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Procedures Manual
ALS COMMUNICATIONS
ALS COMMUNICATIONS PROCEDURES TO BE USED BY ALL ADVANCED EMTs
1. An AAREMS Advanced EMT may request Medical Control (a “Signal”) under any
of the following circumstances:
A. To request, from a physician, a diagnosis and therapy for patient situations the
AEMT feels are life threatening or potentially unstable.
B. For orders, advice, and instructions in situations adversely affected by time.
C. Paramedics and Critical Care Technicians may request Medical Control for
interpretation of EKG’s and consultation regarding patient care issues, including
patient RMAs, etc.
2. AAREMS Advanced EMTs may institute all standing orders without establishing radio
contact (a Signal).
3. An AAREMS Advanced EMT MUST request Medical Control (a Signal) any time a
Physician Option ALS modality needs to be attempted. If unable to contact Medical Control,
follow the Communications Failure Procedure. OTHERWISE, THE AEMT IS
PRACTICING MEDICINE WITHOUT HAVING THE PROPER MEDICAL
LICENSE.
INFORMATION EXCHANGE
The request for Medical Control is initiated by the Advanced EMT to the Medical Control
Hospital.
1. The AAREMS AEMT must identify him or herself by level and ID number.
For example:
“Intermediate 2051 to MD ______”, or
“MD _________ , this is Critical Care Technician 328”, or
“MD _________ , this is Paramedic 406”.
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ALS COMMUNICATIONS
(Continued)
PROCEDURES
1. Contact with the medical control hospital may be made by radio or cell phone.
2. When the physician* is on the line, test communications with him/her, and present your
patient in the following format:
A. Identify the patient (age, sex, weight, etc.) E. Physical Findings
B. Chief Complaint
(pertinent physical findings only)
C. Current History
F. Treatment given thus far
D. Past History
G. ETA to your destination hospital
H. Treatment Modalities Requested
* NOTE: A RN or PA may act as a designated communicator for an AAREMS Certified
Physician, provided that the AAREMS physician is available in the Emergency Department for
consultation and the RN or PA has been trained in the AAREMS Physician’s Base Station
Course.
SHORT REPORT
When the patient is in severe distress, do not elaborate on the current history and past
medical history if not significant. Quickly report the pertinent physical findings, vital signs and
any other pertinent data only, bring the AAREMS physician up to date as to any treatment given
and any significant changes in the patient’s status. If you need orders, immediately let the
physician know and inform the physician that you will continue your reporting of the patient’s
condition and report any patient changes after the administration of treatment.
GENERAL PROCEDURES
1. At any time, the AAREMS physician may choose to ask the AEMT direct questions.
2. If Medical Control is not through the receiving hospital, ask the physician to call the
receiving hospital.
3. If you are not “on-line” with the receiving hospital, contact the receiving hospital on 155.340
or 155.400 and ask if they have been called about the patient. If not, present the patient to
them using the standard format.
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COMMUNICATIONS BREAKDOWN
COMMUNICATIONS BREAKDOWN PROCEDURE TO BE USED BY ALL
ADVANCED EMTs
1. Should communications difficulties occur, attempt to quickly resolve the problem with
assistance from your dispatcher.
If problems persist:
2. If a telephone is not available within a reasonable distance, begin transportation, and contact
the dispatcher by radio to see if the dispatcher can relay information .
3. If unable to obtain Medical Control over the radio or telephone, because:
A. An AAREMS physician is not available,
B. Telecommunications failure, or
C. Medical Control is not established by the time of your arrival at the hospital;
THE AEMT MUST:
A. Utilize Protocol Standing Orders ONLY.
B. Document the patient as usual on the Prehospital Care Report and include a
description of the situation encountered that prevented you from contacting Medical
Control.
4. If a communication breakdown occurs after Medical Control has been established, Standing
Orders ONLY must continue to be utilized.
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PHYSICIAN ON THE SCENE
NON-AAREMS CREDENTIALED PHYSICIAN LICENSED IN NEW YORK STATE:
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Verify the identity and specialty of the physician with the patient, family members or
through any written credentials. The physician must be licensed in New York State.
If the identity CANNOT be verified, follow patient care protocols and contact Medical
Control as soon as possible. The physician on the scene may speak to the AAREMS
physician if he/she desires.
If the identity CAN be verified, request the physician to sign the Physician Release Form
and go with the patient in the ambulance.
If the physician is willing to sign the Physician Release Form and accompany the patient
in the ambulance, make equipment available to the physician for his/her treatment and
transportation of the patient.
If the physician is not willing to both sign the Physician Release Form and accompany
the patient in the ambulance, initiate treatment per the protocols and contact Medical
Control.
If you are called to a physician’s office, the patient is under the physician’s care until the
physician releases the patient to your care.
If there are any conflicts or questions, contact Medical Control.
AAREMS PHYSICIAN:
A. If an AAREMS physician is on the scene (as identified by personal knowledge) allow
him/her to assume control of patient care. If the AAREMS physician WILL GO TO
THE HOSPITAL with the patient, advise Medical Control of the situation and use
the AAREMS physician’s name for your records.
B. If the AAREMS physician IS UNABLE TO GO TO THE HOSPITAL, contact
Medical Control when convenient and allow the two AAREMS physicians to discuss
the patient. Transport when appropriate and maintain contact with the “on-line”
AAREMS physician over the radio. Document the call using BOTH AAREMS
physician names.
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PHYSICIAN RELEASE FORM
PHYSICIAN RELEASE FORM TO BE USED BY ALL EMTs AND ADVANCED EMTs
AMBULANCE/RESCUE SQUAD: __________________________ RUN #: _________
WARNING: THE SIGNING OF THIS DOCUMENT CONSTITUTES THE
ASSUMPTION OF LEGAL LIABILITY BY THE SIGNER FOR THE CARE AND
TREATMENT OF THE PATIENT NAMED BELOW.
The physician whose signature appears below, by subscribing this instrument acknowledges that:
1. He/she is aware that the ambulance/rescue squad, named above, called to attend the
below named patient, is operating under the coordination of the Regional Emergency
Medical Advisory Committee (REMAC) of the Adirondack-Appalachian Regional
EMS Council, (hereinafter referred to as AAREMS).
2. AAREMS supplies coordination for Basic and Advanced Life Support Systems in
this geographical area.
3. That there is available to the ambulance/rescue squad, named above, a
communications system capable of eliciting advice and instruction for the care and
treatment of this patient by trained emergency health care physicians under a system
of protocols and procedures subscribed to by physicians in the geographic area
served by AAREMS.
4. That the undersigned physician assumes full responsibility for the care and treatment
of the patient named below, and by his/her signature agrees to hereby forever release
and discharge AAREMS, its agents, servants or employees, and the attending
ambulance/rescue squad and its/their agents, servants or employees from any cause
of action whatsoever, including, but not limited to, any action ever as a defendant in a
lawsuit and hereby promises to indemnify and defend at his/her own expense,
AAREMS and/or the ambulance/rescue squad named above, for any claim, cause of
action or lawsuit brought by the patient or his/her heirs, executors, administration or
assigns against said AAREMS and/or the ambulance/rescue squad, named above, by
reason of the care and treatment tendered to said patient under the orders and control
of said undersigned Physician.
WARNING: THIS IS AN ASSUMPTION OF LEGAL RESPONSIBILITY FOR THE
CARE OF THIS PATIENT AND AN INDEMNIFICATION TO AND RELEASE OF
AAREMS AND THE ATTENDING AMBULANCE/RESCUE SQUAD.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this _________________ day of ______________________, 20______.
_______________________________________.
(Signature)
PHYSICIAN:
PATIENT:
Name: _________________________________
Address:________________________________
________________________________
Name:___________________________
Address: _________________________
_________________________
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Procedures Manual
AEMT STATEMENT OF AGREEMENT
AEMT STATEMENT OF AGREEMENT TO BE SIGNED BY ALL ADVANCED EMTs
The undersigned Advanced Emergency Medical Technician, in accepting the privilege of
being assigned an AEMT TEK number and being allowed to practice in the AAREMS Advanced
Life Support System, agrees to the following:
1. That the undersigned will, at all times, abide by the rules, regulations, and protocols
of AAREMS as they now exist an as they may be hereafter amended.
2. That the undersigned agrees to abide by any standards of training and in-service
training and practice required by AAREMS and attend any classes or practice
sessions required by AAREMS and understands that this is a continuing requirement
necessary to maintain the undersigned’s status as a AAREMS Certified AEMT and
that the failure to meet such requirements may result in the revocation of this
privilege.
3. That the undersigned understands that the privilege to participate as an AAREMS
Certified AEMT in the AAREMS Advanced Life Support System is separate and
apart from the undersigned’s status as a New York State Certified AEMT, although
such State Certification is required to be maintained to remain an AAREMS Certified
AEMT.
4. The undersigned understands and acknowledges that the AAREMS Certification
Number (TEK Number) may be revoked or suspended at any time for good cause
shown under the provisions of the ALS Complaint Procedure as outlined in this
manual.
IN WITNESS WHEREOF this acceptance is executed
this _____________ day of _____________________, 20________.
Name (Print): ___________________________________________
Address: _______________________________________________
_______________________________________________.
Signature: ______________________________________________
NYS AEMT Certification Number: __________________________
Expiration Date: _________________________________________
AAREMS TEK Number: ___________________________________
Witness Signature: _______________________________________
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Procedures Manual
ALS COMPLAINT PROCEDURES
In order to handle complaints concerning participating organizations, or individual
participants such as AEMTs, nurses and physicians involved in prehospital ALS the following
procedure has been established.
Complaints, or notices of untoward events, can be made by a patient, the public,
participating organizations or individual participants, including AAREMS staff members. All
such complaints should be written, signed and delivered to the AAREMS Program Administrator.
Appropriate grounds for complaints include, but are not limited to:
1. Practicing without proper NYS or AAREMS certification;
2. Deviation from the AAREMS Protocol Manual, including interim updates from the
Regional Medical Advisory Committee (REMAC), AAREMS Protocols, Procedures,
Medication Schedule, and Policies;
3. Unprofessional conduct:
A. Disrespect towards patients, families or fellow providers,
B. Under the influence of alcohol or any other drug affecting physical coordination
or intellectual functions while on duty,
C. Breaking a patient’s confidentiality,
4. Immoral or indecent behavior,
5. Being found guilty of fraud, deceit, incompetence, patient abuse, theft, or dishonesty in
the performance of his/her duties and practice,
6. Falsification of records,
7. Conviction of any crime or crimes (felony or misdemeanor) or violation of the NY State
Public Health Law and those requirements included in Chapter VI, Title 10, Part 800 of
the NY State Codes, Rules and Regulations, or
8. Allowing an EMT certified at a lower level to perform skills restricted to individuals
holding a higher level of certification, unless the EMT has been specifically assigned to
him/her to be an intern in a formal internship program.
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ALS COMPLAINT PROCEDURES
(Continued)
Complaints will be handled by the following process:
1. A written, signed complaint is delivered to the AAREMS Program Administrator or
his/her designee.
2. The AAREMS Program Administrator or his/her designee notifies the named
organization, AEMT, nurse or physician of the complaint by mail or telephone and
confers with the named party privately, if possible.
3. The AAREMS Program Administrator or his/her designee sends written notification of
the alleged infraction to the AAREMS Medical Director and the party’s supervisor at
his/her agency or institution
4. The AAREMS Medical Director or his/her designee may choose any of the following
options:
A. Decision that the complaint is unwarranted, and report of the same to the
AAREMS REMAC
B. Issuing of a written warning, and report of the same to the REMAC
C. If life-threatening infraction, the AAREMS Program Administrator may confer
immediately with the AAREMS Medical Director, then hold a meeting of the
same with the named party and one representative of his/her institution. The
Medical Director, in conjunction with the Program Administrator, may suspend
the named party prior to meeting with the named party.
D. Referral of complaint to the REMAC for further investigation and resolution.
The AAREMS Medical Control Hospitals will not honor the named party’s
AAREMS Identification while the party is on suspension.
The REMAC will review, at their next scheduled meeting, complaints processed
through step 4, options A-C above.
In cases where consensus of opinion of the REMAC is that no follow up action is
warranted, the Chairman of the REMAC or the AAREMS Medical Director shall
communicate that opinion, in writing, to the complainant, the named party, and the
named party’s supervisor at his/her agency or institution.
When the complaint is judged meritorious of further investigation, the Chairman of
the REMAC shall appoint a sub-committee of REMAC members that will meet within 30
days with the named party and one representative of his/her agency or institution and
report back to the REMAC.
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Procedures Manual
ALS DISCIPLINARY PROCEDURES
The REMAC sub-committee shall consist of one or two physician members of the
REMAC and two non-physician members. No member of the agency or institution involved in
the complaint shall be appointed to the Sub-committee. The Sub-Committee’s report shall
become the basis for a consensus recommendation to the REMAC.
The REMAC may conduct any subsequent investigations and/or hearings deemed
warranted and shall issue a decision in the matter within 30 days of the receipt of the consensus
recommendation of the Sub-Committee.
The decision shall then be transmitted by registered mail to the complainant, the named
party, and the named party’s supervisor. The decision of the REMAC shall be considered
binding and final.
Examples of disciplinary options include, but are not limited to:
A. Probation with specified supervision,
B. Suspension for a specified period of time, or
C. Revocation of privileges to participate in the AAREMS System.
A record of each complaint and the completion of the appropriate disciplinary steps shall
be kept by the AAREMS staff.
Appeals by the complainant or the named party should be directed to the Medical
Director of the Regional Medical Advisory Committee of AAREMS.
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Procedures Manual
TRANSFER OF PATIENT CARE
RESPONSIBILITIES
1. TRANSFER OF PATIENT FROM PARAMEDIC (OR CRITICAL CARE
TECHNICIAN) TO PARAMEDIC (OR CRITICAL CARE TECHNICIAN).
Each Paramedic (or Critical Care Technician) is responsible for the patient while in his/her
care. The transferring or receiving Paramedic (or Critical Care Technician) will not be
responsible for their counterpart’s actions.
Transferring of patient care may not be appropriate in all situations. Patients in cardiac
arrest or patients who are unstable need rapid transportation, so due to time or manpower
constraints, it may not be appropriate to transfer the patient from Paramedic (or Critical Care
Technician) to Paramedic (or Critical Care Technician).
A. The Paramedic (or Critical Care Technician) transferring patient care to
another Paramedic (or Critical Care Technician) must:
1. Ensure that all patient information is transferred to the receiving Paramedic (or
Critical Care Technician) including: chief complaint, past medical history,
current history, vital signs and care given prior to the arrival of the receiving
Paramedic (or Critical Care Technician).
2. Assist the receiving Paramedic (or Critical Care Technician) until the receiving
Paramedic (or Critical Care Technician) is ready to assume total patient care.
3. Be willing to accompany the receiving Paramedic (or Critical Care Technician)
to the hospital if the patient’s condition warrants or if the receiving Paramedic or
(Critical Care Technician) requests it.
B. The receiving Paramedic (or Critical Care Technician) must:
1. Document patient care given prior to receiving the patient.
2. Request that the transferring Paramedic (or Critical Care Technician) accompany
him/her to the hospital if the patient’s condition warrants it.
C. Documentation (Prehospital Care Reports)
1. Both Paramedics (or Critical Care Technicians) will complete a PCR, and
Continuation Form where appropriate, detailing the care given to the patient
while he/she was in their care.
2. PCR documentation from the transferring Paramedic (or Critical Care
Technician) must be faxed to the receiving hospital within two hours of the call.
ANY DISPARITY BETWEEN THE PARAMEDICS (OR CRITICAL CARE
TECHNICIANS) NEEDS TO BE RESOLVED BY CONTACTING MEDICAL CONTROL
The above procedure must be followed when transferring patients between other equal
levels of care (i.e. EMT-Intermediate to EMT-Intermediate, or EMT-B to EMT-B).
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TRANSFER OF PATIENT CARE
RESPONSIBILITIES
(Continued)
2. TRANSFER OF PATIENT CARE FROM A PARAMEDIC (OR CRITICAL CARE
TECHNICIAN) TO AN EMT-I OR AN EMT-B.
Transferring patient care from a Paramedic (or Critical Care Technician) to an EMT-I or
EMT-B can only be done when the patient is stable and does not require any ALS care. EMT-Is
may accept an ALS patient for transport when the patient has an IV established but has not and
will not require any medications.
A. The Paramedic (or Critical Care Technician) transferring the patient must:
1. Ensure that all patient information is transferred to the receiving EMT-I or
EMT-B, including: chief complaint, past medical history, current history,
vital signs and care given prior to the arrival of receiving EMT-I or EMT-B.
2. Assist the receiving EMT-I or EMT-B until he/she is ready to assume total
patient care.
3. Be willing to accompany the receiving EMT-I or EMT-B to the hospital if
he/she is uncomfortable accepting total patient care.
B. The receiving EMT-I, or EMT-B must:
1. Document patient care given prior to receiving the patient.
2. Request that the transferring Paramedic (or Critical Care Technician)
accompany him/her to the hospital if patient care warrants it.
C. Documentation (Prehospital Care Reports):
1. The Paramedic (or Critical Care Technician) transferring the patient will
complete a PCR or First Responder Form (whichever is appropriate)
detailing the care given to the patient while in his/her care.
2. If a PCR form is used by the transferring Paramedic (or Critical Care
Technician), that PCR must be faxed to the receiving hospital within two
hours of the call.
THE RECEIVING INTERMEDIATE OR EMT-B HAS THE AUTHORITY TO REFUSE
TOTAL PATIENT CARE IF HE/SHE FEELS THE PATIENT SHOULD BE
TRANSPORTED WITH THE TRANSFERRING PARAMEDIC (OR CRITICAL
CARE TECHNICIAN) ON BOARD.
The above procedure must be followed when transferring patients from an EMTIntermediate level of care to EMT-B level, or EMT-B level of care to another EMT-B.
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ENDOTRACHEAL INTUBATION
ENDOTRACHEAL INTUBATION PROCEDURES TO BE USED BY ALL
ADVANCED EMTs
INDICATIONS
1. Orotracheal intubation may be performed by AEMTs on standing orders. This procedure can
be used on patients in cardiac, respiratory or imminent respiratory arrest.
2. Nasotracheal intubation may be performed by AEMTs on standing orders. This procedure
can be used on patients who are breathing, patients who have a gag reflex, patients who have
an intact response to pain, when the patient’s mouth cannot be opened because of clenched
jaws, when the patient is sitting upright (i.e. pinned in a vehicle or in severe pulmonary
edema) or when the patient cannot be ventilated by other means. This procedure can be
performed with the head in the neutral position, which may result in less movement of the
cervical spine in the trauma patient.
CONTRAINDICATIONS/PRECAUTIONS
1. The intubation attempt should not interrupt oxygenation for longer than 15 seconds. The
patient MUST BE OXYGENATED between intubation attempts! Intubation may be
attempted two times by one AEMT, then one more time by a second AEMT. If not
successful, an oro- or nasopharyngeal airway should be inserted.
2. If suctioning is necessary down the ET tube, a sterile catheter and gloves should be used. The
patient must be pre-oxygenated and suction should not be applied for more than 10 seconds.
3. If a patient must be extubated in the field, the patient should be pre-oxygenated. Have
suction ready and have the patient take a deep breath. Deflate the cuff and remove the tube at
the peak of inspiration. Watch the patient for vagal stimulation and dysrhythmias.
4. If a cervical spine fracture is suspected, leave the cervical collar in place to assist in
maintaining immobilization of the neck.
5. Apnea is the only absolute contraindication for nasotracheal intubation in the
prehospital emergency setting. Success in nasotracheal intubation depends on the AEMTs
ability to hear breath sounds through the tube during its insertion.
6. Other relative contraindications to nasotracheal intubation include: bleeding disorders in the
nose, facial fractures and the presence of large nasal polyps or abscesses.
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ENDOTRACHEAL INTUBATION
(Continued)
EQUIPMENT
THE FOLLOWING EQUIPMENT MUST BE CARRIED BY ALL ALS UNITS IN THE
AAREMS REGION:
Disposable ET tubes – sizes 6 thru 9, cuffed,
Disposable ET Tubes – sizes 2.5 thru 5, uncuffed,
“C” sized laryngoscope handle,
#0 and #1 Miller straight laryngoscope blades,
#2 and #3 Macintosh laryngoscope blades,
#2 and #3 Wisconsin or Miller laryngoscope blades,
Adult and pediatric stylettes,
Spare laryngoscope batteries and bulbs for blades,
10 cc syringes,
Tape and oral airways,
Magill forceps and/or large Kelly clamp,
Disposable gloves and goggles,
Xylocaine jelly
Afrin or Neosynephrine Nasal Spray
Orogastric tubes for adult and pediatric patients – sizes 5, 8, 14,and 18 French,
Esophageal Intubation Detector (EID) device.
BAAM Adapters for nasotracheal intubation
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ENDOTRACHEAL INTUBATION
(Continued)
OROTRACHEAL INTUBATION
PROCEDURE
1. Check and assemble all equipment and have it readily accessible. Put on disposable gloves
and goggles.
2. Stop CPR or ventilatory assistance.
3. Align the three axes of the mouth, pharynx and trachea by flexing the neck forward (except in
possible cervical spine injuries) and extending the head backward. This manipulation should
achieve the “sniffing” position, i.e. the occiput of the head is on the same horizontal plane as
the back of the shoulders with the head somewhat elevated. A folded towel under the head
may help you to achieve this “sniffing” position.*
4. While holding the laryngoscope handle in the left hand, open the mouth and insert the
laryngoscope blade in the right side of the mouth, elevating the tongue to the left. Following
the natural contour of the pharynx, insert the laryngoscope blade until you visualize the
epiglottis. If a straight blade is used, insert it until you are below the epiglottis, visualizing
and lifting it anteriorly to expose the glottic aperture. If a curved blade is used, place the tip
of the blade into the vallecula.*
5. Traction is extended upward in the direction of the end of the laryngoscope handle with your
wrist locked. Do not use a prying motion or use the upper teeth as a fulcrum.*
6. Upon proper positioning of the epiglottis and visualization of the vocal cords and cartilages,
with your right hand pass the tip of the endotracheal tube gently between the vocal cords until
the cuff is 1.0 cm distal to the vocal cords and arytenoid cartilages.*
7. Remove the laryngoscope and, while stabilizing the position of the endotracheal tube, inflate
the cuff of the tube with 5-10 ml of air from a syringe until the cuff has sealed the trachea.*
8. Confirm correct placement of the ET tube by attaching the Esophageal Intubation Detector
(EID) to the proximal end of the tube and withdrawing the 60 cc syringe in one continuous
motion. If the syringe fills with air, ventilate the patient once and watch for chest rise. Also,
auscultate all lung fields during ventilation to determine the presence of bilateral lung sounds.
Auscultate the epigastrium for air entering the stomach.*
9. Tape the tube securely in place, preferably by running the tape around the neck and by
wrapping the ends around the tube. An oropharyngeal airway should be properly placed in
the mouth.
10. Reevaluate the patency of the airway and tube placement by observing chest rise and by
auscultating for breath sounds periodically following intubation, especially after
defibrillation, patient movement or during transport.
IF IN DOUBT AS TO THE LOCATION OF THE TUBE, DEFLATE THE
CUFF, REMOVE THE TUBE AS QUICKLY AS POSSIBLE AND ATTEMPT
INTUBATION AGAIN.
* Steps 3, 4, 5, 6, 7 & 8 must be completed in 30 seconds or less.
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ENDOTRACHEAL INTUBATION
(Continued)
NASOTRACHEAL INTUBATION
PROCEDURE
1. Check and assemble all equipment and have it readily accessible. Put on disposable gloves
and goggles.
2. If head or spinal trauma is suspected, have an assistant maintain manual immobilization of
the head and neck.
3. Determine which nasal passage is larger, using the larger passage for tube insertion.
4. If the patient has no contraindications to its use (i.e. allergy or severe hypertension), there
may be instilled 1-2 sprays of a topical vasoconstrictor such as Neosynephrine or
Oxymetolazone (Afrin) into the larger nostril. This must be done prior to administration of
the Lidocaine jelly.
5. The nasal endotracheal tube (usually sizes 7 or 7.5 mm for adults) may be lubricated with a
local anesthetic jelly (Xylocaine 2% Jelly).
6. Stop ventilatory assistance.
7. Place the patient with the head and neck in neutral alignment and with the nasal passage
selected for passage of the tube in alignment with the trachea.
8. Insert the tube into the left or right nostril and guide the tube slowly but firmly into the nasal
passage, going straight back along the floor of the nasal cavity and then going down into the
nasopharynx. The curve of the tube should be aligned to facilitate passage along this curved
course. The Endotrol, a directional tip ET tube, may help in achieving an anterior curve.
9. As the tube passes through the nasopharynx, resistance will be met as the tube is advanced
through the pharynx. Gentle force is often necessary to overcome this resistance. Directing
the tube toward the glottic opening will also help.
10. Once the tube has entered the pharynx, listen for airflow coming from the tube. A BAAM
type airflow device attached to the end of the tube is helpful in this procedure, as it whistles
loudly when the patient exhales and the tip of the tube is over the trachea. Advance the tube
until the sound of air moving is maximal, suggesting the location of the tip of the tube is over
the trachea. Also check for signs of condensation in the tube. While listening to air
movement and verifying condensation in the tube, determine the moment of inhalation and
advance the tube quickly until the BVM adapter on the proximal end of the tube is almost
against the patient’s nostril.
11. If tube placement is unsuccessful, repeat the procedure while applying gentle pressure on the
thyroid cartilage. If still unsuccessful, the thyroid cartilage can be directed toward the head.
Displacing the tongue and jaw forward may also be helpful.
12. Inflate the cuff with enough air to provide an adequate seal.
13. Attach the EID and withdraw 60 cc of air. Ventilate the patient and watch for chest rise.
Then auscultate the chest and epigastric area with a stethoscope to confirm tube placement.
14. Secure the tube in place, preferably by running tape around the head or neck and wrapping
the ends around the tube.
15. Intubation must be completed within 30 seconds.
16. Frequent tube checks are required, especially during patient movement.
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ENDOTRACHEAL INTUBATION
(Continued)
TRAUMA INTUBATION
PROCEDURE
In trauma situations, where spinal injury is suspected, orotracheal intubation is performed using
the following procedure:
1. Apply a rigid extrication collar.
2. Manual stabilization is held by a helper from below the head.
3. The AEMT sits with the patient’s head between his/her thighs and leans back to visualize the
vocal cords, keeping his/her left wrist, elbow and shoulder locked.
4. Intubation is accomplished as usual, but the head and spine are kept in constant alignment.
PEDIATRIC INTUBATION
PROCEDURE FOR ENDOTRACHEAL INTUBATION
In children under 8 years old, the preferred modality is orotracheal intubation using the following
procedures:
1. Use an uncuffed ET tube – determine the size from the Broselow Pediatric Resuscitation
Tape, reading the tube size for the patient’s length.
2. Bradycardia may occur during intubation due to hypoxia or stimulation of the airway. If
bradycardia occurs (infant pulse rate less than 80 BPM, child pulse rate less than 60 BPM),
stop the procedure and hyperventilate the patient with 100% oxygen.
3. Administration of Atropine IV, under a Physician’s order for Critical Care Technicians and
Paramedics, is recommended for intubating the spontaneously breathing infant or child. The
dosage recommended is 0.02 mg/kg, but never less than 0.1 mg.
4. Critically ill children may have significant stomach distention. An orogastric tube is placed
in the stomach of intubated patients to allow gravity drainage, after the ET tube is in place.
5. Movement of the patient’s head against his/her body may dislodge the ET tube. All intubated
pediatric patients should be immobilized on a board to minimize head movement.
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ESOPHAGEAL INTUBATION
DETECTOR DEVICE
ESOPHAGEAL INTUBATION DETECTOR DEVICE PROCEDURE TO BE USED BY
ALL ADVANCED EMTs
INDICATIONS
The purpose of this procedure is to provide immediate feedback to the AEMT after
placement of a cuffed endotracheal tube through either orotracheal or nasotracheal intubation.
The traditional method of chest auscultation must still be used after the Esophageal Intubation
Detector (EID) Device is used.
EQUIPMENT
THE FOLLOWING EQUIPMENT MUST BE CARRIED ON ALL ALS UNITS IN THE
AAREMS REGION:
Esophageal Intubation Detector – syringe-type (preferred) or bulb-type
PROCEDURE FOR SYRINGE-TYPE DEVICE
This procedure is to be followed for every patient intubated with a cuffed endotracheal tube.
1. The patient will be intubated with the usual preparation, equipment and procedure.
2. Once the ET tube is placed and the cuff inflated, the EID is attached to the proximal end of
the tube. The 60 cc syringe plunger is then withdrawn in one continuous motion.
3. If the syringe fills with air and the plunger can be withdrawn without resistance, the
endotracheal tube is correctly placed in the trachea.
4. The EID should then be removed and the patient ventilated normally. Traditional
auscultation methods must be performed at this point to verify tube placement.
5. Intubation, EID tube check and initial ventilation must be completed in 30 seconds or less.
6. IF THE SYRINGE PLUNGER DOES NOT WITHDRAW EASILY OR IF THE
SYRINGE PLUNGER RECOILS BACK TO THE ORIGINAL POSITION, THE
ENDOTRACHEAL TUBE IS IN THE ESOPHAGUS.
7. If the endotracheal tube is thought to be in the esophagus, it should be withdrawn
immediately, the patient hyperventilated, and the intubation repeated. The EID should then
be reapplied and the EID Procedure followed.
8. The endotracheal tube should be secured in the usual fashion once the EID is removed.
9. Anytime the patient is carried or moved, or anytime a change in lung compliance with
ventilation is detected, the EID should be reapplied and the above procedure repeated.
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Procedures Manual
OROGASTRIC TUBE PLACEMENT
This is an optional procedure and may be implemented at the discretion of the agency medical
director.
OROGASTRIC TUBE PLACEMENT PROCEDURE TO BE USED BY ALL AEMTs
INDICATIONS
1. Gastric distension after bag valve mask ventilation.
2. A gastric tube may be inserted by the AEMT on standing orders after endotracheal intubation
has been performed and the tube is adequately secured.
CONTRAINDICATIONS/PRECAUTIONS
1. A gastric tube may not be used in any patient with known esophageal disease or in any
patient that has ingested a caustic substance.
2. The nasal approach is not preferred and should not be used unless expressly ordered by
Medical Control.
3. A gastric tube may not be placed on standing orders unless the patient’s airway has been
adequately secured with an endotracheal tube.
EQUIPMENT
THE FOLLOWING EQUIPMENT MAY BE CARRIED ON ALL ALS UNITS IN THE
AAREMS REGION (Optional at the discretion of the agency medical director):
1. Appropriately sized gastric tubes:
Adults: 14 or 18 French
Children (1-8 years): 8 French
Infants (< 1 year): 5 French
2. 2 oz. (60 cc) syringe
3. Water soluble lubricant
4. Stethoscope
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Procedures Manual
OROGASTRIC TUBE PLACEMENT
(Continued)
PROCEDURE
1. Assemble the required equipment.
2. Measure the proper length of the gastric tube.
- Place the distal end of the gastric tube over the epigastrium and measure up to the
patient’s mouth, noting the black line on the tube that indicates this measurement.
3. Lubricate the distal end of the gastric tube with water-soluble lubricant.
4. If no cervical spine trauma is suspected, keep the patient’s head in a neutral or slightly
forward flexed position and lift the jaw anteriorly. If a cervical spine injury is suspected,
keep the head in alignment.
5. Insert the lubricated gastric tube following the pharyngeal curvature to the predetermined
length.
6. Instill 2 oz. (60 cc) of air (10 cc in infants, 20 cc for larger children) into the gastric tube
while listening for air sounds over the epigastrium with a stethoscope; the presence of air
sounds over the epigastrium indicates proper placement.
7. Connect the gastric tube to low suction for decompression/emptying of the stomach. In
infants and children do not use active suction, merely keep the syringe attached and
allow it to rest lower than the patient’s stomach for gravity drainage.
8. Secure the tube with tape.
9. If in any doubt exists as to the proper placement of the orogastric tube, remove it
immediately.
10. Record the amount and type of any substance removed from the stomach with the gastric
tube.
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Procedures Manual
OXYGEN THERAPY
OXYGEN THERAPY PROCEDURES TO BE USED BY ALL EMTs
AND ADVANCED EMTs
GENERAL PROCEDURES
1. Remember, oxygen is a drug.
2. Always obtain a history prior to the administration of oxygen to the breathing patient.
Determine the presence or absence of Chronic Obstructive Pulmonary Disease (COPD).
3. In the prehospital setting, patients needing oxygen therapy are divided into two categories:
A. Patients requiring low concentration oxygen.
B. Patients requiring high concentration oxygen.
4. OXYGEN MUST NEVER BE WITHHELD FROM PATIENTS IN RESPIRATORY
DISTRESS, EVEN THOUGH THEY MAY HAVE COPD.
5. When administering oxygen, watch the patient for effect. Be prepared to ventilate the patient
if necessary.
6. Do not use greater than 6 LPM with a nasal cannula or less than 12LPM with a nonrebreather mask.
PROCEDURE
1. Determine if the patient has a history of COPD.
2. Patients with a COPD history that are NOT in respiratory distress should receive LOW
concentrations of oxygen:
A. Nasal cannula at the patient’s prescribed flow rate.
3. COPD patients in respiratory distress should always receive HIGH concentrations of oxygen.
A. FIRST CHOICE:
Non-rebreather mask. Fill the bag and have
sufficient oxygen flow to keep the bag 1/3 full during
inspiration. Administer at 12 lpm or greater.
B. SECOND CHOICE: Nasal cannula at 6 LPM. Use only if a non-rebreather mask is
not tolerated.
INVENTORY
THE FOLLOWING EQUIPMENT MUST BE CARRIED ON ALL ALS UNITS IN THE
AAREMS REGION:
1. Nasal Cannulas
2. Non-Rebreathing Masks
3. Pediatric Masks
4. Connective Tubing
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Procedures Manual
PULSE OXIMETRY
PULSE OXIMETRY PROCEDURE TO BE USED BY ALL EMTs
AND ADVANCED EMTs
INDICATIONS
The pulse oximeter is used for the evaluation of blood oxygen saturation at the capillary
level. It is useful in assessing the effectiveness of respirations, oxygen therapy, bronchodilatory
therapy and manual ventilation. Pulse oximeter readings should be taken and recorded at 5
minute intervals, usually with the other vital signs, or more frequently if necessary. Therapy can
then be adjusted for optimum tissue oxygenation. An oximeter reading at room air level may be
obtained while setting up oxygen for the patient, but do not delay oxygen therapy to obtain
oximeter reading. Never withhold oxygen administration as per State BLS protocols
because of a high oximeter reading.
CONTRAINDICATIONS/PRECAUTIONS
1. Carbon monoxide binds with hemoglobin in the blood more readily than oxygen, but still
produces the red color that the pulse oximeter reads. For this reason the oximeter readings
will be high in carbon monoxide poisoning victims while the tissues are starved of oxygen.
2. Chronic smokers normally have 10-15% more residual carbon monoxide in their blood than
non-smokers. Smokers may have falsely high oximeter readings while still suffering from
hypoxia.
3. Oxygen should never be withheld on the basis of a high oximeter reading from a patient
whose condition or appearance conveys a need for it.
EQUIPMENT
In order for a pulse oximeter to be approved for use in the AAREMS system, it must be
able to display: pulse, pulse waveform or other strength of signal indicator, and oxygen
saturation.
PROCEDURE
1. Since the pulse oximeter is not a first line treatment modality, follow the standard AAREMS
Protocol for the clinical problem, including standard oxygen therapy. Never delay definitive
care, such as 100% oxygen, intubation or transportation in order to set up the pulse oximeter.
2. Apply the oximeter probe to a finger or ear.
3. Record the time, pulse waveform quality (good or poor), and oxygen saturation.
4. If oxygen saturation is:
A. Less than 92% with a good pulse waveform:
Increase oxygen therapy, manually ventilate, and/or intubate.
B. More than 92% with a good pulse waveform:
Continue current oxygen therapy
If there is poor pulse waveform, re-measure the pulse oximetry at another site.
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Procedures Manual
SMALL VOLUME NEBULIZER
NEBULIZER PROCEDURE TO BE USED BY ALL PARAMEDICS AND
CRITICAL CARE TECHNICIANS.
INDICATIONS
To deliver small amounts of aerosolized medications to the upper and lower airways of
patients with reversible airway disease, such as Asthma and COPD Exacerbation.
CONTRAINDICATIONS
1. Heart rate greater than 140 BPM (in adults).
2. A previous adverse reaction to Albuterol or Atrovent.
PRECAUTIONS
Contact an AAREMS Physician immediately if any of the following occur:
1. The patient’s heart rate increases by 20 BPM or more during the treatment.
2. Increased bronchospasm is noted.
3. Tremors, nausea or vomiting occur.
PROCEDURE
1. Perform a complete chest exam and obtain the pertinent medical history. If the patient has a
history of asthma, determine the type and amount of bronchodilator medication already taken.
2. Obtain a baseline set of vital signs.
3. Assemble the equipment (nebulizer, oxygen tubing, and mouthpiece or facemask).
4. Place the pre-mixed Albuterol, 2.5 mg in 3 cc (unit dose), and/or Atrovent, 0.5 mg in 2.5 cc
(unit dose), in the nebulizer. Connect the oxygen tubing to a liter flow device and administer
oxygen at 6-10 LPM.
5. Explain the procedure to the patient, instructing the patient to take slow deep breaths through
the mouth.
6. Monitor the pulse rate every two minutes. Discontinue the treatment if the heart rate
increases by 20 BPM or more. If the pulse rate decreases to the patient’s baseline rate,
continue to administer the treatment.
7. Treatment is complete when the nebulizer is no longer producing mist continuously.
8. Upon completion of the treatment, re-assess the lung sounds and vital signs.
9. With patients that will not tolerate a mouthpiece or a facemask, such as infants or toddlers,
hold the facemask in front of the patient’s mouth and nose, as close as the patient will allow
you or a parent to hold it.
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Procedures Manual
THORACIC DECOMPRESSION
THORACIC DECOMPRESSION PROCEDURE TO BE USED BY ALL
ADVANCED EMTs
INDICATIONS
Thoracic decompression is an emergency procedure to treat tension pneumothorax.
CONTRAINDICATIONS/PRECAUTIONS
1. Be prepared to begin positive pressure assisted ventilations whenever indicated by the
patient’s respiratory rate or tidal volume.
2. THORACIC DECOMPRESSION IS A SERIOUS MEDICAL INTERVENTION
THAT NECESSITATES CHEST TUBE THORACOSTOMY IN THE HOSPITAL.
Therefore, ALL thoracic decompressions MUST be well documented and include a
description of the patient’s physical condition that includes:
A. If the patient is in cardiac arrest:
- The patient has an absence of lung sounds on one side, or both sides, of the
chest after the patient has been ventilated by a BVM with an ET tube in
place.
B. If the patient is NOT in cardiac arrest:
- The patient has signs and symptoms consistent with a tension pneumothorax
(absence of breath sounds on one side, extreme dyspnea, JVD , cyanosis
despite the administration of 100% oxygen, tracheal deviation)
AND
- The patient has evidence of hemodynamic compromise (unexplained
hypotension, narrowed pulse pressure, tachycardia).
PROCEDURE
1. Cleanse the overlying skin with povidone-iodine solution.
2. Insert a 14 gauge, 3½-inch catheter-over-the-needle device into the second intercostal space
in the midclavicular line above the top of the third rib.
3. Upon entry into the pleural space, confirmation of air under tension will be evidenced by
hearing the escape of air through the open needle.
4. Remove the needle and leave the catheter in the pleural space open to the air.
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Procedures Manual
PORTABLE TRANSPORT VENTILATORS
(PTVs)
PTV PROCEDURE TO BE USED BY ALL ADVANCED EMTs
Advanced EMTs caring for patients on portable transport ventilators must have
completed a documented in-service by their agency Medical Director or their qualified designee.
This in-service should familiarize the AEMT not only with the specific ventilator unit normally
used by the agency, but should provide a basic understanding of ventilator mechanics, settings,
adjustments and trouble-shooting required to care for the ventilated patient.
The ventilation requirements of the patient being transported should not exceed the
performance capacity of the PTV being used during transport. If it does and further ventilator
setting changes are required to make up for these differences, these changes must be instituted
prior to transfer and must be deemed acceptable by the transferring physician.
INDICATIONS/CONTRAINDICATIONS:
1. The PTV can only be used by AEMTs trained in the use of a PTV, on patients that
have undergone endotracheal intubation and have had tube placement verified in the
usual fashion.
2. Pediatric patients may only be placed on a PTV specifically designed for pediatric
use.
3. Patients may be transferred on their own machines.
PROCEDURE:
1. Record baseline ventilator settings from the sending institution. The most recent
blood gas and chest x-ray results should be available.
A. Average ventilator settings:
Tidal Volume: 5-10 cc/kg
Rate:
Adult: 12-14 bpm
Children (age dependent): 12-30 bpm
B. These ventilator settings are only guidelines for the initiation of the PTV in
the situation where the appropriate settings have not been established. A
physician should be contacted as soon as possible to confirm the appropriate
settings.
C. If the patient requires settings (such as high levels of PEEP) that your
ventilator cannot accomplish, address it with the transferring physician.
2. Record baseline minute ventilation, respiratory rate and peak pressures on the
hospital ventilator and again once the patient is placed on the PTV.
3. Assess and document tube position, lung sounds and respiratory pattern.
4. Assure that the endotracheal tube is adequately secured prior to transfer.
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Procedures Manual
PORTABLE TRANSPORT VENTILATORS
(Continued)
5. Prior to connecting the PTV to the patient, the following pre-checks should be
completed:
A. The Breaths Per Minute knob is set to the appropriate rate.
B. The Tidal Volume knob is set to the desired tidal volume.
C. Count the number of vent cycles for a full minute. The vent should deliver
the desired number of breaths.
D. Occlude the outlet for the Patient Valve Assembly (PVA). An audible alarm
should sound after each cycle.
E. Check the gas source pressure. Tanks under 200 PSI should not be used.
6. Once the patient has been connected to the PTV:
A. Count the number of breaths for a full minute to confirm the vent settings.
B. Auscultate bilateral breath sounds and evaluate for chest rise.
C. Monitor the patient at all times, checking the ventilator rate, breath sounds
and chest rise every 5 minutes.
** Avoid breaking PEEP. If a patient is on high levels of PEEP and the continuity of the system
needs to be broken (i.e. for bagging the patient), make sure that the required pressures are
maintained by using the appropriate PEEP valves.
IF AT ANY TIME DURING THE USE OF A PTV YOU ARE UNSURE WHETHER IT IS
OPERATING PROPERLY, DISCONNECT IT FROM THE PATIENT AND UTILIZE A
BAG VALVE MASK WITH THE ENDOTRACHEAL TUBE.
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Procedures Manual
DEFIBRILLATION
MANUAL DEFIBRILLATION
MANUAL DEFIBRILLATION PROCEDURE TO BE USED BY ALL PARAMEDICS
AND CRITICAL CARE TECHNICIANS
INDICATIONS
Electrical defibrillation is currently the most effective method for converting ventricular
fibrillation (VF) or pulseless ventricular tachycardia (VT) to a life sustaining rhythm. AEMTs
may use defibrillation on standing orders.
CONTRAINDICATIONS/PRECAUTIONS
1. Success of defibrillation depends largely on the amount of time the patient has been in VF or
VT. For this reason, in the cardiac arrest situation, it is essential to check the rhythm and
defibrillate as early as possible.
2. Another important factor in the success of defibrillation is paddle/electrode placement.
Proper placement calls for the Sternum paddle/electrode (-) to be placed to the right of the
upper sternum just below the right clavicle and the Apex paddle/electrode (+) to be placed
just to the left of the left nipple in the midaxillary line. A force of approximately 25 lbs. (11
kg) should be used to apply each paddle to the chest wall, and an appropriate conductive
medium should be used to overcome trans-thoracic resistance to the electrical charge.
3. In the pediatric patient, defibrillation is weight related (2 Joules/kg initially). Refer to the
Broselow Pediatric Resuscitation Tape to approximate energy settings prior to defibrillation.
Proper sized pediatric defibrillation paddles must be used to prevent damage to the chest and
to facilitate proper defibrillation.
PROCEDURE
1. Confirm the patient is in ventricular fibrillation or ventricular tachycardia and has no pulse.
2. Apply conductive gel to the paddles, or apply the electrodes.
3. Select the appropriate energy level for the algorithm or patient age/weight and charge the
paddles/electrodes.
4. Recheck the rhythm and start recording strip.
5. Stop CPR. If paddles are being used, apply them as above to the patient’s chest.
6. Call “clear” and make sure there are no personnel (including yourself) in contact with the
patient.
7. Deliver the countershock by depressing both thumb buttons at the same time (if using
paddles), or by pressing the “shock” button (if using electrodes)..
8. Recheck the rhythm. Resume treatment as appropriate for the rhythm, including
countershocks as per AHA Guidelines.
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Procedures Manual
CARDIOVERSION/EXTERNAL PACING
SYNCHRONIZED CARDIOVERSION
SYNCHRONIZED CARDIOVERSION PROCEDURE TO BE USED BY PARAMEDICS
AND CRITICAL CARE TECHNICIANS
INDICATIONS
Synchronized cardioversion is the treatment of choice for supraventricular and ventricular
tachydysrhythmias when the patient is unstable or the dysrhythmia is refractory to drug therapy
when the patient is stable.
The procedure is the same for defibrillation (see previous page) except:
1. The patient will be conscious, so sedation should be considered prior to cardioversion.
2. The synchronizer circuit must be turned on and there must be capture marks on the QRS
complexes or the defibrillator will not synchronize correctly. If there are no marks, adjust the
EKG size accordingly.
3. If at any time the patient becomes unstable, or if unable to perform synchronized
cardioversion, cardiovert without synchronization.
EXTERNAL PACING
EXTERNAL PACING PROCEDURE TO BE USED BY PARAMEDICS
AND CRITICAL CARE TECHNICIANS
INDICATIONS
External pacing is the treatment of choice in profound bradydysrhythmias.
The pacing circuit monitors the QRS complexes similar to the synchronizing circuit in
cardioversion, but it determines the rate and provides pacing if it is slower than the specified rate
(usually 60 BPM). For this reason, the patient cables must be in place and good QRS complexes
must be sensed.
Be certain that you have the correct pacing electrodes for your unit.
1. The most effective and comfortable position for the pacing electrodes is the anterior-posterior
position:
A. Place the negative electrode on the left anterior chest halfway between the xiphoid
and left nipple with the upper edge of the electrode below the nipple line.
B. Place the positive electrode on the left posterior chest beneath the scapula and lateral
to the spine.
2. If the above placement cannot be used, the anterior-anterior positioning may be used:
A. Anterior-anterior positioning is similar to defibrillator paddle placement with the
negative electrode in the sternal position and the positive electrode in the apex
position.
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Procedures Manual
CARDIOVERSION/EXTERNAL PACING
(Continued)
EXTERNAL PACING
3. During pacing, the patient should be visually monitored at all times and should be assessed
for both electrical and mechanical capture. Skeletal muscle twitching should be expected, but
it is not an indication of pacing capture.
A. Electrical capture is presented by a pacer spike followed by a wide QRS and a tall Twave.
B. Mechanical capture is evidenced by signs of increased cardiac output (i.e. increased
BP, improved capillary refill, increased level of consciousness, and the presence of a
pulse matching the rate on the monitor).
PROCEDURE
1. Connect the monitor to the patient and make sure the EKG size is large enough to be sensed
by the pacer.
2. Apply the pacing electrodes to the patient using the above method. Make sure the pacing
leads are connected to the pacing port, the positive lead is connected to the positive electrode
and the negative lead to the negative electrode.
3. Turn the pacing unit on and set the starting rate (60 BPM).
4. Set the current level at zero milliamps.
5. Check the cardioscope for a capture mark above each QRS complex. If the capture mark is
not present and aligned with each QRS, adjust the EKG size until it captures. If this fails,
select another lead and try readjusting the EKG size.
6. When the unit is sensing properly, start the pacing. Each pacing stimulus should show as a
spike on the cardioscope.
7. Increase the current slowly while observing the cardioscope for evidence of electrical capture
(a QRS complex following every pacer spike). Palpate the patient’s pulse and frequently
check the patient’s blood pressure to assess for mechanical capture.
8. Obtain a rhythm strip of the pacing rate and capture, and record the current level.
9. To terminate pacing, push the stop button. When pacing is resumed, the current should revert
back to zero milliamps.
IF AT ANY TIME THE PATIENT GOES INTO VENTRICULAR FIBRILLATION, STOP
THE PACER AND DEFIBRILLATE AS PER THE NORMAL PROCEDURE. MAKE
SURE NOT TO DEFIBRILLATE OVER THE PACING ELECTRODES.
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Procedures Manual
AUTOMATED EXTERNAL
DEFIBRILLATION (AED)
(Revised 12/06)
AED PROCEDURE TO BE USED BY ALL CFRs, EMTs AND ADVANCED EMTs
INDICATIONS
Electrical defibrillation is currently the most effective method for converting ventricular
fibrillation (VF) or pulseless ventricular tachycardia (VT) to a life sustaining rhythm.
STATEMENT ON THE USE OF BIPHASIC AEDS
The American Heart Association has stated regarding AEDs using biphasic
waveforms, “The data indicates that biphasic waveform shocks of relatively low energy ( or 
200 J) are safe and have equivalent or higher efficacy for termination of VF compared with
higher-energy escalating monophasic waveform shocks (Class IIA).” “The growing body of
evidence is now considered sufficient to support a Class IIa recommendation for this low
energy, BTE waveform.”
Therefore, in addition to monophasic waveform AEDs, biphasic AEDs are also
approved for use in the AAREMS region.
CONTRAINDICATIONS/PRECAUTIONS
1. Success of defibrillation depends largely on the amount of time the patient has been in VF or
VT. For this reason, in the cardiac arrest situation, it is essential to check the rhythm and
defibrillate as early as possible.
2. In the pediatric patient, defibrillation should occur as per the AHA 2005 Guidelines.
PROCEDURE
1. While one team member is doing a primary survey and starting CPR, a second team member
(if available) should be obtaining a patient history. One AED trained member should be
preparing the AED unit and apply the electrode pads to the patient.
2. The AED operator should turn on the AED and attach the defibrillation pads as follows:
A. Pressing the Sternum pad on the right border of the sternum, with the top edge of the
pad just touching the right clavicle.
B. Pressing the Apex pad on the left lower ribs, at the anterior axillary line.
3. Connect the AED unit electrode wires with:
A. The white connector to the Sternum pad.
B. The red connector to the Apex pad.
4. Have the team members stop CPR and check for a pulse. If no pulse, clear the patient and
press the ANALYZE button.
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Procedures Manual
AUTOMATED EXTERNAL
DEFIBRILLATION (AED)
(Continued)
5. If a treatable rhythm, clear all persons from the patient and press the SHOCK button.
6. If an untreatable rhythm, resume CPR and transport the patient as soon as possible. Analyze
the patient’s rhythm every five cycles of CPR (about two minutes).
7. Once the shock has been delivered, continue as per the 2005 AHA Guidelines.
8. If a treatable rhythm occurs while in the ambulance, STOP THE VEHICLE to analyze the
rhythm and shock the patient. If a pulse returns after any defibrillation, continue the
administration of 100% oxygen, preferably through an ET tube, and monitor the patient’s
vital signs and rhythm while enroute to the hospital.
9. If the patient has an untreatable rhythm and no pulse:
A. Continue CPR.
B. Start transporting the patient.
C. ANALYZE the patient’s rhythm every five cycles of CPR (about two minutes).
D. If a treatable rhythm occurs, STOP THE VEHICLE and follow the defibrillation
procedure outlined in this section.
10. Continue the use of the AED as per the 2005 AHA Guidelines
11. Contact Medical Control if the patient regains a pulse or if the patient’s rhythm changes.
12. If you will be traveling through an area that can provide a higher level of care, if at all
possible, make arrangements to meet that agency prior to leaving the scene or arrange to
intercept with that agency while enroute to the hospital.
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Procedures Manual
ANTI-SHOCK TROUSERS
ANTI-SHOCK TROUSER PROCEDURE TO BE USED BY ALL EMTs AND
ADVANCED EMTs
INDICATIONS
1. May be used on trauma patients or those with evidence of significant blood loss (internal or
external) when a patient exhibits a clinical picture of shock and has a Systolic BP of 50 mm
Hg or less. Also, the trousers can be applied and inflated if the patient has evidence of an
unstable pelvic injury and the patient’s Systolic BP is 90 mm Hg or less.
2. If the patient is in cardiac arrest due to hypovolemia or trauma, Anti-Shock Trouser use is
appropriate.
3. Anti- Shock Trousers may be used as an extremity splint in situations where no other
splinting device is appropriate.
CONTRAINDICATIONS/PRECAUTIONS
1. Absolute contraindications to the use of the Anti-Shock Trousers are pulmonary edema and
patients with penetrating trauma injuries above the costal margin (lower rib cage).
2. The abdominal section of the trousers should not be inflated in pregnant women or patients
with eviscerations.
3. The section of the Anti-Shock Trousers covering an impaled object should not be inflated.
PROCEDURE
1. Place the patient on a stretcher or spine board to protect the Anti-Shock Trousers from
abrasion or puncture.
2. Open all of the zippers or velcro and slide the suit under the patient until the abdominal
section is just below the last pair of ribs.
3. Zip or velcro all sections of the suit and attach the pump, gauge and hoses to the appropriate
ports.
4. Open all three valves.
5. Inflate all three sections to a maximum pressure of about 106 mm Hg (on trousers with a
gauge) or until the pop-off relief valves of all three sections pop open (on trousers with
automatic pop-off valves).
6. Close all valves and recheck the patient’s vital signs.
MONITORING AND TRANSPORTATION
1. During and after application, careful monitoring of the patient’s vital signs is important!
2. When preparing for transportation, close all valves and remove all hoses.
3. REMEMBER TO BRING THE PUMP WITH YOU.
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Procedures Manual
INTRAVENOUS THERAPY
IV THERAPY PROCEDURES TO BE USED BY ALL ADVANCED EMTs
INDICATIONS
1. Types of intravenous infusions used:
A. Volume Replacement Infusions: The general use is to replace body electrolytes or to
replace fluid volume. Normal Saline is used with a macro drip administration set and
large bore IV catheters.
B. Medication Line: The general use is to establish venous access in case the patient
arrests or a medication is needed. Normal Saline is used with a micro drip
administration set and an IV catheter of sufficient size to keep the vein open and
administer IV push medications (large bore catheters are helpful during arrests when
large volumes of medications must be pushed).
2. When blood samples are to be drawn this should be done prior to starting the IV infusion.
A. Draw blood after the venipuncture.
B. Fill the tubes in the appropriate order. If extra tubes are requested by a particular
hospital, an agency may enter into an agreement with that hospital emergency
department to draw those tubes when possible. That hospital must agree to restock
the additional type tubes they would like drawn.
C. Remove the tourniquet and start the infusion or use a saline well injection site.
D. LABEL EACH TUBE WITH THE PATIENT’S NAME, DATE AND TIME
THE SAMPLE WAS DRAWN, AND YOUR INITIALS.
CONTRAINDICATIONS/PRECAUTIONS
1. Central venous cannulation is not allowed in the AAREMS system.
2. In adults, the veins of the extremities and the external jugular veins may be used on standing
orders. Standing orders for pediatric IV sites include the upper and lower (below the knees)
extremities, scalp, and intraosseous infusion. All other sites may only be used if a physician
order is given.
3. Patients with IV access in place must not be left unattended. Infusion rates must be watched
carefully to prevent overhydration.
4. Prep the venipuncture site preferably with both povidone-iodine and isopropyl alcohol.
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INTRAVENOUS THERAPY
(Continued)
EQUIPMENT
THE FOLLOWING EQUIPMENT MUST BE CARRIED ON ALL ALS UNITS IN THE
AAREMS REGION:
1. Solutions and administration sets:
- Normal Saline in 500 cc plastic bags or plastic bottles, (250 & 1000 cc bag
optional)
- Macro drip administration sets (10 or 15 drops = 1 ml),
- Micro drip administration sets (60 drops = 1 ml),
- Extension sets with injection ports,
- Soluset or Buretrol IV administration sets,
- Complete set of blood tubes as per receiving hospital protocol
- Vacutainers with luer adapters for drawing bloods,
- Saline well injection sites.
2. IV catheters and needles:
- 14, 16, 18, 20, 22, and 24 gauge IV catheter over needles,
- 15 gauge Jamshidi or other approved bone marrow needle for intraosseous
infusion.
GENERAL PROCEDURES
1. Generally, distal veins should be attempted before more proximal ones.
(In supraventricular tachycardia, where use of Adenosine is anticipated, use an
antecubital vein, if available)
2. Avoid placing IVs in injured extremities.
3. Always wear gloves when starting IVs.
4. Try to avoid using the right antecubital site for IV access in cardiac patients. Frequently
these patients undergo catheterization or thrombolysis and that site is the primary site used
for those procedures.
5. The number of IV attempts, person(s) attempting, site/location, catheter size, solution, time
started and infusion rate MUST be reported on the Prehospital Care Report.
6. While there is no maximum number of times an IV may be attempted, the amount of
discomfort caused the patient must be weighed against the NEEDS of the patient. After two
attempts on a patient who does not need medication “right now”, consider transport. If your
patient is hypovolemic and is entrapped, it may make more sense to continue attempts.
GOOD JUDGMENT on the part of all AEMTs will supplant any thoughts of maximum
attempt numbers.
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Procedures Manual
INTRAVENOUS THERAPY
(Continued)
EXTERNAL JUGULAR VENOUS CANNULATION
INDICATIONS
The more central external jugular (EJ) vein may be cannulated in situations where
peripheral sites lack perfusion. The external jugular vein runs from the angle of the jaw to under
the first third of the clavicle from the sternoclavicular joint, bilaterally. AEMTs may use external
jugular cannulation on standing orders.
CONTRAINDICATIONS/PRECAUTIONS
1. The EJ vein is more a central (although not truly central) vein than the arm veins usually
used. Extra care must be taken during cannulation to prevent infection or air embolus
injection, as these will cause severe complications down the road.
2. Because of the location of the EJ in relation to the pleural space, care must be taken not to
cannulate the lung and produce a pneumothorax. If this happens, do not remove the catheter,
refer to the Thoracic Decompression Procedure and contact an AAREMS physician as soon
as possible
PROCEDURE
1. Place the patient in a supine, head down position to fill the vein. Turn the patient’s head to
the side opposite the EJ you wish to use.
2. Locate the vein and cleanse the overlying skin with povidone-iodine and isopropyl alcohol.
3. Hold the vein in place by applying pressure on the vein distal to the point of entry at the angle
of the jaw.
4. Align the cannula in the direction of the vein with the point toward the ipsilateral nipple.
5. Tourniquet the vein lightly with one finger above the clavicle.
6. Position the catheter, bevel up, against the skin. Make the venipuncture midway between the
jaw and the clavicle on the side of the EJ.
7. Note blood return, advance the catheter and withdraw the stylette. Draw bloods if necessary
and attach the infusion tubing. This should be done with tamponade above the clavicle to
avoid air embolism.
8. Cover and dress the site in an appropriate manner and secure the IV tubing as necessary.
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Procedures Manual
INTRAVENOUS THERAPY
(Continued)
INTRAOSSEOUS INFUSION
INDICATIONS
Obtaining rapid vascular access in children can be difficult. Intraosseous infusion of
fluids and medications has long been regarded as a safe and effective procedure. This procedure
may be performed on standing orders in pediatric cardiac or respiratory arrest and on an
AAREMS physician’s order in other cases when rapid vascular access is difficult.
CONTRAINDICATIONS/PRECAUTIONS
1. The patient must be under three years of age in order to insure that the bone marrow has
sufficient vasculature to handle fluid and medications.
2. Peripheral IV sites should be considered prior to intraosseous infusion because of the inherent
risk of bone marrow infection.
PROCEDURE
1. Select a 15 gauge Jamshidi or similar approved bone marrow needle.
2. Prepare the puncture site with povidone-iodine and isopropyl alcohol. Intraosseous puncture
is performed on the flat, anteromedial surface of the tibial bone of either leg, 1-3 centimeters
below the tibial tuberosity.
3. Direct the needle perpendicular to the flat surface or with a slight angle toward the foot.
4. Advance the needle using firm pressure and a rotary motion. A sudden give of resistance
indicates entry into the bone marrow cavity.
5. Successful cannulation is verified by:
A. Give of resistance after passing through the bony cortex,
B. The needle standing up without support,
C. In most cases, the ability to aspirate bone marrow into a syringe attached to the
needle.
D. Free flow of the infusion without infiltration.
6. Attach an infusion set as per the Pediatric IV Protocol and infuse as per AAREMS
physician’s orders.
7. Secure the needle and IV tubing to the patient’s leg. Monitor the puncture site frequently for
signs of infiltration.
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Procedures Manual
INTRAVENOUS THERAPY
(Continued)
SALINE WELLS
INDICATIONS
If the decision is made not to run IV fluids or medications through an IV site, or you have
completed pushing IV fluids or medications through an injection site, or you are moving the
patient and the IV fluid bag and line may cause problems, saline well injection sites may be
attached to the end of the IV catheter in lieu of IV tubing.
PROCEDURE
1. Attach the injection site adapter for the saline well to the IV catheter after bloods are drawn
and the tourniquet is released. Secure the luer lock with a twist.
2. Aspirate Normal Saline into a syringe.
3. Cleanse the cap of the saline lock with an alcohol wipe.
4. Insert the syringe needle into the saline well, and aspirate gently for a sign of blood return.
5. Inject the syringe contents slowly into the saline well.
6. Observe the site for signs of swelling.
7. If swelling or pain occurs, remove the IV catheter from the patient’s arm.
8. Cover and dress the site and secure the saline well in the appropriate manner.
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Procedures Manual
CHEMSTRIP BLOOD GLUCOSE TESTING
CHEMSTRIP BLOOD GLUCOSE TESTING PROCEDURE TO BE USED ONLY BY
ADVANCED EMTs WHO ARE MEMBERS OF AUTHORIZED AGENCIES
INDICATIONS
1. The use of Chemstrip blood glucose test strips for blood glucose testing in the field is fairly
accurate when used to determine if the patient is hypoglycemic. Only members of agencies
that have received AAREMS REMAC approval may perform blood glucose testing.
2. The Chemstrip is highly specific when used with fresh capillary blood. Readings may vary if
taken from venous blood samples – check the manufacturer’s guidelines. The strips are
specific for D-glucose in whole blood and non-reactive to fructose, lactose, galactose and
pentose sugars.
3. Chemstrips come in non-breakable vials, moisture protected by drying agents in the vial cap.
Each vial contains 25 strips for visual reading.
4. Chemstrips must be kept in a dry location, free from extremes in temperature.
EQUIPMENT
Equipment needed to perform Chemstrip Blood Glucose Testing includes:
- Chemstrip bG Test Strips in 25 strip vials,
- Lancets for fingersticks,
- Cotton balls for wiping blood from the test strips,
- Alcohol wipes for cleansing fingers.
PROCEDURE
1. Remove two test strips from the Chemstrip vial and compare the pads on the unused strips to
the colors on the vial. If the pads on the test strips look darker than the low levels on the
label, use a new vial of Chemstrips.
2. Cleanse the finger site with alcohol. Let the alcohol dry completely prior to making a
fingerstick, if using blood from a fingerstick.
3. Prick the side of the cleansed finger with a lancet or needle and squeeze the finger until a
large droplet of blood is formed OR use droplets of initial IV access blood.
4. Touch the blood droplets to the test pads on the two Chemstrips. Do not smear the blood or
touch the pads with your finger. Make sure both test pads are covered with blood. Begin
timing at once.
5. After exactly 60 seconds, carefully wipe the blood from the test pads with cotton balls.
6. After an additional 60 seconds (total time = 2 minutes) match the color on the test pads with
the color scale on the outside of the Chemstrip vial.
7. If you have a perfect match, use the mg/dl number on the color chart.
8. If you cannot get a perfect match, use an average of the two test strips by:
- finding the closest match on the lowest strip reading,
- finding the closest match on the highest strip reading,
- adding the two readings together and dividing by two for an average reading.
9. If the reading you have is 120 mg/dl or higher, do not administer Dextrose 50% or Glucagon
to the patient. If the patient is symptomatic, contact Medical Control for AAREMS Physician
orders.
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Procedures Manual
GLUCOMETER BLOOD GLUCOSE TESTING
GLUCOMETER BLOOD TESTING PROCEDURE TO BE USED ONLY BY
ADVANCED EMTs WHO ARE MEMBERS OF AUTHORIZED AGENCIES
INDICATIONS
1. The use of a Glucometer for blood glucose testing in the field is very accurate when used to
determine if the patient is hypoglycemic.
2. Only members of agencies that have received AAREMS REMAC approval may
perform blood glucose testing.
3. Some Glucometers are made to test capillary blood only, so readings may vary if taken from
venous blood samples. Check your manufacturer’s guidelines for your Glucometer.
PROCEDURE
1. Follow your manufacturer’s guidelines for blood testing procedures and unit calibration for
your Glucometer.
2. If the reading you have is 80 mg/dl or higher, do not administer Dextrose 50% or Glucagon to
the patient. If the patient is symptomatic, contact Medical Control for AAREMS physician
order
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Procedures Manual
MEDICATIONS
MEDICATION PROCEDURES TO BE USED BY PARAMEDICS AND
CRITICAL CARE TECHNICIANS
ADMINISTRATION PROCEDURES
1. Medications may be given only:
A. On the order of an AAREMS physician, either verbally or by specific written
standing orders.
B. By an AAREMS Paramedic, Critical Care Technician, or a Paramedic /Critical Care
intern under the supervision of his/her preceptor.
C. When selected from the AAREMS medication schedule in this manual.
D. When administered according to AAREMS operating procedures.
2. The AEMT team leader is responsible for patient presentation, confirming orders and
medication box control.
3. Medications will be ordered by the AAREMS Physician in metric weight.
IF AT ANY TIME AN ORDER IS UNCLEAR, ASK THE PHYSICIAN TO REPEAT
THE ORDER OR EXPLAIN IT TO YOU!
4. Three radio transmissions are necessary to confirm an order:
A. The Physician will order the medication and dose.
B. The AEMT must repeat the order back.
C. The physician will acknowledge the order by saying, “that’s confirmed.”
5. Once the order is confirmed:
A. Write the order down.
B. Read the medication container to be sure it is the right one and check the expiration
date.
C. Administer the medication as ordered and document the time.
D. Advise the physician when the medication has been administered.
E. Evaluate the patient for the effects of the medication
F. WHEN ANY MEDICATIONS ARE ADMINISTERED, THEY MUST BE
DOCUMENTED ON A PCR CONTINUATION FORM.
G. An AAREMS physician must be contacted prior to discontinuing any ALS modalities
in the field (i.e. diabetic patients treated with D50 who refuse transportation to the
hospital when he/she becomes alert).
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Procedures Manual
MEDICATIONS
(Continued)
SUPPLY AND INVENTORY PROCEDURES
Medications used in the AAREMS system are obtained through a medical control
hospital pharmacy as arranged by the individual ALS agency. The type, dose, content and
minimum quantity of each medication are reflected on the medication schedule contained within
this manual (see appendix “A”). Quantity of medications carried may vary due to distances from
the hospital and must be approved by the agency’s medical director. NO medications other than
those listed on the medication schedule may be carried by any ALS agency in the AAREMS
system.
1. Each ALS unit MUST conduct a regularly scheduled inventory of all medications
and keep a record of said inventory.
2. Each medication box must be locked or secured in a locked cabinet. ONLY
AAREMS CREDENTIALED AEMTs CAN POSSESS KEYS TO THE
MEDICATION BOX.
3. A separate procedure for controlled substances will be prepared when the proper
application forms and procedures information is received from the N.Y. State Health
Department and the ALS agency is approved to carry controlled substances.
REQUISITION/EXCHANGE PROGRAM
1.
In order to provide each ALS unit with immediate replenishment of ALS
supplies, an exchange program agreement must be arranged with a participating
hospital in the AAREMS Region, to verify the use and replacement of the items on
the list.
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Procedures Manual
MORGAN LENS
MORGAN LENS PROCEDURE TO BE USED BY PARAMEDICS AND
CRITICAL CARE TECHNICIANS ON STANDING ORDERS
INDICATIONS
Irrigation of the eyes should occur whenever chemical burns (such as acid or alkali
burns), thermal burns, and radiation burns [such as ultraviolet (welder’s flash, sun blindness) or
infrared (eclipse blindness, glassblower’s burns)] occur or if a small foreign body is present in the
eye. DO NOT flush the eye if an impaled object is present; stabilize the object as per the usual
procedure.
EQUIPMENT
THE FOLLOWING EQUIPMENT MUST BE CARRIED ON ALL PARAMEDIC AND
CRITICAL CARE UNITS IN THE AAREMS REGION:
- Morgan Medi-Flow Lens Sets (3),
- Tetracaine Ophthalmic Solution, 0.5% (3 for single patient use),
- Normal Saline in 500 or 1000 cc bags,
- Macro drip tubing set-up.
CONTRAINDICATIONS/PRECAUTIONS
1. Do not use Tetracaine Ophthalmic Solution on a patient allergic to Lidocaine.
2. Prevent the patient from rubbing or touching the eye(s) while the cornea is anesthetized.
PROCEDURE
1. Explain the procedure to be followed to the patient.
2. If physical condition permits, place the patient in a modified Trendelenburg position. Turn
the patient’s head to the affected side. Place a dry towel under the patient’s head.
3. Open the upper and lower eyelid and instill 1-2 drops of the short acting local anesthetic
(Tetracaine Ophthalmic Solution) onto the patient’s cornea and globe. Have the patient close
the treated eye(s) and roll the eye(s) until the pain subsides.
4. Begin Normal Saline flow into the Morgan Lens by attaching the female adapter end of the
lens tubing to a macrodrip line that is attached to a 1000 cc Normal Saline bag.
5. Ask the patient to look down. Grasp the Morgan Lens by the long tubing away from the
dome. Slip the upper border of the Morgan Lens under the upper eyelid.
6. Ask the patient to look up, retract the lower eyelid and slip the lower border of the Morgan
Lens under the lower eyelid.
7. Adjust the flow rate of Normal Saline to allow continuous flow into the Morgan Lens.
8. Repeat the procedure for the other eye if necessary.
9. Obtain the name of the product or substance involved and, if possible, bring the item involved
to the hospital with the patient.
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Procedures Manual
INTER-FACILITY GROUND TRANSFER
PROTOCOLS
BASIC LIFE SUPPORT (BLS)
1. Obtain a verbal patient report from an appropriate hospital staff member (nurse or physician),
including:
- Age and sex of the patient
- Diagnosis
- Reason for transfer
- Level of consciousness and last set of vital signs
- Brief history and hospital patient assessment
IF THE PATIENT IS NOT APPROPRIATE FOR BLS TRANSPORT, THIS IS THE TIME TO
DISCUSS IT IN A FRIENDLY, SUPPORTIVE MANNER.
2. Receive the patient’s record and permission for transfer from the transferring facility.
3. Obtain and document a set of vitals prior to leaving the transferring facility and, as indicated,
in transit. If unable to obtain vital signs in transit, document why they are unobtainable, and
report reason to the accepting facility. If a nurse or physician obtains vital signs just before
or during transport, document that a nurse or physician took the vitals.
4. Document the patient’s condition during transport.
5. Treat the patient during transport following the New York State BLS Protocols.
NOTE: BLS transport does not include patients with IVs (except as noted below), Automatic
Transport Ventilators or other ALS procedures in place.
6. Give a report to the appropriate receiving hospital staff member, including the report you
received on the patient, and the patient’s condition and treatment during transport.
7. EMTs may transport stable patients with saline or heparin wells in place that were initiated in
a medical facility.
8. If the patient becomes unstable, contact an AAREMS Medical Control Physician by radio or
cell phone.
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Procedures Manual
INTER-FACILITY GROUND TRANSFER
PROTOCOLS (Continued)
ADVANCED LIFE SUPPORT (ALS)
EMT-Is cannot transfer patients with IV drip medications running.
1. Obtain a verbal patient report from an appropriate hospital staff member (nurse or physician),
including:
- Age and sex of the patient
- Diagnosis
- Reason for transfer
- Level of consciousness and last set of vital signs
- Brief history and hospital patient assessment
2. In the event that the patient’s transfer orders conflict with AAREMS Protocols and
Procedures, the AEMT MUST contact Medical Control (radio or telephone) for AAREMS
physician direction.
3. Receive the patient’s record and permission for transfer from the transferring facility.
4. Obtain and document a set of vitals prior to leaving the transferring facility and, as indicated,
in transit. If unable to obtain vital signs in transit, document why they are unobtainable, and
report reason to the accepting facility. If a nurse or physician obtains vital signs just before
or during transport, document that a nurse or physician took the vitals.
5. Document the patient’s condition during transport.
6. Treat the patient during transport following the AAREMS ALS Protocols. Contact Medical
Control for any new symptoms or treatments not covered by the transfer orders.
7. Give a report to the appropriate receiving hospital staff member, including the report you
received on the patient, and the patient’s condition and treatment during transport.
8. Cellular telephone communication capability is recommended for agencies doing long
distance transports.
9. A NURSE, PHYSICIAN ASSISTANT, OR PHYSICIAN FROM THE
TRANSFERRING HOSPITAL MUST ACCOMPANY THE PATIENT FOR ANY
TREATMENT(S) OUTSIDE OF STANDARD AAREMS PROTOCOLS CONTAINED
IN THIS MANUAL.
Note: Any ongoing treatments, such as IV drip medications, must have accompanying
transfer orders signed by the attending physician at the transferring hospital. If the AEMT
feels the patient may not be stable for transfer, contact an AAREMS Physician in the
receiving hospital for advice.
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Procedures Manual
INTER-FACILITY GROUND TRANSFER
PROTOCOLS (Continued)
INTRAVENOUS DRIP MEDICATION MAINTENANCE
If an ALS agency will be participating in interhospital ground transfers without hospital
staff on board, the agency Medical Director (or designee) must provide an “in-service” regarding
the use of these medications. Documentation of participation in such an “in-service” must be
kept by the agency on each ALS provider who will participate in such transfers. If an agency
wishes authorization to manage medications not included herein, the agency Medical Director
should submit a request to the REMAC for approval.
1. The following IV DRIPS may be used by Paramedics and Critical Care Technicians (in
addition to those medications authorized for use as outlined in the treatment protocols), when
ordered and provided by the transferring physician. Many of these medications are NOT
carried or initiated by prehospital providers.
2. ALL OF THESE MEDICATION DRIPS MUST BE RUN ON INFUSION PUMPS AT
ALL TIMES FOR ACCURATE DOSING AND TITRATION.
3. If the patient deteriorates or has a significant change in status, or if medications ordered by
the transferring physician must be discontinued, Medical Control must be contacted
immediately.
IV DRIP MEDICATIONS
A. NITROGLYCERINE
1. Usual dosage: 10-200 mcg/min.
2. Monitor blood pressure every 5 minutes.
3. Discontinue drip if systolic blood pressure falls below 90 mm Hg, or if diminishing
mental status occurs with diminishing blood pressure. If systolic blood pressure
returns to above 100 mm Hg prior to AAREMS MD contact, follow the Suspected
AMI Protocol.
B. HEPARIN
1. Usual rate: 18 units/kg/hr.
2. Monitor patient for signs of bleeding around IV sites, hemoptysis, hematuria, or
epistaxis.
3. Discontinue drip if patient exhibits any signs or symptoms of bleeding complications.
C. AMINOPHYLLINE
1. Usual dose of no more than 0.5 mg/kg/hr.
2. Children and young adult smokers may need 1.0 mg/kg/hr.
3. Discontinue drip if the patient’s pulse rises above 140 BPM, the patient develops
nausea and vomiting, more than 6 PVC’s per minute occur, or any runs of
Ventricular Tachycardia occur.
D. PROCAINAMIDE
1. Usual dose of no more than 1-4 mg/min.
2. Discontinue drip if hypotension occurs or if the patient’s QRS complex widens by
more than 50%.
E. MANNITOL
1. Usual dose: 0.25-1.0 gm/kg
2. The transferring physician will set rate.
3. Discontinue drip if hypotension occurs.
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Procedures Manual
INTER-FACILITY GROUND TRANSFER
PROTOCOLS (Continued)
INTRAVENOUS DRIP MEDICATION MAINTENANCE (Continued)
F. GP IIb/IIIa RECEPTOR INHIBITORS (usual doses are as indicated)
1. Aggrastat (tirofiban): 10 mcg/kg IV over 3 minutes, then 0.1-0.15 mcg/kg/min.
2. Integrilin (eptifibatide): 135-180 mcg/kg bolus, then 0.5-2.0 mcg/kg/min infusion.
3. Reopro
4. Monitor patient for signs of bleeding around IV sites, hemoptysis, hematuria, or
epistaxis.
5. Discontinue drip if patient exhibits any signs or symptoms of bleeding complications.
G. STEROIDS
1. Usually Methylprednisolone (Solu-Medrol): 30 mg/kg bolus, then 5.4 mg/kg/hr
infusion for 23 hours.
H. AMIODARONE
1. Usual Dose: 150-300 mg IV bolus, then 1 mg/min infusion for 6 hours, then
0.5 mg/min infusion for the next 18 hours.
2. Discontinue drip if hypotension or symptomatic bradycardia occur.
I. CARDIZEM
1. Usual dose: 0.25 mg/kg bolus, may repeat at 0.35 mg/kg prn, with a 10-15 mg/hr
infusion.
2. Discontinue drip if hypotension or symptomatic bradycardia occur.
J. NEUROMUSCULAR BLOCKERS ** only in intubated patients **
1. It is the responsibility of the paramedic to ensure that the endotracheal tube is
properly placed and is adequately secured prior to beginning transport.
2. It is the responsibility of the agency Medical Director to assure the competency of
airway assessment and maintenance skills of personnel participating in interfacility
transfers involving these medications.
3. Vecuronium: Usual dose: 0.05-0.075 mg/kg/hr.
4. Pancuronium: Usual dose: 0.03-0.04 mg/kg/hr.
5. Discontinue drip if the endotracheal tube becomes dislodged (be aware that the
effects of these drugs last greater than 30 minutes!).
6. Realizing that these medications provide no sedation, the Paramedic should assure
that adequate sedation has been ordered.
K. SEDATIVES
1. Propofol ** only for use in intubated patients **: Usual dose starts at 25
mcg/kg/min, titrate as per the transferring physician’s order.
2. Versed: Usual dose 2-10 mg/hr, titrate as per the transferring physician’s order.
3. Ativan: Usual dose: 2-10 mg/hr, titrate as per the transferring physician’s order.
4. Discontinue drip if symptomatic bradycardia, hypotension or respiratory depression
occur.
L. OPIATES
1. Morphine: Usual dose: 0.8 – 10 mg/hour, titrate for effect.
2. Fentanyl: Usual dose: 50 – 100 mcg/hour, titrate for effect.
3. Must continually monitor respiratory rate, blood pressure and pulse oximetry.
4. Discontinue drip if symptomatic bradycardia, hypotension or respiratory depression
occurs. Naloxone may be used as per the ALS Treatment Protocols.
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Procedures Manual
INTER-FACILITY GROUND TRANSFER
PROTOCOLS (Continued)
INTRAVENOUS DRIP MEDICATION MAINTENANCE (Continued)
M. DOBUTAMINE
1. Usual dose: 2-20 mcg/kg/min. Titrate to effect.
2. Discontinue drip if symptomatic hypotension occurs.
N. INSULIN (REGULAR)
1. Usual dose: 0.1 unit/kg/hour
2. Blood glucose must be monitored at least hourly
3. Discontinue drip if symptomatic hypoglycemia occurs and follow the Diabetic
Emergencies Protocol.
O. POTASSIUM
1. Usual dose: not faster than 10 mEq/hour.
2. The patient must be on a cardiac monitor AT ALL TIME S during this infusion.
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Procedures Manual
INTER-FACILITY GROUND TRANSFER
PROTOCOLS (Continued)
BLOOD TRANSFUSION MAINTENANCE
As per New York State law (Title 10, New York State Laws and Regulations,
Section 58-2.16), blood transfusion maintenance is allowable in an ambulance
situation only when a registered nurse or a physician accompanies the AEMT.
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Procedures Manual
PATIENT REFUSAL
AGAINST MEDICAL ADVICE
Talk with patient, family, and friends, and attempt to convince them of the need
for treatment/transport.
If technologically possible, offer to call Medical Control and have the patient
speak with the physician.

If patient still refuses treatment/transport,
assess level of consciousness

Alert and Oriented x3/GCS 15

Yes
No


Rule out:
- Attempted/threatened suicide
- Minor ( 18 y/o)
- Parent refusing and potentially
serious illness/child abuse
suspected
- Police custody

Yes


Patient cannot refuse!
Contact medical control and enlist
assistance from law enforcement
Under no circumstance should field
personnel allow themselves to be placed
in danger. If this potential exists, go to a
safe area and call for assistance.
No

Have patient sign refusal form
(Strongly suggest use of
AAREMS regional refusal form)
Document efforts and patient
response thoroughly on PCR
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Procedures Manual
LARYNGEAL MASK AIRWAY
LMA PROCEDURE TO BE USED BY ALL AEMTS
ALS Agencies in the AAREMS Region may carry the Laryngeal Mask Airway as an
alternate airway device.
INDICATIONS
A method of establishing an airway and providing effective ventilation if endotracheal
intubation attempts have been unsuccessful.
CONTRAINDICATIONS/PRECAUTIONS
1. Do not attempt to place an LMA if the patient has a gag reflex or is not profoundly
unconscious.
2. In patients with severe oropharyngeal trauma, the risk of worsening the condition should be
weighed against the potential benefit of establishing an airway.
3. The LMA does NOT protect against aspiration in the case of forceful vomiting; therefore,
suction should always be available.
EQUIPMENT
1.
2.
3.
4.
5.
Appropriate personal protective equipment.
Proper size LMA.
Appropriately sized syringe.
Water-soluble lubricant.
Tape
PROCEDURE
1. Remove the sterile LMA from the package.
2. Check the integrity of the LMA cuff by inflating it with the maximum volume of air.
3. The cuff should then be tightly deflated using the enclosed syringe so that it forms a flat oval
disk with the rim facing away from the aperture. No wrinkles should remain on the distal
edge of the cuff.
4. Lubricate the posterior surface of the LMA with a water-soluble lubricant.
5. Preoxygenate the patient and position the patient with the neck flexed and the head extended.
If a spinal injury is suspected, keep the head and neck in a neutral position.
6. Hold the LMA like a pen, with the index finger placed at the junction of the cuff and the tube.
Under direct vision press the tip of the cuff upward against the hard palate, flattening the cuff
against it. The black line should be oriented anteriorly toward the upper lip.
7. Use the index finger to guide the LMA, pressing upwards and backwards toward the ears in
one smooth movement. Advance the LMA into the hypopharynx until a definite resistance is
felt.
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LARYNGEAL MASK AIRWAY
(Continued)
8. Before removing the index finger, gently press down on the tube with the other hand to
prevent the LMA from being pulled out of place.
9. WITHOUT HOLDING THE TUBE, inflate the cuff with just enough air to obtain a seal.
The maximum cuff volumes are shown:
LMA SIZE
PATIENT SIZE
MAXIMUM CUFF VOLUME
3
Children > 30 kg
and small adults
20 mL
4
Normal and large
adults
30 mL
5
Large adults
40 mL
NEVER OVER INFLATE THE CUFF.
10. Connect the LMA to the bag valve device and begin manual ventilation. Check for adequate
air exchange with auscultation.
11. Secure the airway tube downward against the chin with tape.
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Procedures Manual
COMBITUBE
INDICATIONS
The Esophageal Tracheal Combitube© is a second line airway management device that
may be inserted on standing orders by AEMTs (Paramedic, Critical Care, and
Intermediate). The Combitube is used in cases of cardiac arrest or in respiratory arrest in
the absence of a gag reflex.
CONTRAINDICATIONS / PRECAUTIONS
1. The standard adult Combitube may not be used in any patient less than 5 feet tall.
The Combitube SA© is a shorter device, designed for use in patients from 4 to 5
feet tall.
2. The Combitube may not be used in any patient with known esophageal disease, or
anyone who has ingested any caustic substance.
3. The Combitube should be avoided in patients with pharyngeal hemorrhage.
4. Known or suspected obstruction of the larynx or trachea, or patients who have
undergone laryngectomy or tracheostomy.
EQUIPMENT
The Combitube is a disposable device, and is not to be cleaned or reused.
1. The tube and both syringes (140cc and 20cc) must be stored in the original
container.
2. Tube cuffs must be checked for leaks prior to insertion, discarded and replaced if
there are any leaks or cuff deformations. A spare tube with syringes must be
carried.
PROCEDURES
1. Following no more than two unsuccessful intubation attempts, the patient is to be
hyperventilated with a bag-valve mask for a minimum of 10 -15 seconds.
2. Stop CPR prior to device insertion.
3. Lubricate the tip of the tube and the small balloon with water soluble lubricant
(i.e., Lubifax©, KY Jelly®)
4. Starting from a neutral position, insert your thumb into the patient’s mouth,
grasping the tongue and lower jaw between your thumb and index finger and lift
upward. If a cervical injury is suspected, c-spine precautions must be taken during
insertion of the Combitube.
5. With the other hand, hold the Combitube so that it curves in the same direction as
the natural pharyngeal curvature. Insert the tip of the tube into the mouth and
advance in a downward curved motion until the teeth (or alveolar ridges) are
between the two black bands.
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Procedures Manual
COMBITUBE
(continued)
CAUTION: DO NOT FORCE THE COMBITUBE INTO POSITION. IF IT DOES NOT
ADVANCE EASILY, REDIRECT THE TIP OR WITHDRAW THE TUBE AND ATTEMPT
TO REINSERT.
6. Inflate the blue pilot balloon (line 1) leading to the pharyngeal cuff with 100cc of
air, using the 140cc syringe.
7. Inflate the white pilot balloon (line 2) leading to the distal cuff with 15cc of air,
using the 20cc syringe.
8. Using a BVM, begin ventilations on the longer, blue tube, observing for chest rise
and auscultating lung fields. If breath sounds are positive, and epigastric
auscultation is negative, continue to ventilate through the blue tube.
9. If there is no chest rise, breath sounds are negative, and epigastric sounds are
positive, begin BVM ventilation through the shorter, clear tube.
10. If no chest rise or positive breath sounds occur from ventilation through either
tube, deflate the cuffs, remove the tube as quickly as possible, hyperventilate the
patient for at least 10 – 15 seconds, and attempt to insert the Combitube again. If a
second attempt is unsuccessful, do not attempt again. Insert an oral or nasal
airway, and ventilate with BVM while transporting as soon as possible.
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