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Emergency Medical Technician – Intermediate Protocols
Emergency Medical Technician - Intermediate Protocols – September, 2002
Page 1 of 45
TABLE OF CONTENTS
INTRODUCTION ....................................................................................................... 3
DEVIATION FROM PROTOCOL ........................................................................ 3
COMMUNICATIONS ........................................................................................... 3
GENERAL HISTORY AND PATIENT PHYSICAL ASSESSMENT ...................... 4
STANDING ORDERS ................................................................................................ 5
ALLERGIC REACTION / ANAPHYLAXIS ............................................................. 6
BURNS ........................................................................................................................ 7
BURNS (continued) ..................................................................................................... 8
CHEST PAIN............................................................................................................... 9
CARDIAC ARREST .................................................................................................. 10
DIABETIC EMERGENCIES ..................................................................................... 11
DYSPNEA .................................................................................................................. 12
DYSPNEA (continued) ............................................................................................... 13
HEAT EMERGENCIES ............................................................................................. 14
HYPOTHERMIA ....................................................................................................... 15
INTRAVENOUS CATHETERIZATION .................................................................. 16
TRAUMA ....................................................................................................................17
TRAUMA (continued) .................................................................................................18
HEAD TRAUMA .................................................................................................. 18
OBSTETRIC EMERGENCIES .................................................................................. 19
OBSTETRIC EMERGENCIES (continued) ...............................................................20
OBSTETRIC EMERGENCIES (continued) ...............................................................21
OBSTETRIC EMERGENCIES (continued) ...............................................................22
OXYGEN THERAPY ................................................................................................ 23
OXYGEN THERAPY (continued) ............................................................................. 24
POISONING / TOXIN EXPOSURE / OVERDOSE ................................................. 25
POISONING / TOXIN EXPOSURE / OVERDOSE (continued) .............................. 26
SEIZURES / GENERAL MOTOR ............................................................................. 27
SHOCK ....................................................................................................................... 28
SHOCK (continued).................................................................................................... 29
UNRESPONSIVE PATIENT ..................................................................................... 30
PEDIATRICS ............................................................................................................. 31
PEDIATRIC DYSPNEA (continued) ......................................................................... 32
PEDIATRIC DYSPNEA (continued) ......................................................................... 33
PEDIATRIC DYSPNEA (continued) ......................................................................... 34
APPENDIX – APGAR ................................................................................................ 35
APPENDIX – GLASGOW COMA SCALE ................................................................36
APPENDIX – SEMI-AUTOMATED EXTERNAL DEFIBRILLATION ................. 37
APPENDIX – SAED (continued)................................................................................ 38
APPENDIX – PARAMEDIC INTERCEPT ............................................................... 39
APPENDIX – PRESUMPTION OF DEATH ............................................................. 40
APPENDIX – RULE OF NINES ................................................................................ 41
APPENDIX – D50W ADMINISTRATION ............................................................... 42
APPENDIX – COMBITUBE ................................................................................ 43-45
Emergency Medical Technician - Intermediate Protocols – September, 2002
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INTRODUCTION
The protocols listed here are intended to be guidelines for pre-hospital patient
management. These protocols have been refined to meet the needs of the evolving EMTIntermediate curriculum and will replace the existing “Charlotte Hungerford Hospital’s
Hospital EMT-IV Protocols”. These protocols should help the Intermediates understand
what is expected of them while providing patient care.
DEVIATION FROM PROTOCOL
These protocols cannot be expanded upon except in extreme circumstances and with the
full agreement and responsibility from the Medical Control Physician. Any deviation
from protocol shall be documented in the Patient Care Report with an explanation of why
it occurred.
COMMUNICATIONS
Medical Control will be obtained from any one of the Region Five Hospitals, depending
on where the patient is being transported. If the patient is going to be transported to a
hospital other than the above listed, then your sponsor Hospital will be utilized as
Medical Control.
Charlotte Hungerford Hospital can be reached by telephone at the following numbers:
(860) 496-6650
(860) 496-6666
Emergency Department
Hospital Operator
Danbury Hospital can be reached by telephone at the following numbers:
(203) 797-7100
(203) 797-7500
Emergency Department
Hospital Operator
New Milford Hospital can be reached by telephone at the following numbers:
(860) 350-7222
(860) 355-2611
Emergency Department
Hospital Operator
St. Mary’s Hospital can be reached by telephone at the following numbers:
(203) 574-6004
(203) 574-6000
Emergency Department
Hospital Operator
Sharon Hospital can be reached by telephone at the following numbers:
(860) 364-4111
(860) 364-4141
Emergency Department
Hospital Operator
Waterbury Hospital can be reached by telephone at the following numbers:
(203) 573-6290
(203) 573-6000
Emergency Department
Hospital Operator
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GENERAL HISTORY AND PATIENT ASSESSMENT
Observation of the environment
Mechanism of injuries
Sex, age and weight
Chief complaint
HISTORY OF PRESENT ILLNESS
Provoked-onset
Quality
Region
Severity
Quantity
Aggravation-alleviation
Associated complaints
Attempts to modify symptoms
PHYSICAL EXAMINATION
Initial Assessment
Focused History & Physical
*Level of consciousness
*Respirations (including lung sounds)
*Pulse
*Blood pressure
*Skin (color-moisture-temperature)
*Pupils
*Neuro (movement of extremities-strength)
*Glasgow Coma Scale
SAMPLE
*Symptoms
*Allergies
*Medications
*Past medical history (appropriate to current chief complaint)
*Last oral intake
*Events leading up to
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IV STANDING ORDERS
Intravenous therapy may be initiated on standing orders by medically authorized
Intermediates in the presence of life threatening situations under the following guidelines
and circumstances:
BURNS (>20% TBSA 2ND AND 3RD DEGREE)
CARDIAC ARREST
CARDIAC CHEST PAIN-sub-sternal, diaphoresis, dyspnea, with cardiac history
DIABETIC EMERGENCIES (altered mental status with diabetic history)
DYSPNEA:
ANAPHYLAXIS-moderate to severe distress with wheezing and/or
hypotension
PULMONARY EDEMA-moderate to severe distress with rhales,
diaphoresis and/or hypertension
6) TRAUMA-with signs of: DYSPNEA
*SCENE TIME NO > THAN 10 MIN*
TACHYCARDIA *IV STARTED ENROUTE*
HYPOTENSION
RIGID ABDOMEN
SIGNIFICANT BLOOD LOSS
7) UNRESPONSIVE PATIENT
8) SHOCK:
HYPOTENSION-systolic blood pressure <100 with signs and symptoms
1)
2)
3)
4)
5)
*IV’S will be started only after a complete examination, including lung sounds
*Intravenous fluid shall consist only of 0.9 sodium chloride (normal saline)
*Whenever possible, IV’s shall be started while enroute to the E.D. or ALS intercept.
*Documentation must include findings to support the standing order
*IV will be run to K.V.O. unless fluid replacement is desired.
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ALLERGIC REACTION / ANAPHYLAXIS
Allergic reaction:
patient is stable (No airway compromise, No shock). Patient may
have red-raised rash, c/o itchy skin, or reported contact/ingestion
of allergic substance.
Oxygen as per protocol
Establish Medical Control
Transport position of comfort
Possible Physician Orders:
Establish IV
Paramedic Intercept
Anaphylaxis:
patient is unstable (Upper airway obstruction, Shock). Patient may
have audible wheezes, altered mental status.
Airway management as per protocol
Oxygen per protocol
Request Paramedic Intercept
Establish Medical Control
Transport to ED or Intercept location
Establish IV while enroute
Possible Physician Orders:
Administration of Epi Pen or Epi Pen jr.
Fluid Challenge patient, IV wide open
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BURNS
Thermal
Stop the burning process and remove the patient from the source of injury if safe
to do so.
Consider respiratory insult due to possible toxic inhalation or from superheated
atmosphere.
Check airway for burns, blackness, or singed hair. Check for signs of dyspnea. If
any of these are present, give the patient high flow O2.
Leave clothing intact (unless burning).
Remove jewelry from affected area.
Do not remove any loose tissue or skin.
Estimate the extent of burn to the total body surface area using the rule of nines.
Palm Method-palm is equal to approx. 1% adult TBSA
Apply sterile burn sheets to area (dry) for 3rd degree burns. If burns are 1st or 2nd
degree and less than 15% TBSA, apply moistened sheets using normal saline.
Use caution as this may precipitate hypothermia.
Oxygen as per protocol.
Monitor vital signs.
Consider Paramedic Intercept for airway or pain control
Establish IV per S.O. protocol
Establish Medical Control
Transport
Possible Physician Orders:
IV flow rate to maintain patient’s fluid balance
Chemical:
Stop the burning process and remove the patient from the source of injury if safe
to do so.
Remove affected clothing.
Brush off all dry chemical-avoid inhalation and contamination of yourself.
Try to obtain the name of the chemical for identification of side effects. If
possible, obtain MSDS form for chemical.
Flush with copious amounts of water/saline unless contraindicated.
Oxygen as per protocol.
Monitor vital signs.
Consider Paramedic Intercept for airway or pain control
Establish IV per S.O. protocol
Establish Medical Control
Transport
Possible Physician Orders:
IV flow rate to maintain patient’s fluid balance.
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BURNS (con’t)
Electrical:
If patient is responsive:
Paramedic Intercept-patient needs cardiac monitoring
Oxygen as per protocol.
Monitor vital signs.
Treat any thermal burns as per protocol.
Transport
Establish Medical Control
Possible Physician Orders:
Establish IV and flow rate.
If patient is unresponsive:
Request Paramedic Intercept
Oxygen and airway as per protocol
Transport to ED or Intercept location
Establish IV enroute as per protocol.
Establish Medical Control
If patient is pulseless and apneic, follow cardiac arrest protocol.
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CHEST PAIN
(possible acute myocardial ischemia)
Initial assessment:
Oxygen –high flow unless contraindicated
Request Paramedic Intercept
Establish IV access per S.O. protocol
Establish Medical Control
Transport to ED or Intercept
Possible Physician Orders:
Administration of Nitroglycerin
Adjustment of IV and/or Oxygen flow rates
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CARDIAC ARREST
MEDICAL
Assess patient (ABC’s)
Request Paramedic Intercept
Initiate CPR-D
If indicated begin Semi-Automatic External Defibrillator sequence:
200J
300J
360J
CPR x 1 Min
360J
360J
360J
Airway Management: EOA if indicated
Establish IV access
Transport patient to ED or intercept. Patient may be reanalyzed while enroute
Establish Medical Control
TRAUMATIC
Establish airway with C-spine control and stabilization.
Begin CPR.
Request Paramedic Intercept.
Immobilize patient
Transport to closest Trauma Center (Please refer to State wide Trauma Protocols).
Establish IV access, Large Bore, wide open. YOU MAY START TWO LINES.
Establish Medical Control-Trauma Alert
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DIABETIC EMERGENCIES
Initial assessment/routine care.
Oxygen as per protocol.
If available, check the patient’s Blood Sugar
If patient is unresponsive (GCS < 10):
Request Paramedic Intercept and refer to Unresponsive protocol
Establish IV access as per S.O. protocol (#18 guage or larger)
Establish Medical Control
Possible Physician Orders:
Administration of D50W
If patient is responsive (GCS > 10):
If patient has an intact gag reflex, and is able to comply, give 1 tube oral
glucose.
Possible Physician Orders:
Paramedic Intercept
Establish IV access and flow rate
Repeat Oral Glucose
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DYSPNEA – Excluding upper airway obstruction
If respiratory distress is due to an allergen (i.e. :insect bite, etc.) proceed to
the anaphylaxis protocol.
Oxygen as per protocol.
If moderate to severe respiratory distress, request Paramedic
Intercept.
Sit patient up on stretcher (if BP low recline to 45 degrees).
Transport to ED or Intercept location.
Establish Medical Control
Possible Physician Orders:
IV and flow rate (if moderate or severe, use S.O. protocol)
Assist patient with their own Multi Dose inhaler
Acute Cardiogenic Pulmonary Edema
Protocols as above.
Paramedic Intercept.
Assist ventilations if necessary.
Have patient sit up on stretcher to ease respiratory effort.
STAT transport to ED or Intercept.
Establish IV, Run to K.V.O.
Establish Medical Control
Asthma
Any patient with a history of asthma or similar presentation experiencing moderate to
severe distress who has not used their inhaler upon EMS arrival should be encouraged to
use it in the manner prescribed by their private physician.
PLEASE REMEMBER: A WHEEZE IS NOT ALWAYS ASTHMA
Moderate to severe patients require a Paramedic Intercept.
Oxygen as per protocol
Assist ventilations if necessary.
Have patient sit up on stretcher to respiratory effort.
Establish Medical Control
Possible Physician Orders:
IV and flow rate (if moderate or severe, use S.O. protocol)
Assist patient with their own Multi Dose inhaler
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DYSPNEA- (con’t)
COPD- with bronchospasm
Any patient experiencing moderate to severe respiratory distress, who has not used their
inhaler upon EMS arrival, should be encouraged to use it in the manner prescribed by
their private physician.
Moderate to severely distressed patients require Paramedic Intercept
Assist ventilations if necessary.
Have patient sit up on stretcher to ease respiratory effort.
Transport to ED or Intercept point
Establish Medical Control
Possible Physician Orders:
IV and flow rate (if moderate or severe, use S.O. protocol)
Assist patient with their own Multi Dose inhaler
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HEAT EMERGENCIES
Elderly patients and children are more susceptible to heat emergencies
Maintain airway, breathing and circulation.
Remove patient from warm environment.
Oxygen as per protocol.
Shock protocol as needed.
Begin gradual cooling measures. Rapid cooling can harm the patient.
Obtain accurate history including rate of onset.
Decide if Paramedic Intercept is needed.
Transport to ED
Establish Medical Control
Possible Physician Orders:
More aggressive cooling measures
IV and flow rate
Paramedic Intercept
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HYPOTHERMIA
The emphasis of this protocol is to perform only the absolutely essential ALS
treatment on the scene and initiate rapid but careful transport.
Maintain airway, breathing and circulation.
Oxygen as per protocol.
Assist ventilations as necessary.
Handle all hypothermia patients with care. Rough handling may precipitate
ventricular fibrillation.
Do not presume death in the unresponsive, non-breathing, pulseless patient with
suspected hypothermia. Patients are not dead until they are warm and dead. Initiate CPR
as needed. Applying external heat may precipitate ventricular fibrillation.
Remove all clothing and maintain the patient in a warm, draft-free environment.
Cover the patient including the head, leaving the face exposed.
Truly hypothermic patients require Paramedic Intercept for cardiac monitoring.
Transport to ED or Intercept location.
Establish Medical Control
Possible Physician Orders:
Warmed IV fluids and flow rate
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INTRAVENOUS ACCESS
Intravenous access may be initiated by standing order or after consultation with Medical
Control using the following guidelines:
ATTEMPTS
-
The Intermediate will not attempt IV access on any patient less
than 12 years old
Only one attempt will be made on scene.
If the patient is in critical condition, one more attempt may be made by
the Intermediate while enroute to the hospital or intercept point.
Trauma patients require rapid transport to the ED, therefore, IV access
shall only be initiated while enroute to the hospital.
DETERMINATION OF SIZE
-
-
All patients requiring IV access, but not fluid resuscitation shall have
an IV established at a flow rate to K.V.O., and access shall be through
an 18 guage catheter or smaller (except in cases of “diabetic
emergency”)
Any patients requiring fluid resuscitation shall have an IV established
with an 18 guage catheter or larger whenever possible.
FLUID RESUSCITATION
-
Lung sounds must be assessed prior to fluid resuscitation
Patients without a cardiac and/or respiratory history, with clear lung
sounds may be given an initial bolus of 250ml (Normal Saline).
Patients with a cardiac and/or respiratory history, with clear lung
sounds may be given and initial bolus of 100ml (Normal Saline).
If the patient’s lungs are not clear, contact Medical Control.
Please remember to reassess after each fluid bolus
LOCATION
-
-
Use of the Anticubital fossa (AC) shall be reserved for those patients
in critical condition, or when previous attempts distal to the AC have
failed.
Please remember, if the vein is infiltrated, you may establish an IV
proximal to the infiltrated site, but you may not make another attempt
distal to that site. That is why we tell you to “start with the hands and
work your way up to the AC”.
DOCUMENTATION
-
Remember to document the number of attempts
The location of the IV
The guage of the catheter
The solution (Normal Saline), and the flow rate
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TRAUMA
(Transport! Transport! Transport!)
The following require Paramedic Intercept: Auto Vs Pedestrian
Motorcycle Operators and Passengers
Prolonged Extrications
Death of the occupant in the same car
Multi-System Trauma
Initial Assessment
Airway-cervical spine immobilization.
Breathing-expose chest, check for adequate air exchange.
Circulation-identify and control bleeding.
Disability-brief neurological evaluation.
Expose-do not palpate blindly.
Focused History & Physical Exam
Head-skull depressions/fluid from nose, ears or mouth/pupils
Maxillo-facial
Chest/Back-rib fx?, lung sounds, Sub. Emphysema, entrance or exit wounds
Abdomen-rigid?, tender?
Extremities-fractures?, bleeding?
GLASGOW COMA SCALE – This will be done on ALL trauma
patients and documented on the run-form.
Treatment
Is the scene safe?
# of patients?
Immobilize C-spine with C-collar, backboard with at least 3 sets of straps & CID.
Oxygen as per protocol.
Airway maintenance, CPR, and other life saving protocols for patient care should
be initiated when the problem is identified.
Transport to ED or Intercept location.
Initiate shock protocol if necessary.
IV per S.O. if patient presents with: Dyspnea
Tachycardia
Hypotension
Rigid Abdomen
Significant blood loss
Possible Physician Orders:
PASG
Aggressive fluid resuscitation with multi-IV’s
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TRAUMA – (con’t)
HEAD TRAUMA
Routine care-Glasgow Coma Scale
Maintain airway while performing spinal immobilization
Oxygen as per protocol
If patient is unresponsive with respiratory compromise, secure airway and ventilate at
normal or slightly increased rates.
Paramedic Intercept for airway control
If hypotensive, treat for shock.
Establish Medical Control
Possible Physician Orders:
IV and fluid rate
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OBSTETRIC EMERGENCIES
Normal Delivery
Routine patient care.
Oxygen as per protocol.
Determine if delivery is imminent, check for crowning.
Other possible indications of imminent delivery:
-Contractions 2-3 minutes apart, duration 1 minute.
-Woman that has had multiple deliveries.
-Amniotic sac has broken
-Woman has the urge to “bear down” or move her bowels
Prepare for delivery, allow delivery to progress, position the patient on her back and
assemble OB kit.
When the head emerges, support it and use bulb syringe to suction nose/mouth. Tear
amniotic sac if not already torn (before delivery of shoulders and chest).
If umbilical cord is around neck, gently slip it over the head. If unable to do so, place
umbilical clamps 2 inches apart and cut cord between clamps (must have access to airway
before clamping).
Deliver anterior shoulder, then posterior shoulder.
If umbilical cord is not already cut, place a clamp 6 inches from the infant’s navel, place
second clamp 8 inches from the infant and cut between the clamps.
Check both ends for bleeding/apply additional clamps if bleeding is present.
Dry baby and wrap up to prevent hypothermia.-Cover the head
Medical Terminology
Gravida: the number of all of the woman’s current and past pregnancies
Para: the number of pregnancies that have remained viable to delivery.
Example: a woman that is pregnant for the fourth time, and has two
children, is said to be gravida 4, para 2.
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OBSTETRIC EMERGENCIES (con’t)
APGAR SCORE
ACTIVITY
LIMP
SOME FLEXION
ACTIVE, MUCH FLEXION
0
1
2
PULSE
NONE
<100 PER MINUTE
>100 PER MINUTE
0
1
2
GRIMACE, REFLEX TO SUCTION
NONE
SOME GRIMACING
SNEEZES, COUGH, OR CRIES
0
1
2
RESPIRATIONS
NONE
IRREG, INEFFECTIVE, BRADYPNEIC
RHYTHMIC, EFFECTIVE, CRYING
0
1
2
Evaluate newborn based on APGAR score at 1 minute and 5 minutes.
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OBSTETRIC EMERGENCIES (con’t)
Delivery of placenta should occur within 30 minutes. Once delivered, place placenta in a
plastic bag and take to hospital. If placenta has not been delivered in 10 minutes, do not
delay transport.
If post-partum bleeding is excessive, massage lower abdomen firmly (uterine massage).
If mother is going to breastfeed, assist her in putting baby to breast.
Transport to ED or Intercept location.
Establish Medical Control
Possible Physician Orders:
IV and flow rate
COMPLICATIONS OF PREGNANCY AND DELIVERY
Breech Presentation
Proceed immediately to the Hospital
Establish Medical Control
Prepare mother for normal delivery.
Allow buttocks and trunk to deliver spontaneously.
Support the infant with the palm and volar surface of arm.
If head does not deliver in 3 minutes, place gloved hand into the birth canal with
the palm toward the baby’s face. Form a “V” with fingers on either side of the
baby’s nose/mouth and push the vaginal wall away from the infant’s face to allow
for ventilation.
Transport the mother with the buttocks elevated on pillows and maintain the
infant’s airway as described above.
Prolapsed Cord
Proceed immediately to the hospital.
Place mother in supine position with hips elevated, (or knee-chest w/hips
elevated).
Place mother on high flow O2
Assess cord, if pulse can be felt, maintain mother’s position. If pulse cannot be
felt when touching the cord, insert a gloved hand into the birth canal and attempt
to gently elevate the presenting part off of the cord to relieve the compression to
the cord, then reassess for return of pulsation to the cord. Maintain this position
until relieved by Emergency or OB staff.
Establish Medical Control
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OBSTETRIC EMERGENCIES (con’t)
Limb Presentation
Place mother in Trendelenberg position (feet elevated).
Transport immediately.
Multiple Births
This should not present a unique problem
After delivery of the first infant, tie off the cord as for normal delivery.
If second infant has not delivered within 10 minutes, transport immediately.
If first infant out is a Breeched presentation that does not deliver the head within 2
minutes, begin rapid transport to the hospital.
Antepartum Hemorrhage
Treat as per shock protocol.
Post Partum Hemorrhage
Treat as per shock protocol.
Uterine massage, put baby to breast (if mother is breast-feeding).
Establish Medical Control
Possible Physician Orders:
Paramedic Intercept
IV and flow rate
Eclampsia: seizures
Paramedic Intercept
Reduce external stimulus-no lights and siren unless extremely necessary.
Place patient on her left side to ease blood flow to the heart.
Monitor blood pressure carefully. Look for hypertension.
Beware of possible seizures and take precautions to minimize injury
High flow O2
Establish Medical Control
Possible Physician Orders:
Paramedic Intercept
IV and flow rate
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OXYGEN
EQUIPMENT
FLOW RATE
Nasal Cannula
Non-Rebreather (NRB)
Bag-Valve-Mask (BVM
1-5 L/Min
10-15 (fill reservoir bag)
15 L/Min
Patient Respiratory Status
Equipment / Flow Rate
No Distress
color pink
skin warm and dry
respirations full, effective, and unlabored
None
Mild Distress
mild chest pain
asthma/COPD with mild distress
Cannula 1-2 L/Min
Moderate Distress
chest pain with dyspnea
CVA
major fractures
head injuries (concussion)
asthma/COPD with moderate distress
multi-system trauma
chest injuries
NRB 10-15 L/MIN
Severe Distress
Shock
head injuries (concussion)
smoke inhalation
CHF/pulmonary edema
Near drowning
Any sign of cyanosis
NRB 15L/MIN, BVM Assist
Respiratory Arrest
BVM with Nasal or Oral
Airway
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OXYGEN (con’t)
Special Considerations
1. COPD patients, gradually increase O2 if signs and symptoms persist. Be
prepared to assist ventilations. DO NOT WITHHOLD O2 IF THE COPD
PATIENT DISPLAYS SIGNS/SYMPTOMS OF RESPIRATORY
DISTRESS.
2. Inadequate respirations need to be assisted with BVM.
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POISONING / TOXIN EXPOSURE / OVERDOSE
Initiate routine care.
Determine the following:
What was ingested?
When was it ingested?
How was it ingested?
How much was ingested?
Did patient vomit after?
Did patient eat before or after?
Was alcohol involved?
If possible, and safe, bring pill bottles or toxin container to ED with patient.
When establishing medical control, provide the above answers to ED as well as the
patient’s condition.
Oxygen as per protocol.
Support ventilations as needed.
Paramedic Intercept if needed.
Treat all life threatening situations as per appropriate protocol.
Specific Treatment
Ingestion
If patient is unresponsive (GCS 3-10) – Paramedic Intercept
If patient is responsive (GCS > 10):
Establish Medical Control
Possible Physician Orders:
IV and flow rate
Charcoal 25-50 Gms. PO (by mouth)
Inhaled Exposure
Remove patient from toxin if safe to do so.
Oxygen and ventilation support as per protocol.
Paramedic Intercept if needed.
Transport to ED or Intercept location.
Establish Medical Control
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POISONING / TOXIN EXPOSURE / OVERDOSE (con’t)
Topical Exposure
Remove patient from the source of contamination if safe to do so.
Remove any contaminated clothing if safe to do so.
Remove any contaminant if safe to do so.
If Solid:
Brush away all solid contaminant if safe to do so.
Establish Medical Control
Possible Physician’s Orders:
Irrigate with copious amounts of water if not contraindicated.
If Liquid:
Establish Medical Control
Possible Physician’s Orders:
Flush with copious amounts of water when not contraindicated.
* Unless contraindicated, if the eye(s) have been exposed to a contaminant they should be
flushed with 1000ml of 9% Normal Saline Solution (per eye).
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SEIZURES / GRAND MAL
Maintain airway / suction as needed. Seizure patients needed good airway management.
Assist ventilations as needed.
Oxygen as per protocol.
Protect patient from injury.
Paramedic Intercept
If patient is unresponsive (GCS 3-10), IV as per SO protocol.
Transport to ED or intercept point
Establish Medical Control
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SHOCK
Defined as:
If the patient’s systolic blood pressure is 80 mm or less.
If the patient’s systolic blood pressure is 80-100 mm and the other signs/symptoms of
shock are present.
Signs:
Altered Mental Status
Tachycardia
Tachypnea
Pale, ashen, cyanotic skin
Clammy, diaphoretic skin
Cool, dry skin
Hemmorrhagic/Hypovolemic Shock
Paramedic Intercept
Trendelenberg position unless contraindicated.
Control obvious bleeding
Oxygen as per protocol.
Establish large bore IV line NaCl
Initiate 250cc fluid bolus and reassess vital signs
Transport to ED or Intercept point
Establish Medical Control
Possible Physician’s Orders:
Second large bore IV NaCl
Second 250cc fluid bolus
IV at wide-open rate.
Apply MAST unless contraindicated.
Cardiogenic Shock
Oxygen as per protocol.
Transport in Trendelenberg position if possible.
Paramedic Intercept
Establish Medical Control
Possible Physician’s Orders:
IV and fluid rate
200cc Fluid bolus
MAST
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SHOCK – (con’t)
Neurogenic Shock
Routine care-GCS
Neurodeficit to lower extremities or upper and lower extremities
*Maintain airway while performing spinal immobilization*
Oxygen as per protocol.
Paramedic Intercept
Establish IV as per SO protocol
Transport to ED or Intercept point
Establish Medical Control
Possible Physician Orders:
Apply & Inflate MAST
Fluid rate
Additional Note
Consider other causes of shock:
Tension pneumothorax
Sepsis
Metabolic
Toxic
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UNRESPONSIVE PATIENT
Maintain airway and administer O2 as per protocol.
Request Paramedic Intercept.
Perform brief neurological exam to include Glasgow Coma Scale and pupil response.
Monitor vital signs.
Treat all underlying complications as per appropriate protocol.
Determine from family/bystanders any pertinent history.
Transport to ED or Intercept point
Establish Medical Control
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PEDIATRICS
Special Note:
The pediatric is not a small adult and therefore requires an “inverted pyramid” approach
to interventions with a secure airway and adequate oxygenation being first and foremost.
Almost all cardiac arrests are secondary to respiratory arrests.
Drying, warming, positioning, suction, tactile stimulation
Oxygen
Bag-valve-mask ventilation
Chest compressions
Intubation
Medications
Normal Heart Rates by Age (beats per min.)
Age
Neonate
Infant (6 months)
Toddler
Preschooler
School-age child
Adolescent
Awake
100-180
100-160
80-110
70-110
65-110
60-90
Sleeping
80-160
75-160
60-90
60-90
60-90
50-90
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PEDIATRICS (cont.)
Normal Systolic Blood Pressure by Age
Age
0 to 1 month old
1 month old to 1 year old
Older children
Systolic Blood Pressure (mmHg)
Greater than 60
Greater than 70
70 + (2 x age in years)
Normal Respiratory Rates by Age
Age
Infant
Toddler
Preschooler
School age
Adolescent
Breaths Per Minute
30-60
24-40
22-34
18-30
12-18
Signs of Respiratory Distress
Nasal flaring
Inspiratory retractions (sternal, supraclavicular, intercostal and substernal
Tachypnea
Head-bobbing
See-saw respirations
Restlessness
Tachycardia
Grunting
Stridor
Signs of Respiratory Failure
Cyanosis
Diminished breath sounds
Decreased level of consciousness
Poor skeletal muscle tone
Inadequate respiratory rate, effort or chest excursion
Tachycardia
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PEDIATRICS (CON'T)
Comparison of Croup and Epiglottitis
Age
Location
Onset
Organism
Fever
Signs and Symptoms
Croup
3 months to 3 years
Subglottic
Gradual
Viral
100-101F
“Barking” cough
Retractions
Hoarse voice
Harsh cough
Loud stridor
Epiglottits
3 to 7 years
Supraglottic
Sudden
Bacterial
102-104F
Drooling
Retractions
Muffled voice
Usually no cough
Prefers to sit up and lean
forward to breathe (Tripod)
General Statement
In the prehospital setting it is very difficult to differentiate between croup and epiglottitis,
therefore always assume the worst. Both conditions will be treated as follows:
Do not attempt to visualize oropharynx.
Cool air - air conditioning as necessary.
Attempt to calm patient, anxiety and stress exacerbate the stridor.
Do not attempt an I.V. This may increase patient's agitation and worsen
their condition.
Oxygen.
Manually ventilate as necessary as this may still be possible when the
patient is unable to move air on his own. External ventilation pressures are
effective even when negative inspiratory pressures are not.
Request Paramedic intercept - for airway control
Transport immediately to ED or intercept point
Signs and Symptoms may include:
1. Fever
2. Hoarse voice, "seal bark", cough, STRIDOR.
3. Tachypnea
4. Drooling - unable to manage (swallow) oral secretions.
5. Positioning to maintain airway, "Tripod" position
6. Accessory muscle usage
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PEDIATRICS (CON'T)
Asthma
Oxygen
Paramedic intercept
Rapid transport
Establish Medical Control
PEDIATRIC TRAUMA
Management of the pediatric trauma includes the same priorities as in the adult
patient:
Rapid assessment
Initiate resuscitative measures
Request Paramedic intercept
Secondary survey
GCS
Initial stabilization
Rapid transport
Establish Medical Control
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APPENDIX - APGAR SCORE
ACTIVITY
LIMP
SOME FLEXION
ACTIVE, MUCH FLEXION
0
1
2
PULSE
NONE
<100 PER MINUTE
>100 PER MINUTE
0
1
2
GRIMACE, REFLEX TO SUCTION
NONE
SOME GRIMACING
SNEEZES, COUGH, OR CRIES
0
1
2
RESPIRATIONS
NONE
IRREG, INEFFECTIVE, BRADYPNEIC
RHYTHMIC, EFFECTIVE, CRYING
0
1
2
Evaluate newborn based on APGAR score at 1 minute and 5 minutes.
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APPENDIX - GLASCOW COMA SCALE
All trauma patients will have a GCS calculated and documented on the run form.
Any patient who has an altered level of consciousness will also have a GCS
calculated and documented on the run form.
EYE OPENING
4
3
2
1
Spontaneous
To Voice
To Pain
None
VERBAL RESPONSE
5
Oriented
4
Confused
3
Inappropriate Words
2
Incomprehensible Words
1
None
______________________________________________________
MOTOR RESPONSE
6
Obeys Commands
5
Localizes Pain
4
Withdraw (pain)
3
Flexion (pain)
2
Extension (pain)
1
None
______________________________________________________
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APPENDIX – SEMI AUTOMATED EXTERNAL
DEFIBRILLATION
There are a number of different types of Semi Automated External Defibrillators (SAED)
on the market today. The guidelines for the use of these different defibrillators vary
somewhat from unit to unit, however, all units function basically the same way. Each
one will analyze the rhythm, charge to a pre programmed energy setting, and defibrillate.
Most of our services are currently using the Medtronic Physio Control LIFEPAK 500.
All medical Cardiac arrest patients will be treated as follows:
A. Establish unresponsiveness, pulselessness, and apnea (ABC’S)
B. Request Paramedic Intercept
C. Determine if defibrillator application is appropriate
The following is a list of cardiac arrest patients excluded:
Cardiac Arrest due to trauma
Patients less than eight years old
Patients less than eighty pounds
Patients in wet or hazardous surroundings
D. Attach defibrillator electrodes to the patient in the prescribed manner.
Delayed defibrillation decreases the patient’s chance of survival. Deferral of
defibrillation should occur only to ensure safety of rescuers, bystanders and/or patient
CPR should be undertaken before defibrillation only if:
The defibrillator is not available.
Defibrillation cannot safely be performed until the patient
environment is safe.
A sufficient number of trained persons are present so that
CPR may be performed without delaying or impeding
defibrillation attempts.
E. Turn on the Defibrillator.
F. Stop CPR, if in progress, cease any patient contact.
G. Press Analyze.
H. If the defibrillator indicates “shock advised” or begins charging:
Check that everyone (including the operator) is clear of the patient.
Deliver the first shock (preset to 200 joules).
Press Analyze.
If “shock advised”, clear all personnel as the unit charges, and
deliver the second shock (preset to 300 joules).
Press Analyze.
If “shock advised”, clear all personnel as the unit charges, and
deliver the third shock (preset to 360 joules).
Check the patient for a carotid pulse, if the patient remains
pulseless, begin CPR and continue for 1 minute. During this time,
insert an O.P.A., or and advanced airway.
After one minute of CPR, press Analyze.
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APPENDIX – S.A.E.D. (cont.)
If “shock advised”, clear all personnel as the unit charges, and
deliver the fourth shock (preset to 360 joules).
Shocks may be delivered in 2 stacks of 3 shocks.
If “no shock advised”, initiate CPR for one minute, then press
Analyze.
If two “no shock advised” messages occur, package the patient and
intercept with the paramedic
If the patient is revived and then returns to cardiac arrest, continue
defibrillating at the preset energy settings. Two additional stacks
of three shocks are allowed if the patient remains in a shockable
rhythm.
If, at any point, a patient regains a pulse, continue BLS then ALS
supportive care(ABC’s, O2 therapy, assisting ventilations, IV
therapy) and continuously reassess and monitor the patient.
The S.A.E.D. should not be removed until the paramedic, RN or
MD requests it’s removal.
S.A.E.D. electrodes should be two to six inches away from
pacemakers, A.I.C.D.s and nitro patches.
A defibrillation report must be filled out along with the run form.
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APPENDIX – PARAMEDIC INTERCEPT
A paramedic may be requested to respond to an incident location or to an intercept site
along the route to the hospital.
Paramedics should be requested as early as possible to avoid delay in further ALS care.
When requesting paramedics, also obtain their ETA. If the EMT’s on the scene can
safely package and transport the patient to the hospital before an intercept can be made,
transport should not be delayed. If a patient is unstable and the benefit of stabilizing the
patient prior to transport is critical a delay for paramedic level care is acceptable.
IV access should be accomplished following standing orders and/or direct Medical
Control consultation as needed.
Once the paramedic has taken report on the patient(s), that paramedic is now in control of
that patient(s) and the scene.
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APPENDIX – PRESUMPTION OF DEATH
Any patient found by an EMT to be pulseless and apneic shall be presumed dead, and no
resuscitation initiated if any or all of the following four criteria apply:
Advanced decomposition
Injury incompatible with life
Decapitation
Total body transection
Body consumed by fire
Massive head injury with exposed brain matter
Rigor mortis with post mortem dependent lividity
A valid DNR bracelet is present
Bracelet approved by DPH/OEMS
Bracelet affixed to the patient’s wrist or ankle
Bracelet displays the patient’s & attending M.D.’s name
Bracelet has not been cut or broken at any time
In the absence of the above criteria, resuscitation efforts should be initiated immediately
as per protocol.
If CPR has been initiated by any first responder prior to EMS arrival, resuscitation efforts
may be discontinued if the patient fits any of the above criteria and the termination of
CPR would not have an adverse effect on the family or the public at scene. This decision
will be made by the senior EMT or crew leader and direct Medical Control authorization.
Special care must be taken with respect to suspected hypothermia patients, as they may
present with signs of rigor mortis. You shall administer emergency care to such victims
unless any of the other above criteria applies or Medical Control advises otherwise.
Presumption of Death must be carefully documented and will include the following:
Check respirations for not less than 30 seconds
Check pulse for not less than 30 seconds
Auscultate lung sounds for not less than 30 seconds
Auscultate heart sounds for not less than 30 seconds
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APPENDIX – RULE OF NINES
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APPENDIX – D50W ADMINISTRATION
Classification: Sugar in solution
Action: Increases serum glucose levels.
Indications: Hypoglycemia
Contraindications: None
Potential Side Effect: Hyperglycemia
Dosage / Route: 1 premixed ampule (25 grams) given via IV only.
Important Points: Obtain a finger stick blood glucose level prior to administration
Be sure IV line is patent. If infiltrated, D50W will cause tissue necrosis
Initial assessment/routine care.
Oxygen as per protocol.
If available, check the patient’s Blood Sugar
If patient is unresponsive (GCS < 10):
Request Paramedic Intercept and refer to Unresponsive protocol
Establish IV access as per S.O. protocol (#18 guage or larger)
Transport patient to the ED or intercept site after one failed IV att.
Obtain a finger stick blood glucose level
Establish Medical Control
Request order for 1 amp (25 grams) D50W
If the order is granted, administer the D50W via the IV line slowly (push
over 1 minute). After the administration, run 10ml of saline to flush the line.
Re check the patient’s blood glucose level
Monitor the patient carefully for any adverse effects.
Please remember, when documenting, include the name of the MD
ordering D50W administration, the time and amount administered, the blood glucose
levels before and after administration, and the EMT-I that administered the medication.
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APPENDIX – DUAL LUMEN AIRWAY – “COMBITUBE”
Introduction:
The Combitube airway is designed to provide a patent airway for arrested patients
(respiratory / cardiac) when visualization of the airway or endotracheal intubation is not possible.
It is designed to be inserted blindly. The double lumen design allows effective ventilations to be
provided regardless of whether esophageal or tracheal placement is accomplished. The
pharyngeal balloon fills the hypopharynx, eliminating the need for a mask seal, and the associated
face/mask seal problems. If the Combitube is placed in the esophagus, the distal cuff will occlude
the esophagus preventing aspiration of gastric content. Ventilations are then provided through the
perforations at the pharyngeal site. If the device is place in the trachea, it functions as an
endotracheal tube, with the distal cuff preventing aspiration.
Indications:
1. Patients in irreversible respiratory arrest. (i.e. narcotic overdose, hypoglycemia)
2. Patients in cardiac arrest.
3. Unconscious patients without a gag reflex, in need of ventilatory support and can not
be intubated.
Contraindications:
1.
2.
3.
4.
5.
6.
Intact gag reflex
Patient height less than 48 inches.
Conscious patient.
Known esophageal disease. (cancer, verices)
Caustic substance ingestion. (acid, lye)
Allergy or sensitivity to latex
Precautions:
1. Take universal precautions (BSI), including facial protection, as expulsion of
stomach content can occur in esophageal placement.
2. May be used in trauma in a neutral position. (flexion or extension need not occur to
facilitate placement)
3. Defibrillation should not be delayed to place Combitube.
4. Pulse oximetry may be unreliable in low perfusion states, such as cardiac arrest.
Procedure:
1. Open the airway and suction mouth and oropharynx.
2. Perform assessment and record vital signs, level of consciousness, and oxygen
saturation if available.
3. Insure there are no contraindications to this procedure.
4. Begin positive pressure ventilation with 100% oxygen and oral airway.
Hyperventilate with each ventilation lasting at least 2 seconds.
5. Auscultate bilateral lung sounds to ensure air entry with BVM and rule out FBAO or
pre-existing condition.
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6. While patient is being hyperventilated, assemble Combitube as follows:
a. Attach the large syringe with 100cc’s of air to the BLUE cuff #1.
b. Attach the small syringe with 15cc’s of air to the WHITE cuff #2.
c. Test the device by inflating both balloons, looking for leaks.
d. Deflate all air from both cuffs, and leave syringes attached.
e. Attach fluid detector to the shorter white tube. (#2)
f. Lubricate tube tip and pharyngeal balloon with a water soluble lubricant.
7. With the head in a neutral position, grasp the mandible and tongue between the
thumb and fingers. Place the Combitube into the midline of the mouth.
8. Slide the Combitube GENTLY along the palate and posterior surface of the
oropharynx. Use a curving motion to guide the tube inward and downward. Advance
the tube until the upper teeth or gums are between the two black rings.
9. DO NOT force the tube. If resistance is met, withdraw the tube, reposition the head
and reattempt.
10. If unable to place the tube within 30 seconds, hyperventilate with 100% oxygen for
1-2 minutes before you reattempt.
11. Inflate large pharyngeal balloon (#1) with 100cc of air.
- 85ml of air for 37 French size.
12. Inflate distal balloon (#2) with 15cc of air. (DO NOT over-inflate, serious damage
may result.)
- 12ml of air for 37 French size.
13. Begin ventilation through the longer blue connecting tube #1.
14. Confirm tube placement by auscultating both lungs and gastric area. If appropriate
breath sounds are heard esophageal placement has occurred continue to ventilate and
continuously monitor for change.
15. If no breath sounds are heard and gastric sounds are appreciated, remove fluid
deflector from the white tube, attach BVM and begin ventilation through tube #2.
16. Confirm tube placement by auscultating both lungs and gastric area. If appropriate
breath sounds are heard tracheal placement has occurred continue to ventilate and
continuously monitor for changes.
17. If no breath sounds are heard and no gastric sounds are heard, the tube is placed to
deep and occluding the tracheal opening. Deflate both balloons, and withdraw 2-3
centimeters. Re-inflate the balloons and attempt again beginning at step #13.
18. A maximum of two attempts at Combitube placement is permitted.
19. If the patient regains consciousness or gag reflex, the Combitube MUST be removed.
- Balloon Deflation Procedure:
a) Have working suction ready, and suction oropharynx.
b) If not contraindicated, roll patient to recovery position.
c) Deflate blue balloon #1.
d) Deflate white balloon #2.
e) Remove Combitube.
Charting and Documentation:
The following information must be charted on the patient care report form:
1. Patient’s presenting signs and symptoms, including vital signs, level of
consciousness, and oxygen saturation if available.
2. Indications for Combitube use.
3. Number of endotracheal intubation attempts.
4. Size of Combitube 41 French or 37 French
5. Which connecting tube was used for ventilation. (blue or white)
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6.
7.
8.
9.
10.
Steps taken to verify tube placement.
Number of attempts made at Combitube placement.
Repeat assessment and vital signs every five minutes.
Changes from baseline that may have occurred, if any.
Signature and certification / license number of EMT performing insertion.
Certification:
1. Attend lecture and demonstration of Combitube placement and evaluation.
2. Demonstrate an understanding of the indications, contraindications, and possible
complications related to the use of the Combitube.
3. In a lab setting, demonstrate the proper insertion, removal, and use of the Combitube.
4. Pass a written examination.
5. Pass an oral examination incorporating practical scenarios.
Continuing Certification:
1. Review class and repeat certification steps 1-5
2. Record review of all cases where this protocol has been used.
3. Recertification at the intermediate level will occur annually.
Quality Assurance:
1. The following will be measured for continuos quality improvement.
- Appropriateness of use
- Adherence to protocol
- Deviations from protocol
- Corrective action taken
2. Biannual statistics will be forwarded to each department using the Combitube.
3. Completion of a “Combitube” form, for feedback in the following areas:
- Ease of use
- Effectiveness of ventilation
- Complications of use
- Suggestions for improvement
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