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Omaha Fire Department
Standard Operating Procedures
EMERGENCY MEDICAL SERVICES 4-0
PARAMEDIC TREATMENT PROTOCOL
REVISION HISTORY
REVISION #
REVISION DESCRIPTION
DATE REVISED
AUTHOR
REVIEWED BY
APPROVED BY
1
Periodic Revision
Ketamine, D10, Glucagon, &
Epi Drip
Oct 2015
Rupp 578
Mancuso 802
Hunter 723
June 2016
Brown 750
Rupp 578
Hunter 723
2
IN EFFECT JUNE 2016
Table of Contents________________________________
General Operations………………………………………………….....Pages 4-15
Introductions
Physicians Orders
Transportation Codes
Special Transportation Considerations
Behavioral Emergencies
Physician on Scene
DNR Orders
Code 4 Patients
Out of Hospital Confirmation of Death
Refusal of Care
4
4
5
6
7
8
9
11
12
14
Standard Operating Procedures
EMS 4-0
General Principles …………………………………………………Pages 16-22
Airway, Oxygen, and Ventilation
CPAP
IV Therapy/Medications
Body Substance Isolation (BSI)
Restraints
Pain Management - Adult Criteria
Pain Management - Pediatric Criteria
16
17
18
19
19
21
22
Cardiac Emergencies (Adult)……………………………………….Pages 22-31
General Guidelines
Ventricular Fibrillation (VF) and Pulseless VT
Asystole
Pulseless Electrical Activity (PEA)
Return of Spontaneous Circulation (ROSC)
Bradycardia
Ventricular Tachycardia with a Pulse
Supraventricular Tachycardia (PSVT)
A-Fib and A-Flutter with Rapid Ventricular Rate
Ventricular Ectopy with Runs of V-Tach
Acute Coronary Syndrome (ACS)
Pulmonary Edema
Cardiogenic Shock
22
23
24
24
25
26
27
27
28
29
29
30
31
Acute Trauma Emergencies………………………………………..Pages 31-38
General Trauma Management
31
Penetrating Injuries to Head, Neck, Chest, and Abdomen 33
Head Injuries
33
Chest Injuries
33
Abdominal Injuries
34
Eye Trauma
34
Burns
34
Snakebites
35
Crush Syndrome
36
Decision Scheme for Trauma Patients
36
Trauma Center Rotation for Mass Casualty Incidents (MCI) 38
Medical Emergencies………………………………………………..Pages 38-49
Upper Airway Obstruction
Altered Mental Status
Excited Delirium
Seizures
Difficulty Breathing
Exposure
Hypotension in the Absence of Trauma
Poisons
Nerve Agents
Overdose/Toxic Ingestion
Toxic Inhalation
Cyanide Poisoning
Stroke (TIA, CVA)
Behavioral Emergencies
Nausea and / or Vomiting
38
39
41
43
44
45
46
46
46
47
47
48
48
49
49
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Obstetrics—Gynecology……………………………………………..Pages 49-51
Imminent Delivery
Neonatal Care
Meconium Stained Fluid
Childbirth Complications
Postpartum Hemorrhage
Hypertensive Disorders of Pregnancy
Vaginal Bleeding
49
49
50
50
51
51
51
Pediatrics………………………………………………………………Pages 52-60
General Guidelines
Airway Management/O2 Therapy
IV Therapy
Pediatric Cardiac Arrest
V-Fib/Pulseless V-Tach
Asystole/PEA
Pediatric General Cardiac Dysrhythmia
Bradycardia (Unstable)
V-Tach with a Pulse
SVT (Unstable)
Difficulty Breathing
Seizures
Altered Mental Status
52
52
53
53
53
54
55
55
56
56
57
58
59
Procedure A, B, C, D, E, F, G, H…………………………………Pages 61-78
A.
B.
C.
D.
E.
F.
G.
H.
Rapid Sequence Intubation
Cincinnati Pre-hospital Stroke Scale
Cervical Spine Immobilization Considerations
Nerve Agent/Organophosphate
Mark 1 Kits / DuoDotes
12-Lead ECG Procedures
Cyanide Poisoning – Cyanokit
Trauma Scoring and GCS
Epinephrine Drip
61
64
65
67
71
73
76
78
Appendix A…………………...…………………………………… Pages 79 - 83
A. OFD EMS Abbreviations
79
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GENERAL OPERATIONS
A. Introduction
1. The Omaha Fire Department has adopted the current Midlands Protocol
Committee Paramedic Treatment Protocol and the State of Nebraska EMS Model
Protocols as a basis for paramedic patient care guidelines. This document consists
of these two protocols with modifications from the Omaha Fire Department Medical
Director for Omaha Fire specific policies and procedures.
2. The Omaha Fire Department Physician Medical Director is responsible for
developing and approving these protocols. This protocol, in its entirety, is
considered a standing order.
3. The Omaha Fire Department will follow all EMS rules and regulations set forth by
the Authority Having Jurisdiction.
4. This document utilizes current American Heart Association BLS, ACLS and PALS
guidelines. In addition, current PHTLS guidelines are used when referring to
trauma situations. Changes to any of these national guidelines will be adopted and
implemented as they occur.
5. At least one Paramedic must be present on all runs governed by this protocol.
6. Definitions:
Bypassed Patient – A patient that the receiving hospital has chosen to divert to
another facility or diverts a trauma patient to the trauma center.
ePCR (Electronic Patient Care Reporting) – The OFD mechanism used for
documentation of EMS patients and EMS runs (patient care report)
Receiving Hospital – The hospital that receives the patient.
B. Physician Orders / Communications
This protocol, in its entirety, is considered a standing order. Radio communications are
not required prior to performing any protocol action.
If at any point the paramedic determines guidance is necessary, the paramedic may
contact the receiving facility or the Omaha Fire Department Medical Director or the
Paramedic Shift Supervisor (PSS) for further direction or confirmation of orders whenever
the patient’s condition or the situation warrants.
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C. Transport Codes and Guidelines
Code 1
Minimal or no apparent disease or injury. Patient transported for
Examination.
Code 2
Obvious illness or injury, not a serious injury or illness but needs
medical attention.
Code 2 Trauma Trauma patient with an obvious injury but doesn’t clearly meet the
criteria for a Code 3. Enough questionable signs, symptoms or MOI
exists to warrant the expertise of the Trauma Center.
Code 3
Apparent serious / life-threatening medical
immediate medical attention.
illness
needing
Code 3 Stroke
Patient has been identified as having a stroke (stroke alert). All
stroke patients will be transported Code 3 Stroke to a hospital with
stroke care capabilities.
Code 3 STEMI Patient has been identified as having ST-segment elevation
myocardial infarction (STEMI alert). All STEMI patients will be
transported Code 3 STEMI to a hospital with cardiac catheterization
lab capabilities.
Code 3 Trauma Trauma patient with an actual or potential life or limb threatening
injury.
Code 99
Cardiopulmonary arrest with resuscitation in progress.
Code 4
Dead patient.
Code 5
For suspected SIDS patient, (patient meets criteria for Code 4, and
transport is for the family/bystanders). CPR only (basic life support).
Hospital of Choice
With the exception of hemodynamically unstable patients, the patient/patient’s family shall
be given the choice of the receiving hospital to which they would like to be transported.
Trauma Center of the Day Schedule:
For patients who are hemodynamically unstable or who do not express a hospital
preference, transport to:

Nebraska Medicine – Odd Days

CHI Alegent Creighton Health – Even Days
MCI (Mass Casualty Incident) – In the event of an MCI, the Omaha Trauma Centers will
both open and receive Code 3 (RED) patients with a 4 and 4 rotation. See Trauma Center
Rotation Protocol.
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D. Special Transport Considerations
Families – Every effort should be made to keep injured family members together and
transported to the same appropriate hospital.
Transplant/Dialysis Patients – If a patient is identified as a transplant or dialysis patient,
they shall be taken to the hospital where they are currently receiving care. An exception
is the patient who suffers a respiratory or medical cardiac arrest. In this case, the patient
shall be taken to the closest hospital.
Use prudent judgment if a dialysis or transplant patient is resuscitated. Go to the institution
that can best care for the patient (usually the hospital where they are currently receiving
care).
LVAD (Left Ventricular Assist Device) Patients – If a patient is identified as an LVAD
patient, they shall be taken to the hospital where they are currently receiving their care.
Law Enforcement - Police officers are not permitted the right to dictate the hospital that
patients will be transported to by OFD medic units.
Pediatric Transport Considerations
A pediatric patient is a patient up to and including 15 years of age.
Pediatric Medical Patients – Code 3 medical pediatric patients should be transported
to the closest hospital.
Pediatric patients with extreme hypothermia exhibiting signs of altered mental status or
cardiac dysfunction and no signs or suspicion of trauma should be transported to
Children’s Hospital.
If the receiving hospital diverts an OFD medic unit attempting to transport a Code 3
medical (non-trauma) pediatric patient, the OFD medic unit should transport the patient
based on the medic unit’s actual physical location at the point of being diverted (go to
closest of):


If west of 60th Street in Omaha, transport to Children’s Hospital.
If east of 60th Street in Omaha, transport to CHI Alegent Creighton Health or
Nebraska Medicine.
Pediatric Trauma Patients – All Code 2 (Level 2) pediatric trauma patients should be
transported to either Children’s Hospital or Nebraska Medicine (see below.)
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The following injured children are best served by evaluation and treatment at
Children’s Hospital. These children must be transported to Children’s Hospital:

Traumatically injured children who do NOT require major immediate resuscitation

Hemodynamically stable

GCS greater than 9

Low risk mechanisms of injury
o Victims of asphyxiation (example: drowning, hangings, smoke inhalation
without burns)
All Code 3 (Level 1) pediatric trauma patients will be transported to The Nebraska Medical
Center. All pediatric patients with asphyxiation injuries will be transported to Children’s
Medical Center. Code 3 pediatric trauma patients will not be transported to Creighton.
For the purposes of this protocol, a child is defined as up to and including 15 years old.
This protocol applies 24/7 regardless of “trauma center of the day” for adult patients.
The following injured children are best served by evaluation and treatment at
Nebraska Medicine. These children must be transported to Nebraska Medicine:

Traumatically injured children who DO require major, immediate resuscitation

Code 99 (traumatic cardiac arrest except asphyxiation – see below)

Hemodynamic instability or poor perfusion

Respiratory compromise, including need to maintain airway and intubation

Neurologic compromise, GCS <9 or deteriorating status

All burn patients

Traumatic amputations

Significant vascular injuries

High risk mechanisms: i.e. ejection, GSW

Unstable pelvic fractures

Spinal cord injury or paralysis
Code 4 Patients – For safety reasons, when appropriate, certain Code 4 patients may
be evacuated from the scene and transported to the appropriate hospital.
E. Behavioral Emergencies (Psychiatric, Overdose and Suicidal Patients)
Transport Considerations
Code 1 and Code 2 psychiatric, overdose and suicidal patients and their families will be
offered hospital of choice options for transports. If they do not indicate a hospital of choice,
they will be transported to the catchment area hospital.
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Patients who are rational and present no risk to OFD EMS personnel or to themselves
may be transported to hospital of choice.
Behavioral, psychiatric, overdose and suicidal patients that are Code 3, Code 99 or a
potential risk to the safety of OFD medic unit personnel will be transported to the
catchment area hospital.
ALWAYS consider a medical etiology for a behavioral emergency.
F. Physician on Scene
There are times that a physician, not affiliated with OFD, but licensed to practice
traditional medicine in the state of Nebraska will identify him/her on a scene and may wish
to direct the actions of OFD EMS personnel. This protocol is intended to provide guidance
to OFD EMS personnel while ensuring the best care possible for the patient. When a
physician is present on the scene and desires to direct the run, OFD EMS personnel
should:
1. Inform the physician that if the physician directs the run, the physician must ride
along, in the rear of the medic unit with the patient to the hospital and transfer care
and treatment history to the emergency room staff.
2. Inform the physician at the onset of the run that OFD paramedic personnel have
strict legal guidelines and established protocols and they may not exceed those
guidelines or protocols.
3. Inform the physician that any procedure outside of these legal guidelines must be
carried out by the physician him/herself.
4. OFD EMS personnel have the right and obligation at any time there is gross
deviation from the accepted protocol to contact the receiving hospital for further
instruction. The physician on the scene should be informed if contact with the
hospital is being made.
5. Only traditional medical practices will be allowed. At no time shall a physician
perform non-traditional procedures. Examples of non-traditional procedures
include chiropractic procedures, acupuncture or spiritual healing.
6. If at any time there is a problem or discrepancy in procedures, OFD EMS personnel
may contact the receiving hospital by phone or radio and have the receiving
hospital physician speak directly to the physician at the scene.
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G. “Do Not Resuscitate” (DNR) Orders and Identification of CPR Only
(Adopted from “Nebraska EMS Model Protocols”)
With the advent of individuals taking greater responsibility for their own health care,
decisions made by the individuals themselves, to not prolong their own life, is recognized
as valid and has become more common. Health Care Power of Attorney, Living Wills and
“Do Not Resuscitate” (DNR) orders are encountered frequently by OFD personnel.
Occasionally, a family member will call 911 even when a DNR order exists or a Living Will
is present. There are also times when OFD will arrive on scene, begin resuscitation
procedures and a DNR or Living Will is discovered. This protocol is designed to provide
guidance for such situations.
“Do Not Resuscitate” (DNR) – A DNR is a written order by a physician stating that no
cardiopulmonary resuscitation will be initiated. A DNR must be signed by a physician,
dated and have the patient’s name on it. OFD EMS personnel can honor a DNR. The
OFD EMS provider must be identified in the patient care report. Verbal confirmation of a
DNR by a family member or friend without verification of a written DNR is not sufficient to
withhold resuscitation efforts.
Health Care Power of Attorney (HCPA) – is a legal document stating the name of the
person the individual (patient) has named as the person who will make medical decisions
for their care. It should be signed by the patient and the patient’s attorney, and only
applies to adults.
Living Will – This document states the patient’s wishes should they require resuscitation
or life support measures. The document must be signed by the patient and the patient’s
physician and only applies to adults.
1. OFD EMS providers will not initiate or continue cardiopulmonary resuscitation on
a patient in cardiac arrest once a valid DNR order is confirmed. In the event of
uncertainty, resuscitative measures should be initiated.
2. DNR does not mean that emergency medical care for any other medical condition
will be changed or limited. Patients shall receive emergency medical treatment
(BVM / airway management, IV therapy and pharmacology) up until the point of
cardiac arrest.
3. Physicians may designate a patient as DNR by written order, verbally – when the
physician is physically present at the scene or by telephone consult from the
paramedic on scene to the patient’s physician.
4. A written DNR order must contain the patient’s name and be signed by the
physician or by the RN who received the order from the physician.
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5. If a physician physically present at the scene designates the patient as a DNR, the
paramedic shall ask the physician to document the DNR designation on the OFD
179 or ePCR and sign it. If the physician refuses to document and sign the OFD
179 or ePCR, the paramedic shall initiate resuscitative measures.
6. In a skilled care facility (nursing home), DNR orders documented in the patient’s
medical record are considered valid if signed by the physician or by the RN for the
physician. A DNR form may be used, but is not required in the nursing home
setting. The OFD EMS provider who observed the DNR order must be identified
on the patient care report.
7. An OFD EMS provider can honor an effective Living Will or Health Care Power of
Attorney. This must be directly observed. OFD EMS providers can presume the
validity of this document if signed in Nebraska. Documents from other states in
compliance with that state’s laws are also valid in Nebraska.
8. If the family desires CPR and/or resuscitation in the presence of a DNR or HCPA,
the family’s wishes shall be honored.
9. Observation of an original or a photocopy of a living will or health care power of
attorney must be documented in the patient care report. An OFD EMS provider
shall not honor a living will if there is no information or evidence that a physician
has determined the patient is in a terminal condition or in a persistent vegetative
state. If there is information or evidence that a physician has determined the patient
is in a terminal condition or in a persistent vegetative state, this information should
be documented in the patient care report. The patient care report must also contain
information that the patient is an adult (is 19 or older or has been married).
10. If a telephone consult with the patient’s physician or the physician’s designee
verifies a DNR, the OFD paramedic can honor the order. Authorization shall be
documented on the patient care report and include the physician’s or physician
designee’s name, telephone number and time of the telephone call from the
paramedic to the physician.
11. Once CPR has been initiated, resuscitative measures may be discontinued when
any one of the following occurs:

A DNR or no code order is confirmed.

A Living Will or HCPA for an adult is being followed.

A physician physically present at the scene or the medical director, based on
information from the OFD EMS provider on scene, determines that CPR is
futile or should be discontinued.

An OFD EMS provider is following termination of CPR protocols that have
been authorized by the OFD Physician Medical Director.

Any time the scene becomes unsafe for rescuers.
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When signs of late death or all early signs of death are identified, the OFD
paramedic may discontinue CPR if previously started (see Code 4 protocol).
The paramedic will document a one minute printed rhythm strip from the
cardiac monitor if no signs of late death are apparent.
Management of Home Hospice Patient – Attempts should be made to contact the
hospice representative to provide additional guidance and support to the family prior to
transporting. If the family desires CPR and/or resuscitation in the presence of a DNR or
HCPA, the family’s wishes shall be honored.
Resuscitation of a DNR Patient – If inadvertently, a DNR patient is resuscitated, and in
the absence of physician directives, care should be continued and the patient should be
taken to the catchment area hospital.
Notification to OFD Dispatch – Once resuscitative measures are terminated, notify OFD
dispatch and request an OPD cruiser if one has not already been dispatched. OFD
personnel will remain on scene until OPD arrives. Give a brief history to the officer. Obtain
the officer’s name and badge number and document in the FRMS patient care report in
the narrative section.
H. Code 4 Patients
OFD personnel may be called to a scene where biologic and clinical death is evident. In
such cases, it is not necessary to begin resuscitation. Situations may also occur where
CPR has been initiated on an obviously deceased patient prior to the arrival of OFD EMS
personnel. This protocol is intended to assist OFD personnel in the identification of such
situations.
If the patient meets code 4 criteria, OFD EMS providers may discontinue CPR or may
choose not to initiate CPR.
A Code 4 patient is identified if he/she is described by one of the following categories:
1. Patient with obvious lethal injury – trauma cardiac arrest with injuries incompatible
with life (i.e. massive blood loss, displacement of brain tissue, decapitation)
2. Patient with one or more of the signs of late death:
–
–
–
–
Wrinkled cornea
Rigor mortis
Postmortem lividity
Decomposition
Paramedic shall obtain and document a 1 minute ECG rhythm strip demonstrating
asystole.
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3. Patient with all the following signs of early death:
– Unresponsive to all stimuli
– No pulse
– No spontaneous respirations
– Pupils which are fixed and dilated
Paramedic shall obtain and document a 1 minute ECG rhythm strip
demonstrating asystole.
4. Valid DNR form
5. Physician authorization
No patient will be declared Code 4 without a complete, hands-on physical evaluation
including:
1. No pulse, respirations or blood pressure
2. No response to painful stimulation, no corneal reflex, and no response to a sternal
rub
*All of the above will be documented in the patient care report (PCR)
The rhythm strip will be uploaded into the ePCR or mounted and sent to the EMS
office for review.
The only exceptions to the above are the following:
1.
2.
Injury not compatible with life
Advanced whole body decomposition. Remember that smell is NOT an
advanced sign of death.
Anytime the exceptions are used to declare death, the state of the body should be
documented in the Narrative section of the PCR.
NOTE: Care should be taken to rule out hypothermia, acute alcoholic intoxication, and
drug overdose.
I. Out of Hospital Confirmation of Death
The purpose of this protocol is to allow Paramedics to confirm / declare a patient dead
based on certain criteria with permission of the base station. This does not include
patients already concluded to be Code 4. Permission for declaration of death will be called
to the Nebraska Medicine ER over radio, cell phone, or landline. Nebraska Medicine
phone number is 402-507-3600.
Only Nebraska Medicine ED physicians can authorize this protocol over the radio or cell
phone.
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CRITERIA FOR REQUESTING DECLARATION OF DEATH IN THE FIELD:
Medical Code 99 patient
1.
2.
3.
4.
Patient found down for unknown period of time (or more than 10 minutes).
No CPR in progress when paramedics arrive on scene.
Patient assessed and found to have no signs of life.
Paramedic EKG evaluation is asystole.
Trauma code 99 patient
1.
No recent signs of life documented by bystanders or initially responding EMS
personnel.
2.
Patient assessed and found to have no signs of life.
3.
Asystole on EKG.
Field Protocol for Requesting Termination of Resuscitation Efforts
1. Paramedics who initially assess patient and meet the listed requirements should
have BLS being performed on the patient.
2. Nebraska Medicine will be contacted via standard radio procedures or cell phone.
3. Paramedic will describe circumstances around the arrest, length of time patient
down without CPR, and EKG findings.
4. Nebraska Medicine will either suggest continuing resuscitation and transport or
give the order to terminate resuscitation attempt.
5. Paramedics should confirm that the family agrees with the termination of efforts.
6. If resuscitation is to continue, the patient will be brought to closest appropriate
hospital based on protocol.
7. If patient is declared dead at scene, documentation will be completed, including
the above criteria and time the patient was confirmed/pronounced dead by the
Nebraska Medicine ED physician. The Coroner’s Office will then be notified (in
appropriate circumstances) and the patient will either be transported to County
Hospital or left at the scene with the appropriate authorities (usually local law
enforcement) for the Coroner’s Office to collect.
8. A one minute cardiac rhythm strip will be obtained to document asystole.
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J. Refusal of Care
The patient has the right to refuse either or both care and transportation. However, OFD
personnel have both a moral and legal obligation to provide adequate medical care, according
to the provider’s level of training and certification, until the patient is delivered to the receiving
hospital. In situations in which the patient is refusing care, the following guidelines shall be
followed.
Adults

An adult is an individual 19 years old or older or who is or has been married (NEB
REV STAT §43-2101). A competent adult can refuse medical services and/or
transportation to a health care facility.

A legal guardian can consent to or refuse medical services and/or transportation to
a health care facility for an incompetent adult.

A person appointed as a Health Care Power of Attorney can consent or refuse
consent for medical services and/or transportation to a health care facility for the
incompetent adult named in the power of attorney.
Minors

A minor is an individual under 19 years of age that has never been married or
emancipated.

A parent or legal guardian can consent or refuse consent on behalf of a minor, for
medical services and/or transportation to a health care facility.

In cases of suspected abuse/neglect and refusal of care and/or transport, law
enforcement shall be notified.
Documentation (required)

Each patient shall be given a minimal physical assessment consisting of pupil
evaluation, level of consciousness, vital signs, lung sounds and/or respiratory rate
and effort and a general head to toe physical exam (palpation as indicated).

If a patient refuses to submit to a physical exam, the OFD EMS provider in charge
of patient care shall document this refusal in the narrative of the patient care report.
The narrative shall also document the following:
1. Results of the minimal physical assessment. Fill in the appropriate areas of the
patient care report.
2. Visual assessment, for example: “The patient is up and walking at the scene with
no apparent injury.”
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3. Patient is alert, coherent and articulate, for example:



alert – “The patient states his name, location and time of day correctly.”
coherent – “The patient is speaking in complete sentences with logical
thought flow.”
articulate – “Speech is distinct.”
Absence of any one of these may indicate insufficient ability to make good decisions.
Therefore, all efforts to convince the patient to allow treatment / transport should be
attempted.
NOTE: ETOH does NOT justify inaction. If after appropriate assessment, treatment is
not necessary, contact OPD for transport to appropriate facility.
1. Reason for the patient’s refusal, for example:
“Patient states he has no pain, injury or medical problem.” or “Patient refuses
treatment / transport for religious reasons.”
2. Attempt to get others involved, for example: “Family members also failed in efforts
to encourage patient to be transported to the hospital.”
3. Consequences explained, for example: “Patient informed that he may suffer
serious physical harm or death as a result of not being treated / transported.”
4. Alternatives explained, for example: “Patient instructed to use alternate means for
transport, or if condition worsens or change of mind occurs, to call 911.”
5. Concluding statement to each incident of patient refusal shall be the following:
“Patient strongly advised to seek medical care as soon as possible.”
6. Signature of patient and witness on OFD 179 form or ePCR. A valid witness shall
be any family member of legal age, a police officer, bystander, or at the very least,
another OFD firefighter on the call. If the patient refuses to sign the refusal form,
then the OFD firefighter documenting the run shall note this in the narrative.
Complete documentation shall include all applicable portions of ePCR and/or the OFD
179 form. From a legal standpoint, this documentation shall provide the basic defense
that appropriate actions were taken. Any omitted patient care documentation can be
challenged whether or not appropriate care was actually provided at the time of the
incident.
NOTE: If a patient needs treatment and/or transport to the hospital but the hospital of
choice is NOT a hospital that the OFD medic unit services (i.e. Mercy Hospital, Council
Bluffs or Offutt) and the patient refuses transport by OFD, the person in charge shall
instruct the patient to call a private ambulance for transport. After a patient assessment,
and if the patient condition warrants, Omaha Fire can remain on scene to monitor the
patient and treat as necessary until the private ambulance has arrived. Contact the PSS
if there is any question regarding the patient’s condition.
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GENERAL PRINCIPLES
A. Airway, Oxygen and Ventilation
An intact airway and adequate oxygenation and ventilation are essential for all patients
with medical or traumatic conditions. Throughout this protocol it is assumed that OFD
personnel will maintain a patent airway and provide appropriate supplemental
oxygenation.
1. Maintain patent airway with head-tilt/chin-lift or jaw thrust maneuver and consider
oral or nasal airway adjunct.
2. If ventilating adequately, apply nasal cannula at 2-6 L/min or non-rebreather mask
at 10-15 L/min.
3. If NOT ventilating adequately, assist ventilations with BVM and 100% oxygen –
advanced airway management may be required.
4. Consider assisting ventilations in those patients whose respiratory status does not
improve after receiving oxygen by non-rebreather mask.
5. Adjust oxygen delivery devices to maintain a blood oxygen saturation of >94%
unless contraindicated.
6. Record all vital signs (blood pressure, pulse, respirations, Oxygen saturation, CO2)
- pulse oximetry is required.
7. Utilize CO2 monitoring when available (Nasal Cannula, ET, King Airway etc)
8. Consider the use of CPAP if indicated by protocol.
9. Use trauma advanced airway techniques with patients who have suspected
compromised cervical spines.
10. Always confirm endotracheal tube placement by:




Attaching an EtCO2 monitoring device and verifying CO2 production by
colorimetric, waveform or mmHg.
Observing for chest rise and fall.
Verifying the presence of bilateral lung sounds at the axilla and the absence of
epigastric sounds by auscultation with a stethoscope.
Confirming improvement in saturations by pulse oximetry.
*Confirmation of endotracheal tube placement is required with capnography
and documentation in ePCR.
11. Immobilize the head with a c-collar or by using tape on the head to prevent
excessive head movement during transport when a patient is intubated.
Commercial securing devices are recommended over tape to secure the ET tube
in place.
12. If unable to intubate after two attempts; consider alternate airway management
methods - BVM ventilation or King Airway, etc.
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13. Consider RSI for patients with the following indications (also see RSI protocol):


Altered mental status with airway compromise.
Head injuries with signs of increased ICP (GCS < 8), but whose combativeness
or gag reflex make them difficult to intubate.
Conscious but unable to maintain airway.
Severe respiratory distress with hypoxia / cyanosis.


14. If the adult intubated patient becomes combative, consider administering one or
both of the following:


Versed 1-5 mg slow IV push or 5-10 mg intranasal
Morphine Sulfate 2-4 mg slow IV push
15. Required documentation.


Reason for intubation.
All vital signs prior to intubation including BP, pulse, respirations, and oxygen
saturation.
All medications administered and doses.
Post – Intubation:
a) Repeat all vital signs (including oxygen saturation).
b) Bilateral breath sounds.
c) No sounds over stomach.
d) CO2 production.
e) Repeat all of above on arrival at hospital.


B. CPAP
Indications:
Any adult patient presenting with respiratory distress, is awake and able to follow
commands, has the ability to maintain a patent airway with adequate mask seal, and
displaying findings in the medical history or assessment suggestive of any of the following
conditions:







COPD
CHF
Asthma
Pulmonary Edema
Pneumonia
Near Drowning
Carbon Monoxide poisoning
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Contraindications








Systolic blood pressure less than 90 mmHg
Suspected pneumothorax
Insufficient respiratory effort
Tracheostomy
Active vomiting
Upper GI or airway bleeding
Altered mental status
Suspected facial fractures
Special Considerations
1. CPAP is to be a continuous therapy and should only be discontinued in the case
of the patient being unable to tolerate the mask or in case of progression to
respiratory failure.
2. Advise the receiving hospital of your patient’s CPAP therapy as soon as practical
so they may prepare for continuation of therapy.
3. Observe patient for signs of gastric distention.
4. Monitor patient closely for changes in hemodynamic or respiratory status.
5. Other therapies, as described in these protocols, may be performed in conjunction
with CPAP.
6. Provide patient instruction and reassurance as required.
7. Reassess mental status, hemodynamic and respiratory status continuously during
CPAP therapy and record every 5minutes.
8. Discontinue CPAP therapy and consider BVM / intubation if either decreased
mental status or respiratory insufficiency become present.
9. Add an in-line nebulized Duo-neb (bronchodilator) treatment when indicated.
Consider Versed 1-5mg IV or 5-10mg intranasal if systolic BP is greater than 90 mmHg
and patient is not tolerating CPAP mask. Assure agitation is not a result of hypoxia or
that the patient needs to be intubated.
C. IV Therapy / Medications
1. All IV insertions refer to peripheral IV's (extremities and external jugular vein),
including saline locks and intraosseous (IO) lines. IO insertion is authorized for
unstable pediatric and adult patients. All medications administered IV can also be
administered IO (D50 should be diluted to D25 prior to administering via IO).
2. For trauma patients, IV’s should be started enroute to the hospital, except when
there is an unavoidable delay such as prolonged extrication time.
3. Large bore IV's refer to 14ga or 16ga IV catheters - infuse at rate as indicated by
pulse and blood pressure (90 mmHg systolic or MAP of 70).
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4. IV fluid refers to (NS) Normal Saline (0.9% Sodium Chloride).
5. Use micro drip (minidrip) IV tubing for all IV infusions and with all premixed and
diluted medications. Establish a 2nd IV whenever infusing medications.
6. This protocol permits 2 attempts per paramedic on the call to a maximum of 4
attempts per patient for IV insertion. If unsuccessful and the patient requires
medication administration, establish IO access. Peripheral IV’s should be
attempted prior to IO access.
7. Pre-existing Venous Access Devices (VAD) may be used in emergency situations
(Code 3 / Code 99 patients).
8. A fluid bolus refers to 200 – 500 ml of fluid for the adult patient and 20 ml / kg of
fluid for the pediatric patient.
9. Use a filtered needle or a filtered straw when drawing up any medication from a
glass ampule.
D. Body Substance Isolation
It is protocol policy to practice body substance isolation when caring for ALL patients. This
means wearing gloves and protective eyewear when administering patient care. BSI shall
be observed when handling blood and body fluids or surfaces or items soiled by blood
and body fluids; masks and protective eyewear during procedures likely to generate
droplets of blood or body fluid; and aprons or gowns during procedures likely to generate
splashes of blood or body fluid. This includes washing hands after each patient care
incident even if gloves were worn or waterless soap was used.
All needles and sharps shall be immediately placed in a disposable impervious container.
There will be no recapping of needles.
All personnel should don N-95 or HEPA masks when in contact with patients in which an
airborne communicable disease is suspected or confirmed by history (e.g. tuberculosis,
influenza). Personnel should also place N-95, HEPA, or surgical masks on these
patients.
E. Restraints
Purpose – OFD personnel occasionally encounter patients who require transport to a
receiving hospital but who also pose a threat to themselves, others or to OFD personnel.
Because of this threat of physical harm, it may be impossible to transport without
restraining the patient. This protocol is intended to provide guidance in the use of
restraints and a procedure to follow in such cases.
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Note: OFD personnel/rigs are prohibited from carrying or using metal handcuffs.
1. Indications:

A patient who needs to be transported for medical care, who is refusing
transport of care, and who is incompetent to refuse.

A person, who appears to be mentally ill and who as a result of such mental
illness, appears to be an imminent danger to others (including OFD personnel)
or to himself/herself or to be gravely disabled.
2. Precautions / Considerations:

Do not restrain a patient in the prone position.

Any attempt at restraint involves risk to the patient and to OFD personnel.

The firefighter’s safety must come before patient considerations. Do not
attempt to restrain the patient without adequate assistance.

Physical restraints are a last resort. All possible means of verbal persuasion
should be attempted first.

A patient who is alert, oriented, aware of his/her condition, and capable of
understanding the consequences of his/her refusal is entitled to refuse
treatment. He/she may not be restrained and treated against his/her will.
(Review consent guidelines and confer with PSS or medical director if in doubt.)

Any restrained patient may vomit, be prepared to suction and reposition as
needed. Once restrained, the patient is never to be left alone. Aspiration can
occur if patient is restrained on his/her back and cannot protect his/her own
airway.

The airway must be free and accessible for airway control.

Do not restrain a patient sandwiched between backboards, scoop stretchers or
other immobilization devices.

Do not “hog tie” patients (hands restrained behind back, feet restrained
together and the two restrained attached together).

Check restraints as soon as applied and every 10 minutes thereafter to ensure
no injury to extremities.

Remove restraints only with sufficient personnel available to control the patient
- generally, only in the hospital setting.

Other than primary psychiatric disorders, medical causes of combativeness
include hypoglycemia, hypoxia, head injury and drug ingestion.

Written and verbal reports must completely document the necessity for the use
of physical restraints. Record condition of extremities before applying restraints
and recheck and record condition on arrival at hospital.
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
Metal handcuffs are not an authorized method of restraint for OFD personnel.
The only exception to this policy is for OFD Fire Investigators whom have been
specifically trained in the use of handcuffs.

If a patient is already handcuffed by law enforcement, an officer must ride with
the patient to the hospital.

Law enforcement should be asked to remove handcuffs as soon as possible
for the patient’s own safety. However, if an officer deems handcuffs are
necessary, place patient supine on stretcher and secure handcuffs to the base
of the stretcher.

Consider utilizing more personnel to restrain patient.

Refer to Altered Mental Status Protocol for additional treatment considerations.
F. Pain Management - Adult Criteria (Severe Pain Ranked as ≥ 6 on 0 -10
Scale)
1. Systolic BP > 90 mmHg.

Consider Morphine Sulfate 2-5 mg slow IV push or 2-5 mg intranasal.

Reassess pain scale and vital signs.

Repeat every 5 minutes as necessary if no response or pain remains severe.
2. Systolic BP = 80-90 mm Hg

Consider Morphine Sulfate 1-2 mg slow IV push or 1-2 mg intranasal

Reassess pain scale and vital signs.

Repeat every 5 minutes as necessary if no response or pain remains severe.
3. If respiratory depression occurs, begin BVM ventilations and administer Narcan
0.4 – 2.0 mg IV push followed by a fluid bolus or 0.4 – 2.0 mg intranasal (repeat
as needed).
4. If hypotension develops, administer Narcan 0.4 – 2.0 mg IV push followed by a
fluid bolus or 0.4 – 2.0 mg intranasal (IN) (repeat as needed) – titrate to vital signs.
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G. Pain Management - Pediatric Criteria (Severe Pain Ranked as ≥ 6 on 0-10
Scale or Wong-Baker Faces Scale)
1. Systolic BP appropriate for age.

Consider Morphine Sulfate 0.1 mg / kg slow IV push or 0.1 mg / kg intranasal
to a maximum of 2 mg increments (IV route preferred).

Reassess pain scale and vital signs.

Repeat every 5 minutes as necessary if no response or pain remains severe.
2. If respiratory depression occurs, begin BVM ventilations and administer Narcan
0.4 – 2.0 mg IV or IN followed by a fluid bolus.
3. If hypotension develops, administer Narcan 0.4 – 2.0 mg IV push followed by a
fluid bolus or 0.4 – 2.0 mg intranasal – titrate to vital signs.
CARDIAC EMERGENCIES - ADULT
A. General Guidelines
1. If cardiac arrest occurs in presence of the paramedic, assess rhythm and
immediately shock X 1 if indicated.
2. If patient is in cardiac arrest on arrival, start or continue basic life support (BLS) for
2 minutes. Consider Auto Pulse, if available.
3. CPR (30:2) Compression rate at least 100 / minute.
Ventilations at 8 – 10 / minute, do not hyperventilate.
ROTATE person doing compressions (compressor) every 2 minutes.
4. Reassess rhythm & pulse check after each 5 cycles (2 minutes) of CPR.
5. Limit interruptions of CPR during pulse & rhythm checks to < 10 seconds for airway
management and/or medication administration. CPR should not be stopped for
advanced airway placement.
6. Preferred medication administration route is IV or IO. IV / IO of NS should be
established during 2 minute period of continuous CPR.
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7. Secure ET airway during pulse & rhythm check, continue CPR immediately then
secure & confirm placement by auscultation of breath sounds & epigastric sounds,
followed by confirmation with capnography.
NOTE: CO2 reading should be present but below normal values during CPR. If
“zero” CO2 reading, immediately reevaluate ET tube placement.
8. If failed IV access or IO access, a final option for medication administration is via
the ET tube for designated ET meds at 2 to 2.5 times IV dose. Meds for Code 99
for ET route are lidocaine, epinephrine, atropine and Narcan (LEAN).
9. If the patient regains a pulse, see the Adult Post Cardiac Arrest – ROSC (Return
of Spontaneous Circulation) protocol.
10. Unless otherwise noted, all defibrillations refer to:
Shock #
Biphasic
1
120 j
2
150 j
3 and on
200 j
11. If patient hypothermic from exposure, follow Hypothermia Protocol for cardiac
arrest guidelines.
12. If the patient has known or highly suspected cyanide poisoning, smoke filled
environment (smoke inhalation) consider Toxic Inhalation Protocol Cyanide
Poisoning and Procedure ‘F’.
B. Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT)
1. Follow General Guidelines for Adult Cardiac Arrest.
2. Unwitnessed arrest – Perform 2 minutes (5 cycles) of CPR. Witnessed arrest – go
directly to confirming VF and defibrillation.
3. Assess and confirm pulseless VT / VF, then shock X 1, immediately resume CPR
(no pulse check, go straight to compressions).
4. Reassess rhythm & pulse after 5 cycles (2 mins), if shockable rhythm, continue
CPR while defibrillator charges, then shock X 1, immediately resume CPR.
5. During CPR, administer Epinephrine 1 mg (1:10,000) IV/IO every 3 – 5 minutes.
6. Reassess rhythm & pulse after 5 cycles (2 mins), if shockable rhythm, continue
CPR while defibrillator charges, then shock X 1, immediately resume CPR.
7. Consider administration of anti-arrhythmic.
Amiodarone 300 mg IV/IO, may repeat once in 3–5 minutes at 150 mg IV/IO
OR
*Lidocaine 1 – 1.5 mg / kg IV/IO, may repeat in 3-5 minutes at 0.5 mg to 0.75
mg / kg IV/IO push (max dose of 3 mg / kg).
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*Only use Lidocaine if Amiodarone is NOT available
8. Consider Mag Sulfate (50%) 1 – 2 gm IV/IO over 2 minutes (For Torsades de
pointes).
9. Consider Sodium Bicarb 1 mEq / kg IV/IO (For suspected hyperkalemia,
overdose or metabolic acidosis).
TCA
C. Asystole
1. Follow General Guidelines for Adult Cardiac Arrest.

Unwitnessed arrest – Perform 2 minutes (5 cycles) of CPR.

Witnessed arrest – go directly to confirming the rhythm.
2. Verify / confirm true asystole in another lead.

Rapid scene survey – any evidence that resuscitation should not be
attempted? (DNR orders, signs of death, see Code 4 Protocol).

If yes, withhold resuscitation efforts. See ‘Out of Hospital Confirmation of Death
Protocol’ if needed for assistance.
3. Immediately resume CPR.
4. Establish IV / IO NS while providing 2 minutes of continuous CPR.
5. During CPR, administer Epinephrine 1 mg (1:10,000) IV every 3 – 5 minutes.
6. Secure airway during pulse & rhythm check, continue CPR immediately then
secure & confirm placement by auscultation of breath sounds & epigastric sounds,
followed by confirmation with capnography.
7. Provide continuous CPR, reassess rhythm & pulse after every 5 cycles (2 mins) of
CPR.
8. Consider Sodium Bicarbonate 1 mEq/kg IV/IO push (for suspected acidosis or
hyperkalemia).
9. If pulse restored, refer to ROSC protocol.
D. Pulseless Electrical Activity (PEA)
1. Follow General Guidelines for Adult Cardiac Arrest.

Unwitnessed arrest – Perform 2 minutes (5 cycles) of CPR.

Witnessed arrest – go directly to confirming the rhythm.
2. Establish IV / IO NS while providing 2 minutes of continuous CPR.
3. During CPR, administer Epinephrine 1 mg (1:10,000) IV/IO every 3 – 5 minutes.
4. Secure airway during pulse & rhythm check, continue CPR immediately then
secure & confirm placement by auscultation of breath sounds & epigastric sounds,
followed by confirmation with capnography.
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5. Provide continuous CPR and reassess rhythm & pulse after every 5 cycles (2
minutes) of CPR.
6. Review causes for PEA. Treat per protocols if condition is present:
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hyper / hypokalemia
Hypothermia
Hypoglycemia
Toxins (overdoses)
Tamponade – cardiac
Tension pneumothorax
Thrombosis – coronary
Thrombosis – pulmonary embolism
Trauma
For suspected hypovolemia - administer fluid bolus of normal saline of 250 – 500
cc, repeating boluses up to 1 Liter of NS (especially with narrow QRS and rapid
rate).
For suspected TCA overdose, acidosis or hyperkalemia, administer Sodium
Bicarbonate 1 mEq/kg IV/IO Push.
For tension pneumothorax, perform needle decompression.
For hypothermia, provide warming measures.
For hypoglycemia, administer D10, if not available administer D50
7. If pulse restored, refer to ROSC protocol.
E. Return of Spontaneous Circulation (ROSC)
If return of spontaneous circulation (ROSC) for non-trauma patients:
1. Reassess airway and breathing.

Maintain ventilation rate at 8-10/min – Avoid routine hyperventilation.

Continuously evaluate the Capnography waveform on monitor and maintain
ETCo2 of 35-45mmHg.

Use the minimum flow rate of Oxygen to maintain a saturation of >94%
2. If BP < 90 systolic:

Consider a fluid bolus of 250 – 500 cc, repeating boluses up to 1 Liter of NS.

Consider Epinephrine drip at 2-10 mcg / min

Titrate to BP of > 90
3. Obtain 12-Lead ECG, transmit to receiving facility.
4. Establish 2nd IV.
5. Initiate hypothermic efforts by applying ice packs to the groin and axilla.
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F. Bradycardias
For heart rates below 60 beats per minute.
STABLE
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Start IV with NS TKO
3. Transport and OBSERVE
UNSTABLE - (Verify serious signs / symptoms are due to the slow rate):
1. Airway, oxygen, monitor, obtain 12 Lead ECG
2. Start IV with NS TKO
3. Give Atropine 0.5 mg IV push, repeat every 3 to 5 minutes as needed up to
maximum dose of 3 mg (0.04mg/kg).
*Atropine is not effective in 2° Type II AV block, 3° heart block or Idioventricular
rhythms. If these rhythms are present and patient is unstable, go directly to
transcutaneous pacing (TCP).
4. If Atropine administration will be delayed or is ineffective, begin transcutaneous
pacing (TCP). Preferred placement for pacing pads is anterior-posterior position.

Start at a rate of 60-70 beats per minute. Adjust milliamps upward as needed
to achieve capture. May consider increasing rate to a maximum of 100 beats
per minute to obtain a BP of > 90 systolic.

Consider patient comfort as milliamps are increased. If pacing is successful
(capture is established and BP improves), consider mild sedation for discomfort
related to pacing.

Versed 1 – 5 mg slow IV, or Versed 5 – 10 mg intra-nasal

Consider Epinephrine drip at 2 – 10 mcg/minute – titrate to blood pressure of
>90 systolic (see Procedure H)

Monitor vital signs every 2 – 5 minutes.
NOTES:
 Do not delay TCP while waiting for IV access or for atropine to take effect if
patient is unstable.
 Never treat the combination of 3º heart block and ventricular escape beats
with amiodarone, lidocaine or any agent that suppresses ventricular escape
rhythms.
 Atropine is not effective for denervated transplanted hearts.
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G. Monomorphic Ventricular Tachycardia with Pulse
For wide complex [> 0.12 seconds] tachydysrhythmias
STABLE patient / NO serious signs and symptoms
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Start IV with NS TKO.
3. Consider Medications:

Adenosine 6 mg rapid IVP (over 1 second) and flush the line, may repeat once
in 2 min at 12 mg.

Amiodarone infusion - 150 mg in D5W 100 cc over 10 minutes.
UNSTABLE patient / Displays serious signs and symptoms
1. Airway, oxygen, monitor.
2. Start IV NS TKO.
3. Consider fluid bolus 250 - 500cc.
4. Consider pre-medicating with:

Versed 1 – 5 mg slow IV push, or 1 – 5 mg intranasal, may repeat once
5. Perform synchronized cardioversion at 100 J.
IF NO RESPONSE, continue synchronized cardioversion with increasing joule
settings as necessary (120J, 150J, 200J).
6. If successful and time allows, obtain and transmit a 12-Lead EKG.
IF SUCCESSFUL (at any point), maintain status with anti-arrhythmic infusion (see
above).
NOTE:
If polymorphic or Torsades de pointes, give Magnesium Sulfate 1 – 2 grams
slow IV push (over 5 minutes).
H. Supraventricular Tachycardia (SVT)
For narrow complex QRS <0.12 seconds
STABLE patient / NO serious signs and symptoms
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Start IV with NS TKO.
3. Consider vagal maneuvers.
4. Give Adenosine 6 mg rapid IV push (over 1 second) and flush the line.
IF NO RESPONSE in 2 minutes:
5. Give Adenosine 12 mg rapid IV push (over 1 - 2 seconds) and flush the line.
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IF NO RESPONSE in 2 minutes:
6. Consider Adenosine 12 mg rapid IV push (over 1 - 2 seconds) and flush the line.
UNSTABLE patient / Displays serious signs and symptoms
1. Airway, oxygen, monitor.
2. Start IV with NS TKO.
3. Consider pre-medicating with:

Versed 1 – 5 mg slow IV push, or 1 – 5 mg intranasal, may repeat once.
4. Perform synchronized cardioversion at 50 J.
5. IF NO RESPONSE, continue synchronized cardioversion with increasing joule
settings as necessary (75J, 100J, 120J, 150J, 200J).
6. If successful and time allows, obtain and transmit a 12-Lead ECG.
I. Atrial Fibrillation and Atrial Flutter with Rapid Ventricular Rate
Greater than 150 beats per minute
STABLE patient / NO serious signs and symptoms
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Start IV with NS TKO.
3. Observe and transport.
UNSTABLE patient / Displays serious signs and symptoms
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Start IV with NS TKO.
3. Prepare for immediate cardioversion, consider pre-medicating with:

Versed 1 – 5 mg slow IV push, or 1 – 5 mg intranasal, may repeat once.
4. Perform synchronized cardioversion at 120J for atrial fibrillation.
5. Perform synchronized cardioversion at 50J for a-flutter.
6. IF NO RESPONSE, continue synchronized cardioversion with increasing joule
settings as necessary.
7. If successful and time allows, obtain and transmit a 12-Lead EKG.
NOTE: In the absence of a characteristic saw tooth pattern, the rhythm is atrial
fibrillation until proven otherwise
*Use caution in converting an atrial fibrillation rhythm that has an unknown duration
or a known duration of greater than 48 hours. Prolonged atrial fibrillation has been
documented to create clots and converting the rhythm may disseminate these clots
throughout the body.
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J. Ventricular Ectopy / Presence of Runs of V-Tach
Runs of V-Tach = 3 or more PVCs in a row
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Start IV with NS TKO.
For couplets, multi-focal PVCs or bigeminy, continue oxygen therapy maintaining a
saturation of > 94%.

Follow applicable protocol based on patient presentation (signs & symptoms)
i.e. Acute Coronary Syndrome (Chest Pain), Bradycardias, Dyspnea,
Hypotension Protocols.
For runs of V-Tach AND underlying heart rate is below 60:

Administer Atropine 0.5 mg to a max of 3 mg (0.04 mg/kg) slow IV push to
speed up underlying rhythm and “overdrive” the rhythm.
For runs of V-Tach AND underlying heart rate is above 60:

Consider medications - choose ONE of the following agents (Amiodarone is the
preferred medication):
Amiodarone infusion - 150 mg in D5W 100 cc over 10 minutes. (If successful
conversion, start Amiodarone drip at 1 mg / minute).
OR
*Lidocaine 0.5 to 0.75 mg / kg IV push (If successful conversion, start
Lidocaine infusion at 1 – 4 mg / minute).
*Only use Lidocaine if Amiodarone is NOT available
K.
Acute Coronary Syndrome (ACS)
(Chest Pain, Acute MI / STEMI, Suspected Cardiac Event, etc.)
1. Airway, oxygen, monitor, obtain 12-Lead ECG within 10 minutes of arrival.
2. Start IV with NS TKO.
3. Administer medications:

ASA (2 to 4 baby aspirin) 162 – 324 mg PO (chewable).

Nitroglycerin 0.4 mg SL, every 5 minutes if systolic BP remains greater than 90
mmHg up to 3 doses.

Repeat Nitroglycerin as needed until cardiac symptoms are relieved or patient
becomes symptomatic from the medication (i.e., headache becomes the chief
complaint, hypotension develops, etc)
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*Do NOT administer Nitroglycerin if:
a. The patient has used any erectile dysfunction (ED) medication
(Viagra/sildenafil, Levitra/vardenafil, and Cialis/tadalafil) within the
previous 48 hours.
b. 12 Lead shows Inferior MI (ST Elevation in any two of the following
leads – II, III, aVF).

Morphine Sulfate 2 - 5 mg slow IV/IO/Intranasal for chest pain may repeat up
to a maximum of 10 mg (if systolic blood pressure remains greater than 90
mmHg). Use with caution in unstable angina / non-STEMI.
4. Correct perfusion-altering dysrhythmias according to protocol guidelines.
5. Transport Code 3 STEMI to closest hospital with emergency cardiac
catheterization lab availability.
6. Contact receiving hospital as early as possible and notify of any S-T elevation, call
a STEMI Alert.
7. Transmit 12-Lead ECG to receiving hospital.
8. Start 2nd IV en route.
L. CHF/Pulmonary Edema
Dyspnea in the presence of diminished lung sounds, wheezes, rales, or frothy
sputum with a BP that is hypertensive or within normal limits
1. Airway, oxygen, monitor.
2. CPAP w/ supplemental O2.
3. Upright position (45o - 90o), maintain this position and treat before moving.
4. Obtain and transmit 12-Lead ECG.
5. Start IV with NS TKO.
6. Administer Medications:
 Nitroglycerin SL:
a. If systolic BP is > 180, give 0.4 mg per dose (1 tablet, may repeat once
after 3 - 5 minutes)
b. If systolic BP is < 180, give 0.4 mg (1 tablet)
c. Continue if systolic BP remains greater than 90 mmHg
d. Monitor pulse and blood pressure before each dose
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Morphine Sulfate, 2 - 5 mg slow IV/IO/Intranasal (to a maximum dose of 10
mg).
Use with caution in patients who are elderly, have COPD history or who
are hypotensive.
 Consider DuoNeb by nebulizer.
 Consider CPAP protocol.
M. Cardiogenic Shock
Dyspnea in the presence of diminished lung sounds, wheezes, rales, or frothy
sputum with a BP that is hypotensive
1. Airway, oxygen, monitor.
2. Start IV with NS TKO.
3. Correct perfusion altering dysrhythmias according to protocol guidelines.
4. Obtain and transmit 12-Lead ECG.
5. Consider fluid bolus 250 - 500 cc NS up to 1 Liter.
6. Administer Epinephrine Drip: (Procedure H)

Begin infusion at 2 – 10 mcg / min

Pulse and BP should be monitored every 2 - 5 minutes.

Goal is to maintain systolic BP at > 90 mmHg.
ACUTE TRAUMATIC EMERGENCIES
A. General Trauma Management
Priorities for Treatment
1. Provide airway management.
2. Control the cervical spine. Assume cervical spine injury is present in any patient
with:

Evidence of high impact with a distracting injury.

Any head or neck injury.

Neck pain following trauma.

Altered mental status.

Presence of any neurological deficit.
3. In trauma code situations (Usually PEA) attempt all mechanical interventions, i.e.:
CPR, ET/King airway, IV/IO, and Needle decompression prior to administering first
line cardiac drugs.

REMINDER: Pain, loss of sensation or motor activity MAY NOT be present
initially with cervical spine fractures.
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Also see Spinal Injury Assessment Protocol.
4. Consider helicopter transport to the Trauma Center if:

Incident is located well north of I-680 or west of 150th Street.

Transportation by ground to the Trauma Center will be greater than 20 minutes.

Extrication time and ground transport time to the Trauma Center will be greater
than 20 minutes.

Consider requesting standby status while enroute to the scene. This will be
based on the incident location and information given by dispatch regarding the
nature of the call.

If the helicopter is not on scene when the medic unit is ready to transport, do
not wait for the helicopter to arrive. Transport the patient in the medic unit to
the Trauma Center unless traffic conditions warrant otherwise.

See OFD SOP OPS 17-0 Helicopter Procedures for more information.
5. Helmet Removal:

Remove all helmets to avoid airway management problems according to ACS
and PHTLS guidelines. The exception may be football helmets with shoulder
pads in place. In these cases, removal of the football helmet is an option, but
removal of the face guard is required. Cervical immobilization is without the ccollar, utilizing other resources, i.e. towel rolls, commercial head immobilization
devices.
6. Control external hemorrhage:

Direct pressure

Apply a wide band tourniquet 2” above the injury for life-threatening extremity
hemorrhage, mangled extremity, or traumatic amputation that is not controlled
by direct pressure. Document tourniquet application time and do not cover the
tourniquet.
7. Hypovolemic shock (assume shock present when pulse greater than 120 and/or
systolic BP less than 100 mmHg in a previously normotensive patient; or systolic
drops 40 - 50 mmHg in a previously hypertensive patient, especially if
accompanied by pale, clammy skin and decreased level of consciousness).

Apply oxygen and ventilate if necessary.

Keep patient warm and dry.

Start 1 or 2 large bore IV's with warm NS, fluid bolus titrating to a systolic blood
pressure of 90mmHg. DO NOT delay transport for IV starts.
8. Apply ECG monitor enroute.
9. Extremity Injuries (fractures/dislocations) - General Guidelines:

Check and record peripheral pulses and neurological status before and after
manipulating or splinting fractures.
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
Apply gentle in-line traction to fractures with the exception of dislocations or
fractures involving joints (especially the elbow).

May straighten severely angulated fractures of extremities with the exception
of those involving knee or elbow. For knee or elbow with neurovascular deficit,
attempt once to realign extremity to restore neurovascular status.

Immobilize fractures, including joint above and joint below.

For suspected femur fracture (open or closed), consider traction splint.

For suspected unstable pelvic fractures, tie a sheet snugly around pelvis.
10. DO NOT remove any impaled objects unless obstructing airway or interfering with
CPR.
11. All life or limb-threatening injuries should be transported immediately to the
Trauma Center.
12. If Quik Clot, Celox, or other similar coagulation agent has been applied for bleeding
control prior to O FD arrival, leave in place. Do not remove. Follow standard
bleeding control measures.
13. Place all amputated parts in NS solution and keep cool if possible
B. Penetrating Injuries to Head, Neck, Chest and Abdomen
1. Airway, oxygen, monitor.
2. Consider c-collar and backboard if appropriate.
3. Start IVs enroute, NOT on scene.
4. Scene time should be < 5 minutes.
C. Head Injuries
1. Maintain / manage airway and apply oxygen, monitor. Maintain oxygen saturation
> 94%.
2. Consider RSI.
3. Ventilate with adequate tidal volume at normal respiratory rate for patient age.
Using capnography, maintain CO2 at 35-45mmHg.
4. Start large bore IV with NS enroute and titrate to vital signs. Maintain blood
pressure > 90 systolic.
D. Chest Injuries
1. Airway, oxygen, monitor.
2. For tension pneumothorax WITH EVIDENCE OF SHOCK, insert 12 gauge
catheter at 2nd intercostal space in mid-clavicular line.

Perform bilateral needle decompression in all Code 99 patients with penetrating
or blunt thoracic trauma.
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3. Cover sucking chest wounds with occlusive dressing, remove if patient’s condition
deteriorates.
4. Start 1 or 2 large bore IV’s with NS enroute and titrate to a systolic blood pressure
of 90mmHg.
E. Abdominal Injuries
1. Airway, oxygen, monitor.
2. Dress any penetrating wound with a dry sterile dressing or occlusive dressing.
3. For evisceration: DO NOT REPLACE eviscerated tissue. Cover with a moist sterile
dressing. Place a dry sterile dressing over moist dressing to maintain warmth.
4. Start 1 or 2 large bore IV's with NS during transport titrating to a systolic blood
pressure of 90mmHg.
F. Eye Trauma
1. Chemicals - Flush with Normal Saline or water continuously enroute to the
receiving hospital. Remove contacts prior to irrigation.
2. Foreign body or punctured eye - Leave foreign body in place. Apply loose
protective covering over impaled eye. Patch other eye. DO NOT apply a pressure
dressing.
3. Loss of eye tissue - If possible, transport tissue with patient. Keep eyes moist with
NS.
4. Keep patient from rubbing eye(s).
G. Burns
1. Airway, oxygen, monitor.
2. Assess for inhalation burns, consider ET intubation, RSI if indicated.
3. Protect from hypothermia.
4. Remove rings, bracelets and other constricting items in burned areas.
5. Thermal burns.

Remove any clothing near area of burn wound.

Apply clean, dry dressings or sheets.

If an isolated burn of less than 10% BSA, consider moistening with saline
(prevent hypothermia).
6. Chemical burns (wet)

Flush with large volumes of fluid.

Apply clean, dry dressings or sheets.
7. Chemical burns (dry)
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
Safely brush off as much of the chemical as possible.

Flush with large volumes of fluid.

Apply clean, dry dressings or sheets.
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8. Electrical burns

Apply clean, dry dressings to entrance and exit wounds.

Apply ECG monitor and follow applicable protocol as indicated.
9. Consider large bore IV with NS. Titrate to vital signs.
10. Consider pain control.
11. Transport to the Trauma Center for suspected airway involvement and/or burns
greater than 10% of total body surface area, circumferential burns, burns to the
hands, feet, or genitalia.
H. Snakebite
In the event of an actual or probable snakebite:
1. Confirm that the responsible snake or snakes have been appropriately and safely
contained and there is no danger of additional bites to patient or OFD personnel.
2. Keep patient calm (minimize patient movement).
3. For incidents at Henry Doorly Zoo – obtain and confirm appropriate antivenom for
snake involved. Quickly package patient and initiate Code 3 transport directly to
Nebraska Medicine. Establish early radio contact to hospital to inform them of
situation.
4. Airway, oxygen, monitor.
5. Splint any bitten extremity and maintain the extremity in a position below the level
of the heart.
6. Remove any rings or jewelry on the bitten extremity.
7. Apply a blood pressure (BP) cuff, as a tourniquet, one-inch above the site of the
bite on the extremity. Inflate cuff to 60 - 70 mmHg and maintain this pressure. If no
BP cuff available, may use other resources for constricting bands (tourniquet, cling,
Coban, etc.). Goal is to apply just enough pressure to occlude only superficial
veins and the lymphatics. A pulse should be palpable below the bite site after
application.
8. Attempt IV enroute in a non-affected extremity.
9. Do not rinse bite site.
10. Do not cut or incise the bite site, or apply ice or cold packs.
11. Do not administer antivenom in the field.
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I. Crush Syndrome
This protocol is to be used for adult patients who are being rescued from being
trapped by having an extremity muscle mass compressed for more than four hours
or more than two hours in a cold climate, but also who have pulses distal to the
compression. Preventive treatment for Crush Syndrome is secondary to primary
interventions for acute traumatic injuries. The risks of Crush Syndrome are greater if
the patient’s extremity is hard, swollen, cold and insensitive.
1. Airway, oxygen, monitor – patients should have high flow oxygen applied,
especially at time of release.
2. Start two (2) large bore IVs of NS at TKO rate prior to extrication and releasing
compression.
3. Adjust one of the IVs to wide open at the time muscle compression is released.
4. After the first 1000 cc of NS has been infused, mix 50 cc of Sodium Bicarbonate
into the second IV bag and adjust the second IV to 500 cc per hour.
5. Continue running 1st IV of NS wide open (change to new bag as needed).
6. Administer up to three (3) L of normal saline (clear lung sounds and no shortness
of breath), over the first 90 minutes following release of compression.
7. Transport to the trauma center.
J. Decision Scheme for Trauma Patients
Metropolitan Omaha Triage Decision Scheme for Trauma Patients
Vital Signs and Level of Consciousness

Glasgow Coma Scale ≤ 13

Systolic BP 90 mmHg or less

Respiratory Rate < 10 or > 29 Or need for ventilatory support

(<20 in infant less than one year old)
Injuries

All penetrating injuries to head, neck, torso and extremities proximal to elbow
and knee

Chest wall instability or deformity (flail chest)

Two or more proximal long bone fractures

Crushed, degloved, mangled or pulseless extremity

Amputation proximal to wrist or ankle
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
Suspected pelvic fracture

Open or depressed skull fracture

Paralysis

Combination trauma and burns

Suspected airway involvement and/or burns greater than 10% of total body
surface
Mechanism of Injury and/or Evidence of High Energy Impact


Falls

Adults: > 20 ft. (one story is equal to 10 ft.)

Children: > 10 ft. or 2 – 3 times the height of the child
High Risk Auto Crash

Intrusion (including roof) > 12 inch occupant site and/or 18 inch any site

Ejection (partial or complete) from automobile

Death in same passenger compartment

Vehicle telemetry data consistent with high risk injury

Auto versus Pedestrian/Bicyclist Thrown, Run Over, or with Significant (> 20
mph) Impact

Motorcycle Crash > 20 mph
Consider transport to the Trauma Center for the following conditions/situations:

Patient age of 55 years old or greater

Systolic BP < 100 in patients 65 years old or older

Anticoagulation and Bleeding Disorders

Time Sensitive Extremity Injury

End Stage Renal Disease Requiring Dialysis

Pregnancy > 20 weeks

EMS Provider Judgment
The Trauma Center is the only hospital to contact if the above criteria are met. Trauma
patients that do not meet these guidelines, and are stable, may be taken to any hospital.
ANY HOSPITAL OR EMS PROVIDER HAS THE OPTION TO BYPASS TO THE
TRAUMA CENTER IF IT IS FELT IT IS IN THE BEST INTEREST OF THE PATIENT
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Trauma Center of the Day Designation (Omaha area Trauma Center days rotate at 0700
every day):
Nebraska Medicine
CHI Alegent Creighton Health
Odd Days
Even Days
K. Trauma Center Rotation for Mass Casualty Incidents (MCI)
In the event of an MCI, both Omaha Trauma Centers will open for trauma patients.
1. Follow Standard Operating Procedures EMS 5-0 Multi-Casualty Response.
2. The Incident Commander at the scene will notify Omaha Fire Dispatch of a MCI
event along with the estimated number of victims. Dispatch will then contact the
Trauma Center of the Day.
3. The ED staff at the Trauma Center of the Day will then contact the ED staff at the
non-Trauma Center of the Day to inform them of the situation and need for both
Trauma Centers to open for trauma patients.
4. When 4 critically injured / RED patients arrive or are being transported to the open
Trauma Center of the Day, the alternating Trauma Center will receive the next 4
critically injured / RED patients. This rotation of 4 and 4 will continue until all
critically injured / RED patients have been transported.
5. Minor injury / GREEN patients should be transported to the other local hospitals,
not to the Trauma Centers. For a large scale incident with more than 20 critically
injured / RED patients, consider transporting all serious injury / YELLOW patients
to the other hospitals.
6. Each Trauma Center will be responsible for informing Omaha Fire Dispatch when
they are no longer able to accept any additional patients in the rotation.
7. If both Trauma Centers are overwhelmed, critically injured / RED patients should
then be transported to the other local hospitals.
MEDICAL EMERGENCIES
A. Upper Airway Obstruction (Choking)
1. Attempt to relieve obstruction according to the American Heart Association Foreign
Body Airway Obstruction (FBAO) guidelines.
2. If unsuccessful:
 Attempt to visualize obstruction with laryngoscope and remove with Magill
Forceps.
 Administer oxygen, monitor.
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If all of the above fail, consider needle cricothyrotomy. Use 12 or 14 gauge
needles.
Start IV with NS TKO.
B. Altered Mental Status
Altered Mental Status with History of Diabetes Mellitus (Hypoglycemia)
1.
2.
3.
4.
Airway, oxygen, monitor.
Check blood sugar level.
Start IV/IO with NS, titrate to vital signs.
If blood sugar is less than 70 and / or signs & symptoms are present which are
consistent with hypoglycemia:
 Ensure patent IV with a 20ml flush of NS.
 Administer D10 (D10 = 25 Grams of Dextrose in 250 mL premixed bag)
If D10 is not available then


Administer 12.5 – 25 grams (25-50 ml) of D50W IV push, followed by 10ml NS
flush.
Recheck blood sugar. Consider repeating if blood sugar remains less than 70.
Altered Mental Status, Excluding Exposure
1.
2.
3.
4.
5.
6.
7.
8.
Airway, oxygen, monitor.
Check blood sugar level.
Start IV with NS, titrate to vital signs.
If blood sugar is less than 70 and/or signs & symptoms are present which are
consistent with hypoglycemia, see Altered Mental Status, hypoglycemia protocol.
If narcotic overdose suspected (GCS <13, pin point pupils, and/or respiratory
depression), administer Narcan, 0.4 mg to 2.0 mg IV/IM/IO/IN, repeat as indicated.
Note: If the patient is not an imminent safety concern consider Physical
Restraint Procedures.
Ketamine if patient is an (Imminent safety concern)
RASS SCORE +2, +3, or +4 (document in your report before Ketamine
administration and 5 min after administration of Ketamine, and once again upon
ED arrival)
Adult – 250 mg IM (16 y/o and older)
 May repeat once (250 mg) in 5 minutes if needed (Max 500 mg)
Pediatric – 150 mg IM (12 y/o – 16 y/o)
 May repeat once (150 mg) in 5 minutes if needed (Max 300 mg)
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9. Obtain 12 Lead ECG
10. Apply O2 Nasal Cannula with CO2 monitoring (if patient is sedated)
11. If the patient is not calm after 10 minutes:
 Administer Versed 5 mg IM / IN
 Administer Versed 2 mg IV (as needed every 5 minutes x 3 doses up to 6
mg max dose)
12. If patient is sedative apply nasal cannula and monitor CO2
13. Documentation
 Ensure statements of self-harm, harm to others are reported to Law
Enforcement and document in the patient care report.
RASS SCALE:
Pearls


Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro
Crew / responders safety is the main priority.

Any patient who is handcuffed or restrained by Law Enforcement and transported
by EMS must be accompanied by law enforcement in the ambulance of follow
immediately behind the ambulance.

Consider sedatives (Ketamine or benzodiazepine) for patients with other
presumed substance abuse. While benzodiazepines may be indicated for patients
with alcohol intoxication, consider that alcohol and benzodiazepines together may
lead to respiratory depression
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All patients who receive either physical or chemical restraint must be continuously
observed by ALS personnel on scene or immediately upon their arrival. Consider
bringing extra personnel during transport.
If cardiac rhythm changes, evaluate QTc interval with a 12-lead EKG. If QTc >
500ms, consider administering Magnesium Sulfate (2 grams IV / IO). If the QRS
is greater than .12 seconds consider administering Sodium bicarbonate (1mEq /
kg). Consult medical control if appropriate.
Be sure to consider all possible medical/trauma causes for behavior
(hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.)
Do not irritate the patient with a prolonged exam.
Do not overlook the possibility of associated domestic violence or child abuse.
If patient is suspected of agitated delirium suffers cardiac arrest, consider a
fluid bolus and Sodium Bicarbonate early
Do not position or transport any restrained patient is such a way that could impact
the patient's respiratory or circulatory status.
Documentation
o Ensure statements of self-harm, harm to others are reported to Law
Enforcement and document in the patient care report.
o
Document RASS Score before Ketamine administration, 5 minutes after
administration and upon ED arrival.
Altered Mental Status associated with anxiety, agitation, confusion,
hallucinations, bizarre behavior, combative, violent, delusional thoughts,
paranoia, hyper aggression tachycardia, increased strength, hyperthermia –
C. Excited Delirium
1. Ketamine
RASS SCORE +2, +3, or +4 (document in your report before Ketamine
administration and 5 min after administration of Ketamine, and once again upon
ED arrival)
Adult 250 mg IM (16 y/o and above)
May repeat x 1 dose in 5 minutes if needed (Max 500mg)
Pediatric 150 mg (12 y/o – 16 y/o)
May repeat x1 dose in 5 minutes if needed (Max 300mg)
2. If patient is not calm after 10 minutes:
a. Versed 5 mg IM/IN
b. Versed 2 mg IV (as needed every 5 min X3 doses up to 10 mg max)
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3. IV Access - NS 1,000 mL Bolus May repeat 500 mL bolus x2
a. Maximum 2 Liters
4. Glucose Check – Refer to hypoglycemia protocol
5. Temperature measurement and cooling measures as needed
6. Apply O2 Nasal Cannula with CO2 monitoring (if patient is sedated)
7. 12 Lead ECG procedure
a. Cardiac monitor
8. Sodium Bicarbonate 1mEq/kg IV / IO if patient has S/S of cardiac arrhythmias or
presents in cardiac arrest.
9. Monitor and reassess frequently.
10. If patient is sedated apply nasal cannula and monitor CO2
11. Document RASS score before Ketamine administration, 5 minutes after
administration and on ED arrival.
Pearls


Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro
Crew / responders safety is the main priority.
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Any patient who is handcuffed or restrained by Law Enforcement and transported
by EMS must be accompanied by law enforcement in the ambulance of follow
immediately behind the ambulance.
Consider sedatives (Ketamine or benzodiazepine) for patients with other
presumed substance abuse. While benzodiazepines may be indicated for patients
with alcohol intoxication, consider that alcohol and benzodiazepines together may
lead to respiratory depression
All patients who receive either physical or chemical restraint must be continuously
observed by ALS personnel on scene or immediately upon their arrival. Consider
bringing extra personnel during transport.
If cardiac rhythm changes, evaluate QTc interval with a 12-lead EKG. If QTc >
500ms, consider administering Magnesium Sulfate (2 grams IV / IO). If the QRS
is greater than .12 seconds consider administering Sodium bicarbonate (1mEq /
kg). Consult medical control if appropriate.
Be sure to consider all possible medical/trauma causes for behavior
(hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.)
Do not irritate the patient with a prolonged exam.
Do not overlook the possibility of associated domestic violence or child abuse.
If patient is suspected of agitated delirium suffers cardiac arrest, consider a
fluid bolus and Sodium Bicarbonate early

Do not position or transport any restrained patient is such a way that could impact
the patient's respiratory or circulatory status.
 Excited Delirium Syndrome:
o Medical emergency: Combination of delirium, psychomotor agitation,
anxiety, hallucinations, speech disturbances, disorientation, violent / bizarre
behavior, insensitivity to pain, hyperthermia and increased strength.
Potentially life-threatening and associated with use of physical control
measures, including physical restraints and Tasers. Most commonly seen
in male subjects with a history of serious mental illness and /or acute or
chronic drug abuse, particularly stimulant drugs such as cocaine, crack
cocaine, methamphetamine, amphetamines or similar agents. Alcohol
withdrawal or head trauma may also contribute to the condition.
Documentation
Ensure statements of self-harm, harm to others are reported to Law Enforcement and
document in the patient care report. RASS Score before and after Ketamine administration.
D. Seizure Disorder
1. Airway, oxygen, monitor.
2. Protect patient from further injury, DO NOT restrain or force bite block.
3. Check blood sugar level.
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4. Start IV/IO with NS, titrate to vital signs.
5. If blood sugar is less than 70 and/or signs & symptoms are present which are
consistent with hypoglycemia, see Altered Mental Status, hypoglycemia protocol.
6. For recurrent seizures, consider one of the following:

Versed 2.5 mg slow IV push (may repeat once), OR 5 mg IM, OR 5 mg intranasal (may repeat in 5 minutes at half the dose).
7. If narcotic overdose suspected, consider Narcan 0.4 mg to 2.0 mg IV push or 0.4
– 2.0 mg intranasal or other route as accessible, repeat as indicated.
E. Difficulty Breathing
Acute Allergic Reactions / Anaphylaxis (Difficulty Breathing in the presence of
urticaria, wheezing and/or contact with a known allergen)
BP <70 Systolic
1. Airway, oxygen, monitor.
2. Start IV/IO with NS, titrate to vital signs.
3. Administer Medications:

Epinephrine 0.1 - 0.2 mg (1:10,000) IV/IO OR If intubated, 0.2 - 0.4 mg
(1:10,000) ET (Dose is doubled for ET route).

Repeat every 5-10 minutes depending on vital signs and respiratory status.

DuoNeb by nebulizer, may repeat as necessary. Consider BVM aerosol setup;
do not wait for IV access.

Benadryl 50 mg slow IV push over 1 - 3 minutes.
BP >70 Systolic
1. Airway, oxygen, monitor, intervene when needed.
2. Administer Medications:

Epinephrine 0.3 – 0.5 (1:1,000) IM. Repeat in 5 minutes as necessary.
NOTE: Epinephrine has no contraindication in acute anaphylaxis.

DuoNeb by nebulizer or nebulized with CPAP, may repeat as necessary.

Benadryl 50 mg IM OR slow IVP over 1 - 3 minutes
3. Start IV with NS TKO if not started already, titrate to vital signs. Do not delay
medications while waiting for IV access.
Asthma/COPD (Difficulty breathing in the presence of wheezing with history of
asthma, chronic bronchitis, emphysema, or irritant exposure)
1. Airway, oxygen, monitor, intervene when needed, CPAP if BP > 90 systolic.
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2. Administer Medications:

DuoNeb by nebulizer, may repeat x1.
If the nebulizer treatments are ineffective:

Magnesium Sulfate 2 Grams IV/IO diluted in 10 ml NS, slow push over 10
minutes.

Epinephrine 0.3 - 0.5 mg (1:1,000) IM OR 0.1 – 0.2 mg (1:10,000) IV (IV dose
used in severe asthma with impending arrest, only.)
NOTE: Do NOT administer epinephrine if the patient has chest pain, is being
treated for angina, has a history of coronary artery disease, or AMI.
3. Start IV with NS TKO if not started already, titrate to vital signs. Do not delay
medications while waiting for IV access.
F. Exposure
Hypothermia (Lowered Skin Temperature with Altered Mental Status)
1. Remove wet clothing, protect against heat loss and wind chill.
2. Avoid rough movement and excess activity.
3. Maintain horizontal position.
4. Monitor temperature, if possible.
5. Monitor cardiac rhythm.
If Pulse/Breathing Present
1. Oxygenate with warm oxygen (if available).
2. Start IV with NS TKO, use warm IV fluid (if available).
If Pulse/Breathing Absent
1. Start CPR.
2. If VF/VT, defibrillate X 1.
3. Continue CPR if pulseless and apneic.
4. Ventilate with warm oxygen (if available).
5. Start IV with NS TKO, use warm IV fluid (if available).
NOTE: Medications are not indicated in extreme hypothermia.
Transport considerations:

Adult patients with extreme hypothermia and no signs or suspicion of trauma,
transport to catchment area hospital.
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Pediatric patients with extreme hypothermia and no signs or suspicion of
trauma, transport to Children’s Hospital.
Hyperthermia (Elevated Skin Temperature with Altered Mental Status)
1. Remove from environment and wrap with moist sheets.

Replace moist sheets frequently.

Increase airflow to improve evaporation and convection.
2. Airway, oxygen, monitor.
3. Start IV with NS, titrate to vital signs.
G. Hypovolemic Shock (Hypotension in the Absence of Trauma)
Shock is present when pulse greater than 120 and systolic BP less than 90 mmHg in a
previously normotensive patient or systolic drops 40-50 mmHg in a previously
hypertensive patient, especially if accompanied by pale, clammy skin and decreased level
of consciousness.
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Start 1 or 2 large bore IVs, NS and titrate to vital signs, up to 2 liters.
3. Consider Epinephrine drip at 2-10 mcg / min
H. Poisons
Consider calling Poison Control Center
Omaha area-------------------------402-955-5555
Outside of Omaha area---------1-800-222-1222
I. Nerve Agents
See Procedure D
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J. Overdose/Toxic Ingestion
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Check blood sugar level is less than 70, follow hypoglycemia protocol.
3. Start IV with NS, titrate to vital signs.
4. If altered mental status, respiratory depression and/or pin point pupils consider
Narcan, 0.4 mg to 2.0 mg IV push or 0.4 – 2.0 mg intranasal, repeat as necessary.
5. If patient demonstrates one of the following:

Prolonged or widening of QRS ( > 120ms).

Ventricular dysrhythmias.

Hypotension unresponsive to fluid challenge of 500 ml NS.

Seizure with no previous history of seizures.
Administer 1mEq/Kg Sodium Bicarbonate slow IV push.
6. Treat dysrhythmias according to protocol guidelines.
7. Combative patients see Physical and/or Altered Mental Status Protocols
K. Toxic Inhalation
1. Remove from exposure.
2. Airway, oxygen, monitor, consider CPAP.
3. If wheezing and/or signs of bronchoconstriction:

DuoNeb by nebulizer or nebulized with CPAP, may repeat as necessary.
4. Start IV with NS, titrate to vital signs.
5. If CO poisoning, treat with high flow oxygen, 15LPM via non-rebreather mask.
6. If only CO poisoning is suspected and no inhalation injury, assess for the presence
of any of the following and transport directly to Nebraska Medicine for possible
hyperbaric chamber treatment:

Chest pain.

Headache in pregnant patient.

Altered LOC or history of unconsciousness.

Dizziness.

Seizures.

Unsteady gait or difficulty speaking.
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L. Cyanide Poisoning (see Procedure ‘F’)
1. Assess and treat Airway, Breathing, and Circulation.
2. Start (2) IV’s with NS, titrate to vital signs.
3. Administer Cyanokit if known or suspected cyanide poisoning in persons exposed
to smoke from a fire in closed spaces and in victims with soot around the mouth,
nose, and oropharynx with a depressed mental status, systolic blood pressure <
90, seizure activity or who are unresponsive.
Adult Dose (19 years and older):

5 Grams of Cyanokit (hydroxocobalamin) in 200 mL 0.9% sodium chloride IV
infusion over 15 minutes

15 drop IV tubing – 200 gtts/min or 3 drops / sec (nearly wide-open).

Check in 7 minutes and ½ the antidote should be infused.
Pediatric Dose: Contact medical control at the receiving hospital.
4. Follow ACLS guidelines if the patient in pulseless, apneic and unresponsive –
establish and use a second IV / IO site for all other medications.
5. Notify PSS and EMS B/C when used.
**DO NOT DELAY TRANSPORT FOR CYANOKIT ADMINISTRATION
**Monitor blood pressure as the patient could have significant increases.
M. Stroke
1. Airway, oxygen, monitor, obtain 12-Lead ECG.
2. Check blood sugar level is less than 70 follow hypoglycemia protocol.
3. Start IV with NS en route to hospital. Do NOT delay transport. Titrate to vital signs
if BP is < 90 systolic.
4. Perform, document and report results of the Cincinnati Prehospital Stroke Scale
(see Procedure B) to receiving facility.
5. Obtain history – if possible, determine onset time of signs and symptoms from
patient and / or bystanders – report to receiving facility for possible activation of
hospital stroke team.
6. Code 3 Stroke Transport if:

Signs/symptoms have recently developed (onset within last 3 hours).

Signs/symptoms are progressing.

Unstable vital signs.
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N. Behavioral Emergencies
1. A patient with a behavioral emergency should be transported to the catchment
hospital for medical clearance and psychiatric evaluation.
2. Patients who are rational and present no risk to OFD personnel or to themselves
may be transported to hospital of choice.
3. Patients who pose a risk to themselves or OFD personnel (See Refer to Altered
Mental Status Protocol)
ALWAYS consider a medical etiology for a behavioral emergency.
O. Nausea and/or Vomiting
1. Follow appropriate protocol for the patient’s condition.
2. Start IV with NS, titrate to vital signs.
3. Administer Zofran (ondansetron), single dose only.

For adult patients < 250 lbs., give 4 mg IV, slow push 2-5 minutes, or SL

For adult patients > 250 lbs., give 8 mg IV, slow push 2-5 minutes, or SL

For pediatrics age 1 or older, give 0.15 mg/kg IV, slow IV push, max of 4 mg.
OBSTETRICS - GYNECOLOGY
A. Imminent Delivery with History of Pregnancy, a Palpable Uterus and
Contractions
1. Airway, oxygen, monitor.
2. Consider IV with NS, titrate vital signs. If possible, start IV’s in forearms.
3. If not crowning (no signs & symptoms of imminent delivery), transport patient in
position of comfort, usually on left side.
4. If crowning present, prepare mother for delivery.
5. Allow placenta to deliver naturally. DO NOT forcibly extract. If mother allows, put
baby to breast. Massage fundus. Transport all tissue passed with patient to
receiving facility.
B. Neonatal Care
General Care Given Newborn, Full-Term or Premature
1. Suction nose with bulb syringe.
2. Keep baby warm and dry, keep at same level as vagina.
3. Stimulate to breathe.
4. Maintain airway and apply blow-by oxygen as necessary.
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5. Assess APGAR score at 1 minute and 5 minutes. (See Appendix)
6. Within 1 - 2 minutes, double clamp cord 6 - 12 inches from baby and cut.
7. Continue supportive care as needed.
If spontaneous respirations absent or inadequate, or pulse rate below 60:

Ventilate with bag-valve-mask at a rate of 40 - 60/minute with ROOM AIR.

If pulse remains less than 60, despite positive pressure ventilation, intubate and
ventilate with 5 L/min oxygen.

If pulse remains less than 60 after intubation OR drops below 60 at any time,
start chest compressions.



Compression to ventilation ratio is: 3:1 (90 compressions and 30
ventilations per minute).
If no change after this point, Administer Epinephrine:

0.01 – 0.03 mg / kg IV / IO, (1:10,000).

Repeat every 3 – 5 minutes.

For ET administration, give 0.1 mg / kg, (1:1,000)
Fluid Bolus at 10 cc / kg
C. Meconium Stained Fluid
1. Use a suction catheter or infant bulb syringe to clear mouth and nose.
2. If meconium present, intubate with #3.0 ET tube, suction the tube as the tube is
pulled out, re-intubate with a new tube each time until CLEAR (consider use of
Meconium Aspirator).
3. Once clear, re-intubate and ventilate, maintain a patent airway and provide oxygen
at no greater than 5 L/min.
D. Childbirth Complications
Prolapsed cord, breech presentation, limb presentation, significant hemorrhage,
decreased fetal heart rate.
1. Airway, oxygen, monitor, start 1 or 2 IVs with NS and titrate to vital signs.
2. If prolapsed cord, place patient on back and elevate the hips or consider kneechest position. Place two fingers of a gloved hand in vagina to raise the presenting
part of the infant off the cord. Check cord for pulsations and avoid compressing
the cord. Continue during transport. Apply warm, moist sterile dressings to the
exposed cord to maintain temperature.
3. If breech delivery and unable to deliver head, place gloved hand in the vagina with
palm towards the infant’s face. Form a “V” with the index and middle fingers on
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either side of infant's mouth and nose and push the vaginal wall away from the
infant’s face. If necessary, continue during transport.
4. If arm or leg presentation, place patient on back and elevate hips or consider kneechest position, transport immediately.
5. If significant hemorrhage, place dressings to monitor bleeding and elevate hips.
E. Postpartum Hemorrhage
1. Airway, oxygen, monitor.
2. Massage the fundus of the uterus and put baby to breast.
3. Start IV with NS and titrate to vital signs.
F. Hypertensive Disorders of Pregnancy
Toxemia of Pregnancy/Eclampsia - Toxemia is characterized by hypertension and
diffuse edema
1. Airway, oxygen, monitor, position patient on her left side.
2. Start 2 IVs with NS TKO.
3. Consider blood sugar check if blood sugar is <70 follow hypoglycemia protocol.
4. Administer Medications if patient has eclampsia (actively seizing):

Magnesium Sulfate (50%) 5 grams in 50 cc D5W with a minidrip setting.
Infusion must be over a minimum of 5 minutes.
If patient has pre-eclampsia (headache, confusion, visual disturbances, chest pain,
dyspnea or history of recent seizure prior to medic unit arrival), consider
Magnesium Sulfate at the above dose.
If still seizing after 5 minutes, repeat Magnesium Sulfate at half dose.

Magnesium Sulfate (50%) 2.5 grams in 50 cc D5W with a minidrip setting.
Infuse over a minimum of 5 minutes.
5. For continued seizures, consider:

Versed 2.5 mg slow IV push (may repeat once), OR 5 mg IM, OR 5 mg intranasal (may repeat in 5 minutes at half the dose).
G. Vaginal Bleeding
1. Airway, oxygen, monitor.
2. Start IV NS and titrate to vital signs.
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PEDIATRICS
A. General Guidelines
This protocol acknowledges that age limits for pediatric patients should be flexible and
that the exact age of a patient is not always known. Between the ages of 13 and 16, OFD
personnel should use his / her own judgment in making medical care decisions. OFD
personnel always have the option of contacting medical control directly for assistance in
decision making.
See General Operations section (Refusal of Care) for patient consent and refusal
guidelines.
Parents / caregivers should be allowed to stay with children during assessment and
transport, if appropriate.
OFD personnel shall transport all size-appropriate pediatric patients using the Pedi Mate.
OFD personnel are strongly encouraged to use current length based resuscitation tapes
and guidelines for dosage and equipment recommendations for pediatric patients.
If specific protocol not found in Pediatric Section, OFD personnel should follow
appropriate Adult Protocol, adjusting all medications and interventions to pediatric
dosages and guidelines.
B. Airway Management and Oxygen Therapy
OFD personnel should administer high flow oxygen by mask as needed. If patient will not
tolerate mask, use high flow blow-by oxygen.
Do not hyperextend the neck in newborns and infants.
Avoid hyper-oxygenating newborns and infants after resuscitation. Keep O2 saturation >
94% once ROSC is achieved in a previously pulseless patient.
Consider appropriately sized oral airway for all unconscious patients.
When ventilation is needed, use appropriately sized bag valve mask device.
Endotracheal intubation is allowed, but is not necessary when ventilations are effectively
maintained with BVM.
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C. IV Therapy
For pediatric trauma patients and for all types of shock, attempt IVs enroute. Do not delay
scene time to establish an IV with a code 3 pediatric trauma patient.
For pediatric patients that are in critical or unstable condition, establish an intraosseous
(IO) infusion if difficult or unable to establish an IV.
D. Pediatric Cardiac Arrest
General Guidelines
1. If respirations are absent or inadequate, begin assisted ventilations using the
appropriately sized bag-valve-mask with 100% oxygen.
2. Begin chest compressions if:

No pulse.

Bradycardia (< 60 beats/min) is causing severe cardiorespiratory compromise
as evidenced by poor perfusion, hypotension, respiratory difficulty or altered
mental status.
3. Apply ECG monitor and follow standing orders as indicated using protocol
guidelines or Broselow tape.
4. Use Zoll Pediatric pads for patients up to 55 pounds (25kg).
5. A patient that is over 8 years old or over 55 pounds (weight over age) should be
treated as an adult with respect to electrical therapy. A patient that has signs of
puberty (breast development or under arm hair) should be treated as an adult with
respect to electrical therapy.
6. Consider drug overdose and/or hypoglycemia as precipitating factors in
cardiopulmonary arrest. Treat confirmed hypoglycemia with glucose. Dosing
guidelines based on patient age:

If blood sugar is less than 70, administer D10 (1 Gram / kg) OR D50W
(1 Gram / kg) up to 25 grams for patients four (4) years or older if D10
not available (slow IV or IO push).

For patients three (3) years or younger, Administer Dextrose 25% 2-4
ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with
NS or sterile water, which will result in D25W).
7. If BVM ventilation is effective, do not delay scene time to establish ET intubation
E. Pediatric Cardiac Arrest: V-Fib / Pulseless Ventricular Tachycardia
1. UNWITNESSED arrest, perform 5 cycles (2 minutes) of CPR.
WITNESSED arrest, shock X 1 at 2 joules per kilogram (2 J / kg).
2. Immediate CPR after defibrillation for 2 minutes.
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3. Shock # 2 at 4 J / kg.
4. Immediate CPR after defibrillation for 2 minutes.
5. Repeat shocks at 4 J / kg; continue with 2 minutes of CPR between each shock.
6. Consider endotracheal intubation at any time with minimal interruption to CPR.

Ventilate with BVM (15 compressions to 2 ventilations) until ET tube
established, then ventilate 8 to 10 times per minute with continuous
compressions.
7. Deliver chest compressions at > 100 per minute.
8. Establish IV or IO at any time without interrupting CPR.
9. Administer Medications:

Epinephrine 0.01 mg / kg (1:10,000) IV or IO every 3 to 5 minutes
OR
0.1 mg / kg (1:1,000) ET every 3 to 5 minutes.

Amiodarone 5 mg / kg IV or IO
If Torsades de Pointes:

Magnesium Sulfate 25 - 50 mg/kg to a Max of 2 Grams IV / IO slow IV push
(over 5 minutes).
F. Pediatric Cardiac Arrest: Asystole / PEA
1. Perform 5 cycles (2 minutes) of CPR.
2. Confirm rhythm is asystole or PEA.

Ventilate with BVM (15 compressions to 2 ventilations) until ET tube
established, then ventilate 8 to 10 times per minute with continuous
compressions.
3. Deliver chest compressions at > 100 per minute.
4. Establish IV or IO at any time without interrupting CPR.
5. Consider endotracheal intubation at any time with minimal interruption to CPR.
6. Administer Medications:

Epinephrine 0.01 mg / kg (1:10,000) IV or IO every 3 to 5 minutes
OR
0.1 mg / kg (1:1,000) ET every 3 to 5 minute.
7. Consider treatable causes in the field:

Hypovolemia, administer fluid boluses at 20 ml / kg. May repeat 2 more times,
as needed.
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Tension Pneumothorax, consider needle decompression.

Infants up to 1 year use 18 ga needle

1 year and older use 14-16 ga needle

Hypothermia, provide warming measures.

Acidosis or Tricyclic Overdose, administer sodium bicarbonate 1 mEq / kg IV
or IO.

Hypoglycemia,

If blood sugar is less than 70, administer D10 (1 Gram/kg) or D50 W (1
Gram / kg) up to 25 grams for patients four (4) years or older if D10 not
available (slow IV or IO push).

For patients three (3) years or younger, Administer Dextrose 25% 2-4
ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with
NS or sterile water, which will result in D25W).
G. Pediatric General Cardiac Dysrhythmia
In general, pediatric patients do not have cardiac dysrhythmias due to cardiac disease.
Most often, the cause of dysrhythmias in pediatrics is due to an airway/ventilation or
volume condition. For pediatric patients with signs & symptoms of poor perfusion, clear &
maintain the airway, provide BVM ventilations and fluid resuscitation (20 ml / kg) as
needed.
Most pediatric arrhythmia guidelines follow the adult protocols. OFD personnel should
refer to a pediatric reference guide (length based pediatric tape) if assistance is needed
with drug dosages for pediatric patients.
Stable Pediatric Patient –
If tolerating the rhythm, monitor and provide supportive care without medications or
electrical intervention.
Unstable Pediatric Patient –
Treatments are based on the patient’s condition and how rapidly a medication may be
delivered versus how rapidly an electrical therapy can be performed.
H.
Bradycardia (HR <60 / min)
Bradycardia with signs and symptoms of poor perfusion
1. Airway, oxygen and monitor.
2. Establish an IV or IO of NS.
3. If unstable (poor perfusion, hypotensive, respiratory distress, altered mental
status), start chest compressions and assure airway and oxygen with BVM and/or
endotracheal intubation.
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4. Administer Medications:

Epinephrine 0.01 mg / kg (1:10,000) IV or IO every 3 to 5 minutes
OR
0.1 mg / kg (1:1,000) ET every 3 to 5 minutes.

Atropine 0.02 mg / kg IV or IO (minimum atropine dose is 0.1 mg).
Consider reversible causes (H’s and T’s)

Administer Epinephrine Drip:

Begin infusion at 0.1 - 1mcg / min

Pulse and BP should be monitored every 2-5 minutes.

Goal of resuscitation:

HR > 60 (80 for neonates/infants)

Systolic BP > 70 + (age in years x2)

Improving mental status

Improving capillary refill
5. Consider Transcutaneous Pacing (TCP)

If possible, pre-medicate with Versed 0.1 mg / kg IV/IO to a maximum dose of
2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg
I. Monomorphic Ventricular Tachycardia with a Pulse and Poor Perfusion
1. Airway, oxygen and monitor.
2. Establish an IV or IO of NS.
3. Administer Medications: If patient appears to be critically unstable go straight to
Synchronized Cardioversion.

Adenosine 0.1 mg / kg rapid IV or IO push followed by 10ml flush (max dose is
6 mg). May repeat once in 2 – 3 minutes at double the dose (max dose 12 mg).

Amiodarone 5 mg / kg SLOW IV / IO over 60 minutes.
4. Consider Synchronized Cardioversion

Pre-medicate if possible with Versed 0.1 mg / kg IV or IO to a maximum dose
of 2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg

Synchronized Cardioversion #1 at 0.5 – 1 joule / kg

Synchronized Cardioversion #2 at 2 joules / kg.
J. SVT with signs and symptoms of poor perfusion
1. Airway, oxygen and monitor. If patient appears to be critically unstable, go straight
to Synchronized Cardioversion.
2. Establish an IV or IO of NS.
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3. Vagal maneuvers, if patient is old enough to understand commands.
4. Administer fluid bolus at 20 ml / kg, repeat bolus as needed, up to a total of 3 times,
to increase perfusion. If patient has history of SVT, adenosine should not be
delayed for multiple fluid boluses.
5. Administer Medications:

Adenosine 0.1 mg / kg rapid IV or IO push followed by 10ml flush (max dose is
6 mg). May repeat once in 2 – 3 minutes at double the dose (max dose 12
mg).
6. Consider Synchronized Cardioversion

Pre-medicate if possible with Versed 0.1 mg / kg IV or IO to a maximum dose
of 2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg

Synchronized Cardioversion #1 at 0.5 – 1 joule / kg.

Synchronized Cardioversion #2 at 2 joules / kg.
K. Difficulty Breathing
Asthma, Bronchiolitis (Difficulty Breathing in the presence of wheezing)
1. Airway, oxygen, monitor, maintain position of comfort.
2. If patient in respiratory arrest, begin ventilations with a BVM, consider endotracheal
intubation.
3. Administer Medications:

DuoNeb by nebulizer, immediately. May repeat as necessary.
For patients in severe respiratory distress or the nebulizer treatment is ineffective:

Epinephrine 0.01 mg / kg (1:1,000) IM to a maximum dosage of 0.3mg. Repeat
Epinephrine in 5 minutes, if necessary.
4. If unconscious, consider Bag-In nebulizer setup for DuoNeb.
5. Start IV with NS TKO if not started already, titrate to vital signs. Do not delay
medications while waiting for IV access.
Acute Allergic Reaction/Anaphylaxis (Difficulty Breathing in the presence of
urticaria, wheezing and/or contact with a known allergen)
1. Airway, oxygen, monitor.

If patient in respiratory arrest, begin ventilations with a BVM, consider
endotracheal intubation.
2. Administer Medications immediately:

Epinephrine 0.01 mg / kg (1:1,000) IM to a maximum dosage of 0.3 mg.
OR
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0.01 mg / kg (1:10,000) IV/IO (in severe anaphylaxis w/ imminent
arrest).

May repeat epinephrine in 3 - 5 minutes if necessary and/or start epinephrine
infusion at 0.1 – 1 mcg/kg/min.

DuoNeb by nebulizer, may repeat as necessary.

Benadryl 1 mg / kg IM or slow IV/IO push (over 1 - 3 min), maximum dosage of
50 mg.
3. IV of NS if not started already, titrate to vital signs.
Croup and Epiglottitis (Difficulty Breathing in the presence of stridor and history
of illness)
1. Airway, oxygen, monitor.
2. Maintain patient in position of comfort, try to keep patient calm.
3. If unconscious, position supine and ventilate with BVM.
4. Consider early and rapid transport.
5. For suspected croup, administer medications:

Nebulized Epinephrine 0.5 ml / kg of 1:1000 solution (may dilute in 3 ml saline).
Maximum dose for patients < 4 years old is 2.5 ml per dose.
Maximum dose for patients > 4 years old is 5.0 ml per dose.

If unable to give epi nebulizer treatment, consider Epinephrine 0.01 mg/kg
(1:1,000) IM (maximum of 0.3 – 0.5 ml).
6. Consider IV of NS TKO.
Choking
1. Attempt to relieve obstruction according to the American Heart Association Foreign
Body Airway Obstruction (FBAO) guidelines.
2. If above maneuvers are unsuccessful, attempt to visualize obstruction with
laryngoscope and remove with Magill forceps.
3. Administer oxygen, monitor.
4. If all of the above fail, consider needle cricothyrotomy, 12 – 14 gauge for children,
16 – 18 gauge for infants or the largest catheter that will fit into the airway /
cricothyroid space.
5. Start IV with NS TKO enroute.
L. Seizures - recurrent or prolonged
1. Airway, oxygen, monitor.
2. Protect patient from further injury, DO NOT restrain.
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3. Check blood sugar level.
4. Start IV with NS and titrate to vital signs.
5. Administer Medications:
If blood sugar less than 70:

If blood sugar is less than 70, administer D10 (1 Gram/kg) or D50 W (1
Gram / kg) up to 25 grams for patients four (4) years or older if D10 not
available (slow IV or IO push).


For patients three (3) years or younger, Administer Dextrose 25% 2-4
ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with
NS or sterile water, which will result in D25W).
For continued seizures, consider one of the following:

Versed 0.05 mg / kg slow IV/IO push up to a maximum dose of 2.5 mg, may
be repeated with authorization from receiving hospital.

If no IV access, Versed 0.05 mg / kg IM to a maximum dose of 2.5 mg,
OR
0.2 mg / kg (max of 5 mg) intranasal (max of 1 ml per nostril). If
given via nasal route, may be repeated at half-dose with
authorization from receiving hospital.
OR


If no IV/IO access, Valium 0.5 mg / kg rectally, may repeat to a maximum
dose of 10 mg.
If narcotic overdose suspected:

Narcan 0.1 mg / kg IV/IM/IO/IN up to 2 mg, repeat as necessary.
M. Altered Mental Status
1. Airway, oxygen, monitor.
2. Check blood sugar level.
3. Start IV with NS and titrate to vital signs.
4. Administer Medications:
If blood sugar less than 70:

If blood sugar is less than 70, administer D10 (1 Gram / kg) OR D50W
(1 Gram / kg) up to 25 grams for patients four (4) years or older if D10
not available (slow IV or IO push).

For patients three (3) years or younger, Administer Dextrose 25% 2-4
ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with
NS or sterile water, which will result in D25W).
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If narcotic overdose suspected:
1. Narcan 0.1 mg / kg IV/IM/IO/IN up to 2 mg, repeat as necessary.
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PROCEDURE A - RAPID SEQUENCE INTUBATION
Indications
1. Altered mental status with airway compromise.
2. Head injuries with signs of increased ICP (GCS < 8), but combativeness or
agitation threatens the airway, spinal cord stability, and/or patient and crew safety.
3. Conscious but unable to maintain airway.
4. Severe respiratory distress with hypoxia / cyanosis, impending respiratory failure.
NOTES:

High flow oxygen should be applied. If the patient has inadequate
ventilations, ventilate with BVM @ 12 – 16 / minute with 100% oxygen.

Maintain cricoid pressure during entire intubation until tube placement is
confirmed by O2 saturations, physical exam and CO2.

DO NOT PERFORM IN TRANSPORT. Stop vehicle to initiate RSI.
Pre-medication Considerations
1. Administer Atropine 0.02 mg / kg IV or IO (minimum of 0.1 mg, maximum of 1mg)
to the pediatric patient due to potential bradycardia (any patient under 4 years of
age).
2. Sedation

Versed (Midazolam)
Adults:
2 - 5 mg IV (may repeat every 5 minutes to a total dose of 10 mg) OR
5 – 10 mg intranasal, repeat at half-dose in 5 minutes. Max of 1 cc
per nostril.
Peds:
0.1 mg / kg IV or IO OR 0.4 mg / kg intranasal, max of 10 mg. Max
of 1 cc per nostril.
3. Paralyzing Agent

Succinylcholine
Adults:
1.5 mg / kg IV or IO
Peds:
1.5 mg / kg IV or IO
(DO NOT REPEAT Succinylcholine)
Procedure
1. Establish IV/IO access.
2. BVM (12-16 / min for adults, 14-20 / min for pediatrics) to preoxygenate the patient
for approximately 2 minutes if necessary. If patient has adequate ventilations
before RSI procedure, ventilations with BVM are not required prior to intubation.
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3. Maintain cricoid pressure at all times.
4. If trauma, maintain spinal immobilization (per trauma protocol).
5. Obtain & record vital signs (BP, Pulse, Respirations, O2 saturations and ECG).
6. Prepare equipment and medications.
7. Pre-medicate with Versed.
8. Administer Atropine 0.02 mg / kg IV or IO (minimum of 0.1 mg, maximum of 1mg)
to the pediatric patient due to potential bradycardia (any patient under 4 years of
age).
9. Administer Succinylcholine 1.5 mg / kg rapid IV push (100 mg for 70 kg adult
patient).
Once fasciculations stop (approximately 30 seconds), with cricoid pressure continued,
intubate.
Confirm endotracheal tube placement by:

Attaching the EtCO2 monitor and verify CO2 production by waveform or mmHg.

Observing for chest rise and fall.

Verifying the presence of bilateral lung sounds and the absence of epigastric
sounds by auscultation with a stethoscope.

Confirming improvement in saturations by pulse oximetry.
Once ET tube confirmed, inflate the ET tube cuff. Release cricoid pressure and secure
the tube in place.
Apply c-collar, repeat vital signs and O2 sats.
NOTE: Failed intubation should be followed by BVM ventilation, then placement of the
King Airway.
Contraindications (for the procedure):

Inability to ventilate with BVM
Examples: lodged foreign body, severe maxillofacial injury tracheo-bronchial
injury (fractured larynx)

Body habitus (physical exam reveals potential difficult intubation)
Examples: large tongue, no neck, and morbid obesity
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Contraindications (for succinylcholine):

Known hyperkalemia (peaked T-waves), renal failure.

Burns greater than 8 hours old.

History of chronic paraplegia or quadriplegia

History of muscular dystrophy, ALS, multiple sclerosis or myasthenia gravis.

History of malignant hyperthermia or pseudo cholinesterase deficiency.

Open eye injury.
If patient goes into cardiac arrest after administration of Succinylcholine, defibrillate if VFIB or pulseless V-TACH, then:
Administer Sodium Bicarbonate for presumed hyperkalemia
Adults:
1 mEq / kg IV push
Peds:
1 mEq / kg IV push
Follow protocol for cardiac arrest and dysrhythmia management
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PROCEDURE B – CINCINNATI PREHOSPITAL STROKE SCALE
Facial Droop (have patient show teeth or smile):
 Normal – both sides of face move equally well.
 Abnormal – one side of face does not move as well as the other side.
Arm Drift (patient closes eyes and holds both arms out):
 Normal – both arms move the same or both arms do not move at all (other
findings, such as pronator grip, may be helpful).
 Abnormal – one arms does not move or one arms drifts down compared
with the other.
Speech (have the patient say “you can’t teach an old dog new tricks”):
 Normal – patient uses correct words with no slurring.
 Abnormal – patient slurs words, uses inappropriate words, or is unable to
speak.
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PROCEDURE C - PRE-HOSPITAL SPINAL INJURY ASSESSMENT AND
TREATMENT (CERVICAL SPINE IMMOBILIZATION CONSIDERATIONS)
NOTE: Maintain manual c-spine immobilization until evaluation is complete.
Evaluate for the presence of any of the following:

Multi-system trauma.

Any loss of consciousness.

Altered mental status.

Significant injury above the clavicles (i.e. head/neck wounds).

Presence of a distracting injury (i.e. fractured femur).

Presence or suspicion of alcohol or drug use.

Presence of language/communication barrier.

Ask patient if any presence of neck pain.
If negative findings to all listed above, proceed with the following focused
physical exam:

Test for motor/sensory function.

Finger abduction/adduction.

Finger/hand extension.

Foot plantar flexion.

Foot/great toe dorsiflexion.

Light touch sensation to hands and feet.

Palpate spine for tenderness.
Pre-Hospital Spinal Injury Assessment and Treatment – (continued):
If all findings negative for potential injury, ask patient to:

Flex and extend the head up and down.

Rotate the head to the right and left.

Tilt the head to the right and left.
If the paramedic assesses any criteria above to be positive findings OR if the patient has
any complaints of neck pain, pain on palpation, neurological deficit, positive mechanism
of injury or is unreliable, the paramedic will immobilize patient to back board.
NOTE: For patient to be reliable, he/she must be calm, cooperative, and alert and have
no suspicion of alcohol or drug use.
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If the paramedic assesses that all criteria above to be negative findings, spinal
immobilization is not indicated.
It is advised to document the following:

Absence/presence of complaints of pain.

Neck pain to direct palpation.

Neck pain to motion.

Injury above the clavicles.

Neurologic abnormality.

Obvious injury.

Patient reliability.
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PROCEDURE D – NERVE AGENT / ORGANOPHOSPHATE POISONING –
MARK 1 / DUODOTE KITS (ADULT), VALIUM AUTO-INJECTORS
(ADULT) AND ATROPEN AUTO-INJECTOR (PEDIATRIC)
Purpose: To establish guidelines concerning the local EMS response to a WMD
(Weapons of Mass Destruction) event and to provide local EMS providers with access to
pharmaceutical resources and guidance on the use of auto-injectors (Mark I Kits,
DuoDote, Diazepam and pediatric AtroPens).
EMS providers are reminded to:
1. Consider scene safety and first responder safety as primary goal.
2. Consider implementing local protocol for mass casualty incidents and/or
requesting the opening of the county EOC (Emergency Operations Center) in the
event of a mass casualty incident to assist in assembling treatment resources and
facilitating the transportation of large numbers of patients.
3. Contact the Nebraska Regional Poison Center for immediate assistance at 1-800222-1222.
Until the Douglas County EOC Medical Table is activated and opened, the Poison
Center will serve as the point of contact for local first responders and hospitals to
access the stockpiles distributed throughout the community. DuoDotes and Mark
1 Kits are available on most area rescue squads for self-administration, in small
cache supplies at several local fire departments, in other local stockpiles and in
federally supplied assets in the Omaha Metropolitan Medical Response System
(OMMRS) area for treatment of victims of nerve agent exposures.
The requesting agency will be responsible for providing the transportation of the
product to the scene locally. This may often be delegated to the 911 Center by preestablished protocol. The Nebraska State Patrol may serve as the medium for
movement across jurisdictions that do not already have established plans or when
movement of product must come from other assets across the state.
Mark I Kit:
For adult patients and pediatrics over 84 lbs. (38 kg)
1. Atropine auto-injector (2 mg total dose per injection)
2. Pralidoxime chloride auto-injector (600 mg total dose per injection)
DuoDote:
For adult patients and pediatrics over 84 lbs. (38 kg)
1. *Atropine (2.1 mg total dose per injection)
2. *Pralidoxime chloride (600 mg total dose per injection)
* DuoDote is a newer version of the Mark 1 Kit and contains the same medications
and doses as the Mark 1 Kit. The only difference is the DuoDote contains both
atropine and pralidoxime chloride in a single auto-injector for IM injection.
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For pediatric patients up to 84 lbs. (38 kg)
Atropine auto-injector (0.5 mg total dose per injection)
Diazepam (Valium): For adult patients
Diazepam auto-injector (10 mg total dose per injection)
Nerve Agents: A classification of potential WMD chemical agents that might be used in
a terrorist attack. Examples include Tabun, Sarin, Soman and VX.
Organophosphates: Insecticides such as Malathion, Diazinon and Parathion
Nerve Agent or Organophosphate Poisoning Signs/Symptoms by Severity:
Mild
Constricted (pinpoint) pupils, excessive sweating, tearing, drooling,
runny nose/nasal secretions, mild chest tightness, mild shortness of
breath, chest tightness
Moderate
Severe chest tightness, wheezing, profuse airway secretions,
respiratory distress, muscle weakness, vomiting, abdominal cramps
and diarrhea
Severe
Unconsciousness, coma, seizures, no muscle tone (flaccid
paralysis), cyanosis, respiratory failure, apnea
Authorization for Use
The auto-injectors are authorized for use by the local Physician Medical Directors for the
departments that have received them and for use by personnel who have received
adequate training (by the Physician Medical Director or designee) on the recognition and
treatment of nerve and/or organophosphate agent exposure in the event of a chemical
release. In the case of a nerve agent incident, it would be specific to the disaster setting.
Organophosphate exposure may be treated as an isolated case with the Mark 1 kits or
DuoDotes.
Pediatric strength atropine (AtroPen 0.5 mg) and diazepam auto-injectors are to be
distributed only to paramedic staffed rescue squads.
Guidelines for Use
The decision to use the Mark I kit or DuoDote is based on signs and symptoms of the
patient, regardless if the patient is an EMS provider, firefighter or a civilian. The goal of
using the auto-injectors is directed at relieving respiratory distress and alleviating
seizures. The suspicion or identified presence of a nerve agent is not sufficient reason on
its own to warrant the administration of the medication.
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EMS providers/firefighters may self-administer the Mark 1 kit or DuoDote. The premeasured doses in the auto-injectors are generally safe for most adults suffering from a
nerve agent or organophosphate exposure.
Paramedics are reminded to review the indications for use and to only treat victims with
an auto-injector that are exhibiting signs and symptoms from a nerve agent or
organophosphate exposure.
Mark 1 Kit / DuoDote Dosage Guidelines for Adults
Each Mark 1 Kit contains two auto-injectors: Atropine 2 mg and Pralidoxime Chloride 600
mg. Each DuoDote contains the same medications in a single auto-injector. Dosing is
based on signs & symptoms.
For MILD signs & symptoms, administer one Mark 1 Kit OR one DuoDote.
For MODERATE signs & symptoms, administer two Mark 1 Kits OR two DuoDotes.
For SEVERE signs & symptoms, administer three Mark 1 Kits OR three DuoDotes.
Diazepam (Valium) Dosage Guidelines for Adults
Each Valium auto-injector contains Diazepam 10 mg
For SEIZURES and/or SEVERE signs & symptoms, administer one Valium auto-injector
May repeat every 5 – 10 minutes as needed
AtroPen Dosage Guidelines for Children
Each AtroPen auto-injector contains Atropine 0.5 mg
Dosing is weight based:

13 to 40 lbs. (6-18 kg), administer one AtroPen, repeat every 5-10 mins
as needed

41 to 62 lbs. (19-28 kg), administer two AtroPens, repeat every 5-10
mins as needed

63 to 84 lbs. (29-38 kg), administer three AtroPens, repeat every 5-10
mins as needed

Greater than 84 lbs. (>38 kg), administer one Mark 1 Kit OR one
DuoDote, repeat every 5-10 mins as needed
Mark 1 Kit Injection Procedure
1. Remove the Mark I kit from the protective foam case.
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2. With the non-dominant hand, hold the kit so that the larger injector is on top and
position the kit at eye level.
3. With the other hand, check the injection site (outer thigh or buttocks) for buttons or
objects in the pocket, which may interfere with the injections.
4. Grasp the small (green tipped) injector (atropine) with your thumb and first two
fingers.
5. Pull the injector out of the clip with a smooth motion.
6. Hold the injector like a pen, between your thumb and first two fingers.
7. Position the green tip of the auto injector against the injection site (thigh or
buttocks).
8. Apply firm even pressure (not a jabbing motion) to the injector until it pushes the
needle in to the site. Hold the injector firmly in place for at least 10 seconds.
9. Carefully remove the auto injector and place it into a sharps container. In an
emergency, and no sharps container available, bend the used needle over, or blunt
the end to avoid any accidental needle sticks.
10. Pull the 2-PAM auto injector (larger, black tipped one) out of the clip and inject
using the same procedure outlined above.
11. Document the number of auto injectors administered on the patient care report, on
the triage tag or attached the used injector(s) to the patient.
DuoDote Injection Procedure
1. Remove the DuoDote from the plastic pouch.
2. Place the DuoDote in your dominant hand. Firmly grasp the center of the DuoDote
with the green tip pointing down. Do not touch the green tip.
3. With your other hand, pull off the gray safety release. The DuoDote is now ready
to be administered.
4. Make sure pockets at the injection site are empty.
5. Firmly push the green tip straight down against the outer thigh. Continue to firmly
push until you feel the auto-injector trigger.
6. Hold the DuoDote in place for 10 seconds.
7. Remove the auto-injector from the thigh and look at the green tip. If the needle is
visible, the drug has been administered.
8. If the needle is not visible, check to be sure that the gray safety release has been
removed and repeat the procedure.
9. Place the auto-injector in a sharps container.
10. Document the number of auto injectors administered on the patient care report, on
the triage tag or attached the used injector(s) to the patient.
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PROCEDURE E – 12 LEAD ECG
Indications
1. Chest pain / discomfort (signs / symptoms suggestive of MI), any suspected
cardiac event.
2. Cardiac dysrhythmias.
3. Patient presents with cardiac signs / symptoms including but not limited to:

HR greater than 150.

HR less than 50.

Epigastric pain, unless there is other evidence indicating a GI bleed.

Thoracic back pain without trauma.

Diaphoresis not explained by fever or other environmental factors.

Shortness of breath or dyspnea with clear lung sounds.

Syncope without seizure or obvious blood loss.

PVCs unchanged by oxygen and/or PVCs greater than 6 / minute.

CHF / Pulmonary edema.

Tricyclic overdose.

All overdoses with abnormal rhythms.
4. Patients with the following chief complaints should be treated as suspected AMI:

Chest pain or pressure in a patient > 25 years old.

Syncopal episode in any patient > 25 years old.

Unexplained respiratory distress.

Atypical upper body pain (shoulder, arm or jaw pain) in the absence of chest
pain, especially with past medical history of cardiac problems, irregular pulse,
diabetes, or female and elderly patients.

Consider in young adult patients with a history of cocaine or methamphetamine
use.
Contraindications
1. Treat all life-threatening conditions (A B Cs, Dysrhythmias) prior to obtaining 12Lead.
2. Do NOT allow 12-Lead to delay transport of a critically ill patient.
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Patient Preparation
1. Protect patient modesty.
2. Area where leads applied should be clear of items that may cause artifact (clothing,
jewelry, etc.).
3. Skin should be clean and dry.
4. Shave chest hair as needed.
12 Lead ECG Placement
Limb Leads:
RA
right arm, upper arm or upper chest near the shoulder
LA
left arm, upper arm or upper chest near the shoulder
RL
right leg or lower abdominal quadrant near the hip
LL
left leg or lower abdominal quadrant near the hip
Chest Leads:
V1
4th intercostal space, right sternal border
V2
4th intercostal space, left sternal border
V4
5th intercostal space, left mid-clavicular line
V3
placed between V2 and V4
V5
5th intercostal space, anterior axillary line
V6
5th intercostal space, mid-axillary line
Procedures
1. Acquire 12 Lead ECG when indicated per protocol.
2. Identify rhythm and treat THE PATIENT per protocol.
3. Transmit 12 Lead ECG to receiving hospital as soon as possible.
4. Transport Code 3 STEMI to receiving hospital (closest hospital with functioning
Cath Lab capability).
5. Radio report to receiving hospital should include your interpretation, treatment, and
notification that 12 Lead ECG has been transmitted.
6. If STEMI, inform receiving hospital that you are enroute with a STEMI Alert.
Remember: A 12 Lead ECG is only a diagnostic tool.
TREAT THE PATIENT, NOT THE MONITOR
*An MI may present with a normal ECG, maintain a high index of suspicion, especially
with diabetics, elderly, and female patients.
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PROCEDURE F – CYANIDE POISONING AND CYANOKIT
Rationale:
Smoke inhalation is the most common cause of mortality due to fires of all sources. For
decades it had been suggested that carbon monoxide is the most common cause of death
due to smoke inhalation. However, recent research suggests that cyanide exposure may
contribute to fire mortality. Cyanide is produced in every type of fire, residential,
commercial, regardless of the known presence of hazardous materials of chemical
process.
Cyanide has an affinity for all body tissues and can be considered a primary gas of
incapacitation for anyone attempting to escape a smoke charged environment. Cyanide’s
primary action is to block cellular respiration. Cyanide impairs the body’s ability to use
oxygen required for normal respiration. Tissues with the greatest oxygen requirements
(brain and heart) are the most affected by acute exposure. At the cellular level the body
switches from aerobic metabolism to an anaerobic metabolism in an attempt to
compensate –resulting in production of toxic waste (lactic acid), which contributes further
to metabolic derangements. Death typically results from central respiratory arrest.
Carbon monoxide poisoning and cyanide poisoning can be clinically indistinguishable in
the pre-hospital setting. The classis signs and symptoms include (cherry red skin, bitter
almond odor on the skin and/or breath, profound cyanosis) are insensitive indicators of
exposure. Cyanide exposure should be considered in any person (firefighter or civilian)
exposed to smoke within a confined compartment with the following signs and symptoms:
altered mental status, seizures, or who are unresponsive.
Cyanokit Administration Procedure
Indications:
A.
Known or suspected cyanide poisoning – suspect cyanide poisoning in
persons exposed to smoke from a fire in closed spaces and in victims with
soot around the mouth, nose with an altered mental status, seizure activity
or unresponsive.
Toxic Inhalation (Smoke Inhalation) – exposure to an enclosed smoke filled
environment.
1. Remove from exposure.
2. Assess and treat Airway, Breathing, and Circulation.
3. Start (2) IV with NS, titrate to vital signs.
4. Follow appropriate ACLS Guidelines for dysrhythmia treatment and or Cardiac
Arrest treatment.
5. Administer the following - Cyanokit: Adult Dose (19 years and older)

5 Grams of Cyanokit (hydroxocobalamin) in 200 mL 0.9% sodium chloride
IV infusion over 15 minutes using the provided 15 gtt set.
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Mixing Procedure:
1. Reconstitute: Add 200 mL of 0.9% Sodium Chloride to vial using sterile rapid
transfer spike.
a. Fill to line on the Cyanokit (hydroxocobalamin) bottle.
b. Vial must be in an upright position.
2. Mix solution: Rock or rotate vial for 60 seconds to mix solution. DO NOT SHAKE
**Visually inspect solution prior to administration. If the solution is not dark
red or if particulate matter is seen, do not administer solution.
3. Infuse Vial: Use the supplied vented 15 drop set to infuse over 15 minutes.
a. 15 drop IV tubing – 200 gtts / min or 3 drops / sec
b. Drip set will be run nearly wide open, check in 7 minutes and re-evaluate
drips / minute (1/2 of the solution should be infused)
4. All other IV medications shall be given using a second IV / IO site.
5. Cyanokit (hydroxocobalamin) may be repeated at 5 Grams / 200 mL if no changes
in patient. Infusion rates vary depending on severity if signs/symptoms (15 minutes
to 2 hours). (Follow the above steps for administration).
Contraindications:
Allergy to hydroxocobalamin – otherwise none in a lifesaving attempt
Side Effects:

Elevation in blood pressure – maximum levels towards the end of the
infusion. (blood pressure tend to return to normal values within 4 hours post –
infusion) Substantial increases may occur following administration

Allergic Reaction – Signs of serious allergic reaction include chest tightness,
dyspnea, swelling, hives, itching, or rash.
Erythema – redness of the skin (may last up to 2 wks)
Chromaturia – Urine discoloration (may last up to 5 wks)




Rash – acne type of rash may appear anywhere from 7 – 28 days post
infusion
Throat tightness, dry throat
 Headache, dizziness

Injection site irritation
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Incompatibility:
Physical incompatibility (particle formation) and chemical incompatibility were observed
with the mixture of hydroxocobalamin in solution with selected drugs that are frequently
used in resuscitation efforts.
Hydroxocobalamin is also chemical incompatible with other cyanide antidotes (sodium
thiosulfate, sodium nitrite and ascorbic acid).
Simultaneous administration of whole blood and blood products through the same IV is
not recommended, however, administration in a separate IV line is acceptable –preferably
in collateral extremities if peripheral lines are being used.
Location and Storage of Cyanokit:


Prior to reconstitution – Store at 77 degree F (59 – 86O F recommended)
Once reconstituted it is stable for up to 6 hours at temperatures below 104 F.
Location of Cyanokits:
Currently at least one (1) and up to two (2) Cyanokits are located in each OFD Battalion
Chief vehicle & in Supervisor 1 Vehicle. One additional (spare) kit will be placed on R-30
as available. The number is dictated by the number of kits available to OFD by OMMRS.
Cyanokits are stored in a clear Sterlite Container in the backseat of each BC vehicle and
on R-30.
Restocking of the Cyanokit and Notification of Use:
EMS, OMMRS, and the CDC are collectively working together on replacement funding
for the purchase of additional Cyanokits as well as maintain our current stock. In the
meantime, it is vitally important to document Cyanokit usage for continued support.
Tracking and documentation is required. Immediately notify the PSS upon use of a
Cyanokit (402) 660 - 1060. The PSS shall be responsible for the following:

Notify the Nebraska Poison Control Center (PCC) at 800 -222 -1222 or (402)
955-5555

Redistribution amongst the Suppression BC vehicles if necessary until extra
Cyanokits are obtained.

Contact the OFD IDCO by email informing them that a Cyanokit needs to be
replaced.
Each Cyanokit will have a label specifically stating these instructions to ensure the PSS
is notified and in turn satisfy data collection.
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PROCEDURE G - TRAUMA SCORING AND GCS
TRIAGE & MANAGEMENT OF THE INJURED PATIENT
REVISED TRAUMA SCORE (ADULT)
GLASGOW COMA SCALE
Glasgow Coma Scale
13 - 15
9 – 12
6–8
4–5
3
Value
4
3
2
1
0
Eye Opening
Spontaneous
To Voice
To Pain
None
Value
4
3
2
1
Respiratory Rate
Value
Verbal Response
Value
10 – 29
>29
6–9
1–5
None
4
3
2
1
0
Oriented
Words or Phrases
Incomprehensible
Grunts or Moans
None
5
4
3
2
1
Systolic Blood Pressure
Value
Motor Response
Value
>89
76 - 89
50 - 75
1 - 49
None
4
3
2
1
0
Obeys Commands
Localizes Pain
Withdraws (Pain)
Flexion (Pain)
Extension (Pain)
None
6
5
4
3
2
1
Score
0 – 12
Score < or = 11, transport to the
Trauma Center
Score
3 – 15
Score < or = 13, transport to the
Trauma Center
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PEDIATRIC TRAUMA SCORE
Component
Weight
Airway
Systolic BP
Pulses
CNS
Fractures
Wounds
> 20 kg (44 pounds)
10 – 20 kg (22 – 44 pounds)
< 10 kg (22 pounds)
Patent 1
Maintainable2
Unmaintainable3
> 90 mmHg
50 – 90 mmHg
< 50 mmHg
Radial
Carotid
Non-palpable
Awake
Responds to voice, pain or temporary
loss of consciousness noted
Unresponsive
None
Closed or suspected
Multiple closed or open
None
Minor *
Major, penetrating or burns **
Score
+2
+1
-1
+2
+1
-1
+2
+1
-1
+2
+1
-1
+2
+1
-1
+2
+1
-1
+2
+1
-1
(Possible Scoring of - 6 to + 12, decreases with severity of condition)
9 – 12
6–8
0–5
<0
Minor Trauma
Potentially life-threatening
Life threatening
Usually fatal
Score of 9 or less, transport to the Trauma Center
Key
1
2
3
*
**
No assistance required.
Protected by patient, but requires continuous monitoring for changes, may require
positioning.
Requires airway adjuncts NPA, OPA and ET or suctioning.
Abrasions, minor lacerations, burns < 10% and not involving hands, face, feet or
genitalia.
Penetrating, major avulsions, lacerations, burns > 10% or involving hands, face, feet or
genitalia.
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PROCEDURE H – EPINEPHRINE DRIP
Administration Guidelines
Mix 1mg of Epinephrine (1:1,000) in 250 mL bag of NS or D5W



Begin infusion at 2 - 10 mcg / min
Pulse and BP should be monitored every 2-5 minutes.
Goal is to maintain systolic BP at > 90 mmHg.
mcg /min
1
2
3
4
5
6
7
8
9
10
drips (gtt / min)
15 gtt / min
30 gtt / min
45 gtt / min
60 gtt / min
75 gtt / min
90 gtt / min
105 gtt / min
120 gtt / min
135 gtt / min
150 gtt / min
Note: 1mg of Epi 1:1,000 = 1000 mcg =
250 mL bag
250 mL
4 mcg = 4 mcg = 60 drops using (mini drip)
1 mL
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APPENDIX A- OMAHA FIRE DEPARTMENT EMS ABBREVIATIONS
ā
AAA
ABC
before
abdominal aortic aneurysm
airway, breathing, circulation
Letter A
AMI
amio.
AMPLE
abd
a/c
ACLS
A.D.
ADD
abdomen
antecubital
advanced cardiac life support
right ear (auris dexter)
attention deficit disorder
AMS
amt
ant.
APAP
APGAR
AED
A-fib
AHA
AIDS
AKA
ALS
A.S.
ASA
A.T.
ATV
AU
AV
AMA
automated external defibrillator
atrial fibrillation
American heart association
acquired immunodeficiency syndrome
above knee amputation
advanced life support, amyotrophic
lateral sclerosis (ALS), "Lou Gehrig's
disease
against medical advice
amb
ambulatory
B.A.
bb
BBB
blood alcohol
back board
bundle branch block
BCP
Bergan
Bicarb
bid
bilat
BLS
birth control pill
Bergan Mercy hospital
sodium bicarbonate
twice a day
bilateral
basic life support
c̅
Ca++
CA
CABG
CAD
CAO
C/C
cc
CHB
with
calcium
cancer
coronary artery bypass graft
coronary artery disease
conscious alert
chief complaint
cubic centimeter
complete heart block
AVPU
ax
Letter B
BKA
BM
BOT
BP
bpm
BS
BSA
BSI
BVM
Letter C
CO
CO2
c/o
COPD
CP
CPAP
CPR
cric.
C-spine
acute myocardial infarction
amiodarone, cordarone
allergies, medications, past medical
history, last oral intake, event
preceding incident
altered mental status
amount
anterior
acetaminophen
appearance, pulse, grimace, activity,
respirations
left ear (auris sinister)
aspirin
atrial tachycardia
all-terrain vehicle
both ears
atrio-ventricular (reference to heart
blocks)
alert, verbal, pain, unresponsive
(mental status eval)
axillary
below knee amputation
bowel movement
reeves portable stretcher (big orange
thing)
blood pressure
beats per minute
breath sounds, blood sugar
body surface area
body substance isolation
bag-valve mask
carbon monoxide
carbon dioxide
complains of
chronic obstructive pulmonary disease
chest pain, cerebral palsy
continuous positive airway pressure
cardiopulmonary arrest
cricoid
cervical spine
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Standard Operating Procedures
EMS 4-0
Table of Contents
CHF
CISD
CISM
cm
CNS
congestive heart failure
critical incident stress debriefing
critical incident stress management
centimeter
central nervous system
D5W
D25
D50
d/c
DCAP-BTLS
5% dextrose in water
25% dextrose in water
50% dextrose in water
discontinue
deformities, contusions, abrasions,
puncture/penetration, burns,
tenderness, lacerations, swelling
DKA
diabetic ketoacidosis
DuoNeb
dL
DM
DNR
deciliter
diabetes mellitus
do not resuscitate
DVT
Dx
EBL
ECG (EKG)
ED
EDC
EJ
EMS
EMT
EMT-P
FA
FB
FD
ft
G or gm
GCS
GERD
GI
h, hr
HA
HBV
HCPA
CSF
CSM
CUMC
CVA
Letter D
DOA
drsg
d/t
DT’s
DUMBELS
Letter E
estimated blood loss
ENT
electrocardiogram
Epi
emergency department
est.
estimated date of confinement (due
ET(T)
date-pregnancy)
external jugular
ETA
emergency medical services
ETOH
emergency medical technician
eval
emergency medical technicianparamedic
Letter F
forearm
fib
foreign body
FRMS
fire department
fx
foot
Letter G
gram
GSW
Glasgow coma scale
Gtt(s)
gastro-esophageal disease
GU
gastro-intestinal
GYN
Letter H
hour
HIV
headache
H2O
hepatitis B virus
HOH
Health Care Power of Attorney
HR
cerebrospinal fluid
circulation, sensory, motor
CHI Alegent Creighton Health
cerebrovascular accident (stroke)
dead on arrival
dressing
due to
delirium tremors
diaphoresis and diarrhea; urination;
miosis; bradycardia, bronchospasm,
bronchorrhea; emesis; excess
lacrimation; and salivation)
3.0 mg Albuterol & 0.5 mg Ipratropium
in 3 ml by nebulizer
deep vein thrombosis
diagnosis
ears, nose, throat
epinephrine
estimated
endotracheal (tube)
estimated time of arrival
alcohol
evaluate
fibrillation
fire record management system
fracture
gun shot wound
drop(s)
genitourinary
gynecology
human immunodeficiency virus
water
hard of hearing
heart rate
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Standard Operating Procedures
HCO3
HEENT
HEPA
bicarbonate
head, eyes, ears, nose, throat
high efficiency particulate arresting
IC
IM
IMM
IN
IO
IV
incident command
intramuscular
Immanuel hospital
Intranasal
intraosseous
intravenous
J
joules (electrical measure)
K+
potassium
(L)
L.
L1-L5
LA
lb
lac
lat
lg
lido
left
liter
lumbar veterbrae
left arm
pound
laceration
lateral
large
lidocaine
m
MCI
mag
max
mcg
MDI
meds
mEq
meter
multiple casualty incident
magnesium (sulfate) 50%
maximum
micrograms
metered dose inhaler
medications
milliequivilant
mg
Mg
MgSO4
MI
milligram
magnesium
magnesium sulfate
myocardial infarction
N-95
Na+
N/A
NAHCO3
NC
neb
hepa mask
Sodium
not applicable
sodium bicarbonate
nasal cannula
nebulizer
EMS 4-0
Table of Contents
ht
HTN
Hx
Letter I
ICP
IDDM
inf
IVP
IVPB
Letter J
JVD
Letter K
kg
Letter L
LBBB
LLQ
lpm
LMP
LOC
lsb
LUQ
LV
LVH
Letter M
min
Min
mL
mm
mmHg
MMR
MOI
MRSA
MS
MVA
MVP
Letter N
NKDA
NMC
NOI
npo
NPA
NR
height
hypertension (high blood pressure)
history
intra-cranial pressure
insulin dependent diabetes mellitus
inferior
intra-venous push (IV-push)
intra-venous piggy back
jugular vein distention
kilogram
left bundle branch block
left lower quadrant
liters per minute
last menstrual period
level of consciousness
long spine board (backboard)
left upper quadrant
left ventricle
left ventricular hypertrophy
minute
minimal
milliliter
millimeter
millimeters of mercury
measles, mumps, rubella
mechanism of injury
methicillin resistant staphylococcus
aureus
multiple sclerosis or morphine sulfate
motor vehicle accident
mitral valve prolapse
no known drug allergies
Nebraska Medicine
nature of illness
nothing by mouth
nasopharyngeal airway
non-rebreather mask
Page 81 of 83
Standard Operating Procedures
neg
neuro
NG
NH
NKA
EMS 4-0
Table of Contents
O/A
O2
O2 sat
NS
NSR
NTG
n/v
n/v/d
Letter O
on arrival
OPD
oxygen
OPA
oxygen saturation by pulse oximetry
OPQRST
OB
OBS
O.D.
od
obstetrics
organic brain syndrome
right eye (oculus dexter)
overdose
P
p
PAC
PALS
PAT
PCR
PE
PEA
PEARL
pedi
PHTLS
PI
PJC
pm
PMH
pulse
after
premature atrial contraction
pediatric advanced life support
paroxysmal atrial tachycardia
patient care report
pulmonary embolism
pulseless electrical activity
pupils equal & reactive to light
pediatric
pre-hospital trauma life support
personal injury
premature junctional contraction
afternoon
past medical history
q
every
(R)
RBBB
re
reg
RLQ
RMS
right
right bundle branch block
regarding
regular
right lower quadrant
record management system (OFD
documentation program)
s̅
SAMPLE
negative
neurologic
nasogastric
nursing home
no known allergies
with
signs/symptoms, allergies,
medications, pertinent past history,
OTC
O.U.
oz
Letter P
pnd
PNS
POC
Po
post.
Pov
PPE
PR
Prn
PSS
SVT
pt.
PTA
p/u
PVC
Letter Q
normal saline
normal sinus rhythm
nitroglycerin
nausea and vomiting
nausea/vomiting and diarrhea
Omaha police department
oropharangeal airway
onset, provocation, quality, radiation,
severity, time (pain assessment)
over the counter
both eyes
ounce
paroxysmal nocturnal dyspnea
peripheral nervous system
position of comfort
by mouth
Posterior
private owned auto
personal protective equipment
per rectum
as needed
paramedic shift supervisor
supraventricular tachycardia
patient
prior to arrival
pick up
premature ventricular contraction
Letter R
r/o
ROM
RR
RSI
RUQ
Rx
rule out
range of motion
respiratory rate
rapid sequence induction (intubation)
right upper quadrant
prescription, treatment
Letter S
SOB
SOP
shortness of breath
standard operating procedure
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Standard Operating Procedures
sec.
SIDS
SL
SLUDGE
sm
SOAP
T
T1-T12
TB
TCA
TCC
TCP
ud
unk
UR
vag.
VF
VRE
w/c
W&D
WNL
wt
x
XR
last oral intake, events preceding
injury/illness
second
SQ
sudden infant death syndrome
s/s
sublingual
STEMI
salivations, lacrimation, urination,
SVT
defication, GI distress, emesis
small
Sx
subjective, objective, assessment plan Sz
Letter T
temperature
TIA
thoracic spine
tib/fib
tuberculosis
TKO
tricyclic antidepressant
trach
trauma center candidate
Tx
transcutaneous pacing
Letter U
unit dose
URI
unknown
UTI
unresponsive
Letter V
vaginal
VS
ventricular fibrillation
VT
vanocomycin-resistant enteroccocci
Letter W
wheel chair
WMD
warm and dry
WPW
within normal limits
w/o
weight
Letters X Y Z
times
y/o
x-ray
EMS 4-0
Table of Contents
subcutaneous
signs and symptoms
st elevation MI
supraventricular tachycardia
symptom
seizure
transient ischemia attack
tibia and fibula
to keep open
tracheal, tracheostomy
treatment
upper respiratory infection
urinary tract infection
vital signs
ventricular tachycardia
weapons of mass destruction
wolff-parkinson-white syndrome
without
year-old
Page 83 of 83