on throughout hospital transport – a correctly applied tourniquet should only be
removed by the receiving hospital.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
63
4020 TRAUMATIC SHOCK PROTOCOL - ADULT (AGE > 12 YEARS)
EMT
EMT-I
Trauma with suspected
serious injury and/or
signs of shock
AEMT
Paramedic
Shock is defined as impaired tissue perfusion and may
be manifested by any of the following:
General Trauma Care
Protocol
•
•
•
•
• Titrate oxygen 90-94%
• Large bore IV
• 2nd IV preferred
Altered mental status
Tachycardia
Poor skin perfusion
Low blood pressure
Traditional signs of shock may be absent early in the
process, therefore, maintain a high index of suspicion
and be vigilant for subtle signs of poor perfusion
Yes
SBP < 90 and/or definite
signs of shock?
EMT-IV
• IV NS bolus 20 cc/kg
• Consider IO per protocol
Evaluate breath sounds,
respiratory effort, and
consider tension
pneumothorax
No
• Treat en route
• Complete General
Trauma Care
• Keep patient warm
Monitor:
• ABCs, VS, mental
status
• Rapid transport to
appropriate trauma
center
Monitor cardiac rhythm
Repeat NS bolus 20
cc/kg as needed
based on mental
status and perfusion
Reassess
Chest needle
decompression if arrest
or impending arrest
Prehospital End-Points of Fluid Resuscitation:
Over aggressive resuscitation with IV fluid before
hemorrhage is controlled may worsen bleeding,
hypothermia and coagulopathy.
Do not withhold IV fluids in a critically injured patient,
but give judiciously with goal to improve signs of
perfusion and mental status rather than to achieve a
“normal” blood pressure.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
64
4030 TRAUMATIC PULSELESS ARREST - ADULT (AGE > 12 YEARS)
EMT
EMT-IV
AEMT
General Trauma Care Protocol
EMT-I
Are there obvious signs of death OR the
presence of non-survivable injuries?
Yes
(SEE BELOW)
Paramedic
Contact Base for Field
Pronouncement
No
• Consider bilateral needle chest
decompression
• Did signs of life return?
Yes
• General Trauma Care
• Treat injuries per protocol
No
Consider MOI
(isolated GSW to head treated similar to
blunt trauma)
Penetrating Trauma
Blunt Trauma
Contact Base for Field
Pronouncement
Yes
• Unwitnessed arrest – never
were signs of life seen?
• Suspected arrest time > 10
minutes and no signs of life
No, witnessed arrest by
EMS < 10 min ago
Non-survivable Injuries
• Decapitation
• 90% 3º burns
• Evidence of massive head or
thoraco-abdominal trauma
•
•
•
•
•
Rapid transport
General Trauma Care
Initiate Basic Life Support
CPR with ventilations
IV access with NS bolus en route
Document:
•
•
•
•
General impression
Mechanism: blunt vs. penetrating
Time and duration of arrest
Were vital signs present at any time?
• Treat injuries per protocol
• Complete General Trauma Care
• Rapid transport to appropriate trauma
center
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
65
4040 ABDOMINAL TRAUMA
• General Trauma Care Protocol
• Rapid transport to Trauma Center
EMT
• Review Trauma in Pregnancy if
EMT-IV
AEMT
pregnant
EMT-I
Paramedic
• IV access
• Consider 2nd line if MOI significant
Yes
Cover wounds, viscera with saline moistened gauze
Penetrating Trauma?
dressing
Do not attempt to repack exposed viscera
No
Yes
Resuscitate per Trauma Shock Protocol
SBP <90 and/or Shock?
No
End points of fluid resuscitation should be improved mental status and pulses, not
necessarily a normal blood pressure. This is especially true for abdominal trauma.
Consider Fentanyl for pain control
Documentation
Monitor ABC’s, VS, mental status, SPO2,
ETCO2
•
MOI
•
Time of injury
•
Initial GCS
•
Penetrating trauma
•
Weapon/projectile/trajectory
•
Blunt vehicular trauma
•
Condition of vehicle
•
Speed
•
Ejection
•
Airbag deployment
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
66
4050 AMPUTATIONS
General Trauma Care
Protool
EMT
EMT-IV
EMT-I
Bleeding Controlled
AEMT
Paramedic
Uncontrolled Bleeding
Control with direct pressure to
bleeding area or vessel
• Large bore IV
• If hypotensive, treat per
Traumatic Shock Protocol
• Document neurovascular exam
Complete Amputation
Amputated part:
•
•
•
•
Wrap in moist, sterile dressing
Place in sealed plastic bag
Place bag in ice water
Do not freeze part
If bleeding not controlled with
direct pressure, see Tourniquet
Protocol
Partial/NearAmputation
• Cover with moist sterile
dressing
• Splint near-amputated part in
anatomic position
Stump:
• Cover with moist sterile dressing
covered by dry dressing
Treat severe pain with opioids as
needed
• Monitor and transport to
appropriate Trauma Center
• Treat other injuries per protocol
• 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 primary care
hospital.
• Try to help the family and
patient understand this, and
d ' f l l l
h
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
67
4060 BURNS
EMT
EMT-IV
• General Trauma Care Protocol
• Rapid transport to Trauma Center
EMT-I
Stop burning process:
• Remove clothes if not adhered to
patient’s skin
• Flood with water only if
flames/smoldering present
Yes
Respiratory
Distress?
• O2 NRB 15 lpm
• Manage airway and assist
ventilations as indicated
• Consider CO, CN
AEMT
Paramedic
Document:
•
•
•
•
•
•
•
Type and degree of burn(s)
% BSA
Respiratory status
Singed nares, soot in mouth
SpO2
PMH
Confined space
No
*Critical Burn:
Evaluate degree and body
surface area involved
Yes
Critical Burn?*
• Start 2 large-bore IVs
• Adults NS at 500 ml/hour
• Peds:
o
6-13 250 ml/hour
o
<6 125 ml/hour
•
•
•
•
2º > 30% BSA
3º > 10% BSA
Respiratory injury, facial burn
Associated injuries, electrical or
deep chemical burns, underling
PMH (cardiac, DM), age < 10 or >
50 yrs
No
Types of Burns:
IV NS TKO
• Remove rings, jewelry, constricting
items
• Dress burns with dry sterile
dressings
• Treat other injuries per protocol
• Cover patient to keep warm
• Thermal: remove from
environment, put out fire
• Chemical: brush off or dilute
chemical. Consider HAZMAT
• Electrical: make sure victim is deenergized and suspect internal
injuries
• Consider CO if enclosed space
• Consider CN if plastics, shock,
pulseless arrest
Consider opioid for pain
control
Monitor ABCs, VS, mental
status, SpO2, ETCO2
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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4070 CHEST TRAUMA
EMT
 General Trauma Care
Protocol
 Rapid transport to Trauma
Center
EMT-IV
EMT-I
AEMT
Paramedic
No
Are you able to oxygenate and
ventilate effectively?
Airway management and assisted
ventilations as indicated
Yes
Consider tension pneumothorax
and chest needle decompression
Yes
Penetrating
trauma?
Rapid transport &
stabilize in route
Occlusive dressings
for sucking wounds
No
Large bore IV and
consider 2nd line
Yes
Flail Chest?
Splint with
bulky dressing
Assess for need for
assisted ventilations
Consider intubation
if decompensating
No
Yes
SBP < 90 and/or shock?
Treat per traumatic shock protocol
in route
No
Consider fentanyl or morphine
for pain control
Tension pneumothorax
should be suspected with presence of the following:
Monitor ABCs, VS, mental
status, SpO2, ETCO2
 Unilateral absent breath sounds AND:
o
JVD
o
Hypotension
o
Difficult/unable to ventilate
 Needle decompression is NEVER indicated for simple
pneumothorax
End points of fluid resuscitation should be improved mental
status and pulses, not necessarily a normal blood pressure. This
is especially true for penetrating chest trauma.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
69
4075 TENSION PNEUMOTHORAX DECOMPRESSION
Indication:
EMT-I
Paramedic
A. Needle decompression of tension pneumothorax is a standing order for EMT-I and Paramedics.
B. All of the following clinical indicators must be present:
1. Severe respiratory distress
2. Hypotension
3. Unilateral absent or decreased breath sounds
Technique:
A. Expose entire chest
B. Clean skin overlying site with available skin prep
nd
C. Insert largest, longest available angiocath either at 2 intercostal space at midclavicular line, or
th
5 intercostal space at midaxillary line
1. Either approach is acceptable, generally the site with the least soft tissue overlying ribs
is preferred
D. Notify receiving hospital of needle decompression attempt
Precautions:
A. Angiocath may become occluded with blood or by soft tissue
B. A simple pneumothorax is NOT an indication for needle decompression
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
70
4080 FACE AND NECK TRAUMA
EMT
EMT-I
General Trauma Care
Protocol
• Clear airway
• Rapid trauma assessment
• Spinal immobilization
Protocol
• Assess for need for airway
management
Laryngeal
trauma*
EMT-IV
AEMT
Paramedic
Spinal Immobilization not routinely indicated
for penetrating neck injury
Penetrating injury is very rarely associated with
unstable spinal column
Yes
Rapid transport
Avoid intubation if patient can be
oxygenated by less invasive means
No
Severe airway
bleeding?
Yes
Direct Pressure if
appropriate
No
Consider ETI
• Nasal intubation relatively
contraindicated with midface trauma.
• Avoid if mid-face grossly
unstable
•
•
•
•
Complete neuro exam
Asses for subcutaneous air
Cover/protect eyes as indicated
Do not try to block drainage from
ears, nose
• Save avulsed teeth in saline-soaked
gauze, do not scrub clean
*Suspect laryngeal trauma with:
• Laryngeal tenderness, swelling,
bruising
• Voice changes
• Respiratory distress
• Stridor
• Transport ASAP to appropriate
Trauma Center
• IV access en route
• Treat other injuries per protocol
• Suction airway as needed
• Consider opioids for pain control as needed
• Monitor ABCs, VS, mental status, SpO2,
ETCO2
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
71
4090 HEAD TRAUMA PROTOCOL
EMT
EMT-I
General Trauma Care
Protocol
<8
GCS?
Check BG if
altered (BMK)
1.
Open airway and
assist ventilations
Call for ALS
2.
3.
4.
5.
≥8
Paramedic
Support ventilations at rate
to maintain ETCO2 35-40
mmHg
Yes
Call for ALS
Establish venous access and treat
hypotension with crystalloid 20 cc/kg or 1 liter
in adults. Call base if > 2 boluses. Check BG
if altered mental status and treat per Diabetic
Emergencies Protocol.
Watch closely and avoid hypotension in these
patients.
•
•
•
•
•
AEMT
Cardiac monitor. Do not treat arrhythmias without
base contact first.
Consider intubation; administer lidocaine 1 minute
prior to intubation.
Consider odansetron for emesis.
Consider midazolam for status seizures.
If patient combative consider tranquilization with
droperidol and midazolam; REQUIRES BASE
PHYSICIAN CONTACT.
Systolic BP < 90
and/or signs of
shock?
No
EMT-IV
Support ventilations PRN
Rapid Trauma Assessment
IV access if not done already
Treat other injuries per protocol
Watch for status changes
Glasgow Coma Score (GCS)
(Minimum 3, Maximum 15)
4.
3.
2.
1.
Eyes:
Opens eyes spontaneously
Opens eyes to voice
Opens eyes to pain
Does not open eyes
5.
4.
3.
2.
1.
Verbal:
Oriented
Confused, disoriented
Inappropriate words
Incomprehensible sounds
No sounds
6.
5.
4.
3.
2.
1.
Motor:
Obeys commands
Localizes to painful stimuli
Withdrawal to painful stimuli
Flexion to painful stimuli
Extension to painful stimuli
No movement
Monitor:
• ABCs, VS, mental status, ETCO2
• Rapid transport to appropriate trauma
center
• Monitor cardiac rhythm
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
72
4100 SPINAL TRAUMA - ADULT
EMT
EMT-IV
General Trauma Care
Protocol
EMT-I
• Spinal immobilization per protocol
• Document neuro assessments before
and after immobilization
AEMT
Paramedic
Signs of Spinal Cord Injury:
• Any neurological complaint
• Sensory loss, weakness and/or paralysis
• Numbness, tingling or painful burning in
arms, legs
Rapid transport to appropriate
Trauma Center
Spinal Immobilization not routinely
indicated for penetrating neck injury
Large bore IV and consider 2nd line
Penetrating injury is very rarely associated
with unstable spinal column
If BP < 90 and/or signs of shock,
resuscitate per Traumatic Shock Protocol
• Complete patient assessment
• Treat other injuries per protocol
• Monitor for status changes
Monitor ABCs, VS, mental status, SpO2,
ETCO2
Consider opioids for pain control or
ondansetron for nausea
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
73
4105 SPINAL IMMOBILIZATION PROTOCOL
• Backboards have not been shown to be of any benefit
for spinal injuries, but they may cause patient harm
• We wish to reduce the use of back boards in patients
with traumatic injuries where appropriate
Does patient have signs of
traumatic injuries?
No
Yes
Did patient sustain only
penetrating trauma?
No
Yes
No
Yes
Is patient able to follow commands?
•
No language barriers
•
Calm/cooperative
•
No significant AMS
•
No intoxication rendering
patient incapacitated
No
Yes
Is altered mental status
due to known seizure
disorder (post-ictal) or
known dementia?
No
Immobilize using
backboard and
c-collar with standard
technique
EMT-IV
EMT-I
AEMT
Paramedic
• Backboards are useful tools for carrying
patients to a gurney. Patients who do not need
a backboard should be gently slid off of
backboard onto gurney.
• Self-extrication from a vehicle with assistance
is likely better than standard extrication
procedures.
• The goal of spinal “immobilization” is to reduce
stress on the spine. Patients should not be
“forcefully” restrained if they can be managed
with verbal calming techniques.
• Vacuum mattresses should be used
preferentially over a backboard if readily
available.
• If for any reason you are uncomfortable NOT
immobilizing someone, then place them on a
backboard.
Yes
Is the patient ambulatory
on scene at time of EMS
arrival?
EMT
Patient does NOT require a
backboard. Have them lie still on the
gurney which will provide sufficient
spinal immobilization
Does patient have/complain of:
•
Neck pain
•
Neck tenderness on palpation
•
Neurologic
deficits/paresthesias
•
Other injuries which are
potentially distracting
Yes
Place c-collar on
patient and ask
them to not move
neck
No
Cervical collar not
needed.
Patients should never be transported between facilities while still immobilized on a long
backboard. Please request that the sending facility remove patient from backboard after
discussion with receiving facility.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
74
4110 SPECIAL TRAUMA SCENARIOS PROTOCOL
EMT
See General Trauma
Care Protocol
EMT-I
Sexual Assault
Abuse/neglect
Confine history to
pertinent medical needs
Observe patient’s behavior around
caregivers
• Provide same-sex
provider if possible
• Respect patient’s
emotional needs
EMT-IV
AEMT
Paramedic
Watch out for:
• Injury inconsistent with
stated mechanism
• Delayed treatment
• Spreading blame
• Conflicting stories
• Prior/ healing injuries
Don’t judge, accuse or
confront victim
Protect evidence:
No washing or changing
clothes
Coordinate transport
destination with law
enforcement
Don’t judge, accuse or
confront victim or
suspected assailant
Transport patient if
suspected abuse or
neglect, no matter how
apparently minor the
injury
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
75
4120 TRAUMA IN PREGNANCY
EMT
See General Trauma
Care Protocol and any
other applicable Trauma
Protocol
Pregnant Trauma
(EGA < 20 weeks)
• Priority is mother.
• Transport all patients with
any thoracic, abdominal,
pelvic injury or complaint.
Estimated Gestational Age (EGA)
If EGA > 20 weeks, consider two patients: mother
and fetus. Estimation of gestational age may be
made based on fundal height by palpating for top of
uterus:
EMT-IV
EMT-I
AEMT
Paramedic
Pregnant Trauma
(EGA > 20 weeks)
• Priority is mother.
• Transport all patients.
• Assure hospital is aware of
pregnancy and EGA
Patients with any thoracic, abdominal, or
pelvic complaint or injury may require
prolonged fetal monitoring in hospital,
even if asymptomatic at time of
evaluation, and even for seemingly
minor mechanism
• Avoid supine position:
• Place in left lateral recumbent position
if possible
• If immobilized tilt backboard 15 to 30
degrees to the left side
Interpret VS with caution. Pregnant
patient has:
• Increased heart rate
• Decreased blood pressure
• Increased blood volume
If uterus is at umbilicus then EGA > 20 weeks
Estimation by Last Menstrual Period:
Due Date = LMP + 9 months + 7 days
EGA = due date – current date
• Pregnant patients having contractions
after trauma should be considered to
be abrupting until proven otherwise
• They should be transported rapidly
even if vital signs are stable in mother
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
76
5000 HIGH ALTITUDE ILLNESS
EMT
Acute mountain sickness
(AMS): headache, insomnia,
anorexia, nausea, fatigue
High-altitude pulmonary edema
(HAPE): dyspnea, cough,
headache, nausea, fever
High-altitude cerebral edema
(HACE): ataxia, confusion, neuro
deficits, seizure, coma, and
headache
Symptoms of illness at
altitude
EMT-I
• ABCs Oxygen
• Complete history:
• Rate of ascent, prior altitude
illness, rapidity of sx onset
• Consider non-altituderelated illness
HAPE
20cc/kg NS bolus
Odansetron for
nausea or vomiting
• O2 NRB facemask
• Assist ventilations as
needed
• Consider CPAP
• Do NOT give diuretic
• Airway management as
indicated
AEMT
Paramedic
• Never assume that symptoms at
altitude are necessary due to altitude
illness.
• Acute exacerbations of chronic
medical illness at altitude are more
common that altitude illness.
• IV
• Cardiac monitor
AMS
EMT-IV
HACE
•
•
•
•
•
Descent from altitude
O2 NRB facemask
Assist ventilations as needed
Elevate head of bed
Assess for need for airway protection
HACE is rare at elevations in
Colorado; always consider alternative
cause of altered mental status
Special Notes:
•
•
•
Oxygen is the mainstay of therapy.
Descent from altitude is mandatory for severe respiratory distress or altered mental status.
Most altitude illness occurs above 7,000 ft. However, rapidity of ascent is also a factor so mild cases can be seen at
lower altitudes.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
77
5010 ENVIRONMENTAL HYPERTHERMIA
EMT
EMT-IV
EMT-I
AEMT
Paramedic
Hyperthermia
• Classify by clinical syndrome
• Consider non-environmental
causes (see below)
Heat Cramps
• Normal or slightly elevated
body temperature
• Warm, moist skin
• Generalized weakness
• Diffuse muscle cramping
Heat Exhaustion
•
•
•
•
•
•
•
Heat Stroke
Elevated body temperature
Cool, diaphoretic skin
Generalized weakness
Anxiety
Headache
Tachypnea
Possible syncope
•
•
•
•
•
•
Very high core body temperature
Hot skin, may be dry or moist
Hypotension
Altered mental status
Seizure
Coma
Rapid transport indicated
IVF 20cc/kg bolus with cool
saline
Adequate airway
and breathing?
Monitor VS and transport
No
Consider other causes of hyperthermia
besides environment exposure, including:
• Neuroleptic malignant syndrome (NMS):
patients taking antipsychotic medications
• Sympathomimetic overdose: cocaine,
methamphetamine
• Anticholinergic toxidrome: overdose
(“Mad as a hatter, hot as a hare, blind as a
bat, red as a beet”) common w. ODs on
psych meds, OTC cold medications,
Benadryl, Jimson weed, etc.
• Infection: fever (sepsis)
• Thyrotoxicosis: goiter (enlarged thyroid)
Yes
Assist ventilations and
manage airway as
needed
Start IV, titrate O2 90-94% SaO2
IVF 20cc/kg bolus with cool saline unless
signs of volume overload
• Remove excess clothing
• For heat stroke, consider external
cooling measures if prolonged
transport
• If altered mental status, check BG and
treat per protocol (BMK)
• Treat seizures, cardiac arrhythmias
per protocol
• Monitor and transport
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
78
5020 ENVIRONMENTAL HYPOTHERMIA
Hypothermia and
Frostbite
EMT
EMT-IV
EMT-I
Localized cold injury
Frostbite, frostnip
• Remove wet garments, dry
and insulate patient
• Transport, even if initial
assessment normal
• Monitor ABC, VS, mental
status
• Dress injured area lightly in
clean cloth to protect from
further injury
• Do not rub, do not break
blisters
• Do not allow injured part to
refreeze. Repeated thaw
freeze cycles are especially
harmful
• Monitor for signs of systemic
hypothermia
PEA
• Handle very gently
• Insulate patient
• High flow O2
• ABCs
Awake but altered LOC
• Remove wet garments, dry
and insulate patient
• Suction as needed
• BGL, oxygen
• Transport
• Monitor ABC, VS, mental
status
Start CPR, attach
AED/monitor/defibrillator and treat
per Universal Pulseless Arrest
Algorithm with following changes:
Asystole or V-fib/VT
• Single dose Epinephrine
IV/IO
• For Vfib/VT: single attempt
defibrillation only
Comatose or unresponsive
Pulse Present?
No
Yes
• Remove wet garments, dry and
insulate patient
• Consider all causes of Altered
Mental Status
• Suction as needed
• Check BGL and give oxygen
(BMK)
• Transport
• Monitor ABC, VS, mental status,
ETCO2
• Monitor cardiac rhythm
• Start IV – WARM FLUIDS
• Consider advanced airway,
especially if suspected
pulmonary edema
•
•
•
• Consider advanced airway
especially if suspected
pulmonary edema
• Monitor cardiac rhythm,
ETCO2
Paramedic
Systemic hypothermia
Presumed to be primary problem
based on clinical scenario
Start
IV- WARM
• Monitor
cardiacFLUIDS
rhythm BMK
Consider opioid pain control
for painful frozen extremities if
painful.
AEMT
•
•
Shivering stops around 90 degrees
core temperature.
Fibrillation is common below 88
degrees and may not respond to
defibrillation. Prolonged CPR may be
necessary.
Atrial fibrillation is also common in
hypothermia while rewarming and
does not require treatment.
Bradycardias should not be treated
as they are physiologic.
Do not automatically assume altered
mental status is due to hypothermia,
look for other causes.
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
79
5030 INSECT/ARACHNID STINGS AND BITES PROTOCOL
EMT
Initiate general care for bites
and stings
EMT-I
Assess for localized vs.
systemic signs and symptoms
and depending on animal
involved
Localized Symptoms:
• Pain, warmth and
swelling
Consider opioid for
severe pain (e.g.: black
widow spider) and /or
diphenhydramine if
needed for itching
EMT-IV
AEMT
Paramedic
General Care
Systemic Symptoms:
• Hives, generalized
erythema, swelling,
angioedema
• Hypotension
• Altered mental status
• Other signs of shock
• Administer oxygen
• Start IV
• For bees/wasps: Remove stinger
mechanism by scraping with a
straight edge. Do not squeeze
venom sac
• For spiders: Bring in spider if
captured or dead for identification
Specific Information Needed:
• Timing of bite/sting
• Identification of spider, bee, wasp,
other insect, if possible
• History of prior allergic reactions to
similar exposures
• Treatment prior to EMS eval: e.g.
EpiPen, diphenhydramine, etc
Treat per allergy &
anaphylaxis protocol
Specific Precautions:
• For all types of bites and stings, the goal of prehospital care is to prevent further envenomation and to treat allergic
reactions
• BLS personnel may assist patient with administering own Epipen and oral antihistamine
• Anaphylactoid reactions may occur upon first exposure to allergen, and do not require prior sensitization
• Anaphylactic reactions typically occur abruptly, and rarely > 60 minutes after exposure
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
80
5040 NEAR DROWNING
ABCs
Specific Information
Needed:
EMT
Spinal Immobilization
before moving patient if
trauma suspected
EMT-IV
• Length of submersion
• Degree of contamination of
water
• Water temperature
• Diving accident and/or
suspected trauma
EMT-I
AEMT
Paramedic
Assess mental status
Awake and alert
• Remove wet garments, dry
and insulate patient
• Transport, even if initial
assessment normal
• Monitor ABC, VS, mental
status
Awake but altered LOC
• Remove wet garments, dry and
insulate patient
• Suction as needed
• Start IV, check BGL, give oxygen
• Transport
• Monitor ABC, VS, mental status
Comatose or unresponsive
Pulse Present?
No
Yes
• Monitor cardiac rhythm
Start CPR, attach
AED/monitor/defibrillator and treat
per Universal Pulseless Arrest
Algorithm with following changes:
PEA
• Handle very gently
• Start IV with warm IVF
• Insulate patient
• Consider advanced airway
especially if suspected
pulmonary edema
• Monitor cardiac rhythm,
ETCO2
• Do not use TOR protocol
without obvious mortal
wounds.
Asystole or V-fib/VT
• Single dose Epinephrine
IV/IO
• For Vfib/VT: single attempt
defibrillation only
• Remove wet garments, dry
and insulate patient
• Heimlich maneuver NOT
indicated
• Consider all causes of
Altered Mental Status
• Suction as needed
• Start IV, obtain BGL and
give oxygen (BMK)
• Monitor ABC, VS, mental
status, ETCO2
• Consider advanced airway
especially if suspected
pulmonary edema
• Monitor cardiac rhythm
• Drowning/submersion commonly associated with hypothermia.
• Even profound bradycardias may be sufficient in setting of severe hypothermia and
decreased O2 demand
• Good outcomes after even prolonged hypothermic arrest are possible
• Patients should not be pronounced dead until rewarmed in hospital,
• BLS: pulse and respirations may be very slow and difficult to detect if patient is severely
hypothermic. If no definite pulse, and no signs of life, begin CPR
• If not breathing, start rescue breathing
• ALS: advanced airway and resuscitation medications are indicated
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5050 SNAKE BITE PROTOCOL
•
•
•
•
Assess ABCs, mental status
Administer oxygen
Start IV
Monitor VS
EMT
EMT-IV
EMT-I
AEMT
Paramedic
Initiate general care for snake
bites
Assess for localized vs.
systemic signs and symptoms
Localized Symptoms:
• Pain and swelling
• Numbness, tingling to
bitten part
• Bruising/ecchymoses
Opioid for
severe pain
• Transport with bitten
part immobilized
• Monitor ABCs and for
development of
systemic signs/sx
• Complete General Care
en route
General Care:
Systemic Symptoms:
• Metallic or peculiar
taste in mouth
• Hypotension
• Altered mental status
• Widespread bleeding
• Other signs of shock
Be prepared to manage
airway if signs of airway
obstruction develop
Opioid for severe pain
and if not contraindicated
by hypotension
Treat hypotension w.
20cc/kg IV NS bolus
See hypotension/shock
protocol
• Remove patient from proximity to snake
• Remove all constricting items from bitten
limb (e.g.: rings, jewelry, watch, etc.)
• Immobilize bitten part
• Initiate prompt transport
• Do NOT use ice, refrigerants, tourniquets,
scalpels or suction devices
• Mark margins of erythema and/or edema
with pen or marker and include time
measured
Obtain specific information:
• Appearance of snake (rattle, color, thermal
pit, elliptical pupils)
• Appearance of wound: location, # of fangs
vs. entire jaw imprint
• Timing of bite
• Prior 1st aid
• To help with identification of snake,
photograph snake, if possible. Include
image of head, tail, and any distinctive
markings.
• Do not bring snake to ED
Specific Precautions:
• The Rattlesnake is the most common venomous snake in our RETAC.
• Exotic venomous snakes, such as pets or zoo animals, may have different signs and symptoms than those of pit
vipers. In case of exotic snakebite, contact base and consult zoo staff or poison center for direction.
• If adequate photo can be taken, it is not necessary to bring snake to ED.
• Never pick up a presumed-to-be-dead snake by hand. Rather, use a shovel or stick. A dead snake may reflexively bite
and envenomate.
• > 25% of snake bites are “dry bites”, without envenomation.
• Conversely, initial appearance of bite may be deceiving as to severity of envenomation.
• Fang marks are characteristic of pit viper bites (e.g. rattlesnakes).
• Jaw prints, without fang marks, are more characteristic of non-venomous species.
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6000 CHILDBIRTH PROTOCOL
Overview:
• EMS providers called to a
possible prehospital childbirth
should determine if there is
enough time to transport
expectant mother to hospital or if
delivery is imminent
• If imminent, stay on scene and
immediately prepare to assist
with the delivery
ABCs
O2 15 liters via NRB
IV access
EMT
EMT-IV
EMT-I
AEMT
Paramedic
Obtain obstetrical history
(see adjacent)
Needed items:
• Number of pregnancies (gravida)
• Live births (para)
• Expected delivery date
• Length of previous labors
• Narcotic use in past 4 hours
If suspected imminent
childbirth:
• Allow patient to remain
in position of comfort
• Visualize perineum
• Determine if there is
time to transport
Imminent Delivery
Delivery is imminent if there is
crowning or bulging of perineum
Delivery not imminent
• Transport in position of comfort, preferably on left
side to patient’s requested hospital if time and
conditions allow
• Monitor for progression to imminent delivery
Emergency Childbirth Procedure
• If there is a prolapsed umbilical cord or apparent breech presentation, go to
obstetrical complications protocol and initiate immediate transport
• For otherwise uncomplicated delivery:
• Position mother supine on flat surface, if possible
• Do not attempt to impair or delay delivery
• Support and control delivery of head as it emerges
• Protect perineum with gentle hand pressure
• Check for cord around neck, gently remove from around neck, if present
• Suction mouth, then nose of infant as soon as head is delivered
• If delivery not progressing, baby is “stuck”, see obstetrical complications
protocol and begin immediate transport
• As shoulders emerge, gently guide head and neck downward to deliver anterior
shoulder. Support and gently lift head and neck to deliver posterior shoulder
• Rest of infant should deliver with passive participation – get a firm hold on baby
• Keep newborn at level of mother’s vagina until cord stops pulsating and is
double clamped
Critical Thinking:
• Normal pregnancy is accompanied by
higher heart rates and lower blood
pressures
• Shock will be manifested by signs of
poor perfusion
• Labor can take 8-12 hours, but as
little as 5 minutes if high PARA
• The higher the PARA, the shorter the
labor is likely to be
• High risk factors include: no prenatal
care, drug use, teenage pregnancy,
DM, htn, cardiac disease, prior breech
or C section, preeclampsia, twins
• Note color of amniotic fluid for
meconium staining
Postpartum Care Infant
Postpartum Care Mother
• Suction mouth and nose only if signs of obstruction by
secretions
• Respirations should begin within 15 seconds after
stimulating reflexes. If not, begin artificial ventilations at 3040 breaths/min
• If apneic, cyanotic or HR < 100, begin neonatal
resuscitation
• Dry baby and wrap in warm blanket
• After umbilical cord stops pulsating, double clamp 6” from
infant abdominal wall and cut between clamps with sterile
scalpel. If no sterile cutting instrument available, lay infant
on mother’s abdomen and do not cut clamped cord
• Document 1 and 5 minute APGAR scores
• Placenta should deliver in 20-30 minutes. If delivered,
collect in plastic bag and bring to hospital. Do not pull cord
to facilitate placenta delivery and do not delay transport
awaiting placenta delivery
• If the perineum is torn and bleeding, apply direct pressure
with sanitary pads
• Postpartum hemorrhage – see obstetrical complications
protocol
• Initiate transport once delivery of child is complete and
mother can tolerate movement
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83
6010 OBSTETRICAL COMPLICATIONS
EMT
EMT-IV
EMT-I
AEMT
Paramedic
For All Patients with obstetrical complications
• Do not delay: immediate rapid transport
• Give high-flow oxygen
• Start IV en route if time and conditions allow. Treat signs of shock with IV fluid boluses per Medical Hypotension/Shock
Protocol
Possible actions for specific complications (below)
• The following actions may not be feasible in every case, nor may every obstetrical complication by anticipated or
effectively managed in the field. These should be considered “best advice” for rare, difficult scenarios. In every case,
initiate immediate transport to definite care at hospital
Prolapsed Umbilical Cord
• Discourage pushing by mother
• Position mother in trendelenberg or supine with hips
elevated
• Place gloved hand in mother’s vagina and elevate the
presenting fetal part off of cord until relieved by physician
• Feel for cord pulsations
• Keep exposed cord moist and warm
Complications of Late Pregnancy
3rd Trimester Bleeding (6-8 months)
•
•
•
•
•
•
High flow O2 via NRB, IV access
Suspect placental abruption or placenta previa
Initiate rapid transport
Position patient on left side
Note type and amount of bleeding
IV NS bolus for significant bleeding or shock
Eclampsia/Toxemia
Breech Delivery
• Never attempt to pull infant from vagina by legs
• IF legs are delivered gently elevate trunk and legs to aid
delivery of head
• Head should deliver in 30 seconds. If not, reach 2 fingers
into vagina to locate infant’s mouth. Press vaginal wall
away from baby’s mouth to access an airway
• Apply gentle abdominal pressure to uterine fundus
• IF infant delivered see childbirth protocol – Postpartum care
of infant and mother
• High flow O2 via NRB, IV access, check BG
(BMK)
• SBP > 140, DBP > 90, peripheral edema,
headache, seizure
• Transport position of comfort
• Treat seizures with 2-4 gm of Magnesium sulfate
IV over 10 minutes
• See seizure protocol
Shoulder Dystocia
Postpartum Hemorrhage
•
•
•
•
Massage abdomen (uterine fundus) until firm
Initiate rapid transport
Note type and amount of bleeding
Treat signs of shock with IV fluid boluses
•
•
•
•
Support baby’s head
Suction oral and nasal passages
DO NOT pull on head
May facilitate delivery by placing mother with
buttocks just off the end of bed, flex her thighs
upward and gentle open hand pressure above
the pubic bone
• If infant delivered see childbirth protocol –
Postpartum care of infant and mother
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84
6020 NEONATAL CONSIDERATIONS
General Considerations:
A. A neonate refers to a newly born child under the age of 30 days. While most neonates transition
to post-natal life without difficulty, 10% will require medical assistance. Respiratory insufficiency
is the most common complication observed in the newly born.
B. Neonates born precipitously may exhibit signs of stress such as apnea, grunting respirations,
lethargy or poor tone
1. Provide warmth, bulb suction mouth and then nose, and dry the infant
2. If breathing spontaneously, HR >100 and infant is vigorous, continue to monitor
3. If apneic, cyanotic, lethargic, or HR <100, provide 100% oxygen via BVM ventilations at a
rate of 40-60 bpm
4. If HR < 60, begin CPR at 3:1 compression: ventilation ratio.
C. For neonates who do not respond to initial interventions as above:
1. Obtain blood glucose level and if < 60, administer dextrose IV/IO (D10 4 mL/kg)
2. Administer epinephrine IV for persistent HR < 60
3. Consider hypovolemia and administer 10-20ml/kg NS over 5-10 minutes
D. Neonates with congenital heart disease may not be detected prior to hospital discharge after
delivery. Consider a cardiac cause of shock in the neonate who remains hypoxic or has
persistent cyanosis despite 100% oxygen. These neonates may decompensate precipitously and
fluid administration should be used judiciously (10ml/kg NS)
E. Newborns are at high risk for hypothermia. Provide early warming measures, keep covered as
much as possible (especially the head) and increase the temperature in the ambulance
F. Acrocyanosis (cyanosis of only the hands and feet) is normal in newborns and does not require
intervention
G. Prolonged apnea without bradycardia or cyanosis may indicate respiratory depression caused
by narcotics. However, naloxone should be avoided in infants of a known or suspected narcoticaddicted mother as this may induce a withdrawal reaction. Respiratory support alone is
recommended
H. Obtain pregnancy history, gestational age of the neonate, pregnancy complications, and any
illicit drug use during pregnancy.
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6030 PEDIATRIC NEONATAL RESUSCITATION
Birth
Yes
Term Gestation?
Breathing or crying?
Good tone?
No
Routine Care:
 Provide warmth
 Clear airway if
necessary
 Dry
 Ongoing evaluation
EMT
EMT-IV
EMT-I
AEMT
Paramedic
Warm, clear airway if
necessary, dry, stimulate
No
30 sec
HR < 100, gasping
or apnea
No
Yes
Yes
60 sec
Labored breathing
or persistent
cyanosis?
PPV, SpO2
monitoring
Clear airway
SpO2 monitoring
No
HR < 100?
Post resuscitation care
Yes
Take ventilation
corrective steps
HR < 60?
No
Yes
General Considerations
(From 2010 AHA Guidelines)
 Newborn infants who do not require
resuscitation can be identified generally
based on 3 questions:
 Term gestation?
 Crying or breathing?
 Good muscle tone?
 If answer to all 3 questions is “yes” then
baby does not require resuscitation and
should be dried, placed skin-to-skin on
mother and covered to keep warm
 If answer to any of 3 questions is “no” then
infant should receive 1 or more of following
4 categories of intervention in sequence:
 Initial steps in stabilization (warm,
clear airway, dry, stimulate)
 Ventilation
 Chest compression
 Administration of epinephrine and/or
volume expansion
 It should take approx. 60 seconds to
complete initial steps
 The decision to progress beyond initial
steps is based on an assessment of
respirations (apnea, gasping, labored or
unlabored breathing) and heart rate (>/<
100 bpm)
Assisting Ventilations:
Chest compressions
Coordinate w. PPV
Take ventilation
corrective steps
 Assist ventilations at rate of 40-60 breaths
per minute to maintain HR > 100
Chest compressions:
No
HR < 60?
Yes
IV epinephrine
Consider:
Hypovolemia
Pneumothorax
 Indicated for HR < 60 despite adequate
ventilation w. supplemental O2 for 30
seconds
 2 thumb – encircling hands technique
preferred
 Allow chest recoil
 Coordinate with ventilations so not
delivered simultaneously
 3:1 ratio of compressions to ventilations w.
exhalation occurring during 1st
compression after each ventilation
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86
6040 GENERAL GUIDELINES FOR PEDIATRIC PATIENTS
General Guideline:
EMT
EMT-IV
AEMT
A. Pediatric patients, defined as age < 13 years for the
purpose of these protocols, have unique anatomy,
physiology, and developmental needs that affect
EMT-I
Paramedic
prehospital care. Because children make up a small
percentage of total calls and few pediatric calls are
critically ill or injured, it is important to stay attuned to these differences to provide good
care. Therefore, CONTACT BASE early for guidance when treating pediatric patients with
significant complaints, including abnormalities of vital signs. 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.
Specific Considerations:
The following should be kept in mind during the care of children in the prehospital setting:
1. Airways are smaller, softer, and easier to obstruct or collapse.
2. Respiratory reserves are small. A minor insult like improper position, vomiting, or airway
narrowing can be a major problem.
3. Circulatory reserves are also small. The loss of as little as one unit of blood can produce severe
shock in an infant. Conversely, 500 mls of unnecessary fluid can create acute pulmonary edema.
4. Don’t forget to check BG if patient not acting right.
5. Obtain the parents’ assessment of the patient’s problem. They often can detect small changes in
their child’s condition.
6. The proper equipment is very important when dealing with the pediatric patient. A complete
selection of airway management equipment and IV catheters should be available and stored in a
separate pediatric kit.
7. Three main drugs used in pediatrics are oxygen, glucose and epinephrine.
ALWAYS USE THE LENGTH BASED TAPE FOR ALL PEDIATRIC PATIENTS (BMK). FOLLOW
GUIDELINES FOR SIZING EQUIPMENT AND DRUG DOSAGES.
PATIENT COLOR LEVEL SHOULD BE CALLED IN TO ED WITH REPORT.
8. When using these protocols, remember the age breakdown used:
a. Neonate:
birth to one month
b. Infant:
one month to 1 year
c. Child:
1 – 12 years or within length based tape sizing
d. Adult:
> 12 years old or larger than length based tape sizing
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87
6050 PEDIATRIC UNIVERSAL RESPIRATORY DISTRESS ALGORITHM (AGE < 13 YEARS)
All patients:
• Give oxygen to all patients w. respiratory distress via least
distressing means, either blow-by or NRB facemask
• Minimize patient discomfort and avoid agitation. Transport in
position of comfort
General Assessment:
• Attempt to determine cause of respiratory
distress based on clinical scenario, age, past
history and exam
• Assess Airway, Breathing, perfusion and
mental status in all patients
Inadequate ventilations?
• Assist with BVM per Assisted Ventilations Protocol
• Reposition airway, place oral airway if unconscious
• Normal RR by age: neonates > 40, infants > 20, children > 12
Airway Assessment
• If obstructed, see Obstructed Airway Protocol
• Observe for stridor, hoarseness, drooling
• Consider foreign body if sudden onset stridor in
young child
• Early suctioning of secretions may dramatically
improve respiratory distress in bronchiolitis
Inadequate ventilations and unable to ventilate with BVM?
• Perform laryngoscopy
• Remove FB, if present, w. Magill forceps
• Consider ETI in a child ONLY if unable to adequately
ventilate with BVM and oral airway
• If ETT placed, confirm position with ETCO2 per Oral
Endotracheal Intubation Protocol
Breathing Assessment
• Note rate and effort (“work of breathing”)
• Listen for upper airway abnormal sounds which
may mimic wheezing: stridor, hoarseness,
barky cough (suggests croup)
• Note grunting, nasal flaring, head bobbing,
chest wall movement, retractions, accessory
muscle use
• Auscultate breath sounds for wheezing,
crackles, decreased air movement (suggests
bronchospasm)
Treat specific conditions
Croup
Age 6 months to 5 years w.
stridor, barky cough, URI sx.
Sx often rapid, nocturnal onset
• Transport in position of
comfort w. parent
• Blow-by O2
•
•
•
•
Severe symptoms?
Stridor at rest
Severe retractions
Cyanosis
Altered LOC
• Give epinephrine by
nebulizer
Inadequate response to
treatment?
Contact base for consult
Bronchiolitis
Age < 2 yrs w. cough, fever,
resp. distress, +/- wheezing,
crackles
• Transport in position of
comfort w. parent
• Blow-by O2
•
•
•
•
Severe symptoms?
Hypoxia despite O2
Severe retractions
Cyanosis
Altered LOC
• Nasal suctioning
• Give albuterol by nebulizer
Inadequate response to
treatment?
Contact base for consult
Asthma
EMT may administer either mdi or nebulized
albuterol with base contact for verbal order
• Give albuterol by nebulizer
•
• Repeat as needed, may use continuous
nebulization for respiratory distress
• If age > 2 yrs, add ipratropium
•
•
•
•
Severe symptoms?
Hypoxia despite O2
Severe retractions
Cyanosis
Altered LOC
Inadequate response to treatment?
• Give epinephrine IM
• Contact base for consult
Consider pulmonary and non-pulmonary causes of respiratory distress in all cases:
Common: croup, bronchiolitis, asthma. Less common: foreign body aspiration, allergic reaction, pneumonia. Rare: epiglottitis,
bacterial tracheitis. Also: Congenital heart disease (CHF), sepsis, other metabolic acidosis (e.g.: DKA, inborn error of metabolism)
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88
6060 PEDIATRIC BRADYCARDIA WITH POOR PERFUSION
EMT
EMT-IV
AEMT
Bradycardia with pulse
and poor perfusion
EMT-I
Paramedic
Ensure adequate oxygenation and ventilation
 Maintain patent airway; assist breathing as needed
 Assist breathing as needed
 Give oxygen
Bradycardia:

Consider and treat other underlying causes
Consider any HR < 60 in an ill child
abnormal regardless of age
Signs of Poor Perfusion:
No




Persistent hypotension, altered
mental status or signs of poor
perfusion?
Cool, pale extremities
Prolonged CRFT (> 2 sec)
Lethargy/alt mental status
Hypotension:
o < 1 month: < 60 mmHg
o 1 month-1 yrs: < 70 mmHg
o >1 yrs: < 70 + (2x age) mmHg
Yes




Support ABCs
Monitor VS
Give oxygen
Observe for
deterioration
 Base Contact if
deteriorates
CPR if HR < 60/min with poor
perfusion despite oxygenation
and ventilation
No
If pulses,
perfusion and
respirations are
adequate, no
intervention
indicated.
Monitor and
transport
Bradycardia
persists?
After 2 minutes
reevaluate patient for
persistent brady and
signs of compromise.
check airway, oxygen
source and
effectiveness of
ventilations
Yes
 Epinephrine IV/IO
 Atropine IV/IO for increased
vagal tone or AV block
 Treat underlying causes
 Consider Pacing
if pulseless arrest develops, go to
Pulseless arrest algorithm
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6070 PEDIATRIC (AGE < 13 YEARS) TACHYCARDIA WITH POOR PERFUSION
Tachycardia with poor perfusion
Identify and treat underlying cause
ABCs and high flow oxygen
Cardiac monitor
IV/IO access (if unable to establish
IV after 1 attempt or 90 sec
establish IO
12-lead ECG
Narrow (≤ 0.09 sec)
Evaluate QRS
duration
Wide (> 0.09 sec)
Evaluate rhythm by 12lead ECG or monitor
Probable Sinus Tachycardia
• Compatible hx and
consistent with suspected
cause (e.g. dehydration,
infection)
• P waves present, normal
• Constant PRI
• Infants: rate usually < 220
• Children: rate usually < 180
Possible Ventricular Tachycardia
Probable AVNRT
(historically “PSVT”)
• Compatible hx (vague, nonspecific); hx of abrupt rate
changes
• P waves absent/abnormal
• HR not variable
• Infants: rate usually ≥ 220
• Children: rate usually ≥ 180
Cardiopulmonary compromise?
Hypotension, altered mental status
or other signs of shock
Yes
Search for and treat underlying
cause:
e.g.: dehydration, fever,
hypoxia, hypovolemia, pain,
anxiety
No
Cardiopulmonary compromise?
Hypotension, altered mental status
or other signs of shock
No
Contact base before
giving adenosine
Yes
• Contact base for
consultation before
giving adenosine in a
pediatric patient
• May consider
adenosine if rhythm
regular and QRS
monomorphic
Synchronized
cardioversion
Synchronized Cardioversion
• When possible give midazolam prior to
cardioversion
• Administer doses by 2J/kg if needed.
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90
6080 PEDIATRIC (AGE < 13 YEARS) CARDIAC ARREST-GENERAL PRINCIPLES
General Guideline:
A. Pediatric cardiac arrest more frequently represents progressive respiratory deterioration or
shock rather than primary cardiac etiologies. Unrecognized deterioration may lead to
bradycardia, agonal breathing, and ultimately asystole. Resulting hypoxic and ischemic insult to
the brain and other vital organs make neurologic recovery extremely unlikely, even in the
doubtful event that the child survives the arrest. Children who respond to rapid intervention with
ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much
more likely to survive neurologically intact. Therefore, it is essential to recognize the child who
is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention
before asystole occurs
Specific Information Needed For Patient Care Report
A. Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime before CPR
and duration of CPR
B. Past History: medications, medical history, suspicion of ingestion, trauma, environmental
factors (hypothermia, inhalation, asphyxiation)
Document Specific Objective Findings
A.
B.
C.
D.
E.
Unconscious, unresponsive
Agonal, or absent respirations
Absent pulses
Any signs of trauma, blood loss
Skin temperature
General Treatment Guidelines
A. Treat according to Pediatric BLS and ALS pulseless arrest algorithms
B. Primary cardiac arrest from ventricular arrhythmia, while less common than in adults, does
occur in children. If history suggests primary cardiac event (e.g.: sudden collapse during
exercise), then rapid defibrillation is most effective treatment
C. Most pediatric pulseless arrest is the result of primary asphyxial event, therefore initial
sequence is chest compressions with ventilations, unlike adult pulseless arrest
D. Call for ALS assistance if not already on scene or responding
General Guidelines: Chest Compressions for 2 Rescuers
Once advanced airway in place, chest compressions should be given continually with ventilations at 810/minute
Neonate (≤ 1 month old)
• 1 cycle of CPR = 3:1 chest compressions: breaths.
Infant and Child (1 month to 12 years old)
A. 1 cycle of CPR = 15:2 chest compressions: breaths
• Push hard and fast at a compression rate of 100/minute
• Minimize interruption to chest compressions
a. Continue CPR while defibrillator is charging, and resume CPR immediately after all
shocks. Do not check pulses except at end of CPR cycle and if rhythm is organized at
rhythm check
b. Increase in compression interruption correlates with decrease in likelihood of successful
defibrillation
• Ensure full chest recoil
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91
•
•
a. Represents diastolic phase for cardiac filling due to negative intrathoracic pressure
Avoid hyperventilation
a. Associated with barotrauma and air trapping
b. Makes CPR less effective by inhibiting cardiac output by increasing intrathoracic
pressure and decreasing venous return to the heart
Rotate compressors every 2 minutes during rhythm checks
General Guidelines: Defibrillation
A. First shock delivered at 2 J/kg biphasic
B. All subsequent shocks delivered at 4 J/kg biphasic
General Guidelines: Ventilation during CPR
A. Do not interrupt chest compressions and do not hyperventilate
B. Contrary to adult cardiac arrest, pediatric arrest is much more likely to be asphyxial and
prolonged. During this period, blood continues to flow to the tissues causing oxygen saturation
to decrease and carbon dioxide to increase. Pediatric patients need both prompt ventilation
and chest compressions.
C. Hyperventilation decreases effectiveness of CPR and worsens outcome
General Guidelines: Timing Of Placement Of Advanced Airway
A. BVM is preferred method of ventilation in all pediatric patients age < 8 years
B. Do not hyperventilate
C. Always confirm advanced airway placement by objective criteria: ETCO2
a. Use continuous waveform capnography if available
General Guidelines: Pacing
A. Effectiveness of transcutaneous pediatric pacing has not been established and is not
recommended
General Guidelines: ICD/Pacemaker patients
A. If cardiac arrest patient has an implantable cardioverter defibrillator (ICD) or pacemaker: place
pacer/defibrillation pads at least 1 inch from device. Bi axillary pad placement may be used
Special Notes:
A. Consider reversible causes of cardiac arrest (“Hs And Ts”):
Hypovolemia
Hypoxia
Hydrogen Ion (acidosis)
Hyperkalemia
Hypothermia
Toxins: e.g.: opioid overdose
Tamponade (cardiac)
Tension pneumothorax
Thrombosis (coronary)
Trauma
IV Fluid bolus
Ventilation
Ventilation
Sodium bicarbonate
See hypothermia protocol
Naloxone 2mg IVP
Needle thoracostomy
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6090 PEDIATRIC (AGE < 13 YEARS) PULSELESS ARREST BLS/AED ALGORITHM
EMT
Unresponsive and not breathing
or only gasping
EMT-IV
EMT-I
AEMT
Paramedic
High quality CPR
Check pulse (< 10 sec)
Is there a definite pulse?
• Rate 100-120/min
• Compression depth 1 ½
inches in infants, 2 inches in
children
• Allow complete chest recoil
after compression
• Minimize interruptions of chest
compressions
• Avoid excessive ventilation
Pulse > 60
• Give 1 breath every 3
seconds
• Recheck pulse every 2
minutes
Definite Pulse
Check Rate
Pulse < 60
• Infant/child: start CPR
• Age > 11: start CPR if
signs of poor perfusion
• Go to Peds Bradycardia
Algorithm
No Pulse
Neonate (< 1 month)
Infant/Child (> 1
month)
• Start CPR cycles in 3:1
• Go to Neonatal
resuscitation
Child > 11 years
• Follow adult
pulseless arrest
algorithm
• Start CPR cycles in
15:2
Apply AED/Defibrillator
• Use pediatric system if available for
ages 1 year to 8 years
• Use defibrillator for < 1 year (may
use AED if not available)
Check Rhythm
Shockable rhythm?
Shockable
• Give 1 shock
• Resume CPR immediately for 2
minutes after shock
• Check rhythm every 2 minutes
Not Shockable
• Resume CPR immediately for
2 minutes
• Check rhythm every 2 minutes
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6100 PEDIATRIC PULSELESS ARREST ALS ALGORITHM
•
•
EMT
Start CPR
Give O2
Attach Monitor/defibrillator
EMT-IV
EMT-I
Rhythm
Shockable
?
•
Asystole/PEA
•
B
CPR 2 min
IV/IO access
Epinephrine
every 3-5 min
•
•
•
CPR 2 min
• IV/IO
•
Rhythm
Shockable
?
Rhythm
Shockable
?
Shock
Paramedic
CPR Ventilation and Advanced
Airway:
VF/VT
Shock
AEMT
•
•
CPR 2 min
Treat
reversible
•
No intubation for cardiac arrest
< age 12
BVM preferred for all patients <
8 years old and is the
appropriate as primary means
of ventilation in all pediatric
patients
An appropriately-sized
supraglottic airway (e.g. King)
may be placed if available at
any point in resuscitation in
children ≥ 8 years old
If no advanced airway,
alternate ventilations and
compression in 15:2 ratio
If advanced airway in place,
ventilate continuously at 8-10
breathe/minute
Avoid excessive ventilation
Shock energy for defibrillation:
•
•
CPR 2 min
Epinephrine 35 min
Treat
reversible
Rhythm
Shockable
?
Rhythm
Shockable
?
Go to
box A
• If asystolic, go to box
B
• If organized rhythm,
check pulse. If no
pulse, go to box B
• If ROSC, Begin postcardiac arrest care
•
•
•
A
CPR 2 min
Amiodarone
Treat
reversible
1st shock 2 J/kg, subsequent
shocks 4 J/kg
•
Return of
•
Pulse and blood pressure
Regarding where to work arrest and presence of
family members
Shock
•
•
•
•
•
CPR in a moving ambulance or pram is
ineffective
In general, work cardiac arrest on scene
either to return of spontaneous circulation
(ROSC), or to field pronouncement, unless
scene unsafe
Family presence during resuscitation is
preferred by most families, is rarely
disruptive, and may help with grieving
process for family members
Family presence during resuscitations
recommended, unless disruptive to
resuscitation efforts
Contact base for terminations of resuscitation
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6110 PEDIATRIC MEDICAL HYPOTENSION / SHOCK GUIDELINE
Shock is a state of decreased
tissue oxygenation. Significant
vital organ hypoperfusion may
be present without hypotension.
Home medications and/or
comorbidities may also limit
development of tachycardia
**
Goal is to maximize oxygen
delivery with supplemental
oxygen and assisted
ventilations (if needed), and to
maximize perfusion with IV
fluids
SBP < 70 + 2 x age in years
AND/OR signs of poor perfusion
EMT
EMT-I
•
•
•
•
•
•
4.
Presence of Systemic
Inflammatory Response
Syndrome (SIRS)
5.
Altered mental status
Tachycardia
Cool, clammy skin
Venous lactate > 4 (see below)
Paramedic
No
Recheck and monitor
If patient remains
asymptomatic and clinically
stable, treatment may not be
necessary
Yes
Treat according to appropriate
protocol
Yes
Life-threatening brady or
tachydysrrhythmia?
AND
AEMT
ABCs
Complete set of vital signs
Full monitoring
Titrate O2 90-94% SaO2
IV access
ALS transport
Signs of poor perfusion?
Septic Shock
Defined by:
EMT-IV
Suspected infection
No
AND
6.
Signs of hypoperfusion
(hypotension or elevated
venous lactate)
PEDS SIRS criteria:
Positive if two of T, HR or RR
Temp > 100.4° or < 96.8° F
Age
HR
RR
<2
>180
>35
2-5
>140
>30
6-12
>130
>20
The initial treatment of septic
shock involves maximizing
perfusion with IVF boluses, not
vasopressors
• Consider etiology of shock state
• Give 20cc/kg NS bolus IV/IO and
reassess
Repeat 20cc/kg boluses, reassessing for
pulmonary edema, up to 3 boluses total or
until goal of SBP > 70 + 2 x age in years
mmHg and signs adequate perfusion
Consider the etiology of your
patient’s shock state, which
may have specific treatments,
e.g.:
•
•
•
•
•
Sepsis
Hemorrhage
Anaphylaxis
Overdose
Cyanide or carbon
monoxide poisoning
• Other: PE, MI, tension
pneumothorax
For ongoing hypotension, poor perfusion or
pulmonary edema, contact base for
dopamine drip
If patient at risk for adrenal insufficiency,
see Adrenal Insufficiency guideline
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6120 PEDIATRIC APPARENT LIFE-THREATENING EVENT (ALTE)
DEFINITION:
An infant < 1 year of age with episode frightening to the
observer characterized by apnea, choking/gagging, color
change or change in muscle tone
Support ABCs as necessary
Obtain detailed history of event and medical
history
Complete head-to-toe assessment
• Any child with an ALTE should be
transported to ED for evaluation
• Monitor vital signs en route
Clinical history to obtain from observer of event:
•
•
•
•
•
Document observer’s impression of the infant’s color, respirations and muscle tone
For example, was the child apneic, or cyanotic or limp during event?
Was there seizure-like activity noted?
Was any resuscitation attempted or required, or did event resolve spontaneously?
How long did the event last?
Past Medical History:
•
•
•
•
•
Recent trauma, infection (e.g. fever, cough)
History of GERD
History of Congenital Heart Disease
History of Seizures
Medication history
Examination/Assessment
•
•
•
•
•
•
Head to toe exam for trauma, bruising, or skin lesions
Check anterior fontanelle: is it bulging, flat or sunken?
Pupillary exam
Respiratory exam for rate, pattern, work of breathing and lung sounds
Cardiovascular exam for murmurs and symmetry of brachial and femoral pulses
Neuro exam for level of consciousness, responsiveness and any focal weakness
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6130 PEDIATRIC SEIZURE (< 13 YEARS)
• Support ABCs:
• Give oxygen
• Rule out and/or treat
hypoglycemia (BMK)
• Universal seizure precautions
(see below)
• Consider the cause (see
below)
EMT
EMT-IV
EMT-I
AEMT
Paramedic
Actively Seizing?
Yes
No
• If seizure brief and self-limited, treatment
not necessary
• If prolonged (e.g.: > 5 min) or recurrent sz,
then treat as follows:
Check pulse and reassess ABCs
Give supplemental oxygen
• Transport (left lateral recumbent if postictal) and monitor ABCs, vital signs, and
neurological condition
• Complete head to toe assessment
Establish IV access if not already in
place
Actively seizing after 5 minutes?
Common Causes of Seizures
No
•
•
•
•
•
•
•
•
Yes
Administer midazolam
Epilepsy
Febrile seizure
Trauma/NAT
Hypoglycemia
Intracranial hemorrhage
Overdose (TCA)
Meningitis
Stimulant use (cocaine, meth)
Actively seizing after 5 minutes?
No
Yes
Contact Base
Universal Seizure Precautions
• Ensure airway patency, but do not force anything
between teeth. NPA may be useful
• Give oxygen
• Suction as needed
• Protect patient from injury
• Check pulse immediately after seizure stops
• Keep patient on side
Document:
• Document: Seizure history: onset, time interval,
previous seizures, type of seizure
• Obtain medical history: head trauma, diabetes,
substance abuse, medications, compliance with
anticonvulsants, pregnancy
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6140 CARE OF THE CHILD WITH SPECIAL NEEDS
General Guideline:
A. Children with special health care needs include those with chronic physical, developmental,
behavioral or emotional health issues. These children often have complex medical needs and
may be technology-dependent. Parents or caregivers for such children can be a wealth of
knowledge about their child’s care and may carry a reference care sheet. Contact Base Station
for any concerns.
Feeding Tubes:
A. Feedings tubes are used for administration of medications and to provide feeds to children with
an impaired ability to take oral feeds. Tubes may be placed through the nose, mouth or abdomen
and end in the stomach or jejunum (upper intestine) Always ask caretaker the type of feeding
tube (does the tube end in the stomach or jejunum?) and when it was placed
B. Consider venting and/or gently aspirating the feeding tube in a child with respiratory or
abdominal distress to allow removal of gastric contents and decompression
C. Feeding tubes that have been placed less than 6 weeks ago are not well established and may
close within 1 hour of tube removal. If transport time is prolonged, place an 8 Fr suction catheter
tube 2 inches into the stoma to maintain patency. Do NOT use the tube.
Tracheostomy:
A. A tracheostomy is a surgical opening between the trachea and the anterior surface of the neck.
B. Use bag-valve attached to the tracheostomy to assist ventilations if needed. May also attempt
BVM with gloved finger over the tracheostomy
C. Inability to ventilate and/or signs of respiratory distress (nasal flaring, retractions, hypoxia, etc)
may indicate tracheostomy obstruction. Suction tracheostomy, passing the suction catheter no
further than 6 cm. Limit suctioning time to minimum amount of time necessary to accomplish
effective suctioning. Oxygenate between passes with the suction catheter.
D. 0.5ml of saline may be instilled into the tracheostomy to assist suctioning of thick secretions
E. If unable to ventilate through the tracheostomy tube and patient is apneic, bradycardic, or in
pulseless arrest, remove tracheostomy tube and pass an appropriately sized endotracheal tube
through the stoma approximately 1-2 inches, secure and ventilate. Appropriate depth must be
based upon breath sounds, as right mainstem intubation is likely.
F. Remember that caregivers are often the best people to change and suction a tracheostomy tube.
Use them as your resource when possible.
Central Venous Catheters (CVCs):
A. Because of their size and location, a much greater risk of serious bacterial infections exist with
CVCs compared to peripheral intravenous lines. Special care must be used when accessing
such lines. THESE SHOULD ONLY BE ACCESSED IF PATIENT IN EXTERMIS OR WITH BASE
CONTACT.
B. Prior to accessing a CVC, hands should be washed and gloves worn. Vigorously scrub the CVC
hub with an alcohol swab. The friction produced by scrubbing is the most effective action.
C. A port is an implanted venous central venous catheter (below the surface of the skin). These
devices require a non-coring (e.g. Huber) needle for accessing and should not be accessed in
the field
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6150 PEDIATRIC TRAUMA CONSIDERATIONS (AGE < 13 YEARS)
Spinal Immobilization
A. Context/Special Considerations:
EMT
EMT-IV
AEMT
B. 60-80% of spine injuries in children occur at the cervical
level
EMT-I
Paramedic
C. Children < 8 age year are more likely to sustain high C1C3 injuries
D. Less force is required to injure the cervical spine in children than adults
E. Children with Down Syndrome are at risk for cervical spine injury
F. Avoid strapping abdomen- children are abdominal breathers
G. Use age/size appropriate immobilization devices
H. Proper immobilization of pediatric patients should prevent:
1. Flexion/extension, rotation, lateral bending or axial loading of the neck (car seats do not
prevent axial loading and are not considered proper immobilization technique)
2. Non-neutral alignment or alteration in normal curves of the spine for age (consider the
large occiput)
3. Twisting, sliding or bending of the body during transport or care
Spinal Immobilization criteria:
A. Be conservative. Children are difficult to assess and “clinical clearance” criteria are not well
established, as in adults
B. Immobilize the following patients as well as any child you suspect clinically may have a spine
injury:
1. Altered Mental Status (GCS < 15, AVPU < A, or intoxication)
2. Focal neurologic findings (paresthesias, loss of sensation, weakness)
3. Non-ambulatory patient
4. Any complaint of neck pain
5. Torticollis (limited range of motion, difficulty moving neck in history or physical)
6. Substantial torso Injury (thorax, abdomen, pelvis)
7. High Risk MVC (head on collision, rollover, ejected from the vehicle, death in the same
crash, or speed > 55 m/h)
8. Diving accident
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7000 MEDICATIONS
ADENOSINE (ADENOCARD)
Description
Adenosine transiently blocks conduction through the AV node thereby terminating reentrant
tachycardias involving the AV node. It is the drug of choice for AV nodal reentrant tachycardia
(AVNRT, often referred to as “PSVT”). It will not terminate dysrhythmias that do not involve the AV
node as a reentrant limb (e.g. atrial fibrillation).
Onset & Duration
• Onset: almost immediate
• Duration: 10 sec
Indications
• Narrow-complex supraventricular tachyarrhythmia
• Stable, undifferentiated, regular, monomorphic wide-complex tachycardia
• Pediatric administration requires call in for direct verbal order
Contraindications
• Any irregular tachycardia. Specifically, never administer to an irregular wide-complex tachycardia,
which may be lethal
• Heart transplant
Adverse Reactions
• Chest pain
• Shortness of breath
• Diaphoresis
• Palpitations
• Lightheadedness
Drug Interactions
• Methylxanthines (e.g. caffeine) antagonize adenosine, a higher dose may be required
• Dipyridamole (persantine) potentiates the effect of adenosine; reduction of adenosine dose may
be required
• Carbamazepine may potentiate the AV-nodal blocking effect of adenosine
Dosage and Administration
Adult:
6 mg IV bolus, rapidly, followed by a normal saline flush.
Additional dose of 12 mg IV bolus, rapidly, followed by a normal saline flush.
Contact medical control for further considerations
Pediatric (Requires Call in and direct verbal order):
0.2 mg/kg IV bolus (max 6 mg), rapidly followed by normal saline flush.
Additional dose of 0.2 mg/kg (max 12 mg) rapid IV bolus, followed by normal saline flush
Contact medical control for further considerations
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101
Protocol
• Adult Tachyarrhythmia with Poor Perfusion
• Pediatric Tachyarrhythmia with Poor Perfusion
Special Considerations
• Reliably causes short lived but very unpleasant chest discomfort. Always warn your patient of this
before giving medication and explain that it will be a very brief sensation
• May produce bronchospasm in patients with asthma
• Transient asystole and AV blocks are common at the time of cardioversion
• Adenosine is not effective in atrial flutter or fibrillation
• Adenosine is safe in patients with a history of Wolff-Parkinson-White syndrome if the rhythm is
regular and QRS complex is narrow
• A 12-lead EKG should be performed and documented, when available
• Adenosine requires continuous EKG monitoring throughout administration
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ALBUTEROL SULFATE (PROVENTIL, VENTOLIN)
Description
• Albuterol is a selective ß-2 adrenergic receptor agonist. It is a bronchodilator and positive
chronotrope.
• Because of its ß agonist properties, it causes potassium to move across cell membranes inside
cells. This lowers serum potassium concentration and makes albuterol an effective temporizing
treatment for unstable patients with hyperkalemia.
Onset & Duration
• Onset: 5-15 minute after inhalation
• Duration: 3-4 hours after inhalation
Indications
• Bronchospasm
• Known or suspected hyperkalemia with ECG changes (i.e.: peaked T waves, QRS widening)
Contraindications
• Severe tachycardia is a relative contraindication
Adverse Reactions
• Tachycardia
• Palpitations
• Dysrhythmias
Drug Interactions
• Sympathomimetics may exacerbate adverse cardiovascular effects.
• ß-blockers may antagonize albuterol.
How Supplied
MDI: 90 mcg/metered spray (17-g canister with 200 inhalations)
Pre-diluted nebulized solution: 2.5 mg in 3 ml NS (0.083%)
Dosage and Administration
Adult:
Single Neb dose
Albuterol sulfate solution 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8
lpm) that will deliver the solution over 5 to 15 minutes. May be repeated twice (total of 3 doses).
Continuous Neb dose
In more severe cases, place 3 premixed containers of albuterol (2.5 mg/3ml) for a total dose of
7.5 mg in 9 ml, into an oxygen-powered nebulizer and run a continuous neb at 6-8 lpm.
Pediatric:
Single Neb dose
Albuterol sulfate 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that
will deliver the solution over 5-15 minutes. May be repeated twice during transport (total of 3
doses).
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103
Protocol
• Asthma
• COPD
• Pediatric Respiratory Distress
• Allergy and Anaphylaxis
Special Considerations
• Consider inline nebs for patients requiring endotracheal intubation or CPAP.
• May precipitate angina pectoris and dysrhythmias
• Should be used with caution in patients with suspected or known coronary disease, diabetes
mellitus, hyperthyroidism, prostatic hypertrophy, or seizure disorder
• Wheezing associated with anaphylaxis should first be treated with epinephrine IM.
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AMIODARONE (CORDARONE)
Description
Amiodarone has multiple effects showing Class I, II, III and IV actions with a quick onset. The
dominant effect is prolongation of the action potential duration and the refractory period.
Indications
• Cardiac arrest in patients with shock refractory VF/VT
• Wide complex tachycardia not requiring immediate cardioversion due to hemodynamic
instability
• Following successful cardioversion of VF/VT, if used prior to defibrillation or for recurrent VF/VT
Precautions
• Wide complex irregular tachycardia
• Sympathomimetic toxidrome, i.e. cocaine or amphetamine overdose
• NOT to be used to treat ventricular escape beats or accelerated idioventricular rhythms
Contraindications
nd
rd
• 2 or 3 degree AV block
• Cardiogenic shock
Adverse Reactions
• Severe hypotension
• Bradycardia
Dosage and Administration
Adult:
Pulseless Arrest (Refractory VT/VF)
300 mg IV bolus.
Repeat once 150 mg IV bolus in 3-5 minutes.
Post arrest following successful conversion of VT/VF
150 mg IV bolus infusion over 10 minutes
Symptomatic wide complex tachycardia with a pulse (CONTACT BASE)
150 mg IV bolus infusion over 10 minutes.
Pediatric: (Use length based tape for appropriate dosing)
Pulseless Arrest (Refractory VT/VF)
5mg/kg IV over 3-5 minutes. (CONTACT BASE for additional doses)
Protocol
• Adult Universal Pulseless Arrest Algorithm
• Pediatric Universal Pulseless Arrest Algorithm
• Adult Tachycardia with Poor Perfusion
Special Considerations
• A 12-lead EKG should be performed and documented, when available.
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ASPIRIN (ASA)
Description
Aspirin inhibits platelet aggregation and blood clotting and is indicated for treatment of acute
coronary syndrome in which platelet aggregation is a major component of the pathophysiology.
It is also an analgesic and antipyretic
Indications
• Suspected acute coronary syndrome.
Contraindications
• Active gastrointestinal bleeding
• Aspirin allergy
How Supplied
Chewable tablets 81mg
Dosage and Administration
• 324mg PO
Protocol
• Chest Pain
Special Considerations
• Patients with suspected acute coronary syndrome taking warfarin (Coumadin) or clopidogrel
(Plavix) may still be given aspirin
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ATROPINE SULFATE
Description
Atropine is an endogenous antimuscarinic, anticholinergic substance. It is the prototypical
anticholinergic medication with the following effects:
• Increased heart rate and AV node conduction
• Decreased GI motility
• Urinary retention
• Pupillary dilation (mydriasis)
• Decreased sweat, tear and saliva production (dry skin, dry eyes, dry mouth)
Indications
• Symptomatic bradycardia
• 2nd and 3rd degree heart block
• Organophosphate poisoning
Precautions
• Should not be used without medical control direction for stable bradycardias
• Closed angle glaucoma
Adverse Reactions
• Anticholinergic toxidrome in overdose, think “blind as a bat, mad as a hatter, dry as a bone, red
as a beet”
Dosage and Administration
Hemodynamically Unstable Bradycardia
Adult:
0.5 mg IV/IO bolus.
Repeat if needed at 3-5 minute intervals to a maximum dose of 3 mg. (Stop at ventricular rate
which provides adequate mentation and blood pressure)
Pediatric: (Use length based tape for appropriate dosing)
0.02 mg/kg IV/IO bolus. Minimum dose is 0.1 mg, maximum single dose 0.5 mg
Stable Bradycardia: CONTACT BASE
Poisoning/Overdose
Adult: 2 mg and contact base
Pediatric: CONTACT BASE
Protocol
• Bradycardia
• Neonatal Resuscitation
• Poisoning/Overdose
Special Considerations
• Atropine causes pupil dilation, even in cardiac arrest settings
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DEXTROSE 10%
Description
Glucose is the body's basic fuel 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 glucagon, which mobilizes
stored glucose into the blood stream.
Indications
• Hypoglycemia
• The unconscious or altered mental status patient with an unknown etiology.
Precautions
• None
Dosage and Administration
Adult:
5-10 gm (50 – 100 ml of a 10% solution) IV/IO bolus
Pediatric: (Use length based tape for approximate weight)
1 ml/kg of D10 or adult dosing, whichever is less
Protocol
• Universal Altered Mental Status
• Seizures
• Poisoning/Overdose
• Psych/Behavioral
• Neonatal Resuscitation
Special Considerations
• The risk to the patient with ongoing hypoglycemia is enormous. With profound hypoglycemia
and no IV access consider IO insertion.
• Draw blood sample before administration if possible.
• Use glucometer before administration, if possible.
• Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to ensure
route patency.
• Dextrose can be irritable to the vein and the vein should be flushed after administration.
• Dextrose should be diluted 1:1 with normal saline (to create D25W) for patient 1-8 years old.
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DIPHENHYDRAMINE (BENADRYL)
Description
Antihistamine for treating histamine-mediated symptoms of allergic reaction. Also
Anticholinergic and antiparkinsonian effects used for treating dystonic reactions caused by
antipsychotics and antiemetic medications (e.g.: haloperidol, droperidol, Compazine, etc).
Indications
• Allergic reaction
• Dystonic medication reactions or akathisia (restlessness)
Precautions
• Asthma or COPD, thickens bronchial secretions
• Narrow-angle glaucoma
Side effects
• Drowsiness
• Dilated pupils
• Dry mouth and throat
• Flushing
Drug Interactions
• CNS depressants and alcohol may have additive effects.
• MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines.
Dosage and Administration
Adults:
50 mg IV/IO
Pediatrics: (Use length based tape for appropriate dosing)
<8 years: 1-2 mg/kg slow IV/IO (not to exceed 50 mg)
Protocol
Allergy/Anaphylaxis
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DOPAMINE (INTROPIN)
Description
Endogenous catecholamine chemically related to epinephrine and norepinephrine. Increases
blood pressure through combination of dopamine, alpha and beta receptor effects leading to
increased heart rate, contractility and peripheral vasoconstriction.
Indications
• Hypotension refractory to adequate fluid resuscitation
• Symptomatic bradycardia with signs of poor perfusion
Contraindications
• Hypovolemia
• Hemorrhagic shock
Adverse Reactions
• Tachydysrhythmia
• Hypertension
• Increased myocardial oxygen demand
Dosage and Administration
CONTACT BASE for direct physician order
Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of 1600 mcg/ml.
Adult IV/IO:
2~20 mcg/kg/min, start at 5 mcg/kg/min, titrate dose up 5 mcg/kg/min every 5 min to a
max of 20 mcg/kg/min to achieve desired effect.
Pediatrics IV/IO: (Use length based tape for appropriate dosing)
2~20 mcg/kg/min, start at 5 mcg/kg/min, titrate dose up 5 mcg/kg/min every 5 min to a
max of 20 mcg/kg/min to achieve desired effect.
Protocol
• Medical Hypotension/Shock Protocol
• Adult Bradycardia
Special Considerations
• May become ineffective if added to alkaline solution.
• 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 dopaminecontaining solutions so that proper treatment can be instituted.
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INTRAVENOUS DRIP RATES FOR DOPAMINE
Concentration: 1600 mcg/ml
Dose (mcg/kg/min)
5
10
15
20
50 kg
10
20
30
40
60 kg
10
25
35
45
70 kg
15
25
40
50
80 kg
15
30
45
60
90 kg
15
35
50
70
100 kg
20
35
55
75
110 kg
20
40
60
85
Weight
microdrops/min
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DROPERIDOL (INAPSINE)
Description
Droperidol is a dopamine antagonist antipsychotic medication. Droperidol produces a
dopaminergic blockade, a mild alpha-adrenergic blockade, and causes peripheral vasodilation.
Its major actions are sedation and tranquilization.
Onset & Duration
• Onset: Within 10 minutes after IM administration. Peak effect within 30 minutes
• Duration: 2-4 hours (may be longer in some individuals)
Indications
• Sedation of a severely agitated combative patient
Contraindications
• Suspected myocardial infarction
• Hypotension
• Respiratory or CNS depression
• Pregnancy
• Children < 8 years old
Precautions
• Droperidol may cause hypotension, tachycardia, and prolongation of the QT interval. Use with
caution in severe cardiovascular disease.
• Cardiac monitor and establish an IV as soon as possible with all administrations.
• Some patients may experience unpleasant sensations manifested as restlessness, hyperactivity,
or anxiety following Droperidol administration.
• Rare instances of neuroleptic malignant syndrome (very high fever, muscular rigidity) have been
known to occur after the use of haloperidol.
Dosage and Administration
Adults and Pediatrics > 8 years old
5 mg IM
BASE CONTACT must be made for additional doses (consider if no effects within 10 minutes)
Special Considerations
• 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.
• Hypotension and tachycardia secondary to droperidol are usually self-limiting and should be
treated with IV fluid bolus.
• Use reduced dose in patients age ≥ 65
Protocol
Agitated/Combative Patient Protocol
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
112
EPINEPHRINE (ADRENALIN)
Description
Endogenous catecholamine alpha, beta-1, and beta-2 adrenergic receptor agonist. Causes doserelated increase in heart rate, myocardial contractility and oxygen demand, peripheral
vasoconstriction and bronchodilation.
Indications
• Pulseless Arrest
• Anaphylaxis
• Asthma
• Bradycardia with poor perfusion
• Severe Croup
Adverse Reactions
• Tachycardia and tachydysrhythmia
• Hypertension
• Anxiety
• May precipitate angina pectoris
Drug Interactions
• Should not be added to sodium bicarbonate or other alkaloids as epinephrine will be inactivated
at higher pH.
Dosage and Administration
Adult:
Pulseless Arrest
1 mg (10 ml of a 1:10,000 solution), IV/IO bolus.
Repeat every 3-5 minutes.
Bradycardia/ hypotension refractory to other interventions (Contact Base):
Continuous infusion titrated to effect: 1 mg in 250 ml of Normal Saline IV/IO infused at 2
mcg/min until desired BP of > 90 mmHg systolic achieved.
Asthma:
0.3 mg (0.3 ml of a 1:1,000 solution) IM. May repeat dose x 1.
Systemic allergic reaction:
0.3 mg (0.3 ml of a 1:1,000 solution) IM. May repeat dose x 3.
Severe systemic allergic reaction (Anaphylaxis) refractory to IM epi (Contact Base):
Continuous infusion titrated to effect: 1 mg in 250 ml of Normal Saline IV/IO infused at 2
mcg/min until desired BP of > 90 mmHg systolic achieved
Epinephrine Auto-Injector: requires BASE CONTACT for EMT administration
Systemic allergic reaction:
Adult: 0.3 mg IM with autoinjector (adult EpiPen)
Pediatric: 0.15 mg IM with autoinjector (EpiPen Jr.)
Pediatric: (Use length based tape for appropriate dosing)
Cardiac arrest:
0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 solution).
Subsequent doses repeated every 3-5min: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 solution)
Bradycardia (CONTACT BASE)
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
113
0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO
Asthma
0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM
Moderate to Severe Allergic Reactions
0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM
Severe systemic allergic reaction (Anaphylaxis) refractory to IM epi (Contact Base):
0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO
ALTERNATIVE to racemic epinephrine: (for bronchiolitis, croup, epiglottitis, miscellaneous
causes of stridor)
5 mL of 1:1000 epinephrine via nebulizer x 1
Protocol
• Adult Universal Pulseless Arrest Algorithm
• Pediatric Pulseless Arrest ALS Algorithm
• Adult Bradycardia
• Neonatal Resuscitation
• Allergy and Anaphylaxis Protocol
• Bradycardia with Poor Perfusion
• Pediatric Respiratory Distress
Special Considerations
• May increase myocardial oxygen demand and angina pectoris. Use with caution in patients with
known or suspected CAD
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
114
IPRATROPIUM BROMIDE (ATROVENT)
Description
Ipratropium is an anticholinergic, antimuscarinic bronchodilator chemically related to atropine.
Onset & Duration
• Onset: 5-15 min. after inhalation
• Duration: 6-8 hr. after inhalation
Indications
• Bronchospasm
Contraindications
• Do not administer to children < 2 years
• Soy or peanut allergy is a contraindication to use of Atrovent metered dose inhaler, not the
nebulized solution, which does not have the allergen contained in propellant
Adverse Reactions
• Palpitations
• Tremors
• Dry mouth
How Supplied
Premixed Container:
0.5 mg in 2.5ml NS
Dosage and Administration
Adult
Bronchospasm:
Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer
Child (2yrs – 12yrs)
Moderate and Severe Bronchospasm
Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer
Not indicated for more than 3 successive doses or continuous neb use
Protocol
• Asthma
• COPD
• Pediatric Respiratory Distress
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
115
LIDOCAINE 2% SOLUTION
Description
Local anesthetic for relief of pain during intraosseous fluid administration.
Indications
• Analgesic for intraosseous infusion
Side Effects
• Seizures
• Drowsiness
• Tachycardia
• Bradycardia
• Confusion
• Hypotension
Precautions
• Lidocaine is metabolized in the liver and therefore, elderly patients and those with liver disease
or poor liver perfusion secondary to shock or congestive heart failure are more likely to
experience side effects
Dosage and Administration
Adults – 40 mg IO slow push
Children (2-12) – 20 mg IO slow push
Infants (< 2 yo) – 10 mg IO slow push
Protocol
Intraosseous Administration
Special Notes
• Seizure from lidocaine toxicity likely to be brief and self-limited. If prolonged, or status
epilepticus, treat per seizure protocol
• Treat dysrhythmias according to specific protocol
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MAGNESIUM SULFATE
Description
Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular
transmission by reducing acetylcholine release at the myoneural junction. In cardiac patients, it
stabilizes the potassium pump, correcting repolarization. It also shortens the Q-T interval in the
presence of ventricular arrhythmias due to drug toxicity or electrolyte imbalance.
Indications
Antiarrhythmic
• Torsade de pointes associated with prolonged QT interval
Muscle Relaxant
• Eclampsia
Precautions
• Bradycardia
• Hypotension
• Respiratory depression
Adverse Reactions
• Bradycardia
• Hypotension
• Respiratory depression
Dosage and Administration
Torsades de Pointes suspected caused by prolonged QT interval:
2 gm, IV bolus
Eclampsia:
2-4 grams IV over 10 minutes
Protocol
• Adult Universal Pulseless Arrest Algorithm
• Adult Seizures
• Obstetrical Complications
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
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MIDAZOLAM (Versed)
Description
• Benzodiazepines are sedative-hypnotics that act by increasing GABA activity in the brain. GABA
is the major inhibitory neurotransmitter, so increased GABA activity inhibits cellular excitation.
Benzodiazepine effects include anticonvulsant, anxiolytic, sedative, amnestic and muscle
relaxant properties.
Onset & Duration
• Given IV it will have the fastest onset of action, typical time of onset 2-3 minutes
• Intranasal administration has slower onset and is less predictable compared to IV
administration, however it may still be preferred if an IV cannot be safely or rapidly obtained.
Intranasal route has faster onset compared to intramuscular route.
• IM administration has the slowest time of onset.
Indications
• Status epilepticus
• Tranquilization of the severely agitated/combative patient
• Anxiolysis for cardioversion or transcutaneous pacing (TCP)
• Treatment of severe muscle spasms associated with large muscle groups such as back or
quadriceps muscle groups.
Contraindications
• Hypotension
• Respiratory depression
Adverse Reactions
• Respiratory depression, including apnea
• Hypotension
• Consider ½ dosing in the elderly
Dosage and Administration
MIDAZOLAM:
Seizure or anxiolysis for cardioversion or transcutaneous pacing:
Adult:
IV/IO route: 3 mg
• Dose may be repeated x 1 after 5 minutes if still seizing. Contact Base for more than
2 doses
IN route: 5 mg
• Dose may be repeated x 1 after 5 minutes if still seizing. Contact Base for more than
2 doses
IM route: 10 mg
• Dose may be repeated x 1 after 5 minutes if still seizing. Contact Base for more than
2 doses
Pediatric: (Use length based tape for appropriate dosing)
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118
IV/IO route 0.1 mg/kg
• Maximum single dose is 2 mg IV. Dose may be repeated x 1 after 5 minutes if still
seizing. Contact Base for more than 2 doses.
IN/IM route: 0.2 mg/kg.
• Maximum single dose is 5 mg IN or IM. Dose may be repeated x 1 after 5 minutes if
still seizing. Contact Base for more than 2 doses.
Tranquilization of severely agitated or combative patient OR anxiolysis for CPAP
Adult:
IV route: 2 mg
IN/IM route: 5 mg
• Dose may be repeated x 1 after 5 minutes for agitation. Contact base for more than 2
doses, unless Excited Delirium Syndrome present, in which case up to a total of 3
doses may be given as standing order in order to rapidly sedate patient.
Pediatric:
• CONTACT BASE before any consideration of sedation of severely agitated/combative
child
Protocol
• Synchronized Cardioversion
• Transcutaneous Pacing
• CPAP
• Adult Seizure
• Pediatric Seizure
• Pediatric tachycardia with poor perfusion
• Agitated/Combative Patient
• Poisoning/Overdose
Special Considerations
• All patients receiving midazolam must have cardiac, pulse oximetry monitoring during transport.
Continuous waveform capnography recommended.
• Sedative effects of midazolam are increased in combination with opioids, alcohol, or other CNS
depressants.
• Coadministration of opioids and midazolam is discouraged and may only be done with direct
physician verbal order.
• In elderly patients > 65 years old or small adults < 50kg, lower doses may be sufficient and
effective. Consider ½ dosing in these patients.
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NALOXONE (NARCAN)
Description
Naloxone is a competitive opioid receptor antagonist
Onset & Duration
Onset: Within 5 minutes
Duration: 1-4 hours
Indications
• For reversal of suspected opioid-inducted CNS and respiratory depression
• Coma of unknown origin
• Seizure of unknown etiology (rule out narcotic overdose, specifically propoxyphene )
Adverse Reactions
• Tachycardia
• Nausea and vomiting
• Pulmonary Edema
Dosage and Administration
Adult:
0.4 mg IV/IO/IM/IN and titrate to desired effect, up to 2 mg total
In cases of severe respiratory compromise or arrest, 2 mg bolus IV/IO/IM is appropriate,
otherwise drug should be titrated
Pediatrics: (Use length based tape for appropriate dosing)
0.4 mg IV/IO/IM/IN and titrate to desired effect, up to 2 mg total
Protocol
• Universal Altered Mental Status Protocol
• Poisoning/Overdose
Special Considerations
• Patients receiving naloxone must be transported to a hospital
• Narcotic-dependent patients may experience violent withdrawal symptoms. Before administering
naloxone to a suspected opioid overdose, consider if supportive care alone may be adequate.
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NITROGLYCERINE (NITROSTAT, NITROQUICK, etc)
Description
Short-acting peripheral venodilator decreasing cardiac preload and afterload
Onset & Duration
Onset: 1-3 min.
Duration: 20-30 min.
Indications
• Pain or discomfort due to suspected Acute Coronary Syndrome
• Pulmonary edema due to congestive heart failure
Contraindications
• Suspected right ventricular ST-segment elevation MI (Inferior STEMI pattern plus ST elevation in
right sided-precordial leads)
• Hypotension SBP < 100
• Use of erectile dysfunction (ED) medication (e.g. Viagra, Cialis) in last 36 hours
Adverse Reactions
• Hypotension
• Headache
• Syncope
Dosage and Administration
0.4 mg (1/150 gr) sublingually or spray, every 5 minutes
PRN up to a total of 3 doses for persistent CP.
Nitropaste: 1” to chest if patient responds to SL NTG.
Protocol
• Adult Chest Pain
• CHF/Pulmonary Edema
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ONDANSETRON (ZOFRAN)
Description
• Ondansetron is a selective serotonin 5-HT3 receptor antagonist antiemetic. Ondansetron is the
preferred antiemetic, if available.
Indications
• Nausea and vomiting
Contraindications
• Ondansetron: known QT prolongation syndrome
Adverse Effects:
• Ondansetron: very low rate of adverse effects, very well tolerated. May cause QT prolongation.
Dosage and Administration
Ondansetron:
Adult:
4 mg IV/IM/PO/ODT. May repeat x 1 dose as needed:
Pediatric < 4 years old:
2 mg IV/PO/ODT
Pediatric ≥ 4 years old:
4 mg IV/PO/ODT
Protocol
• Abdominal Pain/Vomiting
• Altitude Illness
• Diphenhydramine (Benadryl)
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OPIOIDS (FENTANYL, MORPHINE)
Description
Opioid analgesics with desired effects of analgesia, euphoria and sedation as well as undesired
effects of respiratory depression and hypotension. A synthetic opioid, fentanyl is 100 times
more potent than morphine, and is less likely to cause histamine release.
Indications
• Treatment of hemodynamically stable patients with moderate to severe pain due to traumatic or
medical conditions, including cardiac conditions, abdominal pain, back pain, etc.
• Treatment of shivering after therapeutic induced hypothermia (TIH).
Contraindications
• Hypotension, hemodynamic instability or shock
• Respiratory depression
Caution/Comments:
• Opioids should only be given to hemodynamically stable patients and titrated slowly to effect.
• The objective of pain management is not the removal of all pain, but rather, to make the patient’s
pain tolerable enough to allow for adequate assessment, treatment and transport
• Respiratory depression, including apnea, may occur suddenly and without warning, and is more
common in children and the elderly. Start with ½ traditional dose in the elderly.
• Coadministration of opioids and benzodiazepines is discouraged and may only be done with
direct physician verbal order.
• Chest wall rigidity has been reported with rapid administration of fentanyl
Dosage and Administration
FENTANYL:
Adult:
IV/IO/IM route: 1-2 mcg/kg, SLOW IV/IO bolus.
• Dose may be repeated after 10 minutes and titrated to clinical effect to a maximum
cumulative dose 200mcg
• Additional dosing requires BASE CONTACT
IN route: 1-2 mcg/kg IN single dose.
• Repeat dosing only via IV route, and 10 minutes after initial IN dose up to a maximum
cumulative dose of 200mcg
• Additional dosing requires BASE CONTACT
Pediatric (1-12 years): (Use length based tape for appropriate dosing)
IV/IO/IM route: 1 mcg/kg SLOW IV/IO bolus.
• Dose may be repeated after 10 minutes and titrated to clinical effect to a maximum
cumulative dose of 3 mcg/kg
IN route: 1 mcg/kg IN single dose.
• Repeat dosing only via IV route, and 10 minutes after initial IN dose up to a maximum
cumulative dose of 3 mcg/kg
• IN route requires BASE CONTACT and approval for any patient < 5 years old, or any
patient < 12 years old with indication other than isolated orthopedic injury or burns
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123
Pediatric < 1 year: BASE CONTACT
MORPHINE:
Adult:
IV/IO/IM routes: 4 mg.
• Repeat doses of 2.0 mg, up to 10 mg.
• Additional cumulative dosing > 10 mg requires BASE CONTACT.
• Morphine may not be given IN as it is poorly absorbed
Pediatric (1-12 years): (Use length based tape for appropriate dosing)
IV/IO/IM routes: 0.1 mg/kg slowly.
• Maximum single dose is 5.0 mg.
• Additional cumulative dosing > 5 mg requires BASE CONTACT.
• Morphine may not be given IN as it is poorly absorbed
Pediatric < 1 year: BASE CONTACT
NOTE: IV route is preferred for more accurate titration. Continuous pulse oximetry is mandatory.
Frequent evaluation of the patient’s vital signs is also indicated. Emergency resuscitation equipment
and naloxone must be immediately available.
Protocol
Extremity Injuries
Adult Chest Pain
CHF/pulmonary Edema
Therapeutic Induced hypothermia
Abdominal Pain
Amputations
Burns
Bites/Stings
Snake Bites
Face and Neck Trauma
Chest Trauma
Abdominal Trauma
Spinal Trauma
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
124
ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE)
Description
Glucose is the body's basic fuel and is required for cellular metabolism
Indications
• Known or suspected hypoglycemia and able to take PO
Contraindications
Inability to swallow or protect airway
Unable to take PO meds for another reason
Administration
One full tube 15 g buccal.
Protocol
• Universal Altered Mental Status Protocol
• Hypoglycemia
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
125
OXYGEN
Description
Oxygen added to the inspired air increases the amount of oxygen in the blood, and thereby
increases the amount delivered to the tissue. Tissue hypoxia causes cell damage and death.
Breathing, in most people, is regulated by small changes in the acid-base balance and CO2
levels. It takes relatively large decreases in oxygen concentration to stimulate respiration.
Indications
• Suspected hypoxemia or respiratory distress from any cause
• Acute chest or abdominal pain
• Hypotension/shock states from any cause
• Trauma
• Suspected carbon monoxide poisoning
• Obstetrical complications, childbirth
Precautions
• If the patient is not breathing adequately, the treatment of choice is assisted ventilation, not just
oxygen.
• When pulse oximetry is available, titrate SpO2 per protocol. This may take some time.
• Do not withhold oxygen from a COPD patient out of concerns for loss of hypoxic respiratory
drive. This is never a concern in the prehospital setting with short transport times
Administration
Flow
Low Flow
Moderate Flow
High Flow
LPM Dosage
1-2 LPM
3-9 LPM
10-15 LPM
Indications
Minor medical / trauma
Moderate medical / trauma
Severe medical / trauma
Special Notes
• Do not use permanently mounted humidifiers. If the patient warrants humidified oxygen, use a
single patient use device.
• Adequate oxygenation is assessed clinically and with the SpO2 while adequate ventilation is
assessed with clinically and with ETCO2.
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126
METHOD
Room Air
Nasal Cannula
Simple Face Mask
Non-rebreather Mask
Mouth to Mask
Bag/Valve/Mask (BVM)
Bag/Valve/Mask with Reservoir
OXYGEN -powered breathing
device
OXYGEN FLOW RATES
FLOW RATE
1 LPM
2 LPM
6 LPM
8 - 10 LPM
10 LPM
10 LPM
15 LPM
Room Air
12 LPM
10-15 LPM
hand-regulated
OXYGEN INSPIRED AIR
(approximate)
21%
24%
28%
44%
40-60%
90%
80%
50%
21%
40%
90-100%
100%
NWRETAC Combined Medical Protocols Approved: June 2016. Next Revision: January 2017
127
SODIUM BICARBONATE
Description
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
• Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures
• Suspected hyperkalemic pulseless arrest: consider in patients with renal failure
Contraindications
• Metabolic and respiratory alkalosis
• Hypocalcemia
• Hypokalemia
Adverse Reactions
• Metabolic alkalosis
• Hyperosmolarity may occur, causing cerebral impairment
Drug Interactions
• May precipitate in calcium solutions.
• Alkalization of urine may increase half-lives of certain drugs.
• Vasopressors may be deactivated.
Dosage and Administration
Adults and children (>10 kg), 8.4%
Tricyclic OD with hypotension or prolonged QRS > 0.10 sec or suspected hyperkalemiarelated pulseless arrest:
1.0 mEq/kg slow IV push
Repeat if needed in 10 minutes.
Protocol
• Adult Universal Pulseless Arrest Algorithm
• Poisoning/Overdose
Special Considerations
• Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a
paradoxical intracellular acidosis.
• Sodium bicarb is no longer recommended for routine use in prolonged cardiac arrest. Its use in
pulseless arrest should be limited to known or suspected hyperkalemia (e.g. dialysis patient).
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8000 PROCEDURE PROTOCOL: THERAPEUTIC INDUCED HYPOTHERMIA AFTER CARDIAC ARREST
EMT
EMT-IV
AEMT
ROSC after cardiac arrest
EMT-I
Paramedic
Universal patient assessment and
treatment
Return of spontaneous circulation
(ROSC) criteria:
Manage airway & do not hyperventilate
• Pulse and measurable blood pressure
• Increase in ETCO2 on capnography
Contraindications to TIH:
Initiate therapeutic hypothermia if
there is no contraindication
Check patient temperature, if possible
Give 30 cc/kg (up to 2 liters) ice-cold
(4°C) normal saline bolus as a rapid
infusion AND/OR place ice packs to
neck, axillae, groin
1.
2.
Treat shivering with opioid IV/IO
If pulses lost after initiation of TIH,
follow universal pulseless arrest
algorithm and continue cooling
5.
If hypotensive, call base for
dopamine order
•
•
•
•
•
•
Purposeful response to painful stimuli
Age < 12 years
Active bleeding
Traumatic arrest
Definite pregnancy
Temperature < 34° C (93.2° F) or
suspected hypothermia
Document:
• Time of arrest (or time last seen normal)
• Witnessed vs. unwitnessed arrest
• Initial rhythm shockable vs. nonshockable
• Bystander CPR given
• Time of ROSC
• GCS after ROSC
• Initial temperature if TIH patient
Consider and Contact Base For Other
Indications For Cooling:
• Drowning
• Hanging or asphyxiation
• Hyperthermia
12 lead ECG to identify STEMI if present
Transport to a hospital with TIH program
and capacity for coronary intervention
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129
ROUTT COUNTY SPECIFIC
EMS PROTOCOLS
Revised July 26, 2016
Routt County Specific Protocols
130
NWRETAC COMBINED MEDICAL PROTOCOLS ............................. Error! Bookmark not defined.
0010 GENERAL GUIDELINES: INTRODUCTION .........................Error! Bookmark not defined.
0020 GENERAL GUIDELINES: BENCHMARKS ............................Error! Bookmark not defined.
0030 GENERAL GUIDELINES: PATIENT DETERMINATION: “PATIENT OR NO PATIENT”
...................................................................................................................Error! Bookmark not defined.
0040 GENERAL GUIDELINES: CONSENT ......................................Error! Bookmark not defined.
0050 GENERAL GUIDELINES: CONFIDENTIALITY ...................Error! Bookmark not defined.
0060 GENERAL GUIDELINES: PATIENT NON-TRANSPORT OR REFUSALError! Bookmark
not defined.
0070 GENERAL GUIDELINES: PHYSICIAN AT THE SCENE/MEDICAL DIRECTION ... Error!
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1000 ADULT (AGE > 12 YEARS) UNIVERSAL RESPIRATORY DISTRESS ALGORITHMError!
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1010 OBSTRUCTED AIRWAY ..........................................................Error! Bookmark not defined.
1020 PROCEDURE PROTOCOL: CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)Error!
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1030 ADULT (AGE > 12 YEARS) ASTHMA ..................................Error! Bookmark not defined.
1040 COPD ............................................................................................Error! Bookmark not defined.
1050 CHF / PULMONARY EDEMA..................................................Error! Bookmark not defined.
1060 PROCEDURE PROTOCOL: OROTRACHEAL INTUBATIONError! Bookmark not defined.
1070 PROCEDURE PROTOCOL: NASOTRACHEAL INTUBATION........Error! Bookmark not
defined.
1080 PROCEDURE PROTOCOL: KING AIRWAY .........................Error! Bookmark not defined.
1100 PROCEDURE PROTOCOL: PERCUTANEOUS CRICOTHYROTOMYError! Bookmark not
defined.
1110 PROCEDURE PROTOCOL: SURGICAL CRICOTHYROTOMY.........Error! Bookmark not
defined.
2000 ADULT CHEST PAIN ................................................................Error! Bookmark not defined.
2010 CARDIAC ALERT PROTOCOL................................................Error! Bookmark not defined.
2020 ADULT (AGE > 12 YEARS) BRADYARRHYTHMIA WITH POOR PERFUSION... Error!
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2030 ADULT (> 12 YEARS) TACHYARRHYTHMIA WITH POOR PERFUSION ............ Error!
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2040 ADULT (AGE ≥ 12 years) CARDIAC ARREST GENERAL PRINCIPLESError! Bookmark
not defined.
2050 GENERAL GUIDELINES: ADVANCED MEDICAL DIRECTIVES .....Error! Bookmark not
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131
2060 ADULT (AGE > 12 YEARS) UNIVERSAL PULSELESS ARREST ALGORITHM.... Error!
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2070 GENERAL GUIDELINES: TERMINATION OF RESUSCITATION AND FIELD
PRONOUNCEMENT GUIDELINES ....................................................Error! Bookmark not defined.
2080 PROCEDURE PROTOCOL: INTRAOSSEOUS CATHETER PLACEMENTError! Bookmark
not defined.
2090 PROCEDURE PROTOCOL: SYNCHRONIZED CARDIOVERSION ..Error! Bookmark not
defined.
2100 PROCEDURE PROTOCOL: TRANSCUTANEOUS CARDIAC PACINGError! Bookmark not
defined.
3000 UNIVERSAL ALTERED MENTAL STATUS .........................Error! Bookmark not defined.
3010 HYPOGLYCEMIA .......................................................................Error! Bookmark not defined.
3020 SEIZURE - ADULT (> 12 YEARS)..........................................Error! Bookmark not defined.
3030 STROKE .......................................................................................Error! Bookmark not defined.
3040 ALCOHOL INTOXICATION .....................................................Error! Bookmark not defined.
3050 ABDOMINAL PAIN/VOMITING ............................................Error! Bookmark not defined.
3060 ALLERGY AND ANAPHYLAXIS .............................................Error! Bookmark not defined.
3070 AGITATED/COMBATIVE PATIENT PROTOCOL .............Error! Bookmark not defined.
ROUTT COUNTY SPECIFIC EMS PROTOCOLS ............................... Error! Bookmark not defined.
Drug Table with Provider Levels and Allowed Drugs ...........Error! Bookmark not defined.
Routt EMS Protocol Changes to the NWRETAC Protocols ....Error! Bookmark not defined.
Operational ...........................................................................................Error! Bookmark not defined.
BLOODBORNE / AIRBORNE PATHOGENS EXPOSURE CONTROL PLAN ....... Error! Bookmark not
defined.
CISD STRESS MANAGEMENT .................................................................Error! Bookmark not defined.
CONTROLLED SUBSTANCES INVENTORY ...........................................Error! Bookmark not defined.
DISCIPLINARY PROCEDURES: AGENCIES ...........................................Error! Bookmark not defined.
DISCIPLINARY PROCEDURES: PROVIDERS .........................................Error! Bookmark not defined.
PROTOCOL DEVIATION LEVELS: PROVIDERS .....................................Error! Bookmark not defined.
HAZARDOUS MATERIALS PROTOCOL..................................................Error! Bookmark not defined.
INTERAGENCY ASSISTANCE ..................................................................Error! Bookmark not defined.
INTER-FACILITY PATIENT TRANSFER ...................................................Error! Bookmark not defined.
MEDICAL HELICOPTER EVACUATION / RENDEZVOUS ......................Error! Bookmark not defined.
MEDICAL QUALITY CONTROL PROGRAM ............................................Error! Bookmark not defined.
NURSES FUNCTIONING IN THE PREHOSPITAL ENVIRONMENT ........Error! Bookmark not defined.
TRIAGE COLOR GUIDELINES .................................................................Error! Bookmark not defined.
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not defined.
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Drug Protocol .......................................................................................Error! Bookmark not defined.
DIPHENHYDRAMINE (BENADRYL) .........................................................Error! Bookmark not defined.
HYDROMORPHONE (DILAUDID) .............................................................Error! Bookmark not defined.
ETOMIDATE (AMIDATE) ...........................................................................Error! Bookmark not defined.
FENTANYL .................................................................................................Error! Bookmark not defined.
HALOPERIDOL (HALDOL) .......................................................................Error! Bookmark not defined.
LIDOCAINE 2% SOLUTION ......................................................................Error! Bookmark not defined.
LORAZEPAM (ATIVAN).............................................................................Error! Bookmark not defined.
METHYLPREDNISOLONE (SOLU-MEDROL) ......................................Error! Bookmark not defined.
MIDAZOLAM (Versed) ...............................................................................Error! Bookmark not defined.
SUCCINYLCHOLINE (ANECTINE) ............................................................Error! Bookmark not defined.
VECURONIUM (NORCURON) ...................................................................Error! Bookmark not defined.
Procedure Protocol ............................................................................Error! Bookmark not defined.
AIRWAY MANAGEMENT: LARYNGEAL MASK AIRWAY/i-Gel .............Error! Bookmark not defined.
ADVANCED AIRWAY MANAGEMENT: NEEDLE CRICOTHYROTOMY Error! Bookmark not defined.
RAPID SEQUENCE INTUBATION (R.S.I.) ADULT ...................................Error! Bookmark not defined.
SPLINTING: EXTREMITY .........................................................................Error! Bookmark not defined.
Routt County Specific Protocols
133
Drug Table with Provider Levels and Allowed Drugs
Medication Name
Adult Dose
Pediatric Dose
Routes
Paramedic
EMT-I
AEMT
EMT IV
EMT
Adenosine (Adenocard)
6mg, 12mg, 12mg
0.2 mg/kg
IV, IO
SO
CI
N/A
N/A
N/A
Albuterol sulfate (Ventolin)
2.5 mg
2.5 mg
SVN
SO
CI
CI
CI
CI
Amiodarone - Arrest
300 mg, 150mg
5mg/kg
IV, IO
SO
CI
N/A
N/A
N/A
Symptomatic wide
complex tachycardia
150mg over 10 min
SO
CI
N/A
N/A
N/A
Post arrest following
successful conversion of
VF or VT
Aspirin
150mg over 10 min
SO
CI
N/A
N/A
N/A
Oral
SO
SO
SO
SO
SO
Atropine sulfate
0.5mg
0.02 mg/kg
IV, IO
SO
CI
N/A
N/A
N/A
Dextrose 10%
5g=50ml BGL 40-60
10g=100ml BGL <40
50 mg
1ml/kg
IV, IO
SO
SO
SO
SO
N/A
1-2 mg/kg
IV, IO,
IM
SO
CI
CI
N/A
N/A
SO
CI
N/A
N/A
N/A
Diphenhydramine (Benadryl)
Pregnancy
324 mg
25mg
Dopamine (Intropin)
2-20 mcg/kg/min
2-20 mcg/kg/min
IV, IO
SO
N/A
N/A
N/A
N/A
Droperidol (Inapsine)
5mg
5mg < 8 years old
IM
SO
CI
N/A
N/A
N/A
Epinephrine 1:10,000 - Cardiac
Arrest
1 mg
0.01 mg/kg
IV, IO
SO
CI
N/A
N/A
N/A
Refractory Bradycardia
2 mcg/min
0.01 mg/kg
IV, IO
SO
CI
N/A
N/A
N/A
Severe allergic reaction
2 mcg/min
0.01 mg/kg
IV, IO
SO
CI
N/A
N/A
N/A
IV, IO
SO
CI
N/A
N/A
N/A
0.01 mg/kg
IM
SO
CI
CI
N/A
N/A
5 mL
SVN
SO
CI
N/A
N/A
N/A
0.15 mg
IM
SO
SO
SO
SO
SO
IV, IO
SO
N/A
N/A
N/A
N/A
IV, IO,
IM, IN
IV, IO
SO
CI
N/A
N/A
N/A
SO
N/A
N/A
N/A
N/A
Epinephrine 1:1000 - Cardiac
Arrest
Asthma/allergic reactions
0.3 mg
0.3 mg
Croup
Epi-Pen
0.3 mg
Etomidate (Amidate)
0.3-0.6 mg/kg
Fentanyl citrate
1-2 mcg/kg
Post RSI
1 mcg/kg
100mcg
Haloperidol (Haldol)
5-10 mg IM
>65 YO 2.5 mg
IM
SO
CI
N/A
N/A
N/A
Hydromorphone (Dilaudid)
0.5 - 1mg,
0.5mg if prior
narcotics
0.5 mg
IV, IO
SO
N/A
N/A
N/A
N/A
SVN
SO
CI
CI
N/A
N/A
IV, IO
SO
CI
N/A
N/A
N/A
IO
SO
SO
SO
N/A
N/A
SO
N/A
N/A
N/A
N/A
Ipratropium bromide
(Atrovent)
Lidocaine RSI
IO infusion
100mg
0.5 mg/kg slow
0.5 mg
Lidocaine (viscous)
Routt County Specific Protocols
134
Lorazepam(Ativan)
Seizure
Behavioral management
SO
CI
N/A
N/A
N/A
SO
CI
N/A
N/A
N/A
0.5-1
IV, IO
IN, IM
IV, IN,
IM
IV, IN
SO
CI
N/A
N/A
N/A
Magnesium Sulfate - Torsades
2 mg
IV, IO
SO
N/A
N/A
N/A
N/A
Methylprednisolone (SoluMedrol)
Midazolam (Versed) Seizure,
Cardioversion or pacing
125 mg
2 mg/kg
IV, IO
SO
CI
N/A
N/A
N/A
3 mg IV, IO - 5mg
IN, 10 mg IM
0.1 mg/kg IV, IO 0.2 mg/kg IN, IM
IV, IO,
IM, PR
SO
CI
N/A
N/A
N/A
SO
CI
N/A
N/A
N/A
SO
N/A
N/A
N/A
N/A
SO
N/A
N/A
N/A
N/A
IV, IO,
IM
IV, IO,
IM, IN
SO
CI
ODT
N/A
N/A
SO
SO
SO
SO
SL
SO
SO
SO
N/A
SO
IN
ONLY
N/A
20 ml/kg
IV, IO
SO
SO
SO
SO
N/A
IV, IO,
IM,
ODT
PO
SO
CI
ODT
ONLY CI
SO
SO
ODT
ONLY
CI
SO
SO
ODT
ONLY
CI
SO
NC,
NRB
IN
SO
SO
SO
SO
SO
SO
N/A
N/A
N/A
N/A
IV, IO
SO
CI
N/A
N/A
N/A
Anxiety
Agitated of Combative
RSI Trauma
RSI Medical
0.05 mg/kg IV, IO
0.1 mg/kg IN, IM
2mg
2mg
2mg IV or 5mg IN,
IM
2.5-5 mg RSI
Trauma
5 mg RSI Medical
Morphine sulfate
4 mg, repeat 2 mg
0.1 mg/kg
Naloxone (Narcan)
0.4-2 mg
0.4-2 mg
Nitroglycerine
0.4 mg
Normal saline
Ondansetron (Zofran)
4mg
4 mg >40 Ibs or
2mg < 4 years old
Oral glucose (Glutose)
15 mg
15 mg
Oxygen
1-25 L
1-25L
Phenylephrine - topical (NeoSynephrine)
Sodium bicarbonate
1-2 sprays in each
nostril
1 mEq/kg
Succinylcholine (Anectine)
1.5 mg/kg
IV, IO
SO
N/A
N/A
N/A
N/A
Vecuronium (Norcuron)
10 mg
IV, IO
SO
N/A
N/A
N/A
N/A
SO=Standing Order
1 mEq/kg 8.4%
Peds, 2mEq/kg
4.2% Neonates
CI=Call In
N/A=Not Allowed
Routt County Specific Protocols
135
Routt EMS Protocol Changes to the NWRETAC Protocols
1. Drug table above is allowed drugs, routes and dosages for Routt County EMS Providers.
Routt County Specific Protocols
136
Operational
BLOODBORNE / AIRBORNE PATHOGENS EXPOSURE CONTROL PLAN
I. PURPOSE: To provide a standard procedure to reduce the risk to employees from
bloodborne and airborne pathogens and to comply with the OSHA
Bloodborne pathogens standard, 29 CFR 1910.1030.
II. SCOPE:
A.
This policy will apply to all field ambulance personnel.
Definitions
1.
Airborne Pathogens - Pathologic microorganisms spread by droplets expelled into the
air, typically through a productive cough or sneeze.
2.
Blood - human blood, human blood components and products made from human blood.
3.
Bloodborne Pathogen - pathologic microorganisms that are present in human blood that
can cause disease in humans.
4.
Contaminated - the presence or the reasonable anticipated presence of blood or other
potentially infectious materials on an item or surface.
5.
Contaminated Sharps - any contaminated object that can penetrate the skin including,
but not limited to, needles, scalpels, broken glass and blood tubes.
6.
Decontamination - the use of physical or chemical means to remove, inactivate, or
destroy bloodborne or airborne pathogens on a surface or item rendering it safe for
handling use or disposal.
7.
Occupational Exposure - any reasonably anticipated skin, eye, mucus membrane or
parenteral contact with blood or other potentially infectious materials that may result
from the performance of an employee’s duties.
8.
Other Potentially Infectious Materials (OPIM) - 1) the following body fluids: semen,
vaginal fluid, synovial fluid, peritoneal fluid, amniotic fluid, saliva, urine, feces, any fluid
visibly contaminated with blood and all body fluids in situations where it is impossible to
differentiate between body fluids. 2) Any unfixed tissue or organ (other than intact skin)
from a human (living or dead).
9.
Parenteral - piercing mucous membranes or other skin barrier through such events as
needle sticks, human bites, cuts and abrasions.
10.
Personal Protective Equipment - specialized equipment or clothing worn by an employee
for protection against a hazard. (I.e. surgical or exam gloves, protective eye wear, gowns,
face masks etc.) Protective equipment shall be considered appropriate if it does not
permit blood or OPIM to pass through to reach the employees undergarments, skin,
eyes, mouth or other mucous membranes or if it prevents airborne pathogens from
reaching the respiratory system under normal conditions of use and for the duration of
time which protective equipment will be used.
11.
Universal Precautions - an approach to infection control that assumes all human blood
and certain human body fluids are treated as if known to be infectious for HIV, HBV and
other bloodborne pathogens.
Routt County Specific Protocols
137
A.
B.
Exposure Determination
1.
Routt County EMS providers have determined that the following job descriptions are
likely to have potential exposure to bloodborne / airborne pathogens or OPIM:
2.
EMT Basic or Basic/ IV, EMT Intermediate, EMT Paramedic
3.
The above personnel can expect occupational exposure while performing patient care.
Risk is particularly present when performing the following skills: Bleeding control,
dressing wounds, intravenous access, intubation, intra-muscular injection,
subcutaneous injection, suctioning, cricothyrotomy, chest decompression, intraosseous
access, delivery of the newborn, multi-trauma patients, and cleaning / disinfecting
ambulances and equipment.
4.
Should an employee have a parenteral or mucous membrane exposure to human blood
or OPIM they shall immediately, or as soon as feasible notify the on-duty Medical control
physician and their supervisor. The employee shall then be instructed to seek medical
attention if necessary. The employee shall complete an incident form (see appendix A)
and any other required worker’s compensation forms. These forms will be submitted to
the employee’s immediate supervisor as soon as possible.
Methods of Compliance
1.
C.
D.
In general, Universal Precautions will be observed to prevent contact with blood or OPIM.
All blood or OPIM will be considered infectious regardless of the perceived status of the
source individual.
Gloves
1.
All Routt County EMS providers shall wear disposable, single use gloves that are
provided in each agency. These gloves shall be worn for any patient contact where it can
be expected that the employee may have hand contact with blood, OPIM, mucous
membranes or non-intact skin. This should include all emergency responses.
2.
Contaminated gloves shall be discarded in an appropriate container as soon as possible
after each patient contact. Gloves should not be used for multiple patient contacts.
Gloves shall be discarded before leaving the patient area and entering the cab. Single
use gloves are not to be washed or decontaminated for reuse. However, utility gloves
such as those worn for cleaning the ambulance can be reused unless torn, punctured or
peeling.
3.
Gloves in the medium and large sizes shall be provided by each agency and shall be kept
in each response vehicle and medical kit. Each agency may provide other sizes of
gloves and will supply their responders with other gloves of appropriate size upon
request. All responders are encouraged to carry a limited supply of gloves on their
person.
Eye / Face Protection
1.
In those situations where it can be reasonably anticipated that splashes, spray, splatter
or droplets of blood or OPIM may be generated, the employee shall wear masks in
combination with eye protection with solid side shields or chin length face shields. This
level of protection should be utilized during all airway management (intubation,
suctioning, etc.) activities. Additionally, this protection should be immediately available
to the employee during all emergency responses
Routt County Specific Protocols
138
2.
E.
F.
Protective Body Clothing
1.
Protective body clothing shall be worn when an occupational exposure exists that could
potentially soak through an employee’s clothing. Should employee’s clothes become
soaked with blood or OPIM the employee will change into clean clothes as soon as
possible. Contaminated clothing shall not be taken home. Contaminated clothing should
be placed in a biohazard bag and the Agency Management should be notified of any
clothing requiring decontamination. All contaminated protective equipment shall be
decontaminated before reuse or disposed of if applicable. The Responder’s agency will
incur any cost for decontamination or replacement.
2.
Impermeable personal protective equipment (PPE) kits will be provided in the patient
compartment of each ambulance.
Assisting Respirations
1.
G.
I.
Employees shall utilize a pocket mask, bag-valve-mask or mechanical ventilator with
disposable circuit when assisting respirations on a patient. These devices will be
provided by EMS Agency and be available in the patient compartment and / or Medical
Kit when needed.
Sharps
1.
H.
Masks and protective eye wear will be stocked in each vehicle in the patient
compartment and medical kits.
There shall be sharps containers mounted in the patient compartment of each
ambulance that is readily accessible to the patient treatment area. In addition there will
be portable, single use sharps containers in the Medical Kits with the IV supplies. Sharps
containers will be inspected weekly and replaced when full. Once full, sharps containers
will be sealed and disposed of as bio-hazard waste. Contaminated needles and other
sharps shall not be bent, recapped, removed, sheared, or purposely broken. If it is
absolutely necessary to recap a needle, a safe, preferably one-handed method should be
used. All personnel shall observe universal precautions when disposing of contaminated
sharps.
Vehicles
1.
Contaminated Surfaces shall be decontaminated after contact with blood or OPIM
immediately or as soon as feasible. In addition vehicles will be thoroughly cleaned,
including the patient compartment, cab, inside and outside compartments at least
monthly. Trash cans will be continuously lined with appropriate, non-permeable liners.
2.
Eating and drinking will limited to the cab area or the patient compartment when not
transporting a patient after it has been adequately decontaminated. Smoking or other
use of tobacco is not permitted in the vehicle at any time. Lip balm, contact lenses or
cosmetics should not be applied in the patient compartment. Antiseptic hand cleaner will
be provided on each ambulance so personnel may immediately cleanse their hands after
removing gloves, before leaving the patient compartment area.
Equipment
1.
Equipment that has become soiled from use or exposure to blood or OPIM will be
cleaned and decontaminated before being used again. Personnel will use disinfectant
Routt County Specific Protocols
139
provided to clean equipment. Personnel will wear gloves (as well as gowns, eye wear and
masks if necessary) when cleaning equipment. Equipment will be cleaned in designated
areas only, away from food preparation or personal hygiene areas. Equipment that
cannot be cleaned immediately should be transported in an impermeable bag and
labeled as biohazard.
J.
Hand Washing
1.
K.
Airborne Pathogens
1.
L.
Personnel who have an occupational exposure from a known HIV infected source should
report immediately to Yampa Valley Medical Center for evaluation and may be placed on
the prophylactic medication regimen. This should ideally occur within two (2) hours of
the exposure. The prophylactic medication regimen may also be utilized after an
unknown source is identified as HIV infected.
Training
1.
P.
Each Department will have their own policy on post exposure evaluation and follow up.
HIV Prophylaxis
1.
O.
Routt County EMS Agencies will offer the Hepatitis B vaccination to all personnel
identified in section 2 free of charge before being placed on active status. Personnel
declining the vaccination must sign a waiver indicating such. Personnel who refuse may
elect to receive the vaccination free of charge at any time thereafter. Hepatitis B titer will
be checked 60 days after completion of the series.
Post Exposure Evaluation and Follow Up
1.
N.
When EMS personnel or others must transport patients with confirmed or suspected
active tuberculosis or meningitis a NIOSH approved and fitted mask should be fitted to
the patient. Personnel attending the patient should also wear a NIOSH approved and
fitted mask. The ventilation system in the vehicle should also be set to prevent recirculation of air (use of exhaust fan). All personnel will be issued and fit tested for a
NIOSH approved mask. TB screening for all employees will be conducted upon hiring
and annually thereafter. Screening may also be included in the follow up of contacts to
patients with infectious tuberculosis. Personnel should wear respiratory protection for
any patient with a productive cough or sputum reasonably suspected of carrying an
airborne pathogen.
Hepatitis B Vaccine
1.
M.
Hand washing is still the best method of preventing the spread of infectious material. All
personnel shall wash their hands immediately after removing gloves, either with soap
and water or with the antiseptic hand cleaner provided in each vehicle. If personnel use
the antiseptic hand cleaner, they should still wash with soap and water as soon as
feasible.
Training on this policy for all personnel will be conducted during initial orientation prior
to being placed on active status. Additional training will occur as required by the OSHA
standard.
Responsibility
Routt County Specific Protocols
140
1.
Q.
All affected employees are required to be familiar with the procedures outlined within
this policy. Disregard for the policy may result in disciplinary action.
References
1.
OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030
Routt County Specific Protocols
141
CISD STRESS MANAGEMENT
POLICY
A.
B.
C.
Posttraumatic stress disorder (PTSD) is a known complication of service in the prehospital environment.
The problems associated with PTSD include but are not limited to performance decline, drug
and alcohol abuse, domestic violence, clinical depression and suicide.
The following policy shall be followed in order to assure that efforts to identify and
mediate the effects of PTSD in the pre-hospital providers in the Routt County EMS
System.
PROCEDURE
A.
B.
C.
All approved agencies within the Routt County EMS System shall have a policy
addressing the following:
1.
Method of identification of critical incidents which may require group or individual
therapy and/or debriefings.
2.
Identification of a service outside of agency to provide such stress management should
it be required.
3.
Attendance requirements of meetings related to critical incident stress or any job related
stress.
The above-mentioned policy shall be provided to the EMSMD within 3 months of
becoming an approved agency within the Routt County EMS System.
While NOT a requirement, the EMSMD recommends:
1.
Aggressive use of peer monitoring for signs of stress reactions or PTSD in the prehospital providers.
2.
Requiring mandatory attendance at least for initial meeting following identified critical
incidents or signs of stress.
Routt County Specific Protocols
142
CONTROLLED SUBSTANCES INVENTORY
POLICY
A.
B.
C.
D.
E.
All agencies shall have appropriate systems in place for the proper security, storage and
inventory of all medications.
In addition, proper safeguards must exist for the controlled access to benzodiazepines and
narcotics.
Monthly inventory for the controlled medications shall be submitted to the Medical
Director for review of proper use, wasting and inventory control.
All agencies will follow all storage and reporting requirements of the DEA.
PROCEDURE
A.
B.
C.
D.
E.
F.
G.
All agencies procuring, storing and administering medications shall have their own DEA License
and number.
It is the responsibility of each agency to know, and follow ALL rules and requirements as put
forth by the DEA.
Responsibility for security, controlled access, inventory and record keeping lies
exclusively with each agency.
The Medical Director shall have over-sight responsibility for each agency.
The controlled substance medication inventory shall be updated monthly or quarterly.
The Medical Director will reconcile inventory for each Agency prior to this meeting
1.
Inventories will be compared to prior balances, as well as the prescriptions
written for the agency by the Medical Director.
2.
Variances found in the inventory of controlled substances will be discussed at the
CQI/QA meeting, and agencies will be required to investigate the discrepancy.
3.
Any discrepancy will be re-addressed with the Medical Director within 48 hours
by the AQD.
Agencies with recurrent discrepancies will be found to be in non-compliance with these
protocols and will be treated according to the Disciplinary Procedures: Agencies Protocol.
Routt County Specific Protocols
143
DISCIPLINARY PROCEDURES: AGENCIES
A standardized system is needed to deal with complaints and deviations from the protocols stated
herein. Due process must be observed in order for the system to be above reproach in dealing with
personnel or agencies which do not adhere to these protocols.
POLICY
All agencies covered by these protocols will abide by and follow the due process procedures for
deviations or non-compliance with the Policies and Procedures set forth in the Routt County EMS
Protocols. This is a condition of EMSMD approval for ambulance licensure in Routt County and has
been agreed to in writing by each agency when applying for an ambulance license.
PROCEDURE
A.
B.
C.
Notice of deficiency:
1.
Once a deviation from or non-compliance with the Routt County EMS protocols by an
approved agency has been identified, written notice of said deviation shall be sent to
the Agency QA Director (AQD), the agency Supervising Director, and the Routt County
EMS Coordinator. E-mail will be considered written notice.
2.
Notice may include an order to cease all patient care activities if deviation is found
to constitute a significant risk to patient or public safety.
Reply to deficiency:
1.
Within five business days of receipt of written notice, the agency in question shall
provide a written response to the Medical Director with a copy to the Routt County EMS
Coordinator.
2.
Response shall detail the reasons for the deviation and steps which will be taken to
remediate the deviation and to prevent it from occurring in the future.
3.
If so requested, the agency may meet with the Medical Director to discuss the
deviation. This does not alleviate the obligation to provide a written reply to the
deviation.
Resolution:
1.
Once the deviation has been addressed by the agency and the Medical Director, a
written notice of action/resolution shall be given to the AQD, the agency Supervising
Director, and the Routt County EMS Coordinator.
2.
Potential actions include:
a.
No action needed – Documentation will be provided of why this deviation is
unlikely to recur.
b.
Probationary period – The AQD will be required to meet monthly with Medical
Director and demonstrate compliance with all protocols and conditions set forth
by the Medical Director. Probationary period duration shall be at the sole
discretion of the Medical Director.
c.
Remediation – Patient care activities will cease until remedial activities to be
determined by the Medical Director have been accomplished. The agency will
then resume transport activities under a probationary period as discussed
above.
d.
Termination of Supervision – The agency will be permanently removed from the
approved agency list and Medical Director Supervision will cease immediately.
3.
Written documentation of compliance with all requirements set forth in the above
actions will be kept with the original notifications and written notice of actions. This will
also be forwarded to the Agency involved as well as the Routt County Department of
Emergency Management. Lack of compliance or timely completion of the requirements
set forth in the above actions is grounds for termination of supervision.
Routt County Specific Protocols
144
DISCIPLINARY PROCEDURES: PROVIDERS
POLICY
A.
B.
All personnel covered by these protocols will abide by and follow these due process
procedures for investigating deviations from these protocols, or from the generally
accepted Standards of Care for EMS providers.
Each agency may enact more stringent regulations on its personnel, but may not allow less
regulation than the procedure set forth herein.
PROCEDURE
A.
B.
C.
Notification:
1.
The Medical Director shall be notified by the AQD as soon as possible of any Level I or
Level II deviations from these protocols, or any other significant issues, events or
deviations from the generally accepted standard of care.
2.
The Medical Director shall be notified by the AQD of any Level III deviations, or other
issues, being investigated by the AQD/agency.
3.
Failure to notify the Medical Director in a timely fashion may be grounds for immediate
suspension of oversight services by the Medical Director to either the provider, the
AQD or the agency.
4.
In addition, the providers themselves are responsible for IMMEDIATE notification of the
EMSMD by phone and/or e-mail of the following issues as outlined in the Provider
Relationship Protocol:
a.
Cardiac and/or respiratory arrest after administration of a
benzodiazepine or a narcotic.
b.
Cardiac arrest occurring after administration of an anti-arrhythmic agent in a
previously stable patient.
c.
Any attempt (successful or un-successful) at needle and/or surgical
airways.
d.
Incorrect medication administration or use with adverse patient
outcomes.
e.
Any cardiac and/or respiratory arrest or patient injury while attempting
physical restraint.
f.
Any EMS vehicular accident involving injuries.
g.
Any significant injury to a provider in the course of their duties.
h.
Any unusual circumstance or intervention that potentially causes or caused
patient harm.
i.
EMS Provider who has operated outside of his/her level of certification and/or
training (i.e., EMT-B level performing endotracheal intubation).
Suspension of Care Privileges:
1.
Any Level I deviation will result in immediate removal of the individual provider(s) from
patient care activities by the AQD.
2.
Any Level II deviation will be immediately discussed with the Medical Director by the
AQD, and a decision made- at the sole discretion of the Medical Director- about
immediate removal of the individual provider(s) from patient care activities.
Investigation:
1.
Level I and II Deviations, or other issues under notifications:
a.
Responsibility for an immediate, full and complete investigation lies with the
AQD.
b.
AQD will present a written summary of their investigation to the EMSMD within 96
hours of EMSMD notification.
c.
This report MUST include the AQD’s written recommendations for
resolution/remediation/discipline.
Routt County Specific Protocols
145
2.
D.
E.
Level III Deviations, or other issues as under notifications:
a.
Responsibility for an immediate, full and complete investigation lies with the
AQD, including a plan for resolution/remediation/discipline.
b.
Repeat offenses/offenders will discussed by the AQD with the agency Chief, and a
further plan for resolution/remediation/discipline put in place. iii. Further
offenses will be discussed with the EMSMD.
Meeting of Affected Parties:
1.
Within 96 hours of receiving the AQD’s written summary of Level I and II Deviations, the
EMSMD will arrange a meeting with all affected parties. This will be expedited to the best
ability of all involved. This may occur via phone or email, if appropriate.
2.
At the meeting, all parties will have the opportunity to be heard.
Resolution:
1.
Following this meeting, a determination of severity shall be made by the Medical
2.
Director in conjunction with AQD and/or Chief/Manager of the provider’s Agency. b.
Possible actions which may be taken include:
a.
System failure identified.
(1)
Incident shall be referred to the QA Committee for review, revision,
or development of protocols/policies, or modification/addition of
CME.
b.
Provider deviation identified.
(1)
No action necessary – Documentation shall be provided outlining
why this incident unlikely to recur.
(2)
Probationary period – provider may return to patient care activities with
regular meetings or chart reviews with Medical Director or his/her
designee for a time frame to be determined by the Medical Director. The
provider may have his patient care activities limited at the sole discretion
of the Medical Director.
(3)
Remediation – Provider will be suspended from patient care activities
until remedial education and/or skills training has been successfully
accomplished. The provider may then return on probationary status as
described above with Medical Director approval.
(4)
Termination – Supervision of the provider by the Medical Director may be
terminated.
c.
A written record of the violation which occurred and the actions taken shall
be placed in the provider’s file at their agency and a copy kept by the Medical
Director or his/her designee.
d.
Failure to complete probation or remediation in a timely fashion, as
determined by the Medical Director, may result in termination of supervision.
e.
The State of Colorado will be notified of any action which is required to be
reported.
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PROTOCOL DEVIATION LEVELS: PROVIDERS
THE FOLLOWING WILL BE CONSIDERED LEVEL I DEVIATIONS:
Immediate notification of EMSMD. Immediate removal of provider(s) from patient care activities by
AQD. Immediate, full investigation by the AQD.
•
•
•
•
•
•
•
Any significant deviation from these protocols, or from the generally accepted standard of care,
which causes patient harm or a delay in diagnosis.
Incorrect medication administration which causes adverse patient outcome.
Knowingly and/or intentionally falsifying a patient care report, dispatch report, or any other
MCEMS document. This also includes not immediately notifying EMSMD of those items listed
in the Provider Relationship Protocol requiring such notification.
Performing acts not authorized by the State of Colorado or by the Routt County EMS
Medical Director.
Driving an emergency vehicle in a reckless manner.
Responding to the scene of an emergency while under the influence of alcohol or other
performance altering drugs.
Any other instance, at sole discretion of the EMSMD.
THE FOLLOWING WILL BE CONSIDERED LEVEL II DEVIATIONS Immediate
notification of EMSMD. Immediate, full investigation by the AQD.
•
•
•
•
•
•
•
Any significant deviation from these protocols, or from the generally accepted standard of care,
without patient harm or a delay in diagnosis.
Incorrect medication administration without any adverse patient outcome.
Any patient injury or cardiac arrest while attempting restraint.
Unprofessional conduct which hinders, delays, eliminates, or deters the provisions of
medical care to the patient or endangers the public.
Improper use of lights and sirens.
Release of any Protected Health Information.
Any other instance, at sole discretion of the EMSMD.
THE FOLLOWING WILL BE CONSIDERED LEVEL III DEVIATIONS
Immediate, full investigation by the AQD. Addressed within the Agency as per the Disciplinary
Procedures: Providers protocol.
•
•
Protocol deviations, documentation errors/omissions, conduct issues, or any other
deviation for the generally accepted standard of care.
Any incidents or providers of concern should be discussed with the EMSMD by the AQD
after the AQD has investigated the situation fully.
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HAZARDOUS MATERIALS PROTOCOL
Indications
A.
B.
Responding to reported and/or known hazardous materials incident.
Vapor clouds, fire and smoke, leaking substances, frost lines on cylinders, sick personnel, dead or
distressed animals and noxious odors are present on or near scene.
Precautions
A.
B.
C.
D.
E.
Senses are one of the best ways to detect chemicals, particularly the sense of smell. If you smell
something you are too close.
A safe approach to the scene is the first element of any EMS response to a hazardous materials
emergency. Unless you arrive safely at the site, you will not be able to perform your duties.
Observe the site from a distance using binoculars, if possible, before you get too close. Look for
danger signs such as vapor clouds, fire and smoke, placards, shape of vehicle or container,
leaking substances, frost lines on cylinders, injured personnel, and dead or distressed animals.
These are key clues to warn you not to get too close. Remember, you want to be part of the
solution, not part of the problem.
If the fire department is already on the scene, report in to the incident commander. If you are first
on the scene and a hazardous material is suspected, request a hazardous materials team
response. Keep yourself and your unit at a safe distance. This usually requires your unit to leave
the scene, leaving patients and bystanders in a hazardous situation. Your safety comes first.
Seek a location uphill and upwind from the incident.
EMS personnel should not be participating in patient decontamination unless trained and
equipped to do so.
Procedure
A.
B.
C.
D.
Your safety is the highest priority. EMS operations should be established in the cold zone. You
should report to the incident commander.
Position your vehicle to make a hasty retreat. This may require you to leave the scene to seek
safety.
Initial assessment, treatment, and decontamination should be performed by the hazardous
materials team. Decontaminated patients will be brought to the EMS unit.
Once the situation has been assessed, notify the receiving hospital of the following information:
1.
2.
3.
4.
5.
6.
7.
A.
Location of the incident
Name of chemicals/products involved
Number of injured and contaminated
Extent of the injuries/contamination
Extent that the patients will be decontaminated in the field
Your estimated time of arrival
Other pertinent information that is available
Patient treatment is usually based on signs and symptoms. Specific patient treatment should be
based on information obtained from medical control.
FOR MEDICAL TREATMENT OR PROBLEMS CAUSED BY HAZARDOUS MATERIALS CALL
CHEMTREC 1-800-424-9300
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INTERAGENCY ASSISTANCE
Interagency assistance is to be initiated any time the medical or transport needs of a patient or patients
cannot be provided by the primary responding crew.
In general, interagency assistance will be for addition of ALS trained EMT’s (EMT-I or EMT-P) to the
primary responding crew.
ALS providers are mandatory for the following patient categories:
A.
B.
C.
D.
E.
ACLS is required, including medical cardiac arrest and post arrest patients.
Chest pain of suspected cardiac origin.
Critical patients, including, but not limited to: patients with systolic blood pressure of 80 or less,
symptomatic bradycardia or tachycardia, sustained hypertension with headache or altered
mental status, and overdose or trauma patients with abnormal vital signs.
Head injuries, altered level of consciousness, decreasing level of consciousness.
Analgesia needed.
Procedure: Interagency assistance should be requested through Routt County Dispatch. Interagency
assistance will never be automatically paged out. The primary responding agency should request
interagency assistance prior to the assessment of the patient if it appears from dispatch information,
that assistance will be necessary. (For example, if a patient is reported to be in a cardiac arrest and
there are no ALS providers on the primary responding crew, that crew should request interagency
assistance prior to assessment of the patient.)
Note: EMT-I’s are ALS providers and need to only call for EMT-P assistance if they feel it is necessary.
EMT-I’s should bear in mind that there are stabilizing and lifesaving procedures and medicines that only
EMT-P’s can perform or administer. At no time and for no reason should appropriate and/or necessary
care be withheld from a patient. (Do not hesitate to call for a paramedic.)
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INTER-FACILITY PATIENT TRANSFER
Purpose
A.
To provide guidelines for transporting patients between hospital facilities.
B.
The EMS Medical Director, in collaboration with the transferring facility’s medical director,
should have protocols in place to ensure the appropriate level of care is available during inter
facility transport and the transporting EMT may decline to transport any patient they feel
requires a level of care beyond their capabilities.
General Principles
A.
Yampa Valley Medical Center is Routt County EMS “Medical Control”.
B.
The Medical Control physician shall decide any destination questions that may arise.
C.
In cases of an inter-facility transport where the ambulance crew has reason to question the
patient’s treatment and/or destination, it is advisable to contact the Medical Control Physician onduty before continuing with the transport. Changes in patient destination during transport should
be documented in the agencies incident report.
Special notes
A.
Inter-Facility Transport Staffing:
1.
The attendant will be an EMT-Basic or higher level of training.
2.
If the physician writes orders for medications that an EMT - Intermediate or Paramedic must
administer, then the EMT of the required skill level must attend the patient for the duration of
the inter-facility transport.
B.
Staff of the ambulance service may only provide care and medications for which they are trained
and have protocols. Should the transferring Physician order care or medications outside the
Ambulance Staff’s protocols, then the physician must provide staff with appropriate level of
training to provide this care or medication during the transport.
C.
Critical or unstable patients should generally have two attendants in the back of the ambulance,
at least one being an ALS provider.
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MEDICAL HELICOPTER EVACUATION / RENDEZVOUS
Purpose: Facilitate appropriate and timely use of Medical Helicopter response in Routt County:
General Principles
A.
B.
C.
D.
Consider use of Medical Helicopter scene response when:
1.
Multi Systems trauma patient with prolonged extrication and/or transport time (i.e. using
Medical helicopter will reduce “scene to hospital” time).
2.
Multiple casualty incidents and inability of ground transport units to manage and transport
all patients in a timely manner.
3.
Inability or difficulty in transporting patient using conventional means.
Highest level EMS provider on-scene or the Incident Commander should make the decision to
mobilize a Medical helicopter. If possible medical control contact should be made prior to
helicopter mobilization.
Consider time of helicopter vs ground transport, where is the helicopter coming from.
Consider use of Emergency Medicine Physician scene response if appropriate.
Procedure
A.
B.
C.
D.
Decision made to request Medical Helicopter.
Request helicopter through Routt County Dispatch. (They will make arrangements.)
Give the Medical Helicopter Service Dispatch needed information: scene location with GPS
coordinates, LZ, weather and scene ground contact with radio frequency.
Continue patient care and stabilization efforts while awaiting helicopter arrival or rendezvous.
Destination
A.
B.
In general, patients are to be transported per helicopter service protocol.
If there are extenuating circumstances and the patient is to be transported to YVMC this decision
is to be discussed with the receiving physician at YVMC.
Medical Helicopter Services
•
•
•
•
•
•
Classic Lifeguard
HealthONE Airlife
Flight for Life
St Mary’s Airlife
Greeley Airlife
Flight for Life (Colorado Springs)
1-800-444-9223
1-800-821-1994
1-800-332-3123
1-800-332-4923
1-800-247-5433
1-800-442-2254
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MEDICAL QUALITY CONTROL PROGRAM
Intent
This policy is designed to assure the continuing competency of all of the EMT's in the Routt County
EMS system. This policy is also designed to insure continuous quality and quality improvement in all
aspects of the system.
Protocols and Standing Orders
The NWRETAC protocols will be followed with exception and/or additions as noted in the Routt County
Specific Protocol Section.
The protocols and standing orders contain procedure guidelines and operational guidelines.
The protocols and standing orders are to be strictly adhered to. Deviation from the protocols is to be
explained in patient care documentation. All EMT's in Routt County must be familiar with the entire
protocol manual and are to complete the form attesting to this familiarity.
Evaluation
Prospective evaluation is performed through assuring that all in the EMT's in the system have the
proper certification.
Concurrent evaluation is performed on every run. The low volume nature of the EMS environment in
Routt County allows an intimate familiarity with all of the EMT's. On-line medical control is provided
through the base station at Yampa Valley Medical Center by the Medical Director or one of the other
emergency medicine physicians. The local control of all on-line medical interactions allows evaluation
of communication capabilities and assures the appropriateness of all verbal orders. In addition, nearly
100% of patients are transported to Yampa Valley Medical Center and all of these patients are evaluated
by the Medical Director or one of the other emergency medicine physicians. Feedback is provided
immediately to the EMT's providing care.
Retrospective evaluation is performed on every patient interaction through review of run sheets. Every
run is reviewed in detail by the representative of the service and a cross section is reviewed by the
Medical Director. Comments, positive and negative, are noted on the Routt County EMS Run Review
Form and returned to the service. The comments are reviewed by the EMT. Trends are noted and
addressed on an individual basis remedial action and education/training is recommended on an
individual basis, if necessary.
Complaint Processing
Any written or verbal complaint delivered to any provider or administrator in the Routt County system is
to be formally documented and presented to the chief or director of the involved service and to the
Medical Director.
Complaints will be addressed on an individual basis.
Concerns regarding inappropriate care or other patient care incidents that surface from inside or
outside the system should be addressed in an identical manner.
Continuing Medical Education
The individual EMT's and service agencies are responsible for maintaining appropriate continuing
education. Remedial education or experience is addressed on an individual basis.
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NURSES FUNCTIONING IN THE PREHOSPITAL ENVIRONMENT
The Board of Nursing generally takes the position that a nurse may practice according to his/her skill
and training, regardless of the environment (prehospital or in-hospital). If a question arises as to
whether or not the nurse should have performed a particular delegated medical act, the nurse would
have to prove to the Medical Director or Board of Nursing that he/she was adequately trained and
competent to perform the particular act. The Nurse Practice Act does not specifically require that a
nurse function with written protocols. However, in the prehospital setting, written protocols are
considered customary and appropriate. COPIC Risk Management
recommendations with regard to supervision of non-physician health care providers at any level are
that the physician specify what medical acts and skills (scope of practice) the delegate be allowed,
protocols be written consistent with that scope of practice, documentation of the training and work
history of the delegate be maintained, and a quality improvement program be developed to ensure
that supervision is reviewed in a timely fashion.
POLICY
1. Nurses may function in the prehospital environment on EMS agencies in the Routt
County EMS.
2. They will be required to follow the same procedures as any other provider including
signing agreements, probationary periods, and skills testing.
3. The Medical Director reserves the right to set the level of practice of any RN at the level
appropriate for that nurse given their experience and training level.
PROCEDURE
1. Any nurse who wishes to practice in the Routt County EMS System will meet with the EMSMD,
and a plan for probation and level of practice (EMT-B, EMT-I or EMT-P) will be decided upon.
2. The details of this agreement between the EMSMD and a specific nurse will be placed in
writing, so as to avoid any confusion regarding the Medical Skills and Acts allowed or the
Formulary of Medications Allowed to be Administered by the nurse under the EMSMD’s
medical license.
3. The level a specific nurse may function at is solely at the discretion of the EMSMD.
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TRIAGE COLOR GUIDELINES
Red – critically injured or ill patient – needs immediate treatment and transport in order to survive –
findings may include:
1.
patient is unconscious or has a markedly altered mental status that is not improving or is
deteriorating
2.
patient has significant respiratory compromise secondary to airway or breathing
problem (very rapid or very slow respirations, ineffective effort or inability to breathe)
3.
patient has circulatory compromise – signs of shock or impending shock (weak pulse,
low BP, cold or clammy skin severe uncontrolled bleeding)
Yellow – significantly injured or ill patient – will most likely survive but requires treatment – findings
may include:
1.
patient is conscious
2.
patient may have altered mental status
3.
patient has chest pain or shortness of breath
4.
patient has multiple fractures or torso trauma
5.
patient involved in incident with significant MOI, regardless of findings
Green – minimally injured or ill patient – findings may include:
1.
patient is very stable
2.
patient has isolated extremity injury with minimal distress
3.
patient has no findings for Red or Yellow status
Mechanism of Injury (MOI)/Indicators of Possible Significant Injury:
MVC with death of any involved party
MVC with high energy
MVC with ejection of patient
Motorcycle crash
Auto-pedestrian accident with significant impact (>5mph)
Radio reports for red trauma patients should always be given directly to the ED Physician.
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YAMPA VALLEY MEDICAL CENTER EMERGENCY PHYSICIAN SCENE RESPONSE
Purpose
Facilitate the provision of advanced care at the scene of an individual or mass casualty incident.
Emergency Medical Physician (EMP) will have the capability to perform endotracheal intubation,
cricothyroidotomy, chest decompression, amputation and central line placement and assist in triage or
other EMS activities.
Procedure
EMP and scene response pack are to be picked up at Yampa Valley Medical Center and taken to scene
by dispatched transport unit at the discretion of the incident commander.
EMP will take direction from the incident commander until he/she is assigned to a medical task. While
functioning at a task or station the EMP at scene will provide direction to the medical personnel in that
area or assisting with a task.
EMP will provide assistance at scene as long as feasible. Variables dictating time at scene include
continued need for EMP at scene, hospital need for EMP in ER and resources available for EMP at
scene.
EMP will be transported back to Yampa Valley Medical Center by dispatch transport unit at the
discretion of the incident commander.
Notes
EMP will be equipped with helmet, turn-out coat and trauma pack.
Please note that the EMP is not trained in detailed fire/scene Safety procedures and will need direction
at the scene.
This SOP should only be utilized if advanced care, of the nature mentioned above, is necessary.
EMP will only be available for scene response if the ER at Yampa Valley Medical Center is adequately
staffed.
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155
Drug Protocol
DIPHENHYDRAMINE (BENADRYL)
Description
Antihistamine for treating histamine-mediated symptoms of allergic reaction. Also
Anticholinergic and antiparkinsonian effects used for treating dystonic reactions caused by
antipsychotics and antiemetic medications (e.g.: haloperidol, droperidol, Compazine, etc).
Indications
• Nausea in Pregnancy
Precautions
• Asthma or COPD, thickens bronchial secretions
• Narrow-angle glaucoma
Side effects
• Drowsiness
• Dilated pupils
• Dry mouth and throat
• Flushing
Drug Interactions
• CNS depressants and alcohol may have additive effects.
• MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines.
Dosage and Administration
Adults:
25 mg IV first line in pregnancy
Protocol
Allergy/Anaphylaxis
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HYDROMORPHONE (DILAUDID)
Description
• Opioid analgesics with desired effects of analgesia, euphoria and sedation as well as undesired
effects of respiratory depression and hypotension. A synthetic opioid, fentanyl is 100 times
more potent than morphine, and is less likely to cause histamine release.
Indications
• Presumed cardiac chest pain unresponsive to nitroglycerin
• Suspected nephrolithiasis.
• Extremity injury when severe pain is present
• Severe burns
• Severe pain secondary to trauma without any altered level of consciousness, SOB or chest pain.
Contraindications
• Hypotension, hemodynamic instability or shock
• Respiratory depression
Caution/Comments:
• Opioids should only be given to hemodynamically stable patients and titrated slowly to effect.
• The objective of pain management is not the removal of all pain, but rather, to make the patient’s
pain tolerable enough to allow for adequate assessment, treatment and transport
• Respiratory depression, including apnea, may occur suddenly and without warning, and is more
common in children and the elderly.
• Coadministration of opioids and benzodiazepines is discouraged and may only be done with
direct physician verbal order.
• Chest wall rigidity has been reported with rapid administration of fentanyl
Dosage and Administration
• Management of pain:
• Administer 0.5-1 mg IV or IM over 2-5 minutes, 1-2 mg IM, titrated to pain relief, with a
maximum dose of 3 mg. Systolic blood pressure must be >100.
• Administer 0.5 mg IV or IM over 2-5 minutes, if prior analgesia has been administered.
Repeat as needed with a maximum dose of 3 mg. Systolic blood pressure must be >100.
• Monitor vital signs after each dose.
• If respiratory depression occurs administer titrate naloxone (Narcan) until respiratory rate is
greater than 10 per minute or patient is responding appropriately.
Protocol
Extremity Injuries
Adult Chest Pain
CHF/pulmonary Edema
Therapeutic Induced hypothermia
Abdominal Pain
Amputations
Burns
Bites/Stings
Snake Bites
Face and Neck Trauma
Chest Trauma
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Abdominal Trauma
Spinal Trauma
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158
ETOMIDATE (AMIDATE)
Description
• Etomidate is a hypnotic drug without analgesic activity, IV injection of etomidate produces
hypnosis characterized by a rapid onset of action, usually within one minute.
Onset & Duration
• Etomidate is a hypnotic drug without analgesic activity, IV injection of etomidate produces
hypnosis characterized by a rapid onset of action, usually within one minute. Duration of
hypnosis is dose dependent but relatively brief, usually three to five minutes when an average
dose of 0.3mg/kg.
Indications
• Rapid sequence intubation
Contraindications
• In patients with known hypersensitivity to drug
Adverse Reactions
• Significant venous pain may be a side effect, but this appears to be less frequently noted when
larger, more proximal arm veins are employed, and it appears to be more frequently noted when
smaller, more distal hand or wrist veins are employed.
• Transient skeletal muscle movements may be noted, and may be bilateral or unilateral.
• Nausea and/or vomiting may be noted.
• Causes adrenocortical suppression, so it is not used for prolonged sedation.
• Overdose may occur from too rapid or repeated injections. Too rapid injection may be followed by
a fall in blood pressure.
Dosage and Administration
• Administer etomidate 0.3 mg/kg slow IVP, over 30-60 seconds. If not adequately sedated, may give
up to 0.6mg/kg mg for adults and pediatrics
Protocol
Rapid Sequence Intubation
Special notes
• EMT-B-IVs or EMT-I will be allowed to administer medication under the direct supervision of an
EMT-P if the patient is in extremis.
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FENTANYL
Description
• Opioid analgesics with desired effects of analgesia, euphoria and sedation as well as undesired
effects of respiratory depression and hypotension. A synthetic opioid, fentanyl is 100 times
more potent than morphine, and is less likely to cause histamine release.
Indications
• Post RSI in medical patients only
Contraindications
• Hypotension, hemodynamic instability or shock
• Respiratory depression
Caution/Comments:
• Opioids should only be given to hemodynamically stable patients and titrated slowly to effect.
• The objective of pain management is not the removal of all pain, but rather, to make the patient’s
pain tolerable enough to allow for adequate assessment, treatment and transport
• Respiratory depression, including apnea, may occur suddenly and without warning, and is more
common in children and the elderly. Start with ½ traditional dose in the elderly.
• Chest wall rigidity has been reported with rapid administration of fentanyl
Dosage and Administration
For medical RSI administer 100 µg of Fentanyl every 15 minutes
Protocol
Rapid Sequence Intubation
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HALOPERIDOL (HALDOL)
Description
•
Haloperidol is a butyrophenone in the therapeutic 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.
Onset and Duration
•
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.
Contraindications
•
Do not administer to any patient:
1.
with a suspected acute myocardial infarction
2.
with a systolic blood pressure under 100 mm Hg, or the absence of a radial pulse
3.
exhibiting signs of sedation, respiratory depression, or CNS depression
4.
with known Parkinson's Disease
5.
with a known pregnancy
6.
with severe liver or cardiac disease
7.
under the age of 8
Indications
•
Primary indication: to act as a chemical restraint in patients that require transport and are
behaving in a manner that poses a threat to their own well-being or others.
Dosage and Administration
•
Adult dose
1.
Administration: 5 mg – 10 mg IM, if 65 years or older start at 2.5 mg IM (max 10 mg)
2.
Administer 50 mg diphenhydramine, IV or IM following the use of haloperidol to prevent
extrapyramidal reactions.
Protocol
Agitated/Combative Patient Protocol
Precautions:
•
•
•
•
Haldol may cause hypotension, tachycardia, and prolongation of the QT interval.
When administering this IM medication, paramedic must put patient on cardiac monitor and
establish an IV as soon as possible.
Due to the vasodilatory effect, haloperidol can cause a transient hypotension that is usually selflimiting and can be treated effectively with position and fluids. Haloperidol has also been known
to cause tachycardia, which usually does not require pharmacologic intervention.
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
Routt County Specific Protocols
161
•
•
•
•
•
•
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 Section VI – Drug Protocols – Diphenhydramine (Benadryl))
Rare instances of neuroleptic malignant syndrome (very high fever, muscular rigidity) have been
known to occur after the use of haloperidol.
Haloperidol lowers seizure threshold and should be administered with great caution to anyone
with a known seizure disorder.
Hypotension and tachycardia secondary to haloperidol are usually self-limiting and hypotension
is correctable through recumbent positioning and fluid administration. Be aware of other causes
of these conditions, especially in relation to a patient that is the victim of trauma.
The action of haloperidol potentiates the effect of sedative/tranquilizer type medications and is
relatively contraindicated in the presence of these types of medications. In this setting, be
prepared for respiratory depression, apnea, muscular rigidity, and hypotension.
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LIDOCAINE 2% SOLUTION
Description
• Decreasing intracranial pressure by decreasing the cough reflex and reflex from direct
laryngoscopy.
Indications
• RSI or intubation of head injured patients.
Side Effects
• Seizures
• Drowsiness
• Tachycardia
• Bradycardia
• Confusion
• Hypotension
Precautions
• Lidocaine is metabolized in the liver and therefore, elderly patients and those with liver disease
or poor liver perfusion secondary to shock or congestive heart failure are more likely to
experience side effects
Dosage and Administration
• Head trauma
• 100 mg IV bolus: no additional bolus is required.
Protocol
Rapid Sequence Intubation
Special Notes
• Seizure from lidocaine toxicity likely to be brief and self-limited. If prolonged, or status
epilepticus, treat per seizure protocol
• Treat dysrhythmias according to specific protocol
• EMT-B-IVs will be allowed to administer medication under the direct supervision of an EMT-P or
EMT-I if the patient is in extremis.
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LORAZEPAM (ATIVAN)
Pharmacology and actions
A.
Lorazepam acts as a tranquilizer, anticonvulsant, and skeletal muscle relaxant through effects
on the central nervous system.
Indications
A.
B.
C.
D.
Status seizures: in the field this will be any seizure lasting longer than 5 minutes, or two
consecutive seizures without regaining consciousness.
Behavior management.
Anxiety
For the treatment of drug induced hyper-adrenergic states manifested by tachycardia and
hypertension (i.e., cocaine, amphetamine overdose)
Contraindications
A.
B.
In patients with known hypersensitivity or angle-closure glaucoma; patients with sleep apnea
syndrome and patients experiencing shock.
Lorazepam should not be administered in patients who are pregnant, may cause fetal damage
Administration
A.
F.
Adult
1.
Status seizures:
a)
2 mg slow IVP or IM, IN, IO, may repeat twice if needed up a total of 6 mg (5 minutes
between doses)
2.
Behavior management:
a)
2 mg slow IVP or IN, IM, may repeat twice if needed up to a total of 6 mg.
3.
Anxiety:
a)
0.5-1 mg slow IVP or IN, IM, may repeat 1 mg, up to a total of 2 mg.
Pediatric:
1.
Status seizure:
a.
0.05 mg/kg IV, IO may repeat once in 5 min.
b.
0.1 mg/kg IN, IM, may repeat once in 5 min.
Precautions
A.
B.
C.
Since lorazepam can cause respiratory depression the patient should be monitored closely. Very
rarely, cardiac arrest can occur.
In seizures, do not give unless the patient is actively seizing.
Be prepared for respiratory depression and airway control in combative patients who are under
the influence of alcohol and/or narcotics.
Side effects and special notes
A.
B.
C.
D.
E.
If combination with narcotics in necessary, contact Medical Control.
Common side effects include drowsiness, dizziness, fatigue, and ataxia. Paradoxical excitement
or stimulation can occur.
Should not be mixed with other agents or diluted with intravenous solutions. Push lorazepam in a
proximal IV port.
If the patient is seizing on your arrival, status seizure can be assumed.
When used to treat drug-induced hyper-adrenergic states, larger doses of lorazepam may be
required.
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METHYLPREDNISOLONE (SOLU-MEDROL)
Description
Methylprednisolone is a synthetic steroid that suppresses acute and chronic
inflammation and may alter the immune response. In addition, it potentiates vascular
smooth muscle relaxation by beta-adrenergic agonists and may alter airway
hyperactivity.
Indications
• Anaphylaxis
• Severe asthma
• COPD
• Suspected Addisonian crisis (cardiovascular collapse in patient at risk for adrenal
insufficiency)
Contraindications
• Evidence of active GI bleed
Adverse Reactions
Most adverse reactions are a result of long-term therapy and include:
• Gastrointestinal bleeding
• Hypertension
• Hyperglycemia
Dosage and Administration Adult:
125 mg, IV/10 bolus, slowly, over 2 minutes
Pediatric:
2 mg/kg, IV/10 bolus, slowly, over 2 minutes to max dose of 125 mg
Protocol
• Asthma
• Allergy and Anaphylaxis
• Chronic Obstructive Pulmonary Disease
• Adult hypotension/shock
• Adrenal Insufficiency
Special Considerations
• Must be reconstituted and used immediately
• The effect of methylprednisolone is generally delayed for several hours.
• 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. If primary treatment priorities have been completed and there is
time while in route to the hospital, then methylprednisolone can be administered.
Do not delay transport to administer this drug
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MIDAZOLAM (Versed)
Description
• Benzodiazepines are sedative-hypnotics that act by increasing GABA activity in the brain. GABA
is the major inhibitory neurotransmitter, so increased GABA activity inhibits cellular excitation.
Benzodiazepine effects include anticonvulsant, anxiolytic, sedative, amnestic and muscle
relaxant properties.
Onset & Duration
• Given IV it will have the fastest onset of action, typical time of onset 2-3 minutes
• Intranasal administration has slower onset and is less predictable compared to IV
administration, however it may still be preferred if an IV cannot be safely or rapidly obtained.
Intranasal route has faster onset compared to intramuscular route.
• IM administration has the slowest time of onset.
Indications
• Post Rapid Sequence Intubation.
Contraindications
• Hypotension
• Respiratory depression
Adverse Reactions
• Respiratory depression, including apnea
• Hypotension
Dosage and Administration
• RSI
• Medical patient administer: midazolam, 5 mg IV, and repeat every 15 minutes.
• Trauma patient administer: midazolam, 2.5-5 mg IV only if patient is not hypotensive.
Protocol
• Rapid Sequence Intubation
Special Considerations
• All patients receiving midazolam must have cardiac, pulse oximetry monitoring during transport.
Continuous waveform capnography recommended.
• Sedative effects of midazolam are increased in combination with opioids, alcohol, or other CNS
depressants.
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SUCCINYLCHOLINE (ANECTINE)
Description
• Succinylcholine is an ultra-short action depolarizing type skeletal muscle relaxant.
• As does acetylcholine it combines with the cholinergic receptors of the motor end plate to
produce depolarization
Onset & Duration
• Onset of flaccid paralysis is rapid (less than 1 minute after IV administration) and with single
administration lasts approximately 4-6 minutes.
Indications
• Rapid sequence intubation
• Short term paralysis to facilitate endotracheal intubation.
Contraindications
• Preexisting hyperkalemia
• Chronic myopathy or denervating neuromuscular disease
• 48 hours post-acute denervating event.
• In patients with known hypersensitivity to the drug and in patients with abnormally low plasma
pseudocholinesterase, angle-closure glaucoma, malignant hypertension or penetrating eye
injuries.
• Massive crush injuries.
• Burns greater than 8 hours.
Adverse Reactions
• Include the following; Apnea, malignant hyperthermia, dysrhythmias, bradycardia, hypertension,
cardiac arrest, hyperkalemia, increased intraocular pressure and fasciculations
• Succinylcholine has no effect on consciousness, pain threshold or cerebration.
Dosage and Administration
• Administer succinylcholine 1.5 mg/kg rapid IVP (paralyzing dose)
Protocol
• Rapid Sequence Intubation
Special Notes
• EMT-B-IVs or EMT-I will be allowed to administer medication under the direct supervision of an
EMT-P if the patient is in extremis.
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VECURONIUM (NORCURON)
Description
• A non-depolarizing agent that prevents acetylcholine from binding to receptors on the muscle end
plate, thus blocking depolarizing.
Onset & Duration
• Norcuron will produce complete neuromuscular block with clinical duration of action of 25-45
minutes.
Indications
• Rapid sequence intubation
• Long term paralysis to facilitate endotracheal intubation.
Contraindications
• In patients with known hypersensitivity to drug.
• Newborns
• Myasthenia Gravis
Adverse Reactions
• Apnea
• Profound weakness
Dosage and Administration
• Adult dose for long term paralysis, administer Norcuron 10 mg.
Protocol
• Rapid Sequence Intubation
Special Notes
• EMT-B-IVs or EMT-I will be allowed to administer medication under the direct supervision of an
EMT-P if the patient is in extremis.
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Procedure Protocol
AIRWAY MANAGEMENT: LARYNGEAL MASK AIRWAY/i-Gel
EMT
Indications
•
EMT-IV
AEMT
Rescue airway if unable to intubate a patient in need
Paramedic
EMT-I
of airway protection
Primary airway if intubation anticipated to be difficult
and rapid airway control is necessary
Primary airway in pulseless arrest, when attempts at intubation are likely to interrupt CPR
Designated advanced airway for EMTs
•
•
•
Contraindications
•
•
•
•
Pharyngeal pathology (abscess or hematoma)
Obstructive lesion below glottis
Limited mouth opening
Intact gag reflex
Equipment needed
•
•
•
•
•
•
•
•
BSI
Correctly sized laryngeal mask airway or i-Gel(see charts below)
Bag valve mask
Suction unit
Tube tie, securing device
Appropriate syringe for expanding cuff
End tidal CO2 and oxygen saturation monitoring device
Cricothyrotomy equipment
Mask size
Patient weight(kg)
1
1.5
2
2.5
3
4
5
<5 kg
5-10
6.5-20
20-30
30-60
60-80
>80
Laryngeal Mask Airway Sizes
Age(years)
Length (cm)
Cuff Volume
(ml)
<0.5
10 cm
4ml
10
5-7
0.5-1
11.5
7-10
5-10
12.5
14
10-15
19
15-20
>15
19
25-30
>15
19
30-40
Largest ETT*
3.5
4.5
5.0
6.0
6.5
7.0
LMA Technique
A.
B.
C.
D.
E.
F.
G.
H.
I.
Prepare the LMA for use
Perform LMA test, check cuff
Deflation of the LMA cuff without wrinkles in cuff
Lubricate tube (spread about the cuff) with water soluble lubricant
Position the patient’s head
Properly orient and grasp the tube
Insert LMA upward against the hard palate, and push the device inwards and backward with the
index finger. Advance until definite resistance is felt. Do not use force.
Use the other hand to press down on the LMA tube before removing index finger.
Ensure that the black line on the airway tube is oriented anteriorly toward the upper lip.
Routt County Specific Protocols
169
J.
K.
Inflate the cuff with just enough air to obtain a seal. Varies with cuff size and patient anatomy.
Do not hold the tube during cuff inflation.
Ventilate the patient
i-Gel
i-gel size
1
Patient size
Neonate
1.5
Infant
Patient weight guidance (kg)
2-5
5-12
2
Small paediatric
10-25
2.5
Large paediatric
25-35
3
Small adult
30-60
4
Medium adult
50-90
5
Large adult+
90+
1. Grasp the lubricated i-gel firmly along the integral bite block. Position the device so that the i-gel
cuff outlet is facing towards the chin of the patient.
2. The patient should be in the ‘sniffing the morning air’ position with head extended and neck flexed.
The chin should be gently pressed down before proceeding to insert the i-gel.
3. Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate.
4. Glide the device downwards and backwards along the hard palate with a continuous but gentle push
until a definitive resistance is felt.
5. WARNING: Do not apply excessive force on the device during insertion. It is not necessary to insert
fingers or thumbs into the patient’s mouth during the process of inserting the device. If there is
early resistance during insertion, a ‘jaw thrust’, ‘Insertion with deep rotation’ or triple manoeuvre is
recommended.
6. At this point the tip of the airway should be located into the upper oesophageal opening and the cuff
should be located against the laryngeal framework. The incisors should be resting on the integral
bite-block
Post Placement
1. Auscultate breath sounds and confirm placement
2. End tidal CO2
a. Capnometer digital (preferred)
i. Attach capnometer
ii. Readings
1. Head injuries at 30 mm/Hg.
2. Severe asthma; intubated >50 mm/Hg initially; maintain at 40 mm/Hg
3. If patient has probable acidosis (significant CPR or apneic time) consider
readings at 25 mm/Hg
4. All others patients maintain at 30-40 mm/Hg
iii. Check for good waveform readings.
iv. Once ETT placement is verified, capnometer is to remain in place.
3. Insert a bite block and secure the tube.
4. Monitor end-tidal carbon dioxide level.
5. Monitor oxygen saturation levels
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ADVANCED AIRWAY MANAGEMENT: NEEDLE CRICOTHYROTOMY
Introduction
Paramedic
Needle cricothyrotomy is a difficult and hazardous procedure that is to be used only in
extraordinary circumstances as defined below. The reason for performing this procedure must be
documented and submitted for review to the physician advisor or designee within 48 hours.
Percutaneous cricothyrotomy is to be performed only by paramedics trained in the procedure.
Indications
A.
B.
When a life threatening condition exists and advanced airway management is indicated, and you
are unable to establish airway by other means.
Children under the age of 8 years of age.
Precautions
A.
Bleeding is possible, even with correct technique. Straying from the midline is very dangerous
and likely to cause hemorrhage from the carotid or jugular vessels, or their branches.
Equipment needed
A.
B.
C.
D.
E.
BSI
14 gauge Angiocath
10cc syringe
3.0 endotracheal tube
BVM
Technique
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Expose the neck.
Identify the trachea; palpate the prominent thyroid notch anteriorly. Palpate the cricoid cartilage
inferiorly. The space between the cricoid and thyroid cartilages is the cricothyroid space, in which
is located the cricothyroid membrane.
Using aseptic technique (Betadine/alcohol wipes) cleanse the area.
Position the patient in a supine position, with in-line spinal immobilization if indicated.
Insert the needle or over-the-needle-catheter through the cricothyroid membrane in a caudal
direction at a 45-degree angle.
If using an over-the-needle-catheter, remove the syringe and needle
Use a 3.0 endotracheal tube hub to connect to catheter.
Ventilate with BVM and 100% oxygen.
It will be difficult to adequately ventilate the patient with the resistance from the catheter, allow
for exhalation.
Confirm needle placement is successful. (Chest rise and fall, breathe sounds).
End tidal CO2
1.
Capnometer digital (preferred)
a)
Attach capnometer
b)
Readings
(1)
If less than 4 mm/Hg, Angiocath may be in the esophagus.
(2)
Head injuries at 30 mm/Hg.
(3)
Severe asthma; intubated >50 mm/Hg initially; maintain at 40 mm/Hg
(4)
If patient has probable acidosis (significant CPR or apneic time) consider
readings at 25 mm/Hg
(5)
All others patients maintain at 30-40 mm/Hg
c)
Check for good waveform readings.
d)
Once ETT placement is verified, capnometer is to remain in place.
Routt County Specific Protocols
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2.
L.
M.
Colormetric
a)
Attach capnometer
b)
Patients with good perfusion
c)
Purple with no color change, 0.01-0.5%, less than 4mm/Hg. ET tube not in place.
(May have false negative purple readings with patients in cardiac arrest.)
d)
Moderate color change, 0.5-2%, 4-15 mm/Hg. ET tube in trachea with low
perfusion.
e)
Tan on exhalation, purple in inhalation, 2-5%, 15-38 mm/Hg. ET in trachea with
good continuous color change.
Observe for subcutaneous air, indicating tracheal injury or improper placement.
Secure tube with ties or tape.
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RAPID SEQUENCE INTUBATION (R.S.I.) ADULT
Indications
A.
B.
C.
D.
E.
F.
G.
GCS ≤ 9 with intact gag reflex and potential for airway compromise.
Trismus / Clenched Jaw
Closed head injury or major stroke with unconsciousness.
Respiratory Failure or Insufficiency
Combative with Inability to Maintain Airway.
Airway Injury, swelling or obstruction
Potential for Airway Compromise
Paramedic
Drugs Needed
A.
B.
C.
D.
E.
F.
G.
Lidocaine hydrochloride
Atropine
Etomidate (Amidate)
Succinylcholine chloride (Anectine)
Vecuronium bromide (Norcuron)
Fentanyl
Versed
Procedure
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
BSI
Restrain the patient if necessary.
Do neurological exam with Glasgow Coma Scale.
Attempt to have 2 paramedics on scene.
Establish IV access (2 sites recommended), proximal vein preferred.
Pre-oxygenate the lung by providing 100% oxygen by mask or BVM while holding cricoid
pressure. If the patient is ventilating adequately, use non-rebreather mask only.
Assemble required equipment:
1.
BVM
2.
Suction
3.
ET Tube and Stylet
4.
Bougie
5.
King Vision (Primary) and Laryngoscope (Secondary)
6.
Cricothyrotomy tray
7.
King Airway or LMA
8.
EtCO2
Monitor Cardiac Rhythm.
Monitor oxygen saturation with pulse oximeter, if saturation drops below 95% stop procedure
and ventilate.
Set monitor to take blood pressure to every two minutes.
Premedicate as appropriate:
1.
Lidocaine 100 mg IV over 30 to 60 seconds (if time permits 3 min prior to intubation). (for
TBI)
2.
Atropine 0.5mg IV push for patients in symptomatic bradycardia.
3.
Etomidate 0.3 mg/kg slow IV push. If not adequately sedated, may give up to 0.6 mg/kg.
Apply cricoid pressure is optional.
Administer succinylcholine 1.5 mg/kg IV push.
Bougie may be used
Perform endotracheal intubation. If unable to intubate during the first 20 seconds stop and
ventilate the patient with BVM for 30 to 60 seconds.
Treat bradycardia occurring during intubation with atropine, 0.5-1 mg IV push, halt intubation
attempt and ventilate with BVM until 100% saturation.
Routt County Specific Protocols
173
Q.
R.
S.
T.
Verification of proper tube placement.
1.
Visualization of tube passing through the cords
2.
Visualization of the chest rising and falling with ventilation.
3.
Presence of bilateral breath sounds
4.
Absence of air sounds over the epigastrium.
5.
Clearing of the tracheal tube with lung inflation, and misting of the tube with lung deflation.
6.
End tidal CO2
1.
Capnometer digital (Mandatory)
a)
Attach capnometer
b)
Readings
(1)
If less than 4 mm/Hg, ET tube may be in the esophagus.
(2)
Head injuries at 30 mm/Hg, keep above 25 mm/Hg.
(3)
Severe asthma; intubated >50 mm/Hg initially; maintain at 35
mm/Hg
(4)
If patient has probable acidosis (significant CPR or apneic time)
consider readings at 25 mm/Hg
(5)
All others patients maintain at 30-40 mm/Hg
c)
Check for good waveform readings.
d)
Once ETT placement is verified, capnometer is to remain in place.
2.
Colormetric (Back up)
a)
Attach capnometer
b)
Patients with good perfusion
c)
Purple with no color change, 0.01-0.5%, less than 4mm/Hg. ET tube not in
place.
d)
Moderate color change, 0.5-2%, 4-15 mm/Hg. ET tube in trachea with low
perfusion.
e)
Tan on exhalation, purple in inhalation, 2-5%, 15-38 mm/Hg. ET in trachea
with good continuous color change.
7.
Obtain pulse oximetry reading. SaO2 should be over 95%.
1.
May not be reliable in shock or cold.
2.
Always correlate with heart rate from cardiac monitor or measured pulse.
8.
Note proper tube position and secure with appropriate device.
9.
Reassess the patient.
For long term management (use if time between RSI and arrival to Emergency Room will be
greater than ten min.), administer Norcuron, 10 mg IVP.
If RSI was performed for traumatic brain injury, check BP multiple times. If patient not
hypotensive, consider 2.5-5 mg of versed, every 15 minutes.
If RSI was performed for medical reasons, consider.
1.
Fentanyl 100 µg, every 15 minutes.
2.
Versed 5 mg, every 15 minutes.
Complications
A.
B.
C.
D.
E.
F.
G.
H.
I.
Esophageal intubation: particularly common when tube not visualized as it passes through cords.
The greatest danger is in not recognizing the error. Auscultation over stomach during trial ventilations 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 dysrhythmias or fibrillation in hypothermia patients from stimulation of airway.
Induction of pneumothorax, either from traumatic insertion, forceful bagging, or aggravation of
underlying pneumothorax.
Routt County Specific Protocols
174
J.
it is the responsibility of the paramedic to notify theAll RSI procedures will be reviewed by the
agency physician advisor or his/her designee within 48 hours.
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175
SPLINTING: EXTREMITY
EMT
Indications
A.
B.
Pain, 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
EMT-IV
EMT-I
AEMT
Paramedic
Precautions
A.
B.
C.
D.
Critically injured trauma victims should not be delayed in transport by lengthy evaluation of
possible noncritical 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.
In a stable patient where no environmental hazard exists, splinting should be done prior to moving
the patient.
Extremity Splinting Technique
A.
B.
C.
D.
E.
F.
G.
H.
Check pulse and sensation distally prior to movement or splinting.
Remove bracelets, watches, or other constricting bands prior to splint application.
Identify and dress open wounds. Note wounds which contain exposed bone or lie 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 injured joint above and below injury or splint injured bone above and
below if indicated. Pad rigid splints to prevent pressure injury to extremity.
Apply gentle continuous traction to extremity and support to fracture site during splinting
operation.
Reduce angulated fractures (if no pulses), including open fractures, with gentle axial traction as
needed to immobilize properly.
Check distal pulses and sensation after reduction splinting. Manipulate gently if adequate
circulation and sensation is lost.
Traction Splinting Technique (for suspected middle third femur fractures):
A.
B.
C.
D.
E.
F.
G.
H.
I.
Use two persons if available for splint application procedure.
Remove sock and shoe and check for distal pulse and sensation (unless you cannot protect
exposed foot from weather; then just ask patient about sensation and observe movement).
Identify and dress open wounds, and note exposed bone or wounds overlying fractures and
potential communicating wounds.
Measure splint length prior to application.
Apply gentle axial traction with support to calf and fracture site if second person available,
reducing angulation of open fractures as necessary for secure traction splint.
Position splint, empty pockets if needed.
Secure groin strap carefully.
Maintain continuous traction and support to fracture site throughout procedure if second person
available.
Adjust straps to appropriate positions under leg.
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176
J.
K.
L.
Apply ankle hitch and tighten traction until patient experiences improved comfort. (Movement at
the fracture site will cause some pain, but if traction continues to cause increased pain, do not
proceed. Splint and support leg in position of most comfort.)
Secure support straps after traction properly adjusted.
Recheck distal pulses and sensation.
Complications
A.
B.
C.
D.
Circulatory compromise from excessive constriction of limb
Continued bleeding not visible under splint
Pressure damage to skin and nerves from inadequate padding
Delayed treatment of life-threatening injuries due to prolonged splinting procedures
Side effects and special notes
A.
B.
C.
Traction splints should only be used if the leg can be straightened easily and patient is
comfortable with the traction device on. Particularly with injuries about the hip and knee, forced
application of traction device can cause increased pain and damage. If this occurs, do not use
traction device, but support in position of most comfort and best neurovascular status.
When in doubt and the patient is stable, splint. Do not be deceived by absence of deformity or
disability. Fractured limbs often retain some ability to function.
Splinting body parts together can be a very effective way of immobilizing: arm-to-trunk or leg-toleg. Padding will increase comfort. This method can be very useful in children when traction
devices and pre-made splints do not fit.
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177
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
6 CCR 1015-3
CHAPTER TWO - RULES PERTAINING TO EMS PRACTICE AND MEDICAL DIRECTOR OVERSIGHT
SECTION 1 - Purpose and Authority for Establishing Rules
1.1
The purpose of these rules is to define the qualifications and duties of medical directors to
Emergency Medical Services (EMS) agencies and to define the authorized medical acts of EMS
providers.
1.2
The general authority for the promulgation of these rules by the executive director or chief
medical officer of the department is set forth in Sections 25-3.5-203 and 206, C.R.S.
1.3
These rules apply to and are controlling for any physician functioning as a medical director to an
EMS organization and who authorizes and directs the performance of medical acts by EMS
providers at all levels of certification in the State of Colorado. These rules also define the scope of
practice for EMS providers.
SECTION 2 - Definitions - All definitions that appear in Section 25-3.5-103, C.R.S., and 6 CCR 10153, CHAPTER ONE shall apply to these rules.
2.1
“Advanced Cardiac Life Support (ACLS)” - a course of instruction designed to prepare students in
the practice of advanced emergency cardiac care.
2.2
“Advanced Emergency Medical Technician (AEMT)” - an individual who has a current and valid
AEMT certificate issued by the department and who is authorized to provide limited acts of
advanced emergency medical care in accordance with these rules.
2.3
“Board for Critical Care Transport Paramedic Certification (BCCTPC)”- a non-profit organization
that develops and administers the Critical Care Paramedic Certification and Flight Paramedic
Certification exam.
2.4
“Colorado Medical Board” - the Colorado Medical Board established in Title 12, Article 36, C.R.S.,
formerly known as the state Board of Medical Examiners.
2.5
“Department” - the Colorado Department of Public Health and Environment.
2.6
“Direct Verbal Order” - verbal authorization given to an EMS provider for the performance of
specific medical acts through a Medical Base Station or in person.
2.7
“Emergency Medical Practice Advisory Council (EMPAC)” - the council established pursuant to
Section 25-3.5-206, C.R.S., that is responsible for advising the department regarding the
appropriate scope of practice for EMS providers and for the criteria for physicians to serve as
EMS medical directors.
2.8
“Emergency Medical Technician (EMT)” - an individual who has a current and valid EMT
certificate issued by the department and who is authorized to provide basic emergency medical
care in accordance with these rules.
2.9
“Emergency Medical Technician with Intravenous Authorization (EMT-IV)” - an individual who has
a current and valid EMT certificate issued by the department and who has met the conditions
defined in Section 5.5 of these rules.
2.10
“Emergency Medical Technician-Intermediate (EMT-I)” - an individual who has a current and valid
EMT-Intermediate certificate issued by the department and who is authorized to provide limited
acts of advanced emergency medical care in accordance with these rules.
18
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
6 CCR 1015-3
2.11
“EMS Provider” - means an individual who holds a valid emergency medical service provider
certificate issued by the department and includes Emergency Medical Technician, Advanced
Emergency Medical Technician, Emergency Medical Technician-Intermediate and Paramedic.
2.12
“EMS service agency” - any organized agency including but not limited to a “rescue unit” as
defined in Section 25-3.5-103(11), C.R.S., using EMS providers to render initial emergency
medical care to a patient prior to or during transport. This definition does not include criminal law
enforcement agencies, unless the criminal law enforcement personnel are EMS providers who
function with a “rescue unit” as defined in Section 25-3.5-103(11), C.R.S. or are performing any
medical act described in these rules.
2.13
“Graduate Advanced EMT” - an individual who has a current and valid Colorado EMT certification
issued by the department and who has successfully completed a department-recognized AEMT
initial course but has not yet successfully completed the certification requirements set forth in the
Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter One.
2.14
“Graduate EMT-Intermediate” - an individual who has a current and valid Colorado EMT or AEMT
certification issued by the department and who has successfully completed a departmentrecognized EMT-Intermediate course but has not yet successfully completed the certification
requirements set forth in the Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3,
Chapter One.
2.15
“Graduate Paramedic” - an individual who has a current and valid Colorado EMT certificate,
AEMT certificate, or EMT-I certificate issued by the department and who has successfully
completed a department-recognized paramedic initial course but has not yet successfully
completed the certification requirements set forth in the Rules Pertaining to EMS Education and
Certification, 6 CCR 1015-3, Chapter One.
2.16
“Interfacility Transport” - any transport of a patient from one licensed healthcare facility to another
licensed healthcare facility, after a higher level medical care provider (i.e. a physician, physician
assistant, or an individual of similar/equivalent training, certification, and patient interaction) has
initiated treatment.
2.17
“Licensed in Good Standing” - as used in these rules, means that a physician functioning as a
medical director holds a current and valid license to practice medicine in Colorado that is not
subject to any restrictions.
2.18
“Maintenance” – to observe the patient while continuing, assessing, adjusting and/or
discontinuing care of a previously established medical procedure or medication via standing
order, written physician order, or the direct verbal order of a physician.
2.19
“Medical Base Station” - the source of direct medical communications with EMS providers.
2.20
“Medical Director” - for purposes of these rules means a physician licensed in good standing who
authorizes and directs, through protocols and standing orders, the performance of students-intraining enrolled in department-recognized EMS education programs, graduate AEMTs, EMT-Is
or paramedics, or EMS providers of a prehospital EMS service agency and who is specifically
identified as being responsible to assure the competency of the performance of those acts by
such EMS providers as described in the physician’s medical CQI program.
2.21
“Monitoring” – to observe and detect changes, or the absence of changes, in the clinical status of
the patient for the purpose of documentation.
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2.22
“Paramedic” - an individual who has a current and valid paramedic certificate issued by the
department and who is authorized to provide advanced emergency medical care in accordance
with these rules.
2.23
“Paramedic with Critical Care Endorsement (P-CC)” – an individual who has a current and valid
paramedic certificate issued by the department and who is authorized to provide critical care in
accordance with these rules.
2.24
“Prehospital Care” – any medical procedures or acts performed prior to a patient receiving care at
a licensed healthcare facility.
2.25
“Protocol” - written standards for patient medical assessment and management approved by a
medical director.
2.26
“Rules Pertaining to EMS Education and Certification” - rules governing the education and
certification of EMS providers, located at 6 CCR 1015-3, Chapter One, promulgated by the state
Board of Health.
2.27
“Scope of Practice” - refers to the medication administration and acts authorized in these rules for
EMS providers.
2.28
“State Emergency Medical and Trauma Services Advisory Council (SEMTAC)” - a council created
in the department pursuant to Section 25-3.5-104, C.R.S., that advises the department on all
matters relating to emergency medical and trauma services.
2.29
“Standing Order” - written authorization provided in advance by a medical director for the
performance of specific medical acts by EMS providers independent of making medical base
station contact.
2.30
“Supervision” - oversee, direct or manage. Supervision may be through direct observation or by
indirect oversight as defined in the medical director’s CQI program.
2.31
“Waiver” - a department-approved exception to these rules granted to a medical director.
2.32
“Written Order” - written authorization given to an EMS provider for the performance of specific
medical acts.
SECTION 3 - Emergency Medical Practice Advisory Council
3.1
The Emergency Medical Practice Advisory Council (EMPAC), under the direction of the executive
director of the department, shall advise the department in the areas set forth below in Section 3.8.
3.2
The EMPAC shall consist of the following eleven members:
3.2.1
Eight voting members appointed by the governor as follows:
A)
Two physicians licensed in good standing in Colorado who are actively serving
as EMS medical directors and are practicing in rural or frontier counties;
B)
Two physicians licensed in good standing in Colorado who are actively serving
as EMS medical directors and are practicing in urban counties;
C)
One physician licensed in good standing in Colorado who is actively serving as
an EMS medical director in any area of the state;
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D)
One EMS provider certified at an advanced life support level who is actively
involved in the provision of emergency medical services;
E)
One EMS provider certified at a basic life support level who is actively involved in
the provision of emergency medical services; and
F)
One EMS provider certified at any level who is actively involved in the provision
of emergency medical services;
3.2.2
One voting member who is a member of the SEMTAC, appointed by the executive
director of the department; and
3.2.3
Two nonvoting ex officio members appointed by the executive director of the department.
3.3
EMPAC members shall serve four-year terms; except that, of the members initially appointed to
the EMPAC by the governor, four members shall serve three-year terms.
3.4
A vacancy on the EMPAC shall be filled by appointment by the appointing authority for that
vacant position for the remainder of the unexpired term.
3.5
EMPAC members serve at the pleasure of the appointing authority and continue in office until the
member’s successor is appointed.
3.6
The EMPAC shall meet at least quarterly and more frequently as necessary to fulfill its
obligations.
3.7
The EMPAC shall elect a chair and vice-chair from its members.
3.8
The duties of the EMPAC include:
3.8.1
Provide general technical expertise on matters related to the provision of patient care by
EMS providers;
3.8.2
Advise or make recommendations to the department on:
A)
The acts and medications that EMS providers are authorized to perform or
administer under the direction of a medical director.
B)
Requests by medical directors for waivers to the scope of practice of EMS
providers as established in these rules.
C)
Modifications to EMS provider certification levels and capabilities.
D)
Criteria for physicians to serve as EMS medical directors.
SECTION 4 - Medical Director Qualifications and Duties
4.1
A medical director shall possess the following minimum qualifications:
4.1.1
Be a physician currently licensed to practice medicine in the State of Colorado.
4.1.2
Be trained in Advanced Cardiac Life Support.
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4.1.3
4.2
6 CCR 1015-3
Physicians acting as medical directors for department-recognized EMS education
programs must possess authority under their licensure to perform any and all medical
acts to which they extend their authority to EMS providers, including any and all curricula
presented by EMS education programs.
The duties of a medical director shall include:
4.2.1
Be actively involved in the provision of emergency medical services in the community
served by the EMS service agency being supervised. Involvement does not require that a
physician have such experience prior to becoming a medical director, but does require
such involvement during the time that he or she acts as a medical director. Active
involvement in the community could include, by way of example and not limitation, those
inherent, reasonable and appropriate responsibilities of a medical director to interact with
patients, the public served by the EMS service agency, the hospital community, the
public safety agencies and the medical community and should include other aspects of
liaison oversight and communication normally expected in the supervision of EMS
providers.
4.2.2
Be actively involved on a regular basis with the EMS service agency being supervised.
Involvement does not require that a physician have such experience prior to becoming a
medical director, but does require such involvement during the time that he or she acts as
a medical director. Involvement could include, by way of example and not limitation,
involvement in continuing education, audits and protocol development. Passive or
negligible involvement with the EMS service agency and supervised EMS providers does
not meet this requirement.
4.2.3
Notify the department on an annual basis of the EMS Service Agencies for which medical
control functions are being provided in a manner and form as determined by the
department.
4.2.4
Establish a medical continuous quality improvement (CQI) program for each EMS service
agency being supervised. The medical CQI program shall assure the continuing
competency of the performance of that agency’s EMS providers. This medical CQI
program shall include, but not be limited to: appropriate protocols and standing orders
and provision for medical care audits, observation, critiques, continuing medical
education and direct supervisory communications.
4.2.5
Submit to the department an affidavit that attests to the development and use of a
medical CQI program for all EMS service agencies supervised by the medical director. As
set forth below in section 4.3, the department may review the records of a medical
director to determine compliance with the CQI requirements in these rules.
4.2.6
Provide monitoring and supervision of the medical field performance of EMS providers.
This includes ensuring that EMS providers have adequate clinical knowledge of, and are
competent in performing, medical skills and acts within the EMS provider’s scope of
practice authorized by the medical director. These duties and operations may be
delegated to other physicians or other qualified health care professionals designated by
the medical director. However, the medical director shall retain ultimate authority and
responsibility for the monitoring and supervision, for establishing protocols and standing
orders and for the competency of the performance of authorized medical acts.
4.2.7
Ensure that all protocols issued by the medical director are appropriate for the
certification and skill level of each EMS provider to whom the performance of medical
acts is delegated and authorized and compliant with accepted standards of medical
practice.
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4.2.8
Be familiar with the training, knowledge and competence of EMS providers under his or
her supervision and ensure that EMS providers are appropriately trained and
demonstrate ongoing competency in all skills, procedures and medications authorized in
accordance with Section 4.2.7.
4.2.9
Be aware that certain skills, procedures and medications authorized in accordance with
Section 4.2.7 (and as identified by the department) may not be included in the National
EMS Education Standards and ensure that appropriate additional training is provided to
supervised EMS providers.
4.2.10 Ensure that any data and/or documentation required by these rules are submitted to the
department.
4.2.11 Notify the department within fourteen business days excluding state holidays prior to his
or her cessation of duties as medical director.
4.2.12 Notify the department within fourteen business days excluding state holidays of his or her
termination of the supervision of an EMS provider for reasons that may constitute good
cause for disciplinary sanctions pursuant to the Rules Pertaining to EMS Education and
Certification, 6 CCR 1015-3, Chapter One. Such notification shall be in writing and shall
include a statement of the actions or omissions resulting in termination of supervision and
copies of all pertinent records.
4.2.13 Physicians acting as medical directors for EMS education programs recognized by the
department that require clinical and field internship performance by students shall be
permitted to delegate authority to a student-in-training during their performance of
program-required medical acts and only while under the control of the education
program.
4.2.14 Physicians acting as medical directors responsible for the supervision and authorization
of a P-CC shall have training and experience in the acts and skills for which they are
providing supervision and authorization. Additional duties related to the medical directors
responsible for the supervision and authorization of a P-CC is located in Section 16 of
these rules.
4.3
Departmental review of medical directors
4.3.1
The department may review the records of a medical director to determine compliance
with the requirements and standards in these rules and with accepted standards of
medical oversight and practice.
4.3.2
Complaints in writing against medical directors for violations of these rules may be
initiated by any person, the Colorado Medical Board or the department.
4.3.3
Complaints in writing against medical directors may be referred to the Colorado Medical
Board for review as deemed appropriate by the department.
SECTION 5 - Medical Acts Allowed for the EMT
5.1
An EMT may, under the supervision and authorization of a medical director, perform emergency
medical acts consistent with and not to exceed those listed in Appendices A and C of these rules
for an EMT.
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5.2
An EMT may, under the supervision and authorization of a medical director, administer and
monitor medications and classes of medications consistent with and not to exceed those listed in
Appendices B and D of these rules for an EMT.
5.3
Any EMT who is a member or employee of an EMS service agency and who performs said
emergency medical acts must have authorization and be supervised by a medical director to
perform said emergency medical acts.
5.4
EMTs may carry out a physician order for a mental health hold as set forth in Section 27-65105(1), C.R.S. Such physician order may be a direct verbal order or by electronic
communications.
5.5
An EMT who has successfully completed a department-recognized Intravenous Therapy and
Medication Administration Course may be referred to as an Emergency Medical Technician with
Intravenous Authorization (EMT-IV). Any provisions of these rules that are applicable to an EMT
shall also be applicable to an EMT-IV. In addition to the acts an EMT is allowed to perform, an
EMT-IV may, under supervision and authorization of a medical director, perform medical acts
consistent with and not to exceed those listed in Appendices A and C of these rules for an EMTIV. In addition to the medications and classes of medications an EMT is allowed to administer and
monitor pursuant to these rules, an EMT-IV may, under supervision and authorization of a
medical director, administer and monitor medications and classes of medications consistent with
and not to exceed those listed in Appendices B and D of these rules for an EMT-IV.
5.6
An EMT-IV may, under the supervision and authorization of a medical director, administer and
monitor medications and classes of medications which exceed those listed in Appendices B and
D of these rules for an EMT-IV under the direct visual supervision of an AEMT, EMT-I or
paramedic when the following conditions have been established:
5.7
5.6.1
The patient must be in cardiac arrest or in extremis.
5.6.2
Drugs administered must be limited to those authorized by these rules for an AEMT,
EMT-I or paramedic as stated in Appendices B and D.
5.6.3
The medical director shall amend the appropriate protocols and medical CQI program
used to supervise the EMS providers to reflect this change in patient care. The medical
director and the protocols of the EMT-IV and the AEMT, EMT-I or paramedic shall all be
in agreement.
In the event of a governor-declared disaster or public health emergency, the chief medical officer
for the department or his or her designee may temporarily authorize the performance of additional
medical acts, such as the administration of other immunizations, vaccines, biologicals or tests not
listed in these rules.
SECTION 6 - Medical Acts Allowed for the Advanced EMT
6.1
An AEMT may, under the supervision and authorization of a medical director, perform emergency
medical acts consistent with and not to exceed those listed in Appendices A and C of these rules
for an AEMT.
6.2
An AEMT may, under the supervision and authorization of a medical director, administer and
monitor medications and classes of medications consistent with and not to exceed those listed in
Appendices B and D of these rules for an AEMT.
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6.3
Any AEMT who is a member or employee of an EMS service agency and who performs said
emergency medical acts must have authorization and be supervised by a medical director to
perform said emergency medical acts.
6.4
AEMTs may carry out a physician order for a mental health hold as set forth in Section 27-65105(1), C.R.S. Such physician order may be a direct verbal order or by electronic
communications.
6.5
An AEMT may, under the supervision and authorization of a medical director, administer and
monitor medications and classes of medications which exceed those listed in Appendices B and
D of these rules for an AEMT under the direct visual supervision of an EMT-I or paramedic when
the following conditions have been established:
6.6
6.5.1
The patient must be in cardiac arrest or in extremis.
6.5.2
Drugs administered must be limited to those authorized by these rules for EMT-I or
paramedic as stated in Appendices B and D.
6.5.3
The medical director shall amend the appropriate protocols and medical CQI program
used to supervise the EMS providers to reflect this change in patient care. The medical
director and the protocols of the AEMT and the EMT-I or paramedic shall all be in
agreement.
In the event of a governor-declared disaster or public health emergency, the chief medical officer
for the department or his or her designee may temporarily authorize the performance of additional
medical acts, such as the administration of other immunizations, vaccines, biologicals or tests not
listed in these rules.
SECTION 7 - Medical Acts Allowed for the EMT-Intermediate
7.1
In addition to the acts an EMT, an EMT-IV and an AEMT are allowed to perform pursuant to
these rules, an EMT-I may, under the supervision and authorization of a medical director perform
advanced emergency medical care acts consistent with and not to exceed those listed in
Appendices A and C of these rules for an EMT-I.
7.2
In addition to the medications and classes of medications an EMT, an EMT-IV and an AEMT are
allowed to administer and monitor pursuant to these rules, an EMT-I may, under the supervision
and authorization of a medical director, administer and monitor medications and classes of
medications defined in Appendices B and D of these rules for an EMT-I.
7.3
An EMT-I may carry out a physician order for a mental health hold as set forth in Section 27-65105(1), C.R.S. Such physician order may be a direct verbal order or by electronic
communications.
7.4
An EMT-I may, under the supervision and authorization of a medical director, administer and
monitor medications and classes of medications which exceed those listed in Appendices B and
D of these rules for an EMT-I under the direct visual supervision of a paramedic, when the
following conditions have been established:
7.4.1
Drugs administered must be limited to those authorized by these rules for paramedics as
stated in Appendices B and D.
7.4.2
The medical director shall amend the appropriate protocols and medical CQI program
used to supervise the EMS providers to reflect this change in patient care. The medical
director and protocols of the EMT-I and paramedic shall all be in agreement.
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7.5
6 CCR 1015-3
In the event of a governor-declared disaster or public health emergency, the chief medical officer
for the department or his or her designee may temporarily authorize the performance of additional
medical acts, such as the administration of other immunizations, vaccines, biologicals or tests not
listed in these rules.
SECTION 8 - Medical Acts Allowed for the Paramedic
8.1
In addition to the acts an EMT-I is allowed to perform pursuant to these rules, a paramedic may,
under the supervision and authorization of a medical director, perform advanced emergency
medical care acts consistent with and not to exceed those listed in Appendices A and C of these
rules for a paramedic.
8.2
In addition to the medications and classes of medications an EMT-I is allowed to administer and
monitor pursuant to these rules, a paramedic may, under the supervision and authorization of a
medical director, administer and monitor medications and classes of medications defined in
Appendices B and D for a paramedic.
8.3
Paramedics may carry out a physician order for a mental health hold as set forth in Section 2765-105(1), C.R.S. Such physician order may be a direct verbal order or by electronic
communications.
8.4
In addition to the acts of a paramedic, a P-CC may, under the supervision and authorization of a
medical director, perform advanced emergency medical care acts consistent with and not to
exceed those authorized in Appendix E of these rules for Critical Care.
8.5
In addition to the medications a paramedic is allowed to administer and monitor, a P-CC may,
under the supervision and authorization of a medical director, administer and monitor medications
defined in Appendix F of these rules for Critical Care.
8.6
In the event of a governor-declared disaster or public health emergency, the chief medical officer
for the department or his or her designee may temporarily authorize the performance of additional
medical acts, such as the administration of other immunizations, vaccines, biologicals or tests not
listed in these rules.
SECTION 9 - Graduate Advanced EMTs, Graduate EMT-Intermediates and Graduate Paramedics
Medical directors may supervise graduate AEMTs as defined in these rules acting as AEMTs for
a period of no more than six months following successful completion of an appropriate
department-recognized initial course. Medical directors may supervise graduate EMT-Is as
defined in these rules acting as EMT-Is for a period of no more than six months following
successful completion of an appropriate department-recognized initial course. Medical directors
may supervise graduate paramedics as defined in these rules acting as paramedics for a period
of no more than six months following successful completion of an appropriate departmentrecognized initial course. Such graduate AEMTs, graduate EMT-Is and graduate paramedics
must successfully complete certification requirements, as specified in Rules Pertaining to EMS
Education and Certification, 6 CCR 1015-3, Chapter One, within six months of the successful
completion of a department-recognized initial course to continue to function under the provisions
of these rules.
SECTION 10 - General Acts Allowed
10.1
Any EMS provider working for an EMS service agency shall be supervised by a medical director
who complies with the requirements in these rules.
10.2
A medical director may limit the scope of practice of any EMS provider.
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10.3
6 CCR 1015-3
The gathering of laboratory and/or other diagnostic data for the sole purpose of providing
information to another health care provider does not require a waiver provided:
10.3.1 The method by which the data is gathered is within the scope of practice of the EMS
provider as contained in these rules;
10.3.2 The collection method and analysis of the information collected is done in accordance
with applicable regulations including but not limited to the Clinical Laboratory
Improvement Amendments (CLIA), and FDA requirements; and,
10.3.3 Unless otherwise allowed in Table A.6, the information obtained will not be used to alter
the prehospital treatment or destination of the patient without a direct verbal order.
A medical director shall obtain a waiver as set forth in Section 11 of these rules for any other data
gathering activities that do not meet the provisions listed above.
10.4
EMS providers may function in acute care settings. Functioning in this environment must be in
compliance with the Colorado Medical Board’s statutes and rules, under the auspices of a
medical director and within parameters of the acts allowed or waiver as described in these rules.
10.5
EMS providers may not practice in camps in a nursing capacity including the dispensing of
medications.
SECTION 11 - Waivers to Scope of Practice
11.1
Any medical director may apply to the department for a waiver to the scope of practice set forth in
these rules for EMS providers under his or her supervision in specific circumstances, based on
established need, provided that on-going quality assurance of each EMS provider’s competency
is maintained by the medical director.
11.2
A waiver is not necessary for the allowed skills and medications listed in Appendices A, B, C or D
of this rule.
11.2.1 In addition to the skills and medications allowed in Paragraph 11.2, a P-CC does not
require a waiver for the allowed skills and medications listed in Appendices E and F.
11.3
All levels of EMS provider may, under the supervision and authorization of a medical director,
perform specific skills or administer specific medications not listed in Appendices A, B, C, D, E, or
F of this rule, only if the medical director has been granted a waiver from the department for that
specific skill or medication. Waivered skills or medication administration may be authorized by the
medical director under standing orders or direct verbal orders of a physician, including by
electronic communications. No EMS provider shall function beyond the scope of practice
identified in these rules for their level until their medical director has received official written
confirmation of the waiver being granted by the department.
11.4
Medical directors seeking a waiver shall submit a completed application to the department in a
form and manner determined by the department.
11.4.1 The application shall include, but not be limited to, a description of the act or medication
to be waived, information regarding the justification for the waiver, the proposed
education, training and quality assurance process, literature review, and copies of the
applicable protocols. The forms and affidavit required by Section 4 of these rules shall
also be included.
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11.4.2 The department may require the applicant to provide additional information if the initial
application is determined to be insufficient.
11.4.3 An application shall not be considered complete until the required information is
submitted.
11.4.4 The completed waiver application shall be submitted to the department in a timely fashion
as specified by the department.
11.4.5 The application shall be a matter of public record and is subject to disclosure
requirements under the Colorado Open Records Act (C.R.S. § 24-72-200.1 et seq.).
11.5
The EMPAC shall review waiver requests and make recommendations to the department. The
EMPAC may make recommendations, including but not limited to: deny, approve, table, request
more information from the medical director or impose special conditions on the waiver.
11.6
After receiving recommendations from the EMPAC, the department shall make a decision on the
waiver request and send notice of that decision to the medical director within thirty (30) calendar
days of the recommendation. If granted, the notice shall include the effective date and expiration
date of the waiver.
11.6.1 If the waiver is granted, the department may:
A)
Specify the terms and conditions of the waiver.
B)
Specify the duration of the waiver.
C)
Specify any reporting requirements.
11.6.2 The department may require the submission of data or other information regarding
waivers.
A)
Unless otherwise specified by the department, any data or information submitted
to the department shall not contain patient-identifying information.
B)
If the department requires submission of data or reports containing patientidentifying information for purposes of overseeing a statewide continuing quality
improvement system, that information shall be kept confidential pursuant to
C.R.S. § 25-3.5-704(2)(h)(I)(E).
C)
If the department requires submission of data, information, records or reports
related to the identification of individual patient’s, provider’s or facility’s care
outcomes for purposes of overseeing a statewide continuing quality improvement
system, that information shall be kept confidential pursuant to C.R.S. § 25-3.5702(2)(h)(II).
11.6.3 The department may deny, revoke or suspend a waiver if it determines:
A)
That its approval or continuation jeopardizes the health, safety and/or welfare of
patients.
B)
The medical director has provided false or misleading information in the waiver
application.
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C)
The medical director has failed to comply with conditions or reporting on an
approved waiver.
D)
That a change in federal or state law prohibits continuation of the waiver.
11.7
If the department denies a waiver application or revokes or suspends a waiver, it shall provide the
medical director with a notice explaining the basis for the action. The notice shall also inform the
medical director of his or her right to appeal and the procedure for appealing the action.
11.8
Appeals of departmental actions shall be conducted in accordance with the state Administrative
Procedure Act, Section 24-4-101, et seq., C.R.S.
11.9
If the rule pertaining to a waived skill or medication administration is amended or repealed
obviating the need for the waiver, the waiver shall expire on the effective date of the rule change.
11.10
If a medical director has made timely and sufficient application for renewal of a waiver and the
department fails to take action on the application prior to the waiver’s expiration date, the existing
waiver shall not expire until the department acts upon the application. The department, in its sole
discretion, shall determine whether the application was timely and sufficient.
11.11
In the case of exigent circumstances, including but not limited to, the death or incapacitation of a
medical director or the termination of the relationship between a medical director and an EMS
service agency, the department may transfer waivers upon request by a replacement medical
director for a period not to exceed six (6) months. The medical director shall then apply for new
waiver(s) for consideration and department action within sixty (60) days of the transfer.
SECTION 12 - Technology and Pharmacology Dependent Patients
The transport of patients with continuous intravenously administered medications and nutritional support,
previously prescribed by licensed health care workers and typically managed day-to-day at their
residence by either the patient or caretakers, shall be allowed. The EMS provider is not authorized to
discontinue, interfere with, alter or otherwise manage these patient medication/nutrition systems except
by direct verbal order or where cessation and/or continuation of medication pose a threat to the safety of
the patient.
SECTION 13 - Combination Benzodiazepine and Opiate Therapy
13.1
The administration of a combination of benzodiazepines and opiates, for the purpose of pain
management, anxiolysis and/or muscle relaxation is permitted. Safeguards shall be taken to
maximize patient safety including but not limited to the patient’s ability to:
13.1.1 Independently maintain an open airway and normal breathing pattern,
13.1.2 Maintain normal hemodynamics, and
13.1.3 Respond appropriately to physical stimulation and verbal commands.
13.2
The administration of combination therapy requires appropriate monitoring and care including but
not limited to: IV or IO access, continuous waveform capnography, pulse oximetry, ECG
monitoring, blood pressure monitoring and administration of supplemental oxygen.
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SECTION 14 - Scope of Practice
14.1
All of the following appendices define the maximum skills, acts or medications that may be
delegated to an EMT, EMT-IV, AEMT, EMT-I and paramedic under appropriate supervision by a
medical director.
14.2
A medical director may establish the circumstances and methods by which an EMS provider
obtains authorization to perform any medical act, skill or medication contained in these rules
including, but not limited to: standing order, direct verbal order, written order.
14.2.1 “Y” = YES: May be performed or administered by EMS providers with physician
supervision as described in these rules.
14.2.2 “VO” = Verbal Order: May only be performed or administered by EMS providers if
authorized by direct verbal order by a physician unless specific exception criteria are
established by the supervising physician. Exception criteria may include, but are not
limited to cardiac arrest, behavioral management or communications failure. Supervising
physicians shall not develop exception criteria that merely waive all direct verbal order
requirements.
14.2.3 “N” = NO: May not be performed or administered by EMS providers except with an
approved waiver as described in Section 11 of these rules.
14.2.4 “EMT” = Medical acts, skills or medications that may be performed or administered by an
EMT with appropriate medical director supervision and training recognized by the
department.
14.2.5 “EMT-IV” = Medical acts, skills or medications that may be performed or administered by
an EMT-IV with appropriate medical director supervision and training recognized by the
department.
14.2.6 “AEMT” = Medical acts, skills or medications that may be performed or administered by
an AEMT with appropriate medical director supervision and training recognized by the
department.
14.2.7 “EMT-I” = Medical acts, skills or medications that may be performed or administered by
an EMT-I with appropriate medical director supervision and training recognized by the
department.
14.2.8 “P” = Medical acts, skills or medications that may be performed or administered by a
paramedic with appropriate medical director supervision and training recognized by the
department.
Note: SECTION 15 - INTERFACILITY TRANSPORT begins following APPENDIX B.
Note: Section 16 – CRITICAL CARE begins following APPENDIX D.
APPENDIX A
PREHOSPITAL
MEDICAL SKILLS AND ACTS ALLOWED
A.1.1
Additions to these medical skills and acts allowed cannot be delegated unless a waiver has been
granted as described in Section 11 of these rules.
30
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
A.1.2
6 CCR 1015-3
Not all medical skills and acts allowed are included in initial education for various EMS provider
levels. Medical directors shall ensure providers are appropriately trained as noted in Sections
4.2.8 and 4.2.9.
TABLE A.1 - AIRWAY/VENTILATION/OXYGEN
Skill
Airway - Supraglottic
Airway - Nasal
Airway - Oral
Bag - Valve - Mask (BVM)
Carbon Monoxide Monitoring
Chest Decompression - Needle
Chest Tube Insertion
CPAP
PEEP
Cricoid Pressure - Sellick’s Maneuver
Cricothyroidotomy - Needle
Cricothyroidotomy - Surgical
End Tidal CO2 Monitoring/Capnometry/ Capnography
Flow Restrictive Oxygen Powered Ventilatory Device
Gastric Decompression - NG/OG Tube Insertion
Inspiratory Impedence Threshold Device
Intubation - Digital
Intubation - Bougie Style Introducer
Intubation - Lighted Stylet
Intubation - Medication Assisted (non-paralytic)
Intubation - Medication Assisted (paralytics) (RSI)
Intubation - Maintenance with paralytics
Intubation - Nasotracheal
Intubation - Orotracheal
Intubation - Retrograde
Extubation
Obstruction - Direct Laryngoscopy
Oxygen Therapy – Humidifiers
Oxygen Therapy - Nasal Cannula
Oxygen Therapy - Non-rebreather Mask
Oxygen Therapy - Simple Face Mask
Oxygen Therapy - Venturi Mask
Peak Expiratory Flow Testing
Pulse Oximetry
Suctioning – Tracheobronchial
Suctioning - Upper Airway
Tracheostomy Maintenance - Airway management only
Tracheostomy Maintenance - Includes replacement
Ventilators - Automated Transport (ATV)
1
EMT
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
EMT-IV
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
AEMT
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
EMT-I
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
N
N
Y
P
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
N
Y
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
N
N
Y
N
Y
Y
N
N
Y
N
Y
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
N
N
Y
N
Y
Y
N
N
Y
N
Y
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
N
N
Y
N
Y
N
Y
Y
N
N
N
N
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1
Use of automated transport ventilators (ATVs) is restricted to the manipulation of tidal volume (TV or VT), respiratory rate (RR),
fraction of inspired oxygen (FIO2), and positive end expiratory pressure (PEEP). Manipulation of any other parameters of
mechanical ventilation devices by EMS providers requires a waiver to these rules.
31
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
6 CCR 1015-3
TABLE A.2 - CARDIOVASCULAR/CIRCULATORY SUPPORT
Skill
EMT
Cardiac Monitoring - Application of electrodes and data
Y
transmission
Cardiac Monitoring - Rhythm and diagnostic EKG
N
interpretation
Cardiopulmonary Resuscitation (CPR)
Y
Cardioversion - Electrical
N
Carotid Massage
N
Defibrillation - Automated/Semi-Automated (AED)
Y
Defibrillation - Manual
N
External Pelvic Compression
Y
Hemorrhage Control - Direct Pressure
Y
Hemorrhage Control - Pressure Point
Y
Hemorrhage Control - Tourniquet
Y
Implantable cardioverter/defibrillator magnet use
N
Mechanical CPR Device
Y
Transcutaneous Pacing
N
Transvenous Pacing - Maintenance
N
2
N
Therapeutic Induced Hypothermia (TIH)
Arterial Blood Pressure Indwelling Catheter Maintenance
Invasive Intracardiac Catheters - Maintenance
Central Venous Catheter Insertion
Central Venous Catheter Maintenance/Patency/Use
Percutaneous Pericardiocentesis
2
EMT-IV
Y
AEMT
Y
EMT-I
Y
P
Y
N
N
Y
Y
Y
N
N
Y
N
Y
Y
Y
Y
N
Y
N
N
N
Y
N
N
Y
N
Y
Y
Y
Y
N
Y
N
N
N
Y
N
N
Y
Y
Y
Y
Y
Y
N
Y
Y
N
VO
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
N
N
N
Y
N
Therapeutic Induced Hypothermia (TIH) 1.
Approved methods of cooling include:
a.
Surface cooling methods including ice packs, evaporative cooling and surface cooling blankets or surface heatexchange devices.
b.
2.
3.
Internal cooling with the intravenous administration of cold crystalloids (4°C / 39°F)
Esophageal temperature probe allowed for monitoring core temperatures in patients undergoing TIH.
The medical director should work with the hospital systems to which their agencies transport in setting up a “systems”
approach to the institution of TIH. Medical directors should not institute TIH without having receiving facilities that also
have TIH programs to which to transport these patients.
TABLE A.3 - IMMOBILIZATION
Skill
Spinal Immobilization - Cervical Collar
Spinal Immobilization - Long Board
Spinal Immobilization - Manual Stabilization
Spinal Immobilization - Seated Patient
Splinting - Manual
Splinting - Rigid
Splinting - Soft
Splinting - Traction
Splinting - Vacuum
EMT
Y
Y
Y
Y
Y
Y
Y
Y
Y
EMT-IV
Y
Y
Y
Y
Y
Y
Y
Y
Y
AEMT
Y
Y
Y
Y
Y
Y
Y
Y
Y
EMT-I
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
32
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
6 CCR 1015-3
TABLE A.4 - INTRAVENOUS CANNULATION / FLUID ADMINISTRATION / FLUID MAINTENANCE
Skill
EMT
EMT-IV
AEMT
EMT-I
Blood/Blood By-Products Initiation (out of facility
N
N
N
N
initiation)
Colloids - (Albumin, Dextran) - Initiation
N
N
N
N
Crystalloids (D5W, LR, NS) - Initiation/Maintenance
N
Y
Y
Y
Intraosseous - Initiation
N
N
Y
Y
Medicated IV Fluids Maintenance - As Authorized in
N
N
N
Y
Appendix B
Peripheral - Excluding External Jugular - Initiation
N
Y
Y
Y
Peripheral - Including External Jugular - Initiation
N
N
Y
Y
Use of Peripheral indwelling Catheter for IV medications
N
Y
Y
Y
(Does not include PICC)
TABLE A.5 - MEDICATION ADMINISTRATION ROUTES
Skill
Aerosolized
Atomized
Auto-Injector
Buccal
Endotracheal Tube (ET)
Extra-abdominal umbilical vein
Intradermal
Intramuscular (IM)
Intranasal (IN)
Intraosseous
Intravenous (IV) Piggyback
Intravenous (IV) Push
Nasogastric
Nebulized
Ophthalmic
Oral
Rectal
Subcutaneous
Sublingual
Sublingual (nitroglycerin)
Topical
Use of Mechanical Infusion Pumps
EMT
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
Y
N
Y
N
N
Y
Y
Y
N
EMT-IV
Y
Y
Y
Y
N
N
N
N
Y
N
N
Y
N
Y
N
Y
N
N
Y
Y
Y
N
AEMT
Y
Y
Y
Y
N
N
N
Y
Y
Y
N
Y
N
Y
N
Y
N
Y
Y
Y
Y
N
P
N
N
Y
Y
Y
Y
Y
Y
EMT-I
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
33
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
TABLE A.6 - MISCELLANEOUS
Skill
Aortic Balloon Pump Monitoring
Assisted Delivery
Capillary Blood Sampling
Diagnostic Interpretation - Blood Glucose 3
Diagnostic Interpretation - Blood Lactate 3
Dressing/Bandaging
Esophageal Temperature Probe for TIH
Eye Irrigation Noninvasive
Eye Irrigation Morgan Lens
Maintenance of Intracranial Monitoring Lines
MAST/Pneumatic Anti-Shock Garment
Physical examination
Restraints - Verbal
Restraints - Physical
Restraints - Chemical
Urinary Catheterization - Initiation
Urinary Catheterization - Maintenance
Venous Blood Sampling - Obtaining
3
6 CCR 1015-3
EMT
N
Y
Y
Y
EMT-IV
N
Y
Y
Y
AEMT
N
Y
Y
Y
EMT-I
N
Y
Y
Y
P
N
Y
Y
Y
N
N
Y
Y
Y
Y
N
Y
N
N
Y
Y
Y
Y
N
N
Y
N
Y
N
Y
N
N
Y
Y
Y
Y
N
N
Y
Y
Y
N
Y
N
N
Y
Y
Y
Y
N
N
Y
Y
Y
VO
Y
Y
N
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
See also Section 10.3
APPENDIX B
PREHOSPITAL
FORMULARY OF MEDICATIONS ALLOWED
B.1.1
Additions to this medication formulary cannot be delegated unless a waiver has been granted as
described in Section 11 of these rules.
B.1.2
Not all medical skills and acts allowed are included in initial education for various EMS provider
levels. Medical directors shall ensure providers are appropriately trained as noted in Sections
4.2.8 and 4.2.9.
TABLE B.1 - GENERAL
Medications
Over-the-counter-medications
Oxygen
Specialized prescription medications to address acute
crisis 1
EMT
Y
Y
VO
EMT-IV
Y
Y
VO
AEMT
Y
Y
VO
EMT-I
Y
Y
VO
P
Y
Y
V
O
1
EMS providers may assist with the administration of, or may directly administer, specialized medications prescribed to the patient
for the purposes of alleviating an acute medical crisis event provided the route of administration is within the provider’s scope as
listed in Appendix A.
TABLE B.2 – ANTIDOTES
34
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
Medications
Atropine
Calcium salt - Calcium chloride
Calcium salt - Calcium gluconate
Cyanide antidote
Glucagon
Naloxone
Nerve agent antidote
Pralidoxime
Sodium bicarbonate
6 CCR 1015-3
EMT
N
N
N
N
N
Y
Y
N
N
EMT-IV
N
N
N
N
N
Y
Y
N
N
AEMT
N
N
N
N
VO
Y
Y
N
N
EMT-I
VO
N
N
Y
VO
Y
Y
N
N
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
TABLE B.3 - BEHAVIORAL MANAGEMENT
Medications
Anti-Psychotic - Droperidol
Anti-Psychotic - Haloperidol
Anti-Psychotic - Olanzapine
Anti-Psychotic - Ziprasidone
Benzodiazepine - Diazepam
Benzodiazepine - Lorazepam
Benzodiazepine - Midazolam
Diphenhydramine
EMT
N
N
N
N
N
N
N
N
EMT-IV
N
N
N
N
N
N
N
N
AEMT
N
N
N
N
N
N
N
N
EMT-I
VO
VO
VO
VO
VO
VO
VO
VO
P
Y
Y
Y
Y
Y
Y
Y
Y
TABLE B.4 - CARDIOVASCULAR
Medications
Adenosine
Amiodarone - bolus infusion only
Aspirin
Atropine
Calcium salt - Calcium chloride
Calcium salt - Calcium gluconate
Diltiazem - bolus infusion only
Dopamine
Epinephrine
Lidocaine - bolus and continuous infusion
Magnesium sulfate - bolus infusion only
Morphine sulfate
Nitroglycerin - sublingual (patient assisted)
Nitroglycerin - sublingual (tablet or spray)
Nitroglycerin - topical paste
Sodium bicarbonate
Vasopressin
Verapamil - bolus infusion only
EMT
N
N
Y
N
N
N
N
N
N
N
N
N
VO
N
N
N
N
N
EMT-IV
N
N
Y
N
N
N
N
N
N
N
N
N
VO
N
N
N
N
N
AEMT
N
N
Y
N
N
N
N
N
N
N
N
N
Y
Y
VO
N
N
N
EMT-I
VO
VO
Y
VO
N
N
N
N
VO
VO
N
VO
Y
Y
VO
VO
VO
N
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
TABLE B.5 - DIURETICS
35
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
Medications
Bumetanide
Furosemide
Mannitol (trauma use only)
6 CCR 1015-3
EMT
N
N
N
EMT-IV
N
N
N
AEMT
N
N
N
EMT-I
N
VO
N
P
Y
Y
Y
TABLE B.6 - ENDOCRINE AND METABOLISM
Medications
IV Dextrose
Glucagon
Oral glucose
Thiamine
EMT
N
N
Y
N
EMT-IV
Y
N
Y
N
AEMT
Y
Y
Y
N
EMT-I
Y
Y
Y
N
P
Y
Y
Y
Y
TABLE B.7 - GASTROINTESTINAL MEDICATIONS
Medications
Anti-nausea - Droperidol
Anti-nausea - Metoclopramide
Anti-nausea - Ondansetron ODT
Anti-nausea - Ondansetron IM/IVP
Anti-nausea - Prochlorperazine
Anti-nausea - Promethazine
Decontaminant - Activated charcoal
Decontaminant - Sorbitol
EMT
N
N
VO
N
N
N
Y
Y
EMT-IV
N
N
VO
N
N
N
Y
Y
AEMT
N
N
Y
Y
N
N
Y
Y
EMT-I
VO
VO
Y
Y
N
VO
Y
Y
P
Y
Y
Y
Y
Y
Y
Y
Y
EMT
N
EMT-IV
N
AEMT
Y
EMT-I
Y
P
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
VO
N
N
N
N
N
N
N
VO
VO
VO
VO
VO
N
VO
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
TABLE B.8 - PAIN MANAGEMENT
Medications
Anesthetic - Lidocaine (for intraosseous needle
insertion)
Benzodiazepine - Diazepam
Benzodiazepine - Lorazepam
Benzodiazepine - Midazolam
General - Nitrous oxide
Narcotic Analgesic - Fentanyl
Narcotic Analgesic - Hydromorphone
Narcotic Analgesic - Morphine sulfate
Ophthalmic anesthetic-Opthaine
Ophthalmic anesthetic-Tetracaine
Topical Anesthetic - Benzocaine spray
Topical Anesthetic - Lidocaine jelly
36
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
6 CCR 1015-3
TABLE B.9 - RESPIRATORY AND ALLERGIC REACTION MEDICATIONS
Medications
EMT
EMT-IV
Antihistamine - Diphenhydramine
N
N
Bronchodilator - Anticholinergic - Atropine
N
N
(aerosol/nebulized)
Bronchodilator - Anticholinergic - Ipratropium
N
N
Bronchodilator - Beta agonist - Albuterol
VO
VO
Bronchodilator - Beta agonist - L-Albuterol
VO
VO
Bronchodilator - Beta agonist - Metaproterenol
N
N
Corticosteroid - Dexamethasone
N
N
Corticosteroid - Hydrocortisone
N
N
Corticosteroid - Methylprednisolone
N
N
Corticosteroid – Prednisone
N
N
Epinephrine 1:1,000 IM or SQ Only
N
N
Epinephrine IV Only
N
N
Epinephrine Auto-Injector
Y
Y
Magnesium Sulfate - bolus infusion only
N
N
Racemic Epinephrine
N
N
Short Acting Bronchodilator meter dose inhalers (MDI)
VO
VO
(Patient assisted)
Short Acting Bronchodilator meter dose inhalers (MDI)
VO
VO
Terbutaline
N
N
TABLE B.10 - SEIZURE MANAGEMENT
Medications
Benzodiazepine – Diazepam
Benzodiazepine - Lorazepam
Benzodiazepine – Midazolam
OB -associated - Magnesium sulfate - bolus infusion
only
TABLE B.11 - VACCINES
Medications
Post-exposure, employment, or pre-employment related
- Hepatitis B
Post-exposure, employment, or pre-employment related
- Tetanus
Post-exposure, employment, or pre-employment related
- Influenza
Post-exposure, employment, or pre-employment related
- PPD placement & interpretation
Public Health Related - Vaccine administration in
conjunction with county public health departments and
local EMS medical direction, after demonstration of
proper training, will be authorized for public health
vaccination efforts and pandemic planning exercises.
AEMT
VO
N
EMT-I
VO
VO
P
Y
Y
VO
VO
VO
N
N
N
N
N
VO
N
Y
N
N
VO
VO
VO
VO
VO
N
VO
VO
N
VO
VO
Y
N
VO
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
VO
N
VO
N
Y
Y
EMT
N
N
N
N
EMT-IV
N
N
N
N
AEMT
N
N
N
N
EMT-I
VO
VO
VO
VO
P
Y
Y
Y
Y
EMT
N
EMT-IV
N
AEMT
N
EMT-I
N
P
Y
N
N
N
N
Y
N
N
N
N
Y
N
N
N
N
Y
N
N
Y
Y
Y
37
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
TABLE B.12 - MISCELLANEOUS
Medications
Analgesic Sedative - Etomidate
Benzodiazepine - Midazolam for TIH
Lidocaine - bolus for intubation of head-injured patients
Narcotic Analgesic - Fentanyl for TIH
Topical Hemostatic agents
6 CCR 1015-3
EMT
N
N
N
N
Y
EMT-IV
N
N
N
N
Y
AEMT
N
N
N
N
Y
EMT-I
N
VO
VO
VO
Y
P
N
Y
Y
Y
Y
SECTION 15 - INTERFACILITY TRANSPORT
15.1
The EMS medical director shall have protocols in place to ensure the appropriate level of care is
available during interfacility transport.
15.2
The transporting EMS provider may decline to transport any patient he or she believes requires a
level of care beyond his or her capabilities.
15.3
Inter-facility transport typically involves three types of patients:
15.3.1 Those patients whose safe transport can be accomplished by ambulance, under the care
of an EMT, EMT-IV, AEMT, EMT-I, or paramedic, within the acts allowed under these
rules.
15.3.2 Those patients whose safe transport can be accomplished by ambulance, under the care
of a paramedic, but may require skills to be performed or medications to be administered
that are outside the acts allowed under these rules, but have been approved through
waiver granted by the department.
15.3.3 Those patients whose safe transport requires the skills and expertise of a critical care
transport team under the care of an experienced critical care practitioner.
15.4
The hemodynamically unstable patient (typically from an Intensive Care setting) who requires
special monitoring (e.g. central venous pressure, intracranial pressure), multiple
cardioactive/vasoactive medications, or specialized critical care equipment (i.e. intra-aortic
balloon pump) should remain under the care of an experienced critical care practitioner, and
every attempt should be made to transport that patient while maintaining the appropriate level of
care. The capabilities of the institution, the capabilities of the transporting agency and, most
importantly, the safety of the patient should be considered when making transport decisions.
15.5
Unless otherwise noted, the following Appendices C and D indicate hospital/facility initiated
interventions and/or medications.
15.5.1 Additions to these medical skills and acts allowed cannot be delegated unless a waiver
has been granted as described in Section 11 of these rules.
15.5.2 The following medical skills and acts are approved for interfacility transport of patients,
with the requirements that the skill, act or medication allowed must have been initiated in
a medical facility under the direct order and supervision of licensed medical providers,
and are NOT authorized for field initiation. EMS continuation and monitoring of these
interventions is to be allowed with any alterations in the therapy requiring direct verbal
order. The EMS provider should continue the same medical standards of care with
regards to patient monitoring that were initiated in the facility.
38
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
6 CCR 1015-3
15.5.3 It is understood that these skills and acts may not be addressed in the National EMS
Education Standards for EMT, AEMT, EMT-I or paramedic. As such, it is the joint
responsibility of the medical director and individuals performing these skills to obtain
appropriate additional training needed to safely and effectively utilize and monitor these
interventions in the interfacility transport environment.
APPENDIX C
INTERFACILITY TRANSPORT - ONLY
MEDICAL SKILLS AND ACTS ALLOWED
TABLE C.1 - AIRWAY/VENTILATION/OXYGEN
Skill
Ventilators - Automated Transport (ATV) 1
EMT
N
EMT-IV
N
AEMT
N
EMT-I
N
P
Y
1
Use of automated transport ventilators (ATVs) is restricted to the manipulation of tidal volume (TV or VT), respiratory rate (RR),
fraction of inspired oxygen (FIO2), and positive end expiratory pressure (PEEP). Manipulation of any other parameters of
mechanical ventilation devices by EMS providers requires a waiver to these rules.
TABLE C.2 - CARDIOVASCULAR/CIRCULATORY SUPPORT
Skill
EMT
Aortic Balloon Pump Monitoring
N
Chest Tube Monitoring
N
Central Venous Pressure Monitor Interpretation
N
EMT-IV
N
N
N
AEMT
N
N
N
EMT-I
N
N
N
P
N
Y
N
APPENDIX D
FORMULARY OF MEDICATIONS ALLOWED
TABLE D.1 - CARDIOVASCULAR
Medications
Anti-arrhythmic - Amiodarone - continuous infusion
Anti-arrhythmic - Lidocaine - continuous infusion
Anticoagulant - Glycoprotein inhibitors
Anticoagulant - Heparin (unfractionated)
Anticoagulant - Low Molecular Weight Heparin (LMWH)
Diltiazem
Dobutamine
Nicardipine
Nitroglycerin, intravenous
EMT
N
N
N
N
N
N
N
N
N
EMT-IV
N
N
N
N
N
N
N
N
N
AEMT
N
N
N
N
N
N
N
N
N
EMT-I
Y
Y
N
N
N
N
N
N
N
P
Y
Y
Y
Y
Y
Y
N
Y
Y
TABLE D.2 - HIGH RISK OBSTETRICAL PATIENTS
Medications
Magnesium sulfate
Oxytocin - infusion
EMT
N
N
EMT-IV
N
N
AEMT
N
N
EMT-I
N
N
P
Y
Y
39
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
TABLE D.3 - INTRAVENOUS SOLUTIONS
Medications
Monitoring and maintenance of hospital/medical facility
initiated crystalloids
Monitoring and maintenance of hospital/medical facility
initiated colloids (non-blood component) infusions
Monitoring and maintenance of hospital/medical facility
initiated blood component infusion
Initiate hospital/medical facility supplied blood
component infusions
Total parenteral nutrition (TPN) and/or vitamins
TABLE D.4 - MISCELLANEOUS
Medications
Antibiotic infusions
Antidote infusion - Sodium bicarbonate infusion
Electrolyte infusion - Magnesium sulfate
Electrolyte infusion - Potassium chloride
Insulin
Mannitol
Methylprednisolone - infusion
Octreotide
Pantoprazole
6 CCR 1015-3
EMT
N
EMT-IV
Y
AEMT
Y
EMT-I
Y
P
Y
N
N
N
Y
Y
N
N
N
N
Y
N
N
N
N
Y
N
N
N
Y
Y
EMT
N
N
N
N
N
N
N
N
N
EMT-IV
N
N
N
N
N
N
N
N
N
AEMT
N
N
N
N
N
N
N
N
N
EMT-I
Y
N
N
N
N
N
N
N
N
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
SECTION 16 - CRITICAL CARE
16.1
In addition to the medical skills and acts within the scope of practice of a paramedic contained
within Appendices A, B, C, and D, a P-CC may perform the medical skills and acts contained
within this section, Appendices E and F, under the direction of a qualified medical director.
16.1.1 Additions to these medical skills and acts allowed cannot be delegated unless a waiver
had been granted as described in Section 11 of these rules.
16.1.2 It is understood that these medical skills and acts may not be addressed in the National
EMS Education Standards for Paramedics. As such, it is the joint responsibility of the
medical director and individuals performing these skills to obtain appropriate additional
training needed to safely and effectively utilize and monitor these interventions in the
critical care environment.
16.2
A P-CC may decline transport of any patient that requires a level of care outside of their defined
scope of practice or that the P-CC believes is beyond their capabilities.
16.3
In addition to the duties of a medical director outlined in Section 4 of these rules, the duties of a
medical director responsible for supervision and authorization of a P-CC shall include:
16.3.1 Be qualified, by education, training, and experience in the medical skills and acts for
which the medical director is authorizing the P-CC to practice.
16.3.2 Have protocols in place clearly defining which medical skills and acts, from Appendices E
and F, the medical director is authorizing the P-CC to perform.
16.3.3 Have protocols in place to ensure the appropriate level of care is available during critical
care transport. The capabilities of the transporting agency and the safety of the patient
should be considered when making transport decisions.
40
CODE OF COLORADO REGULATIONS
Health Facilities and Emergency Medical Services Division
6 CCR 1015-3
Appendix E – MEDICAL SKILLS AND ACTS ALLOWED
TABLE E.1
Skill
Manual Transport Ventilators
Blood Chemistry Interpretation
Rapid Sequence Intubation – Adult (age 13 & over)
P-CC
Y
Y
Y
Appendix F – FORMULARY OF MEDICATIONS ALLOWED
TABLE F.1 – RAPID SEQUENCE INTUBATION AND/OR MAINTENANCE OF ALREADY INTUBATED
PATIENTS
Medications
P-CC
diazepam (Valium)
Y
etomidate (Amidate)
Y
fentanyl (Sublimaze)
Y
ketamine (Ketalar)
Y
midazolam (Versed)
Y
morphine sulfate
Y
propofol (Diprivan) – maintenance only
Y
rocuronium (Zemuron)
Y
succinylcholine (Anectine)
Y
vecuronium (Norcuron)
Y
TABLE F.2 – CRITICAL CARE INTERFACILITY FORMULARY
Medications
acetylcysteine (Mucomyst)
alteplase (Activase)
bilvalirudin (Angiomax)
dobutamine (Dobutamine)
esmolol (Brevibloc)
fosphenytoin (Cerebyx)
labetalol (Normodyne)
levitiracetam (Keppra)
metoprolol (Lopressor)
norepinephrine (Levophed)
phenytoin (Dilantin)
TNKase (Tenecteplase)
tPA infusion maintenance
P-CC
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
41